Kristin Kirkpatrick is the President of KAK, Consulting, LLC, and a dietitian and consultant of Wellness Nutrition Services at the Cleveland Clinic Wellness Institute in Cleveland, Ohio. She is also a best-selling author and frequent presenter; she’s appeared on both local and national shows such as the TODAY show, NBC Nightly News, and the Dr. Oz show, and in national newspapers and magazines, including The New York Times, Wall Street Journal, TIME, Runners World, Oprah, Martha Stewart Living, Food Network, Self, and Women’s Health. In January 2017, Kristin published her first book, Skinny Liver: A Proven Program to Prevent and Reverse the New Silent Epidemic—Fatty Liver Disease. In December, 2017, Kristin’s show “The New Rules of Food” aired nationally on PBS.
Kristin’s career began in Washington, DC, where she assisted in lobbying efforts for Medical Nutrition Therapy reform on behalf of the American Dietetic Association Policy and Advocacy group. She then became the Regional Coordinator of the Montgomery County, Maryland, Hearts N Parks program, where she designed, implemented and measured health promotion programs within the DC metro area. Kristin returned to Ohio to work for the Cleveland Clinic's Department of Cardiovascular Genetics, eventually becoming the lead Dietitian in the Cleveland Clinic Wellness Institute.
Kristin has over 18 years of experience in the health management area, holds an MS in Health Promotion Management from American University and a BA in Political Science from The George Washington University, both in Washington, DC. In her free time, Kristin enjoys running, hiking, skiing, reading, and spending time with her husband Andy, her two sons, and their dogs at their home outside of Denver, Colorado.
Barb: Today my guest is Kristin Kirkpatrick. Kristin is a dietitian and consultant of Wellness Nutrition Services at the Cleveland Clinic Wellness Institute. She’s been a guest on many shows including the TODAY show and NBC Nightly News. She’s also the author of Skinny Liver, a book about preventing fatty liver disease, and the creator of “The New Rules of Food,” a show on PBS that received rave reviews.
Thank you Kristin for joining me today. I’m grateful for your time and willingness to talk about this topic which I’m sure is of interest to many individuals—especially the women that I see in practice—but I know many beyond that.
Kristin: Absolutely, Barbara. It’s an honor and privilege to be with you today.
Barb: Well, let’s start and hear about when and how you became interested in nutrition.
Kristin: Yeah, this was an interest that started, oh my gosh, several decades ago. I was an overweight child, and I had gone to my physician with my mom, and they did some bloodwork and found out that my blood sugar was too high. He was worried about pre-diabetes, diabetes. And he said, “You know, I think it’s time that we start talking about weight loss.” and he sent me to a dietitian. So, I went to go see that dietitian and I had kind of shut down immediately when I walked in the door because she was perfect looking—in my eyes—and she never had an issue with struggling with food. So she asked me a series of questions and goals she wanted me to change, but she never really tapped into my inability to change those goals. I would have loved to change the fact that I was overeating, and eating the wrong things. But it’s not as easy as flipping a switch. So that was really my early motivating factor; to think, “I want to get into this business. I want to succeed with losing weight and coming to peace with what healthy eating looks like.” But I also want to do it because I’ve been there and understand a patient who will now walk into my door and say, “I’m really struggling.”
In some ways I feel I’m a better dietitian because I’ve been there, and I’ve walked the walk, and I understand the issues—the behavioral issues more than anything else—in our head that stop us from making the right choices.
Barb: Yeah, I think your comments there about the behavioral issues so—does it always take a dietitian to help individuals be successful in this, or is much of your work really around the behavioral aspect of if?
Kristin: I think, you know, for my patients that I see at Cleveland Clinic, obviously integrated medicine. Obviously we’ve got this wonderful interdisciplinary team, so I have access to our behavioral health counselors, and I oftentimes, depending on the situation, I’ll tell my patients, “I really think you should work with some of our therapists while you work with me. Because my role is to change the diet to kind of give you an environment where you are more successful. But really, I can’t change your head. That’s not my expertise. My expertise is the food part of it.” And the head part of it is probably, perhaps, even more important on so many levels.
Barb: So I’m just curious about your personal journey. During your teen years were you able to be successful in achieving the goals you had, or was it only after you had more understanding and training yourself that you were successful in maybe normalizing your hemoglobin, A1C and blood sugar, etc.?
