Diet and Cirrhosis: What Should You Be Eating?
Hosted By: David R. Marks, MD, WNBC, New York
Participants: Howard J. Worman, MD - New York Presbyterian Hospital
Carol Semrad, MD - Columbia- Presbyterian Hospital DAVID MARKS, MD:
Hi, and welcome to our webcast. I'm Dr. David Marks. When you think
of common causes of death, you usually think of cancer or heart
disease. You may not think of cirrhosis, but it's in the top ten
causes of death in this country. Of course, not everyone with
cirrhosis dies, and people with cirrhosis, to stay alive, need to
watch their diet. That's what we're going to talk about in this
webcast. Joining me to help talk about that topic are two doctors.
First is Dr. Carol Semrad. She's director of clinical nutrition at
Columbia University. Welcome. Next to her, also from Columbia
University, is Dr. Howard Worman. He's the director of their
Division of Digestive and Liver Diseases. Welcome.
As I alluded to in my introduction, there's a wide range of
cirrhosis patients. Not everyone dies from it. Some people have
mild cases. Do they all have to watch their diet?
CAROL SEMRAD, MD: No. The most important part is to eat a healthy
diet. Certainly, if you have cirrhosis and you have no symptoms of
intolerance to the diet, you should eat just a healthy diet.
However, there is a subset of patients who develop intolerance to
protein in the food that they eat, and in that subset of patients
they may want to change to eating a different type of protein in
the diet, from eating animal-type protein -- meat -- to eating
predominantly vegetables and milk. The reason for that is the type
of protein in vegetables and milk is tolerated much better than the
protein in meat.
DAVID MARKS, MD: Before we get into the specific foods that they
have to eat, all patients with cirrhosis should watch their diet in
that they need to eat a healthy diet. How far along in the
cirrhosis do they actually have to start doing extra things like
watching protein intake. Is there a rule?
CAROL SEMRAD, MD: There's no rule. It really is by their symptoms.
So if they are at a point in their disease where they start to
develop confusion or sleepiness or behavior changes that the family
notices, or if they develop swelling in their extremities or in
their belly, then they're starting to get into trouble, dietary
DAVID MARKS, MD: Then they need to move the next phase of dietary
CAROL SEMRAD, MD: Correct.
HOWARD WORMAN, MD: One thing that I think Carol's bringing out
that's important is you're really treating not the cirrhosis itself
but the complications of cirrhosis, and I think that's maybe a
subtle distinction but an important one.
DAVID MARKS, MD: Why is that?
HOWARD WORMAN, MD: Because cirrhosis is a change in the liver, in
the architecture of the liver. There is scarring in the liver,
abnormal growth of the liver that the diet doesn't really change,
but that can cause many different problems. That's what you need to
watch. Those are what you want to stop or prevent by altering your
DAVID MARKS, MD: What are some of the foods that people should or
should not be eating?
CAROL SEMRAD, MD: Again, if you have cirrhosis of the liver and you
have absolutely no symptoms, in fact, other than being told by your
doctor that you have cirrhosis -- you have no other overt symptoms
of your disease -- you should, again, eat a normal, healthy diet,
which includes whatever foods you want to eat as long as it's
within the pattern that's recommended for any other American.
DAVID MARKS, MD: How about people with cirrhosis who are
symptomatic? What do they need to eat?
CAROL SEMRAD, MD: The patients who are symptomatic need to eat
according to, again, what kind of symptoms they're having. A
patient who starts to become confused or sleepy is a patient who's
starting to have trouble with, perhaps, protein in the diet. It's
important to know that there are other medial conditions that can
trigger confusion and sleepiness in a patient with cirrhosis.
However, there is a subset of patients where just plain old protein
in the diet is what the trigger is. In that subset of patients, at
that point, the two options are either to cut down the protein in
your diet or to switch to a different type of food in which the
protein is better tolerated, which means cut down either on the
meat protein you eat or change to eating vegetables and drinking
milk, which contain a protein that can be metabolized much more
easily than the meat proteins, which require the liver to break it
down into its nitrogenous waste and eliminate it, essentially. So
in that subset of patients only would I recommend to switch to the
vegetable and the milk type of protein. It's important to
understand that there's less protein in vegetables and milk than in
meat, so an individual would have to eat more of those types of
proteins than if they were eating meat protein in order to meet
their protein needs in the diet.
Again, the most important part is to individualize, that no one
should restrict unless they've gotten into a problem. It should not
be a preventive measure, to restrict protein in the diet to prevent
confusion or sleepiness, because what often happens is it just
leads to undernutrition and to, perhaps, a worsening of their
DAVID MARKS, MD: Are there any supplements that people with
cirrhosis should have?
CAROL SEMRAD, MD: Again, the answer is not in general, no. But in
certain patients, again, who get into trouble with advanced
cirrhosis, where they have poor appetites and maybe are a little
bit confused and somnolent and not eating well, they may take oral
supplements better. In those cases, again, a standard oral
supplement could be tried if on medication their confusion and
sleepiness is controlled. But if they're having a great difficulty
getting protein in the diet, then one would switch to a special,
designer type of oral supplement, which has a protein profile,
again, that has the type of protein that's present in vegetable and
milk that's metabolized easier. You can get more protein in and not
cause more confusion.
