Ep.87 Revitalizing Your Liver in Midlife: Dr. Supriya Joshi Unlocks the Path to Metabolic Health and Longevity

In midlife, when we think about our overall wellness, the topics of menopause, weight gain, bone and joint health, and our skin are usually top-of-mind, but what about our livers? This organ often gets forgotten until there is an actual issue.

On this episode we are unlocking the secrets of liver health with liver specialist Dr. Supriya Joshi, as we navigate the underrated importance of this vital organ in your midlife journey. Through our in-depth conversation, you'll gain a wealth of knowledge about how metabolic health intertwines with liver function and the steps you can take to prevent conditions like fatty liver disease. Dr. Joshi's approach shatters the conventional reliance on medication, championing lifestyle adjustments and preventive measures to achieve lasting well-being.

Embark on a myth-busting expedition about liver disease and its connection to diet, especially the often misunderstood roles of fat, sugar, and alcohol. Our discussion reveals the pivotal role of muscle mass in metabolic health and unwraps the complexities of aging's impact on our bodies' alcohol metabolism. Dr. Joshi equips you with the truth behind liver detox fads and the actionable insights needed to make informed decisions about supporting your liver health through consistent, healthy living.

The episode culminates with a powerful blend of dietary and exercise strategies designed to revitalize your health. Learn why eating vegetables first could revolutionize your eating habits, the importance of protein and healthy fats in your diet, and how intentional exercise, like zone two training, enhances mitochondrial health. With Dr. Joshi's expert advice at your fingertips, you're empowered to embark on a proactive path toward a healthier liver and a more vibrant life.

CORRECTION:
In the podcast Dr. Joshi accidentally misstated that a can of Coke contains 10 grams of sugar. She meant to say 10 teaspoons of sugar.
Also, she wishes to clarify that two-thirds of North Americans with type two diabetes have fatty liver disease, but one-third of all North Americans have it.

You can find Supriya Joshi, MD at:
https://www.liverhealthclinic.com/
https://www.instagram.com/liverhealthmd/

I'd love to work with you! Let me help you reach your health and fitness goals.
https://www.fasterwaycoach.com/?aid=MicheleFolan

Have questions about Faster Way? Feel free to reach out.
mfolanfasterway@gmail.com

Follow Asking for a Friend on Social media outlets:
https://www.instagram.com/askingforafriend_pod/
https://www.facebook.com/askforafriendpod/

Please provide a review and share. This helps us grow!
https://lovethepodcast.com/AFAF

This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they may have and should seek the assistance of their healthcare professionals for any such conditions.

Transcript

Michele Folan: 0:07

Health, wellness, fitness relationships and everything in between. We're removing the taboo from what really matters in midlife. I'm your host, michelle Fohlen, and this is Asking for a Friend. Welcome to the show. Everyone In midlife, when we think about our overall wellness, the topics of menopause, weight gain, bone and joint health and our skin are all top of mind. But what about our livers? This vital organ often gets forgotten until there's an actual issue. Our guest on the podcast today is a specialist in liver disease and gastroenterology. Dr Supriya Joshi wants us to be proactive in optimizing the health of our livers and prevent disease progression. Her focus on metabolic health is very timely and one that I know will be of great interest to our audience. Welcome, Dr Supriya Joshi.

Supriya Joshi, MD: 1:14

Thank you so much, Michele. Thank you for the invitation to share my passion with you today and all of your listeners.

Michele Folan: 1:19

Well, you caught my eye and caught my interest because of your passion around what you do. Before we get started, I would love for you to tell the audience a little bit more about you, where you're from and also your career path.

Supriya Joshi, MD: 1:36

First, I'm Canadian, for your listeners, and I was born in small town, ontario, canada, and I'm the adolescent three children. My parents are my dad's retired teacher, my mom's retired nurse, and so growing up, I have to say, they really did instill in us children to take risks, take chances, help people and education being really important and to share education. Thinking back to my upbringing, I think that's partly why I've gone on this trajectory of trying to educate the masses. I look at it as my public service. I also had amazing family members that were inspiring to me, who were doctors some of them.

Supriya Joshi, MD: 2:13

So I was interested in science, biology, health, when, down that route, I did my undergraduate degree at Western University and I did an undergrad in physiology and then I got into medical school there. And then I went to the University of Toronto where I did my intramedicine residency, followed by my gastroenterology fellowship, and then I realized things I was more interested in and I wanted a more niche practice. I did another fellowship in liver disease, which is called hepatology. At that point I had to make a choice Do I stay in the academic venue or in pursuit research? And I had been doing both vent research, clinical research and published in those fields but I realized I really liked education and clinical care, taking care of patients. We had this opportunity to electives in the community and I did a few of them and I was super lucky to be offered jobs and this is what kind of made me change my mind from being an academic physician to going into the community, which is not so far from the University Center anyway. So I was fortunate to get a position as a gastroenterologist with a specialty in liver disease and it's one of the largest, busiest urban hospitals in Canada, just outside of Toronto, and I've now, shockingly, been in practice for 20 years.

