What diet should I recommend my patient with Hepatic Encephalopathy?

Abstract

Purpose of Review

The burden of malnutrition is high in patients with cirrhosis, especially in those with hepatic encephalopathy (HE). This has a bearing on increased morbidity and mortality. Heightened attention needs to be paid to screen the patients at high nutritional risk both in the outpatient and hospitalized settings. This review summarizes the current evidence for nutritional support in HE patients and compares the recommendations about nutritional requirement as laid out by various organizations.

Recent Findings

On survey of the literature, there is a consensus on avoiding protein restriction of the diets in HE patients along with uniform recommendations on caloric requirements. An exciting field of manipulating the gut microbiome in nutritional sciences may hold promise as well as there may be a future role for branched chain amino acids in nutritional management of HE patients.

Summary

Even though the data suggest that nutritional improvement lead to better outcomes including lower readmission rates in cirrhosis, operationalizing these into practice remains a challenge. To achieve this, a multi-disciplinary approach with nutritional education of the frontline care providers, earlier nutritional risk screening of patients, involvement of the nutrition professionals as part of the team and repeated dietary counseling for the patient and caregiver/s is required. Ultimately, this may need more focus, resource allocation and uniform guidelines across all countries to make this a success.

Introduction

Even as evidence supporting the beneficial effects of optimizing the nutritional status of liver cirrhosis patients exists, it remains as one of the poorly understood areas in the overall management of cirrhosis(1). Hepatic Encephalopathy (HE) is a serious complication of cirrhosis exacting a huge toll on the utilization of healthcare resources (2, 3). Malnutrition is an under recognized problem in patients with HE and the presence of severe malnutrition can in turn worsen the symptoms of HE. The prevalence of malnutrition increases as per the severity of the liver disease as assessed by Child-Turcotte-Pugh (CTP) class; with 46% in CTP class A and as high as 95% in class C(4). The high prevalence of sarcopenia in 65%−90% of cirrhosis patients, resulting from multiple reasons has been reported(5, 6), which highlights the magnitude of this problem. Both sarcopenia and replacement of muscle with fat called as “myosteatosis” lead to changes in muscle strength and are not only prognosticators for survival but are associated with higher complications of cirrhosis like HE(7, 8). It is known that skeletal muscle has a role in clearing ammonia via muscle-bound glutamine synthetase. Hence, sarcopenia may further exacerbate the manifestations of HE(9, 10). A recent prospective study (n=64), demonstrated that myosteatosis and sarcopenia as determined by CT scanning of skeletal muscle at the L3 level in malnourished cirrhosis patients are independently associated with minimal hepatic encephalopathy (MHE) and further progression to overt hepatic encephalopathy (OHE) (11). Hence, it is imperative to address nutritional needs of patients with cirrhosis and HE with a view to improve their malnourished status. It is unclear, however, which diet we should we recommend to our patients with HE. Let us examine some of the available evidence and guidelines to answer these questions.

Nutritional requirements in cirrhosis and HE

Guidelines

Various organizations across US and Europe have laid out evidence-based guidelines to help the providers in achieving the nutritional goals in patients with cirrhosis and HE. These bodies include the International Society for Hepatic Encephalopathy (ISHEN)(12), the American Association for the Study of Liver Diseases (AASLD)(13), European Association for the Study of the Liver (EASL)(1) and European Society for Clinical Nutrition and Metabolism (ESPEN)(14). ISHEN and AASLD uses the ideal body weights for calculation of energy and protein requirements with EASL using the weight corrected to ascites for doing the same with ESPEN not giving any direction on which weight to use. These recommendations are summarized in Table 1. Energy recommendations range from 30–45 kcal/kg/day and protein recommendations are uniformly 1.2–1.5g/kg/day. Hence, there is a consensus on avoidance of protein restricting diets in all of these guidelines.

Table 1.

