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Liver disease and diet problems

Liver disease and diet problems

This section gives brief advice on diet, based on available information, for people with particular liver problems. If you have further questions or worries about your particular condition, the best person to talk to is your doctor or dietician. If you have already been advised to follow a special diet it is essential to talk to your doctor or dietician before making any changes.

The liver conditions that are covered here are:
acute viral hepatitis
chronic viral hepatitis 
autoimmune hepatitis 
primary biliary cirrhosis 
primary sclerosing cholangitis 
fatty liver 

cirrhosis
Acute viral hepatitis
 
If you have a short-term (acute) hepatitis infection caused by a virus – like hepatitis A, for example – you may actually feel quite well and should try to eat a normal diet. However, some people may need extra nutrition to prevent unplanned weight loss and may benefit from a high calorie and protein diet. A dietician can advise on this. If you develop nausea and vomiting, which make eating difficult, then the advice given under ‘Coping with eating difficulties’ earlier in this leaflet may help.

Chronic viral hepatitis
 
If you have a long-term hepatitis infection (when infection lasts longer than six months – sometimes coming and going) caused by a virus – hepatitis B or C, for example – you can eat a normal, well balanced diet. You should not need to change what you eat unless you have problems with poor appetite and unintended weight loss. A poor appetite, nausea and vomiting are unpleasant but these symptoms only cause a nutritional problem if they last longer than a few days or if you are continuing to lose weight. In this case you should consult your doctor.

Autoimmune hepatitis
 
Some people who are prescribed steroids for autoimmune hepatitis may find their appetite increases and that they gradually gain weight. If this happens, it is still important to eat a varied and well balanced diet. However, if you are gaining too much weight you should try to reduce calorie-rich foods – including sugar, sweets, cakes, biscuits, fried food, pasties and pies, crisps and chocolate – use low-fat versions instead and fill up on fruit and vegetables. If weight gain is a problem, your doctor may suggest specialist help from a dietician.

Primary biliary cirrhosis and primary sclerosing cholangitis
 
If you have primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC) you may need to change your diet as the way you digest fats may be altered. In order to digest fat we need bile. This is a yellowish acid made in the liver and stored in a pear-shaped bag called the gallbladder. It is squirted into the small intestine where it acts as a detergent, breaking fat into tiny droplets so it can be absorbed by the body.

With PBC and PSC the flow of bile into the gut may be reduced, particularly if you are jaundiced, so you may find you cannot tolerate the same amount of fat as normal. In this situation you develop a type of diarrhoea, known as steatorrhoea, which causes bulky, pale faeces/stools that are difficult to flush away. It can cause nausea and a sick, bloated feeling.

If this happens, you may find that eating less fat in the diet will help to reduce the problems and symptoms of this fatty diarrhoea. However, fat is essential – it contains the fat-soluble vitamins A, D, E and K, as well as essential fatty acids – and should not be cut out of your diet completely without proper advice from a dietician. People vary in the amount of fat they can tolerate so this does not mean you will necessarily need to eat a strict, low-fat diet. Most people find they are able to work out how much fat they can take by trial and error by reducing amounts of the higher fat foods.

Improvement in bowel habit shows that your body is tolerating the amount of fat you are eating. Stools will become less frequent, darker and easier to flush away. If you are reducing fat in your diet and do not need to lose weight, top up calories with snacks between meals, for example, toast, crackers, crumpets or tea-cakes. Your dietician can help you with this.

Cutting down on fat

If you want to cut down on the fat you eat you need to avoid ‘hidden’ fats as well as the obvious ones you can see in meat and greasy foods. The list below gives examples of high-fat foods and ideas for alternatives.
Butter, margarine, lard, dripping – try using low fat spreads.
Cream and full-cream milk – substitute half-fat versions. There is as much calcium (needed for healthy bones) in half-fat or skimmed as there is in full-cream milk. 
Cheese – you may be able to tolerate small amounts of normal cheese, or try lower-fat hard cheese. Try reduced-fat spreads and cottage cheese. 
All kinds of cooking oil including olive oil, sunflower and vegetable oil – use these sparingly. 
Fatty meats, such as duck and belly pork – eat more fish, poultry, lean red meat, beans and eggs. 
Meat products such as sausages and pies – you may be able to eat small amounts of these. 
Chips, crisps and nuts – try oven-chips instead. 
Biscuits, cakes and pastry – try low-fat alternatives such as teacakes, scones and low-fat cakes or biscuits. 

