Diet& Liver

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Fighting liver disease

Diet and liver disease

b r i t i s h

l i v e r

t r u s t

Recognised by


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Diet and liver diseaseThe British Liver Trust works to:

support people with all kinds o liver disease

improve knowledge and understanding o the liver and related health issues

encourage and und research into new treatments

lobby or better services.

All our publications are reviewed by medical specialists and people living with liver

disease. Our website provides inormation on all orms o adult liver disease and

our Helpline gives advice and support on enquiries about liver health. Call theHelpline on 0800 652 7330, general enquiries on 01425 481320, or visit

www.britishlivertrust.org.uk

For the latest updates to this inormation, please reer to our websitewww.britishlivertrust.org.uk

A list o reerence sources or this inormation is available on our website

or by contacting [email protected]

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The liver

Your liver is your bodys actory carrying out hundreds o jobs that are vital to lie.

It is very tough and able to continue to unction when most o it is damaged. It can

also repair itsel even renewing large sections.

Your liver has around 500 dierent unctions. Importantly it:

ghts inections and disease

destroys and deals with poisons and drugs

lters and cleans the blood

controls the amount o cholesterol

produces and maintains the balance o hormones

produces chemicals enzymes and other proteins responsible or most o thechemical reactions in the body, or example, blood clotting and repairing tissue

processes ood once it has been digested

produces bile to help break down ood in the gut

stores energy that can be used rapidly when the body needs it most

stores sugars, vitamins and minerals, including iron

repairs damage and renews itsel.

How liver disease develops

Liver damage develops over time. Any infammation o the liver is known as

hepatitis, whatever its cause. Sudden infammation o the liver is known as acute

hepatitis. Where infammation o the liver lasts longer than six months the condition

is known as chronic hepatitis.

Fibrosis is where scar tissue is ormed in the infamed liver. Fibrosis can take a

variable time to develop. Although brosis is present the liver keeps on unctioning

quite well. Treating the cause o the infammation may prevent the ormation o

urther liver damage and may stop or reverse some or all o the scarring.


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Cirrhosis is when infammation and brosis has spread throughout the liver and

disrupts the shape and unction o the liver. Even at this stage, people can haveno signs or symptoms o liver disease. When the working capacity o liver cells

has been badly impaired and they are unable to repair or renew the liver,

permanent damage occurs.

Cirrhosis can lead to liver ailure or liver cancer. All the chemicals and waste

products that the liver has to deal with build up in the body. In the nal stages o

liver disease the build up o waste products may cause multiple organ ailure and

lead to death.

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Right hepatic duct

Stomach

Left hepatic duct

Inferior vena cava

Liver

Spleen

Pancreas

Pancreatic

duct

Pancreatic ducts

emptying into

duodenum

Commonbile duct

Cystic duct

Duodenum

Bowel

Gallbladder

Small intestine

Portal vein

Large intestine


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Staying nutritionally well

Eating a good, balanced diet to maintain strength and a healthy weight is essential

or people with liver problems. Good nutrition can help to support your liver to

unction and plays a crucial role in your health.

I you have a liver condition, there are some special considerations you may needto make in your diet to stay nutritionally well and to help to manage your condition.

Some o these are specic to certain liver diseases, others relate to how advanced

your liver disease is.

In this publication well cover: how your liver is aected by the ood you eat;

elements o a well-balanced diet suitable or most people; disease specic dietary

considerations and special or therapeutic nutritional diets or those with more

advanced liver disease.

I you are experiencing symptoms such as loss o appetite, nausea, low energy

levels, fuid retention in the legs or accumulation o fuid in the abdomen (ascites),

you will need to ollow a more specialised diet. These, and other problems

associated with advanced liver disease, require specialist dietary advice rom a

registered dietitian.

It is important that you talk to your doctor as well as reading this inormation. Your

consultant will be able to reer you to a registered dietitian. I you have alreadybeen given dietary advice you should not make changes without rst

talking to your consultant or dietitian.

The British Liver Trust has a range o publications covering specic areas o liver

disease which you may also nd helpul.


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Fat

Fat comes rom butter, cheese, oil, animal at and rom many hidden sources, or

example, biscuits, pastry, crisps, cakes and nuts.

Fat can be used as a long-term energy store. Each gram o at provides 9kcal o

energy, compared with only about 4kcal rom a gram o carbohydrate or protein.

It also provides the at-soluble vitamins A, D, E and K, and essential atty acids.

Fat is broken down in the liver to provide supplies o energy, or is stored in tissues

to be used when energy sources are low. In some people at builds up in the liver

cells, stopping them rom working properly. This is more likely i you are overweight

or obese, have diabetes, high blood cholesterol levels or drink alcohol excessively.

Protein

Protein comes rom oods such as meat, sh, eggs, nuts, pulses and dairy

products. It is made up o units called amino acids and when these reach the liverthey provide building blocks to make cells and tissues throughout the body.

