Diet and Hepatitis C

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Diet and Hepatitis C

Diet and Hepatitis CLiz Highleyman

http://www.hcvadvocate.org/news/newsLetter/2009/advocate1109.html#3In the past, when less was known about hepatitis C and its treatment, strict dietary modification was considered an important aspect of disease management, especially for people with advanced liver fibrosis or cirrhosis.Today, hepatology experts increasingly recognize the importance of the metabolic aspects of chronic hepatitis C, and pay more attention to managing obesity and blood sugar and fat abnormalities.The Liver as Food ProcessorThe liver plays an important role in digestion and processing of food, including filtering out toxins, regulating sugar and fat metabolism, converting food into usable forms of energy, and storing nutrients for later use. Therefore, it is not surprising that

what we eat can have major effects on the liver, and vice versa.Blood sugar, or glucose, levels increase after eating. The liver converts some of this glucose into glycogen, which is stored for later use. Conversely, when energy is needed, the liver converts glycogen back into glucose, a process called gluconeogenesis.Liver enzymes called aminotransferases (ALT and AST) process amino acids from digested food, which are then used to build compounds including fatty acids, cholesterol, hormones, neurotransmitters, and immune and clotting factors. When the body does not get enough sugar, the liver can convert fatty acids into ketones, which provide an alternative source of energy. In addition, the liver stores nutrients including vitamin A, vitamin D, and iron.When Liver Function Goes AwryAs the liver becomes increasingly damaged by HCV infection, heavy alcohol use, or other causes, it loses it ability to carry out crucial

metabolic functions. People with cirrhosis are less able to process proteins and eliminate toxic by-products such as ammonia. Elevated ammonia levels can lead to impaired brain function known as hepatic encephalopathy, which may progress to hepatic coma.For this reason, cirrhotic patients have traditionally been advised to limit the amount of protein in the diet – a legacy of the days when there were few other therapies for encephalopathy. But clinical trials do not support this approach, and today other therapies are preferred (e.g., lactulose, neomycin).In the July 2004 Journal of Hepatology, Cordoba and colleagues from Barcelona reported results from a study of dietary protein in 30 cirrhotic patients hospitalized with episodic hepatic encephalopathy. Participants were randomly assigned to receive either a normal-protein (1.2 gm/kg/day) or a low-protein diet for 14 days; they were also treated with standard measures to reduce

blood levels of ammonia.Encephalopathy outcomes did not differ significantly between the two groups. The groups also exhibited similar levels of protein synthesis, but the low-protein group had greater protein breakdown. “Diets with a normal content of protein, which are metabolically more adequate, can be administered safely to cirrhotic patients with episodic hepatic encephalopathy,†the researchers concluded. “Restriction of the content of protein of the diet does not appear to have any beneficial effect for cirrhotic patients during an episode of encephalopathy.â€The milder cognitive impairment – or “brain fog†– commonly reported by people with hepatitis C who do not have advanced liver damage is not thought to be related to toxic metabolic by-products, and protein restriction is not recommended for this group.Cirrhosis also interferes with the liver’s ability to synthesize blood proteins such as albumin,

which helps regulate the body’s fluid balance. Reduced albumin levels, in conjunction with portal hypertension due to impaired blood flow through a heavily scarred liver, can lead to ascites, or build-up of fluid in the abdominal area. Sodium, or salt, worsens this condition, as well as edema or swelling in the feet and legs, so patients are often be advised to limit dietary sodium.In addition, impaired bile synthesis and flow may result in reduced ability to digest fat and absorb certain vitamins, and altered metabolism and storage can lead to various nutrient deficiencies.Fatty Liver and the Metabolic SyndromeSteatosis, or fat accumulation in the liver, is increasingly recognized as a manifestation of the metabolic syndrome – a constellation of conditions including high blood pressure, insulin resistance, elevated blood lipids, systemic inflammation, and abdominal obesity that are associated with increased risk of

cardiovascular disease.A growing body of evidence indicates that insulin resistance (decreased ability of cells to respond to insulin, which they need to absorb and use glucose), diabetes, and obesity are associated with accelerated steatosis and fibrosis progression, as well as poorer response to interferon-based therapy.Furthermore, a study presented at the European Association for the Study of the Liver (EASL) meeting this past April indicated that insulin resistance, high body mass index, and elevated cholesterol were the strongest predictors of liver-related mortality in people with hepatitis C.The effect of HCV on blood lipids is less clear, but considerable research indicates that it appears to actually lower blood fat levels, which may mask cardiovascular disease risk.In the October 2009 issue of Hepatology, K. Corey and colleagues found that people with HCV had significantly lower total and harmful low-density

lipoprotein (LDL) cholesterol than uninfected control subjects. In a retrospective analysis, treated hepatitis C patients who achieved sustained virological response had larger increases in total and LDL cholesterol from baseline than patients without viral clearance. After treatment, one-third of patients who cleared HCV had elevated total cholesterol levels warranting lipid-lowering therapy.“A significant portion of successfully treated patients experience LDL and cholesterol rebound to levels associated with increased coronary disease risk,†the researchers concluded. “We suggest that serum lipid levels should be assessed in follow-up among patients undergoing successful antiviral therapy, as clearance may reveal some patients with previously unappreciated coronary risk.â€What is a Healthy Diet?A healthy diet for people with hepatitis C closely follows the type of diet recommended to the general population for optimal

health and lowering cardiovascular risk. Such a diet is low in fat, sodium, and processed sugar, and rich in fruits, vegetables, and complex carbohydrates like those found in starches and whole grains. The new Food Guide Pyramid is a good basis for a healthy diet.

