Nutrition for people with Cirrhosis
Diets for People With Cirrhosis
SODIUM AND HEPATITIS C
Advanced scarring of the liver (cirrhosis) may lead to an abnormal accumulation of fluid in the abdomen, referred to as ascites. Patients with HCV 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 of the diet, the better this excessive fluid accumulation is controlled. Sodium intake should be restricted to 1,000 mg. a day or less. This requires careful shopping and reading all food labels. It is often surprising to discover which foods are high in sodium. For example, one ounce of corn flakes contains 350 mg. of sodium; one ounce of grated parmesan cheese, 528 mg. of sodium; one cup of chicken noodle soup, 1,108 mg. of sodium; and one teaspoon of table salt, 2,325 mg. of sodium. Avoid fast food restaurants, because most fast foods are high in sodium. Meats, especially red meats, are high in sodium, so meat consumption may need to be reduced and vegetarian alternatives considered. Patients with chronic HCV without ascites are advised not to overindulge in salt intake, although their restrictions need not be as severe.
At this stage the diet is generally high in complex carbohydrates (breads, cereals, grains, legumes, dried beans and peas, pasta, rice). These foods are important because they provide our bodies fuel source called blood glucose (also referred to as "blood sugar"). During cirrhosis, individuals frequently experience low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia). Your body is better able to maintain a healthy, sustained level of energy from complex carbohydrates ("starches") rather than from simple carbohydrates ("sugars").
Think of your body as an automobile. Your body's "gasoline" is blood glucose. Sugars found in candy, fruits, sweet pastries, and milk products supply the body with "gasoline", but your body uses it quickly. The result is that your energy level usually rises and then falls too quickly with sugars than it would with complex carbohydrates, especially those with higher fiber content. This is not to say that simple sugar foods cannot be eaten, only in smaller proportion to complex carbohydrates and in more controlled portions.
You will also continue to need adequate, but not excessive protein in your diet (see When you discover you're Hepatitis C positive). Protein is needed for repair and maintenance of blood and body tissues, including liver tissue. Persons with cirrhosis tend to better tolerate the protein from dairy and plant sources than from meat sources, and therefore may benefit from a more vegetarian type diet. Daily protein needs in grams will vary according to your nutritional state. Your R.D. can give you more specific guidelines on this according to your body weight and the status of your disease.
Persons with cirrhosis often begin to experience difficulty digesting and absorbing fat in the diet. The result is steatorrhea, (the presence of undigested fat in the stool), and thereby may require dietary fat modification. Fatty liver is also a condition that can occur which is the accumulation of fat in the liver. In either of these cases, reducing the fat to 25% of total calories (about 40-70 grams of fat daily) is recommended. Use of a special prescription type of fat called MCT oil is sometimes necessary. MCT (medium-chain triglycerides) does not require bile for absorption into the blood stream, so is advantageous when the liver can no longer produce adequate bile for digestion and absorption of dietary fat (lipid). MCT can be used in place of other fats in cooking and some recipes and is also available in certain types of liquid nutritional drinks.
Therapeutic nutritional drinks now contain a mixture of MCT and other fats (called structured lipids). Using MCT alone can produce undesirable gastrointestinal complaints and is not indicated for the diabetic or significantly starved person. Structured lipids also have been found to enhance the immune system over other types of fats. Also, if MCT is the exclusive fat used in the diet, supplementation with the essential fatty acid called linoleic acid is required to prevent a dietary deficiency.
Vitamin deficiencies can occur during this stage of the disease. Fat-soluble vitamins A, D, E, and K may need to be taken in their water-soluble form by prescription from your doctor. Deficiencies of the minerals zinc, calcium, and magnesium can also occur during cirrhosis and may require supplementation. It is important that you do not take vitamins or minerals not prescribed by your doctor as toxicity can occur with overdosing. Sodium typically needs to be restricted with cirrhosis. Unfortunately for many salt lovers, this means learning to enjoy the taste of foods without salt. Since the taste for salt is acquired, it can also be lost, (usually taking 4-6 weeks of "biting the bullet" until you finally come to enjoy the many tastes of food, spices, and herbs without the salt shaker!)
Beware: many foods are high in sodium because of what's added in processing. Processed meats, cheeses, frozen dinners, canned soups and vegetables, snack chips and crackers can pack over 1000 milligrams of sodium per serving. Considering that the person with cirrhosis must usually limit sodium to 2,500 milligrams per day, these foods leave little room for other necessary, more healthy foods in the diet. Remember that sodium acts like a "sponge" in the body and can cause your body to hold on to more fluid, predisposing you to abdominal fluid retention seen in cirrhosis called ascites.
NUTRITIONAL MANAGEMENT:
Energy Requirements: Due to extreme weight loss in cirrhosis, energy requirements are increased. A diet with 25-35 Kcal/Kg IBW (Ideal Body Weight) per day is recommended. Small and frequent meals should be given.
