Baby and Toddler

Vitamin C (ascorbic acid): Helps the body to absorb iron from plant sources. May play a protective role against some cancers. Dietary sources include fresh fruits, especially citrus fruits, fruit juices, green vegetables, potatoes, berries.

Vitamin A (retinol): Involved in maintaining good vision, and in cell growth and development. Excess retinol can be toxic, particularly to the unborn child, so pregnant mothers should limit consumption and avoid high-dose multi-vitamin supplements, liver and liver products such as pate. Dietary sources include Liver, whole milk, fatty fish, cheese, butter, carrots, dark green leafy vegetables, and orange coloured fruits.

Vitamin D :Most important source is via the action of UV light on skin. Dietary sources include fortified margarine, oily fish, egg yolk and fortified breakfast cereal.

Vitamin E: An antioxidant. Can reduce risks of some types of cancers and heart disease. Dietary sources include vegetable oils, nuts, vegetables, wheat germ, margarine, liver.

Vitamin B1(thiamin): Needed to release energy from nutrients in all cells in the body. Dietary Sources include whole grains, nuts, meat, broccoli, peas, green beans, potatoes, dairy products, fortified bread and breakfast cereals.

Vitamin B12: Used in the formation of blood cells and nerves. Animal products are the only natural dietary source of this vitamin. Dietary sources include beef, eggs, milk, fish, poultry, fortified breakfast cereals.

Folate (folic acid): Involved in the formation of red blood cells. Higher intake of folic acid or foods rich in Folate, before conception and during the first 12 weeks of pregnancy reduce the incidence of nervous system defects in babies e.g. spina bifida. Dietary sources include wholemeal breads, fortified breakfast cereals, vegetables, oranges, milk, dairy foods, nuts and pulses.

Minerals Facts

• Minerals are required by the body for a variety of functions including

• Formation of bones and teeth.
• Essential constituents of body fluids and tissues.
• Components of enzyme systems.
• Nerve function.

• Some minerals are needed in larger amounts than others e.g. calcium, sodium and chlorine.
• Other minerals, although equally important, are required in smaller quantities and are called trace minerals e.g. iron and fluoride.
• Two minerals most often lacking in the diet are calcium and iron

Calcium: Calcium is the main mineral in bones and teeth. Absorption is controlled by vitamin D. An adequate calcium intake is vital to health, especially during periods of growth e.g. childhood, adolescence, pregnancy, and also during lactation. Calcium is sometimes bound by phytates (found in wholegrain cereals and pulses) and oxalates (found in spinach and rhubarb) in foods. This makes it less available to the body. Calcium is easy to absorb from milk and dairy products, but more difficult to absorb from plant foods.

Dietary sources of calcium

Milk, cheese, yoghurt and canned fish containing soft bones e.g. canned salmon, green leafy vegetables, fortified bread.

Iron: Required for the formation of haemoglobin in red blood cells which transport oxygen around the body. Iron from animal sources (haem iron) is much more easily absorbed than iron from plant sources (non-haem iron). Phytate (in cereals and pulses), tannins (in tea and coffee) and calcium can bind non-haem iron and reduce its absorption by the body. Vitamin C (in fruit and vegetables) aids the absorption of non-haem iron. Loss of blood through injury or during menstruation increases iron requirements. Women and teenage girls are particularly prone to iron deficiency anaemia.

Dietary sources of iron

Red meat and meat products are rich in available iron. Other meats, eggs, fish, bread, vegetables and fortified breakfast cereals also contain some iron.

Sodium: Regulates body water content and is involved in energy usage and nerve function. Most raw foods contain very small amounts of sodium chloride (salt), and during processing, preparation, preservation and serving, additional salt is added. Too much salt has been associated with hypertension (high blood pressure). Excess sweating e.g. due to exercise in a hot environment, may result in an increased requirement for salt.

Dietary sources of sodium

The main source of salt in the UK diet is from manufactured foods. It may also be added to foods at the table.

Fluoride: Uncommon in foods, but added to water in many areas. It is also included in most brands of toothpaste. Fluoride helps in the formation of bones and teeth and protects teeth against decay.

Dietary sources of fluoride

Fluorinated water, seafood and toothpaste.

