Diet
and Exercise
Marshall
Kaplan M.D.
Chief, Division of
Gastroenterology
Question:
There has been some
discussion in the digest of PBC patients avoiding foods containing copper.
Is there research to suggest or support that PBC livers retain more copper
than those not infected with PBC?
Answer:
Patients with PBC do
retain more copper in their livers than others. However, there is no information
that this causes harm. This is in contrast to patients with Wilson's disease
where copper is harmful. Copper seems to be stored differently in patients
with Wilson's disease.
Hugo
E. Vargas M.D.
Medical Director,
Transplantation
University of Pittsburgh Medical Center
November
1999
Question:
There is much conflicting
advise about pbcers following low fat diets and avoiding additives etc. As
the liver filters everything that is put in our bodies I would be
interested
to know your thoughts on this. Also since I'm now on low fat diet
I am craving salt....do you have any ideas on this?
Answer:
Low fat diets are recommended
based on the fact that PBC causes increases in cholesterol. I make no specific
recommendations on fat unless the levels of cholesterol are extremely high.
I do not know what you mean by additives, if you are referring to vitamins,
I recommend a multivitamin tablet, avoid mega doses of anything, but discuss
any specifics with your hepatologist.
Melissa
Palmer M.D.
Specialty: Gastroenterology
and Hepatology
Medical advisory board
of the ALF
ALF National Chapter
Nutrition Education Subcommittee
January
2000
Question:
I was diagnosed with
osteoporosis, and understand it is common in PBC. I was told to be careful
of breaks because it will take longer for bones to heal. What are your
suggestions for someone with osteoporosis. Would
you discourage bouncing activities such horseback riding?
Answer:
Osteoporosis (a decrease
in bone quantity) is the most common bone disorder in PBC. The hip and spine
are the areas of the body most commonly affected. Thus, people with osteoporosis
are susceptible to hip fractures and often suffer from bad backs. Bouncing
activities should be avoided. Instead it is important to strengthen bones
with weight bearing exercises using light weights. This should be incorporated
with an aerobic exercise. Full discussion of these topics
are beyond the scope of this chat, but entire chapters are devoted
to these issues - osteoporosis sand exercise, in my book. I will incorporate
these issues in my website-
www.liverdisease.com on the next update.
The Mount Sinai Medical Center
February 2000
Question:
Is it possible to have
an occasional glass of white (or red) wine after being diagnosed with
pbc or should one avoid alcohol in any form, including
any that may be used in cooking recipes? Thank you for your input.
Answer:
There is little data regarding alcohol
use by people with PBC. Because alcohol does not play a role in the development
of liver disease in PBC, it is probably reasonable to have an occasional
glass of wine. Women (the population most commonly affected by PBC) are more
susceptible to alcohol related injury and therefore daily or heavy consumption
of alcohol is not wise. In chronic hepatitis C, alcohol seems to play an
additive role in the development of scarring in the liver. It is unclear
whether this information is at all applicable to patients with PBC. Since
alcohol generally evaporates when used in cooking, it shouldn’t be a
problem. Patients taking methotrexate need to be
particularly careful because alcohol increases the likelihood of scarring
in the liver.
Melissa
Palmer M.D.
Specialty: Gastroenterology
and Hepatology
Medical advisory board
of the ALF
ALF National Chapter
Nutrition Education Subcommittee
April 2000
Question:
Why is it so difficult
for some to digest meat, particularly red meat? It seems to stay in my system
for hours.
Answer:
Many gastrointestinal
disorders have been associated with PBC, particularly gallstones and diarrhea.
Many people with PBC especially those in advanced stages who are
cholestatic are unable to digest fats efficiently.
this is known as fat
malabsorption. This is caused by a failure to secrete
bile salts necessary to absorb fats due to bile duct destruction. Since red
meats tend to be particularly fatty, this may explain why it is difficult
to digest. I recommend sticking with chicken and/or fish for animal protein.
Again, you may find it helpful to refer to my book for more detailed nutritional
advice.
Melissa
Palmer M.D.
Specialty: Gastroenterology
and Hepatology
Medical advisory board
of the ALF
ALF National Chapter
Nutrition Education Subcommittee
April
2000
Question:
Combucha tea derived drinks, are supposed to
boost immune system. Do you think they are beneficial? Do you recommend any
special teas or other drinks?
Answer:
I am not aware of
combucha tea, but green tea, camellia
sinensis, contains a high dose of
catechin. Catechin is
a plant chemical with proclaimed antioxidant liver-protective properties.
Experimentally induced liver damage in rats has demonstrated the protective
effects on the liver afforded by catechin. However,
human studies have failed to show similar results.