Comparison of the Macronutrient and Micronutrient Recommendations from various organizations

Organization	Calorie Recommendation	Protein Recommendation	Micronutrient Recommendations	Remarks
ISHEN(12)	35–45 kcal/kg/day	1.2–1.5g/kg/day	MVI supplementation in decompensated cirrhosis, replete electrolytes like magnesium and sodium, IV Thiamine for WE	Uses Ideal body weight MVI’s are safe and cheap to use Sodium correction should be done slowly
AASLD(13)	35–40 kcal/kg/day	1.2–1.5g/kg/day	Use MVI’s, replete deficient micronutrients, Zinc supplementation for HE & Thiamine for WE	Uses Ideal body weight High dose IV Thiamine for WE
EASL(1)	35 kcal/kg/day	1.2–1.5g/kg/day	Assess for vitamin D deficiency and if found treat accordingly	Uses actual body weight corrected to ascites Treat confirmed or suspected vitamin/micronutrient deficiency as per standard practice
ESPEN(14)	30–35 kcal/kg/day	1.2–1.5g/kg/day	Administer micronutrients for confirmed/suspected deficiency Vitamin A & Zinc supplements improve dysgeusia and can improve dietary intake.	Does not specify whether to use actual or ideal body weight Cautions to watch for refeeding syndrome

Abbreviations: International Society for Hepatic Encephalopathy, ISHEN; American Association for the Study of Liver Diseases, AASLD; European Association for the Study of the Liver, EASL; European Society for Clinical Nutrition and Metabolism, ESPEN; Multivitamins, MVI; Wernicke’s Encephalopathy; WE, Hepatic Encephalopathy; HE, Intravenous, IV

Avoiding protein restriction

Although old literature supported the use of protein-restricted diets in patients with HE(15–17), we review how this has been debunked (Table 2). Cardoba et al. (2004), in the first randomized controlled trail conducted on the hospitalized patients with overt hepatic encephalopathy (OHE), not only established the safety of normal protein diet in patients with HE but as well showed that protein restricted diet increased the protein catabolism(18). Gheorghe et al. (2005), conducted an open label study in the inpatient setting demonstrating that high calorie and high protein (casein-vegetable based) diet improved HE in patients and supported the idea that protein restriction was not needed(19). Maharishi et al. (2016) building on these data in a randomized study conducted in the outpatient setting on patients with minimal hepatic encephalopathy (MHE) showed that vegetable and casein-based protein diets as compared to no dietary therapy led to improvement in MHE, health related quality of life (HRQOL) and hospitalizations(20). Two earlier, smaller sample studies also support the idea that vegetable based protein diets have better effect on cognition in patients with HE; in these studies vegetable protein diet was compared to meat protein diet and patients with HE showed improvement in cognition on former diets(21, 22). Similarly, another older single blind crossover study (n=10) showed that as compared to meat proteins, vegan diet has a better effect on mental status as determined on psychometric testing in patients with HE(23). Hence, the source of the dietary protein should be richer in vegetable proteins like legumes such as beans, etc. and dairy proteins rather than meat-based proteins alone.

Table 2.

Summarizes some of the current evidence in support of dietary management in OHE and MHE