Nutritional Values of the Egg

Eggs are an important source of protein, essential vitamins and minerals and can make a significant contribution to a healthy diet. To illustrate the contribution that eggs make to the diet and nutritional requirements, please refer to the table below. The data on the nutritional content of a single egg is based on a medium egg and all percentage composition figures relate to the contents, excluding the shell.

Source: Royal Society of Chemistry/ MAFF 1991 The Composition of Foods (5th edition)

* Assumes edible portion = 89%

Energy value of eggs
A medium egg has an energy value of 76 kilocalories (318 kilojoules) and the consumption of one egg daily would contribute only around 3% of the average energy requirement of an adult man; 4% for an adult woman.
With their significant protein, vitamin and mineral content and relatively low saturated fat content, eggs are a valuable component in a healthy diet.

Protein
Eggs are an excellent source of protein. Egg protein is of high biological value as it contains all the essential amino acids needed by the human body. Eggs therefore complement other food proteins of lower biological value by providing the amino acids that are in short supply in those foods. 12.5% of the weight of the egg is protein and it is found in both the yolk and the albumen. Although protein is more concentrated around the yolk, there is in fact more protein in the albumen.
On the evaluation scale most commonly used for assessing protein, egg is at the highest point, 100, and is used as the reference standard against which all other foods are assessed.

Vitamins
Eggs contain most of the recognised vitamins with the exception of vitamin C. The egg is a good source of all the B vitamins, plus the fat-soluble vitamin A. It also provides useful amounts of vitamin D, as well as some vitamin E.

Minerals
Eggs contain most of the minerals that the human body requires for health. In particular eggs are an excellent source of iodine, required to make the thyroid hormone, and phosphorus, required for bone health. The egg provides significant amounts of zinc, important for wound healing, growth and fighting infection; selenium, an important antioxidant; and calcium, needed for bone and growth structure and nervous function. Eggs also contain significant amounts of iron, the vital ingredient of red blood cells, but the availability of this iron to the body is uncertain.

Carbohydrate and dietary fibre
Eggs contain only traces of carbohydrate and no dietary fibre.

Fat
10.8% of the egg content is fat. The fat of an egg is found almost entirely in the yolk; there is less than 0.05% in the albumen.
Approximately 11% of an egg’s fatty acids are polyunsaturated, 44% monounsaturated and only 29% saturated.

Cholesterol 
Cholesterol and Lecithin are fat-like substances and are essential to the structure and function of all cells in the body. Cholesterol helps to maintain the flexibility and permeability of cell membranes and is also a raw material for the fatty lubricants that help to keep the skin supple. Cholesterol is essential for the production of sex hormones, cortisol, vitamin D and bile salts.
Lecithin is involved in general lipid transportation in the blood and in the metabolism of cholesterol.

WHAT IS THE ISSUE?

For many years the consensus view among many nutritionists was that adequate amounts of essential nutrients could be obtained from a varied diet and that additional micronutrients would be only necessary for vulnerable groups in times of increased need or when food intake was inadequate to meet the needs of that group. Such vulnerable groups include the elderly, the chronically sick, hospital patients, women at various life stages, children and adolescents, people trying to lose weight, cigarette smokers and some ethnic minorities.

However, today there are many social, demographic, economic and lifestyle changes that determine our nutritional status, and for a variety of reasons many people are not achieving the Recommended Daily Amounts (RDAs) for specific essential micronutrients. In addition, research on the physiological functions of certain micronutrients is demonstrating that they may have benefits to health from intakes higher than those currently consumed.

WHAT IS THE HFMA POSITION?

There needs to be much greater attention paid to the dietary and lifestyle patterns that can have direct health, economic and social consequences. National surveys continue to demonstrate areas of nutritional concerns and it is important that the essential micronutrients are present in the diet in the optimal proportions for health and well-being.

Although it should be possible to achieve current RDAs by eating a varied and balanced diet, it is clear that there is a gap between the ideal balanced diet and the reality of what people actually eat. For those whose eating habits and food selections may compromise nutritional adequacy, dietary supplements can serve as the means of ensuring that nutritional needs are fulfilled.

1. KEY ARGUMENTS

Good health is not a matter of luck. Regular exercise, adequate sleep, stress management and, most of all, a healthy diet, must be regarded as essential. It is never too late to make the necessary lifestyle and dietary changes. The HFMA is constantly reviewing the scientific evidence and the concepts of "optimal" nutrition and the relationships between higher levels of micronutrients and other protective substances and the benefits to human health.

