~Hepatitis C, Part 6 - Functional and Practical Medicine
FUNCTIONAL AND PRACTICAL MEDICINE
The extent of the impact of poor nutrition on HCV activity and progression of liver damage is unknown. However, the liver is the primary metabolic organ and the intermediary in the metabolism of nutrients and bile salts. As such, it significantly influences absorption, storage, and metabolism in the body. Damage to the liver can lead to vitamin and mineral deficiencies and malnutrition.373
Nutrition can play a critical role in the management of HCV infection at all stages of the disease. Preventive measures, such as dietary changes and avoidance of alcohol, can reduce the progression of liver disease significantly. The consequences of the interaction of HCV with alcohol, HBV, and malnutrition are well recognized. Superinfection with hepatitis A or B virus can lead to liver failure. HCV and alcohol act synergistically to accelerate the development of cirrhosis;374 moreover, alcohol is at least as important as HCV in the process.375 A study that explored the role of diet on disease risk in cirrhotic men showed that a high-fat, low-protein and low-carbohydrate diet significantly increased the risk of cirrhosis and that the alcohol and CHC further increased the risk.270
Being overweight is strongly associated with elevated ALT levels and increases the risk of liver disease. A large, national study found that central adiposity (i.e., higher waist-to-hip circumference ratio) and elevated levels of leptin and insulin were major determinants of the association of overweight with elevated serum ALT.376 A diet that restricts total calories, fat, iron, and protein reduced serum ALT levels in patients with long-term HCV infection.377 Weight reduction and exercise can improve liver function in patients with fatty liver disease374 and may be able to reduce steatosis and fibrosis.373
In addition to increasing the response to treatment and decreasing its side effects, healthy eating can improve the quality of life for HCV patients. Good nutrition has the potential to hinder disease progression, as well. Subtle nutritional deficits are not always obvious at early stages of infection with HCV. Usually liver failure is only evident after most hepatocytes have been destroyed; then it is difficult for the body to use nutrients appropriately, synthesize plasma proteins, and remove toxic substances. HCV patients usually do not need special diets unless they have advanced liver disease or some condition that requires dietary modification, such as diabetes.373
A healthy diet for HCV-positive patients should be composed of foods from all food groups. It should include enough calories and protein to fight infection and regenerate the liver and an ample supply of vegetables and fruit to maximize free radical-fighting antioxidants. High-fat and high-sugar foods should be limited. Ideally, eat small meals that are spread out over the day. In general, low-protein diets promote malnutrition and are only recommended for patients with acute hepatic encephalopathy.373
Dietary modifications can have a beneficial effect on complications of HCV infection, such as cirrhosis, hepatic encephalopathy, and transplantation surgery.373 Dietary needs for individuals with compensated cirrhosis are similar to those with acute HCV infection. However, frequent, small meals improve nitrogen and substrate use, diminish fat and protein oxidation, and prevent depletion of glycogen stores. Because cirrhotic patients experience swings in blood sugar, the diet should be high in complex carbohydrates and low in sugars. Protein needs vary, but these individuals tend to tolerate the protein from dairy and plant sources better than those from meat. Cirrhosis often makes it difficult to digest and absorb dietary fat which results in steatorrhea, i.e., undigested fat in the stool. Reduction of fat to 25% of total calories is recommended. If steatorrhea is severe, supplementation of fat-soluble vitamins might be recommended. Nutritional drinks containing medium-chain triglycerides do not need bile to be absorbed into the bloodstream, and can be helpful when the liver can no longer produce enough bile. Fatty liver can also benefit from reduction of fat in the diet. Sodium is typically restricted for patients with cirrhosis.
Encephalopathy is a condition in which ammonia—normally neutralized by the liver—builds up in the body. Untreated, encephalopathy can lead to confusion, personality changes, coma, and death. Encephalopathy is characterized by abnormally high aromatic amino acids and low branched chain amino acids.373 The treatment for encephalopathy373 is usually protein restriction and medication that helps rid the body of ammonia. Even in encephalopathy, protein is never eliminated completely from the diet.373 Supplementing the diet with branched chain amino acids is can improve encephalopathy, particularly in malnourished individuals prone to infection. Because vegetable proteins contain less aromatic amino acids than other foods, a carefully balanced vegetarian-type diet is usually beneficial. Some investigators think that mineral imbalance is implicated in the development of encephalopathy.373
Treatment with Interferon-a and ribavirin induces malnutrition in the early stage of therapy. Anorexia, nausea, and vomiting—frequent side effects of treatment—can cause dehydration, electrolyte imbalances, abnormal metabolism, and weight loss.378 There is a positive connection between elimination of HCV RNA and nutritional status. It has only recently been learned that some amino acids can modulate immunological response. A study that analyzed the effects of nutrition on the clearance of HCV showed that total amino acids and branched chain amino acids decreased during therapy. Early in the course of therapy, the balance of amino acids changed to levels similar to patients with cirrhosis. There was a decrease in total and branched chain amino acids and differences in the concentration of citrulline and ornithine between HCV RNA-negative and HCV RNA-positive groups. These results suggested that modifying the balance of amino acids at the beginning of treatment might upregulate the immunological response by improving the nutritional status. Adequate nutrition support would contribute to patient quality of life as well as decrease the number of patients who withdraw because of side effects.379
Almost all drugs are metabolized in the liver before they are eliminated from the body. Consequently, all medications, even over-the-counter preparations and herbal remedies, are potentially hepatotoxic and should be used with caution in patients with chronic liver disease. Non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen should be avoided, in particular. ([See the Acetaminophen Poisoning (Analgesic Toxicity) protocol.).] Some vitamins taken in mega-doses could be harmful. Vitamin A taken in very high doses has caused permanent liver damage.
Moderate physical activity is recommended for all HCV patients, unless they have decompensated cirrhosis or serious metabolic complications. Exercise will not affect the course of infection, but it can help relieve fatigue, stress, and depression; improve appetite; build up the immune system; and in general improve the quality of life.373
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