THE QUICK GUIDE ON LIVER DISEASE MANAGEMENT FOR NEWLY DIAGNOSED LIVER PATIENTS

by Dorothy Spencer, RN

TABLE OF CONTENTS AUTHOR: Dorothy Spencer, BSN, RN

1. Your Liver and What It Does

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2. Anatomy and Functions of the Liver Alcoholic Liver Disease Non-Alchoholic Fatty Liver Disease Hepatitis Fibrosis Cirrhosis

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3. Understanding Liver Disease Tests Alanine Aminotransferase (ALT) Aspartate Aminotransferase (AST) Alkaline Phosphatase (ALP) Gamma Glutyamyl Transferase (GGT) Bilirubin Albumin Other Tests...

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4. Tips for Managing Most Liver Diseases Alcohol Abstinence/Restriction Aiming for a Healthy Weight Diet General Fitness and Exercise

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5. Tips for Managing Cirrhosis Know the Underlying Cause... Managing Cirrhosis Through Diet Medications and Other Substances to Avoid

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6. Being an Active Participant of Your Health

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1. YOUR LIVER AND WHAT IT DOES

Did you know that your liver is your heaviest organ? And that‘s really no great wonder; after all, it‘s second in size only to your skin. But that‘s not the only reason why it‘s so important.

Your liver carries out many important functions that are vital to survival. All in all, it has about 500 different tasks, and if that weren‘t impressive enough, it is also especially hardy—it can continue to function even when significantly damaged, and is even capable of self-repair. Some of its more major roles include: • Filtering and cleaning blood • Fighting disease and infection • Dealing with drugs and poisons in your system • Producing hormones and maintaining their balance • Controlling the amount of cholesterol

• Producing many proteins and enzymes—molecules that are vital for your body‘s continued survival • Producing bile, which aids in digestion • Processing food once digestion has occurred • Storing sugars, vitamins, and minerals • Storing readily usable energy • Repairing damage to itself

Because it plays a big role in keeping you healthy, any issues with your liver will undoubtedly have serious effects on your overall health.

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2. HOW DOES LIVER DISEASE DEVELOP? If you‘re a newly diagnosed liver disease patient, you‘re probably still unclear on how liver disease actually comes about.

confirms (and Cleveland Med Clinic states clearly) that Alcoholic Fatty Liver Disease is a universal finding among heavy drinkers.

Generally, significant liver damage does not occur overnight:

Prolonged and higher doses of alcohol cause ALD to progress to even more complicated forms.

It develops over time. There are various forms of liver disease, but these are some of the most common conditions that patients experience:

ALCHOHOLIC LIVER DISEASE (ALD) ALD is a form of liver disease where —yes, you‘ve guessed it right— alcohol is the culprit. Almost every information source

Alcohol Intake

When people begin to show symptoms of liver damage, they are usually diagnosed with variably reversible alcoholic hepatitis. In the worst case, this can progress into irreversible alcoholic cirrhosis. This leads to a higher risk of endstage liver diseases such as liver cancer and liver failure. Here‟s a quick view of how ALD develops overtime: (duration varies per individual)

Effect

≤ 10g/day, everyday

Patients exhibit fat congestion in their liver

≤ 40g/day, everyday

Can cause pathologic changes associated with alcohol hepatitis

≤ 60g/day, everyday

Increased risk of progressing into alcoholic cirrhosis 5

NON-ALCHOHOLIC FATTY LIVER DISEASE (NAFLD) NAFLD is the buildup of extra fat in liver cells which isn‘t caused by alcohol use. Fatty liver (or steatosis) happens when more than 5% to 10% of your liver‘s total weight is made up by fat. A normal liver isn‘t fat-free—it‘s normal for it to contain some fat— but as for most things, anything in excess is bad.

NAFLD tends to develop in people who are overweight or obese, or have diabetes, high cholesterol or high triglycerides. Rapid weight loss and poor eating habits may also lead to NAFLD. Also, NAFLD typically shows up as an unexpected abnormality in the liver function tests of people who otherwise feel well. The elevation of these tests is generally minor and in younger patients, does not indicate a serious liver condition. However, if the cause of NAFLD— such as obesity or diabetes—is not treated, the condition may progress.

HEPATITIS Hepatitis refers to any type of inflammation in the liver. When it occurs suddenly, it‘s called acute hepatitis. When it persists for more than six months, the condition is known as chronic hepatitis.

FIBROSIS Fibrosis occurs when scar tissue begins to form in an inflamed liver. The time it takes for it to develop can vary widely, so there‘s usually no definitive way to tell if and when scarring might occur. Fortunately, in many cases, fibrosis is reversible once the cause for inflammation is identified and treated. On the other hand, if the damage goes undetected or if treatment is too late, the disease might progress into cirrhosis.