Study	Type of Study; Inpatient vs. Outpatient	Number of Patients	OHE or MHE	Intervention	Outcomes	Summary
Cordoba et al. (18)	RCT Inpatient	20 patients: 10 in low protein group, 10 in normal protein group	OHE	Participants in both groups were fed enterically via NG tube for 2 weeks. Low protein group received 0g protein for first 3 days the incrementally increased every 3 days until goal of 1.2g/kg/day reached with 2 days remaining. Normal protein group provided 1.2 g/kg/day on first day and through duration of study. Protein synthesis and breakdown studied at days 2 and 14 with glycine-N15 infusion method	No significant difference in HE between both groups. -Protein breakdown was increased in the low protein group.	No benefit in restricting protein in episodic HE, while provision of a low protein diet worsens protein catabolism. Normal protein diets are safe and can be provided to patients with cirrhosis and episodic HE.
Maharishi et al. (20)	RCT Unblinded Outpatient	120 patients with MHE randomized into 2 groups- 60 patients in each group.	MHE	Group A – Nutrition Therapy Group Monthly nutrition education 30–35 kcal/kg/d 1.0–1.5g/kg/IBW vegetable protein – including casein-based dairy products. Group B – No intervention, continued on their diet	Baseline PHES, SIP – No significant difference in above scores. - At 6 months; 71.1% of patients in nutritional therapy group had reversal of MHE vs. 22.8% 10% of patients in nutritional therapy group developed overt HE vs. 21.7% in control group.	In patients with MHE nutrition intervention leads to improvement in HRQOL, MHE, and reduces hospitalizations
Gheorghe et al. (19)	Open Label Inpatient	153 patients	Overt HE	High-calorie High-protein (HCHP) diet 30 kcal/kg/day and 1.2g protein/kg/day. Serial assessments included: mental status, asterixis, Number Connection Test (NCT), bowel movements, and blood ammonia level. Favorable results were defined by improvement in HE stage after 14 days of diet.	There was a 79.7 % improvement in HE with HCHP diet. All patients were noted to have a significant decrease in blood ammonia levels.	A casein-vegetable based HCHP diet improved mental status in 79.7% of patients. Protein restriction is not necessary. A daily meal pattern of 4 meals/snacks with an evening meal can improves HE
Vaisman et al. (24)	Randomized Controlled Trial Outpatient	42 patients: Study group: 21 subjects with Child A cirrhosis and MHE. Control group: 21 age and sex matched healthy controls.	MHE	Both Child Class A subjects and controls were divided into 2 groups. The first group received a 500 kcal and 21g protein breakfast, the second group received no breakfast. Cognitive performance and serum ammonia levels were analyzed before and 2 hours after consumption of breakfast.	Patients with normal serum ammonia scored higher for attention than those with hyperammonemia. Groups responded differently to breakfast consumption in respect to attention and executive functions. Controls who fasted performed better, while patient’s scores improved with breakfast meal.	In patients with MHE, regular intake of breakfast improves attention and executive functions.
Kato et al. (40)	Prospective-Open Label Outpatient	19 Patients	MHE	19 Pts. provided with 30–35 Kcal with 1.0–1.5g protein/kg of Ideal body weight. Periodic nutritional consultations	11/19 patients became non-MHE at 4 weeks and 13/19 at 8 weeks. Significant improvement in mental summary scores at 8 weeks.	Periodic nutritional consultations improve MHE, QOL and albumin levels as compared to nonimproved MHE patients.
Plank et al. (26)	Randomized control trial. Outpatient	103 patients randomized into 2 groups. Daytime group (52 patients) Night-time group (42 patients)		Both groups received 710 kcal/day of supplemental nutrition during assigned hours. The daytime group (0900–1900 hours) Night-time group (2100–0700 hours) Total body protein (TBP) measured by neutron activation analysis at baseline, 3, 6 and 12 months.	TBP was similar for both groups. Compared to baseline, there were significant increases in TBP group, no significant increase in daytime group.	In patients with cirrhosis, providing a night-time feed resulted in about 2kg of lean tissue accretion over 12 months.
Les et al. (42)	Randomized, double blind, controlled multicenter study/Outpatient	116 patients with cirrhosis and a previous episode of HE.	MHE	All patients provided diet plan 35 kcal/kg & .7g protein/kg/day. Patients were divided into 2 groups, BCAA group was provided 30g BCAA supplement. The second group received maltodextrin (MDX). The study was 56 weeks long.	21 patients in BCAA group and 27 patients in MDX group completed full 56 weeks. Patients in BCAA group had increase in MAMC and improvement in 2 neurocognitive tests. There was no significant difference of remaining HE free between groups.	Supplementation with BCAA does not reduce risk for HE recurrence. But improvement in MHE and muscle mass was shown in those who had previous episode of HE.
Vidot et al. (50)	Randomized Blinded Placebo-Controlled Trail Outpatient	49 patients	OHE	Intention to treat Allocation: 4 Groups, a) placebo (Synbiotic Forte)+Placebo (BCCA) b)Synbiotic Forte+Placebo (BCCA) c)BCCA+Placebo (Synbiotic Forte) d)Synbiotic Forte + BCAA TMT and ICT were used to assess cognition	Significant Improvement in Psychometric testing in pts. on combined Synbiotics/BCCAs	Larger study is needed to confirm these results
Mousa et al. (35)	Double blind randomized controlled trial Outpatient	58 patients with MHE. 31 patients in Group A (Antioxidant and Lactulose group). 27 patients in group B (Lactulose only).	MHE	Patients in group A received 175mg zinc gluconate, 50,000 IU vitamin A, 500mg vitamin C, 100mg vitamin E 1x daily Plus Lactulose 30–60 mL daily for 3 months. Group B received 30–60 mL daily for 3 months.	There was a significant improvement of MHE in group A patients after 3 months. Group A also had significantly reduced arterial ammonia, alanine aminotransferase (ALT), aspartate aminotransferase (AST) and improved Child-Pugh score.	In patients with cirrhosis, supplementation with antioxidants and zinc can improve MHE.

