Ramadan fasting and liver diseases

2. By
Dr . Ashraf Omar
Prof of internal medicine
Mansoura Faculty of medicine

3. 1. Energy sources

4. Malnutrition in chronic liver diseases
1. Inadequate dietary intake.
2. Impairment of digestion / absorption of nutrients.
3. Metabolic alterations.
4. Modifications in the energetic metabolism.
The relationship of the nutrional status to prognosis
and mortality is accepted as an independent risk factor
for prediction of outcome in patients with chronic liver
disease.

5. Malnutrition in liver cirrhosis

6. 0
10
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30
40
50
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Child A Child B Child C
Child A
Child B
Child C

7. Etiology and pathophysiology
• Several metabolic changes occur in CLD.
• Decreased levels of hepatic and muscle glycogen are also
common, leading to reduced availability of glucose as energy
substrate, which results in increased consumption of fats and
proteins.
• Up to 70% of cirrhotic patients have some degree of glucose
intolerance or insulin resistance , and between 14 and 40%
have type II Diabetes mellitus.
Bémeur C, Butterworth RF. Nutrition in the management of cirrhosis and its neurological
complications. J Clin Exp Hepatol.2014.

8.  Patients with advanced liver disease should be
recommended for a diet providing adequate calories,
proteins, minerals and vitamins.
 Dietary supplementation is much essential in CLD,
which can decrease malnutrition, infections and sepsis.
GENERAL GUIDELINES FOR NUTRITION IN
LIVER DISEASE

9. • Most people with cirrhosis need to take in more energy 35-45
kcal/kg/day and protein than healthy people of the same
weight.
• Excess calories should be avoided, particularly as
carbohydrates, as this promotes hepatic lipogenesis, liver
dysfunction, and increase CO2production and the work of
breathing.
Gunsar F, et al. Nutritional status and prognosis in cirrhotic patients. Aliment Pharmacol
Ther. 2006.

10. • Carbohydrates should be sufficient to maintain normal blood
glucose levels, and should not exceed insulin reserves. They
should supply 60-70% of non nitrogen calories.
• Snacking between meals can top up the patient calories and
protein, a bedtime snack is especially effective.
• Patients often do better on multiple small meals with a late
bed-time meal, which has been shown to reduce the need
for gluconeogenesis and conserve proteins and nitrogen
balance after an overnight fast, and prevent protein
breakdown.
Sam J, Nguyen GC. Liver Int. 2009.

11.  VITAMINS.
 MINERALS.
 PROTEIN.
 AMINO ACID SUPPLEMENTS.
 CARBOHYDRATES.
 FAT.
 CHOLESTEROL AND THE LIVER.
 FOODS AND SUPPLEMENTS TO AVOID ABDMINAL GAS.
 CAFFEINE AND THE LIVER.
 GLUTEN AND THE LIVER.
GENERAL GUIDELINES FOR NUTRITION IN
LIVER DISEASE

12.  Avoid vitamin A unless documented to be deficient.
 Vitamin E: 400-1200 iu per day.
 Can help cell-mediated immune function, releive
skin problems, enhances memory.
 Vitamin C: Improves the immune function.
Vitamins

13. Calcium (Ca)
 Patients with chronic liver disease are at increased
risk for the development of osteoporosis, so it is
important to advice foods rich in calcium and/or to
supplement the patient diets with calcium and
vitamin D.

14.  Na: Not exceed 2g (88mmol/d).
 Tense ascites: 40mmol/d.
 Na intake should be restricted before fluid.
Ways leading to Na depletion:
-Vasopression analogues.
-Large volume paracentesis without volume expansion.
-Diuretic therapy.
Na restriction

15.  No need to restrict water at the beginning.
 Restrict fluid only in patients with hyponatremia.
Water

16. -Indications of Albumin in liver diseases:
1-Interactable ascites.
2-Hepatorenal syndrome.
3-Spontaneous bacterial peritonitis.
Albumin

17. Iron (Fe)
 Only 15% of ingested animal iron, and only 3% of
ingested plant iron, is absorped by the body.
 Only 1-2 mg of iron is excreted daily. Therefore, if
excess iron is ingested (whether in food or
supplements), iron is accumulated in body tissues.
 In extreme excess, iron is toxic to the liver, and can
lead to cirrhosis, liver failure and liver cancer.

18. Dietary Recommendations for Protein
 Approximately 0.8 grams of protein per kilogram is
recommended in the diet each day for patients with
stable liver disease.
 As such, total protein intake would range between 40-
100 gm/day; equaling 20-30% of daily calories .
 People with decompensated cirrhosis should reduce
intake of animal protein and eat mostly vegetable
sources of protein.

19.  Health benefits of Vegetable Protein:
1. Favourable intestinal intraluminal pH.
2. Decrease intestinal ammonia synthesis.
3. Proper gastrointestinal transit time.
 Suggest about 30-40g/d.
Hepatic Encephalopathy

20. Branched – chain amino acid suplementation
-Conserve or restore muscle mass in patients with liver
disease.
-Transport across the blood – brain barrier, improve
hepatic encephalopathy.
-Stimulation of hepatocyte growth factor favoring liver
regeneration, improve prognosis in patients with HCC.

