Really good diet/nutrient information for cirrhotics

[evangelin]

I found this information very helpful. There is about 7 pages with information about nutrition and supplements needed for cirrhotics.  This is not anything selling supplements but it is research based information.  It certainly explains why my husband went downhill and lost lots of muscle mass on a vegetarian diet.  He improved over time with a more liberal amount of protein.   He isn't a gym type but he does some physical work and he has actually built back muscle in the last couple years.  I don't have any scientific verification for that...I can see it.  If I pat his shoulders, they don't just feel like a bunch of bones anymore.

        http://www.medscape.com/viewarticle/575158

[eureka254]

Medical care for hcv and cirrhosis and better management guidelines have made significant gains in both understanding and application in recent years; though I have read Dr. Palmer's book myself and found her informative, they her book is also outdated and contain many inaccuracies that are better understood today.  (By the way, the link does not work.)  

More recent journal literature, some of which evangelin supplied above, has debunked much of the older nutritional guidelines for cirrhotics.  Here's a few other pieces more recent than Dr. Palmer's book:

Nutrition in Hepatic Encephalopathy
Author(s): Chadalavada, R, Biyyani, RSS, Maxwell, J, Mullen, K.
Citation: Nutrition In Clinical Practice 25 (3): 257-264 Jun 2010 Year: 2010
Abstract: “Protein calorie malnutrition (PCM) is a well-known complication of chronic liver disease (CLD). A major contribution to PCM in CLD is restriction of dietary protein intake. After many decades of injudicious reduction in dietary protein, cirrhotic patients are now prescribed appropriate amounts of protein. PCM in CLD is known to be associated with life-threatening complications. In the general approach to these patients, the initial and most important step for the clinician is to recognize the extent of malnutrition. Most patients tolerate a normal amount of dietary protein without developing hepatic encephalopathy (HE). Oral branched-chain amino acids (BCAAs) have a limited role in HE. Patients who exhibit dietary protein intolerance originally were thought to be best treated with BCAA formulations. Mixed evidence has been reported in multiple studies. In keeping with other reports, this article shows that in animal protein intolerant patients, even those with advanced cirrhosis, vegetable protein based diets are well tolerated. Another approach to management of apparent dietary intolerance is to optimize HE treatment with available medications. This article reviews the causes of HE, minimal HE, and PCM; examines nutrition requirements and assessment; and discusses treatment options for malnutrition in HE.”

Improvement of hepatic encephalopathy using a modified high-calorie high-protein diet.
Author(s) Gheorghe L, Iacob R, Vădan R, Iacob S, Gheorghe C.
Rom J Gastroenterol. 2005 Sep;14(3):231-8.
Abstract
BACKGROUND AND AIM: Protein-calorie malnutrition (PCM) occurs in 20-60% of patients with hepatic cirrhosis and is associated with the development of life-threatening complications. We evaluated the effect of a modified, casein-vegetable-based, high-protein high-calorie (HPHC) diet on the outcome of cirrhotic patients with hepatic encephalopathy (HE).
METHODS: One hundred and fifty three consecutive cirrhotic patients with overt HE were included in this study. An HPHC diet based on better-tolerated vegetable and milk-derived proteins was initiated in order to ensure the adequate protein-energy requirements of 30 kcal/kg/day and 1.2g proteins/kg/day. Serial (daily) assessments were done, including mental status, asterixis, a conventional Number Connection Test (NCT), bowel movements and blood ammonia level. The assessment of the mental status was performed using the West Haven scale. Favorable evolution or response to HPHC diet was defined as an improvement in HE stage with 1 or more (Delta > or =1 stage) after 14 days of diet.
RESULTS: During the HPHC diet, 122 patients (79.7%) improved in terms of response definition. A significant decrease in blood ammonia level was observed after 14 days (p<0.0001) in all patients, whatever the improvement of the mental status. A significant improvement in the NCT scores was also noted (p<0.0001). More patients with advanced HE (West Haven stage 3) precipitated by various factors showed a Delta = -2 improvement of their mental status during the modified HPHC diet compared with patients in lower initial stages (50% vs 18.9%, p=0.002). More patients in Child-Pugh B class had a Delta = -2 decrease in the grade of HE compared with patients in Child-Pugh C class (61.7% vs. 14%, p=0.001).
CONCLUSIONS: Almost 80% of patients in our study improved their mental status during the casein-vegetable-based HPHC diet, showing that dietary protein restriction is not required for the improvement of HE. A higher rate of improvement was noted in patients with severe impairment of mental status related to precipitating factors and in patients with well preserved liver function. The daily eating pattern consisting of 4 snack-meals and a late evening meal may contribute to HE improvement by equal protein distribution during the day.
http://www.ncbi.nlm.nih.gov/pubmed/16200232

