By Author
  By Title
  By Keywords

March 1986, Volume 36, Issue 3

Original Article

EFFECTS OF NUTRITION ON THE MANAGEMENT OF CIRRHOSIS

Fatima Nizami  ( PMRC Research Centre, Jinnab Postgraduate Medical Centre, Karachi. )
Sarwar J. Zuberi  ( PMRC Research Centre, Jinnab Postgraduate Medical Centre, Karachi. )

Abstract

Irrespective of socio-economic groups, thirty two cirrhotics of both sexes were followed-up to assess the effect of nutrition on their management. An average of 62gm and 54gm protein and 48gm and 40gm of fat intake was well tolerated in males and females respectively. The inclusion of fat and animal proteins helped these patients to overcome the deficiency of these nutrients. A rise of serum albumin from 2.7gm% to 3.8% and from 2.9gm% to 4.2gm% in males and females respectively is an index of improvement of hepatic function. Hemoglobin concentration of these cases also improved from 1 0.3gm% to12.9gm% (JPMA 36: 58, 1986).

INTRODUCTION

Apart from anorexia in cirrhosis of liver, imposed restriction of fats and animal proteins not only leads to deficiency of essential fatty acids, amino acids, certain vitamins and mineral but also results in diet deficient in calories.1
The body compensates the requirements by catabolising its own stores of protein, fat and carbohydrates which may not be metabolized adequately by the damaged livet2-4. Moreover, catabolism of body protein in cirrhotics liberates more ammonia than is generally produced from proteinous foods of animal origin5. It is therefore, likely that malnourished cirrhotics are more likely to develop portosystemic encephalo­pathy6. This study was, therefore, carried out to provide a balanced diet with adequate protein and fat to the cirrhotic patients and thereafter find the out-come.

METHODS

Thirty two patients (19 males, 13 females) with liver cirrhosis irrespective of their socio-eco­nomic status were selected from the PMRC Re­search Centre, Karachi. The history of their pre-existing dietary intake/week was recorded by recall method and then calculated from the table of ‘nutritional value of food7 to get the daily intake of different nutrients. Then therapeutic dietary advices were given to them according to age, sex weight and height as well as other complications and condition of hepatic disorder. They were followed up every week initially and once or twice a month thereafter depending upon theirb condition. Sixty percent of them had ascites and oedema, and 50% had jaundice. Most of them complained of bone pains, cramps, skin roughness anorexia, nausea and malaise.

RESULTS

The average intake of nutrients both prior and during the follow-up is shown in table I,

II and III.


Their pre-existing dietary intake was poor. Fat and proteins were grossly restricted which resulted in significantly inadequate intake of calories.
Table II shows that during treatment animal proteins were adequately consumed by both sexes. Most females received protein from legumes and males from animal source (Table III). Twenty three percent of the total calories were obtained from the dietary fat (Table I). Vitamins and minerals were also adequately consumed by these cases, (Table VI).


Table IV and V show the clinical and laboratory data both prior and during treatment period which indicates the effects of nutrition on the management of cirrhosis. The column of weight shows no difference between prior and after treatment, (Table V).

However, the average weight shown prior treatment may not be the actual weight due to fluid retention. But after treatment the average weight includes weight after disappearance of ascites and oedema.
Serum albumin level both prior and after treatment were available in 14 males and 11 females. Seventy nine percent males and 36% females had serum albumin level below 3 gm/1OOml (group 1) and 21% and 64% had 3gm/ lOOml or more respectively (group 2). After treat­ment both the groups showed significant increase in their serum albumin levels. No increase in serum albumin was noted in 3 males in group I (Table IV).