Judging from the above questions,
there appears to be a thirst for knowledge concerning the effects of nutrition
on liver disease, and the use of supplements on liver disease. I therefore
recommend all individuals with PBC to refer to my book Dr. Melissa Palmer's
Guide to Hepatitis and Liver Disease", or to my - website
www.liverdisease.com.
In my book I have extensive information on these topics relating specifically
to individuals with PBC.
David Bernstein, M.D.
Chief, Division of
Gastroenterology
July
2000
Question:
How important is diet
to a person with PBC? Do you recommend 3 meals a day or smaller more frequent
meals?
Answer:
I firmly believe that
you are what you eat. A well balanced diet is essential for good health.
I feel that three meals a day is a good way to eat. This system provides
some structure into eating and helps prevent constant snacking that may lead
to eating the wrong foods. I also recommend not eating within four hours
of going to sleep.
David
Bernstein, M.D.
Chief, Division of
Gastroenterology
July
2000
Question:
What could be the cause
of craving salty foods? I know PBCers are supposed to lower their salt intake,
which I immediately did on diagnosis?
Answer:
One of the most common
causes of salt craving is dehydration caused by not enough fluid
intake. It is important to limit ones over all salt
intake to prevent fluid overload and heart disease.
However, salt craving is usually a sign of the body needing fluids. Salt
helps the body hold on to water. The best way to avoid salt craving is to
drink plenty of fluids.
David
Bernstein, M.D.
Chief, Division of
Gastroenterology
July
2000
Question:
I hate the taste of plain
water and in its place drink herbal or green tea with lemon or honey. Is
this taking the place of my daily water requirement or is 8 glasses of plain
water still required?
Answer:
The answer to this question is dependent
upon the amount of tea which you drink. You should ingest 8 glasses of 8
ounces of fluid a day. Whatever tea you drink is made up of water and counts
towards this fluid goal. If you drink 8 glasses of 8-ounce tea, you have
met your fluid requirement for the day.
Nathan
Bass M.D.
Professor of Medicine,
Medical Director, Liver
Transplantation
Program,
2000-2001
Question:
Can those with PBC have
an occasional glass of wine?
Answer:
Alcohol is hepatotoxic
and its use in certain liver diseases has been shown to be detrimental. Similar
data are not available for PBC. If you want to play it
absolutely safe, no alcohol. If you want to take advantage of the
lack of data, it’s your decision.
I personally advise abstinence as
the most prudent practice to maintaining liver health in PBC. Also, everyone
seems to have a different idea about the meaning of
occasional.
Alfred
L. Baker, M.D.
Division of Gastroenterology
& Hepatology
Northwestern
2000-2001
Question:
Can PBCers drink
non-alcoholic beer? Usually they contain less than 0.5% alcohol in 100cc.
If the answer is yes, how often can we drink it? Almost every day,for instance?
Answer:
Patients with many types of mild liver
disease, including primary biliary cirrhosis, can probably safely consume
small quantities of alcoholic beverages. Patients with more advanced liver
disease, those with esophageal varices or with edema and ascites, should
probably not drink alcoholic beverages at all. Patients with Hepatitis B
and C should avoid alcohol consumption completely because alcohol can be
additive to the harmful effects of the viruses on the liver. Low alcohol
content beers are therefore safe for many patients with primary biliary
cirrhosis. Because of differences in the severity of liver disease among
patients and the details of the medical regimens, I suggest that you consult
with your physician about how much alcohol it would be safe for you to
consume.
2001
Question:
Most doctors tell us
that diet plays no role in how PBC may or may not progress. How is this known?
Have controlled studies been done?
Answer:
There are no data on
diet but no reason or even hint of a reason to think that diet plays a role.
What kind of diet are you thinking of? There are many different kinds of
diet.
Nathan
Bass M.D.
Professor of Medicine,
Medical Director, Liver
Transplantation
Program,
January
2002
Question:
Drinking at least 8 ounces
of water per day is recommended for those with liver disease. Must it be
water or can it be other fluids such as juice and herbal tea? Do you recommend
a special diet for PBC?
Answer:
Usually it will not matter
in which reasonable form one take in fluid. Fruit juices contain more calories
and potassium. Overweight or diabetic patients or patients taking
potassium-sparing diuretics (e.g., spironolactone) may need to be cautious
with these. Herbal teas are usually fine, especially the common commercially
available types. Specialized herbal teas obtained from herbal medicine
practitioners or web sites should be checked with your physician, as there
are some herbal products that may actually cause liver disease. Diet in PBC
depends on stage of disease. There is no medically recognized "special" or
healing diet for PBC per se, but there are certainly important dietary aspects
to the management of patients with this disease. Patients at all stages of
disease may benefit from a multivitamin and trace mineral supplement. Calcium
supplements are also recommended to prevent and treat bone thinning. Patients
with very early disease can eat almost anything that agrees with them, but
it is wise to adhere to a generally balanced, healthy cardiovascular diet.
