REOST: INFO: Loving your Liver by Johansen, RD

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Sep 15, 2007 9:06 am (PST)

Loving your liver

Canada develops nutrition guidelines for hepatitis C

by Johansen

In 2003, Health Canada commissioned Dietitians of Canada, a national

organization, to develop national nutrition guidelines for the

management of hepatitis C (HCV). About 240,000 Canadians have

hepatitis C, which accounts for most cases of chronic liver disease in

this country. The liver is intimately related to and interdependent

with nutrition. It is involved in digestion, absorption, storage, and

metabolism of the nutrients in food. The nutrients provided by our

diet in turn nourish the liver. The principle goal of nutritional

therapy in HCV is to protect the liver and slow the progression of

liver damage.

People only infected with hepatitis C can go for many years without

showing any symptoms of liver disease. No specific dietary

restrictions are required during this period, but general guidelines

aim to preserve optimal nutritional health. As liver disease

progresses to cirrhosis or liver failure, nutritional needs become

more specific to address individual problems. The following summary of

the national nutrition guidelines is not meant to replace

individualized counselling for people with more advanced liver

disease. These general goals of nutrition intervention in liver

disease vary in importance according to an individual's stage of liver

disease:

.. To provide adequate energy and protein to facilitate hepatocyte

regeneration, which will improve liver metabolism and overall

nutritional status

.. To promote and maintain nitrogen balance, avoiding excess production

of ammonia from endogenous or exogenous protein catabolism

.. To avoid complications related to the role of the liver in

intermediary metabolism of carbohydrates, lipids, and proteins

.. To provide adequate vitamins and minerals

.. To avoid fluid and electrolyte imbalance

.. To use appropriate supplementation when needed

.. To treat or reduce symptoms or treatment side effects

.. To prevent increased morbidity or death related to nutritional factors

Interpreting the guidelines

Energy requirements are the number of calories a person needs to

achieve certain weight goals—meaning to lose, gain, or maintain

weight—in healthy individuals. These requirements are modified to

address any complications imposed by a disease like HCV or HIV.

Requirements vary for individuals with HCV, depending on

weight goals and the stage of liver disease. The hepatocytes (liver

cells) need energy to make new cells and regenerate liver tissue.

People with chronic HCV have higher calorie needs than normal because

of the hepatitis viral load. If liver disease progresses to cirrhosis

or decompensated cirrhosis, the calorie requirements increase even

more to prevent undesired weight loss and malnutrition.

Protein provides the building blocks for liver, immune, and muscle

cells. Individuals with HCV need more protein than does the healthy

population. The recommended dietary allowance (RDA) for healthy

individuals is 0.8 grams of protein per kilogram of body weight (0.4

grams/pound). People with HCV need at least 1.0-1.2 grams/kg and those

with cirrhosis need up to 1.5 grams/kg.

The problem with protein is that one of the products of metabolism is

ammonia, which the liver must then break down. A sick liver does not

keep up with the demand, so ammonia builds up and gets into the brain,

causing hepatic encephalopathy (brain fog). Contrary to popular

belief, protein is never restricted unless severe encephalopathy that

can't be treated any other way is present.

Spread protein intake throughout the day in smaller portions, so the

liver can handle it. More protein choices should come from vegetarian

sources such as eggs, beans, lentils, tofu, and soymilk. Some people

with chronic encephalopathy benefit from supplements that contain

branched-chain amino acids that are metabolized more by muscle than

liver. Your liver specialist and dietitian can advise you if you need

to cut back on protein intake or try the specialized amino acid formulas.

Carbohydrate metabolism can become impaired, which sometimes results

in glucose intolerance (high or low blood sugar levels). Insulin

builds up because a cirrhotic liver does not degrade it well. High

insulin levels increase the breakdown of muscle proteins and cause low

blood sugar levels. Producing glycogen, the storage form of glucose,

can also be a problem. Blood sugar levels can thus become quite prone

to shifting too high or too low. People with cirrhosis are more

susceptible to glucose intolerance, insulin resistance, and

hyperinsulinemia; sometimes they develop diabetes. Blood sugar levels

should be checked regularly.

Carbohydrates come from starches, grains, fruits, vegetables, and

sugars. It is not necessary to limit grains, fruits, and vegetables,

but choose more whole grains. Sugar and sweet drinks such as juice,

pop, and even pure fruit juice, may exacerbate blood sugar problems

and high triglyceride levels. Fat metabolism is generally not affected

by chronic liver disease.

As liver disease progresses to cirrhosis or liver failure, nutritional

needs become more specific to address individual problems.