Vitamins and minerals

In addition to carbohydrates, at and protein, the body also needs a number o

vitamins and minerals to unction properly.

Most people can get all the vitamins and minerals they need by choosing a variety

o oods rom a normal, healthy, well-balanced diet (see A well-balanced diet onpage 9). However, i you have cirrhosis, or certain types o liver disease, you may

become decient in (short o) certain vitamins and minerals, and your doctor or

dietitian may prescribe supplements.

Calories

In the same way that we measure distance in centimetres (cm), the energy in

ood is measured in units o calories (kcal). For example an apple will have about

50kcal and a chocolate bar will have about 300kcal.


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The eatwell plate, developed by the Department o Health, will help you to get a

eel o how much you should eat rom each ood group to keep a good balance.

For example, starchy oods should make up about a third o the ood we eat, as

should ruit and vegetables.

Crown copyright Department o Health in association with the Welsh Assembly Government,

the Scottish Government and the Food Standards Agency in Northern Ireland.

Group 1. Bread, cereal, potatoes, rice, pasta, noodles, chapatti

(starchy carbohydrates good or slow release energy).

Choose one o these oods at each meal they release energy slowly into the

bloodstream. High-bre versions will keep you eeling uller or longer (i your

appetite is poor or you can only manage small portions, too much bre may notbe advisable).

A lot o the at we get rom these oods is the at we eat with them, such as butter

on bread or potatoes, ull cream milk on cereal or at used in cooking5. Watch out

or these added ats and opt or low at versions (unless you have been advised by

your doctor that you need to gain weight).


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Fighting liver disease 11

Group 2. Fruit and vegetables (high in bre, vitamins and minerals).

Aim or ve portions a day. Fruit and vegetables provide essential vitamins and

bre, helping to protect the body against heart disease and some orms o cancer.

A portion is 80g or one o the ollowing:

one glass (150ml) o ruit juice

three heaped tablespoons o vegetables raw, cooked, rozen or canned

one dessert bowl o salad

one apple, orange, banana or similar sized ruit

two small ruits plums, apricots

a small handul o grapes or cherries

a hal-tin o tinned ruit in natural juice or dessert bowl o stewed ruit.

Group 3. Milk and dairy oods (high in protein, good or calcium or healthy bones

and teeth and blood clotting).

Milk, yoghurt and cheeses are oods high in saturated at. Eating small amounts

(the eatwell plate shows the proportion o your meal which should be in this group)

and choosing low-at versions, will stop you rom putting on excess weight. I you

are underweight, adding oods such as butter and cream to meals can help to

give you extra calories.

Group 4. Meat, poultry, sh, nuts, pulses, beans, tou, eggs (high in protein).

All these oods provide protein. Beans and pulses also provide useul bre,

vitamins and minerals and are useul alternatives to meat i you are vegetarian.

Try to have two helpings o protein-rich oods a day. I you are struggling to keep

your weight up, you may need extra protein to help to re-build muscles.

Red meat is higher in at than chicken and sh, but is a very good source o iron,

so should be included in the diet at least twice a week. Try to grill, bake or poach

ood rather than rying.


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It is important to maintain a healthy weight; to do this you need to balance the

amount o ood you eat with the energy you need. I you eat ewer calories than

your body needs (especially i you are physically active) you will lose weight.

I you eat more than you need, your weight will increase.

The amount o energy we need diers according to our sex, age, weight and theamount o physical activity we take. For example, a small elderly woman will need

less ood than a young, active man. As a basic rule o thumb, healthy adult men

are advised to eat about 2,500kcal every day and women 2,000kcal a day. In

general, patients with chronic liver disease need more energy and more protein

than healthy people.

I you are trying to lose weight you should not crash diet. There is no quick and

easy way to lose weight and crash dieting may cause other health complications.

Beore attempting to lose weight you should consult your doctor so that they

can advise you on the saest method o doing so. An increase in exercise and a

decrease in calorie intake is usually the best route.

Body Mass IndexYour BMI (body mass index) gives a guide as to whether you are a healthy

weight or your height.

BMI = weight (kg) or example 95kg = 29.3

height (m) x height (m) 1.8m x 1.8m

BMI below 18.5: under weight

BMI 18.5-24.9: healthy weight BMI 25.0-29.9: overweight

BMI above 30.0: obese

People o South Asian origin may be at greater risk o ill-health at

lower BMI ranges than those shown above, with a BMI o greater than 23

suggested as being overweight.


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I you have been diagnosed with advanced liver disease and are

experiencing symptoms such as fuid retention in the abdomen, this will

aect your weight and your BMI can be misleading. In this instance your

diet will need to be managed very careully by a dietitian, as it is possible to be

overweight as a result o the fuid retention but to be malnourished.

I you have been ill and have lost a lot o weight, you may not eel like eating, andkeeping to a well-balanced diet may be dicult. Try to keep eating as much as you

can, and ask your doctor or dietitian or advice on how to increase your calories

and protein intake.

