Nutrition in PSC

1. Nutrition in PSC By Nickie Francisco-Ziller RDN, LD

2. Objectives • Goals for healthy nutrition while living with PSC • Address nutrition for those with IBD • Provide general food safety guidelines

3. Nutrition-related Liver Functions • Stores specific nutrients like vitamins and minerals • Stores energy (glycogen) and plays a role in glucose management. • Synthesizes proteins • Produces bile, which is released after eating and aids in the absorptions of fats • Filters harmful substances

4. Potential nutritional issues related to PSC • Absorption of foods/nutrients • Vitamins/minerals • Bone Health • Lipid Abnormalities • Weight

5. Malabsorption • An elevated bilirubin indicates that less bile is getting into the intestinal tract. • One of bile’s roles in the intestinal tract is to aid in fat absorption. • A person who is not absorbing fat well may notice light-colored stool or stool that tends to float. This indicates a loss of calories and nutrients. • Fat soluble vitamins (A, D and E) are the most likely to be low in people with PSC or those with an elevated bilirubin.

6. Vitamins/Minerals • Certain vitamins/minerals are stored in the liver. • Some are activated into their usable form in the liver • People with PSC are at increased risk for fat soluble vitamin deficiencies. A, D and E levels can be checked with a blood test. Vitamin levels should be supplemented if low and monitored on a regular basis • Vitamin A affects vision, especially night vision • Vitamin D can be beneficial for bone health as well as other functions such as immune health and insulin production, but much of this is still being researched. • Vitamin E is an anti-oxidant that affects the health of your blood, brain and skin.

7. Bone Health • Osteopenia or osteoporosis develops to some degree in all patients with cirrhosis • People with PSC should be screened for bone loss • Reasons for low bone mass is multifactorial and include fat malabsorption, decreased muscle mass, and decreased activity levels. • If low bone mass is identified, it may be beneficial to choose foods high in calcium and vitamin D. Your physician may recommend supplementation with calcium and D and, in significant bone loss, medications may be needed. • Weight-bearing activities may be encouraged, if safe to do so. Sohki, Liver Tr, 2004

8. Lipid Abnormalities • Bile is involved with the excretion of cholesterol • If bilirubin is elevated in the bloodstream, cholesterol may also become increased. • Research shows a direct correlation with cholesterol and bilirubin levels. • Studies have shown that elevated cholesterol seen with cholestasis does not carry the same cardiac risk as high cholesterol without cholestasis. • A low fat diet/lipid lowering medication typically is not indicated. Sinakos, Dig & Liver Dis, 2011

9. Weight issues • Weight is within normal limits (BMI 20-26) • Weight is excessive (BMI > 30) • Weight is low (BMI < 20) • **The focus for all three categories to avoid loss of muscle mass/strength

10. Normal Weight • Make an effort to choose healthful foods overall • Include at least five servings of vegetables and fruits each day • Choose lean protein sources • Choose healthy fat sources • Choose complex carbohydrates such as whole grains in place of refined bread, rice, pasta (as tolerated) • Select low fat dairy products • Regular daily exercise

11. Overweight • Make an effort to reduce weight in a healthful manner to BMI < 30. • People who are overweight can have fat accumulate in the their livers, further compromising liver function. • Avoid skipping meals/fasting which may contribute to loss of muscle mass instead of fat mass. • Avoid fad diets which may eliminate entire macronutrients. • Focus instead on appropriate portion sizes, healthy choices and exercise. • The use of weight loss medications is not recommended in this setting unless you have approved this through your physician. • Don’t skimp on protein to save calories.

12. Underweight/Unintentional Loss • Eat frequent meals/snacks • Try to increase the caloric density of the foods you are eating. • Have a protein source at each meal. • May need to add nutritional supplement beverages (available at most stores that have grocery and/or pharmacy services and on-line). Please check with your dietitian if you are unsure which supplement is right for you. Taste more than one! • Regular daily exercise, which may be better tolerated by doing 10 minutes three times per day instead of 30 minutes at one time.