Most people with HCV can continue to follow general guidelines to eat

a moderate amount of fat and limit saturated and trans fats. In some

cases, the cirrhotic liver does not produce enough bile acids to

digest and absorb dietary fats, which results in fat malabsorption and

diarrhea. A dietitian or doctor can prescribe specialized

fats—medium-chain triglycerides— to supplement the diet. Fluid

requirements are generally the same for people with HIV as they are

for the general population. Most people need 35mL of fluid for every

kilogram of body weight (for example, a 60kg person needs 2100mL

fluid). However, people with fluid retention in the abdomen (ascites)

or legs (peripheral edema) may need to restrict the fluid and sodium

they consume.

Vitamins and minerals as antioxidants

Like HIV, HCV is a disease that causes high levels of oxidative

stress, which contributes to liver injury. Studies examining the

potential benefit of antioxidant supplementation have shown promising

results. Although the guidelines acknowledge the potential therapeutic

role of antioxidant supplementation, they suggest that vitamin and

mineral supplementation should be restricted to the research

environment. People living with HCV should at least be sure to meet

the recommended daily intake and keep supplements to below the upper

tolerable limit. The goal of supplementation is to support liver

health without damaging an already fragile liver with toxic

doses of vitamins and minerals.

Here are some key points about vitamins and minerals:

.. Fat-soluble vitamins (A, D, E, and K) may not be absorbed properly

in patients with fat malabsorption.

.. Vitamin D is activated in the liver and can become compromised in

cirrhosis.

.. Vitamin A deficiency may increase the risk of developing liver

cancer. However, vitamin A can also be toxic to the liver.

.. Vitamin C offers antioxidant protection, but high doses can increase

iron levels in the liver.

.. Vitamin E has been shown to decrease oxidative stress, lower liver

enzyme levels, and delay anemia associated with ribavirin treatment.

.. Thiamine has antiviral properties in test tube studies and may slow

liver injury by reducing the iron load.

.. Niacin can be toxic to the liver in doses of 1000 mg per day.

.. Iron is stored in the liver. Cirrhotic livers sometimes store

dangerously high amounts of iron.

.. Selenium levels may be low in persons co-infected with HIV and HCV.

.. Zinc deficiency is common in cirrhosis and may be involved in the

development of encephalopathy.

.. Calcium deficiency may develop because of poor nutrition,

malabsorption, or vitamin D deficiency.

.. Magnesium deficiency may occur, especially in persons taking diuretics.

The overall recommendation is to take a multivitamin mineral, without

iron if cirrhosis or iron overload are a problem. Take all other

vitamins, minerals, and antioxidants under the supervision of a

physician or as part of a study.

Ultimately, the best approach is to eat a nutritious diet with enough

calories to maintain a healthy weight and enough protein to heal the

liver and maintain lean body mass. Eat plenty of fruits and vegetables

for their vitamin content and antioxidant properties. Limit high-sugar

foods. Get some exercise. Avoid alcohol to protect the liver. If you

have complications that affect your nutritional well-being, see a

dietitian.

This article summarizes a small portion of a very comprehensive document.

To read the complete Canadian Guidelines, go to

http://www.dietitians.ca/resources/resourcesearch.asp?fn=view & contentid=2516

(Updated URL) *NOTE*

These guidelines are suitable for anyone with chronic liver disease.

Johansen, RD, is the dietitian at Oak Tree Clinic in Vancouver.

She specializes in HIV.

-----------------------------------

Part 1 (May/June 2004) Source:

http://bcpwa.org/articles/issue_30_28-29_loving_your_liver.pdf

To read Part II (July/Aug. 2004) download the *PDF below:

http://www.bcpwa.org/articles/issue_31_30-31_loving_your_liver.pdf

====================================

*NOTE*: The above URL is corrected as the original link to the

Hepatitis C: Nutrition Care Canadian Guidelines in the document was

outdated.

The Nutrition Care Canadian Guidelines (Mar. 2003) provides

information on nutrition and lifestyle. (70 pgs.)

* PDF requires free Adobe Reader to view files.

http://www.adobe.com/products/acrobat/readstep2.html

About :

< Dietitian

Johansen works full time at the Oak Tree Clinic. She counsels

patients on HIV-related nutrition issues, including healthy eating,

metabolic complications and micronutrient supplementation. She also

does body composition measurements. She is active in advocacy,

outreach and research and is the author of B.C.'s Therapeutic

Nutrition Guidelines for HIV/AIDS. has been doing extensive

international work through the Pan-American Health Organization. >

Source URL:

http://www.bcwomens.ca/Services/HealthServices/OakTreeClinic/MultidisciplinaryTeam.htm