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General Nutritional Guidelines for individuals with                                       Liver Disease

About Miss Noreen Aslam

After being diagnosed with liver disease, among the first question that patients typically ask concerns nutrition. Unfortunately one can't expect to walk into the doctor's office and request " a diet for liver disease ". Such an across-the-board diet simply does not exist. Many factors account for the unfeasibility of a standardized liver diet including variations among the different stages of liver disease (e.g. stable liver disease without much damage versus unstable decompensated cirrhosis, complicated by encephalopathy). Other medical disorders unrelated to liver disease, such as diabetes or heart disease must also be factored
into any diet. Each person has his or her own individual nutritional requirements, and these requirements may change over time.

Nutrition and liver disease is a complicated subject. An optimal diet for a person with stable liver disease (modifications to be made as per individual needs) might contain all of the factors listed below.

1- 60-70% carbohydrates - Primarily complex carbohydrates, such as whole grain.
2- 20-30% protein - only lean animal protein and/or vegetable protein.
3- 10-20% polyunsaturated fat.
4- 8-12 ounce glasses of water per day.
5- 1,000 to 1,500 milligrams of sodium per day.
6- Avoidance of excessive amounts of vitamins and minerals especially vitamin A, Vitamin B3 and iron.
7- No alcohol.
8- Avoidance of processed food.
9- Liberal consumption of fresh organic fruits and vegetables.
10- Avoidance of excessive caffeine consumption - no more than 1-3 cups of caffeine - containing beverages per day.

Adequate protein intake is important to build and maintain muscle mass and to assist in healing and repair. Protein intake must be adjusted in accordance with a person's body weight and the degree of liver damage present. Approximately 0.8 grams of protein per kilogram (2.2 pounds) of body weight is recommended in the diet each day for someone with stable liver disease.

People with unstable liver disease or decompensated cirrhosis need to lower the percentage of protein content in their diets so that it falls between approximately 10-15%. And, they need to eat only vegetable sources of protein. A diet high in animal protein (which typically contains a lot of ammonia) may precipitate an episode of encephalopathy among these people.

Vegetarian diets, on the other hand, have a low ammonia content and have been shown to be much less likely than animal protein diets to induce encephalopathy. It is important.

Fats are the body's most efficient means for storing excess energy. Gram for gram, fats contain more than double the amount of calories of other nutrients. That is why a diet high in fat is likely to result in more weight gain than a diet high in calories from protein or carbohydrates. It is important for people with liver disease to minimize their fat intake by avoiding foods that are high in fat content. Excess fat can result in a fatty liver or nonalcoholic steatohepatitis (NASH). Not only can a fatty liver cause liver disease, it may contribute to the worsening of other liver diseases. e.g. it has been demonstrated that people with Hepatitis C and a fatty liver are likely to develop scarring in the liver at an accelerated rate. Furthermore, although uncommon, it is possible for someone with NASH to develop cirrhosis and liver failure. In fact, fatty livers are felt to be so unhealthy that they are not
even considered viable for use in transplantation.

People who are overweight should aim for something in the neighborhood of 10% while it is important to eat as little fat as possible. Eating a small amount of the more healthy fats does have some benefit. e.g., people need some fat in order to properly absorb the four fat-soluble vitamins - A, D, E and K. Without some fat, these vitamins may become deficient in the body, even if they are taken in supplemental form. This type of vitamin deficiency sometimes occurs in people with cholestatic diseases such as Primary biliary cirrhosis.

To keep in mind that some popular weight-loss diets involve the consumption of a very high animal protein content. People with cirrhosis are advised to avoid any such diets.

The major function of carbohydrate is to provide a ready supply of energy to the body. The liver plays a crucial role in carbohydrate metabolism. Before sugars are able to supply energy to the body, they are routed to the liver, which is incharge of deciding their fate. Thus, it may immediately send sugar into the blood stream to provide an instant energy boost or, the liver may send glucose to the brain or muscles, depending upon what activities are being performed at the time, e.g. (taking a test versus exercising) or it may decide to store glucose (in the form of starch glycogen) for later use. Converting foods other than carbohydrates into energy is stressful, even to a normal liver. By eating an unbalanced diet that is low in complex
carbohydrates, a person with liver disease will add to the stress that the disease has already caused the liver. In fact, this is one reason why so many people with liver disease feel fatigued. Simply putting, their diets are working against them.

People with liver disease should strive for a diet consisting of approximately 60-70% carbohydrate, with complex carbohydrates (starches & fibers) predominating. A well balanced diet will include at least 400 grams of carbohydrates. If there are too few carbohydrates in a person's diet, this will likely result in excessive protein & fat intake.

Vitamins and Minerals
The liver is the body's main warehouse for storing nutrients. It absorbs and stores excess vitamins and minerals from the blood. If a person's diet does not supply an adequate amount of these nutrients on a given day, the liver releases just the right amount of them into the bloodstream. However, the liver has only a limited capacity for processing vitamins and minerals. Any excess amounts that the liver is unable to process are generally eliminated from the body. Yet, at same point, the liver can become damaged due to the strain of processing an overabundance of certain vitamins and minerals (particularly iron, vitamin A and niacin).

The liver plays an important role in the metabolism of iron since it is the primary organ in the body that stores this metal. Patients with chronic Hepatitis C sometimes have difficulty in excreting iron from the body. This can result in an overload of iron in the liver, blood and other organs. Excess iron can be very damaging to the liver. Studies suggest that high iron levels reduce the response rate of patients with Hepatitis C to Interferon. Thus, patients with chronic hepatitis C whose serum iron level is elevated, or who have cirrhosis, should avoid taking iron supplementation. In addition one should restrict the amounts of iron rich foods in their diet, such as red meats, liver and cereals fortified with iron, and should avoid cooking in iron coated utensils.

Advanced scarring of the liver (cirrhosis) may lead to an abnormal accumulation of fluid in the abdomen referred to as ascites. Patients with hepatitis C who have ascites must be on sodium (salt) restricted diets. Every gram of sodium consumed results in the accumulation of 200 ml of fluid. The lower the salt content in the diet, the better this excessive fluid accumulation is controlled. While often difficult, sodium intake should be restricted to 1000 mg each day, and preferably to 500 mg perday.

One must become a careful shopper, diligently reading all food labels. It is often surprising to discover which foods are high in sodium. Meats, especially red meats, are high in sodium content and adherence to a vegetarian diet may often become necessary. Patients with chronic hepatitis C without ascites are advised not to overindulge in salt intake, although their
restrictions need not be as severe.

Alcohol is a potent toxin to the liver. Excessive intake can lead to cirrhosis and its complications, including liver cancer. Heavy drinkers are not the only individuals at risk for liver disease as damage can occur in even some moderate " social drinkers ". The hepatitis C virus has frequently been isolated from patients with alcoholic liver disease. In fact these patients have been found to have a higher incidence of severe liver damage, cirrhosis and a decreased life span, when compared to individuals without the virus. It is suggested that the combination of alcohol and hepatitis C accelerates the progression of liver disease. The
consensus statement concerning management of hepatitis C released March 1997 from the National institutes of Health, further warned about the dangers of excessive alcohol use in patients with hepatitis C. These recommendations stressed limitations of alcohol use.

Pakistan Dietetic & Nutrition Association
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