CIRRHOSIS Cirrhosis is the disruption of the liver‘s shape and function due to widespread inflammation and scarring. This is already a very serious stage of liver disease,

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A liver with too much scar tissue cannot work properly.

although in some cases, there may still be no outward signs or symptoms. As already mentioned, the liver can continue to function in spite of heavy damage. But eventually, the working capacity of liver cells will be compromised. When this happens, the liver is unable to repair itself, and permanent damage occurs. This is a common scenario with the onset of cirrhosis. When the liver is damaged to a great enough extent, the disease may progress into liver cancer or liver failure. Generally, cirrhosis is classified as either compensated or alternatively,

decompensated.  COMPENSATED CIRRHOSIS

If you have compensated cirrhosis, your liver is scarred but your body still functions fairly well. This means there are still enough healthy cells in your liver to perform all of its functions adequately. Many people with compensated cirrhosis feel quite well, and in fact many live for years with cirrhosis without being aware of it. Up to 40% of people with cirrhosis experience no symptoms, although most other patients do.

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Early symptoms of compensated cirrhosis (not all of which occur together) may include: • Unexplained loss of appetite • Weight loss or loss of muscle mass • Fatigue and loss of energy • Nausea or abdominal pain • Spider veins or spider-shaped blood vessels under your skin • Redness of the palms of the hand (palmar erythema)

compensated cirrhosis to decompensated cirrhosis. This means the liver is not able to perform its normal functions anymore. The result is a number of lifethreatening complications. You may develop the following symptoms: • Fluid retention in the legs and feet (edema) and abdomen (ascites) •Severe itching • Dark, tea-colored urine

POINT TO REMEMBER: If nothing is done to treat the cause of cirrhosis, the pressure in the portal vein gets higher and the few remaining healthy liver cells become overwhelmed. This could cause cirrhosis to progress further.

• Bleeding or easily bruised gums • Nosebleeds • Frequent bacterial infections in fluid accumulated in the belly (spontaneous bacterial peritonitis) • Enlarged veins (or varices) may develop in your esophagus and stomach, • Vomiting blood • Black and tarry stools

 DECOMPENSATED CIRRHOSIS If you experience any of the symptoms described below, then your disease has progressed from

• Poor memory and concentration or mental confusion (hepatic encephalopathy) • Jaundice (yellowing of the eyes and skin)

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Jaundice is a common sign of liver and gallbladder disorders.

If you have cirrhosis and notice any of these symptoms, talk to your healthcare provider as soon as possible.

This is a sign that your cirrhosis is getting worse.

POINTS TO REMEMBER:  Another serious complication of cirrhosis is liver cancer, which can occur in the compensated or decompensated stage. There may be no signs or symptoms until the cancer has grown very large and causes pain.  In the final stages of disease, the liver becomes unable to continue processing the chemicals and waste products of the body. As these waste products build up in the system, organs begin to fail, and eventually, this leads to the loss of life.

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3. UNDERSTANDING LIVER DISEASE TESTS As a newly diagnosed patient, you‘ve probably been through a battery of tests requested by your doctor.

Lastly, while tests are a good indicator of liver health, they aren‘t perfect.

These tests provide a wealth of information regarding your condition.

Each of these tests can be affected by factors other than your liver, so it‟s still best to consult with a professional if you‟re still confused about your lab results.

To make the most out of this information, it will be to your advantage to learn more about liver disease tests. Here are some of the most significant and commonly encountered ones: • Alanine aminotransferase (ALT) • Aspartarte aminotransferase (AST) • Alkaline phosphatase (ALP) • Gamma glutamyl transferase (GGT or ‗Gamma GT‘)

To help you out, some alternative causes for abnormal results are listed for each test.

• Bilirubin • Albumin • Clotting studies

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ALANINE AMINOTRANFERASE (ALT) ALT is an enzyme released mainly by liver cells. It was previously called serum glutamic pyruvic transamin-ase (SGPT). There are normally low levels of ALT in the blood. When the liver is diseased or damaged, liver cells release ALT, causing the concentration in the blood stream to go up.

For this reason, determining the ALT level is considered a reliable test for liver damage. This enzyme can also be found in other organs—like the muscles, kidneys, heart, and pancreas—but increases in ALT level are generally from liver damage. ALT is often examined in conjunction with aspartate aminotransferase (AST).

Some Alternative Causes For Abnormal ALT Results • The intake of certain herbs and natural supplements (like echinacea or valerian)

• Strenuous exercise • Injury or injections into a muscle • Medications: Antibiotics, statins, barbiturates, aspirin and other pain medications, narcotics, and chemotherapy • Recent cardiac catheterization or surgery • Mononucleosis • Exposure to carbon tetrachloride • Lead poisoning • Necrosis (as in the decay of large tumors) • Rapid growth spurts, for young children

Together, ALT and AST are called ―aminotransferases‖. The AST/ALT ratio can be used to distinguish the cause of liver damage.