21. Dietary Recommendations for Carbohydrates
 Patients with liver disease should strive for a diet
consisting of approximately 60-70% carbohydrates. For
such patients, a well-balanced diet will include at least
400 grams of carbohydrates daily.
 Excessive complex carbohydrates, may lead to bloating
and to malabsorption of certain vitamins and minerals.

22. Dietary Recommendations for Fat
 The essential fatty acids, perform a variety of
functions that are essential to the body. However, it
should be pointed out that as little as a tablespoon of
polyunsaturated fat a day can provide all of the
required essential fatty acids.
 people need some fat in order to properly absorb the
fat-soluble vitamins (A, D, E, and K). This type of
vitamin deficiency usually occurs in patients with
cholestatic diseases.

23. Liver Transplantation-Diet
 Nutrition support: pre- and posttransplantation.
 Long-term preventive nutrition to optimize health and
to avoid or minimize:
—Excessive weight gain.
—Hyperlipidemia.
—Hyperglycemia.
—Hypertension.
—Osteopenia.

24.  Carbohydrate Metabolism :
 Increase glycolysis .
 Increase gluconeogensis .
 Fat Metabolism :
 Increase F.A Oxidation.
 Increase keton bodies synthesis .

26. 1. Fasting Promotes detoxification
 Processed foods contain lots of additives that may
become toxins in the body. Some of them promote
production of advanced glycation end products.
Most of these toxins are stored in fats. Fat is burnt
during fasting, especially when it is prolonged.
And the toxins are released. The liver, kidneys and
other organs in the body are involved in
detoxification.

28. 3. Fasting Resolves Inflammatory Response
 Fasting promotes resolution of inflammatory
diseases and allergies. Such inflammatory diseases
are rheumatoid arthritis, and skin diseases such as
psoriasis. Some experts assert that fasting may
promote healing of inflammatory bowel diseases
(ulcerative colitis).

29. 4. Fasting Reduces Blood Sugar
 Fasting reduces production of insulin. This rests the
pancreas. Glucagon is produced to facilitate the
breakdown of glucose. The outcome of fasting is a
reduction in blood sugar.

30. 5. Fasting Increases Fat breakdown
 The first response of the body to fasting is break
down of glucose. When the store of glucose is
exhausted, ketosis begins. This is break down of fats
to release energy.

31. 6. Fasting Corrects high blood Pressure
 Fasting helps to reduce the risk of atherosclerosis.
Metabolic rate is reduced during fasting. The fear-
flight hormones such as adrenaline and
noradrenaline are reduced.

32. 7. Fasting Promotes Weight loss
 Fasting reduces the store of fats in the body.
However fasting is not a good weight loss strategy.
Reducing fat and sugar intake, and increasing fruits
and minimizing rest are better measures to achieve
weight reduction.

33. 8. Fasting Promotes Healthy diet
 It has been observed that fasting reduces craving for
processed foods. It promotes desire for natural
foods, especially water and fruits. This is one way
fasting promote healthy lifestyle.

34. 9. Fasting Boosts Immunity
 Elimination of toxins and reduction in fat store.
When individuals take fruits to break a fast, they
increase the body's store of essential vitamins and
minerals. Vitamins A and E are good antioxidants
that help to boost immunity.

35. 10. Fasting May Help to Overcome Addictions
 Fasting can help addicts reduce their cravings, for
nicotine, alcohol, caffeine and other substance
abuse. In addition to the other regimens required to
resolve addictions, fasting can play a role.

36. Despite these benefits, fasting has some demerits
 It may cause dehydration leading to headaches and
even trigger migraines in predisposed persons. It
may worsen heartburn and peptic ulcer. Pregnant
women, nursing mothers, malnourished people, and
individuals with cardiac arrhythmias, renal or liver
problems are advised not to fast.

37. Worsend malnutrition
• The presence of PCM is associated with an increased number
of complications such as:
 Esophageal varices,
 Hepatic encephalopathy (HE),
 Hepatorenal syndrome,
 Impaired liver function.
Rivera-Irigo in R, Abilés J. Nutritional support in patients with liver cirrhosis. Gastroenterol
Hepatol. 2012.

40.  Try to eat regularly, say every two to three hours. Suitable
snacks include:
• teacake
• toast
• crackers
• cereal
• fruit
• milky drinks
teacake
crackers
toast
cereal
fruit
Sechi G, Serra A. Lancet Neurol. 2007.

41.  Fatty liver disease is increasing as aresult of
obesity and diabetes .decrease of food intake
can improve the metabolic disturbance in
liver … how ???
 Herizg etal 2014 found in his study that a
molecular proteins named GAAD 45B are
genitically expressed in response to fasting
and this protein helps in repair of any
damage of genetic information and cell cycle
of hepatocytes

42.  In this study the effects of fasting on patients with liver
diseases have been evaluated and they found that
dyspeptic symptoms and bleeding are higher in fasting
than non fasting group however bleeding of oesophgeal
varices was more in non fasting than fasting group
.patients with chronic hepatitis showed no changes
regarding liver functions

43.  The questions which is asked frequently is fasting harmful or
beneficial ?
 In facts there is no one answer to that question as it varies from
one patient to anther according to severity of the Diseases .
 Who can fast and who can not
 patients can fast unless the patients in late stags or presence of
complication or frequently administered medication .