Many processed foods are high in fat – for example pizza, lasagne, ready-made curry or other dishes. Eat only small amounts or use a low-fat version.
Cooking with less fat

The list below gives some ideas on how to reduce the amount of fat you use in cooking.
Grill, bake, boil, steam or casserole meals instead of frying.
Add flavour with fresh herbs, spices, lemon juice and mustard. Curry powder and hot spices should be avoided as they may make symptoms worse. 
Trim visible fat off meat and remove the skin from poultry. 
Skim fat off the surface of soups and casseroles.
If you are cutting down the fat in your diet you should try to eat extra carbohydrate to make up any shortfall in energy. This means more starch and sugar – bread and honey, for example. Take advice from a dietician to make sure you are getting enough calories, protein and vitamins. Some people may also need monthly injections of fat-soluble vitamins.

Coping with acidity

Some people with PBC may experience an unpleasant acid taste in the mouth or they may get heartburn – a severe burning sensation in the chest. Stomach acids escaping into your food pipe (oesophagus) are the usual cause of this discomfort. If this happens to you, then try eating little and often to reduce stomach acid. It is a good idea to get into the habit of carrying food around with you, in case you need to eat. Foods that contain carbohydrates – such as crackers, plain biscuits or breadsticks – are the best. If symptoms persist try:
avoiding big meals at night
taking an antacid before bed and after meals 

raising the head of your bed by four or five inches
Fatty Liver

Fatty liver is a condition in which too much fat builds up in the liver. You are more at risk of this if you tend to put on weight around your middle – ‘apple-shaped’ as opposed to ‘pear-shaped’. The fat stored in the liver is just the same as that under the skin. So, if you cut down on fatty foods and lose weight you will also lose fat from the liver. For the majority of people in the UK, the root causes of becoming overweight are down to:
eating too much, especially too much fatty food
drinking too much alcohol (up to nine out of ten people who drink too much alcohol will go on to get a fatty liver – even if they are not overweight) 
not doing enough exercise.

If you have fatty liver you may be advised to make changes to your life-style including:
cutting out or down on alcohol (remember, alcohol is high in calories – around 300 calories in a pint of beer and 100 in a 175ml glass of wine and so drinking alcohol will slow the rate at which you lose weight)
taking more exercise, such as walking or swimming 
eating plenty of fruit and vegetables 
eating slow-release starchy foods, such as bread and potatoes 
avoiding refined sugars and fats – as in chocolate, cakes and biscuits 

lowering your weight to a healthy level for your build and age and keeping it there.
Cirrhosis
 
If you have cirrhosis you should eat a well-balanced diet and may need extra energy and protein. Cirrhosis causes damage that stops the liver working properly. This means it may be unable to store glycogen, the carbohydrate that provides short-term energy. When this happens, the body uses its own muscle tissue to provide energy between meals. This can lead to muscle wasting and weakness. If you have been affected in this way, snacking between meals can top up your calories and protein (a bedtime snack is especially effective) as eating between meals helps preserve muscles and keep them strong. Improved nourishment will also make you feel better.
Try to eat regularly, say every two to three hours. Suitable snacks include:

teacake
toast 
crackers 
cereal 
fruit 
high protein drinks.

If you develop the following symptoms you should see a doctor immediately and you may need to change your diet:
fluid retention causing swelling of your abdomen (ascites) or legs (oedema)
mental slowness or confusion (encephalopathy) 

fatty stools/faeces (steatorrhoea).
Fluid retention

Some people with cirrhosis get a build-up of fluid in the stomach area (ascites) and swelling of the feet and legs (oedema). These symptoms may be treated by drugs called diuretics (also known as water pills). You can help control fluid retention by reducing the amount of common salt (often called sodium chloride by manufacturers) in your food. However, while it may be a good idea to cut out foods with a very high salt content, it could be harmful to change to a diet that is too low in salt. Your taste buds become more sensitive to salt as you eat less of it. It is quite easy to cut down salt in the food you prepare yourself but most of the salt we eat is added to foods by the manufacturers. It is often difficult to tell which processed foods are high in salt, as they may not necessarily taste salty. A dietician can advise you on which foods you can eat and which you should avoid.

