Prevention and management of malnutrition are crucial to enhance clinical outcomes for patients with cirrhosis. It has been observed that 50% to 90% of individuals with cirrhosis have malnutrition. Various factors contributing to the challenge an individual face to meet calorie and protein requirements, include increased nutrient requirements, reduced intake, malabsorption, and alterations in protein and glucose metabolism. Thus, nutrition education, and early and aggressive nutrition interventions are required to prevent and inhibit the progression of malnutrition in patients with cirrhosis.

First nutrition priority for the patient with cirrhosis is to improve adequate overall intake irrespective of the macronutrient distribution. Overall adequate intake reduces the duration of the fasting state in the body and enhances muscle catabolism. Adequate calorie intake is 35-40 kcal/kg body weight or 1.2-1.4 X Resting Energy Expenditure.

Second priority is protein intake. Guaranteeing the patient meets protein requirements is vital to conserve lean body mass. Protein requirements are recommended to be 1.0 to 1.5 g/kg dry body weight. Earlier theories supported protein restrictions in these patients with the intent of preventing encephalopathy, however it is not currently recommended.

Third nutrition priority for patients with cirrhosis includes the ideal composition and frequency of meal and snack intake. Adequate intake of carbohydrate in combination with protein helps in appropriate distribution of protein for muscle maintenance and rebuilding. Aiming for 6 to 8 eating events per day with mixed macronutrient meals and snacks throughout waking hours is needed to help the patient meet nutritional needs and decrease the time spent by the patients body in a fasting state.

Fourth priority is optimizing nutrition care as majority patients may benefit from a higher percentage of protein intake from plant‐based and dairy‐sourced protein. This type of protein is rich in branched‐chain amino acids (BCAAs) which gets imbalanced in these patients due to the changes in amino acid metabolism and insulin resistance. Increased intake of BCAA intake in turn, can ameliorate appetite, increase muscle synthesis, and improve quality of life.

Source: Moss O. Nutrition Priorities: Diet Recommendations in Liver Cirrhosis. Clin Liver Dis (Hoboken). 2019;14(4):146-148. Published 2019 Nov 6.