Abbreviations: Overt Hepatic Encephalopathy, OHE; Minimal Hepatic Encephalopathy, MHE; Randomized Controlled Trail, RCT; Nasogastric, NG; Psychometry Hepatic Encephalopathy Score, PHES; Sickness Impact Profile, SIP; Health Related Quality of Life, HRQOL; Total Body Protein, TBP; Branched Chain Amino Acids, BCCA; Mid Arm Muscle Circumference, MAMC; Trail Making Test, TMT; Inhibitory Control Test, ICT.

Avoiding fasting

Prolonged periods of fasting are not well tolerated by patients with cirrhosis given their unique pathophysiological state with diminished hepatic glycogen reserves from underlying poor synthetic function. One interesting, randomized controlled trail (n=42) conducted on Child A MHE patients versus healthy controls in the outpatient setting showed that by eating breakfast can lead to improvement in cognition and executive functioning in MHE patients(24). An open label study done on hospitalized patients with OHE (n=153) showed that daily 4 meals/snacks with an evening meal improves HE(19). As mentioned above avoidance of fasting state, along with small frequent meals during the day time and a late night snack before bedtime has been shown to be beneficial in a recent systematic analysis as well and should be adhered to(25). This late snack should consist of complex carbohydrates such as whole-grain breads, starchy vegetables and protein. Plank et al. (2008, n=103) conducted a randomized controlled trial in the outpatient setting and the results corroborated with the view that providing nighttime feeds in cirrhosis patients is beneficial as those who received these feeds had an increase in total body protein as measured by neutron activation analysis(26). Hence, the current recommendations of multiple small meals and a late evening snack for HE patients.

Micronutrient supplementation

Micronutrient supplementation can be used empirically for suspected deficiency or after case-by-case testing. EASL and ESPEN specify that for the first 2-weeks of nutritional therapy it is acceptable to replace the micronutrients such as vitamins in patients with cirrhosis. Zinc is an essential trace element, important for immune system functioning with co-factor roles in facilitating anti-oxidant, apoptotic and anti-inflammatory effects(27, 28). In patients with liver cirrhosis, severe zinc deficiency may occur due to various reasons including increased protein binding, enhanced urinary losses and poor absorption from GI tract(29). Further on, HE patients exhibit higher prevalence of zinc deficiency(30). This zinc deficiency may lead to impaired nitrogen metabolism, at the level of liver by decreasing the activity of ornithine transcarbamylase and at the level of skeletal muscle by a similar reduction in the enzyme glutamine synthetase(31, 32). Although, earlier randomized controlled trails have not shown any beneficial association between zinc supplementation and HE(33, 34). However, one recent double-blinded randomized controlled trail by Mousa et al. (n=58, 2016) conducted in the outpatient setting on the MHE patient has shown promising results with zinc supplementation and other antioxidants such as vitamins A, C & E; oral zinc supplementation along with other anti-oxidant in different doses plus lactulose improved MHE significantly as compared to those on Lactulose alone(35). Patients with cirrhosis from any etiology, per se are prone to be deficient in water-soluble vitamins including thiamine as well as exhibit deficiencies in fat-soluble vitamins such as vitamin D(36, 37). Thiamine deficiency can lead to Wernicke’s encephalopathy (WE), which can confound the diagnosis of HE. Moreover, if there is suspicion of WE, parenteral thiamine supplementation prior to administration of glucose containing intravenous fluids should be provided(13). Hence, oral vitamin supplements, which are safe to administer may be considered in HE patients. Correcting of electrolyte abnormalities like low sodium and potassium levels that are risk factors for development of HE is of paramount importance(38, 39).

