How I Approach It: Improving Nutritional Status in Patients With Cirrhosis

When addressing the topic of nutrition in patients with cirrhosis, we adhere to one single rule: keep it simple. As it is, patients with cirrhosis are burdened with a high degree of physical and psychological symptoms [1], medication complexity [2], and disability [3], all of which make it challenging to meet nutritional targets. While published nutritional recommendations have traditionally focused on individual nutrients at specific doses, we find that such detail can miss the forest through the trees and overwhelm the patient and their caregivers, making it nearly impossible to follow through with these recommendations.

Here we offer our approach to improving nutritional status in patients with cirrhosis, based on the well-established Information-Motivation–Behavioral Skills (IMB) model for health behavioral change (Fig. 1) [4]. The IMB framework postulates that, individuals who are knowledgeable about the harms of malnutrition, motivated to focus on their nutritional status, and empowered with specific behavioral skills will take action to enhance their nutritional intake thereby improving their nutritional status. In our own clinical practice, we try to engage both the patient and their caregiver(s) in this process.

Fig. 1.

Framework for approaching nutritional counseling in patients with cirrhosis, based on the Information-Motivation-Behavioral Skills model for behavioral change [4]

INFORMATION: MALNUTRITION IS A RAPID, INSIDIOUS PROCESS IN PATIENTS WITH CIRRHOSIS

It goes without saying that a patient with cirrhosis is, if not already malnourished, at high risk for malnourishment. “I don’t feel like eating anymore” or “I’ve lost all the muscle in my arms” are ways in which they commonly express their symptoms of undernutrition—and represent an opportune moment to provide information on the dire consequences of malnutrition. Here are key “nuggets” of information that, in our experience, resonate with our patients and their caregivers:

• Even if consuming the same number of calories as a healthy person, an individual with cirrhosis displays ~33% higher rate of energy expenditure, largely in the form fatty acids (from muscle and fat breakdown) [5].

• A 12-h period of not eating—such as between dinner and breakfast—for a person with cirrhosis is equivalent to starving a healthy person for 3 days [6].

• Malnutrition leads to frailty, which impairs one’s ability to function independently. Individuals with cirrhosis, with a median age of 57 years, display rates of frailty that are equivalent to individuals in the community who are >85 years old [3, 7]. In other words, cirrhosis adds nearly 30 years to one’s physiologic age.

MOTIVATION: IDENTIFYING PERSONAL AND SOCIAL FACTORS THAT DRIVE INDIVIDUAL CHANGE

Encouraging patients to effectively change their behavior surrounding nutritional intake requires exploration of the personal and social factors that motivate the patient as an individual. It is this component of the IMB model that is critical to helping patients engage in the process of developing a nutritional action plan that works within their environment. This also helps to establish a collaborative approach with our patients (e.g., “What were the barriers to eating a reduced salt intake today?”) rather than confrontational or condescending (e.g., “You shouldn’t have eaten that much salt for lunch”). Specific underlying motivations that can be explored, as well as sample questions to start the conversation, are provided in the Table 1.

Table 1.

Examples of attitudes that impact motivation to engage in behavioral change surrounding improving one’s nutritional status and sample questions to explore those attitudes

Attitudes regarding:	Sample questions to explore a patient’s attitudes
Consumption of high amounts of protein and protein from a wider range of sources	“What have you heard about how much protein you should eat?” “How do you feel about eating red meat?” “How do you feel about eating vegetarian sources of protein such as dairy products, beans, and tofu?”
Consequences of improving (or not improving) one’s nutritional status	“Do you think that improving your nutritional status will directly benefit you?” “Do you believe that what you eat impacts your quality of life, survival, hospitalizations?”
Financial cost of following recommended dietary intake for a person with cirrhosis	“Does the cost of food impact your food choices?” “Do you feel that your environment or your circumstances limit your access to certain foods?”
Burden or benefit to caregivers in adhering to a specific diet and/or improving nutritional status	“How do you feel that your nutritional status or food choices impact your caregiver?”

