Skinny Liver

A Proven Program to Prevent and Reverse the New Silent Epidemic-Fatty Liver Disease


By Kristin Kirkpatrick, MS, RD, LD

By Ibrahim Hanouneh, MD

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Based on the latest research, Skinny Liver is an authoritative, easy-to-follow guide not just for your liver, but for your whole body.

The liver is the seat of our overall health and wellness and the health of nearly every organ is intimately connected with our liver. A healthy liver is essential to a fully functioning body, but our modern sedentary lifestyle and unhealthy eating habits can truly damage the liver — and damage our health overall.

A silent health crisis is impacting one-third of the American population — nonalcoholic fatty liver disease (NAFLD). Because its symptoms often don’t manifest until the liver is seriously compromised, many people are not aware that they are at risk. Did you know that if you have fatty liver disease, you are more likely to develop cardiovascular disease (heart attack and stroke), and potentially several devastating conditions such as liver cirrhosis and liver cancer? Did you know that fat is as dangerous as alcohol to the liver?

Award-winning dietitian Kristin Kirkpatrick and hepatologist Dr. Ibrahim Hanouneh have teamed up for a life-changing program that will help you achieve optimal health. Skinny Liver‘s four-week program shares the steps you can take to get your liver health back on track, with everything from exercise to healthy eating and other lifestyle changes–along with delicious liver-friendly recipes.



A Healthy Liver Promotes a Healthy Life

Indifference and neglect often do much more damage than outright dislike.


If I asked you to pause for a moment to think about the organs that are vital to your survival, your heart, lungs, and brain would probably come to mind. That's as it should be, because without these organs, you simply wouldn't be alive. But there's a key player missing from that essential list: the liver, which is often overlooked in importance, even though it is among the hardest working organs in our body. Many of us don't have a clue where our liver is, let alone what it does. In a way, the liver is like the late comedian Rodney Dangerfield, who frequently complained, "I don't get no respect!" The liver generally doesn't get the respect or attention it deserves until something goes wrong.

Yet the liver is also like the great and powerful Oz, in that it makes magic happen from behind the curtain. If you were to picture what happens in your body as a Hollywood movie, your heart and brain would be among the lead actors but the liver would be the director. It's a silent player behind the scenes, but a powerful one that orchestrates a variety of critical body functions. Located on the right side of the upper abdomen, just below the diaphragm, the liver is one of the largest organs in the body (an adult liver weighs about 3 pounds). It performs more than three hundred tasks, including playing a role in such crucial metabolic processes as converting the nutrients in our diet into substances our body can use and store for energy and removing harmful substances from our blood.

While the liver is tough and resilient, the punishment of our modern lifestyle can wreak havoc on this precious organ—and we may not even realize it's happening! Symptoms of liver disease may be subtle to nonexistent until the condition has reached a severe stage, by which point it may be too late to reverse it. Because mild liver dysfunction is often discovered incidentally through elevated liver enzyme levels on a blood test, and because it doesn't cause alarming symptoms the way heart disease does, most of us don't give a second thought to our liver's well-being or give our liver the TLC it deserves. Many people think of liver disease as related to consuming too much alcohol—but that's only part of the story.

The reality is, a silent health crisis is under way, one that affects 30 percent of people in the United States. You may not have heard of it, but you could be among the potential victims. The crisis relates to a condition called nonalcoholic fatty liver disease (NAFLD), which involves an accumulation of fat deposits (particularly triglycerides) in the liver tissue. Largely related to our nationwide obesity epidemic, it's a disease that's alarmingly on the rise; its prevalence has more than doubled since 1988. Yet, because NAFLD doesn't produce symptoms in the early stages, it often goes undetected until it has progressed to nonalcoholic steatohepatitis (NASH), a more serious condition that results in inflammation and, potentially, irreparable liver damage.

