Diet in cirrhosis of the liver
Cirrhosis needs 35 kcal/kg and 1.2-1.5 g/kg protein, low salt for ascites, frequent meals and a late evening snack to stop muscle breakdown.
Aim and principles of the diet
Aim: To plan, prepare and calculate a diet for a man with cirrhosis of the liver and ascites, without encephalopathy. Principles: In cirrhosis, liver cells are replaced by scar tissue. The liver stores little glycogen, so even an overnight fast acts like a long fast and the body breaks down muscle for energy; many patients are malnourished and lose muscle (sarcopenia). The diet gives high energy (about 35 kcal/kg) and high protein (1.2-1.5 g/kg) (ESPEN 2019). Protein is not restricted, even in hepatic encephalopathy; milk, curd, pulses and other vegetable proteins are better tolerated than large portions of meat. Meals come every 3-4 hours, with a late evening snack of complex carbohydrate (such as ragi porridge) to shorten the night fast. Sodium is moderately restricted when there is ascites or oedema: no added salt at the table and no pickles, papad or salted snacks (about 2 g sodium a day). Fluid is restricted only if serum sodium falls very low (below about 125 mmol/L). Fat is moderate and is reduced only if there is steatorrhoea. Food is soft and well cooked if there are oesophageal varices. Alcohol is stopped completely. B-complex vitamins, zinc and vitamin D are often low and need attention.
Nutrient prescription: Mr. M, 50 y, 170 cm, 68 kg with moderate ascites
| Nutrient | Prescription | Basis and source |
|---|---|---|
| Dry weight (IBW) | About 61 kg (IBW 63 kg) | 68 kg less about 10% for moderate ascites (ESPEN and EASL: 5%, 10%, 15% for mild, moderate, severe) |
| Energy | About 2100 kcal | 35 kcal/kg × 61 = 2135 (ESPEN 2019) |
| Protein | About 75 g | 1.2 g/kg × 61 = 73 (ESPEN 2019: 1.2-1.5 g/kg) |
| Sodium | About 2 g (about 5 g salt) | EASL: 80-120 mmol a day; about 3 g salt in cooking, none at the table |
| Fluid | Not restricted | Restrict only if serum sodium is below about 125 mmol/L |
| Meals | 5-6 meals and a late evening snack | Shortens the overnight fast |
Foods to include and avoid
| Food group | Include | Avoid |
|---|---|---|
| Cereals | Rice, idli, chapati, ragi, oats; a cereal snack at bedtime | Salted snacks; bakery items made with baking soda |
| Protein foods | Milk, curd, paneer, dals, sundal, egg, fish | Salted dried fish; large meat portions if encephalopathy |
| Vegetables and fruits | All well-cooked vegetables; fresh fruits | Hard raw salads if varices are present |
| Fats | Measured oil | Fried foods, vanaspati |
| Flavourings | Lemon, herbs, ginger, garlic, pepper | Table salt, pickles, papad, chips, sauces, salt substitutes without advice |
| Drinks | Water, buttermilk without salt, milk | Alcohol in any form |
Sample one-day menu: cirrhosis with ascites (Mr. M)
| Time | Menu | Approx. amount (raw) |
|---|---|---|
| 6.00 am | Tea | Toned milk 100 mL, sugar 5 g |
| 8.00 am | Idli (4) with low-salt sambar | Rice 80 g + urad dal 20 g; tur dal 15 g, vegetables 50 g, oil 3 g |
| 11.00 am | Papaya | 150 g |
| 1.00 pm | Rice, moong dal, vegetable poriyal, curd | Rice 110 g; moong dal 30 g; vegetables 100 g, oil 6 g; curd 100 g |
| 4.00 pm | Milk with green gram sundal | Toned milk 150 mL, sugar 5 g; whole green gram 20 g, oil 2 g |
| 8.00 pm | Chapati (3), tur dal, egg curry, vegetable | Atta 75 g, oil 3 g; tur dal 20 g; 1 egg; vegetables 100 g, oil 6 g |
| 10.00 pm | Late evening snack: ragi porridge | Ragi 25 g, toned milk 150 mL, sugar 5 g |
Worked calculation: Mr. M's cirrhosis diet
Mr. M, 50 years, 170 cm, weighs 68 kg with moderate ascites. He has cirrhosis of the liver without encephalopathy. Find his dry weight, energy and protein needs and check the menu.
- IBW = (170 − 100) × 0.9 = 63 kg.