Assessing attitudes towards these specific areas not only helps us identify factors that can motivate our patients but also facilitates a motivational interviewing approach which can improve the efficacy of lifestyle recommendations [8].

BEHAVIORAL SKILLS: EMPOWERING PATIENTS WITH PRACTICAL, FEASIBLE NUTRITION-FOCUSED RECOMMENDATIONS

These three key, evidence-based behavioral skills are our favorites because our patients tell us that these recommendations are simple and can be implemented immediately into their daily routine.

• Target caloric intake. We follow existing guidelines to provide specific caloric targets, stratified by the patient’s body mass index (dry weight) [9]. Practical tips that may help to improve overall intake are:

  1. Avoid drinks around meal time as they reduce appetite and provide little nutrition.
  2. If necessary, supplement or substitute some meals with liquid foods such as cream soups, protein smoothies, or high protein meal replacement drinks as patients may find them easier to digest than solid foods.
  3. Set an alarm to eat every 3–4 h during the day (to avoid fasting).

• Adequate protein intake. The recommended daily protein intake target is 1.2–1.5 grams/kg protein [10], which we translate into a “rounded number” of total grams of protein for the patient and their caregiver. For example, if the patient is 80 kg, we set the daily target at ~100 g of protein. We have found that this is far more protein than most of our patients can eat naturally in a day. Therefore, we recommend that they obtain protein from multiple sources to reduce “food boredom”. These sources may include: meal supplements, protein powder, meat, dairy, and vegetable proteins (e.g., beans, tofu). The following food items contain ~20–25 g of protein: 3 ounces of chicken or fish (size of the hand’s palm), 1 cup of Greek yogurt, and 1 scoop of whey protein powder.

• Avoid the nighttime “fast”. A late evening snack—taken shortly before bedtime—or eating during nighttime hours can significantly increase muscle mass [11, 12]. The ideal snack consists of at least 50 g of complex carbohydrates such as 2 slices of toast with peanut butter and 1 glass of milk. We also recommend that patients put a snack at the bedside to eat if/when they wake up at night, such as a handful of unsalted walnuts or a protein snack bar.

IMPLEMENTING THIS FRAMEWORK IN CLINICAL PRACTICE

Given that cirrhosis is characterized by hepatic synthetic dysfunction and sarcopenia, all patients should receive some form of nutrition education [13]. The earlier in the stage of cirrhosis (e.g., Child Pugh) that patients implement nutritional interventions, such as nocturnal feeding, the more likely they are to preserve, if not improve, their total body protein [12]. The demands of a busy clinical practice necessitate tailoring the time spent on—and intensity of—nutrition education to the patient’s current degree of under-nutrition and risk for progression. The Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT) is a cirrhosis-specific nutrition screening tool that considers the following variables: (1) alcoholic hepatitis, (2) fluid overload, (3) recent change in dietary intake, (4) body mass index, and (5) unplanned weight loss—5 factors that we routinely consider for the management of patients with cirrhosis [9]. For circumstances in which assessment using the RFH-NPT is not possible, we commonly use the Clinical Frailty Scale (CSF), a rapid frailty screening tool [14]. While frailty is not synonymous with malnutrition, nutritional status is a key component of the frail phenotype, and this 7-point provider-assessed scale enables us to capture (and document) our clinical intuition about a patient’s nutritional and global health status—within seconds—onto a standardized scale that is predictive of unplanned hospitalization and death in this population [15]. For patients who screen “vulnerable” or worse (CFS score ≥ 4) [15], we refer them to a dietician for a more comprehensive nutritional assessment and development of a detailed nutrition action plan [13].

CONCLUSION

Dedicated education around nutrition empowers patients and their caregivers to take control of their health. We have seen first-hand how the time invested in providing nutritional recommendations through the IMB framework during the clinic visit (Fig. 1) yields a high return on investment in the form of patient engagement, patient satisfaction, and marked improvements in overall quality of life—outcomes that are truly patient-centered but not frequently objectively measured in the literature.