Dietary advice or speciic liver conditions

This section gives advice on diet or people with particular liver problems. We onlyhave space here to cover some o the inormation that is available. You may have

other questions or worries about your particular condition and the best person

to talk to is your doctor or dietitian. I you have already been advised to ollow

a special diet it is essential to talk to your doctor or dietitian beore making any

changes. The liver conditions covered in the ollowing pages are:

alcoholic liver disease haemochromatosis

non alcoholic atty liver disease Wilsons disease

acute viral hepatitis primary biliary cirrhosis

chronic viral hepatitis primary sclerosing cholangitis

autoimmune hepatitis Gilberts syndrome.

Alcoholic liver disease (ALD)

The rst stage o injury to your liver, i you have been drinking alcohol excessively,

is the build-up o atty deposits. This can be reversed completely, i you abstain

rom alcohol. Approximately, one in ve (20%) o those with alcohol-related atty

liver go on to develop alcoholic hepatitis (infammation) and eventually cirrhosis.


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Many people with alcoholic liver damage are malnourished (lacking in all the

nutrients the body requires). This may be due to several actors:

poor diet

loss o appetite

malabsorption (poor absorption o ood nutrients) as the liver is less able

to produce bile to aid digestion

alcohol has no nutritional value but requires a lot o energy or the body

to process.

You may still be malnourished even i you are overweight depending on what and

how you eat or i your weight has been increased by fuid retention.

People who are malnourished due to alcoholic liver disease may particularly lack

the vitamin thiamine (a B vitamin that helps the body convert carbohydrates intoenergy). You should be prescribed B vitamins i you are drinking alcohol at harmul

levels, or are alcohol-dependent, and any o the ollowing apply:

you are malnourished or at risk o malnourishment you have

decompensated liver disease

you are in acute or medically assisted withdrawal.

Consult your doctor or dietitian i this has not been prescribed.

The most important change to your diet which you can make is to stop drinking

alcohol. Eating a balanced diet, with sucient protein and carbohydrate, is

essential. Initially, especially i hospitalised, you may be recommended high energy,

high protein drinks with vitamin and mineral supplements. I you are very unwell,

you may need to have a liquid supplement via a eeding tube into your stomach.

Non alcoholic atty liver disease (NAFLD)

Non alcoholic atty liver disease is a term or a wide range o conditions in whichthere is a build-up o at in the liver cells o people who do not drink alcohol

excessively. Initially the at deposits may not be associated with any symptoms,

however, in some people this may progress to infammation non alcoholic

steatohepatitis (NASH) which may in turn lead to scarring and cirrhosis.


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Chronic viral hepatitis

I you have a long-term hepatitis inection (when inection lasts longer than six

months) caused by a virus such as hepatitis B or C, you can eat a normal,

well-balanced diet.

Try to maintain a body weight appropriate or your height and build. Maintaining

a healthy weight is important as studies show that obesity can speed up the

damage caused by hepatitis C and can also aect how well you respond

to treatment.

Some people nd they have problems with poor appetite and unintended weight

loss, particularly during treatment with anti-viral agents. A poor appetite, nausea

and vomiting are unpleasant but these symptoms only cause a nutritional problem

i they last longer than a ew days or i you are continuing to lose weight. I this is

the case you should consult your doctor.

Some people report that they nd taking oral ribavirin with dietary ats helps to

reduce any side-eects, as does drinking water throughout the day to keep fuid

levels up.

Periods o asting, or instance or religious reasons, are not recommended i you

have chronic liver disease.

Autoimmune hepatitisSome people with autoimmune hepatitis who are prescribed steroids, nd their

appetite increases and that they gradually gain weight. I this happens to you, it is

still important to eat a varied and well-balanced diet. I taking long-term steroids,

it is also important that, you are prescribed calcium and vitamin D supplements to

reduce the risk o osteoporosis. I, however, you are gaining too much weight, you

should try to reduce calorie-rich oods including sugar, sweets, cakes, biscuits,

ried ood, pasties and pies, crisps and chocolate. You should use low at milk and

spreads and ll up on ruit and vegetables.

I weight gain is a problem, your doctor may suggest specialist help rom a dietitian.


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Haemochromatosis

I you have been diagnosed with genetic haemochromatosis, your body will

absorb more iron than normal. Treatment with regular venesection (the removal o

a unit o blood) is a very eective means o getting rid o the excess iron. There is

no need or specic dietary change and it is important to eat a balanced diet.

It is recommended to:

avoid taking supplements or multi-vitamins with iron

avoid oods which are ortied with iron such as some drinks and

breakast cereals

be cautious with vitamin C in pill orm (max 500mg/day) as this can

increase the absorption o iron. Vitamin C rom ruit and vegetables does

not need to be avoided

watch your alcohol intake as excess can speed liver damage and may

increase iron absorption.

Some oods such as calcium, as ound in dairy oods, and tannin, as ound in tea

may reduce the amount iron absorbed when taken with ood. However, the overall

eect on iron absorption over a period o days or weeks is small.

