Nutrition in liver disease

Nutrition for liver includes both supplementation and cut down, depending upon the stage of liver disease, associated complication and other illness. Malnutrition is a common complication of advanced liver disease. Stemming from poor oral intake, faulty absorption and an altered pattern of fuel consumption, it carries important prognostic implications for a hepatic patient and is associated with higher rate of complication and, overall, an increased mortality rate if left untreated. It is, therefore, critical to assess the nutritional status of all patients with chronic liver disease and to optimize their nutritional support. The focus should be on maintaining adequate protein and caloric intake and correcting nutrient deficiencies.

[Here with we addressed the most commonly asked for questions as well as few health tips to guide you. Professional opinion from your doctor is needed. The things explained here are for general information, not to be followed in absence of professional guidance]

1. Fatty Liver And Obesity:

  • Limit foods that are high in calories
  • Eat more fiber rich food
  • Avoid Calorie rich food like sweets, ice cream, cold drinks, sugary juices, sherbet
  • Fried stuffs like samosa, vada, paratha, poori, chips, farsan, nimki, pakoda, burger, pizza, roll, chowmin, excess oil in curries, ghee, butter, margarine etc.
  • Eat more vegetables, saag, salad, fruits, sprouts, oats, seeds etc.
  • Avoid alcohol
  • Increase your physical activity
  • Take your food in proper time; take small portion at frequent interval.

2. Alcoholic Liver Disease:

  • Stop Alcohol
  • Small frequent feed, need to increase your food intake at least 1.5 to 2 times that you used to take before
  • Avoid high fat foods like samosa, vada, paratha, poori, chips, farsan, nimki, pakoda, burger, pizza, roll, chowmin excess oil in curries, ghee, butter, margarine etc
  • Maintain your weight as per height A balanced high protein diet will help.
  • Vitamin & mineral supplementation as per doctor’s advice will help to fight micronutrient deficiencies.
  • Take your food in proper time; take small portion at frequent interval.

3. Nutritional advise in early liver cirrhosis:

  • Limit salt and foods that contain a lot of salt, like: Papad, Pickle, Chips, Bhujia, Mixture, Salted Nuts. Tomato Sauce, Soya Sauce, Road Side Fast Foods, Ready To Eat Packaged Food.
  • Fluid restriction as per doctor’s advice
  • Plant based protein like All variety of Dal& Pulses are good for you, like(Arhar, Mung, Masoor, Chana, Rajmah, Chole, Chawli, Soybean),
  • Restrict animal protein like mutton, beef, Fatty chicken, prawn, crab etc. Fish, egg white, lean chicken can be taken as per Dietitian/doctor advice.

4. Nutritional advise in advanced liver cirrhosis:

    • The essential guidelines for designing nutritional therapy for patients with advanced liver disease are the following
    • Calorie intake: Patients with cirrhosis should receive at least four to five small meals during the day, as well as a late evening snack. A uniform distribution of calories round the clock with as brief an interlude of fasting as possible during nighttime reduces the likelihood of lipolysis and nitrogen catabolism.
    • Protein intake: Cirrhosis is a catabolic disease with increased protein breakdown and inadequate re-synthesis; Protein should be given even to patient even with episodic hepatic encephalopathy. The estimates of protein requirements vary with the state of disease and the nutritional status of the patient. In uncomplicated cirrhosis, protein intake should be in the range of 0.8-1.2 g/kg body weight/day.
    • Water Intake
      • Fluid requirement for normal person/3-4ml/existing body weight/hourly
      • o But in liver disease many times it is restriction due to Ascites and Edema.
    • Salt Restriction (Sodium restricted diets in liver cirrhosis)
      • Min requirement of sodium=1500mg/day (<1tea spoon salt)
      • Moderate Ascites: ½ tea spoon salt = 1200mg of Na
      • Severe tense Ascites: ¼ tea spoon salt = < 500 mg of Na
      • Pedal edema: ½ – ¾ tea spoon salt = 1200-1800 mg of Na
    • Additional Nutritional advice for micronutrients
      • Over time, most patients with cirrhosis develop micronutrient deficits. Almost all patients with advanced liver disease, and particularly those with a cholestatic liver disease, develop a deficiency of patients with alcoholic liver disease show deficiency of thiamine, folate, Vitamin B12, niacin, zinc, and magnesium.
      • Vitamin A: Decreased vitamin A levels result secondarily to fat malabsorption, as well as a defective mobilization of vitamin A from the liver. Supplementation of vitamin A for four to 12 weeks can correct this deficit.
      • Vitamin D and calcium: Deficits of vitamin D and calcium can result from several factors, including poor absorption from the intestinal mucosa, a decreased exposure to UV light and inadequate dietary intake, and impaired hepatic 25-hydroxylation of vitamin D. A prolonged deficiency state eventually produces bone weakness, bone pain and risk of fracture. Supplementation with calcium (1.000 mg/day) and vitamin D3 (800 IU/day) is necessary.
      • Zinc: Zinc deficiency is common in patients with cirrhosis, and may have a possible role in the pathogenesis of hepatic encephalopathy. Supplementation with 600 mg zinc per day for three months has been shown to improve the mental functioning in patients of hepatic encephalopathy.