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ASPARTATE AMINOTRANSFERASE (AST) AST is another liver enzyme, like ALT. It was previously known as serum glutamic oxaloacetic transaminase (SGOT). A small amount of AST in the blood is normal. A significant increase in the AST level can be as sign of liver damage. However, AST is less specific to the liver than ALT, since it can also be found in a lot of other organs. Its concentration in blood can increase significantly when any of these organs are damaged or injured. For this reason, it is often examined alongside ALT, which is more specific to the liver.

Some Alternative Causes For Abnormal AST Results • Taking herbs and natural supplements (like echinacea or valerian) • Strenuous exercise • Injury or injections into a muscle • Excess or high doses of vitamin A • Medications: Antibiotics, statins, barbiturates, aspirin and other pain medications, narcotics, and chemotherapy • Burns, surgery, or seizures • Heart attack, heart failure, or other cardiac procedures • Damage to the lungs or kidneys • Some types of cancer • Mononucleosis • Lead poisoning • Necrosis (as in the decay of large tumors) • Rapid growth spurts, for young children

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ALKALINE PHOSPHATASE (ALP) ALP is an enzyme found throughout the body and has many different forms. Most tests are designed to detect ALP made in the liver or bones. If levels are only somewhat higher than normal, it is usually not a major concern. Like ALT and AST, ALP is released by liver cells whenever the liver is diseased or damaged. A higher level of ALP compared to ALT and AST is often an indication of blocked bile ducts. An ALP level which is significantly less elevated compared to ALT and AST is characteristic of hepatitis and other forms of liver disease.

Some Alternative Causes For Abnormal ALP Results • Deficiency in vitamin D, copper, or zinc • Malnutrition or protein deficiency • Pregnancy • Fractures in the process of healing

• Medications: birth-control pills, narcotics, antidepressants, anti-inflammatory drugs, hormones, anti-epileptics and hypertension medication • Growth spurts, in children and adolescents • Hodgkin's lymphoma, congestive heart failure, ulcerative colitis, and certain bacterial infections (moderate elevation) • Recent blood transfusions • Recent cardiac bypass surgery

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GAMMA GLUTAMYL TRANSFERASE (GGT OR „Gamma GT‟) GGT is found mostly in the liver, bile ducts, and kidneys. Abnormally high values can be a sign of damage to the liver or the bile ducts. It is usually examined alongside ALP. When both GGT and ALP are elevated, it can be a sign of disease in the liver or bile ducts. When only ALP levels are high, there is a more likely chance of bone disease being the culprit. Generally, GGT is higher in men compared to women. However, women‘s GGT levels increase with age, while men‘s do not.

Some Alternative Causes For Abnormal GGT Results • Alcohol within 24 hours of a GGT test • Smoking • Cardiovascular disease and/or hypertension • Medications: phenytoin, carbamazepine, barbiturates, antibiotics, histamine receptor blockers, antidepressants, antifungal agents, antiinflammatory drugs, hormones, lipid-lowering drugs. Clofibrate and birth control pills may cause a decrease

GGT can also be used to monitor alcohol consumption. It is elevated in around 75% of chronic drinkers.

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BILIRUBIN Bilirubin is a substance found in bile. It is produced when the liver breaks down old red blood cells. When bilirubin levels are elevated, signs of jaundice may be observed— the whites of the eyes and the skin appear yellow. This can be indicative of liver disease or blockage of the bile ducts, as well as blood disorders. Significantly high levels can be a sign of serious complications.

There can be two possibilities for this: either too much bilirubin is being produced, or the liver is so damaged that it is unable to process bilirubin.

Some Alternative Causes For Abnormal Bilirubin Results • Strenuous exercise • Caffeine intake before a test • Fasting • Some infections (e.g. cholecystitis or an infected gallbladder) • Medication: Antibiotics, diazepam (Valium), flurazepam, indomethacin (Indocin), phenytoin (Dilantin), birth control pills. Phenobarbital and theophylline may cause a decrease • Excess vitamin C • Glibert‘s syndrome

Bilirubin levels are used to monitor and diagnose liver diseases like hepatitis, gallstones, or cirrhosis.

• Mononucleosis

It is also evaluated to find out the urgency of a transplant.

• Other conditions that destroy red blood cells (e.g. sickle cell disease, transfusion reaction, etc.)

• Blockages of the bile ducts

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ALBUMIN Albumin is a protein made exclusively by the liver. It‘s the most abundant protein in blood plasma. It is needed to prevent fluid from leaking out of blood vessels, and to transport nutrients, hormones, and the proteins required for proper blood clotting. Albumin levels are often tested when determining a person‘s overall health status. Because it is produced by the liver, the concentration of albumin is a good indication of how well the liver is functioning.