People with chronic illness are at greater risk for malnutrition, and it is important to consume an adequate amount of calories and protein for bodily maintenance and repair and to avoid wasting. As noted, research generally does not support severe protein restriction, although some clinicians still recommend low-protein diets for patients with hepatic encephalopathy. Although there is little controlled research on the topic, many experts favor protein from non-animal sources – or from chicken or fish instead of red meat – which contains less ammonia and is more easily processed by the liver.Most people can get an adequate amount of nutrients by eating a well-balanced diet, but others may benefit from nutritional supplementation. However certain vitamins and minerals – including vitamin A, vitamin D, niacin, and iron – can be toxic to the liver at high doses, so consult a healthcare provider before taking supplements

or starting unusual diets.In addition to food, it is important to drink enough water or other liquids. A common recommendation is eight glasses of water per day, though this varies based on a person’s weight. The Institute of Medicine advises that average-sized men should drink about 13 cups and women should drink about nine cups of total fluids each day. Some experts recommend avoiding caffeine, which has a dehydrating effect, though some studies suggest coffee and tea are associated with reduced fibrosis and it is well-known that people with liver disease should avoid alcohol.Recent ResearchOverall, current dietary guidelines for people with hepatitis C are based on “common sense†and general recommendations for the population as a whole, but some research has looked specifically at the link between diet and liver disease.In the July 2009 issue of Hepatology G. Ioannou and colleagues reported that in a study of more

than 9,000 initially non-cirrhotic participants (not limited to those with HCV) followed for an average of 13 years, people who ate a diet high in protein were at higher risk for hospitalization or death due to cirrhosis or liver cancer, while those who reported a diet high in carbohydrates were at lower risk. Total fat consumption was not significantly linked to cirrhosis or liver cancer, but cholesterol consumption significantly increased the risk; blood cholesterol, however, was not a risk factor.In another recent study, published in the September 2, 2009, advance online edition of Journal of Viral Hepatitis, E. Sathiaraj and colleagues found that many patients with acute viral hepatitis in India consumed significantly less calories and protein after becoming ill, which they attributed to perceptions and traditional nutritional practices. Furthermore, individuals who consumed a low-calorie diet required significantly longer hospitalization

than those who ate a high-calorie diet (an average of six vs. eight days, respectively).With regard to treatment, C. Loguercio and colleagues from Italy reported in the December 2008 American Journal of Gastroenterology findings from a study of more than 1,000 chronic hepatitis C patients (432 of them treated with interferon-based therapy) and more than 2,000 uninfected control subjects; about half were overweight. They found that consumption of carbohydrates, lipids, polyunsaturated fatty acids, and alcohol were independent risk factors for liver damage. In addition to heavier alcohol use, levels of unsaturated fatty acids, iron, zinc, vitamin A, and niacin differed significantly between treatment responders and non-responders; steatosis also predicted poorer response.ConclusionWhile dietary restrictions are no longer considered a mainstay of managing liver damage, the contribution of insulin resistance and obesity to liver disease

progression and poor hepatitis C treatment response is increasingly recognized.This has led to an increased emphasis on healthy diet – along with increased exercise, optimal weight, and possibly insulin-sensitizing medications like rosiglitazone (though studies to date have produced mixed results) – as part of a lifestyle modification program to reduce fibrosis progression, optimize treatment response, and improve overall health.

For further information on diet and hepatitis C:,

HCV Wellness: Nutrition and Hepatitis C: www.hcvadvocate.org/hepatitis/factsheets_pdf/nutrition_09.pdf.

Department of Veteran Affairs National Hepatitis C Program:

www.hepatitis.va.gov/vahep?page=diet-00-00.U.S. Department of Agriculture Food Guide Pyramid:

www.mypyramid.gov.

ReferencesCordoba, J. et al. Normal protein diet for episodic hepatic encephalopathy: results of a randomized study. Journal of Hepatitis 41(1): 38-43. July 2004.Corey, K. et al. Hepatitis C virus infection and its clearance alter circulating lipids: implications for long-term follow-up. Hepatology. 50(4): 1030-1037. October 2009. Ioannou, G. et al. Association between dietary nutrient composition and the incidence of cirrhosis or liver cancer in the United States population. Hepatology 50(1): 175-184. July 2009.Loguercio, C. et al. The impact of diet on liver fibrosis and on response to interferon therapy in patients with HCV-related chronic hepatitis. American Journal of Gastroenterology. 103(12): 3159-3166. December 2008.Sathiaraj, E. et al. Dietary alterations due to perceptions in acute viral hepatitis lead to sub-optimal calorie intake and increased length of

hospitalization. Journal of Viral Hepatitis. September 2, 2009 (epub ahead of print).

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