Dietary protein intakes in patients with hepatic encephalopathy and cirrhosis: current practice in NSW and ACT.
Authors:  Heyman JK, Whitfield CJ, Brock KE, McCaughan GW, Donaghy AJ.
Med J Aust. 2006 Nov 20;185(10):542-3.
Abstract
OBJECTIVE: To ascertain whether current practice in teaching hospitals in New South Wales and the Australian Capital Territory delivers adequate dietary protein in the management of malnutrition in adults with cirrhosis, in accordance with European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines for nutrition in liver disease.
STUDY DESIGN: Cross-sectional study of dietitians using a self-administered, mail-back survey.
SETTING: Teaching hospitals in NSW and the ACT treating patients with cirrhosis.
PARTICIPANTS: Dietitians seeing patients with cirrhosis in the 12 months prior to completing the survey.
MAIN OUTCOME MEASURES: Current dietary protein prescription practice for patients with cirrhosis (with and without hepatic encephalopathy); use of nutritional supplements and enteral feeding for malnourished patients with cirrhosis.
RESULTS: Dietitians following the ESPEN guidelines were in the minority: 36% of the dietitians recommended an adequate protein intake for patients with hepatic encephalopathy. Sixty-four per cent of the dietitians had received referrals from the medical team requesting inappropriate protein-restricted diets for patients without hepatic encephalopathy. Seventy-eight per cent of the dietitians requested clarification of the recommended nutritional management of patients with cirrhosis.
CONCLUSION: Many medical and dietetic staff inappropriately restrict protein intake of patients with cirrhosis.
http://www.ncbi.nlm.nih.gov/pubmed/17115965?dopt=Abstract

In addition to a reversal in recent years about protein and carb consumption, limitations for salt consumption are now to stay lower below 1000 mg per day if cirrhotic to prevent the development of ascites -- its incidence and the frequent peritoneal complications -- makes preventing its development a priority.  

[evangelin]

Z Gastroenterol. 2010 Jul;48(7):763-70. Epub 2010 Jul 6.
[Protein catabolism and malnutrition in liver cirrhosis - impact of oral nutritional therapy].
[Article in German]
Norman K, Valentini L, Lochs H, Pirlich M.
SourceKlinik für Gastroenterologie, Hepatologie und Endokrinologie, Charité - Universitätsmedizin Berlin.

Abstract
Malnutrition with loss of muscle is common in patients with liver cirrhosis and has negative impact on morbidity and mortality. The aetiology of malnutrition is multifactorial and includes inflammation, early onset of gluconeogenesis due to impaired glycogen storage and sometimes hypermetabolism. Reduced nutritional intake, however, plays the most important role in the pathogenesis of malnutrition. There is, however, ample evidence that nutritional intake and therapy are inadequate in liver cirrhosis although studies have clearly shown that dietary counselling and nutritional therapy with oral supplements improve intake in these patients. Protein requirement is considered to be increased in liver cirrhosis and high protein intake has been shown to be well tolerated and associated with an improvement of liver function and nutritional status. Protein intolerance on the other hand is uncommon and hepatic encephalopathy can thus rarely be attributed to high protein consumption. Recommendations for general protein restriction must therefore be considered obsolete and rather a risk factor for an impaired clinical outcome. Furthermore, the administration of late evening meals is highly beneficial in patients with liver disease since the rapid onset of the overnight catabolic state is counteracted. The serum concentration of branched-chain amino acids (BCAA) is decreased in patients with liver cirrhosis and long-term supplementation of BCAA has been shown to improve nutritional status and prolong event-free survival and quality of life.