Some Alternative Causes For Abnormal Albumin Results • Malnutrition • Protein deficiency • Shock

• Inflammation • Medications: Anabolic steroids, androgens, insulin, and growth hormones • Conditions that affect the absorption and digestion of protein (e.g. celiac disease, Crohn‘s disease) • Receiving intravenous fluids

A low albumin level can indicate problems with the liver. It can also be a sign of kidney problems, especially when albumin is found in the urine.

CLOTTING STUDIES The clotting of blood—coagulation— is important to the body in many ways, like in repairing cuts or injuries, for example. Your liver plays a major part in this process. One effect of liver damage is the ―thinning‖ of your blood, meaning it takes longer to clot.

Clotting ability is measured through prothrombin time (PT) or international normalized ratio (INR). A significantly prolonged clotting time can be the sign of a worsening chronic liver disease. A vitamin K deficiency may slow down PT.

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OTHER TESTS USED TO GAUGE THE EXTENT OF LIVER DAMAGE Imaging tests are used to detect complications of cirrhosis, such as ascites or hepatocellular carcinoma. Ultrasound scans look at the shape and size of your liver, and checks for fluid. MRIs or CT scans may be used for more in-depth testing. There are also two common tests to monitor the scarring. FibroScan is a non-invasive test used to measure liver stiffness using soundwaves—a scarred liver is stiffer than a healthy one.

In case of cirrhosis, the results of image tests and blood tests, along with the presence of specific complications (ascites and encephalopathy) are used for calculating the Child-Pugh Classification. This is a staging system (from A to C) that helps doctors determine the severity of cirrhosis and predict the development of future complications.

A liver biopsy is the only definite method for confirming a diagnosis of cirrhosis. It also helps assess the severity of liver disease and is a key tool in finding out the underlying causes— so that possible treatments can be explored. The procedure involves inserting a needle into the body to take a small piece of tissue from the liver. The piece is then studied under a microscope to look for damage.

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4. TIPS FOR MANAGING MOST LIVER DISEASES “There is no „one-size-fits-all‟ guideline in managing liver disease.” This rings true about chronic disease management in general, and I know it‘s probably not something you‘d want to hear if you‘ve just found out about a liver problem. But we can‘t just sit and let time go by without doing anything! In this section, we‘ll talk about the things that YOU can do to help yourself manage your disease depending on its cause and severity.

4.1. ALCOHOL ABSTINENCE/RESTIRCTION Fatty liver disease is a result of modest (i.e. ≤10 g/day) to excessive alcohol intake. It accounts for up to 40% of liver diseases.

Luckily, as with other earlier forms of liver disease, it is very much reversible. This tip probably isn‘t a surprise to you. In fact, you might not have a problem with this at all, but I do know that there are people out there who will find abstaining from alcohol more of a challenge than most. I understand how it could be hard to stop drinking completely—after all, most of us enjoy the occasional social drink now and then. It‘s a goto way to get loose and have some fun! However, as much as we wish that there could be another way, we have to stick to medically sound and proven-by-experience advice, and that is:

Get rid of alcohol. It won‘t be a walk in the park, but you can do it, and I‘ll do my best to help you through.

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I can guide you through the process of abstaining and eventually, if we both do it correctly, you‘ll reverse your liver condition in a practical and effective way. And that‘s what we‘ll be dealing with in this section.

They‘re just often too busy and they forget to tell you these things, but if you ask them, they will surely give you an answer.

 THE SACRIFICE

To save time thinking over what you need to know, write your questions down so you won‘t forget (it can‘t hurt to try a little note-taking).

You‘ll have to make a little sacrifice on your end. Follow what your doctor says. Be completely sober for as long as you need to.

If you‘ve been drinking heavily for a long time, you might be worried about delirium tremens (withdrawal induced hallucinations and tremors), seizures, and everything else that comes along with your decision to take care of your liver by eliminating alcohol. This is serious stuff, so let‘s handle this once and for all:

So whenever you have a consultation, be prepared.

QUERIES TO START WITH:  What are the common symptoms of alcohol withdrawal?  What are the worst symptoms of alcohol withdrawal?  How do I manage these symptoms if I experience them alone, at home, or in public?

 Talk to your doctor. You need to take every opportunity to talk to your physician about alcohol withdrawal. Most patients don‘t get around to managing their health because they get close to no information from their doctors.

 Manage Symptoms

Of course, most doctors don‘t do this intentionally.

These symptoms can range from mild anxiety to delirium tremens,

If you‘re still not satisfied with the advice from your physician, here are a few tips to manage your symptoms at home.

