DIET IN DISEASES OF LIVER
The liver has the most varied and extensive function and is one of the most important organs involved in the metabolism of food. Most of the end products of digestion are transported directly to the liver where they are stored or resynthesized into other forms.
FUNCTIONS OF LIVER
1. Protein metabolism - synthesis of plasma proteins, deaminisation of amino acids, the resultant ammonia is detoxified by conversion to urea. Transamination of amino acids to maintain normal blood levels of non essential amino acids synthesis of prothrombin / fibrinogen.
2. Carbohydrate metabolism - synthesis, storage and release of glycogen. Glycogen is converted to glucose when needed (glycogenolysis). Liver cells convert protein to glucose to give energy (gluconeogenesis), synthesis of heparin.
3. Lipid metabolism - synthesis of lipoproteins, phospholipids, cholesterol, formation of bile, oxidation of fatty acids.
4. Mineral metabolism - Iron and copper, both essential to hemoglobin formation are stored in the liver.
5. Vitamin metabolism - All fat soluble vitamins A,D,E,K, as well as ascorbic acid and B-Complex vitamins are stored in the liver. Carotene is converted to vitamin A and vitamin K to prothrombin.
6. Drugs are metabolized and hormones are deactivated in the liver.
Liver detoxifies chemicals, poisons or drugs entering the body through foods.
AGENTS WHICH CAUSE DAMAGE TO THE LIVER
1. A low protein intake and reduced capacity to secrete beta lipoproteins as seen in kwashiorkor cause fatty changes in the liver.
2. Fatty changes in the liver are also common in uncontrolled diabetes, in starvation, and obesity. These changes are reversible.
1. Virus can cause infection and damage to the liver. Hepatitis A virus is excreted in the stools and spread by the faecal - oral route. The patient suffers from jaundice and the liver is enlarged and tender.
2. Improperly sterilized needles used in blood transfusion can transmit Hepatits B virus which causes homologous serum jaundice.
1. Alcohol : Consumption of alcohol produces acute liver damage and jaundice.
2. Drugs and Chemicals : Drugs like paracetamol may damage the liver. Excess stores of iron, copper, galactose and glycogen may accumulate in the liver and lead to cirrhosis.
JAUNDICE - SYMPTOM OF LIVER DISORDERS
Jaundice is a symptom common to many diseases of the liver and biliary tract and consists of a yellow pigmentation of the skin and body tissues because of accumulation of bile pigments in the blood.
Jaundice may be produced due to the following factors / reasons
1. Obstructive jaundice results from the interference of the flow of bile by the formation of stone and tumors.
2. Hemolytic jaundice results from an abnormally large destruction of blood cells as in pernicious anemia.
3. Toxic jaundice originates from poisons, drugs or virus infection.
INFECTIVE HEPATITIS - SYMPT OMS AND DIETARY MANAGEMENT
Infective hepatitis is otherwise known as viral hepatitis.
Symptoms : Anorexia, fever, headache, rapid weight loss, loss of muscle tone and abdominal discomfort precede the development of jaundice. Neglected viral hepatitis leads to cirrhosis of liver. Treatment consists of adequate rest, nutritious diet and avoidance of further damage to the liver.
Dietary Management : The objectives of dietary treatment are to aid in the regeneration of liver tissue and prevent further liver damage.
A high protein, high carbohydrate, moderate fat is recommended. Small attractive meals at regular intervals are better tolerated. Over feeding should be avoided.
Energy : Sufficient calories should be given to maintain weight and reduce protein catabolism. A diet which supplies 1600 k cals to 2000 k cals is suggested.
Proteins : 1 g protein per kilogram of body weight daily is needed to overcome negative nitrogen balance, for liver cells to regenerate and prevent fatty infiltration of the liver. With severe jaundice 40 g and in mild jaundice 60 - 80 g of protein is permitted. In hepatic coma protein containing foods are avoided and high carbohydrate containing foods are given.
Fats : In severe jaundice 20 g and moderate jaundice 20-30 g is given. Fat needs to be restricted when there is obstruction to bile flow and in hepatic coma when fats are not metabolized by the liver.
Carbohydrates : High intake of carbohydrate is essential to supply enough calories so that tissue proteins are not broken down for energy. Fruits, fruit juices, vegetable juices, sugar, jaggery and honey are given to supply adequate electrolytes.