Ideas for reducing salt
 
Try not to add salt at the table, although you can use a small amount in cooking. 
Stock cubes, bouillon cubes and gravy granules can be used instead of salt in cooking. 
Avoid packet and tinned soups if possible. 
Tinned vegetables, including baked beans, can be high in salt. Look for low-salt or no-salt versions. Frozen vegetables are low in salt. 
Smoked and tinned fish, including salmon, tuna and pilchards in brine contain a lot of salt. Only have these occasionally or try the ones tinned in oil. 
Do not eat cured meats – including ham, bacon, sausages, and salami – on a daily basis. Use cold cooked fresh meat, poultry or eggs more often instead. 
Full-fat hard cheese is an excellent source of protein, so include it in your diet but do not have it every day. 
Ready meals and sauces are high in salt so try to have these less often. Pasta and ‘cook-in’ sauces can be used if no other salt is added to the meal. 

Bovril, Marmite and all yeast extracts are high in salt and so should be avoided.
Cooking without salt
 
Salt is not the only way to make your food taste better, instead try:

freshly ground black pepper
lemon juice on fish or meat 
redcurrant jelly, apricots, rosemary or garlic for lamb 
apple or gooseberry sauce with pork 
ginger, garlic and spring onions with mixed vegetables 
olive oil and vinegar with salad and vegetables 
mustard powder or nutmeg with mashed potato 
various home-made sauces – such as onion sauce made with milk and garlic – used instead of gravy 
toasted and ground sesame seeds added to pastries, breads and stir-fries 
washed and finely chopped coriander root in soups, stews and stock.
In hospital, people who are affected by ascites or oedema may be asked to restrict their fluid intake as well as the amount of salt they eat. This is only done under medical supervision and fluid intake is gradually increased by the time the person goes home.

Mental confusion

Some people with cirrhosis develop poor memory and concentration. They can become confused and may even lose consciousness. It happens because the damaged liver is unable to break down poisons that enter the body. These poisons then get into the bloodstream and are carried to the brain. This tends to happen when a person with cirrhosis also has some other problem such as diarrhoea, vomiting, dehydration, constipation, infection or bleeding. The liver cannot cope with the extra stress on the body and is unable to deal with the poisons/toxins properly. Treatment includes tackling the underlying medical problem and paying careful attention to diet, particularly to eating enough protein. The right nutrition is essential to prevent muscle loss and help improve the mental confusion. If you are affected in this way, talk to your doctor or dietician. You may also find some of these ideas helpful.
Eat three or four small meals during the day rather than one large meal.
Eat eggs and cheese as well as meat, fish and poultry for protein. 
Avoid eating large amounts of protein at one meal – full cooked breakfast, for example. Instead have a bacon sandwich, egg or beans on toast, or a sausage sandwich. 
Fill up with starchy foods such as potatoes, rice, pasta and cereals for slow-release energy. 
Breakfast cereal, served with milk, can make a useful snack. Other ideas include scones, teacakes, crumpets, toast and jam, crackers and cheese, crisps, a chocolate bar or flapjack. 

If your appetite is poor and you are not able to eat snacks, you may need to take high-protein and high-calorie drinks on the advice of your dietician or doctor.
High blood sugar
 
If you have too much sugar (glucose) in your blood, it is know as hyperglycaemia and affects some people with cirrhosis. If this happens in your case, you may be advised to follow a diet similar to the one used by people with diabetes. This means avoiding foods that are high in sugar but otherwise eating a well-balanced diet. People with hyperglycaemia have different needs and will require individual advice from a dietician. It is important to eat enough calories and protein to keep well nourished; energy lost by cutting down on sugar must be replaced from another source. Tea, coffee and sugar-free fizzy drinks and squash are better than sugary drinks which release sugar into the system very quickly. If you have a ‘sweet tooth’ then use sweeteners rather than sugar and avoid sweets and filled chocolate. Commercially produced drinks such as Complan and BuildUp also contain quite a lot of sugar but you may need to use them to get all the energy you need. A dietician can advise you on the best type for you and how to work it into your diet.