Carbohydrate Requirements: The carbohydrate content of the diet should be high in order to provide sufficient calories so that protein is not utilized for energy. Also, the liver may store glycogen. Liver function improves when an adequate store of glycogen is present in hepatocytes (liver cells). Simple carbohydrates should be given, i.e., sugars, fruits juices, Sago, Arrowroot products, etc. About 65-70 % of total calories should be provided by carbohydrates.
Protein Requirements: A liberal protein intake is essential for the repair of hepatic cells. The serum albumin which is exclusively synthesized by the liver cells falls down in cirrhosis as a result of which there is water retention. So, in order to maintain serum levels of albumin, it is necessary to take protein. In case of absence of Hepatic Coma (a condition in which ammonia levels increases leading to brain tissue damage), 1.2 -1.5 gms per kg present body weight can be given. Both animal and plant protein can be given. Vegetable and dairy proteins are better tolerated because of their lower content of Aromatic Amino Acids (Methionine and Glutamine) and higher content of Branched chain Amino Acids (Valine, Leucine, and Isoleucine). If protein requirements cannot be met by diet alone, then protein supplements can also be given. However, if cirrhosis progresses to Hepatic Coma, then protein has to be totally restricted.
Fat Requirements: Cirrhosis is marked by impaired fat metabolism and absorption. Triglycerides which contain Medium Chain Fatty Acids (8-10 CARBON FATTY ACIDS) like Ghee, Butter, etc. can be given. These triglycerides do not require bile for their digestion and absorption. This will help to prevent steatorrhea (fatty stools). As the condition improves, large chain triglycerides can be given to avoid deficiency of essential fatty acids.
Vitamin Requirements: All of the vitamin should be supplied in abundance to fortify the liver against stress and to repair the damage. Since the liver is involved in the synthesis of active forms of any B-complex vitamin and due to lack of proper function, it is advisable to give B-complex vitamin supplements. In the presence of steatorrhea, water soluble forms of vitamin A, D, E, and K should be given. In severe cirrhosis with problems of vitamin storage, metabolism, and transport intramuscular injections of Vitamin A, D, E, and K may be necessary.
Mineral Requirements: Iron intake should be increased to prevent anemia because the liver is unable to store iron in the form of ferritin. Iron supplements can be given. However, simultaneous increase of vitamin C is also required. Calcium intake should also be increased. Iron intake can be increased by following measures:
Increase the intake of Green leafy vegetables like Spinach, Mint, Methi, Amaranth etc.
Also, increase the intake of vitamin C. So, consume lots of fresh fruits like Guava, Sweet Lime, Oranges, Aavla, etc.
Consume raw freshly sprouted pulses. It can be consumed with salads too.
Consume Ragi (Nachni), soya bean flours. They can be mixed with wheat flour and chapatis can be made out of it.
Consume Rice flakes (Poha) as they are good source of iron.
Use jaggery instead of sugar, as jaggery is a good source of iron.
Soak 2-3 dates in water at night and then in the morning, consume it with milk or with water.
Sodium and Potassium Requirements: Sodium restriction is prescribed if edema (fluid retention in body) is present. Sodium is restricted to 2 gm per day. At the same time, potassium intake is increased. Some potassium-rich foods are coconut water, water obtained after boiling Moong Dal, Amla, Guava, Sapota, Papaya, Sweet lime, Peaches, Phalsa, Plums, and Gourd vegetables like Lauki, Karela, Turai, etc.
In order to make food palatable even with less salt one should make use of pepper powder, lemon juice, etc. Also, avoid food items like Jam, Canned fruits, Sauces, Pickles, Papads, Salted biscuits, Salted dry fruits, Cheese, Butter, Potato chips, and fruits like Lichi, Pineapple. Due to restriction of salt, the food becomes less palatable and therefore the patient becomes irritable. However, we can make food palatable if we follow the following tips:
Make the food look attractive, so garnish well. Can use coriander leaves, tomato slices, onions, etc. Use Ratanjot for natural red color. Ratanjot is a herb which gives bright red color. Make vagaar with Ratanjot, it will give bright red color to food. Can add Ratanjot in Dal, sabzi, pulav, etc.
Always serve food hot. When food is consumed hot, one does not feel that there is less salt in food. So, serve soups, dal, sabzi hot and ask the patient to consume it hot only.
Squeeze lemon juice from top just before serving food. This will curb the need of salt in food.
Add jeera powder and/or black pepper and/or mango powder to food. This will make food tasty even with less salt.
Serve food in attractive vessels.
Fluid Requirement: In case of edema, fluid restriction is necessary. Total fluid intake equals to urinary output + 500 ml.
Alcohol Intake: Alcohol intake should be completely restricted. Even a single drop can be deadly.
