What Causes Liver Disease? - with Kristin Kirkpatrick | The Empowering Neurologist EP. 38

Hello everyone, I'm Dr. David Perlmutter and welcome again to The Empowering Neurologist. Non-alcoholic fatty liver disease, it might not be a term you're familiar with, but in fact it is a situation that may affect as many as 25% of American adults. And it may be lethal. It is a very common disease that goes hand in hand with obesity and type 2 diabetes. Our guest today has written a very compelling book called Skinny Liver, and her name is Kristen Kirkpatrick. She is a— the manager of the Wellness Nutrition Services at the Cleveland Clinic in Cleveland, Ohio, where she oversees the nutrition-related services for the Center for Lifestyle Medicine. She is an award-winning dietitian, having won the 2012 Dietetic Educator of the Year Award in Ohio. She is a regular guest on both local as well as national television programs. She's been on the Dr. Oz Show, the NBC Nightly News, the Today Show, as well as National Public Radio. She received her BA degree from George Washington University and a master's in health promotion from American University. And her dietetics training took place at the University of Akron. The book is written along with Dr. Ibrahim Hanouna, who is a gastroenterologist. In fact, he's assistant professor of gastroenterology at Case Western Reserve University. So we're about to learn some very interesting information related to the liver and how to protect it. Hi, Kristen. It's really great to talk to you today.

Thank you. It's an honor to be on your show.

I think this is a terrific book, and for all of our viewers, I get the advanced reading copy, which was not for sale, but just so everybody knows, they can go to Amazon and they can buy the book right now. Let's just jump in. I think that people don't really think much about liver disease, and in this case, non-alcoholic fatty liver disease, but it's a big problem, isn't it?

It's a big problem, and it impacts Obviously, it impacts obese people. We have a very huge percentage of Americans that are walking around with it and don't even know that they have it. Obesity is not just the only story, though. It can occur in people that are a little bit overweight, and of course, we have seen cases and studies where people can develop it and they're not even overweight. I think it's a huge problem. It's relatively asymptomatic in the early stages, and many people are not aware that it's even inflicting them.

How big of a deal is it? I've heard statistics saying as many as 25% of adult Americans may be involved with this.

Yeah, about 25%. That's actually a pretty accurate estimate based on some of the recent meetings with the American Liver Foundation. Also looking at the huge percentages of obese people that have it, some of the predictions are anywhere from 60% to 80% of obese people do have it. Again, if you happen to be obese, Morbidly obese for sure, the chances of you having it are very high.

All right. Now, you know, people who read the book, and I'm really excited to see that it's already a bestseller on Amazon in health, which is great.

Thank you.

People are thinking, well, yet another thing to worry about. You know, I've heard of Alzheimer's and diabetes and cancer, and now there's this new thing, but it's really not a new thing, and it's extremely pervasive. Why has it not really been in the forefront if it's such a big deal?

I think that the numbers, Dr. Perlmutter, definitely have been rising over the past few decades, but it's getting a lot more attention now because now we see it as the 4th leading cause of liver transplantation. We're seeing it in the pediatric population. It's starting to get the attention because people are actually going to those more advanced stages of it. As people go to those advanced stages, we hear more about it because it becomes more scary.

All right. We're talking about something called nonalcoholic fatty liver disease. This is a problem with the liver that is not necessarily induced by alcohol, but what's causing it?

The main primary cause of it, and of course if you look at the studies, some researchers will say we're not 100% sure what the mechanism is, but it's a pretty firm belief that lifestyle choices are definitely the cause of it, so a poor diet, inactivity, Stress levels, and then even just looking at toxins. I mean, the liver is the main organ that actually detoxifies things in the body, so looking at some of these toxins and how they then interact. Then, of course, looking at the piggyback conditions. If you have insulin resistance or even if you have heart disease, things of that nature, your prevalence for this goes up. I would say if your diet is something you have not cared about, Whether you are normal weight or even slightly overweight, if you're not active, that's going to be a huge risk factor.

Now, you know, the increased prevalence has kind of very much paralleled the increased prevalence of overweight and obesity. And that said, one would then assume that some of the lifestyle choices that we're making as a population may relate to both of these events. And I think that's clearly what the science is telling us. In the case of the sugar fructose, it looks as if that uniquely may be playing at least an assistive, if not a causative role in causing this situation. How does that work?

The reason that fructose is such a big player in this is that fructose can only be metabolized by the liver. Obviously, the liver metabolizes all of our macronutrients in some way, but with fructose, in the case of fructose, it metabolizes it pretty much 100%. Yeah. When the liver gets overwhelmed with having too much fructose in the diet, a lot of people blame soda for nonalcoholic fatty liver disease. It then develops these fat deposits in the hepatic cells. I think because fructose is primarily the driver that needs to be metabolized by this organ, as opposed to other forms of sugar that are being metabolized by other organs and then have some metabolism from the liver, it's a huge thing. Of course, coinciding with the huge amount of fructose in the American diet, sometimes hidden and sometimes right out there in plain view.