This section gives brief advice on diet, based on available information, for people with particular liver problems. If you have further questions or worries about your particular condition, the best person to talk to is your doctor or dietician. If you have already been advised to follow a special diet it is essential to talk to your doctor or dietician before making any changes.
The liver conditions that are covered here are:

acute viral hepatitis
chronic viral hepatitis 
autoimmune hepatitis 
primary biliary cirrhosis 
primary sclerosing cholangitis 
fatty liver 

cirrhosis
Acute viral hepatitis
 
If you have a short-term (acute) hepatitis infection caused by a virus – like hepatitis A, for example – you may actually feel quite well and should try to eat a normal diet. However, some people may need extra nutrition to prevent unplanned weight loss and may benefit from a high calorie and protein diet. A dietician can advise on this. If you develop nausea and vomiting, which make eating difficult, then the advice given under ‘Coping with eating difficulties’ earlier in this leaflet may help.

Chronic viral hepatitis
 
If you have a long-term hepatitis infection (when infection lasts longer than six months – sometimes coming and going) caused by a virus – hepatitis B or C, for example – you can eat a normal, well balanced diet. You should not need to change what you eat unless you have problems with poor appetite and unintended weight loss. A poor appetite, nausea and vomiting are unpleasant but these symptoms only cause a nutritional problem if they last longer than a few days or if you are continuing to lose weight. In this case you should consult your doctor.

Autoimmune hepatitis
 
Some people who are prescribed steroids for autoimmune hepatitis may find their appetite increases and that they gradually gain weight. If this happens, it is still important to eat a varied and well balanced diet. However, if you are gaining too much weight you should try to reduce calorie-rich foods – including sugar, sweets, cakes, biscuits, fried food, pasties and pies, crisps and chocolate – use low-fat versions instead and fill up on fruit and vegetables. If weight gain is a problem, your doctor may suggest specialist help from a dietician.

Primary biliary cirrhosis and primary sclerosing cholangitis
 
If you have primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC) you may need to change your diet as the way you digest fats may be altered. In order to digest fat we need bile. This is a yellowish acid made in the liver and stored in a pear-shaped bag called the gallbladder. It is squirted into the small intestine where it acts as a detergent, breaking fat into tiny droplets so it can be absorbed by the body.

With PBC and PSC the flow of bile into the gut may be reduced, particularly if you are jaundiced, so you may find you cannot tolerate the same amount of fat as normal. In this situation you develop a type of diarrhoea, known as steatorrhoea, which causes bulky, pale faeces/stools that are difficult to flush away. It can cause nausea and a sick, bloated feeling.

If this happens, you may find that eating less fat in the diet will help to reduce the problems and symptoms of this fatty diarrhoea. However, fat is essential – it contains the fat-soluble vitamins A, D, E and K, as well as essential fatty acids – and should not be cut out of your diet completely without proper advice from a dietician. People vary in the amount of fat they can tolerate so this does not mean you will necessarily need to eat a strict, low-fat diet. Most people find they are able to work out how much fat they can take by trial and error by reducing amounts of the higher fat foods.

Improvement in bowel habit shows that your body is tolerating the amount of fat you are eating. Stools will become less frequent, darker and easier to flush away. If you are reducing fat in your diet and do not need to lose weight, top up calories with snacks between meals, for example, toast, crackers, crumpets or tea-cakes. Your dietician can help you with this.

Cutting down on fat
 
If you want to cut down on the fat you eat you need to avoid ‘hidden’ fats as well as the obvious ones you can see in meat and greasy foods. The list below gives examples of high-fat foods and ideas for alternatives.

Butter, margarine, lard, dripping – try using low fat spreads.
Cream and full-cream milk – substitute half-fat versions. There is as much calcium (needed for healthy bones) in half-fat or skimmed as there is in full-cream milk. 
Cheese – you may be able to tolerate small amounts of normal cheese, or try lower-fat hard cheese. Try reduced-fat spreads and cottage cheese. 
All kinds of cooking oil including olive oil, sunflower and vegetable oil – use these sparingly. 
Fatty meats, such as duck and belly pork – eat more fish, poultry, lean red meat, beans and eggs. 
Meat products such as sausages and pies – you may be able to eat small amounts of these. 
Chips, crisps and nuts – try oven-chips instead. 
Biscuits, cakes and pastry – try low-fat alternatives such as teacakes, scones and low-fat cakes or biscuits. 

