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Cirrhosis and Advanced Liver Disease

If your condition has progressed to cirrhosis, there are additional considerations you will need to make in your diet to support your liver, and asking to be referred for dietary advice is recommended.

The damage present in cirrhosis stops the liver working properly and affects its ability to store and release glycogen, a chemical which is used to provide energy when you need it. When this happens, the body uses its own muscle tissue to provide energy between meals. This can lead to malnutrition, muscle wasting and weakness. Around two in ten (20%) people with compensated cirrhosis and six to nine people out of ten (60 – 90%) with decompensated cirrhosis, will become malnourished as their disease progresses2,17.

Compensated cirrhosis

If you have compensated cirrhosis – where your liver is severely scarred but there are enough healthy cells in your liver to perform all of its functions adequately – you may feel quite well.

It is important to have a well-balanced diet to ensure you are getting enough carbohydrate, protein, fat, vitamins and minerals. Most people with cirrhosis need to take in more energy (kcals) and protein than healthy people of the same weight. You should aim to have a protein and a starch food with every meal, particularly breakfast and evening meals, and to eat 25-35kcal and 1-1.2g of protein for every kg of your body weight per day2.

If you are underweight then you will need to increase your energy and protein intake further. Snacking between meals can top up your calories and protein, as can the addition of a variety of supplements that your dietitian will recommend. A bedtime snack is especially effective.

Try to eat regularly, say every two to three hours. Suitable snacks include:

  • teacake
  • toast
  • crackers
  • cereal
  • fruit
  • milky drinks

Some people with cirrhosis may develop bone thinning (osteopaenia / osteoporosis). This is diagnosed by bone density scanning (DXA scan). If the scan shows you have this condition, it is likely that your doctor will provide you with supplements of vitamin D and /or calcium to reduce the risk of bone fracture9.

Decompensated cirrhosis

Cirrhosis may progress to become decompensated – where the liver is not capable of performing all of its normal functions resulting in a number of complications including, fluid retention and mental confusion (encephalopathy).

If you have decompensated cirrhosis you will need expert dietary advice. A high energy, high protein diet is likely to be recommended to help your liver function (35-40kcal and 1.5g of protein for every kg of your body weight per day)2. You may need supplemental drinks and some specific dietary measures to manage some of the complications of your cirrhosis. It is very important that you have a good diet; your doctors and dietitian are unlikely to suggest any dietary restrictions without careful assessment.

Fluid retention

Some people with cirrhosis get a build-up of fluid in the stomach area (ascites)26 and swelling of the feet and legs (oedema). These symptoms may be treated with drugs called diuretics (also known as water pills). Sometimes the excess fluid in the abdomen will be drained away using a tube, particularly if you are very uncomfortable.

Although you may feel bloated, it is important that you continue to drink enough fluids so that you don’t dehydrate.

You can help to control fluid retention by reducing the amount of common salt (sodium chloride) in your food26. However, while it is a good idea to cut out foods with a very high salt content, it can be harmful to change to a diet that is too low in salt without guidance from a dietitian.

Your taste buds become more sensitive to salt as you eat less of it. It is quite easy to cut down salt in the food you prepare yourself, but most of the salt we eat is added to foods by the manufacturers5. A dietitian can advise you on which foods you can eat and which you should avoid.

It is likely that you will be recommended to reduce the amount salt in your diet to around 5.2g of salt (or sodium to no more than 2.08g) per day27.

Foods which you may think are low in salt can surprise you, reading the labels on the food you buy will help you to monitor your intake more carefully5.

Fresh foods should be eaten wherever possible as they are generally lower in salt than canned or processed foods. Try to buy foods labelled ‘low salt’ or ‘no added salt’. A quick way to tell if your food is high in salt is to look at the nutritional information on the label. Look for the amount of salt per 100g, if there is more than 1.5g salt per 100g (or 0.6g sodium) then it is high in salt, anything up to 0.3g salt or less per 100g (or 0.1g sodium) is low in salt5.