SODIUM AND HEPATITIS C
Advanced scarring of the liver (cirrhosis) may lead to an abnormal accumulation of fluid in the abdomen, referred to as ascites. Patients with HCV 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 of the diet, the better this excessive fluid accumulation is controlled. Sodium intake should be restricted to 1,000 mg. a day or less. This requires careful shopping and reading all food labels. It is often surprising to discover which foods are high in sodium. For example, one ounce of corn flakes contains 350 mg. of sodium; one ounce of grated parmesan cheese, 528 mg. of sodium; one cup of chicken noodle soup, 1,108 mg. of sodium; and one teaspoon of table salt, 2,325 mg. of sodium. Avoid fast food restaurants, because most fast foods are high in sodium. Meats, especially red meats, are high in sodium, so meat consumption may need to be reduced and vegetarian alternatives considered. Patients with chronic HCV without ascites are advised not to overindulge in salt intake, although their restrictions need not be as severe.
At this stage the diet is generally high in complex carbohydrates (breads, cereals, grains, legumes, dried beans and peas, pasta, rice). These foods are important because they provide our bodies fuel source called blood glucose (also referred to as "blood sugar"). During cirrhosis, individuals frequently experience low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia). Your body is better able to maintain a healthy, sustained level of energy from complex carbohydrates ("starches") rather than from simple carbohydrates ("sugars").
Think of your body as an automobile. Your body's "gasoline" is blood glucose. Sugars found in candy, fruits, sweet pastries, and milk products supply the body with "gasoline", but your body uses it quickly. The result is that your energy level usually rises and then falls too quickly with sugars than it would with complex carbohydrates, especially those with higher fiber content. This is not to say that simple sugar foods cannot be eaten, only in smaller proportion to complex carbohydrates and in more controlled portions.
You will also continue to need adequate, but not excessive protein in your diet (see When you discover you're Hepatitis C positive). Protein is needed for repair and maintenance of blood and body tissues, including liver tissue. Persons with cirrhosis tend to better tolerate the protein from dairy and plant sources than from meat sources, and therefore may benefit from a more vegetarian type diet. Daily protein needs in grams will vary according to your nutritional state. Your R.D. can give you more specific guidelines on this according to your body weight and the status of your disease.
Persons with cirrhosis often begin to experience difficulty digesting and absorbing fat in the diet. The result is steatorrhea, (the presence of undigested fat in the stool), and thereby may require dietary fat modification. Fatty liver is also a condition that can occur which is the accumulation of fat in the liver. In either of these cases, reducing the fat to 25% of total calories (about 40-70 grams of fat daily) is recommended. Use of a special prescription type of fat called MCT oil is sometimes necessary. MCT (medium-chain triglycerides) does not require bile for absorption into the blood stream, so is advantageous when the liver can no longer produce adequate bile for digestion and absorption of dietary fat (lipid). MCT can be used in place of other fats in cooking and some recipes and is also available in certain types of liquid nutritional drinks.
Therapeutic nutritional drinks now contain a mixture of MCT and other fats (called structured lipids). Using MCT alone can produce undesirable gastrointestinal complaints and is not indicated for the diabetic or significantly starved person. Structured lipids also have been found to enhance the immune system over other types of fats. Also, if MCT is the exclusive fat used in the diet, supplementation with the essential fatty acid called linoleic acid is required to prevent a dietary deficiency.
Vitamin deficiencies can occur during this stage of the disease. Fat-soluble vitamins A, D, E, and K may need to be taken in their water-soluble form by prescription from your doctor. Deficiencies of the minerals zinc, calcium, and magnesium can also occur during cirrhosis and may require supplementation. It is important that you do not take vitamins or minerals not prescribed by your doctor as toxicity can occur with overdosing. Sodium typically needs to be restricted with cirrhosis. Unfortunately for many salt lovers, this means learning to enjoy the taste of foods without salt. Since the taste for salt is acquired, it can also be lost, (usually taking 4-6 weeks of "biting the bullet" until you finally come to enjoy the many tastes of food, spices, and herbs without the salt shaker!)
Beware: many foods are high in sodium because of what's added in processing. Processed meats, cheeses, frozen dinners, canned soups and vegetables, snack chips and crackers can pack over 1000 milligrams of sodium per serving. Considering that the person with cirrhosis must usually limit sodium to 2,500 milligrams per day, these foods leave little room for other necessary, more healthy foods in the diet. Remember that sodium acts like a "sponge" in the body and can cause your body to hold on to more fluid, predisposing you to abdominal fluid retention seen in cirrhosis called ascites.
NUTRITIONAL MANAGEMENT:
Energy Requirements: Due to extreme weight loss in cirrhosis, energy requirements are increased. A diet with 25-35 Kcal/Kg IBW (Ideal Body Weight) per day is recommended. Small and frequent meals should be given.