Changing lifestyles have had a real impact on food choices and practices in recent years. Working mothers and single-parent families are two of the major sociological phenomena that are related to changes in eating habits. Convenience is an important factor for working parents and there is increasing dependence on ready-to-eat foods and meals eaten outside the home.

Whilst it is possible to calculate how many people are in the "at risk" groups (see the Technical Section on at-risk groups), the HFMA estimates that there are substantial numbers of people with less than optimal nutrition, for whom additional vitamins and minerals and other dietary supplements would be beneficial and appropriate.

For individuals at all life stages and with different lifestyles, it is important for them to include nutrient-dense foods in their diets, i.e. foods and dietary supplements that contribute a relatively high proportion of nutrients in relation to their calorie intake. Any person who is at risk, for any reason, should consider dietary supplements.

2. BASIC TECHNICAL/SCIENTIFIC DATA

1. Recommended Daily Allowances (RDAs) for healthy people

The vitamins and minerals and other protective substances are contained within the foods we eat, and although the amounts needed are very small, these components act as "catalysts" and they perform vital jobs that keep the body going. The lack of any one of the micronutrients will cause a unique deficiency, which can only be corrected by supplying that particular nutrient. Deficiencies do not occur overnight, but if the body is repeatedly deprived of a specific protective component or a combination of protective components, it soon gets into trouble.

An adequate intake of all the nutrients is essential for health and well-being, and there are additional requirements for growth, pregnancy and lactation as well as in times of stress, such as infection. Individual requirements vary widely and depend on factors such as genetic background, age, sex, height and weight, different rates of metabolism, and physical activity. To compensate for some of these variations, RDAs are set for many essential nutrients, and these are estimated to meet the requirements of practically all healthy people. The RDAs are set by national and international expert groups, which select a number of physiological criteria to define adequacy of intake of a particular nutrient. These criteria include the prevention of a deficiency disease (e.g.. scurvy—a deficiency of vitamin C—or rickets—a deficiency of vitamin D), body tissue saturation and the level of body stores. These classical approaches to setting the RDAs as "minimal" levels for food provision and nutritional security are now being challenged by the latest discoveries that the roles of vitamins and minerals can maximise a physiological effect (e.g. antioxidant functions and optimisation of the immune defences) or may reduce the risk of certain degenerative diseases (e.g. certain cancers, coronary heart disease and osteoporosis) and developmental abnormalities (e.g. folic acid and neural tube defects).

2. Nutritional defences for health and well-being

New evidence points to two important health defence systems. All biological tissues are dynamic and in a constant state of flux, being built up and broken down as part of the normal metabolic processes. When all these processes are finely balanced and tissues remain intact, good health is sustained. If the balance is upset by an inadequate diet or hectic lifestyle, there is a net loss of health and day by day a "pre-illness" situation develops until a classical illness finally emerges. Sub-optimal nutrition over a period of years can lead to debilitating or fatal illness.

1. The immune defence system

Many nutrients and protective substances influence the effectiveness of the immune system. It is made up of a highly complex defence mechanism that is designed to protect us against a host of invading microorganisms including bacteria, viruses, parasites and fungi, and against our own cells becoming cancerous. Health problems can occur if the immune system is overwhelmed as a result of smoking, infections or the use of drugs etc. The immune system needs well over 20 different micronutrients to work effectively, and these include vitamins A, C, E, B6 and folic acid.

4.2.2 The antioxidant defences

Free-radicals are a normal part of the body’s metabolic processes but if they get out of balance, highly reactive forms can be produced that can cause biological, oxidative damage. There is now a substantial body of evidence to support the hypothesis that excessive free-radicals in cells and tissues are the causative agents in some chronic diseases, and that these conditions may be prevented, or their progress delayed, by the consumption of dietary antioxidants, including those essential vitamins with known antioxidant capability—vitamin C and vitamin E. Other micronutrients that are involved include some of the carotenoids like the vitamin A precursor beta carotene, as well as selenium, zinc and folate.

Free-radical damage is now known or suggested to be involved in many pathogenic processes of a number of diseases including cardiovascular disease, in which the cholesterol in the blood is oxidised; some forms of cancer, in which the DNA (the genetic code in our body cells) in the mitochondria (energy-producing structures within the cells) can be degraded and become cancerous; rheumatoid arthritis, in which joints are inflamed; cataracts and age-related macular degeneration (ARMD), where there is damage to the eyes; and several neurodegenerative diseases, including Alzheimer’s disease.