Ideas for reducing your salt intake

  • Avoid adding salt to meals at the table. A small amount can be added during cooking if need be.
  • Try making your own stock and not adding salt, as stock cubes, bouillon cubes and gravy granules can be high in salt5.
  • Avoid packet and tinned soups if possible.
  • Tinned vegetables, including baked beans, can be high in salt. Look for low-salt or no-salt versions. Frozen vegetables are lower in salt.
  • Smoked and tinned fish, including salmon, tuna and pilchards in brine contain a lot of salt. Only have these occasionally or try the ones tinned in oil.
  • Do not eat cured meats – including ham, bacon, sausages, and salami. Use cold cooked fresh meat, poultry or eggs instead.
  • Full-fat hard cheese is an excellent source of protein, so include it in your diet but do not have it every day.
  • Ready meals and sauces are high in salt so try to look for low salt alternatives and have these less often. Pasta and ‘cook-in’ sauces can be used if no other salt is added to the meal.
  • Bovril, Marmite and all yeast extracts are high in salt and so should be avoided.
  • Choose unsalted butter.
  • Certain bottled waters are high in sodium – check the labels carefully.

Medications

It is also important to be aware that some prescription and over the counter medications have a high salt content. If the sodium content on the labelling of your medication is not clear, or you are unsure if it is suitable, then your pharmacist or doctor should be able to advise you.

Salt is not the only way to make your food taste better, instead try:

  • freshly ground black pepper
  • lemon juice on fish or meat
  • redcurrant jelly, apricots, rosemary or garlic for lamb
  • apple or gooseberry sauce with pork
  • ginger, garlic and spring onions with mixed vegetables
  • olive oil and vinegar with salad and vegetables
  • mustard powder or nutmeg with mashed potato
  • various home-made sauces – such as onion sauce made with milk and garlic – used instead of gravy
  • try using different types of onion – brown, red, spring onions, shallots or leeks
  • toasted and ground sesame seeds added to pastries, breads and stir-fries
  • washed and finely chopped coriander root in soups, stews and stock
  • try adding fresh herbs, lime, garlic, chilli and ginger to pasta dishes, vegetables and meat.

Mental confusion (hepatic encephalopathy)

Some people with cirrhosis develop poor memory and concentration. They can become confused and may even lose consciousness. This happens because the damaged liver is unable to break down toxins from the bowel which then enter the bloodstream and are carried to the brain.

It can occur when a person with cirrhosis also has some other problem such as diarrhoea, vomiting, dehydration, constipation, infection or bleeding. The liver cannot cope with the extra stress. Treatment includes tackling the underlying medical problem and paying careful attention to diet, particularly to eating enough protein.

Historically people with hepatic encephalopathy were treated with a low protein diet. It is now recognised that this was the wrong approach and that a high protein diet will help to improve liver function29,30.

Many internet sites still wrongly suggest that those with hepatic encephalopathy should restrict dietary protein and some healthcare professionals working outside the specialist liver units may also not know about this change in management.

You are likely to be advised:

  • to spread your protein intake over the waking hours, eating four to six snack meals a day rather than one or two bigger main meals
  • to eat a late-evening snack high in carbohydrate to help support your liver during the night
  • poultry, fish, eggs and cheese are good sources of protein as an alternative to red meat
  • starchy foods such as potatoes, rice, pasta and cereals help to provide energy slowly over a longer period.

If your appetite is poor and you are not able to eat snacks, you may need to take high-protein and high-calorie drinks on the advice of your dietitian or doctor. See the ‘Coping with eating difficulties’ section.

Controlling blood sugar

If you have too much sugar (glucose) in your blood, it is known as hyperglycaemia. This can occur in some people with cirrhosis. You may be advised by your dietitian to follow a diet similar to the one used by people with diabetes. This means avoiding foods that are high in sugar but otherwise eating a well-balanced diet. It is important to eat enough calories and protein to keep well nourished; the energy lost by cutting down on sugar must be replaced from another source.