Supriya Joshi, MD: 3:29

I am a mom to three kids, I've got a supportive husband and as I've gotten older and observed my patient practice as it's changed over time, this has further helped me get to where I am today with education, because I'm realizing we have all these diseases and when you go into the career path as a doctor it's so focused on disease management there really was no education on prevention, nutrition, lifestyle. I think I'm not even sure how much of an FCE is even in medical school today. So I was forced to self-learn a lot of things because I realized I'm not serving my patients from whom I don't have medications, for you know I have my GI practice where I do endoscopy. I've got medications to treat inflammatory bowel diseases and in terms of liver disease, I came into liver disease when hepatitis C treatment was finally available. Also, hepatitis C was our focus in preventing liver failure, liver transplant needs and liver cancer. That was fantastic.

Supriya Joshi, MD: 4:29

We succeeded in treating people, helping them to make a difference in their lives and their trajectory of health, same with autoimmune liver disease and hepatitis B. But then we had this whole area called fatty liver disease and it wasn't really talked about. It was kind of this annoying condition Because, yeah, we have no treatment. Tell people to go lose weight, ok, great. But that to me was just not satisfying because I realized people don't know how, or nor was anyone in medicine making the connection between their diabetes management and their heart disease and their elevated weight and their arthritic issues and inability to mobilize. And yet this liver was largely ignored and I had no focus there before. And so that's what really got me changing my own education path. I had to self-learn but how I communicated with my patients and to give them some empowerment.

Michele Folan: 5:21

Well, you bring up a couple things here. First of all, that when you're in medical school and also your residency some of the training you receive isn't focused on necessarily the prevention piece and I've heard this from other doctors I've had on the show. But as a liver specialist you come off as someone who is truly an advocate for overall health. You don't just talk about the liver, because I guess what I'm picking up from you is that poor liver health can be so far reaching in its whole effect on the body.

Supriya Joshi, MD: 6:00

You're 100% right. I'm so thrilled that you figured that out because with the way I now see liver disease as a center, we've got the stuff I have treatment for, and then we've got the other top liver disease which are alcohol, the treatment. Stop alcohol. Then it comes down to this whole gamiculthagin liver disease just now the number one leading cause for liver transplant in North America, and we have no medical therapy for it. Wow, that's one alarm bell that I saw in my practice. I had all these patients who had a constellation of their diseases, such as bad diabetes, on insulin, bad heart disease, developed kidney disease related to their poor diabetic management, and then there are liver enzymes that keep on fluctuating and then eventually they'd have development of severe scarring of the liver. We call that liver cirrhosis. And now they're on increased doses of insulin, which is further harming their liver health because it's a growth factor. The liver starts to fail and all of a sudden I'm the doctor taking care of this patient with all these?

Supriya Joshi, MD: 7:00

other diseases but they're in liver failure and now, according to very standardized scoring systems that we have, they actually meet criteria for liver transplant. So I would take care of my patients, support them, refer them on for liver transplant. But I already knew they weren't going to be a candidate and that's because they've got bad heart disease they would never survive the operation. They've got such brittle diabetes and they've got very poor compliance to kind of optimize that and take their medications. So this poor patient, they're only in their 50s or 60s and now they're palliative. Yeah, and that broke my heart and I see this pattern over and over and over again. So, to answer your question, it is a widespread disease on which the liver tends to be a victim of all the other medical conditions. Or you can look at it the other way.

Supriya Joshi, MD: 7:51

The fatty liver came first and I don't think anyone's looking yet at that way, and that's how I decided to take this on. Is that before they were a type 2 diabetic needing medications? Before they had their first heart attack, they had fatty liver. Either no one looked or no one talked to them about it, and that is the most common thing, because it's everywhere. It's in two thirds of North Americans that they had an abdominal ultrasound, fatty liver would be detected. Oh, that much, yeah, but that wasn't the reason they had the ultrasound?

Michele Folan: 8:21

Yes, and that's not something that's typically done unless there is quote unquote a problem that's exactly it.

Supriya Joshi, MD: 8:28

It was an incidental finding. They had that ultrasound because of abdominal bloating or pain. Who let a gall stone and the radiologist report will often say evidence of fatty liver. But when I talked to my patients about it it wasn't always brought up or was mentioned. But no one knew what to do with this. Stop drinking alcohol is what they were told. Because I think the connection to metabolic health and newsroom resistance is still a major gap in healthcare and that's why I've taken this on to give education about it.

Michele Folan: 8:56

Okay, I'm going to let you just talk about the genesis of non-alcoholic fatty liver disease, because I was telling my husband about this when he was home just now and I told him what we were going to be chatting again and he's like that's super interesting. And you know, the first thing he did, he looked at the sugar content on the lemonade that he was drinking.