In recent decades, we have developed a collective lifestyle that promotes the development of obesity; this has created what's often referred to as an obesogenic environment. This shift in diet and exercise habits, in particular, has given rise to the incidence of these devastating liver diseases. The exponential rise of NAFLD has paralleled the increase in obesity in the United States—and this is not a coincidence. Both surges stem primarily from an unhealthy lifestyle—too many calories consumed from food (and often the wrong foods) and too few calories expended through exercise. The result: Too much fat in our body, too much fat in our liver, and a serious threat to our health and longevity.

It's a dire picture, indeed, and many people are completely unaware of this looming danger.

Who We Are and What We Do

A brief pause so we can introduce ourselves:

Kristin Kirkpatrick: In my work as manager of wellness nutrition services for the Cleveland Clinic Wellness Institute, I oversee the nutrition programs, which are focused on helping people lose weight and treating and reversing various diseases. Many of the patients who come to see me are overweight and want to lose weight and/or lower their cholesterol or blood sugar levels; often they don't realize there's another hidden threat lurking inside their body. During our meetings, I usually have the lab reports from their blood work: Physicians often refer patients to me because they have elevated liver enzymes (in addition to their cholesterol or blood sugar abnormalities), so that I can put them on the path to weight loss and better health. These elevated liver enzymes suggest the development of NAFLD, which indicates that their lifestyle habits (such as a poor diet and/or sedentary ways), their body weight, or an underlying health condition (such as elevated blood sugar or high blood pressure) could be putting their health in serious jeopardy. Although I never have patients coming to me, saying they need to improve their liver health, that's where we often need to turn our focus.

Ibrahim Hanouneh, MD, a well-regarded expert on liver disorders, and I met at the Cleveland Clinic where he is an associate physician in the department of gastroenterology and hepatology. There, he sees many patients with a variety of liver diseases. Whereas a lot of patients come to me with the goals of eating healthfully and losing weight, some of them who have NAFLD also work in conjunction with a physician like Dr. Hanouneh who can address and serve their medical needs. I asked Dr. Hanouneh to be the medical expert for this book because he's so knowledgeable about these disorders, what's behind their alarming rise, and what needs to be done to reverse this trend. Having the advice and expertise of both a physician and a dietitian often leads to greater success in preventing and treating liver problems—sometimes two heads really are better than one! In the chapters that follow, you will read patient stories from both of our practices, so that you can gain broader insights into these liver disorders, including their causes and consequences—and see how other people have altered their diet and lifestyle habits so they can protect their liver. I've seen success in many of my patients—the road to change is not always easy, but it is always worth it!

While "detox" diets and other plans are very popular these days, this essential organ is at the root of these purification efforts. With so many people unaware of the threats to this organ, which detoxifies the body naturally, we knew that we had to write this book—to raise awareness of this emerging risk to bodies, minds, lives, and longevity and to give you the tools you need to safeguard your liver's health and help it function optimally. Given how important your liver is to your health, well-being, and survival, it's critical to pay attention to these mounting threats right now—before your liver launches a rebellion. You have the power, the wherewithal, and the opportunity to protect your liver, starting now.

How to Use This Book

In Part 1, you'll discover what a healthy liver does and how your lifestyle could be taking a toll on your liver health, as well as the scope of these newly recognized liver problems and the factors that contribute to NAFLD and NASH. You'll also learn about how to take smart precautions to protect yourself from other liver disorders, such as hepatitis, drug-induced liver damage, and alcohol-related liver disease. Part 2 broadly addresses the prescriptive principles for maintaining good liver health (including improving your dietary and exercise habits, managing your weight more effectively, getting enough sleep and getting a grip on stress, and avoiding toxic exposures) and preventing or reversing liver problems through lifestyle modifications. And in Part 3, you'll find an action plan that will allow you to put these healthy liver principles into action with a lifestyle makeover. Think of this as a fresh chance to give your liver and your body a second shot at better health.