Our cells can use glucose as an energy source and do so fairly handily. Glucose is driven into the cell for its metabolism by the hormone insulin, but when we consume fructose like in the form that's in high fructose corn syrup, which does contain glucose as well, But when we get extra fructose, fruit sugar, in that form, then it's not something that our cells use for energy, and it ends up basically storing itself in the liver for the future. The liver then is filled with the end products here, mostly triglycerides, and it becomes fatty and enlarged.

Yes,

absolutely. The liver then is not able to work as well in terms of detoxification.

Yes, that's right. When you, again, look at some of these studies, especially when we start advancing to some of these very advanced stages of the disease, the liver is simply— it can't get things out. That's the whole filter process of it, blood flowing through it, filtering things. That's what the liver has to do. When it is overwhelmed by fats, the liver, of course, has a normal amount of fat. We do see that 5% to 10%, but once we get into those huge amounts of fat really taking over, it simply It simply can't do its job, very similar to looking at heart disease or things like that where we have fat accumulation in an artery or something like that, and the organ can no longer function the way it is meant to.

You mentioned in your book how then toxins that we are all exposed to can be more detrimental to us. First, let's talk about what those toxins may be.

Yeah, so some of the main toxins that I looked at are, number one, coming from our food. Yeah. Because I'm a dietitian, that was the first place where I thought, okay, this is the most interesting and the thing I see most of the days with my patients at Cleveland Clinic. Looking at some of the farmed fishes that we have, the toxins coming in there, looking at non-organic vegetables, especially those that are the Dirty Dozen, and just kind of really breaking down what are those pesticides, herbicides, what are those things doing when they get into our body, especially if our liver is not at Tip-top form and can't really metabolize them and get them out. That was the first one I looked

at. Others may not really be thinking when we talk about toxins about, for example, taking Tylenol, acetaminophen, which is in so many medications and is highly dependent upon liver function to be processed. In a case like this, we start to develop nonalcoholic fatty liver disease, even taking a Tylenol could be a significant trauma to us.

Yes, absolutely. With the book, the contributing author that I worked with is a hepatologist, and so we really did have a lot of discussions about some of the pharmacological toxins that we are putting in our body on a regular basis that we don't need a prescription for, Tylenol being one of them. It's been pretty well known, at least for my patients, that Tylenol is not great for the liver, but it again becomes especially worse when the liver is not functioning normally or we're taking Very large amounts or we're taking it very frequently, and we're just not giving the liver a break.

Generally, these folks who are at risk for NAFLD are the ones who are probably taking diabetic medications, pain medications, and who knows what else. They're the more likely medicated group who can ill afford to challenge their detox pathways.

Right. I agree. I really think that when you look at the numbers here, Typically, someone will have NAFLD, and they will have something else associated with it. Most likely diabetes, could be coronary heart disease, and any number of conditions. I think that because we are looking at that population, for the most part, the majority of the diagnosed cases, yes, I agree that we have things like that, the toxins that are in the medicines, even things like cleaning products. That was another big thing for me because you might not even think about it. You might not think about what you're using to If you spray in your kitchen, where does the aftereffect of that go, and how are we absorbing it through our skin, and then how does it get out of our body? We tend not to think of those things.

I really think you bring up a terrific point that we are so challenged in our modern world with toxins around every corner that we really, really depend on functionality of our liver, and now a lot of people are compromising that They're inducing it based upon their dietary choices. It becomes a vicious circle. You also talk about nonalcoholic steatohepatitis. Tell us about that.

That is when we start to get into more of the advanced stages. Once we have that fat accumulation, that's what we would call the first hits. NAFLD is often referred to as a multi-hit condition. The first hit is that fat accumulation. Once we now get into some fibrosis, increased inflammation, that then can lead to cirrhosis. Now you're in that NASH stage. Once you get into those areas, you're really in a place where it's much more hard to reverse it. Even at the beginning of our conversation, Dr. Perlmutter, talking about how people don't think about it the way they think about heart disease or diabetes, things of that nature. It's so reversible, whereas a lot of those other conditions are not always as easily reversible. They can be as well. This is so reversible in the early stages, but we don't have the symptoms that some of those other conditions provide to us as that warning, that red light to tell us, stop now, let's try and reverse this.

I want to stop you right there because that's a real empowering point, that early on when this is beginning to happen, and, you know, for most people it's a silent issue, they don't know this is happening, but you can be sure if If you're type 2 diabetic or significantly overweight, you're really more than likely to have at least early stages, if not moderate stages of the situation.

Yeah.

