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Habitual pattern of food intake in patients with liver disease
Chr-al
Nutrrrron(1993,12: 293-297
0 Longman Group UK Ltd 1993
Habitual pattern of food intake in patients with liver disease W. P. H. G. VERBOEKET-VAN G. R. SWART*
DE VENNE*,
K. R. WESTERTERP*,
6. VAN HOEKt and
Department of *Human Biology, University of Limburg, PO Box 616,620O MD Maastricht, tDepartment of Gastroenterology and Hepatology, University Hospital Maasstricht, and *Department of Internal Medicine II, University Hospital Rotterdam, The Netherlands (Correspondence and reprint requests to WV-vdV)
ABSTRACT-Patients with liver disease are frequently undernourished. We determined the habitual pattern of energy intake and intake of protein, fat, carbohydrate and alcohol in patients with liver disease. 20 Patients differing with respect to cause, duration and severity of liver disease reported their habitual food intake using a 7-day food record. Control subjects formed a representative sample of the Dutch population. The results showed that patients with liver disease, had a significantly decreased daily energy intake (both expressed in absolute values and per kg body mass), compared with control subjects. Total fat intake was reduced in patients, whereas total intake of protein, carbohydrate and alcohol was similar to the control group. In the first 4 hours after rising, energy and protein intake were significantly increased in the patient group. During the evening the consumption of protein was lower in patients with liver disease than in control subjects. These findings are probably functional in order to minimize episodes of catabolism.
Introduction Undernutrition and malnutrition are common among patients with liver disease (l-3). Undernutrition which can be defined as a state of inadequate energy intake is especially present in patients with end-stage cirrhosis of the liver, resulting in loss of body weight. The lean body mass is one of the variables that indicate the severity of undernutrition: when carbohydrate and fat sources are inadequate in providing energy, muscle protein is used. Mills et al (4) studying the nutritional status of patients with alcoholic liver disease of varying severity, reported a decreased lean body mass, although mean body weight was 108% of ideal body weight. A deficient intake of protein has been reported as a major cause of malnutrition in liver disease. Swart et al (5) reported that cirrhotic patients have increased protein requirements, probably caused by small and inadequate liver glycogen stores, resulting in gluconeogenesis from amino acids and hence extra aminoacid loss. On the other hand, protein-restricted diets are sometimes prescribed to cirrhotic patients to prevent or treat porto-systemic encephalopathy. By in193
creasing the efficiency of nitrogen metabolism, it is not necessary to choose between protein requirement and protein tolerance. A study on the effect of the pattern of food intake on nitrogen balance in cirrhotic patients, revealed that a late evening meal improved the efficiency of nitrogen metabolism (6). In the present study we investigated the habitual pattern of food intake in patients with liver disease. Our hypothesis was that energy intake might be increased during the early morning in patients with liver disease, compared to controls, to compensate for a more catabolic state after an overnight fast in patients, due to reduced liver glycogen stores in liver disease. We also studied the habitual intake of macronutrients, i.e. intake of protein, fat, carbohydrate and alcohol.
Patients and methods Patients
10 male and 10 female patients with liver disease participated in the study. Their mean age was 51 (range 25-71) years. Mean body mass index was 25.4 (range 20.4-33.3) kg/m=. Further details are shown
294
FOOD INTAKE IN PATIENTS WITH LIVER DISEASE
Table 1 Characteristics
of the patients
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Sex M M M M M M M M M M F F F F F F F F F F
Cirrhosis
(years)
BMI (kg/m’)
Diagnosis
(yes/no)
40 49 61 38 49 50 40 49 56 46 71 56 25 58 61 55 41 55 70 48
20.4 23.5 26.4 23.1 26.9 26.6 33.3 27.8 27.8 28.4 21.5 28.5 25.3 22.3 22.9 33.3 22.3 22.4 21.1 24.2
Ale hep PSC CAHB PSC Ale cirrh SH/HL Ale SH SH/HL SH Ale hep AICAH PSC AICAH Crypt cirrh AICAH Crypt cirrh PBC PBC AICAH PSC
yes yes
Age Subject
Child-Pugh
Yes Yes
yes
classification C B A A A
no no ll0
no no yes yes yes yes yes yes yes yes yes no
Abbreviations: AICAH, autoimmune chronic active hepatitis; Ale cirrh, alcoholic cirrhosis; Ale hep, alcoholic hepatitis; Ale SH, alcoholic steatohepatitis; BMI, body mass index; CAHB, chronic active hepatitis B; Crypt cirrh, cryptogenic cirrhosis; HL, hyperlipidaemia; PBC, primary biliary cirrhosis; PSC, primary sclerosing cholangitis; SH, steatohepatitis.