- Ascites adds water weight, so estimate dry weight: subtract about 10% for moderate ascites (5% mild, 15% severe): 68 − 6.8 = 61.2, about 61 kg. This is close to his IBW.
- Energy = 61 kg × 35 kcal/kg = 2135, about 2100 kcal (ESPEN 2019).
- Protein = 61 kg × 1.2 g/kg = 73.2, about 75 g (ESPEN 2019: 1.2-1.5 g/kg).
- Sodium: about 2 g a day; the whole day's cooking gets about 3 g salt and none is added at the table.
- Approximate values used (kcal and g protein per 100 g raw unless stated; rounded from Indian food composition tables, mainly IFCT 2017 and the older Nutritive Value of Indian Foods; a few, such as toned milk, are estimates): toned milk 60 and 3 per 100 mL; sugar 400; rice 355 and 8; urad dal 325 and 23; tur dal 330 and 22; mixed vegetables 30 and 1.5; oil/ghee 900; papaya 35 and 0.5; moong dal 325 and 24; curd 60 and 3; whole green gram 325 and 23; atta 320 and 10.5; egg 75 kcal and 6.5 g per piece; ragi 320 and 7.
- Cereals (rice 190 g, atta 75 g, ragi 25 g): 994.5 kcal, 24.8 g protein.
- Pulses (urad dal 20 g, tur dal 35 g, moong dal 30 g, whole green gram 20 g): 343.0 kcal, 24.1 g protein.
- Milk and milk products (toned milk 400 mL, curd 100 g): 300.0 kcal, 15.0 g protein.
- Egg (1 egg): 75.0 kcal, 6.5 g protein.
- Vegetables (mixed vegetables 250 g): 75.0 kcal, 3.8 g protein.
- Fruits (papaya 150 g): 52.5 kcal, 0.8 g protein.
- Oil and ghee (oil/ghee 20 g): 180.0 kcal.
- Sugar (sugar 15 g): 60.0 kcal.
- Energy = 994.5 + 343.0 + 300.0 + 75.0 + 75.0 + 52.5 + 180.0 + 60.0 = 2080.0 kcal.
- Protein = 24.8 + 24.1 + 15.0 + 6.5 + 3.8 + 0.8 = 75.0 g.
- Compare with the prescription: energy 2080.0 ÷ 2100 × 100 = 99%; protein 75.0 ÷ 75 × 100 = 100%.
- Each group is rounded to one decimal and the totals are the sums of those rounded figures; all values are approximate.
Dry weight about 61 kg; prescription about 2100 kcal, 75 g protein and 2 g sodium. The menu gives about 2080 kcal (99%) and 75 g protein (100%), including a late evening snack.
Preparation and serving tips, and result
- Measure the day's salt in the morning (about 3 g, roughly half a level teaspoon) and use only that for all the cooking.
- Flavour with lemon, tamarind, garlic, ginger, curry leaves and pepper instead of salt; do not use salt substitutes without the doctor's advice, because they contain potassium.
- Never skip the bedtime snack: it is part of the treatment.
- If varices are present, serve soft, well-cooked food and avoid hard or sharp items.
- Result: The cirrhosis diet gives about 2080 kcal and 75 g protein with about 2 g sodium, in 7 meals including a late evening snack, meeting Mr. M's prescription.
In the diet kitchen, the cirrhosis tray is labelled 'low salt': it is cooked in a separate pot with a measured pinch of salt, and pickles and papad are removed. The late evening snack must go out on the night round; a missed snack means an overnight fast that breaks down muscle.
Short answer: “Why is a late evening snack given in cirrhosis?” The cirrhotic liver stores little glycogen, so a bedtime carbohydrate snack shortens the overnight fast and reduces muscle breakdown.
Short answer: “Should protein be restricted in hepatic encephalopathy?” No. ESPEN 2019 advises 1.2-1.5 g/kg; use dairy and vegetable protein and spread it through the day.
Essay: “Plan a diet for a patient with cirrhosis of the liver and ascites.” Dry weight (subtract 10% for moderate ascites); energy 35 kcal/kg; protein 1.2-1.5 g/kg; sodium about 2 g; fluid restricted only if serum sodium is below about 125 mmol/L; meals every 3-4 hours with a late evening snack; soft food if varices; no alcohol. Then the menu, the calculation and the result.
Cirrhosis = '35, 1.2, 2, late': 35 kcal/kg, 1.2-1.5 g/kg protein, 2 g sodium, and a late evening snack.