Supriya Joshi, MD: 9:18

So yes, I love that he's figured it out. First let's address the term. You brought it up Non-alcoholic fatty liver disease. This is a really old name given mostly by radiologists and pathologists. So when they were the it investigates people or assassins for these abnormal liver enzymes, they did imaging like an ultrasound or a cascan and the way that the liver projected or reflected the light. It looked fatty and then at this area was biopsied. It was fat. That's how it got its name and the problem was that it's the message out there is that fatty liver disease is caused by people eating fat and the issue is that that is not the case and in fact, just this year that disease has been renamed. It's now being called metabolic dysfunction associated steatotic liver disease, so it's a whole mouthful. It's called mathled M-A-S-L-D and that's probably take away the stigma from calling something fat and, in addition, to giving a more correct relationship between metabolic disease, because what we see as fat in the liver is directly related to people's metabolic health. When I see people who might get a radiology report they've had a biopsy or I suspect it's fat in the liver causing the problem I want them to realize that this is a huge signal to their future metabolic health and we have to pay attention. And I find this is a condition that's often overlooked, and that's because it seems like every adult over age 50 has it. It's just so prevalent but not commonly addressed with people and therefore people are left to their own vices wondering well, how do I fix this? I'll stop eating fat, I'll stop eating my eggs and my yogurt because that's filled with fat. But that's the wrong treatment. So I love that you've asked this question because we can use this way to really educate people.

Supriya Joshi, MD: 11:08

Liver fat comes from the liver's natural process to produce fat, from excessive sugar consumption or fructose consumption. So when somebody consumes a sugary beverage that contains, I say, 10 grams of sugar, like a can of Coke does, but also if they have something that's not sweet tasting, like a bagel which has 80 grams of carbohydrate, when we eat or drink those products and we digest them, they both become glucose. Our cells don't know the difference. So when this glucose is circulating, the glucose is supposed to get into the cell to provide the cell some energy. But it can't just go into the cell on its own. It needs the hormone insulin to open that cell door and then glucose goes in and natural process occurs. But when there's too much of this glucose, your cells stop saying or start to say I'm not going to respond to that insulin anymore. And that's how insulin resistance develops, which basically is the we name it provide for people who are pre-diabetic. So now they're insulin resistant.

Supriya Joshi, MD: 12:13

But now where does all that glucose go? Well, now there's a smart process your body created to convert that glucose into fat and store it in your liver, almost like an energy bank, waiting for you to need that energy, waiting for you to undergo starvation, waiting for you to undergo famine. But, as we know, in our privileged North American world, for the majority of people that doesn't happen. So this production or conversion from glucose or fructose into fat and storage in our liver is a survival mechanism. That was very much necessary when we were living in a world without excess. When people have fatty liver, or they're told they do have that, what I hope they realize is that they have to cut back on their sugar intake, fructose intake. Refined carbohydrates and processed foods and eggs are good, yogurt's good. Healthy fats are good for you. I'm not telling people to go eat bacon and lard that's not what I'm recommending but because there's bad fats and good fats and you want to try to optimize a variety of good whole foods and people's diets to reverse this, and it can be reversed.

Michele Folan: 13:21

You can. Okay, because that was my next question. Can you reverse fatty liver disease?

Supriya Joshi, MD: 13:28

Absolutely, and if, by lifestyle change, we have no medications to give people to reverse this, it has to come down with what you're eating and drinking, the quality of what you're eating and drinking. Have a glass of water or sugar-free bubbly water. Don't have the sugary drinks, because it's very deceiving how much can be in there, and the World Health Organization has made a statement on this that adults should not have more than six teaspoons of sugar a day, which is 24 grams. So this is where it comes down to sugar math. We not only learn this in school, but four grams of sugar is one teaspoon, as you pointed out, your husband looking at lemonade, but a glass of lemonade, I'll bet you will have six to eight teaspoons of sugar in it.

Supriya Joshi, MD: 14:08

Yeah, it does so. And so that right there in one drink, you're potentially blowing your sugar budget Just with that one drink. So think about how much people are consuming, and the typical North American is having about 20 to 22 teaspoons of sugar a day. When I talk to my patients Most have no idea where they're getting it from.

Michele Folan: 14:30

Well, it's the Starbucks four-pump venti latte or whatever. It's the things that we don't really think about. You know, we can read labels all day long, but there's the sneaky stuff, those things that are habits of ours every single day, that we just don't account for 100% and that's why Education and awareness is key.

Supriya Joshi, MD: 14:53

And I know when I educate my patients, I encourage and read labels and slowly wean themselves off those sugary drinks and soon, if they were to have a drink like that, they would not like it.

Michele Folan: 15:03

Mm-hmm.

Supriya Joshi, MD: 15:04

So your brain chemistry can change super quickly by just weaning off of sugar. Then you won't even have that craving of wanting it. And that all is just to help people's not only reverse or liver disease but also to hopefully prevent extra weight gain. It can prevent high blood pressure or reverse it. It can even reverse early diabetes. A lot of good things can come and of just understanding what you're eating and drinking on a daily basis. So diet's part of it, good sleep part of it, exercises, a big part of it Talking about muscle mass.

Supriya Joshi, MD: 15:35

Everyone needs to be working on improving their muscle mass as they age, not just for survival, but just for being metabolically more healthy perfect.

Michele Folan: 15:43

You brought up cirrhosis before and I know when most people think of cirrhosis they think of you know they're Uncle Bob who drank a little too much and had cirrhosis. That's what most people think of cirrhosis, but the way you termed it it's a broader condition.