Consider this: If a trustworthy agent offered you a free, comprehensive, gimmick- and loophole-free insurance policy that would likely protect your health today, tomorrow, and for the foreseeable future, would you take it? If a friend gave you a no-strings-attached present of a nonstop airplane ticket to a happy, healthy place you've always wanted to visit, would you accept it? It would be foolish not to say "Yes!" to both propositions, right? With this book, we want to give you the gift of good health—a full understanding of the reasons your liver is so important, vital information you (and many other people) aren't aware of, and concrete steps to help you be the healthiest you can be. Along the way, you'll likely lose weight (if you have extra pounds to shed), have more energy, and make major strides in preventing other life-threatening diseases, such as type 2 diabetes, heart disease, and more. It's an opportunity that's yours for the taking!

part one

Say Hello to Your Liver

chapter 1

Your Body's Hard-Working, Multitasking Organ

NOT LONG AGO, Marie, a 45-year-old mother of two, went to her primary care physician for an annual checkup. She reported being in good health and didn't take any medications on a regular basis, but a blood test revealed that her liver enzymes and triglyceride level were elevated and her HDL (the "good") cholesterol level was low. When her health history was examined further, it became clear that Marie had gained 15 pounds in the previous six months and her body mass index (BMI) was now in the obese category (above 30). This wasn't entirely surprising because Marie had been laid off from her consulting job, was feeling slightly depressed, and she had fallen into a habit of eating poorly and being sedentary over the previous months.

After an ultrasound revealed the presence of fatty deposits on her liver, Marie was shocked to learn that she had a liver disease. Her first question was: "Is a fatty liver bad?" (Yes, it is.) Her second question: "Is it reversible?" (Yes, it is.) That was all Marie needed to hear to feel motivated to start a diet and exercise program, which would reduce fat on her liver and improve her liver enzyme levels.

It's ironic: Some people go to great lengths to "detoxify" their body with cleanses, juice fasts, supercharged smoothies, raw food diets, special teas, and other unproven interventions. They swallow various herbs and supplements in an effort to purify their body from the inside out. They try to sweat out toxins in saunas, steam rooms, sweat lodges, and the like. When they do this, they feel that they're being proactive about removing impurities from their body. Well, here's a newsflash: These measures are of dubious benefit because the liver detoxifies the body naturally and automatically, just as a self-cleaning oven does. The key is to keep it in good working order.

The Detox Organ

Despite people's pervasive interest in ridding the body of toxins, many of us generally don't do much for our liver in terms of everyday care. That's a serious mistake, given everything that our liver does for us. On a daily basis, the two lobes of the shiny, smooth, saddle-shaped organ—which are separated by a band of connective tissue that anchors the liver to the abdominal cavity—perform an astonishing array of functions as part of its 24/7 job description. For starters, the liver serves as a highly complex chemical plant, inspection station, garbage disposal, and filtration system, all rolled into one. The liver filters out 1.4 liters of blood per minute. It converts ammonia, a toxic waste product that's formed from processing dietary protein and nitrogen-containing compounds in the body, into urea so it can be excreted by the kidneys. The liver metabolizes drugs and alcohol and gets rid of the by-products that result from the breakdown of these substances. It removes bad bacteria and debris from the bloodstream, and it breaks down worn out or damaged blood cells.

Human digestive system in situ and as detailed view. © Christos Georghiou/Shutterstock

Frontal view of the human liver.

Essentially, your liver—along with your lungs, your gastrointestinal tract, and your kidneys—is detoxifying your body every minute of every day, whether you're awake or you're asleep. No one is immune to the presence of internal (a.k.a. endogenous) toxins, such as metabolic waste products that are generated inside your body, or external (a.k.a. exogenous) toxins, such as pollutants, contaminants, pesticides, food additives, drugs, and alcohol. But having a strong, healthy liver, one that is well cared for and functions the way it should, makes the inherent detoxification process run smoothly and efficiently. If the health of the liver heads south, however, its ability to detoxify your body heads south, too, and no cleanse or juice fast or detox diet can make up for what you've lost with that failing organ.

