NUTRITION AND HEPATITIS C VIRUS INFECTION

BY: Jennifer Muir Bowers, MS, RD

The virus
The incidence of Hepatitis C viral (HCV) infection is rising rapidly.1 In fact, over 4 million Americans are infected, and more than 40% of those infected do not know how they contracted HCV. Approximately 75% to 85% of people infected with HCV develop chronic hepatitis, which can lead to cirrhosis and liver failure. HCV is also the leading cause of liver transplantation in the US.2 Primarily spread through blood, HCV is the most common blood-borne infection in the US. Because of the similar transmission routes, the incidence of co-infection with HCV and HIV is increasing. Risk factors include intravenous drug use, blood or blood-product transfusions, needle stick injuries, and multiple sex partners. HCV infection is four times more prevalent than HIV infection in the US.

Unlike other hepatitis viruses, HCV is a member of the flaviviridae viral family.1 Like other hepatitis viruses, HCV infects the liver and directly damages liver tissue. A Consensus Statement on HCV from the National Institutes of Health can be obtained online at: <http://odp.od.nih.gov/consensus/cons/105/105_statement.htm>.

The liver's role in nutrition
Virtually all blood returning from the intestinal tract to the heart passes through the liver. Therefore, the liver is intricately involved in the metabolism of all ingested nutrients.3,4 The liver regulates short-term and long-term energy supply for normal bodily functions. Alcohol is also metabolized in the liver cells. Glucose, derived from carbohydrates, is produced and stored in the liver. When needed, the liver supplies glucose to cells for energy. Fat is generated, stored, and exported by the liver. The liver is also involved in the production of bile, which aids in the metabolism of fat and cholesterol. The liver manufacturers many essential body proteins, such as albumin and clotting factors. Finally, the liver regulates the supply of many vitamins and minerals. Obviously, the liver is vital to nutritional health. When the liver is not functioning properly, overall nutritional status may suffer.

Calorie needs for hepatitis C
A high-calorie diet is normally recommended for HCV-infected people.3-5 You can figure out your daily calorie needs by multiplying your body weight (in pounds) by a factor of 14 to 16.

Example: 150 pound man x (14 to 16) =2100 to 2400 calories per day

Whole food, nutrient-rich choices that include whole grains, fruits, and vegetables are a priority. The government's current Food Guide Pyramid, available online at usda.gov: 8001/py/pmap.htm> shows how to follow a balanced, nutritious eating style using proper serving sizes from each of the pyramid's food groups. If you choose from the bottom three groups you will receive plenty of complex carbohydrates, fiber, vitamins, and minerals.

Protein needs for hepatitis C
If you have hepatitis, you also need to emphasize lean, low-saturated-fat protein foods.3-5 To calculate your daily protein needs, multiply your body weight (in pounds) by the factor 0.5 to 0.7.

Example: 150 pound woman x (0.5 to 0.7) = 75 to 105 grams of protein per day

The Food Guide Pyramid also defines protein food choices and appropriate serving sizes. The milk and meat groups provide high quality protein foods. There is some evidence that vegetable proteins are better for people with liver disease because of the specific amino acids they contain.6 Vegetable proteins include soy products (i.e., soy milk, soy cheese, tofu), beans, nuts, and seeds. This certainly does not mean you need to avoid animal proteins, but you may want to try to incorporate vegetable proteins to help meet increased requirements and balance out your nutritional intake. For ideas, check out the Vegetarian Food Pyramid at <http://www. vegsource.com/nutrition/pyramid.htm> and the Vegan Food Pyramid at <http://www.vegsource.com/nutrition/pyramid_vegan.htm>.

Alcohol and hepatitis C
Alcoholic beverages need to be completely avoided by patients with liver disease.5 The liver metabolizes alcohol. When the liver is not functioning properly, alcohol becomes a potential toxin. Even minor alcohol use by patients with hepatitis C can speed up the progression to cirrhosis and total liver failure. More information about alcohol and hepatitis C can be obtained online at <http://gi.ucsf.edu/ALF/pubs/updw9697.html-alc&c>.

Vitamins, minerals, and hepatitis C
Well-nourished people with hepatitis C who are eating properly probably do not require vitamin and mineral supplements. If you do take a multivitamin/mineral supplement, check the label and make sure you do not take more than 200% of the RDA for any micronutrient without consulting with your doctor or with a registered nutrition professional such as a Registered Dietitian (RD) or a Registered Dietetic Technician. Fat-soluble vitamins A, D, and K should not be taken in megadoses because of the risk of toxicity.5 Some researchers report that antioxidant supplementation, specifically with vitamins C (1000 mg) and E (800 IU), delayed the anemia commonly seen with the hepatitis medication Ribavirin. The anemia was not prevented entirely, but the onset was delayed.7 Another study demonstrated that hepatitis C patients taking high doses of vitamin E for 3 months had improved liver function tests.8

