Diet and your liver – Patients with liver disease

The approach to diet does change when you have liver disease, particularly cirrhosis. There isn’t specific advice that would say you have to have this vitamin, or this mineral, or you mustn’t eat this type of food because it contains something. We don’t have specific diets for specific diseases. It’s a dietary approach, and consideration, and it’s to do with the changes in energy– metabolism– in the body. So normally, the liver would be central in creating a store of energy in muscle that we use when we’re between meals, or if we miss a meal, or we’re extra busy, or overnight. And that’s stored glucose as starch turned glycogen.

Then you would break this glycogen down, as I say, in times of fasting, when you need extra energy. With people with cirrhosis, that mechanism fails. And when you’re first unwell with first signs of the disease– so when you develop Ascites, or jaundice, or become unwell with liver disease– you burn off that glycogen store over a day or two. But it doesn’t get put back. And that’s where things change. Because the next time you’re between meals, missing a meal, overnight, running on empty, you use your actual muscle mass. Muscle can be broken down very quickly into glucose, which is the primary fuel for the brain and other organs. Fat takes much longer to break down.

So you can use fat as a supplementary fuel overnight, but the predominant fuel, in the absence of sufficient calories, would be muscle protein. And this can lead to significant muscle loss in people with cirrhosis. And we know that that muscle loss can be linked to the severity of the disease, from the point of view that disease can be worse the more poorly nourished you are. So the information we give to people is to explain that mechanism, so they understand the changes in their body. But they need to change the way that they eat.

Which does go against the grain from healthy eating, because we’re then saying it needs to be meals and snacks, or small meals and snacks, to bridge the gap between breakfast and lunch, and lunch and evening meal. And the snacks vary, depending on how much muscle the person’s lost. Because you have an increased need for protein altogether in the diet. Quite significant increase– probably another 50% over the normal intake. So some of these snacks need to be protein-containing.

If we can’t achieve that through snacks because someone’s appetite is very poor, which goes as a characteristic of liver disease, really– poor appetite– then we would use specialist products, nutritional products that are nutritional supplements, to either drink, or take as a powder, or a medicine, to give the extra protein. One of the most important things is to have supper. So studies have shown– we know that having this magical 50 grams of carbohydrate before bedtime gives the body fuel to burn overnight, which stops the use of muscle, and allows the muscle to recoup some strength and some tissue. So those sorts of things.

There’s quite a lot of carbohydrate, like a large bowl of cereal, a few biscuits, and a glass of milk. Some toast. Other ideas would be tea cake. Scone. Even– we do encourage things like cake and sweeter snacks, sandwiches, because your overall requirements for protein and calories are increased with liver disease. So this bedtime snack is very, very important, and it almost is giving the liver something to burn, so it doesn’t need to break down the muscle to feed you. And that allows the muscles some time to recover. So it’s the changes, then, to your metabolism that mean you need to have frequent meals.

Overall, there’s more protein needed to make up for the muscle that is used, and put that muscle back. And because the liver is working much harder, your metabolic rate is increased. So you do need, overall, more calories than normal.

People that suffer with biliary diseases, such as PBC or PSC, may have a problem with digesting fats. It can cause lots of discomfort when eating, so after you’ve eaten, you can get a lot of gurgling, a lot of noise, feeling of indigestion, food sitting in the stomach. And that’s because there isn’t enough bile being released into the system to digest these fats, so to break them down and allow the body to absorb them. The net effect of that is diarrhoea, which is not necessarily watery diarrhoea. It’s bulky stools, but they’re frequent, and pale. Difficulty flushing them away in the toilet is one of the signs of steatorrhea, is the term, for fatty stools.

So we talk through these symptoms with people, and it’s very important to reduce the amount of fat, so that the symptoms go. So it’s not to a specific level, so it’s not the same for everyone. People have different tolerances. But when you’re not digesting fats, they’re being lost in the toilet. And they take with them vital calories, proteins, and vitamins that are all bound up in that undigested food. The consequence of that is that you break down more muscle to feed you, because you can’t digest the fats and get the calories from it.

So we’d advise people to reduce the amount of fat to a level where they feel comfortable, usually reducing higher fat snacks, like the cakes, and biscuits, and chocolates, and going for lower fat alternatives. More starchy foods, and lower fat proteins. So the things like malt loaf, and tea cakes, and scones, and breakfast cereal, and bread and rice and pasta– all those good starchy foods give good, reliable, absorbable energy. And usually in this situation, people do need some lower fat specialist supplement drinks to top up their protein intake. But you can thrive on that diet, and actually put on weight– which sounds a bit backward when you’re reducing energy intake– but because we compensate for that. Keep people symptom free.

That’s very important in the management.

But people that have fatty liver that’s progressed to cirrhosis may be well-nourished. They may need more advice on maintaining a healthy lifestyle, but making sure that their muscle is protected. So we’d still do the measurements that look at muscle mass, and test their strength with hand grip. They require more specific and tailored advice, so they’re getting far more protein than normal to protect the muscle. The regular meals to protect the muscle. But they still need to be reducing the fats and sugars in the diet. Because if fat’s still accumulating in the liver, it’s still causing ongoing liver injury, although there’s cirrhosis. So it’s termed a driver of disease.

So overall, it’s more frequent meals and supper, extra protein, extra calories, watching fat if you are very jaundiced or have a biliary disease, and if you are well-nourished and have fatty liver disease with cirrhosis, we would help with healthy lifestyle and protein advice.