Route of delivery and nutrition consultation

Oral intake is the best method of providing. In patients with higher levels of HE where swallow function has been compromised, alternative routes like nasogastric tubes and parenteral nutrition may be used if there is concern that they cannot maintain adequate nutrition. Periodic nutrition consultation along with nutritional support leads to improvement in MHE and quality of life(40). All the guidelines support the idea that it is helpful to solicit support from nutritional teams for early nutritional risk assessment, anthropometric measurements and dietary recommendations. This perhaps reflects the desire to better the nutritional management in patients with cirrhosis that is our overarching goal.

Role of Branched Chain Amino Acids (BCAAs)

In patients with cirrhosis, aromatic amino acids (AAA) - phenylalanine, tyrosine, and methionine – are increased while BCAAs are reduced(41). This disruption in the ratio of these amino acids contributes ultimately to alteration in the neuronal excitability. BCAAs such as valine, leucine and isoleucine are metabolized by the skeletal muscles and not by liver itself. Les et al. (n=116, 2011) conducted a randomized double blinded trail in patients with MHE in the outpatient setting and showed that oral BCAA supplementation improved MHE and muscle mass in those who had a previous episode of OHE but does not reduce risk for further OHE recurrence(42). Naylor et al. (1989) conducted a meta-analysis on 9 randomized controlled trails, and suggested that there was no clear value of using IV BCCA in the resolution of overt episodes of HE(43). However, Gludd et al. (n=827, 2017) in an updated Cochrane review on 16 randomized controlled trails in patients with both OHE and MHE showed that BCAA had a beneficial effect on manifestations of HE but no such beneficial effect was observed for mortality, quality of life, or nutritional parameters with a note that more data was needed to address these last three measures(44). It is felt that long term BCAA supplementation is helpful in patient with HE by increasing the muscle mass along with improvement in the nutritional status and this may lead to better ammonia clearance(45). It is felt that there is need for more high-quality data before any firm recommendations regarding BCAAs can be made. Pharmaceutical grade-BCAAs are not available in the US currently but are available in several other countries such as Japan, India and parts of Europe.

Role of Prebiotics and Probiotics in nutrition- Modulation of Gut-Liver-Brain Axis

The modulation of the gut microbiome with the idea to seek management of various disease states including HE is an area or active research. Prebiotics are a substrate that is selectively used by microorganisms resulting in beneficial modulation of the micro-flora(46). While as Probiotics are live microorganisms which, when administered in the right amounts may help in keeping the host healthy(47). The combinations of both these agents are called synbiotics. Bajaj et al. studied the effect of the probiotic yogurt on MHE in a small group of patients (n=25) and found that those receiving the intervention of probiotic yogurt versus no yogurt had improvement in MHE on psychometric testing and did not progress to OHE (48). The same group studied the effect of probiotic Lactobacillus GG versus a placebo (14 vs. 16 patients) use on safety in MHE patients and reported that it was safe to use in these patients and resulted in favorable changes in the microbiota and inflammatory markers(49). Vidot et al. in a randomized controlled placebo trail (n=49, 2019) conducted in the out-patients setting in patients with OHE, found that combination of synbiotics and BCAAs significantly improved performance on psychometric testing(50). Agrawal et al. conducted a randomized controlled trail (n=235, 2012) in patients who had recovered from an episode of OHE and have shown that Lactulose and probiotics have similar efficacy for secondary prophylaxis in OHE as compared to a placebo(51). Holte et al. conducted a meta-analysis (n= 393 from 7 RCT’s, 2012) which focused on the utility of using probiotics and synbiotics in HE patients and reported significant improvement in HE with these agents as compared to placebo or lactulose (OR=1.40) but no effect was found on psychometric tests; they concluded that probiotics might offer effective treatment option in HE with the caveat that more randomized clinical trail data is needed to fully evaluate the conclusions(52). Further on, a recent Cochrane meta-analysis on the topic of probiotic usage in HE concluded that routine use couldn’t be recommended at this time for lack of high quality evidence to support this practice(53). As we see there are lot of unresolved questions currently about the dosage and duration of use, optimal strains to use, and how long does the beneficial effects last in HE but these seem to hold some promise. Probiotics are marketed as dietary supplements in the US; therefore, FDA does not regulate their composition and quality in US.