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which involves confusion, increased vital signs (rapid heart rate and very high fever), hallucinations (auditory and visual), and even seizures.

• To have someone else drive you if you need to go somewhere, at least within 10 days from alcohol abstinence.

Always be on your guard, as these symptoms will start to show as early as 6-12 hours after abstaining from alcohol, with peak episodes on the 2nd and 4th days.

• To consider medical attention at every point within the first week of alcohol abstinence. In extreme cases of withdrawal syndromes, patients may need anti-anxiety drugs, oxygen inhalation, and other physician prescribed medications.

You will need: • A significant other/family member/friend who understands what you are going through. He/she needs to be always near you during the first 2 weeks of abstaining, at least. • To rehydrate yourself with WATER. Keeping yourself hydrated allows for flushing, and more importantly, stabilizes your body temperature and other symptoms, such as hot flashes, diaphoresis (over-sweating), and excessive thirst. But be careful with drinking when tremors are getting worse—it could be an impending seizure, and that could cause you to choke while drinking. • To keep yourself free from sharp objects, furniture, or anything that might cause you injury in case of tremors, hallucinations, or falls.

The symptoms and the struggle that comes with it depend on how long you‟ve been drinking and how much excess alcohol you have in your system. I don‘t mean to scare you off with this, but sometimes, we need to take risks, and this is the risk you have to take in order to avoid progression to alcoholic hepatitis, or worse, into the irreversible alcoholic cirrhosis.

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 THE REWARD

 Calculating Alcohol Units

With every sacrifice, there is always a reward.

Alcohol in beverages is expressed in ABV (alcohol by volume), vol., or alcohol volume, which is always expressed in a percentage.

When you finish the ―SACRIFICE TIMELINE‖, you have the right to a reward! (That is, if you still want it). What is it?, you might ask. After the set period of time in which you are asked to abstain from alcohol (without failure or cheating), you can have a drink every now and then, as long as you follow these guidelines set by NHS UK for alcohol consumption :

Alcohol Intake Guidelines • Men should not consume more than 3-4 units of alcohol in a day • Women should not exceed 2-3 units a day • In case of an unavoidable heavy drinking session, keep away from alcohol for at least 48 hours after

But how do you know when you‘ve reached your limit? What do those units mean? Well, now this is the part where I need you to do some math.

You can work out the units by multiplying the total volume of the drink by its ABV and dividing it by 1,000 (for units). For example, for 330ml of beer with a 5% ABV : 5 x 330 / 1000 (units) = 1.65 units The next page contains a list of drinks and their alcoholic units, but it’ll still be more responsible for you to read labels as often as you can.  THE ULTIMATE REWARD + A “CORNERSTONE” SOLUTION I‘d like to tell you a secret, though you might have already figured it out yourself: The greatest reward of all, is knowing that you‘ve already reversed your alcoholic liver disease. I want you to know that the ultimate goal is not just abstaining for a period of time, but to totally

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Beverage Red Wine Red/white/rose wine Red/white/rose wine

Red/white/rose wine

Volume

ABV (%)

Alcohol Units (u)

750 ml

13.5 %

10 u

12

1.5

12

2.1

12

3

125 ml (small glass)

175 ml (standard glass)

250 ml (large glass)

Lower strength lager/beer/cider

1 pint

3.6

2

Higher strength lager/beer/cider

1 pint

5.2

3

5

1.7

4.5

2

5.5

1.5

40

1

40

1.4

Lager/beer/cider Lager/beer/cider

330 ml (bottle)

440 ml (can)

Alcopop

275 ml

Gin, rum, vodka, whisky, tequila, sambuca,

25 ml

Gin, rum, vodka, whisky, tequila, sambuca,

(small shot)

35 ml (large shot)

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get rid of drinking in order to completely reverse your condition and stop it from coming back. I have one simple piece of advice: Stick with a support group. Find a group of people who share the same struggles and the same goals. It doesn‘t have to be a formal organization—you don‘t necessarily have to go to an AA meeting. (But if you want to, then of course you can!) The National Liver Foundation can help too, as well as other government and non-government agencies upholding liver wellness. You also have the option of sticking around with us, as we build this community of 13K+ patients who have managed their liver disease effectively by following through this guide.

4.2 AIMING FOR A HEALTHY WEIGHT Being at a healthy weight is very important for your overall health and well-being. When you are overweight or underweight, you‘re increasing the likelihood of your liver condition getting worse, as well as your risk

for developing serious health problems.  Obesity is linked to some liver diseases. In fact, it is thought that as many as 90% of morbidly obese individuals have fatty liver disease. Aside from that, it can reduce the effectiveness of treatments and quicken the progression of other conditions, like alcoholic liver disease. You can lose weight by taking out high-fat food from your diet. The ideal rate of weight loss is around 12 pounds a week (or .45 to .90 kilograms). Any quicker, and this will trigger your body‘s starvation response—causing you to produce more fat.  On the other hand, being under-weight is not ideal also. This condition means that you are not getting enough of the materials your body needs to function properly and to repair itself. You might not have much of an appetite at times, but try to eat as much as you can. For some people, multiple small meals throughout the day work better, instead of a few large ones. Consult your doctor or dietician to find out how you can increase your calorie intake.