DAVID MARKS, MD: Dr. Worman, fats may also be an issue for some
patients with cirrhosis. Tell us which ones.
HOWARD WORMAN, MD: That's a tough question, to say which fats -- I
don't think, really, having too much or too little fat is a
DAVID MARKS, MD: There are some patients with bile duct disease in
patients with cirrhosis.
HOWARD WORMAN, MD: Patients with cirrhosis from a disease like
primary biliary cirrhosis that affects the bile ducts.
DAVID MARKS, MD: What is that?
HOWARD WORMAN, MD: Primary biliary cirrhosis is a disease of the
bile ducts that leads to cirrhosis, an autoimmune disease,
probably. I wouldn't say certain fats have to be taken or
restricted, but they have problems absorbing fats, in particular,
the vitamins that are soluble in fats. Vitamin D is a very common
problem, and these patients often get bone disease because they
don't absorb enough vitamin D.
DAVID MARKS, MD: What are the other vitamins that are fat-soluble
that they need to worry about?
HOWARD WORMAN, MD: Again, vitamin, A, E, and K is the other one.
Again, I want to emphasize, as Dr. Semrad was talking about protein
supplements, these should be things prescribed by doctors and
vitamins that are given by doctors. People should not just go into
the health food store and buy megavitamins and protein supplements,
because that could lead to a lot of problems.
DAVID MARKS, MD: Zinc can also be a problem.
CAROL SEMRAD, MD: Zinc can be a problem, in particular in the
people who have liver disease that's alcohol-related. But also, in
general, in patients with cirrhosis, there is some evidence that
they may be zinc-deficient. Again, it's hard to know clinically or
what it means in terms of expression of the deficiency, but it's
recommended that people who, certainly, have alcohol-related liver
disease, that they take zinc supplement.
The other thing to point out is in any cirrhotic who has very
advanced disease, they also can get into trouble with the fat and
the fat-soluble vitamins. It's just that the people with bile duct
diseases get into the problem earlier than in other types of
cirrhosis. -In the end stages, when their liver really starts to
fail, at that point they may also not digest and absorb fat and
fat-soluble vitamins, so they may need to also have supplements of
fat-soluble vitamins and to cut down on fat in their diet.
Otherwise they get into problems with malabsorption of fat.
DAVID MARKS, MD: And they'll often have to watch salt because of
all the fluid accumulation of the disease has progressed.
CAROL SEMRAD, MD: Yeah, that's the second issue, aside from eating
protein and vitamins and minerals in the diet, is how much salt to
take in. The people who develop swelling, either in their
extremities or in their abdomen, swelling from fluid accumulation,
they need to restrict their salt. A good guideline to how do you
restrict yourself, how much, is to restrict down to, what we say, a
2 gram salt diet. If you just add no salt to your food, that's
considered a 4 gram salt diet, and then if you don't cook with salt
and you eliminate salty foods and you don't put any salt on your
foods, that's about equivalent to a 2 gram salt diet.
DAVID MARKS, MD: Let me see what you're holding. That looks like
something my kids would like to play with, but I don't think it's a
CAROL SEMRAD, MD: It's not a toy, although I'm sure children would
turn it into a toy instantly. This is a soft feeding tube and this
is something, again, that only is used when an individual cannot
eat on their own and they can't even drink oral supplements because
their disease is so advanced that they either have such a poor
appetite that they won't eat or they're so somnolent and so sleepy
that they can't eat. In that setting -- and oftentimes it's in the
setting of requiring a liver transplant, but you're bridging the
patient nutritionally before they have to go for their transplant
-- we place a feeding tube, with is not to be scared of, because
it's a very soft, flexible tube that can be very comfortably place
through the nose into the stomach and advanced in the early part of
the small intestine. And then the tube feeding is just added to the
end of the tube and dripped into the patient. It's oftentimes a
life-saving measure to allow nutrition to be provided while waiting
for that liver transplant. It also helps for the postoperative
recovery phase. If they're in better shape nutritionally, they'll
get over their transplant and get out of hospital and out of bed,
usually, quicker than if they're malnourished.
DAVID MARKS, MD: But obviously these feeding tubes are really for
the most severe and advanced cases of cirrhosis.
CAROL SEMRAD, MD: Yes. This is for the most severe and advanced
DAVID MARKS, MD: Most people with cirrhosis won't have to deal with
CAROL SEMRAD, MD: No. Most people with cirrhosis don't have to deal
with this, but it's something that people should know can be done
comfortably if they get to this state where they need it, that it
can be done comfortably and safely.
DAVID MARKS, MD: Great. Dr. Semrad, Dr. Worman, thank you very
much. Thank you for joining our webcast. I'm Dr. David Marks.
© 2003 Healthology, Inc.