Wilsons disease

I you have Wilsons disease, your liver cannot adequately metabolise and remove

copper rom your body. This condition is treated using a copper chelating agent,

such as penicillamine, to bind copper and remove it. These agents are very

eective and there really is little need to restrict dietary copper intake.

Most oods contain copper, and some oods contain large amounts, or example

chocolate, nuts, mushrooms, shellsh and oal. However, doctors only rarely

suggest the avoidance o these oods i you are taking and responding well to

your medication.

I you are being treated with penicillamine you may require supplements o

vitamin B. This is because penicillamine can increase your bodys need or

pyridoxine (vitamin B6). It is useul to ask your doctor i you require supplements.

Some people with Wilsons disease may also be treated with zinc as this agent

can block the absorption o copper rom ood in the intestine.


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Gilberts Syndrome

Gilberts syndrome (GS) is a condition in which you have higher than normal

amounts o bilirubin in your blood. Avoid dieting or asting as this may cause your

bilirubin levels to rise, as may dehydration. It is important that you eat regularly and

healthily, and drink plenty o water.

Some people report that they cannot tolerate eating carbohydrate oods very well

(such as bread, pasta, rice and potatoes). Make sure you have enough protein in

your diet to compensate i you have to reduce your carbohydrate intake.

Primary biliary cirrhosis and Primary sclerosing cholangitis

I you have primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC)

your bile ducts will be aected. You may have trouble absorbing at and may need

to change your diet.

In order to break down ats the liver produces a substance called bile. This is

stored in the gallbladder and released via the bile ducts ater a meal. PBC and

PSC aect the fow o bile and thereore you may nd you cannot tolerate ats well.

In this situation at is passed in your stools and you develop a type o diarrhoea,

known as steatorrhoea, which causes bulky, pale aeces/stools that are dicult to

fush away.

I this happens, you will be advised to reduce the amount o at in your diet.

However, at is essential it contains the at-soluble vitamins A, D, E and K, as

well as essential atty acids and should not be cut out o your diet completely

without proper advice rom a dietitian. Your doctor may recommend vitamin

injections or supplements. You should not take supplements without advice rom

your doctor.

People vary in the amount o at they can tolerate so this does not mean you will

necessarily need to eat a strict, low-at diet. Most people nd they are able to workout how much at they can tolerate by trial and error by reducing amounts o the

higher at oods. Improvement in bowel habit shows that your body is tolerating

the amount o at you are eating. Stools will become less requent, darker and

easier to fush away.


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I you are cutting down the at in your diet you should try to eat extra carbohydrate

to make up any shortall in energy. This means more starch and sugar, or

example, toast, crackers, crumpets or tea-cakes, bread and honey. Take advice

rom a dietitian to make sure you are getting enough calories, protein and vitamins.

Some people may also need monthly injections o at-soluble vitamins A, D and K.

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 ood pipe (oesophagus) are the usual cause o this discomort.

I this happens to you, then try eating little and oten to reduce stomach acid. It

is a good idea to get into the habit o carrying ood around with you, in case you

need to eat. Foods that contain carbohydrates, such as crackers, plain biscuits orbreadsticks, are the best.

It can also be helpul to:

avoid big meals at night, but include a snack i you have been advised to do so

take an antacid beore bed and ater meals

raise the head o your bed by our or ve inches.

I symptoms persist discuss this with your specialist, who may recommendother treatments.

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Some people with cirrhosis may develop bone thinning (osteopaenia /

osteoporosis). This is diagnosed by bone density scanning (DXA scan). I the scan

shows you have this condition, it is likely that your doctor will provide you with

supplements o vitamin D and /or calcium to reduce the risk o bone racture.

Decompensated cirrhosis

Cirrhosis may progress to become decompensated where the liver is

not capable o perorming all o its normal unctions resulting in a number o

complications including, fuid retention and mental conusion (encephalopathy).

I you have decompensated cirrhosis you will need expert dietary advice. A high

energy, high protein diet is likely to be recommended to help your liver unction

(35-40kcal and 1.5g o protein or every kg o your body weight per day). You may

need supplemental drinks and some specic dietary measures to manage some o

the complications o your cirrhosis. It is very important that you have a good diet;

your doctors and dietitian are unlikely to suggest any dietary restrictions without

careul assessment.

Fluid retention

Some people with cirrhosis get a build-up o fuid in the stomach area (ascites)

and swelling o the eet and legs (oedema). These symptoms may be treated with

drugs called diuretics (also known as water pills). Sometimes the excess fuid

in the abdomen will be drained away using a tube, particularly i you arevery uncomortable.

Although you may eel bloated, it is important that you continue to drink enough

fuids so that you dont dehydrate.

You can help to control fuid retention by reducing the amount o common salt

(sodium chloride) in your ood. However, while it is a good idea to cut out oods

with a very high salt content, it can be harmul to change to a diet that is too low in

salt without guidance rom a dietitian.