Kristin: You know, the weight, I would say went up and down. So I would lose weight, I would put some back on. I would lose weight… I remember when I went to college—for me it was the “freshman twenty.” And again it was not being able to deal with stress appropriately. So I think for me, I mean people often ask, “How long did it take you to be able to lose the weight?” and oftentimes I would say, “Well, it took me about 10 to 15 years, and for the maintenance part, I’ll let you know when I figure that out.” Because that’s really, that’s the true challenge with weight loss.
The weight can come off easier if you just kind of focus on a few things. But it’s keeping it off, and not dealing with the things that made you gain weight in the first place that are the challenges. So, I would say for me, it probably took me a good 10 to 15 years to get to what I would feel is the comfortable size—size isn’t even the best word for it—but a comfortable place for me where my metabolic profile is good; I like the way I look in clothing. Will I ever be a size two? Never! And that’s okay. That’s kind of hard to communicate sometimes to patients. “You will never be a size two, and that’s okay.” [laughs]
Barb: [laughs] Right. And I think it’s important for others to hear that the journey, you know, it’s not three months and something dramatic. It’s really kind of slow and steady that leads to success generally.
In your experience, how do you think people see food, and is that something you have seen change much over your career?
Kristin: I’ve definitely seen a change. I’ve seen it from a standpoint of just kind of looking at evidence-based approaches of what was recommended. Even decades ago versus what is recommended to us today. Today, for example, we know that sugar is a huge culprit in negatively impacting things like cholesterol, and we used to think it was just fat. So I think from that perspective, that’s encouraging.
I think from a consumer perspective, I think consumers—at least that come to see me—they want to know, really they want to trace back where their food comes from. So I think there’s a greater need for individuals to know, if I’m going to have a piece of chicken, I want to know where this chicken came from. And I might even want to know the life of this chicken. You know, did this chicken live in a tight cage, or did it have a better life and live like a chicken should? So that I can tell you is very important to my patients, especially my patients over 40. And so there’s that perspective. But I also think there was a huge shift that changed from when I was in my weight loss journey—this fallacy that counting calories works. It doesn’t. We have plenty of studies now that show that it doesn’t.
So I think that was a big change in how people viewed food, and started viewing food more in a macronutrient breakdown. “I’m going to look more at carbs.” That’s one of the largest things that I’ve seen is that most of my patients are not on a calorie-restricted diet anymore for a lot of reasons.
Barb: So our adage that counting calories out, are we misguided in suggesting that?
Kristin: Well I think the misguidedness in that is that when we focus solely on calories, we start to focus on quantity, and we stop focussing on quality. Not to say that we can eat as many calories as we want and no problem, but I think the quality of our calories is much more important. And there were many popular programs throughout the 80s, throughout the 90s—early 90s and mid-90s—that focussed on the approach of the 1200-calorie diet, and as long as you had 1200 calories, you could eat whatever you wanted. That can be a diet that’s filled with what I would call aging ingredients—things that are filled with very refined grains or sugar or whatever the case may be—and I think ultimately, it doesn’t help the person who is trying to achieve success because a lot of what I see in my patients is trying to get off a sugar addiction. Or is trying to come to peace with not binging on brownies if they have a bad day.
I think that the fallacy is more so that we stopped eating quality foods and now the shift is more into quality. I also think I’m a really huge proponent of fasting. And so I also think sometimes fasting and calorie counting get confused to be the same thing. And they are not. So again, there’s a lot of things that are out now that are trending or important to many individuals, but for me it all boils down to the data.
Barb: Well that leads me to my next question. I had a note here about asking you about intuitive eating and intermittent fasting. Those are some of the terms I’m hearing. Can you speak into those or talk about those in your understanding or recommendations around that?
Kristin: Yeah. I think the intuitive eating aspect—and this is really where we get into more of the behavioral part of this—is really important. I’ve seen many of my patients really tap into more intuitive eating which is more into mindfulness. It’s more into kind of sitting down, having more chews, not having the distractions. So really kind of focusing on food—not as a byproduct of something you got to do to have energy throughout the day—but something that is really part of your being and your soul. So looking at food in a different perspective. It’s hard to eat an entire bag of potato chips and actually think that that’s good for your soul as well as your body.
