What is the best diet for someone with cirrhosis (liver scarring)?

Optimal Diet for Cirrhosis

For patients with cirrhosis, the best diet is a high-protein (1.2-1.5 g/kg/day), frequent-meal pattern with a late evening snack to prevent muscle wasting and improve survival. 1

Protein Requirements

• Compensated cirrhosis: 1.2 g/kg/day protein 1
• Malnourished/sarcopenic cirrhosis: 1.5 g/kg/day protein 1
• Decompensated cirrhosis: 1.5 g/kg/day protein with late evening snack 1

Contrary to outdated beliefs, protein should NOT be restricted in patients with hepatic encephalopathy, as restriction increases protein catabolism without improving outcomes 1, 2. The concept of "protein intolerance" is largely historical and rarely encountered in modern practice.

Energy Requirements

• Standard recommendation: 30-35 kcal/kg/day 1
• Overweight/obese patients: Avoid increased energy intake 1
• Patients with increased energy expenditure (acute complications, refractory ascites): Consider increased energy intake 1

Meal Timing and Pattern

1. Consume 3-5 meals per day to keep starvation periods short 1
2. Include protein-containing breakfast 1
3. Add a late evening snack to improve total body protein status and prevent overnight catabolism 1

Special Considerations

For Sarcopenia (affects 50-60% of cirrhotic patients)

• Higher protein intake (1.5 g/kg/day) 1
• Late evening protein snack 1
• Consider BCAA supplements (0.25 g/kg/day) in true protein intolerance cases 1

For Obesity with Cirrhosis

• Implement lifestyle intervention for weight reduction 1
• Maintain high protein intake while reducing calories 1
• Include supervised moderate-intensity physical exercise 1
• Target moderate weight reduction to reduce portal hypertension 1

For Sodium Management

• Balance sodium restriction with palatability concerns 1
• Avoid very strict sodium limitations as they may compromise overall nutritional intake 3
• Care should be taken to ensure adequate nutrition when prescribing sodium-restricted diets 1

Practical Implementation

1. Assess nutritional status using tools like skeletal muscle index, hand grip strength, or liver frailty index 1
2. Distribute protein intake throughout the day in small, frequent meals 2
3. Include diverse protein sources including vegetable and dairy products 2
4. Add late evening snack containing protein to prevent overnight catabolism 1
5. Consider BCAA supplementation (0.25 g/kg/day) only for patients who cannot tolerate sufficient protein intake 1

Common Pitfalls to Avoid

1. Restricting protein in hepatic encephalopathy - This worsens muscle wasting without improving encephalopathy 1, 2
2. Overly strict sodium restriction - May lead to poor palatability and reduced overall intake 1, 3
3. Prolonged fasting periods - Accelerates protein catabolism in cirrhotic patients 1
4. Ignoring sarcopenia - Associated with higher rates of wait-list complications, morbidity, and mortality 1
5. Inadequate nutritional monitoring - Regular assessment is needed to adjust interventions 2

A 2018 study demonstrated that a high-protein, high-fiber diet (1.2g/kg protein) combined with BCAA supplementation was safe in cirrhotic patients, helping increase muscle mass without raising ammonia levels or causing hepatic encephalopathy 4.