First nutrition guideline for patients with liver disease spotlights a common diet myth
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Cirrhosis is a catabolic state, so patients are losing their muscle mass, and if they cut protein, they are further exaggerating loss of bone mineral density, putting them at risk for fractures.
—Ashwani K. Singal, MD, MS
The American College of Gastroenterology has issued its first stand-alone guideline on nutrition in patients with liver disease. []It's a long-overdue move, according to lead author Ashwani K. Singal, MD, MS, a transplant hepatologist at the University of Louisville. []
In a conversation with Gastroenterology & Endoscopy News, Dr. Singal laid out how clinicians should approach nutrition for patients with liver disease. []
The message is clear: Stop restricting protein.
Breaking the protein myth
For decades, patients with cirrhosis have been told to cut back on protein to avoid worsening encephalopathy. The new guideline directly confronts this misconception. []
"Cirrhosis is a catabolic state, so patients are losing their muscle mass, and if they cut protein, they are further exaggerating loss of bone mineral density, putting them at risk for fractures," Dr. Singal said. "In addition, muscle plays a big role in the elimination of ammonia. There’s a connection between nutritional state, muscle loss, and hepatic encephalopathy, as well as falls and fractures. This cycle can be broken by improving the patient’s nutritional status, by improving how they eat, how much they eat, and their protein intake." []
The guideline encourages adequate protein intake, with an eye on maintaining muscle mass and breaking the frailty-encephalopathy cycle.
Related: 5 signs you aren't getting enough proteinThe nutrition-linked symptom we underestimate
Fatigue may be one of the most common nutritional symptoms in liver disease, even in patients without cirrhosis. [] Those with metabolic dysfunction–associated steatohepatitis (MASH) and primary biliary cholangitis are especially affected.
For stable outpatients, consider these recommendations:
Frequent smaller meals instead of two to three large ones
A nighttime snack between 7–10 pm to prevent overnight catabolism
Mediterranean-style eating patterns, focusing on easily metabolizable foods
More plant-based proteins, such as soy, lentils, beans, peas, chickpeas, and nuts
White meats over red meats
Avoidance of refined sugars and high-fructose foods
The guideline also notes a benefit to at least two cups of coffee daily.
Related: Stop drinking coffee wrong: Here’s the healthiest time for caffeineRethinking sodium
The classic 2-gram sodium restriction for ascites? Turns out, there's no solid evidence for or against it. []
Overly strict sodium limits often make food unpalatable and inadvertently worsen already precarious nutritional intake. The guideline acknowledges a lack of data and encourages clinicians to individualize rather than reflexively enforce a 2-gram cap.
Obesity doesn’t rule out malnutrition
Another important update: Sarcopenic obesity is real—and common. Excess adiposity can mask profound muscle loss. Muscle wasting—especially when unexplained—may even hint at “hidden" cirrhosis. []
"Clinicians should not think that obesity means there is no malnutrition or sarcopenia. They can go together," Dr. Singal said. [] A simple question like “Have you noticed muscle loss?” can prompt earlier evaluation.
Undernutrition matters
Every hospitalized patient with liver disease should undergo malnutrition assessment using subjective global assessment tools, supplemented by grip strength, walking tests, and psoas muscle evaluation on CT.
Caloric intake matters: Outcomes worsen when intake falls below 21.5 kcal/kg per day. For a patient who weighs 60 to 70 kg, that’s 1,200 to 1,400 kcal per day—levels many hospitalized patients never reach.
Correcting malnutrition isn’t ancillary care—it directly alters hepatic encephalopathy risk, frailty, fatigue, and inpatient outcomes. Consider these recommendations:
If patients eat 100% of their meal trays, add one nutritional drink daily.
If patients eat 20% to 25% of their meal trays, add three to four nutritional drinks per day.
If a patient is still not eating that much, consider a Dobhoff tube.
Nutrition should now be considered a vital sign in liver disease care. Don’t restrict protein, screen for sarcopenia—even in obese patients—and ask detailed questions about diet and intake at every visit.