It is important to know that iron deficiency is not common in liver disease. The anemia experienced by most hepatitis patients is not iron-deficiency anemia. Because iron is stored in the liver, iron should not be supplemented by patients with hepatitis C infection because of the potential for toxicity. High iron levels may reduce the response to interferon, a medication taken by many hepatitis C patients. If you have elevated serum iron or cirrhosis, iron supplements should be completely avoided (including iron present in multivitamin/ mineral supplements).5 If you do not have elevated serum iron or cirrhosis, iron present in multivitamin/mineral supplements is appropriate, but further supplementation is not recommended. Strict vegans who avoid all animal products may need a vitamin B12 supplement to avoid pernicious anemia. Intramuscular B12 injections, oral supplements, or intranasal gels (that are better absorbed) are used to treat B12 deficiency.9,10 Research is also being conducted on an enhanced uptake formulation of vitamin B12 called Cobamax^TM.10 If you do have anemia, to find out what kind of anemia you have, ask your medical doctor to check serum vitamin B12, RBC folate, and serum iron levels.

Hepatitis C medications
Interferon (Intron-A, Roferon-A) and ribavirin (Virazole) are the two most commonly prescribed medications for hepatitis C treatment.11 Rebetron is a combination of interferon and ribavirin. Interferons are injectable and must be kept refrigerated. When taking Interferon, adequate fluids need to be consumed. Try to drink at least 0.5 ounces of fluid for every pound you weigh.

Example: 150 pound man x 0.5 = 75 ounces of fluid per day

Check with your doctor or a registered nutrition professional to see which specific fluids are best for you individually. Generally, avoiding sugar-sweetened beverages is a good rule of thumb; this can minimize extra, empty calories and can help you manage blood fat (especially triglyceride) and blood sugar levels. Table 1 shows nutrition-related side effects that may occur with interferon.

A very common side effect with ribavirin treatment is anemia. This is usually not the kind of anemia that is due to insufficient iron, folate, or vitamin B12 intake, so supplementation with these nutrients probably won't alleviate the anemia.

Nutrition and cirrhosis
Cirrhosis, fibrotic (thickened and hardened) liver tissue, occurs in the later stages of hepatitis C in chronically infected patients.3-5 Complications of cirrhosis include portal hypertension (high blood pressure in the liver's circulatory system). Portal hypertension can result in ascites (fluid retention in the belly area) and varices (enlarged veins in the digestive tract). As with the hepatitis diet described above, people with cirrhosis need a high-calorie, high-protein diet. In addition, with cirrhosis, foods that are high in sodium and ammonia need to be avoided. Table 2 identifies ammonia- and sodium-containing foods.

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Generally, no more than 2000 mg to 3000 mg of sodium should be ingested each day to minimize water retention and facilitate blood-pressure control. In addition to avoiding salty foods, salt in cooking, and salt at the table, it is necessary to select low-sodium foods in order to maintain sodium intake below 3000 mg per day. If varices are present in the esophagus or stomach, a soft diet should be consumed, and the patient should avoid any rough foods such as pretzels or nuts that could scratch those blood vessels and cause bleeding. Blood potassium levels need to be monitored, but potassium supplementation should only occur with a prescription and regular monitoring from your physician. Many cirrhosis patients need supplementation with the B-complex vitamins: zinc, magnesium, and phosphorous.

Nutrition and hepatic encephalopathy
In later stages of cirrhosis, hepatic encephalopathy can occur in a small number of cases. This is a neuropsychiatric disorder, and symptoms can range from minor confusion and mental status changes to end-stage coma.3-5 These mental changes are a result of ammonia and toxin build-up in the blood. A diet very low in protein should be consumed with hepatic encephalopathy, especially if animal proteins are eaten. Vegetable protein allowances can be liberalized. Check with your doctor or dietitian to see if you need to follow a low-protein diet. To figure out the reduced daily protein needs for a patient with hepatic encephalopathy, multiply the patient's body weight in pounds by the factor 0.23 to 0.34.

Example: 150 pound woman x (0.23 to 0.34) = 34.5 to 51 grams of protein per day.

Registered dieticians Registered nutrition professionals can help you to meet caloric needs by designing individualized meal plans. An RD is your best source of accurate and responsible nutrition information. If you do not know an RD in your area, you can receive assistance online from the Nationwide Nutrition Network of the American Dietetic Association at: <http://www.eatright.org/finddiet.html>.

At this site, you can search for an RD by geographic location or by specialty expertise. You can also seek the advice of the HIV-experienced RDs listed on the Questions and Referrals web page at the HIV ReSources website: <http://www. hivresources.com/QandR.htm>.

Jennifer Muir Bowers, MS, RD, is the Undergraduate Program Coordinator for the Department of Nutritional Sciences at the University of Arizona. She is also completing a doctoral degree in Nutritional Sciences and Immunology.