Supriya Joshi, MD: 16:01

So cirrhosis by definition means a severe cross-linked scarring of scar tissue in the liver. I mean you typically see that in the liver. Biopsy or various non-invasive tests may give this indication. It is not a cross that our result. That happens quickly. It takes decades to occur in most people. Most people don't have liver cirrhosis. They have either Miley-elvin liver enzymes, if their doctor checked it, or they may have some degree of fatty liver that it's fat deposition within the liver cells. But cirrhosis Can happen no matter what is in during the liver on an ongoing basis, whether that's a viral infection, whether it's autoimmune disease, whether it's a hereditary disease. There's alcohol consumption and then there's a dietary lifestyle issues I'm trying to educate people about, but only when cirrhosis happens. Then there's the risk of having liver failure and increased risk of liver cancer.

Michele Folan: 16:54

Okay, all right, the risk of liver cancer Can be there with any of these issues. How about hepatitis? So if you have hepatitis, can you be more predisposed to liver cancer as well?

Supriya Joshi, MD: 17:06

Yes, and that's and value about it up because the word hepatitis has a bad name, because I think there's a lot of Connotations, whether it be infectious or alcohol. The word hepatitis is just comes from Latin roots it's. It is inflammation. Hepa is the hepatitis of the liver, so it's inflamed liver and anything can lead to that, even a medication. It's answer your question. The most common viral infections that are chronic and treatment are hepatitis B and hepatitis C. Hepatitis B is probably the leading cause of liver cancer in the world, in addition to things we've talked about like alcohol induced cirrhosis or even the inflammatory fatty liver disease version. Those are what can increase the risk of liver cancer rarely do autoimmune diseases do that.

Michele Folan: 17:50

Is there any heredity component with liver disease and liver cancer?

Supriya Joshi, MD: 17:56

There are, but they're extremely rare and uncommon. So I don't think that would be the focus and I will say some people will say, yeah, my parents had fatty liver disease. Is that inherited? And I'll say no, it's not actually genetic. But what is inherited is what you've learned about your lifestyle and upbringing, how you live your life every day, and that's more a behavioral issue.

Michele Folan: 18:21

That's been to learn behavior versus true genes at play well, we can say that about diabetes and other issues around metabolic diseases, right? Yeah, I want to go back to hepatitis real quick, because you were saying that there's been a lot of advancements in hepatitis and I really don't know the difference between A, b and C.

Supriya Joshi, MD: 18:46

Okay, so hepatitis A is infection people can get from contaminated food products, mostly shellfish, contaminated water, and it was called an acute infection. So you get sick, you can get nausea and vomiting, you could turn yellow, your eyes or skin could become yellow, but people generally recover from that. That is a preventable infection by getting vaccinated against hepatitis A, hepatitis B and C. When you acquire them you rarely get rid of it on your own, so they're the ones that lead to chronic hepatitis. So chronic hepatitis B or chronic hepatitis C, both of them are viral infections and our body does not do a good job of getting rid of it on their own. And that's our people need help because the consequence of having those chronic infections Is that they are always injuring the liver and that eventually can lead to scarring, significant scarring and even liver cirrhosis, and that's where again the increased risk of liver cancer can come in or liver failure. So in terms of treatments, hepatitis B we still have no cure for, and there's a minority of people in hepatitis B that do qualify for lifelong antiviral therapy. After a certain age, like age 50. Then they need ultrasounds of the liver to screen them for liver cancer as well. Anyone who has chronic hepatitis B with an elevated liver enzyme or high viral load. This is something that their doctors would be checking. There's someone who will likely need antiviral therapy, others don't, but they need monitoring by their primary care physicians.

Supriya Joshi, MD: 20:20

Hepatitis C there has been major advancements over the last two decades. Right now we have medications that are all oral, so by mouth as little as eight weeks or 12 weeks, depending on which brand you decide to go down with almost a 99 cure rate and no side effects. There has been a major, significant advancement in hepatitis C eradication, to the point the wHO, or world health organization, made a mandate of eradication of hepatitis C from the planet by 2030. So the United States is on board, canada is on board, and so this is leading to more public awareness. See your doctor get screened for hepatitis C.

Supriya Joshi, MD: 21:03

Back in the day, when Pamela Anderson was a huge advocate for this because she herself had it, as did some other I know big tv stars this led to the you know baby boomers getting screened, people who've had exposure even 30, 40 years ago, of tainted blood, and that could have been from even one exposure to injection, drug use or cocaine, snorting or a shared needle, or shared from a tattoo that wasn't done professionally Just at one time. People are at risk of getting hepatitis C if it was contaminated instrumentation. And there's also, you know, blood transfusions before people screen blood and in Canada we had a huge scandal back in the 80s where there was change to the blood given to the innocent canadiens.

Michele Folan: 21:44

Oh, that's frightening, yeah, but I am so excited that there are therapies out there that seem relatively easy to take. Yeah, absolutely, that's great news. I get the liver cancer risk and for some reason I wrote down what about dementia, and I don't remember why I wrote dementia. But is there a link with dementia and liver disease?

Supriya Joshi, MD: 22:10

Well, interesting If it's metabolic disease. Absolutely, because it's all the same thing. You know they're calling dementia, various forms of it, type 3 diabetes, you know. So related to metabolic health or poor metabolic health, insulin resistance. Absolutely there's a connection, which is why, again, I'm trying to educate people about all little steps you can do in your lifestyle in your 30s, in your 40s, in your 50s, to be preventative, so we can all live long and healthier right. When we call that health span, live longer, healthier Right, yay.