DISCUSSION

Like other well controlled studies,8-13 this study also indicates that dietary fat was well tolerated by cirrhotic patients because the mean intake of fat was 48 and 4Ogms in males and females respectively in comparison to their pre­existing fat intake of 24.7 and l9gms which were derived mostly from cereals and vegetables. All patients tolerated adequate fat intake as has also been observed by other workers14-16
Liberal fat intake results in a rapid improve­ment by providing essential fatty acids and some fat soluble vitamins which help protein meta­bolism as well as increases the resistence against the disease. 17-20
Adequate animal proteins were also well tolerated by these cases (Table III). Sixty percent of the cases of both sexes could meet the RDA recommended by WHO and none of them consumed less than lOgms of animal protein, whereas before any dietary instruction 29-61% of them received none or very negligible amount of animal protein and the remaining consumed only half of the requirement of the RDA.
These patients were adviced to take liberal protein because it is e ssential for repair of hepatic cells and the formation of cholic and other bile acids12,21 This study also shows the same benefical effect because a rise in serum albumin (Table IV) in these cases is an excellant index of improvement of hepatic function.21-24
High legumeous foods were given to patients who did not like meat or developed ascites. It was observed that legumeous foods like peas, beans, dried cow peas and pulses were better tolerated than meat because they contain negli­gible amount of sodium and large amount of Branched-Chain Amino Acids which are oxidized by the skeletal muscles.25-30
The inclusion of fat and animal protein not only helped these patients to overcome the deficiency of these nutrients but also increased the morale of the patients by allowing them a diet which was not veiy different than a normal diet. Moreover, addition of fat increased the palat ability of the diet which inturn increased their intake of food. With increase Carbohydrate intake the caloric intake was also significantly increased in both sexes (Table II) which is most desirable in liver cirrhosis.12,14,19
Vitamins and minerals also play an important role in the management of the disease. Therefore effort was made to supplement all the vitamins and minerals (Table VI) sufficiently by giving only those preparations which could provide the recommended dosage of these nutrients. It was observed that these cases were benefited by these supple mentations because they could overcome theft complications like, bone pain, cramps skin roughness as well as anorexia which are the sign and symptoms of vitamins and minerals de­ficiency.