Your taste buds become more sensitive to salt as you eat less o it. It is quite easy

to cut down salt in the ood you prepare yoursel, but most o the salt we eat is

added to oods by the manuacturers. A dietitian can advise you on which oods

you can eat and which you should avoid.


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It is likely that you will be recommended to reduce the amount o sodium (salt) in

your diet to around 5.2g o salt per day.

Foods which you may think are low in salt can surprise you, reading the labels on

the ood you buy will help you to monitor your intake more careully.

Fresh oods should be eaten wherever possible as they are generally lower insalt than canned or processed oods. Try to buy oods labelled low salt or no

added salt. A quick way to tell i your ood is high in salt is to look at the nutritional

inormation on the label. Look or the amount o salt per 100g, i there is more than

1.5g salt per 100g (or 0.6g sodium) then it is high in salt, anything up to 0.3g salt

or less per 100g (or 0.1g sodium) is low in salt.

Ideas or reducing your salt intake

Avoid adding salt to meals at the table. A small amount can be added

during cooking i need be.

Try making your own stock and not adding salt, as stock cubes, bouillon

cubes and gravy granules can be high in salt.

Avoid packet and tinned soups i possible.

Tinned vegetables, including baked beans, can be high in salt. Look or

low-salt or no-salt versions. Frozen vegetables are lower in salt.

Smoked and tinned sh, including salmon, tuna and pilchards in brinecontain a lot o salt. Only have these occasionally or try the ones

tinned in oil.

Do not eat cured meats including ham, bacon, sausages, and salami.

Use cold cooked resh meat, poultry or eggs instead.

Full-at hard cheese is an excellent source o 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 look or low saltalternatives and have these less oten. Pasta and cook-in sauces can be

used i no other salt is added to the meal.

Bovril, Marmite and all yeast extracts are high in salt and so should

be avoided.

Choose unsalted butter.

Certain bottled waters are high in sodium check the labels careully.


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Salt is not the only way to make your ood taste better, instead try:

reshly ground black pepper

lemon juice on sh or meat

redcurrant jelly, apricots, rosemary or garlic or 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 o gravy

try using dierent types o onion brown, red, spring onions, shallots or leeks

toasted and ground sesame seeds added to pastries, breads and stir-ries

washed and nely chopped coriander root in soups, stews and stock

try adding resh herbs, lime, garlic, chilli and ginger to pasta dishes,

vegetables and meat.

Mental conusion (hepatic encephalopathy)

Some people with cirrhosis develop poor memory and concentration. They can

become conused and may even lose consciousness. This happens because the

damaged liver is unable to break down toxins rom the bowel which then enter the

bloodstream and are carried to the brain.

Medications

It is also important to be aware that some prescription and over the counter

medications have a high salt content. I the sodium content on the labelling

o your medication is not clear, or you are unsure i it is suitable, then your

pharmacist or doctor should be able to advise you.


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It can occur when a person with cirrhosis also has some other problem such as

diarrhoea, vomiting, dehydration, constipation, inection or bleeding. The liver

cannot cope with the extra stress. Treatment includes tackling the underlying

medical problem and paying careul attention to diet, particularly to eating

enough protein.

Historically people with hepatic encephalopathy were treated with a low proteindiet. It is now recognised that this was the wrong approach and that a high protein

diet will help to improve liver unction.

Many internet sites still wrongly suggest that those with hepatic encephalopathy

should restrict dietary protein and some healthcare proessionals working outside

the specialist liver units may also not know about this change in management.

You are likely to be advised:

to spread your protein intake over the waking hours, eating our to six

snack meals a day rather than one or two bigger main meals

to eat a late-evening snack high in carbohydrate to help support your liver

during the night

poultry, sh, eggs and cheese are good sources o protein as an

alternative to red meat

starchy oods such as potatoes, rice, pasta and cereals help to provideenergy slowly over a longer period.

I 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 o your dietitian or doctor. See

the Coping with eating diculties section.

Controlling blood sugar

I you have too much sugar (glucose) in your blood, it is known as hyperglycaemia.

This can occur in some people with cirrhosis. You may be advised by your dietitianto ollow a diet similar to the one used by people with diabetes. This means

avoiding oods that are high in sugar but otherwise eating a well-balanced diet. It

is important to eat enough calories and protein to keep well nourished; the energy

lost by cutting down on sugar must be replaced rom another source.


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Coping with eating diiculties

Some people nd eating a well-balanced diet dicult, especially i they have been

seriously ill.

Two common reasons or this are:

loss o appetite

eeling sick (nausea).

However, it is important to eat as well as possible. The ollowing tips may help.

Loss o appetite

Eat small but requent meals little and oten.

Nutritious snacks may be better than one big meal.

Try to eat something every two hours, however small.

Tempt yoursel with oods you like, you dont have to have a proper

meal; snacks are oten easier to eat.

Dont orce yoursel to eat ood you dont like.

Try to relax beore and ater you eat.

Take your time over eating chew well and breathe steadily.