There is increasing evidence to suggest that particular population groups could benefit from enhanced antioxidant intake, including pregnant and postmenopausal women, smokers, the elderly and the less affluent, as well as athletes, who, during exercise, burn more oxygen and have increased requirements. The theory that the ageing process is itself caused by free-radical damage is gaining momentum and it is thought to be associated with oxidation products of certain body fats. These lipid oxidation products, or the products of "rancidity" of the fatty tissues in the body, are known to be bad for health, and the presence of antioxidants such as vitamin E can reduce their rate of formation.

3. At-risk groups and dietary supplements

4.3.1. The elderly

Energy requirements decline with age and appetites tend to get smaller. Hence, older people may not be eating enough to get all the nutrients they need to maintain healthy immune responses and antioxidant defences. Moreover, their bodies may not be able to benefit fully from the food they do eat because of poor absorption or other physiological changes.

4.3.2. The chronically sick

Chronic diseases and impairments such as arthritis, hypertension and stroke, heart conditions, respiratory problems, diabetes, cancers and osteoporosis can all affect the quality of life in an ageing population. Cataract and age-related macular degeneration (ARMD) are also widespread eye diseases. There is considerable research interest in the role of nutrition to prevent the degenerative processes or, at least, to delay their onset. Many prescription drugs as well as common medications can influence nutritional status adversely and people who are unwell often have a limited appetite. Hence, dietary supplements can minimise depletion of nutrients and contribute towards improved nutritional well-being.

4.3.3. Hospital patients

There are a disturbing number of older people, particularly in hospitals and in nursing homes, who are severely undernourished. With limited resources in the health services, nutritional support, including dietary supplements, can make a significant improvement to a patient’s resistance to infection and speed of recovery.

4.3.4. Women’s health

In surveys of nutritional status there are frequently demonstrated chronic shortages of the micronutrients, not only in a woman’s earlier years but also extending through into later life. Low-energy diets, slimming regimes and eating disorders make women even more vulnerable to nutritional inadequacies. For many women, running a home, bringing up children and taking care of elderly relatives as well as working outside the home, can influence their physical and mental well-being. Dietary supplements can provide reassurances and positive nutrition among women throughout their life to ensure their own health, as well as that of their offspring.

4.3.5. Children and adolescents

There are increasing concerns not only about the provision of adequate nutrients but also that dietary and lifestyle imbalances can lead to an increase in the number of overweight and obese children and increased risks of chronic diseases in later life. Nutrients at risk include the vitamins A, C and E and the minerals calcium, iron, magnesium, zinc, copper, selenium and iodine. In older children low levels of physical activity are reflected in poor vitamin D status, and because vitamin D is synthesised via the action of sunlight on skin, the incorporation of dietary calcium into bone may be compromised. Many children and young adults have a low intake of fruits and vegetables, which are major sources of many vitamins and minerals and other protective substances, including the carotenoids (e.g. beta-carotene) and the flavonoids.

Teenagers often tend to skip meals and develop irregular eating habits and so nutrient-dense foods and dietary supplements can help to provide their nutritional needs throughout the day.

4.3.6. Slimmers

Dieting is a common aspect of life for many adults and children, even among those who are not overweight or obese. Methods of weight reduction range from unsupervised fad diets, without any sound scientific bases, to well structured weight-loss programmes under medical supervision. Many people restrict their calorie and fat intakes without proper attention to nutrient balance, frequently by eating fewer foods, eating less at certain times of the day and skipping meals. Any one of these unsupervised dietary changes can result in inadequate intake of the key vitamins, minerals and other protective substances essential for health and well-being.

The nature and duration of any dietary restriction can impact adversely on nutritional status and dietary supplements can have a beneficial role in any approach to weight loss and maintenance of healthy weight.

4.3.7. Smokers of cigarettes

Cigarette smokers have higher death rates from cardiovascular diseases and cancers compared with non-smokers and smoking is responsible for more than 120,000 premature deaths in the UK every year. Smoking increases the production of harmful free-radicals and there is a great deal of research interest in nutrients and other food components that may offer smokers some protection against the damaging by-products of the chemical reactions taking place in the body. Many smokers are unaware of the importance of eating fruits and vegetables and wholegrain foods, and hence dietary supplements can provide the amounts of nutrients that are unlikely to be met by diet alone. Important antioxidants include vitamins A, C, E, beta-carotene, bioflavonoids, zinc, selenium and manganese.

