Table 10.
Summary of protein, energy, and dietary pattern recommendations for adults with cirrhosis as indicated by medical associations’ Practice Guidance/Guidelines. In addition, individuals with cirrhosis must abstain from alcohol
| Society/Association | EASL 2019 [463] | ESPEN 2019 [461] and Joint ESPEN/UEG guideline 2023 [470] | AASLD 2021 [460] | |||
|---|---|---|---|---|---|---|
| BMI Status† |
Mixed BMIs | Obese (BMI >30 kg/m2) | Mixed BMIs | Obese (BMI >30 kg/m2) | Non-obese | Obese (non-hospitalised, clinically stable) |
| Daily energy | 35 kcal/kg actual BW (in nonobese individuals) | >5–10% WR, moderately hypocaloric diet (-500–800 kcal/d) | 30-35 kcal/kg only for DC. Regular energy requirements in CC |
WR. No need for increased energy intake |
≥35 kcal/kg body weight/day | 25-35 kcal/kg/day for individuals with BMI 30-40 kg/m2, and 20-25 kcal/kg/day for individuals with BMI ≥40 kg/m2. WR if medically required, under the supervision of a multidisciplinary team. Caution applied to prescribing weight loss in decompensated cirrhosis. |
| Daily protein | 1.2–1.5 g/kg actual BW | >1.5 g/kg IBW | 1.2 g/kg (for non-malnourished individuals with CC) to 1.5 g/kg (for malnourished and/or sarcopenic cirrhosis) | Individuals with overweight or obesity and compensated cirrhosis: 1.2 g/kg ABW/d. Individuals with overweight or obesity and compensated cirrhosis undergoing weight-loss programs: 1.2-1.5 g/kg ABW/d. Individuals with overweight or obesity and compensated cirrhosis and malnutrition or sarcopenia: 1.5 g/kg ABW/d. | 1.2-1.5 g/kg IBW For individuals with cirrhosis who are critically ill, a target of 1.2-2.0 g/kg IBW |
Intake of target protein (1.2-1.5 g/kg/day) and physical activity are required to reduce the loss of muscle contractile function and muscle mass that can occur with weight loss. |
| Meal patterns | Split food intake into 3 main meals and 3 snacks | Three to five meals a day and a late evening snack | Maximum interval of 3-4 hours between nutritional intake while awake. To minimise nocturnal fasting time, an early breakfast and/or late-evening snack recommended |
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| Dietary protein source in case of HE | Individuals may tolerate animal protein (meat) less well than vegetable protein (beans, peas, etc.) and dairy proteins | In individuals who are protein “intolerant”, vegetable proteins should be used | A diverse range of protein sources, including vegetable and dairy products, should be encouraged. | |||
ABW, adjusted body weight; BMI, body mass index; CC, compensated cirrhosis; DC, decompensated cirrhosis; HE, hepatic encephalopathy; IBW, ideal body weight; WR, weight reduction.
ABW = reference body weight (in which BMI = 25) + 0.33*(actual body weight - reference body weight).
†In a case of fluid retention, body weight should be corrected by evaluating the individual’s dry weight.