Patients with more advanced disease, especially with evidence of fluid retention
should limit their salt intake to 2 grams or less per day. Limiting protein
intake is very rarely indicated and may be harmful. Only patients with very
advanced disease who have severe hepatic encephalopathy which is difficult
to control with medication are candidates for carefully controlled protein
restriction under medical supervision. Some patients with PBC are intolerant
of fatty foods as these may cause diarrhea. In these cases, patients should
reduce their intake of fat but consume more in the way of carbohydrate calories
to meet their daily requirement. Patients with established cirrhosis may
want to avoid raw shellfish. This is general advice for patients with all
types of cirrhosis who are particularly susceptible to a rare but extremely
serious type of food poisoning that can result from eating raw
shellfish.
Andrew
Mason, MBBS
MRCPI
Associate Professor of Medicine
Division of Gastroenterology, Department of Medicine,
University of Alberta, Edmonton, Canada
December 2002
Question:
Should alcohol consumption be stopped entirely in persons with PBC?
Answer:
Only if regular drinking results in abuse of alcohol.
Question:
If not, how much would be an acceptable amount of drinking?
Answer:
I would recommend sticking to one drink on special occasions.
01/25/04
QUESTION
What type of diet do you suggest for those diagnosed with PBC? Should we lower our protein intake?
ANSWER
Unfortunately, a person with PBC cannot expect to walk into the doctor's office and request "a diet for PBC." Such an across-the-board diet simply does not exist. Many factors account for the unfeasibility of a standardized liver diet, including the stage of PBC (for example, stable liver disease - stage 1-2 without much damage versus unstable decompensated cirrhosis - stage 4 with complications such as ascites) in addition to one's other medical disorders even if unrelated to their liver disease, such as diabetes or heart disease. Each person has his or her own individual nutritional requirements, and these requirements may change over time.
Most people with PBC, especially those suffering from fatigue find that eating multiple small meals throughout the day is the best approach, as it maximizes energy levels and the ability to digest and absorb food. However, if one insists on eating three meals per day try to follow the saying - " eat breakfast like a king, lunch like prince and dinner like a pauper."
Notwithstanding the above information, an optimal diet for a person with stable PBC (modifications to be made as per individualized needs) might contain all of the factors listed below. (You'll note that this diet resembles a generalized healthy diet for all people-even those without liver disease. And, in fact, that's exactly what it is!)
o 60- to 70-percent carbohydrates-primarily complex carbohydrates, such as pasta and whole-grain breads.
o 20- to 30-percent protein-only lean animal protein and/or vegetable protein.
o 10- to 20-percent polyunsaturated fat.
o 8- to 12 eight-ounce glasses of water per day.
o 1,000 to 1,500 milligrams of sodium per day.
o Avoidance of excessive amounts of vitamins and minerals, especially vitamin A, vitamin B3, and iron.
o No alcohol.
o Avoidance of processed food.
o Liberal consumption of fresh organic fruits and vegetables.
o Avoidance of excessive caffeine consumption-no more than 1 to 3 cups of caffeine-containing beverages per day.
o Vitamin D and calcium supplement.
In reference specifically to protein, many people mistakenly believe that
the more protein they consume, the better. Not only is this belief misguided,
but for someone with severe liver damage such an approach to nutrition can
actually be downright dangerous. The trouble is that a damaged liver cannot
process as much protein as a healthy liver. And when a damaged liver gets
unduly overloaded with protein, encephalopathy (a state of mental confusion
that can lead to coma) may occur. Finally, diets high in protein have been
demonstrated to enhance the activity of the cytochrome P450 enzyme system,
which is responsible for drug metabolism. This enhanced activity increases
the likelihood that a drug may be converted into a toxic byproduct capable
of causing liver injury. People with unstable liver disease (decompensated
cirrhosis) need to lower the percentage of animal protein they consume and
they need to eat mostly vegetable sources of protein. A diet high in animal
protein (which contains a lot of ammonia) may precipitate an episode of
encephalopathy among these people. Researchers aren't exactly sure what causes
encephalopathy, but they suspect that an excess of ammonia in the body may
be one of the triggers. Some popular weight-loss diets involve the consumption
of a very high amount of red meat animal protein. People with cirrhosis are
advised to avoid any such
diets.