in Table 1. One patient (subject 1) was studied while staying in the hospital for treatment; the other subjects visited the out-patient clinic regularly and were studied at home. Subject 11 was on a sodiumrestricted diet during the experiment; subject 14 on a protein-restricted diet (60 g protein/day). The patients had not received any other dietary advice. Medication included azathioprine (subject 1 l), diuretics (subjects 2, 11 & 14), lactulose (subject 14), prednison (subjects 11, 12 & 19) and Zn-acetate (subject 14). The research protocol was reviewed and approved by the local Ethical Committee. The procedures in the study were carefully explained to the patients before they gave their consent to participate. Food record
A 7-day food record was filled out by the subjects to determine their habitual dietary intake. During these seven consecutive days, subjects recorded their food intake in a diary that was divided into 7 periods a day (three meals, four inter-meal periods). Brand names were asked for as well as cooking recipes that were used. Energy intake and macronutrient composition of the foods (protein, fat, carbohydrate and alcohol) were calculated using the computerized Dutch food composition table (7).
Analysis of data
The results of the present study were compared with a dietary survey of a representative sample of the Dutch population within the age group 22-75 years (n = 3961, 1954 males and 2007 females) (8). Mean body mass of the reference group was assumed to be 75 kg for men aged 22-65 years, 70 kg for elderly men (265 years), 65 kg for women aged 22-65 years and 65 kg for elderly women (265 years) (9). Differences between patients with liver disease and control subjects were tested using one-group t-tests with p < 0.05 as level of significance. Diurnal distribution of energy and macronutrient intake was studied by determining intake over 4 intervals, i.e. from l-4 hours after rising in the morning (including breakfast and morning snack), from 5-8 hours after rising (including lunch and afternoon snack), from 9-12 hours after rising (dinner) and from 13-24 hours after rising (evening snack). In the text, tables and figures, data are presented as the mean and standard error of the mean (SE). Results Energy and macronutrient intake
Table 2 presents habitual energy and macronutrient
CLINICAL NUTRITION
295
Table 2 Habitual energy and macronutrient
intake for patients with liver disease and control subjects. Intake of protein, fat, carbohydrate and alcohol is expressed in absolute values (g/d) and per kilogram body mass (g/kg d) Liver disease (mean + SE) Kl47*597* Energy intake (kJ/d) 70.9 * 2.8 Body mass (kg) 113.7 + 7.8** Energy intake &J/kg d) 68.9 * 5.8 Protein intake (e/d) Fat intake (g/dj70.8 + 7.8*** Carbohydrate intake (g/d) 235.9 * 17.4 Alcohol intake (g/d) 9.6 + 6.7 Protein intake (g/kg d) 0.98 + 0.08 1.01 * 0.12*** Fat intake (g/kg dl Carbohydrate intake (g/kg d) 3.34 f 0.21 Alcohol intake (g/kg d) 0.11 f0.08
Control subjects (population mean) 9629 69.2 138.5 77.8 106.1 235.2 13.5 1.12 1.53 3.39 0.19
Fig. 1. Habitual pattern of energy intake (EI) for patients with liver disease and control subjects. Statistical significance vs controls: *** p < 0.001, * p < 0.05.
Statistical significance vs control subjects: *** p < 0.001, ** p < 0.01, * p < 0.05.
intake for patients with liver disease and control subjects. Energy intake, both expressed in kJ/d and per kg body mass, was significantly decreased in patients with liver disease, compared with control subjects. Intake of fat, both expressed in g/d and per kg body mass, was significantly lower in patients with liver disease (p < O.OOl), whereas there was no difference in protein-, carbohydrate- or alcohol intake between patients with liver disease and control subjects.
Pattern of food intake Figure 1 presents the diurnal distribution of energy intake for patients with liver disease and control subjects. Patients with liver disease showed an increased energy intake in the first 4 h after rising, compared with control subjects (p < 0.001). During the following interval, energy intake was lower in patients than in control subjects (p < 0.05). The diurnal distribution of protein-, fat-, carbohydrate- and alcohol intake is shown in Figure 2. During the first 4 h after rising the consumption of protein was significantly increased in the patient group (p < O.Ol), whereas intake of protein in the evening was decreased compared with control subjects (9-12 h after rising: p < 0.001; 13-24 h after rising: p < 0.05). Fat intake was greatly decreased in patients with liver disease compared to controls during 3 intervals (i.e. from 5-24 h after rising: p < 0.001). Carbohydrate intake was only significantly different between the two groups during the second interval (p < 0.05). There were no significant differences observed concerning the distribution of alcohol intake.
Discussion One of the causes of undernutrition in patients with late stage cirrhosis or other types of liver disease is insufficient food intake. This is especially common in patients with ascites, probably due to abdominal distension and an early feeling of satiety during eating (2). We investigated the habitual energy and macronutrient intake and the pattern of food intake in patients with liver disease. None of the patients had received dietary advice that would have influenced their habitual eating behaviour, except for subject 11 (sodium-restricted diet) and 14 (protein-restricted diet). Total energy intake (in absolute values and expressed per kg body mass) was significantly decreased in patients with liver disease (Table 2). Because both body mass and body mass index of the patients were within the normal range, we conclude that patients with liver disease have a reduced energy intake. In patients with liver cirrhosis, incorporation of a late evening meal into the daily energy intake pattern was found to improve the efficiency of nitrogen metabolism, presumably by delaying the onset of gluconeogenesis from amino-acids at night (6). Referring to these findings, the habitual pattern of energy intake over the day in patients with liver disease was studied as well. During the first 4 h after rising in the morning, energy intake was significantly elevated in patients compared with controls (Fig. 1). Patients with liver disease probably have limited glycogen stores in the liver, resulting in a more rapid development of a catabolic state (10-l 1). To compensate for
296
FOOD INTAKE IN PATIENTS WITH LIVER DISEASE
Fig. 2. Intake of protein (A), fat (B), carbohydrate (C) and alcohol (D) over 4 intervals for patients with liver disease and control subjects. Statistical significance vs controls: *** p c 0.001. ** p < 0.01, * p < 0.05.
this catabolic state after an overnight fast, patients with liver disease would have higher energy needs in the morning, and they do indeed eat more. Total fat intake was decreased in patients with liver disease, compared to control subjects (Table 2). Patients in this study, as is usual nowadays, were not advised to reduce their fat intake. It is possible, however, that the patients themselves believed that a low-fat, high-carbohydrate diet might have some beneficial effects on their disease, but this is only speculative. Swart et al (5) suggested that patients with liver cirrhosis have elevated protein requirements because of an early onset of gluconeogenesis from amino acids after an overnight fast, due to limited hepatic glycogen storage. In the present study, we did not observe a significant difference in total protein intake between patients and control subjects, although the daily distribution of protein intake varied greatly. Analysis of the diurnal distribution of macronutrient intake revealed that protein intake was increased in patients with liver disease during the first 4 h after rising in the morning (Fig. 2A). On the other hand, we observed a remarkable decrease in protein intake in patients with liver disease during the period from 9-24 h after rising (0.43 g/kg body mass vs 0.61 g/kg body mass for controls; p < 0.001).
In conclusion, patients with liver disease have a lower total energy intake and a reduced fat intake, compared with control subjects. In the morning energy and protein intake is increased in the patient group. During the evening protein intake is decreased in patients with liver disease when compared with control subjects. These findings are probably functional in order to minimize episodes of catabolism.
References 1. O’Keefe S J, El-Zayadi A R, Carraher T E et al. Malnutrition and immuno-incompetence in patients with liver disease. The Lancet 1980; 20: 615617 2. Johnson R D, Williams R. Nutritional support in alcoholic liver disease. Acta Med Stand, Suppl 1985; 703: 209-218 3. McIntyre N. 1987 Undernutrition and malnutrition in cirrhosis. In : Tygstrup N, Orlandi F (eds) Cirrhosis of the liver: Methods and fields of research. Elsevier Science Publishers BV (Biomedical Division), pp 225-234 4. Mills P R, Skenkin A, Anthony R S et al. Assessment of nutritional status and in vivo immune responses in alcoholic liver disease. Am J Clin Nutr 1983; 38: 849-859 5. Swart G R, Van den Berg J W 0, Wattimena J L D et al. Elevated protein requirements in cirrhosis of the liver investigated by whole body protein turnover studies. Clin Sci 1988: 75: 101-107 6. Swart G R, Zikens M C. Van Vuure J K, Van den Berg J W 0.
CLINICAL NUTRITION
Effect of a late evening meal on nitrogen balance in patients with cirrhosis of the liver. Br Med J 1989; 299: 1202-1203 7. Betel voedingsprogramma: Een professioneel prograrnma voor de personal computer (versie NL03a) Rotterdam: Nederlandse Unilever Bedrijven B.V. 8. Ministerie van Welzijn, Volksgezondheid en Cultuur en het ministerie van Landbouw en Visserij. Wat eet Nederland: Resultaten van de voedselconsumptiepeiling 1988; 1987-1988
297
9. Voedingsraad. Nederlandse voedingsnormen, 1989 10. Owen 0 E, Reichle F A, Mozzoli M A et al. Hepatic, gut, and renal substrate flux rates in patients with hepatic cirrhosis. J Clin Invest 198 1;68: 240-252 Il. Owen 0 E, Trapp V E, Reichard G A et al. Nature and quantity of fuels consumed in patients with alcoholic cirrhosis. J Clin Invest 1983: 72: 1821-1832
Submission date: 5 October 1992; Accepted afrer revision: 23 March 1993
Nutrrrron(1993,12: 293-297
0 Longman Group UK Ltd 1993
Habitual pattern of food intake in patients with liver disease W. P. H. G. VERBOEKET-VAN G. R. SWART*
DE VENNE*,
K. R. WESTERTERP*,
6. VAN HOEKt and
Department of *Human Biology, University of Limburg, PO Box 616,620O MD Maastricht, tDepartment of Gastroenterology and Hepatology, University Hospital Maasstricht, and *Department of Internal Medicine II, University Hospital Rotterdam, The Netherlands (Correspondence and reprint requests to WV-vdV)
ABSTRACT-Patients with liver disease are frequently undernourished. We determined the habitual pattern of energy intake and intake of protein, fat, carbohydrate and alcohol in patients with liver disease. 20 Patients differing with respect to cause, duration and severity of liver disease reported their habitual food intake using a 7-day food record. Control subjects formed a representative sample of the Dutch population. The results showed that patients with liver disease, had a significantly decreased daily energy intake (both expressed in absolute values and per kg body mass), compared with control subjects. Total fat intake was reduced in patients, whereas total intake of protein, carbohydrate and alcohol was similar to the control group. In the first 4 hours after rising, energy and protein intake were significantly increased in the patient group. During the evening the consumption of protein was lower in patients with liver disease than in control subjects. These findings are probably functional in order to minimize episodes of catabolism.
Introduction Undernutrition and malnutrition are common among patients with liver disease (l-3). Undernutrition which can be defined as a state of inadequate energy intake is especially present in patients with end-stage cirrhosis of the liver, resulting in loss of body weight. The lean body mass is one of the variables that indicate the severity of undernutrition: when carbohydrate and fat sources are inadequate in providing energy, muscle protein is used. Mills et al (4) studying the nutritional status of patients with alcoholic liver disease of varying severity, reported a decreased lean body mass, although mean body weight was 108% of ideal body weight. A deficient intake of protein has been reported as a major cause of malnutrition in liver disease. Swart et al (5) reported that cirrhotic patients have increased protein requirements, probably caused by small and inadequate liver glycogen stores, resulting in gluconeogenesis from amino acids and hence extra aminoacid loss. On the other hand, protein-restricted diets are sometimes prescribed to cirrhotic patients to prevent or treat porto-systemic encephalopathy. By in193
creasing the efficiency of nitrogen metabolism, it is not necessary to choose between protein requirement and protein tolerance. A study on the effect of the pattern of food intake on nitrogen balance in cirrhotic patients, revealed that a late evening meal improved the efficiency of nitrogen metabolism (6). In the present study we investigated the habitual pattern of food intake in patients with liver disease. Our hypothesis was that energy intake might be increased during the early morning in patients with liver disease, compared to controls, to compensate for a more catabolic state after an overnight fast in patients, due to reduced liver glycogen stores in liver disease. We also studied the habitual intake of macronutrients, i.e. intake of protein, fat, carbohydrate and alcohol.
Patients and methods Patients
10 male and 10 female patients with liver disease participated in the study. Their mean age was 51 (range 25-71) years. Mean body mass index was 25.4 (range 20.4-33.3) kg/m=. Further details are shown
294
FOOD INTAKE IN PATIENTS WITH LIVER DISEASE
Table 1 Characteristics
of the patients
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Sex M M M M M M M M M M F F F F F F F F F F
Cirrhosis
(years)
BMI (kg/m’)
Diagnosis
(yes/no)
40 49 61 38 49 50 40 49 56 46 71 56 25 58 61 55 41 55 70 48
20.4 23.5 26.4 23.1 26.9 26.6 33.3 27.8 27.8 28.4 21.5 28.5 25.3 22.3 22.9 33.3 22.3 22.4 21.1 24.2
Ale hep PSC CAHB PSC Ale cirrh SH/HL Ale SH SH/HL SH Ale hep AICAH PSC AICAH Crypt cirrh AICAH Crypt cirrh PBC PBC AICAH PSC
yes yes
Age Subject
Child-Pugh
Yes Yes
yes
classification C B A A A
no no ll0
no no yes yes yes yes yes yes yes yes yes no
Abbreviations: AICAH, autoimmune chronic active hepatitis; Ale cirrh, alcoholic cirrhosis; Ale hep, alcoholic hepatitis; Ale SH, alcoholic steatohepatitis; BMI, body mass index; CAHB, chronic active hepatitis B; Crypt cirrh, cryptogenic cirrhosis; HL, hyperlipidaemia; PBC, primary biliary cirrhosis; PSC, primary sclerosing cholangitis; SH, steatohepatitis.
in Table 1. One patient (subject 1) was studied while staying in the hospital for treatment; the other subjects visited the out-patient clinic regularly and were studied at home. Subject 11 was on a sodiumrestricted diet during the experiment; subject 14 on a protein-restricted diet (60 g protein/day). The patients had not received any other dietary advice. Medication included azathioprine (subject 1 l), diuretics (subjects 2, 11 & 14), lactulose (subject 14), prednison (subjects 11, 12 & 19) and Zn-acetate (subject 14). The research protocol was reviewed and approved by the local Ethical Committee. The procedures in the study were carefully explained to the patients before they gave their consent to participate. Food record
A 7-day food record was filled out by the subjects to determine their habitual dietary intake. During these seven consecutive days, subjects recorded their food intake in a diary that was divided into 7 periods a day (three meals, four inter-meal periods). Brand names were asked for as well as cooking recipes that were used. Energy intake and macronutrient composition of the foods (protein, fat, carbohydrate and alcohol) were calculated using the computerized Dutch food composition table (7).
Analysis of data
The results of the present study were compared with a dietary survey of a representative sample of the Dutch population within the age group 22-75 years (n = 3961, 1954 males and 2007 females) (8). Mean body mass of the reference group was assumed to be 75 kg for men aged 22-65 years, 70 kg for elderly men (265 years), 65 kg for women aged 22-65 years and 65 kg for elderly women (265 years) (9). Differences between patients with liver disease and control subjects were tested using one-group t-tests with p < 0.05 as level of significance. Diurnal distribution of energy and macronutrient intake was studied by determining intake over 4 intervals, i.e. from l-4 hours after rising in the morning (including breakfast and morning snack), from 5-8 hours after rising (including lunch and afternoon snack), from 9-12 hours after rising (dinner) and from 13-24 hours after rising (evening snack). In the text, tables and figures, data are presented as the mean and standard error of the mean (SE). Results Energy and macronutrient intake
Table 2 presents habitual energy and macronutrient
CLINICAL NUTRITION
295
Table 2 Habitual energy and macronutrient
intake for patients with liver disease and control subjects. Intake of protein, fat, carbohydrate and alcohol is expressed in absolute values (g/d) and per kilogram body mass (g/kg d) Liver disease (mean + SE) Kl47*597* Energy intake (kJ/d) 70.9 * 2.8 Body mass (kg) 113.7 + 7.8** Energy intake &J/kg d) 68.9 * 5.8 Protein intake (e/d) Fat intake (g/dj70.8 + 7.8*** Carbohydrate intake (g/d) 235.9 * 17.4 Alcohol intake (g/d) 9.6 + 6.7 Protein intake (g/kg d) 0.98 + 0.08 1.01 * 0.12*** Fat intake (g/kg dl Carbohydrate intake (g/kg d) 3.34 f 0.21 Alcohol intake (g/kg d) 0.11 f0.08
Control subjects (population mean) 9629 69.2 138.5 77.8 106.1 235.2 13.5 1.12 1.53 3.39 0.19
Fig. 1. Habitual pattern of energy intake (EI) for patients with liver disease and control subjects. Statistical significance vs controls: *** p < 0.001, * p < 0.05.
Statistical significance vs control subjects: *** p < 0.001, ** p < 0.01, * p < 0.05.
intake for patients with liver disease and control subjects. Energy intake, both expressed in kJ/d and per kg body mass, was significantly decreased in patients with liver disease, compared with control subjects. Intake of fat, both expressed in g/d and per kg body mass, was significantly lower in patients with liver disease (p < O.OOl), whereas there was no difference in protein-, carbohydrate- or alcohol intake between patients with liver disease and control subjects.
Pattern of food intake Figure 1 presents the diurnal distribution of energy intake for patients with liver disease and control subjects. Patients with liver disease showed an increased energy intake in the first 4 h after rising, compared with control subjects (p < 0.001). During the following interval, energy intake was lower in patients than in control subjects (p < 0.05). The diurnal distribution of protein-, fat-, carbohydrate- and alcohol intake is shown in Figure 2. During the first 4 h after rising the consumption of protein was significantly increased in the patient group (p < O.Ol), whereas intake of protein in the evening was decreased compared with control subjects (9-12 h after rising: p < 0.001; 13-24 h after rising: p < 0.05). Fat intake was greatly decreased in patients with liver disease compared to controls during 3 intervals (i.e. from 5-24 h after rising: p < 0.001). Carbohydrate intake was only significantly different between the two groups during the second interval (p < 0.05). There were no significant differences observed concerning the distribution of alcohol intake.
Discussion One of the causes of undernutrition in patients with late stage cirrhosis or other types of liver disease is insufficient food intake. This is especially common in patients with ascites, probably due to abdominal distension and an early feeling of satiety during eating (2). We investigated the habitual energy and macronutrient intake and the pattern of food intake in patients with liver disease. None of the patients had received dietary advice that would have influenced their habitual eating behaviour, except for subject 11 (sodium-restricted diet) and 14 (protein-restricted diet). Total energy intake (in absolute values and expressed per kg body mass) was significantly decreased in patients with liver disease (Table 2). Because both body mass and body mass index of the patients were within the normal range, we conclude that patients with liver disease have a reduced energy intake. In patients with liver cirrhosis, incorporation of a late evening meal into the daily energy intake pattern was found to improve the efficiency of nitrogen metabolism, presumably by delaying the onset of gluconeogenesis from amino-acids at night (6). Referring to these findings, the habitual pattern of energy intake over the day in patients with liver disease was studied as well. During the first 4 h after rising in the morning, energy intake was significantly elevated in patients compared with controls (Fig. 1). Patients with liver disease probably have limited glycogen stores in the liver, resulting in a more rapid development of a catabolic state (10-l 1). To compensate for
296
FOOD INTAKE IN PATIENTS WITH LIVER DISEASE
Fig. 2. Intake of protein (A), fat (B), carbohydrate (C) and alcohol (D) over 4 intervals for patients with liver disease and control subjects. Statistical significance vs controls: *** p c 0.001. ** p < 0.01, * p < 0.05.
this catabolic state after an overnight fast, patients with liver disease would have higher energy needs in the morning, and they do indeed eat more. Total fat intake was decreased in patients with liver disease, compared to control subjects (Table 2). Patients in this study, as is usual nowadays, were not advised to reduce their fat intake. It is possible, however, that the patients themselves believed that a low-fat, high-carbohydrate diet might have some beneficial effects on their disease, but this is only speculative. Swart et al (5) suggested that patients with liver cirrhosis have elevated protein requirements because of an early onset of gluconeogenesis from amino acids after an overnight fast, due to limited hepatic glycogen storage. In the present study, we did not observe a significant difference in total protein intake between patients and control subjects, although the daily distribution of protein intake varied greatly. Analysis of the diurnal distribution of macronutrient intake revealed that protein intake was increased in patients with liver disease during the first 4 h after rising in the morning (Fig. 2A). On the other hand, we observed a remarkable decrease in protein intake in patients with liver disease during the period from 9-24 h after rising (0.43 g/kg body mass vs 0.61 g/kg body mass for controls; p < 0.001).
In conclusion, patients with liver disease have a lower total energy intake and a reduced fat intake, compared with control subjects. In the morning energy and protein intake is increased in the patient group. During the evening protein intake is decreased in patients with liver disease when compared with control subjects. These findings are probably functional in order to minimize episodes of catabolism.
References 1. O’Keefe S J, El-Zayadi A R, Carraher T E et al. Malnutrition and immuno-incompetence in patients with liver disease. The Lancet 1980; 20: 615617 2. Johnson R D, Williams R. Nutritional support in alcoholic liver disease. Acta Med Stand, Suppl 1985; 703: 209-218 3. McIntyre N. 1987 Undernutrition and malnutrition in cirrhosis. In : Tygstrup N, Orlandi F (eds) Cirrhosis of the liver: Methods and fields of research. Elsevier Science Publishers BV (Biomedical Division), pp 225-234 4. Mills P R, Skenkin A, Anthony R S et al. Assessment of nutritional status and in vivo immune responses in alcoholic liver disease. Am J Clin Nutr 1983; 38: 849-859 5. Swart G R, Van den Berg J W 0, Wattimena J L D et al. Elevated protein requirements in cirrhosis of the liver investigated by whole body protein turnover studies. Clin Sci 1988: 75: 101-107 6. Swart G R, Zikens M C. Van Vuure J K, Van den Berg J W 0.
CLINICAL NUTRITION
Effect of a late evening meal on nitrogen balance in patients with cirrhosis of the liver. Br Med J 1989; 299: 1202-1203 7. Betel voedingsprogramma: Een professioneel prograrnma voor de personal computer (versie NL03a) Rotterdam: Nederlandse Unilever Bedrijven B.V. 8. Ministerie van Welzijn, Volksgezondheid en Cultuur en het ministerie van Landbouw en Visserij. Wat eet Nederland: Resultaten van de voedselconsumptiepeiling 1988; 1987-1988
297
9. Voedingsraad. Nederlandse voedingsnormen, 1989 10. Owen 0 E, Reichle F A, Mozzoli M A et al. Hepatic, gut, and renal substrate flux rates in patients with hepatic cirrhosis. J Clin Invest 198 1;68: 240-252 Il. Owen 0 E, Trapp V E, Reichard G A et al. Nature and quantity of fuels consumed in patients with alcoholic cirrhosis. J Clin Invest 1983: 72: 1821-1832
Submission date: 5 October 1992; Accepted afrer revision: 23 March 1993