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Here are two ―Good to Know‘s‖ that can help you aim for a healthy weight:

Thus, they can show you support in various ways, like creating meal plans or even creating the same food that you eat.

 Know your daily nutrient goals

Also, holistic care is not only concerned about dieting, but also with complementing it with exercise (discussed in the succeeding sections).

Dietary requirements differ from one liver patient to another. Factors involving underlying conditions (e.g. diabetes) are taken into consideration when creating a diet plan. The plan is customized to suit your need as patient, as they should not only focus on your liver disease, but also on pre-existing conditions and your regular daily health needs. You can start by finding out your daily requirements for the following: calories, carbohydrates, fats, protein, fiber, and alcohol.  Know your most significant “significant other” Although it is not a type of food, this principle targets lots of areas. Your family members are the first few—if not the only—people who understand that you are capable of living your life normally, and can help you through the process of healing.

This is another aspect of treatment that you and your family can work on together to make as fun as possible, so that you don‘t feel burdened.

4.3 DIET Diet is vital to your overall health, and it‘s especially important when you have a liver condition—or any medical condition for that matter. A balanced diet can go a long way to keeping you healthy. By ensuring that you‘re getting the nutrients you need, you‘re supporting liver function, and giving your body the materials necessary for it to begin repairing the damage done. In the absence of other medical conditions, a balanced diet is typically:

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• Low in fat, salt, and sugar • High in fiber It should also have the correct balance of the essential macronutrients—carbohydrates, fats, and protein—and provide a variety of vitamins and minerals.

Proteins should make up around 20-30% of your daily calorie intake, fats another 20-30%, and carbohydrates 60-70%. You‘ll notice that these percentages can potentially add up to more than a hundred. This means you can alter the combinations of these groups, as long as the fat content of the meal does not exceed 30%, carbohydrates 70% and protein 30%.

If you have a more advanced condition, like cirrhosis, go to section 5.2 of the book to get more specific recommendations.  FOODS TO EAT AND AVOID If the amount of food you‘re eating are important, that goes double for the actual types of food you choose to fill those amounts. You should always be thinking of the healthiest options for protein, carbohydrates, and fat. The next page contains guidelines on the best sources for these vital nutrients. These guidelines are applicable for most people, but if you have specific dietary requirements due to other medical conditions, don‘t forget to take those into account as well. Also, try to get your nutrients from as many healthy sources as possible —a diet rich in variation will give you a broader range of vitamins and minerals.

For example, you can have a 10% fat, 20% protein, and 70% carbohydrate diet.

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Diet Group

Avoid (or Eat Less Of) • Red meat: pork, beef, veal, etc (it has a higher fat content)

Protein

• Processed meat: sausages, hot dogs, ham, bacon, corned beef, etc. (may contain chemicals and additives) • Fried meat

Eat More Of • Vegetable protein sources: beans and other legumes, nuts, tofu and other soy products • Lean cuts of white meat: poultry and fish (with the skin removed) • Seafood • Grilled, steamed, or boiled meat

Carbohydrates

Fat

• Simple carbohydrates: white bread, white rice, baked goods, soda (carbonated drinks), table sugar, refined grains, candy, chips, high fructose corn syrup

• Complex carbohydrates: whole grain foods, legumes, starchy vegetables (like potatoes)

• Trans fat: fast food, fried food, doughnuts, pastries, pizza dough, common commercial snack foods (chips, cookies, crackers)

Unsaturated fats:

• Saturated fat: pork, beef, veal

• Fiber sources: fruits and vegetables

• Monounsaturated fats: olive oil, peanut oil, canola oil • Polyunsaturated fats (omega-3 and omega-6 fatty acids): salmon, sardines, soybean oil, corn oil

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4.4 GENERAL FITNESS AND EXERCISE

These exercises may involve (but are not limited to):

Keeping yourself fit and in shape does not only apply to those who are perfectly healthy. Liver disease is one of those chronic diseases that allow patients to include moderate exercise in its disease management strategies.

• Cardio: Early morning walks, jogging, swimming, etc.

Regular exercise allows the body to maintain the equilibrium of calories and improves the absorption of the nutrients we take in from the food that we eat.

• Flexibility Training: Stretching exercises

Physical activity and exercises can also serve as a healthy diversion for alcoholic liver disease patients who are in the maintenance phase of their alcoholic abstinence.