Intuitive eating really does tap into that: the mindfulness approach of how we actually consume foods. And there’s so many different directions you could go to with that. For example, I often have been telling my patients, especially lately in the environment that we’re living in, “You know, don’t eat your dinner in front of the TV. The TV’s got a lot of negativity right now, and you can get your news, of course, but don’t do it while you’re eating.” Right? The distraction of and what could happen of overeating and in excess are much more likely if you are doing something like that. So that’s kind of number one.
In terms of intermittent fasting, there is so much data on intermittent fasting. Really, if you look at it in a more simple, high-level approach, there’s two things I think about; number one, we as humans are not meant to eat around the clock. We have evolved to do that because the environment is now such that we can do that. I also will tell my patients, “If you’re craving a cheeseburger and fries at two in the morning, in most places of the United States you could probably get it.” You have to get in your car, but you can probably get it!
Barb: Yeah, sadly.
Kristin: Sadly, right?! So I think that that’s one function of it. The inability to understand that we’re not meant to eat around the clock. But then when we look at the evidence, putting our body in a fast has really been shown to help on many fronts: improving metabolic profile, improving weight. There was just a study that came out two days ago in the journal Cell Metabolism, that looked at this concept of time-restricted eating where you don’t necessarily change the foods you eat—I mean if your diet is bad, changing it would be beneficial—but really the benefits were shown simply by changing the frequency in which you eat, so, looking at maybe an eight-hour window. This particular study compared to a four- and six-hour window, a lot more drastic. But very impressive results.
Barb: So to translate, you’re talking about consuming your meals—in the recent research—just the four to six hour time frame within a 24-hour day versus maybe otherwise, eight hours has been more adhered to?
Kristin: The latest study showed… it was really trying to compare a four- and six-hour time frame and determine, would there differences in changes in weight and metabolic profile. And so what they found in the study was that there was no difference between the four hour and the six hour. I still think that’s a little, definitely, too drastic to start with that. For my individuals who have been doing time-restricted eating on either an eight or a ten-hour time frame that I’ve shared this study with, some of them have said, “Oh, I’d love to try the six-hour approach maybe Mondays and Wednesdays. Or just try it out.” I think it’s too drastic for the average individual to start with that. But I do think an eight to ten-hour approach given everything else—we’re not talking about a Type 1 diabetic or a pregnant woman, or someone with diminished renal function. I think that it is doable—definitely maybe not easy in the beginning; nothing is when you change your diet—but doable. And easy.
Quite often my clients ask, “What’s the best diet out there?” My answer is always, “The best diet out there is the one you can sustain long term. That’s the best diet. It’s a different answer for everybody.”
Barb: Sure. And for those who are looking at intermittent fasting, the recommendation is to do it on a daily basis. To not just select a Monday-Wednesday-Friday, or a weekend, or do it Monday through Friday and weekends are more fair game, so to speak. Or are we back to whatever works best for you. If you need weekends to be somewhat less restricted, then you can give yourself those days. How do you advise people who suggest sort of a blend, so to speak?
Kristin: It depends on the person. There are two different forms of intermittent fasting. There’s the type that we’ve discussed briefly called time-restricted eating, and the other form is called a 5:2 Approach where you take two days out of the week, and if you’re a woman you only have 500 calories on those two days, and then you eat “normally” on the other days of the week. So it’s just two days on, five days off.
Most of my patients, and the majority of my patients are peri- and post-menopausal women, their desire is to do the time-restricted eating approach which is changing the frequency of hours, and they do that daily. So that doesn’t change. I have had some of my patients, especially high-level... who use the 5:2 approach because they have to be involved with dinner meetings and things like that. So that’s why I said it really depends on your set up and which environment you are most likely to stick with the program. I know a lot of the patients that I have are also friends, and they are also fellow moms, and they want to eat dinner with their kids. They don’t want to send a message, “Okay, mom’s not eating dinner with you tonight because you’re eating too late. So they structure the diet a little differently. They start eating later in the day so that they can stop eating later in the day. I think the key here is what is going to work for you and what works long term, and I think there’s benefits with either program.