Clinical Screening Tools to assess malnutrition risk in cirrhosis

Now that we know that improving the nutritional status is important to improve various outcomes in cirrhosis and HE, how do we screen these patients for nutritional risk in different setting? As per the recommendations of ISHEN, one of the tools to ascertain those at nutritional risk is the Royal Free Hospital-Nutritional Prioritizing Tool (RFH-NPT)(12, 54). The advantages of RFH-NPT are that it does not require any specific training; it is quick to apply and helps to stratify cirrhosis patients using various factors into low (0 point), moderate (1 point) and high-risk (2–7 points) nutritional categories(55). First of all, it is ascertained if the patient is either being tube fed or has alcoholic hepatitis and if so a score of 6 each is added; secondly, evidence of volume overload (either ascites or peripheral edema) is sought which adds 1 point and this leads to asking history and examination directed at nutritional status such as BMI, questions about current acute illness and volume status affecting eating habits, questions about any unplanned weight loss in preceding 3–6 months, and other issues with each response having as score; in the end, all the scores are added to assign the final risk score, which directs the appropriate nutritional management(55). However, RFH-NPT has not been validated yet. Another nutritional assessment tool is, the liver disease undernutrition screening tool (LDUST), based on response to six simple historical questions; recent dietary intake, weight loss over last one year, loss of body fat, muscle loss, any history of ascites/peripheral edema and question about limitations in daily activities-helps to identify the patients into two categories - no undernutrition versus undernutrition categories(56). The LDUST has been validated against dietician assessments, takes minutes to administer, and can be used in both the in-patient and the outpatient settings(57). Registered dieticians can carry additional nutritional and anthropometric assessments. Hand-grip, measured at the bedside with a hand-held dynamometer, needs minimal training has a good sensitivity and specificity for providing information on depletion of body cell mass(58). A growing urgency is felt about the need of having uniform nutritional screening and assessment practices across the countries based on sound large-scale trails so that the results from this research could be rapidly implemented at the patient level(54).

Malnutrition in hospitalized patients

Common reasons leading to hospitalization in cirrhosis patients like infections and sepsis, volume overload, altered mental state from any reason including from HE, abdominal pain/distension, gastrointestinal bleeding, etc. are all associated with anorexia and increased catabolic state. It is know that malnutrition is a common problem in hospitalized patients with cirrhosis(59). Further on, despite the evidence of better outcomes in cirrhosis patients with nutritional support, adherence to guideline directed nutritional management is poor in the hospitalized patients(60). Recognition of the problem is the first and crucial step. The second step is to ascertain where we stand with the implementation of goal directed nutritional therapies for these cirrhosis patents. We conducted a pre-post study of an educational intervention for the providers caring for hospitalized cirrhosis patients. We demonstrated beneficial effects on nutritional inadequacy with educational intervention and early dietary intervention using the help of RDs with significant improvement (74.5% vs. 40.1%; P<0.001) in placing nutritional consultations and getting recommendations in the prospective arm as against the retrospective group(60). Furthermore, the intervention was associated with reduced length of stay (5.7 vs. 8.4 days; P=0.004) and 90-day readmissions (39.4% vs. 28.4%; P= 0.04)(60). These data show that addressing the nutritional status of the patient helps us to reduce readmissions and hospitalization should be used as a golden opportunity to establish this as standard of care, as has been proposed in guidelines related to nutrition and HE(1, 12).

In our clinical practice, we come across patients from various races, ethnicities, religious and cultural beliefs. This holds truer for the patient population in the US. Hence, the providers should exhibit sensitiveness while formulating dietary plans for individual patients keeping in view these cultural differences, dietary practices (regular, vegetarian, vegan, etc.) and country-specific foods and this may be relevant beyond guidelines. Our RDs have devised a sample ideal dietary plan for a patient with HE keeping in view the dietary preferences for one-day period based on calculations using calories at 35kcal/kg = 2625 calories/day of ideal weight and 1.2–1.4g/kg = 90–112g protein per day of ideal weight. This sample plan is shown in Table 3.

Table 3.