Michele Folan: 22:44

I'm like yes, yes, yes. Supriya, I would love for you to give us the straight answer on where your peers are on the subject of alcohol.

Supriya Joshi, MD: 22:58

Great topic and this has cost lots of emotional conversations, even in my friend groups. Yeah, so Canada took the lead on this and they published out an article, a paper, a position statement on alcohol safety, and the recommendations are that there is no safe level of alcohol because with regular alcohol consumption there's increased risks of certain cancers. In fact, alcohol consumption is with 13 different cancers, but a few are a little bit higher risk brain health, gut health, cardiovascular health all of that is related to a negative outcome. None is considered healthy and this is not a popular statement amongst many groups of friends, I'm realizing.

Supriya Joshi, MD: 23:39

Then it comes down to what is considered low risk. Low risk drinking is under two standard drinks a week. Three to seven drinks a week, you start to get associations with increased risks of cancer, specifically colorectal and breast. And over seven drinks a week is when you get the increased risk of cardiovascular disease, dementia and other associated risks that come with that. Back in the day, when people say oh yeah, you know one of your drinks a day is healthy for women and up to three a day for men, that is no longer the case.

Michele Folan: 24:09

I knew you were going to say that.

Supriya Joshi, MD: 24:11

Sorry, but any benefits that were thought they're realizing from European studies. If you look at data on cirrhosis from alcohol, it is huge in Europe no one's talking about that. People think, oh, in France they go and drink their wine every day but they're also suffering from cirrhosis. Yeah, you don't hear that. You don't hear that. But if you look at the metabolic data, yes, they eat better If they follow the traditional diet. They do eat better, not what was going on in the Western world and the North American diet, unfortunately, is taking hold in Europe and Asia, to you know. Gone are the days of that supposed observed effects of good diet.

Michele Folan: 24:46

Right, I do have a question. It's a personal question, but I think other women are going to relate to this. Why is it now, in midlife and I'm post-metapause when I have an alcoholic beverage I feel like I've had three. I just don't feel like I'm metabolizing alcohol the same way as I used to.

Supriya Joshi, MD: 25:10

That is an amazing question, michelle, because no that you are not alone. I noticed the same thing, and this is not something that I've learned in medical school. We had to go and search this up. But why is this happening to me? A lot of my girlfriends also noticed that, and some men do too. My husband does notice that too, as we age. It's interesting, it's not just one thing, but you're not imagining it, and it relates to natural processes that are occurring to our bodies as we are all aging.

Supriya Joshi, MD: 25:35

As we're aging and you probably have noticed already but we all lose our muscle mass. It's estimated that we can lose, between the ages of 50 and 70, almost 1% of muscle mass per year. And understanding muscle physiology is that muscle contains more water in it than fat depths, and as we age, muscle is replaced by fat, and that's when people who are not trying to preserve their muscle mass, but even if they are, it's hard to really be on top of that issue. So, number one, we're losing muscle mass and we're losing our free water. So when you have that drink, it sits in the water. So when you have less water, it's more concentrated.

Supriya Joshi, MD: 26:16

So the alcohol, the blood alcohol level for that same drink you may have had five years ago can now be higher. So that's issue one. This is simple. The natural process of aging promotes this higher blood alcohol concentration and for women, as become perimenopausal, postmenopausal declining estrogen levels, that also increases visceral fat, and so women are already gaining more fat just as a result of the metapausal, the biological process that are naturally occurring. And then on top of that we have to look at natural enzymes that our bodies all have to metabolize alcohol, and that's called alcohol dehydrogenase. And as we age we produce less of this enzyme, so we're not metabolizing it. So again that alcohol will hang around. So it's no wonder as we age you feel that drink hits you earlier, faster and longer.

Supriya Joshi, MD: 27:10

And the other thing to consider is that, as we're aging, there's also the increased likelihood you could have another medical problem and you might need antibiotics. You might need a medication for another medical problem going on, and there could be an interaction with how our liver metabolizes alcohol. It might be slowed down and that could be the third way increase blood alcohol levels. So great question People out there.

Michele Folan: 27:32

You're not imagining it, it's real. It's something that I have friends tell me all the time, and actually I was having a chat with friend this morning and she said the same thing. So if we could do a study, I think we would have a lot of people that would be like I'm in that camp Totally. I wanted to ask you why would someone opt for a liver detox or a cleanse? Are they safe and effective?

Supriya Joshi, MD: 27:58

They're not, and I just did a post-insider day and I realized that a lot of patients take them and I ask about it, and it is an utter waste of people's money. There's nothing you can take that periodically that will cleanse your liver, or your gut for that matter. It really is a consistency and treating your body well with good health and good nutrition. That is a liver detox. Avoiding sugar, alcohol and refined carbohydrates are really the main crux of that. There's no drink you can take that's magically going to make your liver get healthy. It's a very lucrative industry for people to get into, but it's a waste of people's money and it can even cause harm. I have seen cases of liver failure from some herb that's been in something that people thought was healthy and it's not. So it's not worth the risk and it's definitely not worth people spending their money on that.