Your Liver's Role in Metabolism

Moreover, the liver is involved in all of the body's central metabolic processes, including the metabolism of carbohydrates, protein, and fats and the conversion of these macronutrients into forms of energy the body can readily use. When it comes to metabolizing carbohydrates, the liver helps ensure that the level of sugar (or glucose) in your blood stays fairly steady: If your blood sugar level increases (after a meal, for example), the liver removes sugar from the blood and stores it as glycogen (the main source of stored fuel in your body); if your blood sugar level dips too low, the liver breaks down glycogen and releases sugar (glucose) into your blood. As far as dietary protein goes, your liver cells convert amino acids in foods into forms of energy that can be used by the body. And the liver produces bile, a yellowish-greenish-brownish substance that travels to the small intestine where it plays a role in the breakdown and absorption of fats.

Meanwhile, the liver stores fat-soluble vitamins (A, D, E, and K) and vitamin B12, as well as minerals (such as zinc, iron, magnesium, and copper), and releases them into the blood on an as-needed basis. In addition, blood-clotting factors are formed in the liver—these are crucial for preventing excessive bleeding—and the liver helps with the metabolism of sex hormones, including testosterone, estrogen, and progesterone, so that you don't end up with abnormal levels of these hormones. As you can see, the liver is an incredibly hardworking, multitasking organ that never sleeps; it's always on duty.

An Indispensable Team Player

When it comes to organ function, there's often a synergy that's a bit like a well-choreographed dance: if one organ isn't working properly, it can throw the others out of step, too, causing the whole enterprise to function inefficiently. This is true of the liver. For example, the liver works with the kidneys to regulate blood pressure, and it also operates in conjunction with the pancreas and gallbladder to properly digest food; if the liver becomes the weak link in this chain, the whole digestive process suffers. That's just one example of the potential domino effect that liver dysfunction can have.

A few months ago, Robert, a 63-year-old financial planner, had been feeling tired and slightly nauseous, but he chalked it up to stress from work. One night he vomited blood, so he went to the emergency room and was admitted to the intensive care unit. An upper endoscopy revealed that he had actively bleeding varicose veins in his esophagus, a condition that usually occurs in people with liver cirrhosis. Aside from high blood pressure that was well controlled with medication, Robert, a regular exerciser, was lean and quite healthy; a light drinker, he had no prior history of liver disease or a family history of chronic liver disorders.


The detoxification process that occurs in the liver is far more complex than most people realize, yet it is essential to keeping your entire body functioning smoothly, efficiently, and effectively. At the most basic level, it helps to think of your liver as serving a similar purpose to a high-quality filter in your furnace: By trapping dirt, dust, and toxic particles, the filter allows clean air to be continuously circulated throughout your home, so you can maintain a healthy interior environment. In the case of the liver, here's how this process works:

  • In Phase 1, often called the conversion phase, toxins that enter the body are converted into substances that can be excreted through bile (a digestive fluid that's produced by your liver) or urine (which is secreted by your kidneys). Most toxins enter the body as fat-soluble substances, and the liver's job is to transform these substances into water-soluble ones that can be excreted. The problem is, this transformation process can turn these toxins into more unstable compounds that, in turn, form damaging free radicals. Research suggests that proper nutrition—including consuming plenty of antioxidants, B vitamins, vitamins C and E, and carotenoids—is crucial for helping the essential toxin-conversion process in this phase operate effectively and quickly progress to the excretion stage.

  • In Phase 2, known as the conjugation phase, toxins are neutralized and prepared for excretion through either urine (courtesy of the kidneys) or bile (thanks to the liver). Phase 2 metabolizes the free radicals that were formed in Phase 1 and prepares them to exit the body. Both phases rely heavily on key enzymes to complete each part of the breakdown process. Research suggests that certain amino acids and phytochemicals (especially plant-based compounds in cruciferous vegetables, such as broccoli, cauliflower, and cabbage) can actually assist with the Phase 2 enzyme activity that converts potentially damaging substances into harmless ones.

  • In Phase 3, the elimination stage, the now water-soluble waste products are transported out of the cells and into bile or urine for excretion. This is the clearance phase of the operation, when the body actually says good-bye to those toxins. Mission accomplished!