4.3.8. Alcohol

Whether people drink sensibly can substantially affect their mental and physical health and well-being. Low to moderate alcohol consumption as part of a healthy diet is not considered harmful, but excessive intakes over a prolonged period may cause lasting damage. Most of the body organs can be damaged by alcohol but it is the liver that suffers most. Alcoholic drinks—especially spirits—tend to be devoid of nutrients, and hence a daily multivitamin and mineral supplement is advisable

INTRODUCTION

1. The Government will introduce Nutritional Standards on April 1st 2001, they will be the LAW and a legal requirement in all maintained and aided schools in England. Alongside the Standards, the Government has produced guidance, which is not compulsory, but will be used by school caterers and taken into consideration by Local Authorities when preparing specifications for school catering contracts.

It is expected that the Welsh Assembly will introduce Nutritional Standards in Wales on September 1st 2001. At this time LACA is not aware of any proposals to introduce Nutritional Standards for Scotland or Northern Ireland.

2. SET OUT BELOW IS THE BASIS OF THE LAW

The Education (Nutritional Standards for School Lunches) (England) Regulations 2000

Food groups
For the purposes of these regulations, food shall be divided into the following five groups---

A. Fruit and Vegetables. These include fruit and vegetables in all forms (whether fresh, frozen, canned, dried or in the form of juice).
B. Starchy foods. These include bread, chapatis, pasta, noodles, rice, potatoes, sweet potatoes, yams, millet and cornmeal.
C. Meat, fish and other non dairy sources of protein. These include meat and fish in all forms (whether fresh, frozen, canned or dried) including meat and fish products, eggs, nuts, pulses and beans, other than green beans.
D. Milk and dairy foods. These include milk, cheese, yoghurt (including frozen yoghurt and drinking yoghurt), fromage frais, milkshakes and custard but not butter or cream.
E. Foods containing fat and foods containing sugar. These include margarine, butter, other spreading fats, cooking oils and fats, oil based salad dressings, mayonnaise, salad cream, cream, chocolate, crisps, biscuits, pastries, cakes, puddings, ice cream, rich sauces, gravies, jam, sugary soft drinks, sweets, sugar and jelly but not any foods falling within any other group.

The Nutritional Standards relate to four categories as follows: -

2.1 Nutritional requirements for children who attend nursery schools or nursery units in primary schools.
Each day food from each of the groups A, B, C and D shall be available as part of school lunches for registered pupils at nursery schools or nursery units in primary schools.

2.2 Nutritional requirements for pupils at primary schools.
On each day food from each of the groups A, B, C and D shall be available so that
Within group A
Fresh fruit, fruit tinned in juice or fruit salad shall be available every day;
A fruit based dessert shall be available at least twice in any week;
A type of vegetable (which does not fall within group B) shall be available every day;
Within group B, fat or oil shall not be used in the cooking process on more than three days in any week;
Within group C Fish shall be available at least one day in any week;
Red meat shall be available on at least two days in any week.
For the purposes of lunches for registered pupils at primary schools, sources of protein in group C can include dairy sources of protein.

2.3 Nutritional requirements for pupils at secondary schools.
The standards for secondary schools are more flexible as they operate a cash-cafeteria catering operation, offering a wide choice menu and tariff. Students in secondary schools are discerning customers who want to choose branded or similar products that they find in the high street outlets. As you know, if a school-catering outlet does not offer and market a comparable option to its competitors the students (customers) will vote with their feet and go elsewhere.
On each day two types of food from each of groups A, B, C and D shall be available so that –
Within group A both a fruit and a vegetable shall be available;
Within group B every day that a food cooked in oil or fat is available, a food not cooked in fat or oil shall also be available;
Within group C, fish shall be available on at least two days in any week and red meat shall be available on at least three days in any week.

2.4 Nutritional requirements for pupils at community and foundation special schools.
Either the requirements of primary schools or secondary schools shall be complied with in the provision of school lunches for registered pupils at community or foundation special schools.

