Diet and Hepatitis C
     Written for NATAP by Jocelyn Rodriguez

Jocelyn Rodriguez, MPH, RD, CDN is a nutritionist specializing in HIV/HCV. She received her graduate training at University of California at Berkeley and is an alumnus of Hunter College, CUNY. Presently she works with the substance abuse population, where the rate of Hepatitis C infection is high.

The HIV epidemic redefined interdisciplinary medical care toward infectious chronic diseases. As infectious diseases became manageable via medication, education and lifestyle changes, nutritional intervention played a greater role in helping to achieve good quality of life. Hepatitis C embodies this new paradigm (approach to treatment of diseases) and nutritional advice on eating habits and supplements has proliferated since Hepatitis C was identified in the early 1990’s from the former Non A, Non B Hepatitis. Dietary interventions have been used since the first days of treating cirrhosis, but seldom have doctors and dietitians advised dietary changes as prevention of or delay to the progression of the liver toward a cirrhotic state. The Europeans are ahead of the United States in focusing on liver health, ie. milk thistle for liver function assistance and amino acid formulas for liver regeneration, however results remain inconclusive. Nonetheless, we may yet benefit from their treatment suggestions in the management of Hepatitis C.

(Editorial Note: recently reported research data suggested that Milk Thistle might cause a drug interaction with HIV medications, thus affecting the blood levels of HIV medications. At the IAS Conference in Buenos Aires (July 6-11, 2001), Steve Piscitelli (Pharmacologist) reported on new recently completed research from the NIH. Preliminary results of exploring indinavir (Crixivan) and Milk Thistle for 3 weeks did not show clinically significant interactions. This suggests that Milk Thistle should not have a drug interaction with HIV antiretroviral medications such as protease inhibitors and NNRTI) However, there is a question whether milk thistle is effective. There is a little preliminary research suggesting milk thistle may be helpful for the liver. However, the evidence is not strong. In taking herbal supplements for the liver, the question one needs to ask is –is the herb potentially harmful to me? Some herbs have been shown to be harmful to the liver. It appears as though milk thistle may not be harmful, but the data on interactions with HIV meds from Steve Piscitelli is preliminary and still being analyzed).

The question remains whether we should be proactive about early dietary changes for persons infected with Hepatitis C but who have not manifested symptoms of liver failure? While an ounce of prevention is worth a pound of cure, changing eating habits is very difficult to make and harder to adhere to. Recommending vitamin and herbal supplements can get expensive and may not significantly increase quality of life. This by no means implies that person with Hepatitis C should not pay attention to their dietary habits and nutritional requirements. Each individual will need to be evaluated by a dietitian with experience in liver disease to determine his or her own requirements. The reason for this is because people do not select their diets based on physical and/or medical requirements alone, but also from their cultural upbringing, access to food/meals, and certain habits set by choice and convenience.

A nutritional foundation of dietary practices should be the guide for persons with Hepatitis C, especially at times when there are no gastrointestinal symptoms and liver function tests are normal or mildly elevated with no other clinical abnormalities:

1. Get half of your daily calories in carbohydrates. Whole grain starches, vegetables and fruits should be the mainstay of carbohydrates. Sugar and sugary foods, like donuts and candy bars, should be minimized.
2. Keep protein intake up. Have some protein at every meal. Portion matters more than kind of protein. Make sure to include beans and tofu products, nuts, and dairy products.
3. Moderate fat consumption. Cutting back sugary foods tend to reduce fat intake. Nuts and tofu, which are protein sources, have a healthy amount of unsaturated fat. Use vegetable oil and butter sparingly. The goal in reducing fat intake is mainly for weight purposes.
4. Maintain or achieve desirable body weight. Those who are obese, more than twenty pounds over their ideal weight for height, should lose weight. Those who are mildly overweight should watch out for insidious weight gain.

There is controversy regarding eating red meat for the HCV-infected person. There is preliminary and limited research suggesting that iron accumulation in the liver may accelerate HCV progression, and eating red meat or eating excessive amounts of red meat may contribute to iron accumulation in the liver. However, it has not been established by research that eating red meat actually has clinical effect of accelerating HCV. If a person has decompensated liver disease certain diet restriction is considered. Many leading hepatitis doctors do not feel restricting intake of red meat is recommended for HCV-infected patients with chronic infection. It is important to bear in mind that in a person coinfected with HIV and HCV, anemia may be a concern and adequate intake of red meat may be important.

Marion Peters, MD, Hepatologist and GI specialist at UCSF says: if a patient has encepholopathy, which can occur as part of decompensated cirrhosis, they should limit their protein intake, but not necessarily eliminate red meat. Iron accumulation can be a problem only if you eat excessive amounts of red meat. Otherwise, eating red meat is fine and in fact could be part of your diet. Just don’t eat red meat three times per day. If you are taking HCV therapy (IFN, IFN/RBV) you should indulge yourself a little to increase caloric intake and particularly it’s ok to eat red meat. Dr Peters says the studies suggesting iron accumulation in the liver can be a problem is when iron intake is very high and excessive.

On the topic of iron storage in the liver and it’s potential harm, Ms Rodriguez says:

From a nutrition perspective, the following is known--

1. Iron is poorly absorbed through the GI tract. Heme-iron (ie. meats) have a better absorption rate but is not 100%. Non heme-iron (ie. Fortified flour, cereals, spinach, etc) is better absorbed with meats, yet still not at 100%. Therefore, at any given high iron meal a maximum of 40-50% of iron is absorbed. Iron supplementation helps increase the likelihood for absorption.
   
   
2. During inflammation (ie. Fever) iron storage in liver is increased. Diabetics and certain substance abusers may have conditional hemochromatosis. (a hereditary disorder of iron metabolism characterized by excessive accumulation of iron in tissues, diabetes, liver dysfunction, and a bronze skin pigmentation).
   
   
3. As for HCV, earlier studies suggested that increased liver iron levels elicit liver oxidative stress, with consequent steatosis (fatty liver) and glutathione depletion. (Iron storage, lipid peroxidation and gluthathione turnover in chronic anti-HCV positive hepatitis. J. Hepatol 1995 Apr;22(4):44-56 , Therapy of hepatitis C: other options. Hepatology 1997 Sep;26 (Suppl 1): 143S - 151S.) Therefore, in disagreement with Dr Peters Rodriguez feels that this information suggests high iron levels may be harmful to the liver.

However, Ms Rodriguez says the question of whether to restrict iron intake needs to be considered individually, taking into consideration person's dietary habits, bloodwork, meds, physical health, and medical history. It is safe to say, that for men with elevated iron levels (serum ferritin especially), taking a multivitamin without iron is recommended.