PMID:20607635[PubMed - indexed for MEDLINE

[evangelin]

Nutr Clin Pract. 2011 Apr;26(2):155-9.
Low-protein diets for hepatic encephalopathy debunked: let them eat steak.
Cabral CM, Burns DL.
SourceGastroenterology, Lahey Clinic Medical Center, 41 Mall Road, Burlington, MA 01805, USA. Chad.M.***@****

Abstract
Hepatic encephalopathy (HE) is an incompletely understood phenomenon and serves as a poor prognosis in patients with cirrhosis. Confusion from HE can affect the ability to eat adequately. Despite the prevalence of malnutrition in cirrhotic patients in the 1950s, it was reported that bouts of overt HE were controlled with low protein intake. This largely uncontrolled observation led to restriction of protein intake in cirrhotic patients with or without HE and was an accepted standard of care for many decades to follow. Published in 2004, the pivotal article "Normal Protein Diet for Episodic Hepatic Encephalopathy: Results of a Randomized Study" by Cordoba and colleagues was the first controlled study randomizing cirrhotic patients with HE to receive different amounts of dietary protein. At the completion of the study, the authors concluded that a normal-protein diet was safe and did not exacerbate HE. The Cordoba study suggests that low-protein diets should be abandoned. In light of this evidence, nutrition guidelines have proposed that protein restriction should be avoided in patients with HE as protein requirements are increased in cirrhosis. Despite the advice of experts in the field, it has been shown in recent years that some physicians still believe that protein restriction is needed in patients with HE. This belief has not been substantiated in controlled studies, and societal recommendations have changed. There is no real evidence documenting the advantages of protein restriction in HE. On the contrary, Cordoba and colleagues' article has shown that there are disadvantages to restricting protein in HE.

[evangelin]

We found out my husband had HCV and cirrhosis 8 years ago.  At that time, everything you read reflected the protein sparing diet to minimize encephalapthy.  I told Joe that he would have to be a vegetarian, which did not thrill him, to say the least.  He lost weight and even more muscle than he already had from cirrhosis alone.  
About 11/2 -2 yrs ago (losing track of time)  I got the chance to discuss this with a nurse that works in a liver clinic for the VA.  She is also really active in supporting people with HCV.  She told me that my vegetarian diet for cirrhosis had been proven to be all wrong.  The latest data showed that people with cirrhosis actually need more protein than those with a normal liver.  If encephalapathy was a problem, it needed to be handled with lactulose.
Well, Joe has had mild encephalapthy problems in the past and did take lactulose but on a higher protein diet and  with the supplements from Hepatitis Technologies, (not to be taken during TX)  he no longer has the encephalapathy symptoms.  He has not needed lactulose for at least a year now.  I can't say how much is the diet and how much is the supplements but he has grown back some muscle and feels  much better.  
Whey protein isolate shake at bedtime can make it easier to get the protein.  I think the recommendation is still to eat small more frequent meals to make it easier on your liver to process the nutrients.  
It is now confusing to read things on the internet which reflect the old guidelines, but the latest research says not to restrict protein. I don't like Joe to eat much red meat at all because of the iron.  He eats eggs (we have our own chickens) chicken and some fish and milk and cheese.  I throw in a protein shake most days.  I'm not saying this will work for everyone, but it seems to have helped Joe. I worry about meat and cancer because the vegetarian crowd says that it increases that possibility.  I don't know. I just can say that Joe looks better ,feels better, and his albumin went up which may have been more the supplements than the diet but no way to decipher.  
Ev

[PeachStatePam]

GENERAL NUTRITIONAL GUIDELINES FOR INDIVIDUALS WITH LIVER DISEASE
Part 2

FAT

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. For example, 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.

As a general rule, no more than 30% of a person's caloric intake should come from fat. 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. For example, 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.

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 some 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).

If a person eats a healthy, well-balanced diet, all the vitamins and minerals for daily needs and activities should be amply supplied. Despite this, many people feel that they should take vitamin and/or mineral supplements "just to be on the safe side". While this may be fine for an overall healthy person, it may be downright dangerous for someone with liver disease. Thus, excessive doses of vitamin and mineral supplements may do much more harm than good to an already damaged liver.