Barb: That makes sense. Yes. So you just alluded to your patient population includes a number of perimenopausal/postmenopausal women which is my practice as well. Can you speak into a little bit about why this time adds additional challenges for women nutritionally, and how do you explain it to women as to what might be going on that things are changing for them and how they might think about approaching it?
Kristin: I think, you know, one thing that I see very common in many of the women I’m seeing for the first time—they’ll come in and say, “I haven't changed anything in my diet and I feel like in five years I’ve put on 25 pounds. And I exercise. And I do everything right. There’s been no changes.” That is a phrase I hear all the time, and my response is, “Well if you change nothing, you are going to put on weight.”
Barb: Yeah. I echo you exactly. That is exactly the comments I hear as well.
Kristin: Yeah. And it’s unfortunate, right? I mean it’s so unfortunate, but it’s the truth. Obviously, Barbara, as a physician seeing this population, you know much more about this than me, but when we look at things like hormonal changes, that can really negatively impact our ability to maintain the weight that we’ve maintained. And it’s kind of a low creep, right? It’s almost as if you work as hard as you can, and when you are in your 20s it’s easy; in your 30s, ahh, it’s still pretty easy. When you start getting into your 40s/50s/60s, every decade it becomes a little bit more difficult. Part of that is, of course, a loss of muscle mass. So if we are a runner, and we’ve never focussed on resistance training, then you might not have the muscle to maintain a specific weight. That’s an issue.
One of the things that I see has worked really well for this population, and again, taps into hormonal changes, things like insulin, is really looking at a lower carb approach. Many of my peri- and postmenopausal patients have adopted looking more at digestible carbs and trying to keep their digestible carbs at a much lower number than they had the previous decade. And that has seemed to be a little helpful again from a behavioral standpoint and also with the understanding that just like I will probably…I don’t think I’ll ever fit into my prom dress again. And that’s okay.
Kristin: I was seventeen when that happened. A lot has changed so I just think not to say that we should be comfortable if we are overweight or obese, but we have to be comfortable that our bodies will change even under the best circumstances.
Barb: Right. And I tell women even without weight gain, there is some physiologic redistribution of weight.
Kristin: Right. A lot of my patients will complain mainly of belly fat. “I’ve never had a belly before. Now I have this little belly.” So even if they are thin, they come and they say, “Well, I still feel like I’m still kind of thin, but now I’m like skinny fat. I don’t want to be skinny fat!” [laughs] Right?
Barb: Yeah, right. So can you go back and be a little more clear about digestible carbs? You said those were the ones you were encouraging women to lessen in their day-to-day diets. Can you explain a little bit more what that is?
Kristin: Yeah, absolutely. I focus, as a practitioner, on digestible carb versus just saying, “limiting your carbs” because I want my patients to still be able to say that they are eating real food. Just to back up very quickly, Barbara, I always start high-level, and I use the definition that Michael Pollan defines foods as in his book, over two decades ago. And so he said that food is something that comes from nature, is fed from nature, and will eventually rot. So everything outside of that is food-like substances. I always start with we’re going to eat food, and food—whole food plants are often attached to fiber. If we go back to this concept of digestible carbs, digestible carbs is taking the total carbohydrate in a food and subtracting the fiber. What is left is how many carbohydrates you are actually digesting. So that is much more important to me because fiber, number one, is non-digestible, the body doesn’t know how to digest it and we can subtract it. And it’s got other benefits, obviously, outside of weight loss. But it allows my patients to look more at say a big bowl of broccoli which has tons of fiber versus some sort of energy bar that has maybe 15 ingredients and fiber added in.
There’s a lot of ways you can look at digestible carbs, or net carbs, or active carbs—there’s all these different terms that describe it—but for me the ultimate goal in looking at that concept is really to encourage my patients that, “I still want you eating whole foods, but your motivation to eat whole foods with a lot of fiber will go up.” I’ll give you a great example of this. If one of my patients is consuming 50 digestible carbs, and they want to have some pasta one night, Well white pasta, forget about it. A cup of it and you’re done, right? Now let’s move on to whole-grain pasta, 100-percent whole wheat pasta. Better option, but you still have a lot of carbs. Well now let’s move even further to a bean-based pasta, let’s say black beans and water. Now you’re talking. Because now your carbs are something that, per serving, are about 17, and your fiber is about 12. At the end of the day, in my view and the way I practice, you’re eating a lower-carb meal, even though you are eating pasta. That pasta is made with beans, which is loaded with fiber, and you are going to get the benefit of protein, so it’s a better option. For my patients, I’m often looking at examples like that and saying, let’s just not look at, “Okay, I’m going low carbs, but I’m going upgraded carbs. How can I upgrade my carbs?”—and upgrading really means getting as much fiber attached to that plant as possible.