I you dont eel like solid ood, try a nourishing drink.

Nourishing drinks include homemade ruit milkshakes or smoothies and oral

nutritional supplements. It is a good idea to check with your doctor or dietitian

rst to see i they are suitable or you.

Milkshakes and smoothies can be made by blending resh ruits with milk,

ruit juice, ice cream or yoghurt. You can also include honey and two to three

teaspoons o powder drink supplement (see ollowing page).


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Nutritional supplements are also available in sweet or savoury favoured powder

orm and can be mixed with milk or water. Your doctor or dietitian may prescribe

these. They can be taken in-between meals and beore bed this is especially

helpul i you are only eating small amounts.

Non-favoured high-energy or protein powders can also be prescribed. These

powders are virtually tasteless and can be added to drinks, soups, sauces,gravies, casseroles and other oods.

Nausea

I some smells make you eel sick, try a breath o resh air beore you eat.

Keep your mouth resh by brushing your teeth, using a mouthwash or

sucking mints.

Dont let yoursel get too hungry hunger makes nausea worse.

Try to eat something every two hours, even i its only a small amount.

Cold snacks may be easier to cope with than a hot main meal.

Likewise, dry oods can be easier to ace, so nibbling on crackers or plain

biscuits can help reduce nausea.

It is not essential to have a proper meal; small snacks can be just as nutritious.

Is there a pattern? Do you always eel sick at the same time o day? I so,

try eating at other times.

Avoid eating when you are very tired; rest and relax rst.

I cooking makes the problem worse, try using ready-made meals

or sandwiches.

Try sipping cold drinks slowly through a straw.

High-calorie and protein supplements may be a good idea i you nd you

are losing weight. I you eel sick or more than a ew days, or i you start

being sick (vomiting), then talk to your doctor.


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Looking ater yoursel

Can I drink alcohol?

I you have alcohol-related liver disease, it is important that you stop drinking and

remain abstinent lie-long.

Alcohol can accelerate the rate o liver damage in those with hepatitis C and can

limit the eectiveness o anti-viral treatment. It can also accelerate the rate o liver

damage in those with NASH, thereore, it is recommended to avoid alcohol in

these circumstances.

Alcoholic drinks are oten high in calories and i you are overweight, cutting these

out will help to reduce your calorie intake.

Many people with liver disease avoid alcohol as they nd they do not tolerateit well. I you do choose to drink, it is important to stick within the recommended

guidelines.

The Department o Health recommends adult men should drink no more than 21

units o alcohol in a week, and adult women, no more than 14. These units should

be spread over the week:

men should not drink more than 3 to 4 units a day women should not drink more than 2 to 3 units a day

everyone should have at least two consecutive alcohol ree days every week.

I you are unsure whether you should drink, talk to your doctor. For more

inormation on how alcohol aects your liver and calculating units, please reer to

ourAlcohol and liver disease publication.

What is a ad diet and should I try one?

Fad diets are usually weight loss diets that promise you can lose weight quickly.

These diets oten ocus on short term solutions and can be bad or your health.

Fad diets usually involve one or more o the ollowing:


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Crash dieting, this can involve reducing your calorie intake considerably

and can lead to other health conditions, such as gallstones. You may lose

some weight in the short term but side eects oten include: eeling very

unwell, an inability to unction properly, dizziness and eating disorders.

Some diets may involve you cutting certain oods or ood groups out

completely such as wheat, meat, sh, dairy products or carbohydratesthis can lead to your body being decient in certain vitamins and nutrients.

I you need to lose weight, it is better to lose weight steadily, maintain weight loss

and to be healthy. Reer to A well-balanced diet section or urther inormation.

I have read about diets which detox your liver should I try one?

There are many dierent suggested diets that recommend certain oods to help

your liver detox or with liver cleansing. However, there is no evidence that toxins

build up in the liver and some o these diets can be dangerous or people with liverdisease. A healthy balanced diet (see page 9 ) is the best way to look ater

your liver.

Will drinking green tea or coee help my liver?

Some studies have suggested that coee has a benecial eect on the liver and

may help to reduce the risk o liver cancer in those with cirrhosis. For those with

liver damage who enjoy coee, there is no need to stop drinking it. The way in

which coee may aect the liver is still being investigated.

Green tea has also been suggested to have a protective eect on the liver, due to

its anti-oxidant properties. Again, urther research is required to conrm this.

As with everything, it is important to moderate your consumption and vary

your fuids.

Should I take dietary supplements?

Dietary supplements are not an alternative to eating a well-balanced diet. Yourbody needs a wide range o vitamins and minerals to be able to unction correctly,

and the best way to get these is to eat a variety o oods. You should always

consult your doctor or dietitian beore considering a supplement.


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Complementary and alternative medicines (CAM)

There is a great deal o inormation available on diet on the internet with many

people oering dietary advice. I you have liver disease, it is important to seek

advice rom your doctor and ask to be reerred to a dietitian. Registered dietitians

are regulated, whereas other proessionals such as Chinese herbalists are

currently not.