13. Potential Eating Challenges • Appetite change • Fatigue/decreased activity • Malabsorption • Presence of fluid retention (ascites/edema) • Change in bowel habits or flare-up of IBD • Becoming full quickly • Side effects of medications • Recurrent episodes of cholangitis, requiring procedures and/or hospitalizations

14. IBD • There is no One-Size-Fits-All diet for IBD. There are many diet approaches that some may find benefit from, but everyone is different. • Individuals will likely adjust their diets based on personal intolerances- some need to limit foods high in fiber, others have trouble with lactose, some limit gluten. Others may poorly tolerate foods high in fat or those that are gas-forming.

15. IBD suggestions • Chew foods well • Eat a wide variety of foods, as able. • Drink adequate amounts of fluids • May do best with smaller more frequent meals/snacks • During a flare-up, choose lower fiber foods. • If you have an ileostomy, watch for potential increased output after drinking sugared beverages and avoid these if this is the case • If gluten is an issue, ask your physician if you should have a small bowel biopsy for official diagnosis of celiac vs gluten intolerance. • Turmeric and probiotic foods are being researched to determine if they have benefit in IBD.

16. Complimentary medicine in PSC • In general, talk to your physician, pharmacist or dietitian before starting any nutritional/herbal type supplements • Herbal supplements are not FDA approved and therefore are often not tested in large clinical trials. Without this, we do not know about the safety in the setting of liver disease or how the individual supplement may affect the absorption of other medications or treatments you may be receiving. • Natural does not mean safe!!

17. Complimentary medicine in PSC • A daily multivitamin providing 100% of the recommended daily amounts is acceptable • Your physician will advise you take specific vitamins and/or minerals based on blood tests, bone health etc. • Be wary of misinformation. The most accurate nutrition information can be obtained from your physician, dietitian or pharmacist. • Nutritional supplement drinks may be advised by your dietitian or physician • Milk thistle has been shown to be relatively safe but not particularly beneficial.

18. Emerging Nutrition Researchin Liver Disease • Omega 3 Fatty Acids • Anti-inflammatory effect, may reduce triglycerides • Fatty fish such as salmon or tuna, walnuts, flax, chia seeds • Resveratrol • High in antioxidant properties • Grapes, blueberries, cranberries, peanuts, tea, cocoa • Probiotics • Live bacteria that can help with intestinal health • yogurt and Kefir • Coffee (regular or decaf)

19. Food Safety DOs • Wash all fresh produce before eating or peeling • Cook eggs until white and yolk are firm • Heat deli-sliced meat until steaming DON’Ts • Avoid raw sprouts • Avoid eating raw or undercooked fish or meat • Avoid unpasteurized dairy products • Be cautious about eating at buffets/salad bars

20. Food Safety • 1) Clean • Wash hands before handling food • Wash cutting boards and counter surfaces before prep • Wash all fresh produce before eating/peeling • 2) Separate • Avoid cross-contamination i.e. placing cooked meat on a plate that previously held raw meat without washing first • Separate raw meat/poultry/seafood from other foods in your grocery bags and refrigerator

21. Food Safety Continued • Cook • Avoid eating raw or undercooked fish, meat, or poultry • Cook eggs until white and yolk are firm. • Use a meat thermometer to assure safe temperatures • Chill • Refrigerate perishables within 2 hours of cooking or purchasing (1 hour if outside temp is > 90). • Thaw foods in the refrigerator or microwave www.foodsafety.gov

22. Healthy Nutrition for the Liver • Work towards a healthful weight • Eat three meals per day and a snack at bedtime • Choose healthy fats • Avoid added salt • Modest intake of sugars • Protein source at each meal • Avoid/limit alcohol • Be active most days • Avoid herbal supplements unless approved by your medical team