Many processed foods are high in fat – for example pizza, lasagne, ready-made curry or other dishes. Eat only small amounts or use a low-fat version.
Cooking with less fat
 
The list below gives some ideas on how to reduce the amount of fat you use in cooking.

Grill, bake, boil, steam or casserole meals instead of frying.
Add flavour with fresh herbs, spices, lemon juice and mustard. Curry powder and hot spices should be avoided as they may make symptoms worse. 
Trim visible fat off meat and remove the skin from poultry. 
Skim fat off the surface of soups and casseroles.
If you are cutting down the fat in your diet you should try to eat extra carbohydrate to make up any shortfall in energy. This means more starch and sugar – bread and honey, for example. Take advice from a dietician to make sure you are getting enough calories, protein and vitamins. Some people may also need monthly injections of fat-soluble vitamins.

Coping with aidity

Some people with PBC may experience an unpleasant acid taste in the mouth or they may get heartburn – a severe burning sensation in the chest. Stomach acids escaping into your food pipe (oesophagus) are the usual cause of this discomfort. If this happens to you, then try eating little and often to reduce stomach acid. It is a good idea to get into the habit of carrying food around with you, in case you need to eat. Foods that contain carbohydrates – such as crackers, plain biscuits or breadsticks – are the best. If symptoms persist try:
avoiding big meals at night
taking an antacid before bed and after meals 

raising the head of your bed by four or five inches
Fatty Liver

Fatty liver is a condition in which too much fat builds up in the liver. You are more at risk of this if you tend to put on weight around your middle – ‘apple-shaped’ as opposed to ‘pear-shaped’. The fat stored in the liver is just the same as that under the skin. So, if you cut down on fatty foods and lose weight you will also lose fat from the liver. For the majority of people in the UK, the root causes of becoming overweight are down to:
eating too much, especially too much fatty food
drinking too much alcohol (up to nine out of ten people who drink too much alcohol will go on to get a fatty liver – even if they are not overweight) 
not doing enough exercise.

If you have fatty liver you may be advised to make changes to your life-style including:
cutting out or down on alcohol (remember, alcohol is high in calories – around 300 calories in a pint of beer and 100 in a 175ml glass of wine and so drinking alcohol will slow the rate at which you lose weight)
taking more exercise, such as walking or swimming 
eating plenty of fruit and vegetables 
eating slow-release starchy foods, such as bread and potatoes 
avoiding refined sugars and fats – as in chocolate, cakes and biscuits 

lowering your weight to a healthy level for your build and age and keeping it there.
Cirrhosis
 
If you have cirrhosis you should eat a well-balanced diet and may need extra energy and protein. Cirrhosis causes damage that stops the liver working properly. This means it may be unable to store glycogen, the carbohydrate that provides short-term energy. When this happens, the body uses its own muscle tissue to provide energy between meals. This can lead to muscle wasting and weakness. If you have been affected in this way, snacking between meals can top up your calories and protein (a bedtime snack is especially effective) as eating between meals helps preserve muscles and keep them strong. Improved nourishment will also make you feel better.

Try to eat regularly, say every two to three hours. Suitable snacks include:
teacake
toast 
crackers 
cereal 
fruit 
high protein drinks.

If you develop the following symptoms you should see a doctor immediately and you may need to change your diet:
fluid retention causing swelling of your abdomen (ascites) or legs (oedema)
mental slowness or confusion (encephalopathy) 

fatty stools/faeces (steatorrhoea).
Fluid retention

Some people with cirrhosis get a build-up of fluid in the stomach area (ascites) and swelling of the feet and legs (oedema). These symptoms may be treated by drugs called diuretics (also known as water pills). You can help control fluid retention by reducing the amount of common salt (often called sodium chloride by manufacturers) in your food. However, while it may be a good idea to cut out foods with a very high salt content, it could be harmful to change to a diet that is too low in salt. Your taste buds become more sensitive to salt as you eat less of it. It is quite easy to cut down salt in the food you prepare yourself but most of the salt we eat is added to foods by the manufacturers. It is often difficult to tell which processed foods are high in salt, as they may not necessarily taste salty. A dietician can advise you on which foods you can eat and which you should avoid.