5. Nutrition in various complication of advanced liver disease:

Ascites

    • Salt intake: A low-sodium diet (2 g salt per day) is useful, since it helps limit further fluid accumulation in the body.
    • Electrolytes: Since the patient is on a regular diuretic therapy (drug for increased urination), a close watch is necessary on the serum electrolytes.
    • Protein intake: To compensate the protein loss, patients requiring frequent removal of fluid from belly should receive increased amounts of protein.

Hepatic encephalopathy

Protein intake: A normal protein diet, per day should be prescribed. This will barely maintain the nitrogen balance in the body, and yet, not burden the patient with too much protein degradation products. Several studies have documented the benefits of a vegetable protein diet in comparison to the animal protein diet in comparison to the animal protein diet in patients of hepatic encephalopathy. This benefit mostly relates to a reduced urea production in vegetable diets. A higher dietary fiber content in a vegetable diet also
increases the incorporation and elimination of nitrogen through the faecal bacteria.

Vegetable proteins also carry a lower concentration of tryptophan and sulphur-containing amino acids.
The intake of these amino acids is associated with worsening of the hepatic encephalopathy.

Sample menu (For a early cirrhosis patient, 54 year male, diabetic with 70kg body weight

6.30-7AM Toned milk Tea with Biscuits (3nos) NO SUGAR
8.30-9AM Chapati (2nos) with vegetable Curry (1 bowl) 1 CHAPATI= 25gm ATTA
Or: Iddly(3nos) with Samber and Chutney NO COCONUT AND GROUNDNUT
Or: Uttapam(3nos) with Mater curry
Or: Vegetable Daliya Or Oats Upma (1 bowl)
10.30-11AM Buttermilk (200ml) or 1nos Cucumber or Fruits 150gm( Apple/Guava/Orange)
1-1.30PM Salad Full plate( Cucumber+Carrot+Tomato+Onion etc.)
Rice(1cup) or Roti (2nos) ½ cup RICE= 1 nos ROTI
With Dal (1 katori), Vegetable curry, Leafy vegetable,Curd
(weakly 3 times Non-veg/150gm like Egg white/ Less than 1kg fish/Lean chicken)
*Non-veg cook in form of stem, stew, rosted,…….
4-4.30PM Toned milk Tea with Biscuits (3nos) NO SUGAR
5.30-6PM Boiled sprouts salad( 1 bowl)
or vegetale and soyabeen stuff Sandwich(3nos Brownbead)
8-8.30PM Roti(2nos)
With vegetable curry/ soyabeen curry/ Rajma etc…
With Salad
10PM Toned milk (1 cup)

Avoid: Sugar, honey, jaggery , potato, yam etc.(avoid simple carbohydrate, Fried food and no fasting
Moderate intake:

  • Oil 15ml/day
  • Fruits 150gm/day
  • Milk and Milk product (350ml-400ml)/day
  • Non-veg like: egg white, lean chicken, small fish(3times weakly)

Tips:

  • Small and frequent meal, Regular exercise (minimum 1hour)
  • Improved fluid intake if not restricted (3-4 lit/day)
  • Take 7gm Fenugreek /day for controlling sugar level.