REFERENCES

1. Nizami, F., Zuberi, S.J. Food fallacy in cirrhosis. JPMA., 1985; 35:144.
2. Jeejeebhoy, K.N. In clinical Nutrition updates: Amino Acids, By Greeno, H.L; Holiday, M.A. and Munro, H.N. Chicago, Arsical Medical Association, 1977; p. 65.
3. Kessler, J.l., Nirmel, K. and Macleon, L.D. Altration of hepatic triglyceride in patients before and after jejunoileal bypass for morbid obesity. Gastroenterology, 1979; 79: 159.
4. Elwyn, D.H. Nutritional requirements of adults surgical patients. Crit. Care Med., 1980; 8:9.
5. Pinafore, H.M.S., Gilbert, W.S. and Sullivan, A.S. Management of acute portal systemic encephalopathy in the hepatic coma syndromes and lactulose. By Conn, 11.0. and Lieberthal, M.M. Baltimore Williams and Wilkins, 1980; p.193.
6. Nizami, F., Qureshi, H., Shahid, A., Hassan, R. and Zuberi, S.J. Nutritional aspects of hepatic coma. JPMA., 1983; 33:162.
7. Nutritive value of foods. Home and Gardner Bulletin No.72. U.S. Department of Agr., Washington, D.C. 1970. Cited from Funda­ mentals of Normal Nutrition. 3rd Ed. By Robinson, C.H. Collier. Macmillan Inter­ national N.Y. 1978.
8. Hill, R., Linazasoro, J.M., Chevalier, F. and Chaikoff, I.L. Regulation of hepatic lipogenesis; the influence of dietary fat. J. Biol. Chem., 1958; 233:305.
9. Phillips, G.B., Schwartz, R.G.J. Jr. and David- son, C.S. Syndrom of impending hepatic coma in patients with cirrhosis of the liver given certain Nitrogenans substances. N. Engi. J. Med., 1952; 247:239.
10. Klataskin, G. and Yesner, R. Factors in the treatment of Iaenec’s cirrhosis. 1. clinical and histological changes observed during a control period of bed-rest, alcohol with-drawal, and a minimal basic diet. J. Clin. Invest., 1949; 723.
11. Leevy, C.M., Zinke, M.R., White, T.J. and Gnassi, A.M. Clinical observations on the fatty liver. Arch. Intern. Med., 1953; 29:825.
12. Mindrum, G.M. and Schiff, L. Use of high-fat diet in cases of fatty liver. Gastroenterology, 1955; 29 :825.
13. Sherlock, S. Diseases of the liver and billiary system. 6th ed. Oxford, Blackwell, 1981; p. 219.
14. Chalmers, T.C., Eckhardt, R.D., Reynolds, W.E., Cigaroa, J.C. Jr., Deane, N., Reifen­stein, R.W., Smith, C.W. and Davidson, C.S. The treatment of acute infectious hepatitis, controlled studies of the effects of diet, rest and physical reconditioning on the acute course of the disease and on the incidence of relapse and residual abnormalities. J. Clin. Invest., 1955; 34:1163.
15. DaVidson, C.S. and Gabuzda, GJ. Nutrition and disease of liver. N. EngI. J. Med., 1950; 243: 779.
16. Sborov, V.M. Diet and nutritional aids in liver disease. Ami. Dig. Dis., 1958; 3:94.
17. Crew, R.H. and Faloon, W.W. The fallacy of a low-fat diet in liver disease. JPMA., 1962; 18:754.
18. Rivers, J.P.W. and Frankel, T.L. Essential fatty acids deficiency. Br. Med.Buli., 1981; 37:59.
19. Patek, A.J. Jr., Post, J., Ratnoff, O.D., Mankin, H. and Hillman, R.W. Dietary treatment of cirrhosis of the liver. JAMA., 1984; 138: 543,
20. Krascovicova, M., Dibak, O.and Grancicova, E. The influence of the amount of fats in the diets on the biological value of proteins. Thys­iologia Bohemoslovaca, 1979; 28 :257.
21. MacDonald, W.C., Taylor, H.E., Johnstone, F.R.C., Walsh, G.C. and Bogoch, A. Diseases of the liver, in gastroenterology. Edited by Abra­ham Bogoch New York McGrow-Hffl, 1973; p. 743.
22. Harvess, K.B., Ruggiero, J.A., Regan, C.S. et al. Hospital morbidity mortality risk factors using nutritional assessment. Clin. Res., 1978; 26:581.
23. Sherlock, S. Diseases of the liver and billiary system. 5th ed. Oxford, Blackwell, 1975; p.438.
24. Peters, T.J. Serum albumin. Clin. Chem., 1970; 13:37.
25. Miller, L.L. The role of liver and non-hepatic tissue in the regulation of free amino acid levels in blood, in Amino acid pools. Holden, J.J. editor. Amsterdam, Elsevier Publishing, 1962; p. 708.
26. Odessey, R. and Goldberg, A.L. Oxidation of leucine by rat skeletal muscle. Am. J. Physiol., 1972; 223:1376.
27. Odessey, R., Khairallah, E.A. and Goldberg, A.L. Origin and possible significance of alanine production by skeletal muscle. J. Biol. Chem., 1974; 249 :7623.
28. Fulks, R.M., Li, B. and Goldberg, A.L. Effects of insulin, glucose and amino acids on protein turnover in rat diaphragm. J. Biol. Chem., 1975 ;250 :290.
29. Buse, M.G. and Reid, M. Leuceine, a possible regulator of protein turnover in muscle. J. Clin. Invest., 1975; 58:1250.
30. Fraund, H., Yoshimura, N. and Fischer, J.E. The effect of branched chain amino acids and hypertonic glucose infusions on post injury catabolism in the rat Surgery, 1980; 87 :401.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: