Jennifer Byrne , 2025-05-02 13:48:00
Key takeaways:
- Malnutrition adversely affects outcomes among patients with liver disease.
- Protein and fiber supplementation, a late-evening snack and coffee consumption are among recommendations.
ACG released new guidance for the management of malnutrition in patients with liver disease, including the newly renamed spectrum of steatotic liver diseases, previously known as fatty liver disease.
The clinical guideline, published in the American Journal of Gastroenterology, is ACG’s first on malnutrition in liver disease, according to lead author Craig J. McClain, MD, AGAF, FACG, FAASLD, FACN.
Malnutrition is prevalent in liver disease and encompasses a wider range of mechanisms and symptoms than is generally acknowledged, according to researchers.
“Many people think of malnutrition as a condition in which a person is severely underweight and has not been eating well, and that is one component,” McClain, professor of medicine and pharmacology and toxicology and chief of research affairs in the division of gastroenterology, hepatology and nutrition at University of Louisville School of Medicine, told Healio. “However, nutritional excess is also defined as malnutrition, as is an imbalance in nutritional intake. By definition, obesity is malnutrition.”
McClain said approximately one of every four Americans has hepatic steatosis, adding that alcohol-associated hepatic steatosis is another “major problem” contributing to malnutrition.
“Alcohol-associated liver disease is the number one cause of liver transplantation in the United States,” he said. “It’s a major cause [of malnutrition] and it has increased dramatically. There has been a major uptick in alcohol-associated liver disease since COVID, and it’s not quieting down.”
Recommendations
Over the past 2 decades, more than a dozen guidelines and recommendations on malnutrition and liver disease have been drafted by various societies. Most of these focused on advanced liver disease or complications such as hepatic encephalopathy.
This guideline aims to provide succinct nutritional advice for the most common liver diseases.
Authors include hepatology experts across a range of practice settings and career stages, who addressed definitions, diagnosis, causes, prevalence, prognosis and nutritional interventions for malnutrition among patients with liver disease.
The group conducted electronic literature searches in PubMed, EMBASE and the Cochrane Library starting in April 2021, with priority given to systematic reviews and meta-analyses, as well as randomized controlled trials.
The authors developed statements and used the Grading of Recommendations, Assessment, Development and Evaluation process to evaluate the quality of evidence for each one. They also created key concepts, which were not included in the GRADE process and can include expert opinions as well as definitions or epidemiological statements.
Recommendations include:
- For patients with cirrhosis, AGC recommends late evening snacks to improve lean muscle tissue, and to decrease risk for ascites and hepatic encephalopathy.
- For hospitalized patients with cirrhosis, ACG suggests early oral or enteral nutrition supplementation.
- ACG suggests use of nutritional supplementation among patients with cirrhosis or alcohol-associated hepatitis.
- For patients with metabolic dysfunction-associated steatohepatitis without cirrhosis, ACG suggests daily supplementation with vitamin E 800 IU.
- For patients with chronic liver disease, ACG suggests drinking coffee, ideally two or more cups per day, to decrease risk for fibrosis progression or development of hepatocellular carcinoma.
- For patients with cirrhosis and hepatic encephalopathy, ACG recommends using branched chain amino acids as well as standard-of-care treatment.
- ACG advises against limiting dietary protein among patients with decompensated cirrhosis and hepatic encephalopathy.
- ACG refrained from making a recommendation for or against rigorous restriction of dietary sodium among patients with cirrhosis and ascites who are managed with diuretic therapies.
- For patients with cirrhosis and hepatic encephalopathy who need nutritional supplementation, ACG suggests a diet enriched with vegetarian sources of protein.
McClain noted the importance of providing protein and fiber supplementation to patients with liver disease.
“Often our patients are low in dietary protein which can lead to sarcopenia, and because our patients are at high risk for falls, a lack of muscle mass can lead to a terrible outcome,” he said. “We’re also increasingly recognizing the importance of fiber in the diet. Dietary fiber can be metabolized to short-chain fatty acids, like butyrate, which are important for intestinal health and can also have epigenetic effects.”
The potential benefits of coffee consumption are also noteworthy, McClain said.
“Coffee is helpful in fatty liver disease — it’s helpful in decreasing fibrosis and risk for liver cancer,” he said. “Drinking two to three cups of coffee a day is good for our patients with early-stage liver steatosis due to MASLD.”
McClain added that because patients with cirrhosis “go into starvation mode overnight,” a snack at about 9 p.m. is advised to offset muscle loss.
Key concepts
A number of key concepts address the intake of high fructose/sucrose-containing diets as potential drivers of malnutrition. They include:
- High-fructose/sucrose-containing diets play a powerful role in engendering hepatic de novo lipogenesis and insulin resistance.
- High-fructose/sucrose-containing diets correlate in a dose-dependent manner with chronic liver disease and fibrosis.
- Low-fructose diets are advised for all patients with chronic liver disease.
McClain emphasized that diets high in these sugars can trigger malnutrition by amassing large calorie counts without adding nutritional value.
“This is similar to alcohol, in that there’s no protein in there, there are no minerals and no vitamins,” he said. “There was a recent, large study showing that one sugar-sweetened soda or more a day can increase risk for dying of liver disease or getting liver cancer.”
Other key concepts focused on the effects of alcohol on malnutrition in liver disease:
- The risk for malnutrition among those with alcohol use disorder increases in proportion to liver disease severity, especially among those with severe alcohol-associated hepatitis.
- Patients with alcohol-associated liver disease, especially those with alcohol-associated hepatitis, should undergo dietary assessments to ensure adequate nutritional intake.
McClain said the lack of nutritional value in alcoholic beverages can lead to malnutrition in liver disease, much in the same way high fructose/sucrose-containing diets do.
“A standard drink is going to be about a hundred calories, and many of our patients are drinking 15 drinks a day,” he said. “That’s 1,500 empty calories a day that don’t have protein or vital minerals.”
According to McClain, the guideline encourages a broader understanding of the term “malnutrition.”
“I think we need to understand the definition of malnutrition as a very global concept, instead of a narrow concept of nutritional deficiencies,” he said. “It’s also important to understand that malnutrition can impact quality of life and survival of patients with liver disease. If you can improve malnutrition, you can improve outcomes.”
For more information:
Craig J. McClain, MD, AGAF, FACG, FAASLD, FACN, can be reached at craig.mcclain@louisville.edu.