Ideas for reducing salt
 
Try not to add salt at the table, although you can use a small amount in cooking. 
Stock cubes, bouillon cubes and gravy granules can be used instead of salt in cooking. 
Avoid packet and tinned soups if possible. 
Tinned vegetables, including baked beans, can be high in salt. Look for low-salt or no-salt versions. Frozen vegetables are low in salt. 
Smoked and tinned fish, including salmon, tuna and pilchards in brine contain a lot of salt. Only have these occasionally or try the ones tinned in oil. 
Do not eat cured meats – including ham, bacon, sausages, and salami – on a daily basis. Use cold cooked fresh meat, poultry or eggs more often instead. 
Full-fat hard cheese is an excellent source of protein, so include it in your diet but do not have it every day. 
Ready meals and sauces are high in salt so try to have these less often. Pasta and ‘cook-in’ sauces can be used if no other salt is added to the meal. 

Bovril, Marmite and all yeast extracts are high in salt and so should be avoided.
Cooking without salt

Salt is not the only way to make your food taste better, instead try:
freshly ground black pepper
lemon juice on fish or meat 
redcurrant jelly, apricots, rosemary or garlic for lamb 
apple or gooseberry sauce with pork 
ginger, garlic and spring onions with mixed vegetables 
olive oil and vinegar with salad and vegetables 
mustard powder or nutmeg with mashed potato 
various home-made sauces – such as onion sauce made with milk and garlic – used instead of gravy 
toasted and ground sesame seeds added to pastries, breads and stir-fries 
washed and finely chopped coriander root in soups, stews and stock.
In hospital, people who are affected by ascites or oedema may be asked to restrict their fluid intake as well as the amount of salt they eat. This is only done under medical supervision and fluid intake is gradually increased by the time the person goes home.

Mental confusion

Some people with cirrhosis develop poor memory and concentration. They can become confused and may even lose consciousness. It happens because the damaged liver is unable to break down poisons that enter the body. These poisons then get into the bloodstream and are carried to the brain. This tends to happen when a person with cirrhosis also has some other problem such as diarrhoea, vomiting, dehydration, constipation, infection or bleeding. The liver cannot cope with the extra stress on the body and is unable to deal with the poisons/toxins properly. Treatment includes tackling the underlying medical problem and paying careful attention to diet, particularly to eating enough protein. The right nutrition is essential to prevent muscle loss and help improve the mental confusion. If you are affected in this way, talk to your doctor or dietician. You may also find some of these ideas helpful.
Eat three or four small meals during the day rather than one large meal.
Eat eggs and cheese as well as meat, fish and poultry for protein. 
Avoid eating large amounts of protein at one meal – full cooked breakfast, for example. Instead have a bacon sandwich, egg or beans on toast, or a sausage sandwich. 
Fill up with starchy foods such as potatoes, rice, pasta and cereals for slow-release energy. 
Breakfast cereal, served with milk, can make a useful snack. Other ideas include scones, teacakes, crumpets, toast and jam, crackers and cheese, crisps, a chocolate bar or flapjack. 

If your appetite is poor and you are not able to eat snacks, you may need to take high-protein and high-calorie drinks on the advice of your dietician or doctor.
High blood sugar
 
If you have too much sugar (glucose) in your blood, it is know as hyperglycaemia and affects some people with cirrhosis. If this happens in your case, you may be advised to follow a diet similar to the one used by people with diabetes. This means avoiding foods that are high in sugar but otherwise eating a well-balanced diet. People with hyperglycaemia have different needs and will require individual advice from a dietician. It is important to eat enough calories and protein to keep well nourished; energy lost by cutting down on sugar must be replaced from another source. Tea, coffee and sugar-free fizzy drinks and squash are better than sugary drinks which release sugar into the system very quickly. If you have a ‘sweet tooth’ then use sweeteners rather than sugar and avoid sweets and filled chocolate. Commercially produced drinks such as Complan and BuildUp also contain quite a lot of sugar but you may need to use them to get all the energy you need. A dietician can advise you on the best type for you and how to work it into your diet.

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