What foods are allowed and what dietary recommendations should a patient with cirrhosis follow?

Dietary Recommendations for Cirrhosis

Patients with cirrhosis should consume a high-protein, high-calorie diet with frequent meals including a mandatory late-evening snack, moderate sodium restriction only if ascites is present, and absolutely no protein restriction even in hepatic encephalopathy. 1

Core Nutritional Requirements

Caloric Intake

• Non-obese patients (BMI <30 kg/m²): Consume at least 35 kcal/kg body weight per day 1
• Obese patients (BMI 30-40 kg/m²): Target 25-30 kcal/kg/day 1, 2
• Severely obese patients (BMI ≥40 kg/m²): Target 20-25 kcal/kg/day 1, 2
• When ascites or edema is present, calculate using 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, 2

Protein Intake

• Standard target: 1.2-1.5 g protein per kg ideal body weight daily for all cirrhotic patients 1
• Malnourished or sarcopenic patients: Increase to 1.5 g/kg/day 2
• Critically ill hospitalized patients: Target 1.2-2.0 g/kg/day 1
• Never restrict protein, even in hepatic encephalopathy—protein restriction accelerates catabolism and worsens outcomes without improving encephalopathy 1, 2, 3

Meal Timing and Structure

Implement a structured eating pattern to prevent prolonged fasting:

• Three main meals (breakfast, lunch, dinner) plus three snacks (mid-morning, mid-afternoon, and late-evening) 1, 2
• Mandatory late-evening snack between 7-10 PM containing 200 kcal to interrupt nocturnal protein catabolism 1, 2
• Limit fasting intervals to maximum 3-4 hours while awake 1, 2
• Include protein in both breakfast and the late-evening snack to improve total body protein status 1, 4

Sodium Management

Apply sodium restriction selectively, not universally:

• Restrict sodium to approximately 2 g/day (5-6.5 g salt/day) only when ascites or peripheral edema is present 1, 2
• Do not restrict sodium in compensated cirrhosis without fluid retention 2
• Avoid overly strict sodium restriction (<5 g salt/day) as it increases mortality and compromises caloric intake 2
• If sodium restriction makes food unpalatable and prevents meeting caloric/protein targets, liberalize the sodium restriction—overall nutrition takes precedence 1, 2
• Only 31% of patients adhere to 2-g sodium diets, and adherent patients consume 20% fewer calories 1

Fluid Management

• Routine fluid restriction is not recommended for most cirrhotic patients 1, 2
• Reserve fluid restriction only for severe hyponatremia (serum sodium <125 mmol/L) 1, 2
• Water follows sodium excretion passively, so sodium control is more important than fluid restriction 1

Food Choices and Protein Sources

Protein Sources

• Use diverse protein sources including vegetable proteins (legumes, beans), dairy products, and meat 1, 2
• For patients with recurrent encephalopathy who have difficulty tolerating meat, prioritize vegetable and dairy proteins while still meeting total protein goals 1, 2, 3
• Vegetable proteins contain more fiber and fewer aromatic amino acids, which may benefit some patients 5, 3, 6

Other Foods

• Emphasize vegetables and fruits to ensure adequate micronutrient intake 1, 2
• No specific foods are contraindicated except alcohol 2
• No caffeine restrictions are necessary 2
• Do not restrict dietary fat unless cholestasis is documented 2

Branched-Chain Amino Acid (BCAA) Supplementation

• BCAA supplements (0.25 g/kg/day) should be used in decompensated cirrhotic patients to achieve adequate nitrogen intake 1
• Consider BCAAs for the rare "protein intolerant" patient who develops encephalopathy with normal protein intake 1, 2
• BCAAs are not routinely recommended beyond meeting daily protein targets from diverse food sources 1
• BCAAs may improve event-free survival and quality of life in advanced disease 2, 5, 7

Escalation of Nutritional Support

When oral intake is insufficient, escalate systematically:

1. First-line: Oral nutritional supplements to meet energy/protein targets 1, 2
2. Second-line: Enteral nutrition via nasogastric or nasojejunal tube if oral intake plus supplements fail 1, 2
   • Esophageal varices are not an absolute contraindication to feeding tube placement, but monitor closely for rebleeding if placed after recent banding 1
   • Never place percutaneous gastrostomy tubes in patients with ascites due to high complication rates 1, 2
3. Third-line: Parenteral nutrition reserved only for patients intolerant of enteral nutrition 1, 2

Hospitalized Patients

• All hospitalized cirrhotic patients should receive formal dietitian consultation within 24 hours of admission 1, 2
• Minimize NPO (nothing by mouth) periods—provide pre-bedtime or early-morning snacks when procedures are scheduled later in the day 1, 2
• Higher protein targets (1.2-2.0 g/kg/day) for critically ill patients 1

Micronutrient Supplementation

• Monitor and replace fat-soluble vitamins (A, D, E, K) as deficiencies are common 4
• **Vitamin D supplementation if levels <20 ng/mL**, targeting >30 ng/mL 4
• Consider supplementation of vitamin A, thiamine, vitamin B12, folic acid, pyridoxine, and zinc if deficiency is documented 1
• Zinc supplementation may improve ascites and encephalopathy 1

Physical Activity

• Encourage progressive increase in physical activity to avoid hypomobility and improve muscle mass 1, 2
• Moderate intensity exercise tailored to patient ability is recommended 1
• Resistance exercise appears safe even with portal hypertension 1

Weight Management in Obese Cirrhotic Patients

• For obese patients with compensated cirrhosis, implement lifestyle intervention targeting 5-10% weight loss 1, 2
• Use a moderately hypocaloric diet (−500-800 kcal/day) while maintaining adequate protein intake (>1.5 g/kg/day) 1
• Exercise extreme caution with weight loss in decompensated cirrhosis—any weight loss should be supervised by a multidisciplinary team 1
• Maintain target protein intake and physical activity during weight loss to prevent muscle loss 1

Critical Pitfalls to Avoid

• Never restrict protein for hepatic encephalopathy—this accelerates catabolism without benefit 1, 2, 3
• Never impose overly strict sodium restriction (<5 g salt/day) as it increases mortality 2
• Never allow prolonged fasting periods—the late-evening snack is mandatory 1, 2
• Never place percutaneous gastrostomy in patients with ascites 1, 2
• Never use BCAA supplements as a substitute for adequate dietary protein intake 1, 4

Multidisciplinary Approach

Nutritional counseling by a multidisciplinary team (hepatologist, liver-specialized dietitian, nursing staff) improves long-term survival and quality of life 1, 2, 4. The team should assess food quantity, quality, fluid and sodium intake, meal timing, and barriers to eating, with regular reassessment to adjust goals 2.