Michele Folan: 28:50

That brings up a great point that if you are going to take some kind of an herb or some kind of a detox cleanse, check it out with your doctor first before you do any of those things, because you never know if you're already taking something, that there could be some kind of contraindication or bad side effect. You know if taken together. So absolutely.

Supriya Joshi, MD: 29:14

Because an herb might be fine at a normal concentration, but at a high dose it becomes potentially interactive. You know something else in your body or medication you're taking. The results can be disastrous. Absolutely In just. In fairness, they're doctors. They may not even know either. I mean so little information is known about this stuff.

Michele Folan: 29:33

Right Because they're not studied. It's not like the FDA is out there, no, checking out milk thistle. That's exactly it how that does in the body. Metabolic risk has gotten a lot of buzz lately, and particularly, you know, we've got Ozenbeck out there. We've got people wearing constant glucose monitors. Besides family history, how can we best assess our metabolic risk?

Supriya Joshi, MD: 29:59

Well, it's a question that no one I think many people don't think about it, and I hope that they do start thinking about it, because earlier intervention is key and people can do this on their own. So one thing is self-realization of waking or being objective and taking a tape measure and just measuring your waist or conference. That's measuring the widest part of your abdomen, and that might give some clues. And there's good data on this, like it's all over the internet. We don't really follow body mass index or BMI. I don't think it's not as indicative of risk as we once thought.

Supriya Joshi, MD: 30:30

And when we look at metabolic disease, what does correlate is the visceral fat and that's the fat collection, you know, around the waistline. A larger waistline is not good for future health when it comes to cardiovascular risk, and so when I tell people to measure their waist or conference, what we consider it's not zero risk but low risk. For a man is a waist or conference under 37 inches Over 40 inches is high risk, and for a woman, low risk is under 31.5 inches and high risk is over 34.5 inches. When I say it's not a zero risk, that's because even a thin person with a not great lifestyle can still be a high risk of metabolic disease. People hiding under thinness can also, you know, be fooling themselves.

Michele Folan: 31:16

Being thin is not fit, because we all have that one friend that's super thin and does all the bad things.

Supriya Joshi, MD: 31:24

Right, it's not fair, darn them, but it does catch up with them eventually, I guess it would.

Michele Folan: 31:31

You don't want that to happen to people, but it does, yeah. So what are you seeing in patients using Wigowi and Osembic? Are you seeing Some pretty positive cardiovascular outcome data with OZEMPIC they did.

Supriya Joshi, MD: 31:46

It was beautiful to see you know. So certainly there's something going on with the GLP1 receptor in various organs of the body. So, yes, it not only provides weight loss, improved diabetic management, but, as we just reported, just two weeks ago, the report came out on improving cardiovascular risk. From a liver doctor, what's still missing is the improvement on liver fibrosis stage, and that's why it's still not indicated for me to prescribe for my patients with fatty liver disease or fibrosis, because it has not yet been shown to improve liver fibrosis in people with fatty liver disease, even though it's associated with all those conditions. I think part of the problems that the studies just aren't long enough. I said to you earlier, it does take years for fibrosis to occur. Similarly, it's going to take more than 12 months for us to see improvement, but I love seeing the benefit for my patients from those cardiometabolic factors, and they're always happy with their weight loss.

Supriya Joshi, MD: 32:35

The only thing that I do encourage people to do, though, is to strength train, and that's because, with any of these weight loss medications, you will get the desired weight loss, but you're also going to lose muscle mass. Over the age of 30, we all lose 1% of muscle mass per year, and as we age, you're going to be left with being a skinny, fertile person who can't get off the floor Right. You don't want to be that. I know All of us, especially a perimenopausal women as well. Strength training I'm realizing that in that same age group is super important to our insulin sensitivity, keeping us well for now and for the future. So I want people who are on like would go be osempic to realize, while that injection no week is going to make them reach their desired goals, that exercise and fitness is still something they have to put effort into.

Michele Folan: 33:25

My friends laugh at me because I tell them yeah, one of my main goals is that, if I should fall, that I can get up off the floor unassisted. Look at me. They take that so crazy. I said, no, trust me, it's something that we should all strive for.

Supriya Joshi, MD: 33:43

That's amazing, you've said that when you've had that conversation, because it's truth it really is Total truth.

Michele Folan: 33:49

All right, my next question is sugar addictive?

Supriya Joshi, MD: 33:54

Oh yeah, oh yeah, you know, studies show sugar is just as addictive as cocaine. It leads to that surge in dopamine, that reward center in your brain getting lit up and full of joy when you have sugar. And industry makers know this and there's a certain measurement that you get this signal called the bliss point. That's when you're addicted and they know they've got you and they want you to go buy more and more and more of it. They have, you know, the dollars as their objective. But for people it is absolutely addictive and you know you're addicted when you want it again and it made you feel great.