• Strength Training: Push-ups (or the modified wall pushup), modified squats and lunges

• Balance Training • Core Training : Abdominal exercises, although you should be careful about the type of activity you do if you are experiencing liver pains

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5. TIPS FOR MANAGING CIRRHOSIS If you‘ve been diagnosed with cirrhosis, then you might be feeling a bit alarmed. This section aims to provide you with as much information as possible about your condition, so that you don‘t feel overwhelmed or anxious.

• Slowing or reversing the underlying cause • Managing symptoms • Identifying and treating of existing complications • Protecting the liver from other sources of damage

Can I be cured of cirrhosis? Once you have cirrhosis, the liver damage is generally permanent. Scarring cannot be fully reversed, but the good news is that it can lessen with time in the same way a scar on the skin fades. That‘s why it‘s important to find out if you have cirrhosis early and to treat its causes. The healthy parts of a scarred liver can still regenerate. With proper management, cirrhotic patients can see improvements in their liver health. When managing cirrhosis, patients and healthcare providers may have the following major goals in mind:

What can I do to keep cirrhosis from getting worse? Treating or managing the cause of liver cirrhosis can keep your condition from getting worse. Earlier stages of cirrhosis may be reversible with treatment of the underlying cause.

Vaccines against Hepatitis A and B for those who are not immune can help prevent further liver damage. This is because infections can be really hard on people with cirrhosis. It‘s also vital to get other vaccines, including vaccines to protect against flu (1 a year), pneumonia (at least once) and others.

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5.1. KNOW THE UNDERLYING CAUSE OF YOUR LIVER CIRRHOSIS The first part of managing liver cirrhosis involves identifying its underlying cause and treating that if possible. To understand what causes liver cirrhosis, we have to look at what causes damage to liver cells. There are a number of possibilities:  HEPATITIS Hepatitis A and E don‘t appear to cause cirrhosis, however hepatitis B can, especially if it is chronic hepatitis—meaning it has persisted for over six months. Hepatitis C is the most frequent cause of cirrhosis, since it becomes chronic in a high percentage of people affected. Autoimmune hepatitis, and other non-infectious forms of hepatitis, can also progress to cirrhosis if left untreated.  CHRONIC ALCOHOL ABUSE In general, about a third of people who drink excessively develop fat around their liver due to alcohol

abuse. Consequently, about 10% develop cirrhosis.  DISEASE OF THE BILE SYSTEM Primary biliary cirrhosis—the destruction of the bile ducts—is caused by an abnormality of the immune system, found mainly in women.  NON ALCOHOLIC FATTY LIVER DISEASE AND NON ALCOHOLIC STEATOHEPATITIS

Nonalcoholic fatty liver disease can lead to nonalcoholic steatohepatitis (NASH). About 8-20% of people with NASH go on to develop cirrhosis.  SOME GENETIC/INHERITED DISORDERS Some inherited—or thought to be inherited—disorders cause the accumulation of toxic substances in the liver, which in turn leads to cirrhosis: Hemochromatosis - abnormal iron buildup in the body Wilson‘s Disease - abnormal copper buildup in the body Cystic Fibrosis

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Alagille Syndrome - genetic digestive disorder

The more salt they eat, the more severe the fluid buildup is.

Galactosemia - inherited disorders of sugar metabolism

If you are one of these people, it‘s recommended that you go on a low sodium diet.

POINTS TO REMEMBER:

For a low sodium cirrhosis diet, you can start with limiting your sodium intake to 1500 – 2 000 mg a day or aim for less than 2 300 mg of sodium each day.

 Any illness that affects the liver over a long period of time may lead to fibrosis and, eventually, cirrhosis.

You limit will depend on factors like blood pressure, fluid balance, and the presence of other diseases that may affect sodium requirements.

 For some people, there could be more than one underlying cause for cirrhosis, such as a combination of viral hepatitis and alcohol abuse.

 TIPS FOR A LOW SODIUM LIVER CIRRHOSIS DIET

 If your doctor cannot find a cause for your cirrhosis, it is called ―cryptogenic cirrhosis‖. About 20% of people with cirrhosis have cryptogenic cirrhosis.

5.2. MANAGING CIRRHOSIS THROUGH DIET Some patients with cirrhosis experience swelling or fluid accumulation in the abdomen (ascites).

Here are some ways to cut sodium in your diet:  Always go with fresh food choices and reduce the amount of processed foods in your diet. Fresh foods contain less sodium compared to packed or processed foods. Although fresh cuts of chicken, pork or beef still have natural sodium content, it is a lot less than the amount you‘ll find in processed products, such as bacon or ham.

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A HELPFUL TIP: When food can be stored in the fridge for a number of days or weeks, the sodium content is definitely high.