However, there are exceptions to this rule. First, not everyone eats a healthy well-balanced diet. Also, some people follow strict vegetarian diets. Under these circumstances, vitamin and mineral supplementation may be necessary. People with certain liver diseases, especially cholestatic diseases, such as primary biliary cirrhosis, absorb some vitamins poorly. Thus, these people may also require supplementation. Moreover, people with alcoholic liver disease have a need for vitamin supplementation due to the nutrient-depleting effects of alcohol on the body. On the other hand, some liver diseases actually result in an overload of a certain vitamin or mineral. An example of this is hemochromatosis, which is a liver disease of iron overload. Alternatively, there are liver diseases that may be associated with iron deficiency. This may be due to internal bleeding, which can occur in people with bleeding esophageal varices due to decompensated cirrhosis. Therefore, the requirements of vitamins and mineral in the diet of a person with liver disease must be evaluated on an individualized basis.

An in-depth review of every vitamin and mineral is beyond the scope of this article, and the reader is referred to my book for a detailed discussion. However, in general it is important to keep in mind that excessive doses of iron, vitamin A and niacin have been found to be toxic to the liver. Thus, individuals with liver disease are generally advised to avoid these supplements. And, since osteoporosis ( a disease characterized by reduced bone mass resulting in an increased risk for bone fractures), is common to many liver diseases, it is a good idea for all people with chronic liver disease to take a calcium supplement. Calcium supplementation should be limited to no more than 1000 to 2000 milligrams per day and should be taken with a vitamin D supplement ( which is usually included in the calcium tablet). Since stomach acid is needed to properly absorb calcium, antacids, such as Tums, which reduce stomach acid, are poor sources of calcium. Finally. individuals suffering from ascites- a complication of cirrhosis resulting in an abnormal accumulation of fluid in the abdomen, need to limit their intake of sodium. For every gram of sodium consumed, the accumulation of 200 milliliters of fluid results. The lower the consumption of sodium in the diet, the better controlled this excessive fluid accumulation is. For people with ascites, sodium intake should be restricted to under 1,000 milligrams per day and preferably under 500 milligrams. This goal is difficult, yet attainable.

SOME TIPS ON DIET

Dining out can present a challenging situation for a person on a special or restricted diet. The fat, sodium, and calorie content of restaurant foods is not included on the menu. For this reason, it is best to steer clear of fast-food establishments completely. When dining out, food should be ordered cooked "dry", meaning it should be prepared without butter, margarine, or oil. Most people with liver disease find that eating multiple small meals throughout the day is the best approach, as it maximizes energy levels and the ability to digest and absorb food. Finally, it must be stressed that all alcohol consumption should be avoided. This includes hidden alcohol contained in desserts, especially cakes and certain coffees.


http://www.liverdisease.com/nutritionalguidelines.html

[PeachStatePam]

GENERAL NUTRITIONAL GUIDELINES FOR INDIVIDUALS WITH LIVER DISEASE
Part 1

After being diagnosed with liver disease, among the first questions that patients typically ask concern nutrition. Unfortunately, one cannot 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 types of liver disease ( for example, alcoholic liver disease versus primary biliary cirrhosis) and the stage of the liver disease ( for example, 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 can be a complicated subject. That is why I devoted an entire chapter to this topic in my book: "Dr. Melissa Palmer's Guide To Hepatitis And Liver Disease". The following information, which is excerpted from my book, contains just a few highlights that an individual should keep in mind nutritionally.

Notwithstanding the above information, an example of 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 percent carbohydrates - primarily complex carbohydrates, such as pasta and whole-grain breads.

2) 20-30 percent protein - only lean animal protein and/or vegetable protein.

3) 10 - 20 percent polyunsaturated fat.

4) 8-12 eight ounce glasses of water per day.

5) 1,000 to 1500 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.

11) Vitamin D and calcium supplement.

PROTEIN

Proteins are the major building blocks that the body uses to make body components such as muscles, hair, nails, skin, and blood. Proteins also make up important parts of the immune system called antibodies, which help fight off disease. Since protein is such a vital component of the body, many people mistakenly believe that the more protein they consume, the better. Not only is this belief misguided, but for someone with liver damage such an approach to nutrition can actually be downright dangerous. The trouble is that a damaged liver cannot process as much healthy liver. And, when a damaged liver gets unduly overloaded with protein, encephalopathy ( a state of mental confusion that can lead to coma) may occur. Finally, diets high in protein have been demonstrated to enhance the activity of the cytochrome P450 enzyme system, which is responsible for drug metabolism. This enhanced activity increases the likelihood that a drug may be converted into a toxic byproduct capable of causing liver injury.