Many complementary and alternative medicines are available that are suggested

to ease the symptoms o liver disease. Most o these are processed by the liver, so

can be toxic to people with liver problems. Some can damage the liver and make

you more severely ill. At present, healthcare proessionals are not clear on the role

and place o some therapies in managing liver disease. More research needs to be

done on the use o such therapies.

Many products are not classied as a medicine and thereore are not licensed,

which means you cannot be sure how much o the active ingredient you are

getting or how pure it is. Traditional herbal medicines do not have to undergo the

stringent regulatory processes that medical drugs have to; thereore manuacturers

do not have to prove eectiveness in well designed large trials. It is wise to be

cautious about the claims made or herbal remedies, particularly those advertised

on the internet, as they can oer alse hope. It is a good idea to discuss the

use o these remedies with your doctor.

Does milk-thistle help the symptoms o liver disease?

Milk-thistle (also known as Silybum marianum) is an over-the-counter supplement,

which some people believe can be benecial to people with liver disease. Some

laboratory studies have shown the herbs active components (silymarin) have a

positive eect on liver cells. However, milk-thistle is not licensed as a medicine

and so studies into its eectiveness in the body have been limited, with conficting

results. There is not currently enough evidence to prove or disprove any benecial

eects on the liver. Milk-thistle may lower blood sugar levels and people with

diabetes or hypoglycaemia (low blood sugar) should use caution. I you are

thinking o using milk-thistle, it is a good idea to discuss this with your doctor.


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Your dietary needs

It is important to remember that your diet needs to meet your personal nutritional

needs and circumstances. In normal circumstances, it is important to eat a well-

balanced diet, with plenty o ruit and vegetables and only a small amount o at

and sugar.

I you are unwell and losing weight then some o the rules change. I you have

been ill you may not eel like eating your usual meals. In this case it is important

to eat oods that are high in calories, protein and ats to maintain a healthy weight

and avoid muscle wasting. You will probably be prescribed nutritional supplements

as well. I you are losing weight unintentionally or any reason, then it is essential to

seek medical advice.

I you have been told to lose weight, then it is important to do so slowly and saely.

It is important to try and enjoy what you eat and to discuss any problems you may

have with your doctor or dietitian.

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Useul words

Amino acids the compounds that make up proteins. Proteins in the human

body are made o 20 dierent amino acids that are either manuactured by the

body or absorbed rom your diet.

Balanced diet a diet that contains all the dierent substances your body needs,in the right amounts to keep you healthy.

Bile a yellow-green fuid produced by your liver, which passes into your intestine.

It contains chemicals, as well as waste products, and plays a central role in

helping the body to digest at.

Bowel another name or the intestine or gut, that runs rom the stomach to the

anus. It is split into two main sections, the small intestine (where ood is broken

down and absorbed) and the large intestine (which receives the processed ood,absorbs water and salt, and orms solid waste).

Calories units o energy, sometimes written as kilocalories (kcal) or kilojoules (kj).

Compensated cirrhosis a stage at which the liver is severely scarred but there

are enough healthy cells or the liver to perorm all o its unctions adequately.

Decompensated cirrhosis where the liver is not capable o perorming all o its

normal unctions. People may experience a variety o symptoms, including ascites,bleeding varices, jaundice and hepatic encephalopathy.

Diet the range o ood a person eats.

Carbohydrates a substance that provides energy or uel or your body.

Simple carbohydrates are sugars, as ound in ruit, honey and jam. Complex

carbohydrates are starches, as ound in bread, rice and potatoes.

Glucose a simple sugar and main source o quick energy or the body(it is the sole source o energy or the brain).

Glycogen stored in the liver and the muscles, glycogen is the way that the body

stores carbohydrates. It is easily changed back to glucose when the body needs

energy quickly.

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Hepatic anything to do with the liver.

Inerior vena cava the large vein that carries blood back to the heart rom the

lower part o the body.

Intestine another name or the gut or bowel (see previous page).

Nutrients a substance required rom our diet or growth and energy production.

Nutrients can be organic, such as carbohydrates, ats, proteins and vitamins, or

inorganic. Inorganic nutrients are usually minerals such as water, oxygen or iron.

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Who else can help?

British Dietetic Association

E-mail: [email protected]

Web: www.bda.uk.com/oodacts

For evidence based ood act sheets about various topics

Food Standards Agency

Tel: 020 7276 8829

Email: [email protected]

Web: www.ood.gov.uk

The Vegetarian Society o the United Kingdom

Tel: 0161 925 2000 Monday to Friday 8.30am 5pm


Web: www.vegsoc.org

Educational charity who provide inormation on maintaining a well-balanced diet

or vegetarians, including an example o a vegetarian eatwell plate.

Finding a dietitian

You can ask your GP or hospital consultant to reer you to an NHS registered

dietitian or a specialist diet consultation which will usually take place at your

nearest hospital dietetic department. I you are unable to access a dietitian via theNHS, the British Dietetic Association have a specialist Freelance Dietitians Group

o registered dietitians working privately. You can search or a private dietitian at

www.reelancedietitians.org although there will be a cost or a private consultation.