You can start by choosing foods with the lowest Percent Daily Value (%DV). The percent daily value in the nutrition label lets you know if a food is low or high in sodium. Five percent or less is low while twenty percent or more is high.  Rinse Certain Foods

Going for fresh also extends to fruits and vegetables. Fresh fruits and vegetables contain very low sodium. Some varieties of canned and frozen fruits are low sodium as well.

Rinsing certain food products—like vegetables, meats, fish and especially canned goods—is another way to lessen the salt content of foods.

However, when you‘re buying frozen vegetables, make sure that it is labeled ―fresh frozen‖, to make sure that it is really fresh and does not contain other added ingredients or seasonings.

 Spice Up Your Meals

 Read Labels

Allspice - beef, eggs, fish, fruits, vegetables, beverages, baked products, desserts

Reading the labels when purchasing food is a smart way to make sure that you are consuming less sodium. Generally, the sodium content is always listed on the label. Make it a habit to never skip taking a look before buying.

When you must limit salt, herbs and spices can add extra flavor to your foods. Here are some suggestions for blending spices with specific foods:

Basil - lamb, fish, eggs, vegetables, sauces Bay Leaf - beef, chicken, veal, fish

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Cinnamon - chicken, pork, fruits, baked products, beverages, vegetables Cloves - beef, pork, fruits Curry (salt-free) beef, chicken, lamb, veal, eggs

 Make your own meals

Make your own meals instead of eating prepared foods that may be rich in sodium. If you make it, then you‘re more likely to know what‘s in it.

Dill - chicken, veal, fish, vegetables Ginger - chicken, pork, fruits, vegetables, baked products, beverages Marjoram - eggs, fish, meats, poultry Mustard Powder - meats, poultry, fish, eggs, vegetables Parsley - beef, chicken, fish, salads, sauces Rosemary - beef, lamb, chicken, turkey Sage - meats, fish, stuffing, vegetables Savory - egg dishes, meats, poultry, stuffing, rice, vegetables Tarragon - chicken, fish, meats, egg dishes, sauces, vegetables

POINTS TO REMEMBER:  If you are told that your ―sodium level‖ is too low, this is usually a result of too much water in your body. It does not necessarily mean that you should stop limiting your salt intake.  Drinking fluids will not make your ascites or leg swelling worse (only salt intake will do that). Fluid restriction is not necessary for most cirrhotic liver patients, unless your sodium level is less than 125mmol/L. It‘s important for you to confirm with your hepatologist or liver specialist whether you need to watch your salt or fluid intake.

Thyme - fish, meats, poultry, eggs, stuffing, vegetables 32

5.3. MEDICATIONS AND OTHER SUBSTANCES TO LIMIT/AVOID You should avoid all substances that could harm or damage your liver. This includes the following:  Alcohol  Cigarettes have toxins and carcinogens in them. These get in your blood when you smoke. When you have cirrhosis, your liver does not work as effectively to clear out cigarette toxins from the blood, causing further liver damage.

 NSAIDS (Non-Steriodal AntiInflammatory Drugs) include overthe-counter medications such as ibruprofen (sample brand names: Advil, Motrin) and naproxen (Aleve).

Inform your doctor of any herbs or supplements you are considering taking. Some herbal remedies, such as kava, chaparral and other traditional Chinese herbs can increase the risk of liver damage.

As much as possible, avoid medicines unless they are prescribed by your physician.

Cirrhotic patients who take acetaminophen (Tylenol) for mild to moderate aches and pains should not take more than 2,000 milligrams per day (four-extra-strength tablets). Some cold medicines and prescription pain medicines also contain acetaminophen, so it‘s important that you check the labels of any medications.

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6. BEING AN ACTIVE PARTICIPANT OF YOUR HEALTH Confronting diagnosis and managing conditions like chronic liver disease can be daunting, especially if you don‘t know where to start. Without a lifestyle intervention, the degeneration of your body could continue for years. Several public health agencies have attempted to expand and spread information as the need for awareness is recognized. However these efforts will be in vain if, despite awareness, people still choose to go on their own unhealthy way. Apathy is the most obvious challenge of improving health conditions.

But I also know that it can take a lot more than reading and learning to halt liver disease progression. I always say this to my patients and especially their families:

“Sometimes, all you need is someone to back you up with your struggles.” After all it‘s hard to win battles when you‘re alone. And in this case, please remember that you are not. You can always touch base with me.

Refusing to take action simply worsens your condition. Lifestyle modification, specifically a healthy diet and exercise, can be effective in stopping the progression of this disease.

Just send me an email at [email protected] and we will be more than happy to reach out however we can.

I‘ve already handed you important tools that you can use to prevent further damage to your liver.

To your optimal health!

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