Barb: Do you think the food industry, our sources of food, are starting to respond to the demands of improved quality?
Kristin: Oh, I don’t know about that. Because if you look at kind of the trending concepts of low carb and Keto, I think a lot of companies are noticing that people want less carbs, but they will artificially add fiber in, in order to achieve that. I don’t think we have enough data to say whether or not that’s just as beneficial as food.
Kristin: So it’s a tough one.
Barb: So back to farmers markets for your grocery store.
Kristin: As much as possible. And we’re not going to be perfect, and I tell my patients, “Every Sunday morning I get up and I put my boys in the car, and we go get donuts. I have my donut, and I absolutely love it!” But the key is I don’t have the entire box of donuts. Right? So I think allowing ourselves to have some of these, if you will, indulgences can also assist the process because if I every Sunday saw my boys eating donuts, and I smelled them, and I wanted one, and it took me back to my childhood, it’s not a good relationship with food. I might eventually stop and get a whole dozen one day, right? I don’t because I allow it once a week.
Barb: Right. Yeah. Just to change gear here just a little bit, one of the common symptoms of menopause oftentimes is mood disruption and just more exaggerated moods, maybe more anxiety or depression. Not long ago, NPR had a program suggesting that it’s possible to improve moods through diet. I’m just wondering what you have to say about that.
Kristin: This is really interesting. This is like a topic that is near and dear to my heart. So I’m actually a senior fellow for a behavioral health care organization called The Meadows. All of their senior fellows are psychiatrists.... So they are dealing with people that have depression and anxiety and addiction. They went completely outside of the box and hired me as a senior fellow, a dietician. The whole role of me being there was to change the food that we were giving to our patients so it’s more in line with the data on food and mood. More in line with what food do we know contributes to depression and which foods do we know actually reduce depression scores in clinical trials.
This is something I speak about a lot, and it boils down to a few things. It boils down to the diversity of your gut microbiota. When we have low diversity, we are prone to depression and anxiety and mood changes. That’s number one. And also specific nutrients. So we know, for example, that again, if you look at the clinical data—things like vitamin D, folates, Omega-3 fatty acids—all of that has some beneficial approach to reducing depression scores, reducing anxiety. It’s a huge component of diet that we are now just starting to talk about. But because mental health is such an important factor, I think we can’t focus on improving our mental health outcomes if we are unwilling to improve the diet alongside it.
Barb: Wow, that’s really powerful. I’m excited to learn more about that and hopefully there will be an emerging science that can help us better understand that. You know, I find it’s so hard to motivate women to make changes in their diet, but the ones who do and feel so much better, are so motivated to stay with that plan. And I just wish more women would step into that experiment.
Kristin: Well, I think you hit the nail on the head. I think for many the experiment is one that is uncomfortable at first. As humans, we’re not positioned to embrace uncomfortableness,right, for long term. So even when I was talking about the fasting and I said it will probably be hard in the beginning. I remember when I started doing time-restricted eating, so I do 11 to 7 every day, and I remember just my first week—and I did it with my husband because, you know, when you get a buddy, the chances of sticking with it increase. I just remember that first week to ten days. I mean it would be 10 o’clock and we would be just like, “When can we eat? Oh my gosh, we are so hungry.” And now I get to the point where I run errands or I’ll be working and it could be like 12:30, and I’d be like, “Oh my gosh, I totally missed my window.” And then I end up eating six hours because I missed. Your body adapts and evolves, but depending on when you started, it is so hard to make those changes, because the first few weeks to months can be very uncomfortable.
Barb: Sure. Well I think, you know, most change is hard to do, but again, the rewards in this just seem to be so worth the investment. It’s a little mind-boggling to me that so many individuals just aren’t willing to try that journey. But we’ll keep talking about it. We’ll keep hopefully having science to support good reasons to begin the journey at least.
