People diagnosed with liver disease commonly experience malnutrition, according to experts. The reasons for this involve a multitude of factors.1 One of the main causes is that a damaged liver as a result of a disease like hepatitis cannot properly metabolize many of the nutrients that an individual consumes in his or her diet. As a result, some patients may need dietary therapy.2
How is the liver associated with nutrition? Eighty-five percent to 90% of the blood that leaves the stomach and intestines carries significant nutrients to the liver where they are converted into substances the body can use. The liver processes carbohydrates, proteins, fats, and minerals to be used in normal body function.3
Physicians May Miss the Signs
Despite medical practitioners' knowledge of liver disease-related malnutrition, the condition is often underdiagnosed, wrote a team of gastroenterologists at the State University of Rio de Janeiro in Brazil, in a new study. The aim of this study was to help physicians better identify the signs of malnutrition in these patients.
"Malnutrition is often underdiagnosed in cirrhosis because the parameters more frequently used to address malnutrition in these patients, such as weight, measurement of skinfolds, and blood tests, are affected by cirrhosis," explained Fatima Figueiredo, MD, PhD, a gastroenterologist at the university and the study's chief investigator, in an interview with Priority Healthcare. "Cirrhosis can increase the weight and the measurements of skinfolds because of the fluid retention and edema that occurs in cirrhosis. Therefore, the disease itself can change these nutritional parameters, delaying the diagnosis of weight loss, for example."
Malnutrition in cirrhotic patients increases their likelihood of a poor prognosis and has been associated with increases in general illness and death in patients undergoing liver transplantation, Figueiredo explained.
Nailing Down Definitive Signs
To evaluate the signs associated with liver disease-related malnutrition, Figueiredo and his group enrolled 79 patients with liver disease, comparing them with a group of 17 people without liver disease.
"The aims of this study were: to quantify body composition changes, to determine tissue loss pattern, and to assess the relation of these to the severity of [liver] dysfunction," wrote the researchers in their study paper.
The team first measured levels of total body water and extracellular water in each of the patients. Water makes up about one-half to two-thirds of our total body weight. It is divided into two components: water that is contained within our cells (intracellular water), and the water that floats in the space between our cells (extracellular water). Maintaining water balance is essential to normal body function.4
In determining total body water and extracellular water levels, the researchers measured intracellular water and total body cell mass. The team also measured total body fat in each of the patients. All of these assessments were combined to determine an individual patient's overall nutritional status.
At the end of the study, Figueiredo's team learned that extracellular water was increased and intracellular water was lower in people with liver disease. They also found that body cell mass and body fat were lower in these patients, mostly in those with moderate to severe liver disease.
The researchers established a pattern of tissue loss; in those with early-stage cirrhosis, the loss of body fat was predominate. In patients with moderate cirrhosis, there were losses in either body cell mass or body fat. But in those with advanced liver cirrhosis, the researchers noted losses in both body fat and body cell mass.
"Liver cirrhosis was characterized by a significant reduction in body cell mass and body fat, and by a redistribution of body water," Figueiredo's group concluded. "Significant losses occurred even in patients with mild disease."
The investigators say it's hoped their findings will help physicians better diagnose malnutrition and manage the nutritional status of their patients with liver disease.
Altering the Diet is Debatable
What are the treatment options when malnutrition is diagnosed in people with liver disease? Experts say those with advanced liver disease should be recommended a diet providing adequate calories, proteins, minerals and vitamins. These dietary recommendations should be given based on a certain individual's condition.5
However, Figueiredo says that is a topic of debate among physicians. "It makes sense that if we could properly refeed those patients, we would make a difference in their outcomes," he said. "However, no one has proven this theory yet."
Because physicians tend to inadvertently diagnose malnutrition much later in people with cirrhosis, re-designing a proper nutritional diet by then doesn't have much effect because the patients have already developed other related illnesses, which negatively affects their prognoses anyway, Figueiredo explained.
"With other [diagnostic] tools for nutritional assessment, we could demonstrate that nutritional depletion occurs very early even when there is no signal of it in clinical examination," he said. Still, these tools are very expensive and thus impractical in the clinical setting, Figueiredo said.
"If researchers plan a study refeeding patients very early (patients with no obvious signal of malnutrition) instead of patients diagnosed late, we could demonstrate that nutritional therapy would be a very important supportive therapy for these patients," he said.
1. Florez DA, Aranda-Michel J. Nutritional management of acute and chronic liver disease. Semin Gastrointest Dis 2002 Jul;13(3):169-78.
2. Bavdekar A, Bhave S, Pandit A. Nutrition management in chronic liver disease. Indian J Pediatr 2002 May;69(5):427-31.
3. American Liver Foundation. Diet & Your Liver. Available at: http://www.liverfoundation.org/db/articles/1022. Accessed February 16, 2005.
4. The Merck Manual. Disorders of Nutrition and Metabolism. Water Balance.
5. Tozun N. Influence of the metabolic complications of liver cirrhosis on dietary intake. Med Sci Monit 2000 Nov-Dec;6(6):1223-6.
John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include coverage of health news for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.