But again, this is what I want to call attention to for our viewers, is that what you're saying and what the science clearly indicates is that there is profound reversibility. And, you know, the time to fix a roof is when the sun is shining. So, so that said, I think those of you who are significantly overweight in our audience, who are— and/or type 2 diabetic, time to get this book and start the program right away. In reading through, Kristin, your recommendations so beautifully fall in line with what many of the people I interview are talking about. I did do an interview recently with— it's kind of off topic, but just to be fair and have a civil conversation about— Other ideas about gluten and wheat. But that said, I think that you call attention to the incredible amount of sugar, and specifically fructose that we just talked about, in the American diet. I know that you're working there at the Cleveland Clinic. That's pretty much where people are going, isn't it? It's really rejecting the notion of sugar and even complex carbohydrates as being necessarily good foods for us.

Yeah, absolutely, and we do see that a lot with our patients. Even with some of our patients that have been really struggling to try and lose weight, they are eating healthy foods, healthy matters of pattern with their food, and sometimes if we try and take them off of grains for just a little bit, they're able to jumpstart that. They're able to really help to improve their weight loss. We've done that with many of our patients, and obviously at the Wellness Institute where I am, We do test pretty regularly for gluten sensitivities, casein sensitivities, things like that, again, that may not bring up the most obvious symptoms early on.

Whether there's a direct relationship between these sensitivities and the production of NAFLD, nonetheless, the downstream— no pun— well, pun very much intended— effect of this liver issue is increase in inflammation. Yes. And that said, these food sensitivities that you mentioned can contribute yet to more level— higher levels of inflammation, and therefore, you know, certainly add fuel to the fire. You mentioned, you know, we've been talking about the importance of lifestyle factors and choices as it relates to this disease. There are some genetic issues as well, and can you tell us about that?

Yeah, so when we looked at some of the numbers, there were higher prevalence in certain genetic populations. So we saw Native American and Hispanic population Definitely in the Asian population. There were certain populations where if all things were equal and someone from that genetic background was overweight or obese, they were much more likely to develop the condition. Again, some of that is unexplained, but we definitely did see some correlations with certain populations and just having a much higher prevalence regardless of lifestyle factors.

The other points about your book, and just to read the subtitle, it says, Eliminate Everyday Toxins. Who wouldn't want to do that? Avoid Diabetes, Heart Disease, and Obesity. Avoid Diabetes, Heart Disease, and Obesity. It's a liver book. Why do you make that claim? I mean, I know why you make that claim, but I want you to tell our audience.

The reason I did is because really the suggestions that I made in the book in terms of turning your life around, getting the toxins out, being able to lose weight, getting the right diets are really things that also work in the prevention of both diabetes and heart disease. Absolutely. Even improving brain health, and the list could go on and on and on, and cancer and things like that. We didn't have enough room on the COVID for me to put that. Those are the big ones, and those are probably the majority of the patients that I see are either going to have heart disease, diabetes, or they'll have both. It was really important for me to look at this diet in a way that, okay, if we're looking at how we metabolize these nutrients, the role that the liver takes in the metabolism part, and then how that then impacts other diseases, this can also prevent some of those other things and, quite frankly, can even help to reverse some of those other conditions as well.

Again, you said you didn't have enough room on the COVID and I like that explanation because I want to just make it so clear that when we see lifestyle choices that open the door for type 2 diabetes and obesity, that's kind of just the gatekeeper for all of our chronic degenerative conditions including things like Alzheimer's and even cancer for that matter. And I think, you know, in this age of personalized medicine where people want to have a specific recommendation for themselves, nonetheless, we know the broad strokes. And the broad strokes are diets, for example, that are reduced in sugar and simple carbohydrates and have more fiber in them and higher levels of good fat. These are the broad strokes. you know, to be specific about an individual's need based upon his or her genetic predisposition, that's wonderful and exciting. But, you know, I think, you know, a book like yours makes broad-stroke recommendations that are very, very valuable, and I really commend you for it. I think this is terrific, and I think that you're gonna go a long way now that the book is available to really raising awareness to a very pervasive problem that, for whatever reason, has Slipped in under the radar, but not anymore. I mean, now that we have your book, it's really very, very helpful.

Thank you. Thank you so much.

Okay. Well, we'll talk soon, and I sure appreciate you joining us today.

Thank you. It's been a privilege, Dr. Perlmutter.

Bye-bye.

Bye-bye.

This has been a very enlightening interview. Again, the book is called Skinny Liver, now available on Amazon, a bestseller. And Skinny Liver is really an eye-opening experience to read that book, really calling our attention to a very pervasive problem, this non-alcoholic fatty liver disease that is by and large brought on by lifestyle choices. And what is so compelling about the book is that it really gives us a blueprint in terms of doing our best to avoid the situation. It's a really good read. I recommend you pick it up. Thanks for joining us today. I'm Dr. David Perlmutter.