Carbohydrate Requirements: The carbohydrate content of the diet should be high in order to provide sufficient calories so that protein is not utilized for energy. Also, the liver may store glycogen. Liver function improves when an adequate store of glycogen is present in hepatocytes (liver cells). Simple carbohydrates should be given, i.e., sugars, fruits juices, Sago, Arrowroot products, etc. About 65-70 % of total calories should be provided by carbohydrates.
Protein Requirements: A liberal protein intake is essential for the repair of hepatic cells. The serum albumin which is exclusively synthesized by the liver cells falls down in cirrhosis as a result of which there is water retention. So, in order to maintain serum levels of albumin, it is necessary to take protein. In case of absence of Hepatic Coma (a condition in which ammonia levels increases leading to brain tissue damage), 1.2 -1.5 gms per kg present body weight can be given. Both animal and plant protein can be given. Vegetable and dairy proteins are better tolerated because of their lower content of Aromatic Amino Acids (Methionine and Glutamine) and higher content of Branched chain Amino Acids (Valine, Leucine, and Isoleucine). If protein requirements cannot be met by diet alone, then protein supplements can also be given. However, if cirrhosis progresses to Hepatic Coma, then protein has to be totally restricted.
Fat Requirements: Cirrhosis is marked by impaired fat metabolism and absorption. Triglycerides which contain Medium Chain Fatty Acids (8-10 CARBON FATTY ACIDS) like Ghee, Butter, etc. can be given. These triglycerides do not require bile for their digestion and absorption. This will help to prevent steatorrhea (fatty stools). As the condition improves, large chain triglycerides can be given to avoid deficiency of essential fatty acids.
Vitamin Requirements: All of the vitamin should be supplied in abundance to fortify the liver against stress and to repair the damage. Since the liver is involved in the synthesis of active forms of any B-complex vitamin and due to lack of proper function, it is advisable to give B-complex vitamin supplements. In the presence of steatorrhea, water soluble forms of vitamin A, D, E, and K should be given. In severe cirrhosis with problems of vitamin storage, metabolism, and transport intramuscular injections of Vitamin A, D, E, and K may be necessary.
Mineral Requirements: Iron intake should be increased to prevent anemia because the liver is unable to store iron in the form of ferritin. Iron supplements can be given. However, simultaneous increase of vitamin C is also required. Calcium intake should also be increased. Iron intake can be increased by following measures:
Increase the intake of Green leafy vegetables like Spinach, Mint, Methi, Amaranth etc.
Also, increase the intake of vitamin C. So, consume lots of fresh fruits like Guava, Sweet Lime, Oranges, Aavla, etc.
Consume raw freshly sprouted pulses. It can be consumed with salads too.
Consume Ragi (Nachni), soya bean flours. They can be mixed with wheat flour and chapatis can be made out of it.
Consume Rice flakes (Poha) as they are good source of iron.
Use jaggery instead of sugar, as jaggery is a good source of iron.
Soak 2-3 dates in water at night and then in the morning, consume it with milk or with water.
Sodium and Potassium Requirements: Sodium restriction is prescribed if edema (fluid retention in body) is present. Sodium is restricted to 2 gm per day. At the same time, potassium intake is increased. Some potassium-rich foods are coconut water, water obtained after boiling Moong Dal, Amla, Guava, Sapota, Papaya, Sweet lime, Peaches, Phalsa, Plums, and Gourd vegetables like Lauki, Karela, Turai, etc.
In order to make food palatable even with less salt one should make use of pepper powder, lemon juice, etc. Also, avoid food items like Jam, Canned fruits, Sauces, Pickles, Papads, Salted biscuits, Salted dry fruits, Cheese, Butter, Potato chips, and fruits like Lichi, Pineapple. Due to restriction of salt, the food becomes less palatable and therefore the patient becomes irritable. However, we can make food palatable if we follow the following tips:
Make the food look attractive, so garnish well. Can use coriander leaves, tomato slices, onions, etc. Use Ratanjot for natural red color. Ratanjot is a herb which gives bright red color. Make vagaar with Ratanjot, it will give bright red color to food. Can add Ratanjot in Dal, sabzi, pulav, etc.
Always serve food hot. When food is consumed hot, one does not feel that there is less salt in food. So, serve soups, dal, sabzi hot and ask the patient to consume it hot only.
Squeeze lemon juice from top just before serving food. This will curb the need of salt in food.
Add jeera powder and/or black pepper and/or mango powder to food. This will make food tasty even with less salt.
Serve food in attractive vessels.
Fluid Requirement: In case of edema, fluid restriction is necessary. Total fluid intake equals to urinary output + 500 ml.
Alcohol Intake: Alcohol intake should be completely restricted. Even a single drop can be deadly.