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 to 15 %. And, they need to eat only vegetable sources of protein. A diet high in animal protein ( which typically contains alot 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 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.

CARBOHYDRATES

The major function of carbohydrates 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 in charge 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, (for example, taking a test versus exercising). Or it may decide to store glucose ( in the form of the 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 put, their diets are working against them.

People with liver disease should strive for a diet consisting of approximately 60 - 70 % carbohydrates, with complex carbohydrates ( starches and 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 and fat intake.

[PeachStatePam]

Nutrition and Cirrhosis
Nutrition and cirrhosis
Cirrhosis, fibrotic (thickened and hardened) liver tissue, occurs in the later stages of hepatitis C in chronically infected patients.3-5 Complications of cirrhosis include portal hypertension (high blood pressure in the liver's circulatory system). Portal hypertension can result in ascites (fluid retention in the belly area) and varices (enlarged veins in the digestive tract). As with the hepatitis diet described above, people with cirrhosis need a high-calorie, high-protein diet. In addition, with cirrhosis, foods that are high in sodium and ammonia need to be avoided. Table 2 identifies ammonia- and sodium-containing foods.

  TABLE 2. FOODS HIGH IN AMMONIA AND SODIUM  
Foods High in Ammonia Aged cheeses, Salami, Bacon, Ham, Ground beef, Gelatin
Foods High in Sodium Salt, Garlic salt, onion salt, season salt, Soy sauce, Monosodium glutamate (MSG), Canned soups, Canned vegetables & meats, Cured meats (bacon, sausage, ham, lunchmeats), Processed cheeses, Frozen meals, Salty snacks (chips, pretzels, popcorn), Pickled foods (sauerkraut, pickles, olives)


Generally, no more than 2000 mg to 3000 mg of sodium should be ingested each day to minimize water retention and facilitate blood-pressure control. In addition to avoiding salty foods, salt in cooking, and salt at the table, it is necessary to select low-sodium foods in order to maintain sodium intake below 3000 mg per day. If varices are present in the esophagus or stomach, a soft diet should be consumed, and the patient should avoid any rough foods such as pretzels or nuts that could scratch those blood vessels and cause bleeding. Blood potassium levels need to be monitored, but potassium supplementation should only occur with a prescription and regular monitoring from your physician. Many cirrhosis patients need supplementation with the B-complex vitamins: zinc, magnesium, and phosphorous.

http://www.numedx.com/readstory.phtml?story=v3n2nutrition

[crossroadsec]

Nutrition is key. Thanks for the link. I'm certain that's how I got my MELD down to be able to treat. Karen.

[Dee1956]

Dear EV, thank you so very much for the information.  My husband had Hepatitis in 1977 and at the time they told him not to eat any fried food or mayo, butter, dairy.  I think that is how he bounced back in two weeks.  The doc later said that maybe he didnt have Hepatitis as he had never seen anyone get well so fast.  I think he had a very good immune system.  .  Back in 1977 they did not know a lot but they did put him on a strict diet so he could heal faster and a nurse came in once a week to give him a B12 shot.
I "think" this is how I got Hep C, at the time the doc said that everyone living in the home had to get a gamma globulin shot.  We got the vials at the Health Dept and then the doc gave us the shot.  At the time he told me to get out of the house, then sighed and said, it is probably too late.  So fast forward to 2007 when I was finally diagnosed with Hep C.  The hard part for me is that I was tested two different times two different places in 1994, 1995 and both tests came back negative.  I don't know what kind of Hepatitis my husband had.
Thank you again for the diet information
Dee

[eureka254]

Very valuable information, ev, thanks for sharing that.  For so many years, it was standard to recommend cirrhotics against meat proteins, and more and more evidence is coming forth that it's actually counter-productive... same thing with carbs, too.

Hopefully understanding the nutritional needs of cirrhotics will continue to improve and help folks like our husbands stay as healthy as possible! :)  Hugs. ~eureka