Dietary Recommendations for Cirrhosis
Patients with cirrhosis should consume at least 35 kcal/kg/day and 1.2-1.5 g/kg protein/day distributed across 3 meals and 3 snacks (with a mandatory late-evening snack), while completely avoiding alcohol and moderately restricting sodium only if ascites is present—protein should never be restricted even with hepatic encephalopathy. 1, 2, 3
Energy Requirements
Target caloric intake based on body habitus:
- Non-obese patients (BMI <30): Minimum 35 kcal/kg/day 1, 2
- Obese patients (BMI 30-40): 25-30 kcal/kg/day 1, 2
- Severely obese (BMI ≥40): 20-25 kcal/kg/day 1, 2
When calculating targets in patients with ascites or edema, estimate dry weight by subtracting: 5% for mild fluid retention, 10% for moderate, 15% for severe, plus an additional 5% if bilateral pedal edema extends to the knees 1. Alternatively, use post-paracentesis weight 1.
Protein Requirements
Prescribe 1.2-1.5 g/kg ideal body weight per day using diverse protein sources 1, 2. This is the single most critical macronutrient target, as protein catabolism accelerates in cirrhosis 1, 4.
Critical pitfall to avoid: Never restrict protein, even in hepatic encephalopathy 1, 3. A landmark randomized trial demonstrated that protein restriction (starting at 0 g/day) accelerated protein catabolism without improving encephalopathy outcomes compared to maintaining 1.2 g/kg/day 1.
For patients with recurrent hepatic encephalopathy who struggle with meat tolerance, emphasize vegetable proteins (legumes, beans) and dairy proteins over animal proteins, but maintain total protein targets 1, 3. For critically ill hospitalized patients, increase protein to 1.2-2.0 g/kg/day 2.
Meal Timing and Frequency
Structure eating pattern as follows:
- 3 main meals: breakfast, lunch, dinner 1, 2
- 3 snacks: mid-morning, mid-afternoon, and mandatory late-evening snack (7-10 PM) 1, 2, 3
The late-evening snack is the most important intervention, as it covers the prolonged overnight fasting period and prevents the accelerated protein catabolism that occurs during nocturnal fasting in cirrhosis 1, 2, 3. Minimize fasting intervals to maximum 3-4 hours between meals while awake 2.
Sodium Restriction
Restrict sodium moderately (typically 2 g/day) only if ascites or edema is present 1. However, this recommendation requires careful balancing: in one study of 120 cirrhotic patients with ascites, only 31% adhered to 2-g sodium restriction, and adherent patients consumed 20% fewer calories 1.
Key clinical decision point: If sodium restriction makes food unpalatable and reduces total caloric intake below targets, liberalize sodium restriction 1. Adequate nutrition takes priority over strict sodium control 1.
Alcohol and Caffeine
Alcohol is the only food that genuinely damages the liver and must be completely avoided—this is the single most important dietary restriction 3. There are no specific caffeine limits recommended in cirrhosis guidelines; virtually no food other than alcohol is contraindicated 1, 3.
Micronutrient Supplementation
Prescribe a daily oral multivitamin containing B vitamins but ensure it does NOT contain manganese, as cirrhotic patients accumulate manganese in the basal ganglia 5. The AASLD and EASL both recommend routine multivitamin supplementation in decompensated cirrhosis, as vitamin deficiencies are difficult to assess clinically, multivitamins are inexpensive, and side effects are minimal 5.
Assess fat-soluble vitamins (A, D, E, K) at least annually 2. For alcohol-related cirrhosis, add thiamine 100 mg orally daily separately 5. If Wernicke's encephalopathy is suspected, give large doses of thiamine parenterally BEFORE any glucose administration 5.
Branched-Chain Amino Acids (BCAAs)
Use BCAA supplements in decompensated cirrhotic patients to achieve adequate nitrogen intake 2. The EASL specifically recommends leucine-enriched amino acid supplements for decompensated patients 2. While BCAAs show promise in reducing cirrhosis-related complications, they are currently limited by gastrointestinal side effects and poor palatability 4.
Fluid Restriction
Current guidelines do not recommend routine fluid restriction in cirrhosis 1. Fluid limits are typically reserved for severe hyponatremia (sodium <125 mEq/L) and should be individualized based on serum sodium levels rather than applied universally.
Practical Food Recommendations
Emphasize vegetables and fruits for adequate micronutrients 1, 3. However, if high-fiber foods cause bloating that reduces overall intake, report this to the physician, as meeting caloric and protein targets takes priority 1.
Encourage diverse protein sources including vegetable proteins, dairy, and meat 1. While some older studies suggested vegetable and casein-based proteins reduce encephalopathy compared to meat proteins, current guidelines do not recommend limiting meat-based protein sources, as meat may be a staple protein source and the evidence is limited 1.
Escalation of Nutritional Support
If oral diet fails to meet targets despite counseling:
- First-line: Add oral nutritional supplements 2
- Second-line: Enteral nutrition via feeding tube (esophageal varices are NOT an absolute contraindication) 2
- Last resort: Parenteral nutrition only if enteral nutrition is not tolerated 2
Special Considerations for Hospitalized Patients
- Obtain formal dietician consultation within 24 hours of admission 2
- Minimize NPO periods during procedures 2
- Implement pre-bedtime or early-morning snacks if procedures are scheduled for late afternoon 2
- Use higher protein targets (1.2-2.0 g/kg/day) for critically ill patients 2
Physical Activity Integration
Encourage progressive increase in physical activity to prevent sarcopenia 2. Moderate-intensity exercise tailored to patient ability improves muscle mass and function 2. This is particularly crucial in obese cirrhotic patients, where maintaining protein intake and physical activity prevents muscle loss during any supervised weight loss interventions 2.