This section gives advice on diet for people with particular liver problems. We only have space here to cover some of the information that is available. You may have other questions or worries about your particular condition and the best person to talk to is your doctor or dietitian. If you have already been advised to follow a special diet it is essential to talk to your doctor or dietitian before making any changes.
Alcohol related liver disease (ALD)
The first stage of injury to your liver, if you have been drinking alcohol excessively, is the build-up of fatty deposits. This can be reversed completely, if you abstain from alcohol. Approximately, one in five (20%) of those with alcohol-related fatty liver go on to develop alcoholic hepatitis (inflammation) and eventually cirrhosis8.
Many people with alcohol related liver damage are malnourished (lacking in all the nutrients the body requires). This may be due to several factors:
- poor diet
- loss of appetite
- malabsorption (poor absorption of food nutrients) as the liver is less able to produce bile to aid digestion
- alcohol has no nutritional value but requires a lot of energy for the body to process1.
You may still be malnourished even if you are overweight depending on what and how you eat or if your weight has been increased by fluid retention1.
People who are malnourished due to alcohol related liver disease may particularly lack the vitamin thiamine (a B vitamin that helps the body convert carbohydrates into energy). You should be prescribed B vitamins if you are drinking alcohol at harmful levels, or are alcohol-dependent, and any of the following apply:
- you are malnourished or at risk of malnourishment
- you have decompensated liver disease
- you are in acute or medically assisted withdrawal19.
Consult your doctor or dietitian if this has not been prescribed.
The most important change to your diet which you can make is to stop drinking alcohol. Eating a balanced diet, with sufficient protein and carbohydrate, is essential. Initially, especially if hospitalised, you may be recommended high energy, high protein drinks with vitamin and mineral supplements. If you are very unwell, you may need to have a liquid supplement via a feeding tube into your stomach.
Non-alcohol related fatty liver disease (NAFLD)
Non alcohol related liver disease is a term for a wide range of conditions in which there is a build-up of fat in the liver cells of people who do not drink alcohol excessively. Initially the fat deposits may not be associated with any symptoms, however, in some people this may progress to inflammation – non alcoholic steatohepatitis (NASH) which may in turn lead to scarring and cirrhosis.
You are more likely to develop a fatty liver if you:
- are overweight or obese, particularly if you put on weight around your middle (apple shaped)
- have high blood cholesterol
- have diabetes
- have been diagnosed with insulin resistance (where your body does not respond to insulin as it should)7.
If you have a fatty liver you may be advised to make changes to your diet and life-style including:
- cutting out or down on alcohol (remember, alcoholic drinks are often high in calories
- taking regular exercise, such as walking or swimming
- eating plenty of fruit and vegetables
- eating slow-release starchy foods, such as bread and potatoes
- avoiding refined sugars and saturated fats – as in chocolate, cakes and biscuits.
- if necessary, slowly reducing your weight to a healthy level for your build and age, and keeping it there.
If you are diabetic, then it is important to work with your doctor to keep your blood sugar levels under good control. If your blood cholesterol is high or you are insulin resistant, you may be prescribed medication as well given dietary advice.
Acute viral hepatitis
If you have a short-term (acute) hepatitis infection caused by a virus – like hepatitis A, for example – you may actually feel quite well and should try to eat a normal diet. However, some people may need extra nutrition to prevent unplanned weight loss and may benefit from a high energy and high protein diet. A dietitian can advise on this.
If you develop nausea and vomiting, which makes eating difficult, then the advice given under ‘Coping with eating difficulties’ later in this publication may help.
Chronic viral hepatitis
If you have a long-term hepatitis infection (when infection lasts longer than six months) caused by a virus such as hepatitis B or C, you can eat a normal, well-balanced diet.
Try to maintain a body weight appropriate for your height and build. Maintaining a healthy weight is important as studies show that obesity can speed up the damage caused by hepatitis C and can also affect how well you respond to treatment13,14.
Some people find they have problems with poor appetite and unintended weight loss, particularly during treatment with anti-viral agents. A poor appetite, nausea and vomiting are unpleasant but these symptoms only cause a nutritional problem if they last longer than a few days or if you are continuing to lose weight. If this is the case you should consult your doctor.
Some people report that they find taking oral ribavirin with dietary fats helps to reduce any side-effects, as does drinking water throughout the day to keep fluid levels up.
Periods of fasting, for instance for religious reasons, are not recommended if you have chronic liver disease.
Some people with autoimmune hepatitis who are prescribed steroids, find their appetite increases and that they gradually gain weight. If this happens to you, it is still important to eat a varied and well-balanced diet. If taking long-term steroids, it is also important that, you are prescribed calcium and vitamin D supplements to reduce the risk of osteoporosis9. If, however, you are gaining too much weight, you should try to reduce calorie-rich foods – including sugar, sweets, cakes, biscuits, fried food, pasties and pies, crisps and chocolate. You should use low fat milk and spreads and fill up on fruit and vegetables.
If weight gain is a problem, your doctor may suggest specialist help from a dietitian.
If you have been diagnosed with genetic haemochromatosis, your body will absorb more iron than normal. Treatment with regular venesection (the removal of a unit of blood) is a very effective means of getting rid of the excess iron. There is no need for specific dietary change and it is important to eat a balanced diet.
It is recommended to:
- avoid taking supplements or multi-vitamins with iron
- avoid foods which are fortified with iron such as some drinks and breakfast cereals
- be cautious with vitamin C in pill form (max 500mg/day) as this can increase the absorption of iron. Vitamin C from fruit and vegetables does not need to be avoided
- watch your alcohol intake as excess can speed liver damage and may increase iron absorption20.