Supriya Joshi, MD: 34:33

You know you have a sugar addiction when you go with those ups and downs the glucose high, the dopamine high, and then the insulin level goes up to bring that blood sugar down and now you're exhausted or fatigued or grumpy. You know. You know I want to feel good again. I want to feel like I did two hours ago, I'm going to go get more cookies. And that's how that cycle keeps happening, of crashing and getting hungry again. And I think the result of that is that people end up with poor sleep quality, low energy and they think that they were so energetic when they had that sugary drink or treat or whatever that we're having, and they just want it more and more. So absolutely, sugar is totally addictive.

Michele Folan: 35:15

I had to ask that because I've talked to people. They're like no, it's not, you can back away from it. I think that's harder for some people than others, so I absolutely I wanted to ask you that. You posted something on Instagram recently and I love this recommendation about eating your veggies first before you eat what else is on your plate. Is there any other kind of diet recommendations that you have Like? Do you like the Mediterranean diet? What's your thing?

Supriya Joshi, MD: 35:47

I think whatever healthy diet people can adhere to is the right diet. I want people to realize what they're used to having. The North American diet, the quantity, the poor quality, is not in their health interest and so there's many ways to improve this. So I think having a name of a diet just makes it easier because they can go look it up and see okay, this is what I want to adhere to. But I'm glad you like that idea about having your vegetables first, because, in terms of being a gastroenterologist and just simple gastric physiology and gastric emptying and the society centers and make your brain realize you're full.

Supriya Joshi, MD: 36:24

Having fiber first does that. It achieves all of that. It takes time for you to chew it, which slows down eating, and once you've had that vegetable, it slows down absorption, it fills your stomach more. So you're already feeling full a little bit by having a big salad first and getting lots of good nutrition in there and then. So then I recommend vegetables first, followed by your protein, which is also really important because many people don't get that protein in their diets, which pay a price later.

Supriya Joshi, MD: 36:53

Then your healthy fats and then, if you really want to have your carbohydrate, have it at the very end, but definitely don't have the beginning, because that will spike your blood sugar, make you feel tired and you're not going to feel full and that's going to make somebody want to overeat and have more and more platefuls of food. So the plateful of pasta is not the best meal to have for someone when you're trying to change your direction and become metabolically healthy. So in terms of diet, as I said, whatever diet someone can stick to is great and I try to educate people that the North American diet, how much carbohydrate it has and what we typically call a low carbohydrate diet, I say a target goal is 100 grams a day or under that. That's actually what should be called a normal diet.

Michele Folan: 37:35

Okay, I'm making people realize what the world is at, and what's good for? Their health. And then exercise same thing. Do exercise that you're going to do and stick with. It doesn't have to be anything super fancy, right?

Supriya Joshi, MD: 37:49

Not at all, and that's the thing. There's just your basic activity and people need to understand that's different from exercise. So there's people thinking, whether 10,000 steps a day or 6,000 steps a day, that's still a great target to have because you could easily sit in front of a computer all day long, depending on. Some people's occupations are and that is an occupational hazard Sitting all day at your desk. It's just as bad as smoking for cardiovascular risk, and so getting people to realize that to get up, get a desk that goes up and down even, can be hugely helpful to their health. And so I'm going to realize that activity is different from exercise and that exercise is intentionally getting your heart rate up and you should try to strive for at least 150 minutes a week and even with that you don't have to run a marathon because there's people who are afraid of running, they're afraid of sweating, they don't want to do it.

Supriya Joshi, MD: 38:38

Look, do a lot of it. You don't have to do that. And there is strength training as one part of it, which will also get your heart rate up. But in terms of cardiovascular exercise, or something called zone two training, that's just getting your heart rate up to 80% of your maximum. So it's conversational pace and you can do that with a you know, rock sacking with a weighted backpack on and go for a walk. You can go for a jog, go for a bike ride and I encourage people to, you know, get a way to measure it. It doesn't have to be an apple watch, but something like that that can measure their heart rate. If they don't know, their maximum heart rate is a surrogate, for that is taking 220 minus your age and then 80% of that should be your target heart rate when you want to do zone two training.

Michele Folan: 39:20

I'm writing that down because I'll put that in the show notes. Oh great, oh great, because I have been doing the zone two, because I listened to some other podcasts and I thought, oh okay, that's doable. I want people to understand that's actually not an uncomfortable heart rate, that's exactly it.

Supriya Joshi, MD: 39:37

It's doable, right it is. And yet there's a lot of benefit to that, as I'm sure if you've read about it, you get you know improvement in your mitochondrial health, which is a key to longevity and cardiovascular health, but as a side effect according to the things I've read and what I've experienced you get a bit more fat loss as well, because you're in the aerobic zone and we all like that.

Michele Folan: 39:57

Yeah, we all like that, Especially in midlife. Yes, it's awesome, yeah.

Supriya Joshi, MD: 40:01

So so when those little hidden pieces of information for exercise that a lot of people don't realize?

Michele Folan: 40:07

Speaking of midlife women too and you're giving us some incredible advice Is there any other tips that you would give a woman who is just wanting to start to make healthier changes? Because I think we need to not assume that everybody's on the same path. I mean, there's some people that just need that extra encouragement. What would you say to those people?