Patient organisations and support groups

Please reer to the Trust website, our guides on specic liver conditions or contact

the Trust or details o patient organisations and support groups specialising in

specic liver conditions.

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Further inormation

The British Liver Trust publishes a large range o leafets about the liver and liver

problems specially written or the general public.

Leafets that you may nd particularly helpul include:

Alcohol and liver disease Hepatitis C

Autoimmune hepatitis Liver cancer

Fatty liver and NASH Liver disease tests explained

Cirrhosis of the liver Living with liver disease

Gilberts syndrome Primary biliary cirrhosis (PBC)

Haemochromatosis Primary sclerosing cholangitis (PSC)

Hepatitis B Wilsons disease.

Contact us or more inormation:

Tel: 01425 481 320

Helpline: 0800 652 7330


Web: www.britishlivertrust.org.uk

This leafet is or inormation only. Proessional, medical or other advice should be obtained beore

acting on anything contained in the leafet as no responsibility can be accepted by the British Liver

Trust as a result o action taken or not taken because o the contents.

Special thanks

Dr Marsha Morgan, Reader in Medicine & Honorary Consultant Physician,

Centre or Hepatology, Royal Free, London

Dr Richard Aspinall, Consultant Hepatologist, Portsmouth Hospitals NHS Trust

Julie Leaper, Hepatology Specialist / ICU Dietitian,

St Jamess University Hospital, Leeds

Susie Hamlin, Hepatology Specialist / ICU Dietitian,

St Jamess University Hospital, Leeds

Simran Arora, Clinical Specialist Hepatology / Liver Transplant Dietitian,

Royal Free Hospital Hampstead NHS Trust, London

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Did you nd this publication helpul?

The British Liver Trust is always looking or ways to improve the inormation we

provide. Please take a ew minutes to let us know your views we value

your eedback.

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Were there any aspects o the publication which you ound especially useul?

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Did you nd the amount o inormation in the publication

too much about right too little?

How do you preer to access a publication?

I am happy to download publications in PDF format

I prefer to receive a printed publication

Please tell us where you received this publication rom?

e.g. British Liver Trust, doctor, hospital rack ......................................................

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Please tell us about your interest in liver disease. Are you?

a patient a health care professional

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other (please specify)

Would you be interested in any o the ollowing:

sharing your story to help others

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reviewing updates to this publication

a list of all Trust patient information guides

Title .......................... Name ...................................................................................

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.................................................................... Postcode ...........................................

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By giving the British Liver Trust your contact details (postal address, email address, phone

number) you agree the Trust may contact you periodically with updates about its work.

Please tick the box if you do not wish to receive any further information from the British

Liver Trust.

The British Liver Trust does not give your information to other organisations for

marketing purposes.

Please return this orm to:

Freepost RLZS-RJXB-BYLX, British Liver Trust,

2 Southampton Road, Ringwood, BH24 1HY.

Tel: 01425 481320 Fax: 01425 481335


DLD/04/11


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You can also make a donation by calling 01425 481320 or online by visiting our

website at www.britishlivertrust.org.uk

British Liver Trust is a registered charity in England and Wales (298858)and Scotland (SC042140) Tel: 01425 481320 Email: [email protected]

By giving the British Liver Trust your details (postal address, email address, phone number) you agree

the Trust may contact you periodically with updates about its work. Please tick the box if you do not

wish to receive any further information from the British Liver Trust.

THANK YOU

Id like to help reduce the impact o liver disease

by making a donation to the British Liver Trust.

Id like to make a donation of 10 25 other amount ............ I have enclosed

a cheque / postal order / CAF voucher made payable to British Liver Trust OR, I wish to

donate by:

Switch/Maestro Delta Visa Mastercard CAF Card

Card Number

Valid From Expiry Date Switch/Maestro Issue No.

Signature Date

We would like to keep in touch with more of our supporters via email, if you would like to

hear from us this way, please provide your email address:

To qualify for Gift Aid you must pay an amount of Income Tax and/or Capital Gains Tax for this

tax year at least equal to the tax that we will claim from HM Revenue & Customs on your Gift Aid

donations. This is currently 25p for each 1 that you give.

(Please tick) I am a tax payer and authorise the British Liver Trust to treat all gifts of money that I have made

in the past 4 years and all future gifts of money that I make from the date of this declaration as Gift Aid donations,

until I notify you otherwise.


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British Liver Trust2 Southampton Road

Ringwood, BH24 1HY

Helpline:0800 652 7330

Tel: 01425 481320 Fax: 01425 481335


Web:www.britishlivertrust.org.uk

The British Liver Trust acknowledges the contribution o Sovereign

Health Care and The James Tudor Foundation towards the

development o this booklet.

The sponsor has no editorial involvement in the publication.

Diet& Liver

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