Yet, an ultrasound of the liver revealed that he had cirrhosis of the liver—which came as a complete shock to Robert—and further tests revealed the culprit: a chronic hepatitis C infection, which was also surprising because he hadn't had a blood transfusion, hadn't engaged in intravenous drug use, and didn't have tattoos; plus, he was married with a monogamous relationship and his wife didn't have hepatitis C. How he was infected with hepatitis C remains a mystery, but Robert apparently had the infection for many years (and had never been screened for it because he didn't have symptoms or clear risk factors), which led to cumulative damage to his liver. Like many healthy people, Robert hadn't given much thought to his liver over the years and he didn't know that baby boomers, born between 1945 and 1965, are now known to be at higher risk of having contracted hepatitis C and should therefore be screened for the viral infection.

As is the case for many people, Robert's first clue that he was suffering from a liver disorder manifested itself in another organ system—the digestive tract. That's because the health of your liver can have a ripple effect on the well-being and functionality of other major organs in your body. Here's a head-to-toe look at how the state of your liver can support or undermine the functionality of other major organs:

Your brain When it comes to normal brain function, the liver may in fact be the most important organ due to its ability to remove toxins from the blood. When this doesn't happen, the brain can suffer the consequences. For example, when the liver is damaged and can't remove or neutralize toxins (such as ammonia) from the blood, the toxins can build up in the bloodstream and travel to the brain where they damage the nervous system. This can lead to hepatic encephalopathy, a loss of brain function; the symptoms can be as simple as mild confusion, mental fogginess, or changes in thinking abilities, or as severe as mental unresponsiveness, slurred speech and movement, loss of consciousness, and possibly even coma.

Your eyes Few people think of the liver when an eye problem occurs, but in some cases, that may be the first place you should look. Several eye conditions can result from the liver's inability to do its job. A condition called scleral icterus, which involves a yellowing of the white part of the eye, can develop if the liver becomes unable to process bilirubin (an orange-yellow pigment that is formed in the liver by the breakdown of hemoglobin and is excreted in bile). Yellowing of the eyes can also be a sign of jaundice, which occurs due to a buildup of bilirubin—and is sometimes one of the first major signs that things are not going well for your liver. Moreover, the liver helps with the metabolism and storage of vitamin A, which is critical for good vision and eye health.

Your thyroid gland This tiny, butterfly-shaped gland in the front of your neck is like command central for the metabolism, growth, and development of the human body, as well as the regulation of critical body functions. Research has found that people who have cirrhosis of the liver have a greater incidence of an enlarged thyroid and that people with hepatitis are more likely to have abnormal results on thyroid function tests. Other thyroid disorders can go hand in hand with chronic liver diseases, as well; for example, hypothyroidism (low thyroid function) is common in people who have autoimmune liver disease (which is why those who have autoimmune liver disease should get their thyroid function checked periodically).


A fancy name for a simple concept, metabolic syndrome is a constellation of risk factors that increase a person's risk of developing heart disease, stroke, and type 2 diabetes. These risk factors include high blood pressure, elevated fasting blood sugar, a low HDL (the "good") cholesterol level, a high triglyceride level, and excessive belly fat (or a large waist circumference). Given the connection to heart disease and stroke, metabolic syndrome is worrisome enough but complicating matters, it also can cause NAFLD—and vice versa. In fact, some medical experts are now calling NAFLD the new face of metabolic syndrome. The two are that closely intertwined!

Your heart Because the liver plays a major role in the storage and metabolism of cholesterol and triglycerides (blood fats), it helps keep the veins and arteries that flow into and out of the heart healthy. If it weren't for the liver's ability to break down medications, alcohol, and caffeine, your heart rhythm could become irregular. In addition, research has found that people with nonalcoholic fatty liver disease (NAFLD) are more likely to have heart disease, too, probably due to the fact that a dysfunctional liver increases the risk of metabolic syndrome (see box above).

Your blood Your blood relies on the liver to store fat-soluble vitamin K, which is needed for proper blood clotting; plus, the liver makes key proteins that are necessary for normal blood clotting.

Your kidneys When it comes to removing toxins from the body and preparing them for excretion, the kidney and the liver really do need each other, so it's not surprising that when the liver becomes diseased, the kidney suffers as well. People who have hepatitis C, for example, have an increased risk of developing a chronic kidney condition called glomerulopathy, which affects the parts of the kidneys where waste products are filtered from the blood, thus compromising the kidneys' overall ability to function. Meanwhile, those with chronic liver disease are more likely to have decreased blood flow to and through the kidneys.