Kristin: Well I think the other point, Barbara, a patient said this to me once. In the, I don’t know, the hundreds and thousands of patients I’ve seen, I remember this statement more than any other, and that was that I worked very hard with this one woman. And she said to me after probably an 18-month period, “I never had any idea of how bad I felt until I felt good.” I also feel that was really eye-opening because it was like, how many people are walking around feeling awful, and that’s the norm?
Kristin: Right? They don’t realize that they are feeling awful until they actually feel good and say, “How did I do that for so long?” I mean I have yet to meet one patient that has lost weight, improved diet—or a combination of the two—and said, “You know, I really regret that journey.” It’s like, “Why didn’t I do the journey earlier? I can’t believe I waited this long in my life to actually achieve this.”
Barb: Yeah, yeah. Well I hope that’s a message that comes across loud and clear. Just to touch on another topic, I referenced your book Skinny Liver, and I think most people probably aren’t aware of the condition of nonalcoholic fatty liver disease. And would you explain that a little bit as we wrap up our time together?
Kristin: Yeah, absolutely. So nonalcoholic fatty liver disease is a condition we are seeing increasing in huge amounts, and it really is directly related to not alcohol consumption, which is why it’s called nonalcoholic, but more to diet and weight. What we are seeing in individuals for the most part—there are some thing people that are developing it—but when we see overweight and obese and morbid obesity, and especially when we see some of these alterations in insulin levels and blood-sugar levels that directly impacts the liver, it is kind of like a slow burn. So it is a slow disease. It takes years to develop into more serious forms such as cirrhosis, but it’s something we’re seeing increases in, so the whole purpose of me writing the book was to alert individuals that, “Hey if your liver enzymes are off a little bit, this is a slow growth, but you’ve got time to change it, and it’s definitely reversible.”
So we have the potential to see an epidemic of getting a huge increase in cirrhosis. I mean we’re seeing this condition even in kids who are going to live a lot longer than someone who develops it at the age of 60. That was my purpose, and to really just tie in what a wholesome diet looks like in terms of regulating our insulin and our blood sugar levels.
Barb: Yeah, I think it’s interesting that our society has focussed a lot of attention on Type-2 Diabetes and heart disease related to diet and obesity, but this is an area that I think is really not recognized at all as a potential health risk.
Kristin: Not recognized. You know I had the opportunity to follow a hepatologist at the Cleveland Clinic for months while I was writing the book, and just in that environment, just seeing how many patients—one after the next, day after day—coming in with really being in the state of fibrosis, which is kind of the second stage due to obesity, and seeing patients that were in cirrhosis due to obesity. Once you’re at cirrhosis, you get on the liver transplant list. Those are extreme cases, but when you’re in that environment, which I was, I was shocked at how many people were coming in with these conditions.
Barb: Right. Well thank you for your adding to the knowledge base for individuals to learn about that and have more awareness about that.
As we wrap up our time together, I like to ask individuals where do you find fullness at this stage of your life?
Kristin: Oh man.
Barb: Besides Sunday morning donuts with your kids.
Kristin: I think I find fullness in the fact that I can involve my kids—if I’m going to go back to being a mother—involve my kids in shopping and cooking because I think that’s one of the most important things that we can do in order to evolve healthy eaters. I didn’t start there. I started trying to push broccoli like every mom, and failing at it like most moms. [laughs] Right? But it worked better when I involved them in the process. And when I involve the family in the process of how do we look at food? How do we cook food? How do we acquire food? So really going deep into that so that when they get older and they are on their own, they don’t look at a candy bar as food. Because it’s not.
Barb: Sure. Yeah. Perfect. Well, there’s a great message for moms. I’m having a little twinge of guilt right now as you’re making those statements. [laughs] So, if I had a do-over, I think food nutrition would be one area I could have absolutely done better.
Kristin: We all could do better. Me too, believe me.
Barb: We’ll stick with the journey and try to achieve improvement. So thank you so much. There’s just so much in this topic, I’d love to spend more time together, but I so appreciate your time and sharing your knowledge and wisdom with the listeners.
Kristin: Absolutely, Barbara. Thank you for having me.
Dr. Barb DePree, M.D., has been a gynecologist and women’s health provider for almost 30 years and a menopause care specialist for the past ten.