Some foods such as calcium, as found in dairy foods21, and tannin, as found in tea22 may reduce the amount iron absorbed when taken with food. However, the overall effect on iron absorption over a period of days or weeks is small23.
If you have Wilson’s disease, your liver cannot adequately metabolise and remove copper from your body. This condition is treated using a copper chelating agent, such as penicillamine, to bind copper and remove it. These agents are very effective and there really is little need to restrict dietary copper intake.
Most foods contain copper, and some foods contain large amounts, for example chocolate, nuts, mushrooms, shellfish and offal. However, doctors only rarely suggest the avoidance of these foods if you are taking and responding well to your medication.
If you are being treated with penicillamine you may require supplements of vitamin B. This is because penicillamine can increase your body’s need for pyridoxine (vitamin B6). It is useful to ask your doctor if you require supplements24. Some people with Wilson’s disease may also be treated with zinc as this agent can block the absorption of copper from food in the intestine.
Gilbert’s syndrome (GS) is a condition in which you have higher than normal amounts of bilirubin in your blood25. Avoid dieting or fasting as this may cause your bilirubin levels to rise, as may dehydration. It is important that you eat regularly and healthily, and drink plenty of water.
Some people report that they cannot tolerate eating carbohydrate foods very well (such as bread, pasta, rice and potatoes). Make sure you have enough protein in your diet to compensate if you have to reduce your carbohydrate intake.
Primary Biliary Cholangitis and Primary Sclerosing Cholangitis
In order to break down fats the liver produces a substance called bile. This is stored in the gallbladder and released via the bile ducts after a meal. PBC and PSC affect the flow of bile and therefore you may find you cannot tolerate fats well.
In this situation fat is passed in your stools and you develop a type of diarrhoea, known as steatorrhoea, which causes bulky, pale faeces/stools that are difficult to flush away.
If this happens, you will be advised to reduce the amount of fat in your diet. However, fat is essential – it contains the fat-soluble vitamins A, D, E and K, as well as essential fatty acids – and should not be cut out of your diet completely without proper advice from a dietitian. Your doctor may recommend vitamin injections or supplements. You should not take supplements without advice from your doctor.
People vary in the amount of fat they can tolerate so this does not mean you will necessarily need to eat a strict, low-fat diet. Most people find they are able to work out how much fat they can tolerate by ‘trial and error’ by reducing amounts of the higher fat foods. Improvement in bowel habit shows that your body is tolerating the amount of fat you are eating. Stools will become less frequent, darker and easier to flush away.
Cutting down on fat
If you want to cut down on the fat you eat you need to avoid ‘hidden’ fats as well as the obvious ones you can see in meat and greasy foods. The list below gives examples of high-fat foods and ideas for alternatives.
- Butter, margarine, lard, dripping, mayonnaise – try using low fat alternatives.
- Cream and full-cream milk – substitute semi skimmed or skimmed versions. There is as much calcium (needed for healthy bones) in half-fat or skimmed milk as there is in full-cream milk.
- Cheese – try lower-fat hard cheese and low fat cottage cheese.
- All kinds of cooking oil including olive oil, sunflower and vegetable oil – use these sparingly; try using a table spoon to measure the amount you are adding instead of pouring straight from the container5.
- Fatty meats, such as duck and belly pork – eat more fish, poultry, lean red meat.
- Meat products such as sausages and pies – you may be able to eat small amounts of these. Try adding more vegetables, beans or pulses, tofu or meat substitutes to meals and reduce the amount of meat.
- Chips, crisps and nuts – try oven-chips or replacing chips with a low fat alternative like a jacket potato5.
- Biscuits, cakes and pastry – try low-fat alternatives such as teacakes, scones and low fat cakes or biscuits.
- Many processed foods are high in fat – for example pizza, lasagne, ready-made curry or other dishes. Eat only small amounts or use a low-fat version.
Cooking with less fat
The list below gives some ideas on how to reduce the amount of fat you use in cooking.
- Grill, bake, boil, steam or casserole meals instead of frying or roasting to avoid adding extra fats5.
- Trim visible fat off meat and remove the skin from poultry before cooking.
- Skim fat off the surface of soups and casseroles5.
If you are cutting down the fat in your diet you should try to eat extra carbohydrate to make up any shortfall in energy. This means more starch and sugar, for example, toast, crackers, crumpets or tea-cakes, bread and honey. Take advice from a dietitian to make sure you are getting enough calories, protein and vitamins.
Some people may also need monthly injections of fat-soluble vitamins A, D and K.
Coping with acidity
Some people with PBC may experience an unpleasant acid taste in the mouth or they may get heartburn – a severe burning sensation in the chest. Stomach acids escaping into your food pipe (oesophagus) are the usual cause of this discomfort.
If this happens to you, then try eating little and often to reduce stomach acid. It is a good idea to get into the habit of carrying food around with you, in case you need to eat. Foods that contain carbohydrates, such as crackers, plain biscuits or breadsticks, are the best.
It can also be helpful to:
- avoid big meals at night, but include a snack if you have been advised to do so
- take an antacid before bed and after meals
- raise the head of your bed by four or five inches.
If symptoms persist discuss this with your specialist, who may recommend other treatments.
Cryptogenic liver disease (unknown cause)
It is not always possible to identify a clear cause for liver damage and in this circumstance your condition may be referred to as cryptogenic liver disease. Cryptogenic liver disease is frequently only identified at the onset of symptoms of cirrhosis. Please refer to the next section for dietary advice.