Your bones The liver also helps your body absorb important vitamins and minerals—including calcium, phosphorus, and vitamin D—to keep your bones healthy, strong, and happy.

As you can see from this hefty list of responsibilities, the liver plays a vital and indispensable role in your body's ability to function. Unfortunately, through their lifestyle habits, many people place enormous amounts of pressure on their liver without considering the possibility that this vital organ could get fed up and shut down.

Silent Symptoms, Potentially Devastating Outcomes

More often than not, we are blissfully unaware of the harm we may be doing to our liver until the damage becomes extreme and impossible to ignore. Many different hazards of modern living can take a toll on the health and functioning of your liver. When this indispensable organ can no longer remove waste products, bacteria, or toxins from your blood the way it should, or when its ability to metabolize macronutrients and convert them into usable forms of fuel for your body are compromised, your health, energy, and well-being will suffer. It's that simple. And if fatty deposits, inflammation, and scar tissue build up on this vital organ, you can begin to experience severe symptoms, such as persistent fatigue, muscle weakness, nausea, vomiting, abdominal pain, memory loss, mental confusion, and other worrisome signs. That's when your liver is sending out serious distress signals.


  • "Skinny Liver sounds a powerful wakeup call that clearly connects dietary and other lifestyle choices to potentially life-threatening liver disease. More importantly, Kirkpatrick deftly empowers the reader with a scientifically validated, comprehensive, user-friendly plan to prevent and even reverse what has become a major health epidemic."—David Perlmutter, MD, author of the #1 New York Times bestseller, Grain Brain, and The Grain Brain Whole Life Plan
  • "Fatty liver disease is a silent epidemic that is affecting 30 percent of all Americans. Grounded in cutting-edge research, Kristin Kirkpatrick's accessible, practical program will help you prevent liver disease and safeguard your overall health."—Mark Hyman, MD, Director, Cleveland Clinic Center for Functional Medicine, author of the #1 New York Times bestseller Eat Fat, Get Thin
  • "In today's toxic world, we are bombarded with chemicals in our environment, food supply, water, and personal care products, and our liver takes the brunt of the stress. If your liver becomes overwhelmed, it can lead to fatigue, weight gain, liver disease, autoimmune disease, and even cancer. In Skinny Liver, Kristin Kirkpatrick teaches you the secrets on the ideal diet, supplements, and lifestyle to cleanse your liver and take your health to the next level."—Dr. Josh Axe, author of Eat Dirt, founder of
  • "The authors do a thorough job, presenting not only liver-friendly diet choices but also helpful tips including 'smart kitchen makeover strategies' and 'liver health superstars' such as phytonutrients and probiotics."—Energy Times
  • "An informative resource for anyone suffering from fatty liver disease or just looking to avoid it."—Edible East Bay

On Sale
Jan 24, 2017
Page Count
304 pages

Kristin Kirkpatrick, MS, RD, LD

About the Author

Kristin Kirkpatrick, MS, RD, LD, is the manager of Wellness Nutrition Services at the Cleveland Clinic Wellness Institute in Cleveland, Ohio, where she oversees nutrition-related services at the Center for Lifestyle Medicine. She is an award-winning dietitian and a regular guest on local and national television shows, including The Dr. Oz Show, NBC Nightly News, and the Today Show, as well as NPR Radio.

Ibrahim Hanouneh, MD, completed his residency in internal medicine and a fellowship in gastroenterology and hepatology at the Cleveland Clinic. After completing his training, Dr. Hanouneh joined the Gastroenterology and Hepatology staffs at the Digestive Disease Institute at the Cleveland Clinic and has served as an assistant professor at the Lerner College of Medicine, Case Western Reserve University in Cleveland, Ohio. Dr. Hanouneh currently provides care at Minnesota Gastroenterology, a Twin Cities-based gastroenterology practice.

Learn more about this author