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Nutrition

NUTRITION IN LIVER DISEASE

            The liver plays a central role in energy and nutrient metabolism. Malnutrition is highly prevalent among patients with chronic liver disease and leads to increased morbidity and mortality rates. The main goals of providing nutritional support to these patients are multiple: to prevent further liver injury and promote liver regeneration, to slow the overall deterioration of the patient, to minimize the risk of infection, and to prevent macro and micro nutrient deficiencies and, thereby, maximize growth potential.

IMPORTANCE OF MACRONUTRIENTS IN LIVER DISEASE

Energy: Patients with compensated cirrhosis do not appear to need modification of their energy intakes. Optimal nutritional therapy involves maintaining high caloric intake while preventing specific nutrient deficiencies

Protein: Patients with cirrhosis have been shown to have high protein requirements to maintain positive nitrogen balance. Recommended protein intake for cirrhotics is 1.0 - 1.5g protein/kg/day. Increased protein requirement is due to both a defect in meal-induced protein synthesis and increased protein degradation during feeding as well as fasting.

Carbohydrate: Both complex and simple carbohydrates are not restricted unless patient has insulin resistance or diabetes. For those patients, 50% - 60% of calories from carbohydrates (mainly complex carbohydrates); intake should be consistent from day to day and at each meal and snack.

Fat: Medium-chain triglyceride oil is well absorbed in patients with cholestasis; however, long-chain triglycerides should not be decreased to less than 10% of total energy intake, to prevent deficiencies in essential fatty acids. Polyunsaturated fatty acid (PUFA) deficiency is common in cirrhosis, especially alcoholic cirrhosis, because PUFA synthesis from essential fatty acid precursors occurs in the liver. PUFA deficiency is an independent predictive factor of mortality in alcoholic cirrhosis.

Fluid: If ascites is accompanied by low serum sodium levels (< 128mEq/L) restrict fluids to 1200 to 1500ml/day in severe cases (<125mEq/L) restrict fluids to 1000 to 1200ml/day.

SIGNIFICANCE OF MICRONUTRIENTS

Vitamins:

  • Deficiencies in water-soluble vitamins (B and C) are common in alcoholic cirrhosis in particular but also occur in nonalcoholic liver disease.
  • The risks of Wernicke's encephalopathy and Korsakoff's dementia are well described in alcoholic and hepatitis C-related patients deficient in thiamine.
  • Fat-soluble vitamin deficiencies occur more commonly in the cholestatic liver syndromes.
  • Vitamin A (retinol) deficiency has been described in cirrhosis and is considered a risk factor for development of cancer, including hepatocellular carcinoma.
  • Vitamin E, an antioxidant, is reduced in cholestasis and alcoholic liver disease.

Minerals:

  • The presence of advanced chronic liver disease leads to water-electrolyte imbalances clinically characterized by ascites and peripheral edema.
  • Sodium retention plays a key role in the pathophysiology of ascites and edema formation in chronic liver disease. Dietary sodium restriction, with accurate fluid monitoring, is needed to maintain homeostasis.
  • Potassium supplementation is often required to correct the hypokalemia due to losses from diarrhea, use of diuretics, or hyperaldosteronism.
  • Low levels of trace elements such as selenium and zinc have been described in patients with chronic alcoholism is attributed to decreased intake and absorption and diuretic-induced increased urinary excretion.
  • Supplementation with zinc has been shown to improve glucose disposal in cirrhotic patients, and deficiency may contribute to the impaired glucose tolerance and diabetes commonly observed.
  • Magnesium deficiency occurs in alcoholic liver disease, and muscle magnesium is an independent predictor of muscle strength. This is probably related to the reduced content of sodium-potassium pumps in skeletal muscle that accompanies magnesium deficiency.

RECOMMENDED DIETARY ALLOWANCES:

Fat soluble vitamins:

 

Age

Energy

Protein

Vitamin A

Vitamin D

Vitamin E

Vitamin K

k. cal

g

IU

*ug RE

IU

*ug

IU

*mg TE

*ug

Children

4-6

1,800

30/24

2,500

500

400

5

9

7

-/20

 

7-10

2,400/ 2,000

36/28

3,300

500

400

5

10

7

-/30

Males

15-18

3,000

54/59

5,000

1,000

400

5

15

10

-/65

 

19-24

3,000/ 2,900

54/58

5,000

1,000

400

5

15

10

-/70

 

25-50

2,700

56/63

5,000

1,000

-

5

15

10

-/80

 

50+

2,400

56/63

5,000

1,000

-

10

15

10

-/80

Females

15-18

2,100

48/44

4,000

800

400

5

12

8

-/55

 

19-24

2,100

46/46

4,000

800

400

5

12

8

-/60

 

25-50

2,000

46/50

4,000

800

-

5

12

8

-/65

 

50+

1,800

46/50

4,000

800

-

10

12

8

-/65

Water soluble vitamins:

 

Age

Ascorbic Acid

Folacin/ Folate

Niacin

Riboflavin

Thiamine

Vitamin B6

Vitamin B12

mg

mcg

mg

mg

mg

mg

mcg

Children

4-6

40/45

200/75

12

1.1

0.9

0.9/1.1

1.5/1.0

 

7-10

40/45

300/100

16/13

1.2

1.2/1.0

1.2

2.0/1.4

Males

15-18

45/60

400/200

20

1.8

1.5

2.0

3.0/2.0

 

19-24

45/60

400/200

20/19

1.8/1.7

1.5

2.0

3.0/2.0

 

25-50

45/60

400/200

18/19

1.6/1.7

1.4/1.5

2.0

3.0/2.0

 

50+

45/60

400/200

16/15

1.5/1.4

1.2

2.0

3.0/2.0

Female

15-18

45/60

400/180

14/15

1.4/1.3

1.1

2.0/1.5

3.0/2.0

 

19-24

45/60

400/180

14/15

1.4/1.3

1.1

2.0/1.6

3.0/2.0

 

25-50

45/60

400/180

13/15

1.2/1.3

1.0/1.1

2.0/1.6

3.0/2.0

 

50+

45/60

400/180

12/13

1.1/1.2

1.0

2.0/1.6

3.0/2.0

Minerals:

 

Age

Calcium

Phosphorous

Iodine

Iron

Magnesium

Zinc

Selenium

Fluoride

mg

mg

ug

mg

mg

mg

*ug

*mg

Children

4-6

800

800/500

80/90

10

200/130

10

-/20

-/1.1

 

7-10

800

800

110/120

10

250

10

-/30

-/3.2

Males

15-18

1200/1300

1200/1250

150

18/12

400/410

15

-/50

-/3.8

 

19-24

800/1000

800/700

140/150

10

350/400

15

-/70

-/3.8

 

25-50

800/1000

800/700

130/150

10

350/420

15

-/70

-/3.8

 

50+

800/1200

800/700

110/150

10

350/420

15

-/70

-/2.9

Female

15-18

1200/1300

1200/1250

115/150

18/15

300/360

15/12

-/50

-/3.1

 

19-24

800/1000

800/700

100/150

18/15

300/310

15/12

-/55

-/3.1

 

25-50

800/1000

800/700

100/150

18/15

300/320

15/12

-/55

-/3.1

 

50+

800/1200

800/700

80/150

10

300/320

15/12

-/55

-/3.1

For personalised dietetic advice regarding

  1. Metabolic disease
  2. celiac disease
  3. failure to thrive
  4. childhood obesity

please mail request to childrendiet@gmail.com

 
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