Supriya Joshi, MD: 40:31

I would first want them to realize they're not alone. Talk about it. Talk about with a friend, because having a buddy to join you on this journey makes it a lot easier and more comforting. I find I've got two people to look up stuff and then share it with each other and start a project together. I think not doing things alone is important, but some people can do on their own as well. It's not to discount that, but just to get started. Stop saying do it tomorrow, just today. You know what? Tonight I'm just not going to eat that, or I'm not going to buy that when I'm at the store, or I'm not going to have that glass of wine with my dinner. Tonight I'm going to make that change. Or I'm going to go for my walk after dinner and just get those running shoes on and just get started. Wine is the first obstacle, the biggest obstacle. Once day one is done and they realize they've done it, day two is so much easier. Lots of studies show that I agree.

Michele Folan: 41:25

I didn't tell you I was going to ask you this question. I may know the answer, but I'm going to ask you anyway. I was watching it was a video a guy with a mic and a camera. They were at a cardiovascular conference and they were asking all these cardiologists, what's the one thing you would never do as a cardiologist? I would say probably 90% of them said I wouldn't smoke If I went to a hepatology conference and I walked around with a mic and a camera and I came up to you say, dr Supriya Joshi, what's something as a hepatologist, what would you never do? What would that be? Oh gosh.

Supriya Joshi, MD: 42:07

I don't know. There's so much, so much.

Michele Folan: 42:09

I wouldn't do.

Supriya Joshi, MD: 42:11

Oh, I didn't give you time to think about it, yeah, but I would say there's not one thing I wouldn't do For sure I won't smoke, I'm not going to do that. But I wouldn't drink alcohol every day, I wouldn't have sugary cereal ever, I wouldn't have regular cans of Coke every day. I wouldn't do that every day. And I think the everyday part is a good way to look at it, because we still have our lives to live. Life is a journey and I love that. Kamala, one of your other guests you had. That is direction, not perfection. I love that and I've even borrowed it because I think it is such a great safe message that it's okay to stray here and there, depending on what your situation is, but as long as you're going forward and making steady improvements, I think that's the huge win. I don't think we need to be so absolute, because at that confinement people don't do well in confinement.

Michele Folan: 43:06

I used to work with this guy named Dwayne and he would say it's not the exceptions that get you, it's the habits. It's maybe not about totally eliminating any one thing out of your life, because that can cause deprivation or feelings of deprivation. At least I appreciate that advice. It's awesome. And then my last question for you what's one of your own very important pillars of self-care?

Supriya Joshi, MD: 43:32

I think it comes down to realizing I don't need to feel guilty for taking time for myself. I think a lot of women have inherent guilt. It took me a while to figure that out, when I would see it in my patients and I talk to them about it. They could be working women, they've got kids, but they're still doing everything and I get that. I'm also a wife, a mom, I'm a daughter and I'm trying to do everything and it's hard, it's not easy, and I remember seeing a meme.

Michele Folan: 43:58

No wonder women are burning out, because we are doing everything.

Supriya Joshi, MD: 44:00

I think one thing that women definitely need to get better at is taking time for themselves. That's what we do a lot of time, even for if I'm in this 60 minutes since the pandemic, I started working out at home. I will go to the gym. My husband, my kids fully support it. They get it. They give me my time and when I'm getting cranky they'll say do you need to go work out, mom? I'm going to go on their case about something.

Michele Folan: 44:22

So they realize I'm a way happier person to be around after I've come back from exercise. I can't imagine you being too cranky, but maybe you can.

Supriya Joshi, MD: 44:31

Oh, it happens, yeah, yeah, I can I guarantee you oh.

Michele Folan: 44:36

So I think self-care, I think take time for that. That's such a wonderful way to finish this off, because that's also a big thing that I try to tell people all the time. You got to put yourself first. You know that old saying and it can get a little trite, but you can't pour from an empty cup. Thank you for sharing.

Supriya Joshi, MD: 44:53

But that's exactly it. You know, yep, if you're all burnt out, if you're not going to be there to support the masses around you that needs your support, yes, and they still need you, even as a gig owner.

Michele Folan: 45:05

That's a whole other topic for another show. Dr Supriya Joshi. How can people find you Well?

Supriya Joshi, MD: 45:11

you brought up my Instagram. That's probably the best way. I am at liver health MD. I started it literally about six months ago just to kind of empower people. I just call it my public service because when I see patients and they go I wish someone told me this 20 years ago. It's that conversation that triggered me to do something and I didn't know what else to do. I've gone to my hospital to make more public education available. That wasn't the right forum. I've gone to public health in my community. They were so burdened by COVID and now they're starting to get things out. But this is an easy way. I can just post little things to encourage people that are going in the right direction and by the feedback I hope it's helping people. I love it. That is far reaching around the world. It's such a cool way to interact with people.

Michele Folan: 45:58

I encourage everybody to check out Dr Joshi's Instagram because she has some great tips there. Thank you so much. Thank you for being here. I really appreciate it. This was so informative and I hope we get to connect again. I hope so.

Supriya Joshi, MD: 46:12

This was super fun, thank you. Thank you very much. Have a great day you too.

Michele Folan: 46:24

Follow Asking for a Friend on social media outlets and provide a review and share this show wherever you get your podcasts, stories and sharing help us grow.