Diet plays a very large part in looking after our livers and keeping us healthy. There are some very important aspects in what we eat, but also in what we drink. So alcohol is key, and very well associated with liver disease, as we know. There are some safe limits for alcohol intake. So 14 units a week for women and 21 units a week for men. Trying to include some alcohol-free days and avoiding binge drinking, so not saving your units, necessarily, for a night out. There’s some good guidance available from the government about what constitutes the unit, because there can be a lot of confusion about a glass of 13% or 14% strength wine.
People may assume that just a class is a unit, but that can be two to three units in a large glass. So it’s good to make ourselves aware of what we’re drinking. From a dietary point of view, overall, the amount of food, if you’re eating more than you need and not burning it off, it will be stored, and sort of spare food, if you like, is stored as fat, which can then cause weight gain. And if you put weight around your middle, you are far more likely to put fat in the liver, and to have problems with fatty liver that has the potential to cause problems in later life. So food, overall, and the amounts eaten, but also the quality.
We need fruit and vegetables to keep us healthy and provide vitamins. And we’re rarely at risk of overeating on those. It’s more the fats and sugars, which are very, what we call, energy dense. So per gram of fat, you get nine calories. And per gramme of sugar, you would get four. And it’s easy to eat a lots of grammes of both of those types of food. So excess fat, because it’s a very concentrated source of calories, is hard to burn off in our daily needs, and can be stored in the liver, which, again, could lead to problems with fatty liver.
Again, sugar, sugary drinks, probably one of the worst things we can have, but extra sugar, again, is stored as fat. The body, if it can’t burn it off, it wants to put it somewhere. And it will put it as fat under the skin, but also in the liver. So that, the three key things, alcohol, fat, sugar, but also thinking about the overall amount of food.
Well, we can all be aware of what we’re eating. Now that sounds easy, but it’s a very difficult thing to do when we’re faced with rows of nice looking foods in supermarkets and shops and going out for meals. And food is a very important part of our social life– socialising around food, having treats. And none of that has to stop when you’re thinking about eating carefully– none at all. It’s just being sensible and paying a bit more attention to the amounts of things you’re having. So the balance of foods is important. Fruit and vegetables provide fibre. They provide minerals. They provide vitamins, which are sort of key in maintaining a healthy body.
Sometimes trying to increase your intake of those automatically reduces other snacks. And our aim is to have five portions of fruit and veg a day. Now a portion doesn’t have to be an enormous amount, like one melon. It is a slice of melon, or an apple, or two small satsumas, a handful of berries, a few strawberries. So it’s not huge portions of fruit and veg. And just trying to have– salad obviously counts in that five portions a day– can displace some of the other foods that we eat. So it’s not just about cutting things out, it’s about including, as well. Having more whole grain fibres and cereals and breads. Again, they can fill you up more than the white versions.
So trying to include some. If you hate them, you don’t have to eat them. It’s about picking the ones that you can manage and enjoy eating.
So if we think about meat, there’s often the thought that you shouldn’t having much red meat, shouldn’t be having dairy, because they’re high in fat. In actual fact, you can buy much leaner cuts of red meat. Lamb is inherently fatty, but if it’s oven cooked, you lose a lot of that fat. And again, have it occasionally. When it comes to red meats, you can buy mince that is extra lean. Or if that’s too expensive, you can buy the option with more marbled product, but you can dry fry it and pour off the fat. So there are ways of managing the fats that are in meats. Again with dairy, very important for protein, also for calcium and other minerals.
So just choosing lower fat options. It doesn’t have to be skim milk. If you would prefer semi-skimmed and you can manage that, it’s better to choose what works for you. So that it’s more fine tuning of the diet. Things like chicken and fish, obviously, are much lower in fat. And to include those as many times as meat is a good option. So it’s not about stopping anything, it’s about balancing with lower fat products. A big downfall, potentially, is chocolates and cakes and sweets and biscuits– which we all love– and crisps, of course, but are very high in saturated and processed fats, and overall fat. And again, it’s not about stopping eating these, at all. It is simply about moderating them.
So if you have more than one of each a day, just try and make it half the amount over the week. Or if you’re not that bothered about one thing, such as sweets, stop those, but have crisps when you fancy them. So it’s about doing deals with yourself to see what you can reduce in your diet to try and reduce the amount of fat. Likewise, sugar, again, it’s added to a lot of products, such as cakes, sweets, and biscuits– the processed foods. So they make for very high calorie eating. You can buy reduced sugar versions. You can buy lower fat versions of these products, as well.