Showing a one-day Sample of an Ideal Menu for a 75kg (Ideal Body weight) patient with HE with various dietary preferences (Also as figure 1A-C for patient diet bookmark-shaped handouts

	Regular Diet	Vegetarian Diet	Vegan Diet
Breakfast	1 Cup Oatmeal with 1 tsp brown sugar and 1 Tbsp chopped walnuts 1 Cup 2% Milk 1 Hard boiled egg 1 Banana	1 Cup Oatmeal with 1 tsp brown sugar and 1 Tbsp chopped walnuts 1 Cup 2% Milk 1 Hard boiled egg 1 Banana	1 Cup Oatmeal with 1 tsp brown sugar and 1 Tbsp chopped walnuts 1 Cup soy milk 1 oz scrambled tofu 1 Banana
	570 calories, 25g protein	570 calories, 25g protein	557 calories, 22g protein
AM Snack	Oral nutrition supplement/beverage	High protein supplement/beverage	Vegan high protein supplement/beverage
	350 calories 13g protein	350 calories 13g protein	222 calories, 16g protein
Lunch	Whole wheat sandwich made with 2 slices of bread, 2 oz low sodium turkey, 1 slice cheese, 2 tsp mayonnaise, lettuce, tomato 1 cup low sodium chicken noodle soup 10 Saltine crackers, unsalted	Whole wheat sandwich made with 2 slices of bread, 2 Tbsp peanut butter, 1 TBSP grape jelly, 1 cup low sodium tomato soup with 1 oz shredded cheese 10 Saltine crackers, unsalted	Whole wheat sandwich made with 2 slices of bread, 2 Tbsp peanut butter, 1 TBSP grape jelly, 1 cup low sodium tomato soup 10 Saltine crackers, unsalted 1 Cup soy milk
	601 calories 27g protein	689 calories, 19g protein	709 calories, 21g protein
PM Snack	1 medium apple 2 Tbsp peanut butter	1 medium apple 1 oz almonds	1 medium apple 1 oz almonds
	285 calories 7g protein	259 calories, 6g protein	259 calories, 6g protein
Dinner	3oz Grilled Chicken Breast 1 medium baked sweet potato with 2 tsp margarine 1 cup steamed broccoli 1 Cup 2% milk	Black bean burger patty 1 medium baked sweet potato with 2 tsp margarine 1 cup steamed broccoli	Black bean burger patty 1 medium baked sweet potato with 2 tsp margarine 1 cup steamed broccoli
	468 calories 35g protein	491 calories, 31g protein	491 calories, 31g protein
Night Time Snack	1/2 Cup vanilla yogurt 1 Cup fruit cocktail	6oz yogurt 1 Cup fruit cocktail	6oz Soy yogurt 1 Cup fruit cocktail
	333 calories 5g protein	333 calories 5g protein	395 calories, 6g protein
Totals	2607 calories, 112g protein	2692 calories, 99g protein	2633 calories, 102g protein

Abbreviations: Teaspoonful, tsp; Tablespoonful, TBSP; Ounce, Oz

Dietary Rules to Live by for patients with Hepatic Encephalopathy

• Eat frequent meals and snacks including a snack before going to bed

• Eat more protein

• Use total 2gram salt only- if you have fluid (ascites) in belly

• Do not drink alcohol at all

• Avoid dehydration

• Don’t start any dietary/herbal supplements without discussing with your providers prior

• Regular exercise as tolerated will complement your nutritional status

• Discuss your dietary plan during all the visits with your providers

• Seek help from your caregivers for adhering to your diet plan

Conclusions:

The burden of HE on the patients, caregivers and the society as such is huge and patients with HE have to face a negative effect on the quality of life and have to get recurrent hospitalizations. Evidence supports that malnutrition is common in HE patients leading to sarcopenia, which is associated with increased morbidity and mortality in these patients. Improving the overall nutritional status of liver cirrhosis patients in general and HE patients in particular should be considered as a high priority. This can be achieved using a multifactorial approach including to recognize the problem, using malnutrition screening tools in both the in-patient and the out-patient settings to screen the high risk patients, using nutrition professionals as key members of the multi-disciplinary team for cirrhosis, train providers on being vigilant against malnutrition and counseling patients/caregivers so as to properly implement the dietary plans in a guideline congruent manner.