Vitamins : Vitamins are essential to regenerate liver cells. 500 mg of vitamin C, 10 mg of vitamin K, and B-complex vitamins are essential to meet the daily needs. If anorexia, nausea or vomiting are present, the vitamins may be given by injection.
Minerals : Oral feeds of fruit juice, vegetable and meat soups with added salt given orally or through a naso gastric tube help in maintaining the electrolyte balance.
Foods to be included and avoided are presented in List.
List : Foods that can be included and avoided in Infective Hepatitis
Foods to be included :
Cereal porridge, soft chapathis, bread, rice, skimmed milk, potato, yam, fruit, fruit juices, sugar, honey, soft biscuits, custards without butter, and cream.
Foods to be avoided :
Pulses, beans, meat, fish, chicken, egg, sweets with ghee, butter or oil, bakery products, dried nuts and fruits, alcoholic preparation, whole milk and cream.
DIETARY MANAGEMENT IN CIRRHOSIS OF LIVER
Cirrhosis is a condition in which there is destruction of the liver cell due to necrosis, fatty infiltration and fibrosis. It is a serious and irreversible disease. It occurs after years of excessive alcohol intake in individuals whose diets are deficient in nutrients. Malnutrition aggravates injury to the liver and can lead to child hood cirrhosis seen between the age of 1 to 3 years.
The onset of cirrhosis may be gradual with gastrointestinal disturbances such as anorexia, nausea, vomiting and pain. The patient may suffer from weakness, muscle cramps, weight loss and fever. As the disease progresses jaundice occurs. Ascites which is the accumulation of abnormal amounts of fluid in the abdomen develops.
Principles of diet
A high calorie, high protein, high carbohydrate, moderate or restricted fat, high vitamin diet helps in the regeneration of liver and helps to prevent the formation of ascites. Low fat with supplementation of fat soluble vitamins and minerals should be given. Sodium should be restricted only when there is ascites. The diet should be attractive and palatable.
Energy : Since anorexia and ascites are present consumption of food is difficult. A highly nutritious high calorie diet is necessary because of prolonged undernourishment. The calorie requirement should be between 2000 - 2500 k cals.
Proteins : A high protein diet is helpful for regeneration of the liver. It also helps to compensate for the considerable loss of albumin in the ascitic Fluid. In the absence of hepatic coma, a high protein intake of 1.2 g/kg of body weight is recommended. The protein content of the diet varies according to the symptoms.
Fats : About 20 g of fat is given provided adequate amounts of protein is supplied.
Carbohydrates : Carbohydrates should be supplied liberally so that the liver may store glycogen. Liver function improves when an adequate store of glycogen is present.
Vitamins and Minerals : The liver is the major site of storage and conversion of vitamins into their metabolically active form. In cirrhosis the liver concentration of folate, riboflavin, nicotinamide, vitamin B12 and vitamin A are decreased.
Vitamin supplementation especially of B vitamins is required to prevent anaemia. Choline and methionine are useful if fatty infiltration is present.
Sodium is restricted to 400-800 mg/day in oedema and ascites. If there is no ascites very little salt is permitted to make the food more appetizing. Potassium salt is given for ascites and oedema to prevent hypokalemia.
Iron supplementation is essential as anaemia is common. A daily dose of 0.3 g of ferrous sulphate tablet 3 times after meals would also be beneficial. Folic acid 1 mg / day orally is given to treat macrocytic anaemia.
CHOLECYSTITIS AND CHOLELITHIASIS - DIETARY MANAGEMENT
Cholecystitis is an inflammation of the gall bladder and cholelithiasis is the formation of gall stones. Inflammation of the gall bladder results from a low grade chronic infection and may occur with or without gall stones. Gall stones are of two main groups: Cholesterol and pigment stones.
When inflammation and / or stones are present in the gallbladder, fat in the diet is the main cause for contraction which causes pain. Surgical removal is usually indicated if the patient suffers from acute cholecystitis or cholelithiasis. Intake of fat should be greatly reduced to 20g day and energy should be derived from carbohydrate.
Cereals in a soft form, cooked rice, chapathi, bread and idli, milk pudding, curds, cooked vegetables, kichidi and porridge can be included in the diet. Pulses, beans, meat, fruit, fruit juices, fish, soft cooked eggs can also be given. These are high caloric, high protein foods which help in regeneration of liver cells.