So if you do enjoy those on a regular basis, trying to have a lower fat option is better. Drinks can be very deceiving. Some of the fruit juices have lots of natural sugar. So you think you’re being healthy by having a fruit juice, but it could actually be 80 calories in one small carton of 200 mils. So a couple of those over the day can be a couple of hundred calories a day, which, over a week, can add up to 1400 calories. And it takes about 3,000, 3,500 to actually either put on or lose a pound in weight. So you can see the significance.
The other thing to think about with healthy lifestyle is exercise. And it doesn’t mean that we’ve all got to run out and join the nearest gym, or take up a sport that we don’t enjoy, and force ourselves to do it, because you can’t continue that. You get fed up with it, eventually. It’s important to try and include exercise into day-to-day activity. So doing an extra flight on the stairs, taking the stairs instead of the lift. If you’re on the bus, get off a stop earlier. If you’re at the supermarket, instead of trying to do what a lot of people do is park nearest the door, park further away. So you’ve just got that extra little stretch to walk.
If there’s a local shop you can walk to to buy something instead of driving, walking makes a big difference. So it’s trying to incorporate things into what our day-to-day life. Even housework, sort of putting the music on, dancing around doing the Hoovering or the dusting, particularly if you’re on your own, nobody can see you, then these sorts of things can increase our energy expenditure on a daily basis, which can help
prevent weight gain.
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.
Diet and your liver - Transplant patients
People do need more calories and protein to help recover post-transplant. So from what I was saying about people having lost muscle when they are ill, obviously, post-transplant you have a brand new transplanted liver, but you still have some of the problems existing, ie the muscle loss and weight loss. So initially, we’d be giving people high protein advice to help with healing, to help with muscle recovery, and longer term muscle gain. So while the body is healing, you don’t tend to put on weight and muscle, because those proteins are diverted to provide the building blocks for new tissues.
Once the healing process is completed, that can be weeks in people that are better nourished, but it can be a couple of months in people that have got a poorer protein status. Once that healing is completed, that protein can be diverted to muscle to start to get some muscle gain. Also steroids do promote the deposition of fat, so you’re more likely to gain fat, and they hinder muscle gain. So it’s about getting the balance right of calories and protein. So it would be higher calorie and higher protein advice for most patients post-transplant. The duration of that depends on the degree of weight loss pre-transplant.
And again, we tailor that advice to people and say that they would usually be continuing with their supplement drinks, if they were on them. But as their appetite increases, their healing is finished, and they start to gain weight, we would be giving them advice to tail down those supplement drinks, so they’re reducing. Because longer term post-transplant it’s very important to maintain a healthy lifestyle, because you can gain weight. Steroids do set the scene for increased appetite. And so you can get into a habit of eating more.
And because it takes longer to get back to your usual activity level when you’ve had a chronic disease and not used to being as active, and you’ve had surgery, it takes you a while to recover from. Sometimes your eating recovers quicker than the exercise and burning off. So we’ve got to be careful about weight gain. So we’re quite keen to give people the tools to be able to reduce the supplements and the extra calories and protein as their weight improves. And longer term, it’s healthy lifestyle management, as we talked about earlier.
The only exceptions, perhaps, would be that somebody who has been transplanted for fatty liver may not need additional calories, because they’re quite well nourished, but they do need the additional proteins to promote healing and recovery of the muscle. And again, it’s very important in those patients that we give them quite specific advice, that they know when to tail down the protein supplements. And again, longer term, it’s healthy lifestyle management to help prevent the recurrence of the accumulation of fat in the liver.
Anybody avoiding fats, or reducing fats to manage the biliary diseases, once that the bilirubin have been level and the jaundice starts to subside post-transplant, they can re-introduce fats and eat a normal, healthy diet, once they’ve recovered from any weight loss. Those are a key aspects of recovering weight and managing weight. The other aspect of dietary management post-transplant is the consideration of food safety. Obviously, people are immunosuppressed. Their immune systems are not functioning as per a normal healthy individual because of the medication. So we give food safety advice to any food related illness.
So that storage of food in the fridge, so cooked foods, always go above rule, so you don’t get raw juices contaminating that they could drip on cooked foods below. So in the fridge, cooked above raw. People also have got to make sure that unpasteurised foods and cheeses, mayonnaises are made with pasteurised products, not unpasteurised, because of the risk of illness from salmonella. Also, we would make sure that people were having well cooked eggs and poultry. Again, to avoid the risk of salmonella. So we would give that food safety advice. We also give caution to avoid taking probiotics early in the post-transplant period. But longer term, they can be reintroduced under the guidance of the medical and dietetic team.
