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BY: Mary Jan Detroyer, MS, RD, CDN

Hepatitis C (HCV) is a virus that attacks the liver. Because the virus grows very slowly, it can take 30 years or more before you get sick. But you don't want to wait until you get sick to start fighting the virus. There are drug therapies and lifestyle changes you can initiate that can slow down or stop the progress of hepatitis C before it does any damage. Eliminating alcohol, eating a healthful diet, avoiding stress, finding time for relaxation and performing moderate exercise are ways to fight the virus.

Fatigue is the most common symptom associated with HCV. It has various causes. It occurs secondary to medications used to treat both HCV and cryoglobulinemia, an inflammation to suffer more from fatigue compared with those who have hepatitis B or alcoholic liver disease. Of 239 patients questioned about fatigue, 23% thought general overall body pain caused their fatigue. Fatigue could be related to the severity of liver disease or to autoimmune disorders often seen with chronic hepatitis. One study looked at these parameters; it found no such correlation, but it did find that people with chronic HCV felt that their fatigue had a major effect on their quality of life. One of the most important steps you can take to lessen fatigue is to exercise. I know that sounds crazy, and exercise is the last thing you feel like doing when you are tired, but the physiological changes your body goes through during exercise will actually make you feel better.

Renee is a real person who has been living with HCV for 25 years. She hopes that by sharing her experience, others will find encouragement and strategies for coping with their symptoms. At the time of infection, Renee was a competitive athlete training at the Olympic level with 29 male cyclists. She feels her athleticism slowed the progression of the virus and allowed her to train at a high intensity for many years. She has undergone three courses of drug therapy since 1993. Working out and staying fit help her cope with the side effects of therapy. She has experienced fatigue, nausea, vomiting, taste alterations, loss of appetite, hair loss, sleep disturbances, and pain. The most difficult symptom for Renee is constant fatigue, which can be all-encompassing.

Exercising through the fatigue will be challenging. Diminished liver function can cause insufficient levels of oxygen in the blood. Oxygen is crucial for energy production, and exercise increases the need for oxygen. Studies show that people with reduced liver function have poorer oxygen delivery during exercise. They also experience fatigue at lower exercise intensities and have difficulty using energy stored in muscle. People with cirrhosis respond differently to exercise. Some have normal aerobic capacity, while others experience reduced capacity. This means that some people will have to choose exercises like T'ai chi or yoga that require less oxygen delivery. Renee finds she needs a longer warm-up and modifies her routine based on how she feels each day. On some days, she jogs the whole distance; on others she alternates jogging and walking; sometimes all she can handle is walking. She focuses on how good her body feels during exercise, not on her limitations. She even competed in a lower intensity triathlon where the swimming element took place in a pool. She chuckled when she told me how some children cheered her on, yelling "Keep going lady, you're doing great." When Renee feels too ill to run or walk, she uses stretching as a way of staying in tune with her body.

Pain is another symptom associated with chronic hepatitis. When patients with HCV were asked about the kinds of pain that they experienced, back pain was reported most often. Other types of pain reported were morning stiffness, neck pain, general pain, joint swelling, and joint and muscle pain. Current guidelines for managing back pain emphasize exercise and activity rather than rest. Women with neck pain experienced a larger reduction in pain when they participated in three different forms of exercise as compared to nonexercising patients in the control group. Renee has less aches and pains and sleeps better when she exercises.

Depression, anxiety, and irritability are all associated with HCV. Renee told us that the hardest time for her was when she started treatment and realized she would never again be able to compete at the level she was used to. This adjustment was made even more difficult because many of her friends were competitive athletes.

"When your body is sick, it is very easy to disconnect from it," she commented. Exercise helps Renee stay positive and connected with her body. Current methods used to treat depression include exercise, psychotherapy and drugs. Research confirms that people who suffer from depression, anxiety, and panic disorders receive similar symptom relief from aerobic exercise and weight training as they do from meditation and relaxation techniques.

Portal hypertension (increased pressure in the portal vein that delivers blood to the liver) can occur with liver disease. Portal hypertension increases the risk of bleeding in the abdomen and esophagus. Research has shown that venous pressure increases with low-intensity exercise and intensifies as exercise workload increases. Medication can be used prior to exercise to reduce portal hypertension. If you know you have portal hypertension, or are not sure, discuss this with your doctor before beginning any type of exercise program.

There is usually no restriction from exercise for people with hepatitis C, but your choice should be discussed with your doctor. The type of exercise you choose will depend on how fit you were before you became ill, how your body reacts, and what you enjoy. Appropriate activities for beginners are walking, swimming, cycling or low-impact aerobics. T'ai chi and yoga are good for reducing stress and calming the body and work well for those who suffer from anxiety and irritability. However, some yoga techniques are very rigorous, so ask beforehand to determine whether they are appropriate. Don't forget to include resistance training a couple of times a week to maintain or build muscle. Beginners should start slowly with lower weights, gradually adding weight as they get stronger. If you have questions, consult an exercise professional who has experience working within the parameters of HIV and HCV and who understands the limitations and modifications associated with both diseases.

One message that rang clear throughout my interview with Renee was that you will feel tired all the time and you will put off exercising until you have more energy. She emphasized that you shouldn't wait until you feel good enough because you never feel good enough! You have to force yourself off the sofa and out the door. Have faith in yourself, don't become frustrated, and don't give up!

Mary Jane Detroyer is a registered dietitian and exercise physiologist whohas been working with clients for over 14 years to improve their health through diet, exercise, and simple lifestyle changes. She has a private practice in Manhattan specializing in HIV/AIDS, Women's Wellness, Weight Management, and Prevention.

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