3. GUIDANCE

The Guidance has been produced as aid to school caterers. Although most operations have already implemented management and production manuals, it may be helpful to use the Guidance along side these.

4. MONITORING

There is an expectation by the Government that the Local Education Authority or the individual school where the budget has been delegated, should monitor the Standards.

5. Action that LACA members need to take.

5.1 Ensure that all menus conform to the Nutritional Standards.

5.2 Ensure that all catering staff who are responsible for preparing, cooking and serving the school lunches understand the requirements of the LAW and that even if they change their menu it complies with the law. Although it is likely that the primary menu is planned centrally by management, the school caterer still needs to know and understand this new law. Management should decide how best to disseminate the guidance to the school caterer on each site.

5.3 Introduce a simple monitoring system based on the dishes that are served each day. An example of this can be found on the LACA web site, the DfEE web site and in the DfEE Guidance Book.

5.4 If possible circulate the Guidance to the school caterer at each site.

5.5 The DfEE has notified the LEA’s and Schools but it is our responsibility to implement them. Use this opportunity to work more closely with the schools on education projects and to promote the importance of School Catering Provision.

6. FINALLY

The Government sees the introduction of the Nutritional Standards as a first step. The DfEE will monitor the implementation of the standards. There will be reviews and possible changes during the next five years. LACA has been very influential in ensuring that its members have standards that are practical to implement and at the same time will help to improve the health of our young people for their future life as adults. It is now up to all who work in school catering to grasp this opportunity to ensure the continuance of this vital service to pupils, students and staff.

GENERAL NUTRITIONAL GUIDELINES FOR INDIVIDUALS WITH LIVER DISEASE

 

After being diagnosed with liver disease, among the first questions that patients typically ask concern nutrition. Unfortunately, one cannot expect to walk into the doctor's office and request "a diet for liver disease". Such an across-the-board diet simply does not exist. Many factors account for the unfeasibility of a standardized liver diet, including variations among the different types of liver disease ( for example, alcoholic liver disease versus primary biliary cirrhosis) and the stage of the liver disease ( for example, stable liver disease without much damage versus unstable decompensated cirrhosis, complicated by encephalopathy). Other medical disorders unrelated to liver disease, such as diabetes or heart disease, must also be factored into any diet. Each person has his or her own individual nutritional requirements, and these requirements may change over time.

Nutrition and liver disease can be a complicated subject. That is why I devoted an entire chapter to this topic in my book: "Dr. Melissa Palmer's Guide To Hepatitis And Liver Disease". The following information, which is excerpted from my book, contains just a few highlights that an individual should keep in mind nutritionally.

 

Notwithstanding the above information, an example of an optimal diet for a person with stable liver disease( modifications to be made as per individual needs) might contain all of the factors listed below.

 

1) 60 - 70 percent carbohydrates - primarily complex carbohydrates, such as pasta and whole-grain breads.

2) 20-30 percent protein - only lean animal protein and/or vegetable protein.

3) 10 - 20 percent polyunsaturated fat.

4) 8-12 eight ounce glasses of water per day.

5) 1,000 to 1500 milligrams of sodium per day

6) Avoidance of excessive amounts of vitamins and minerals, especially vitamin A, vitamin B3, and iron.

7) No alcohol

8) Avoidance of processed food.

9) Liberal consumption of fresh organic fruits and vegetables.

10) Avoidance of excessive caffeine consumption - no more than 1-3 cups of caffeine-containing beverages per day.

11) Vitamin D and calcium supplement.

 

PROTEIN

Proteins are the major building blocks that the body uses to make body components such as muscles, hair, nails, skin, and blood. Proteins also make up important parts of the immune system called antibodies, which help fight off disease. Since protein is such a vital component of the body, many people mistakenly believe that the more protein they consume, the better. Not only is this belief misguided, but for someone with liver damage such an approach to nutrition can actually be downright dangerous. The trouble is that a damaged liver cannot process as much healthy liver. And, when a damaged liver gets unduly overloaded with protein, encephalopathy ( a state of mental confusion that can lead to coma) may occur. Finally, diets high in protein have been demonstrated to enhance the activity of the cytochrome P450 enzyme system, which is responsible for drug metabolism. This enhanced activity increases the likelihood that a drug may be converted into a toxic byproduct capable of causing liver injury.

Protein intake must be adjusted in accordance with a person's body weight and the degree of liver damage present. Approximately 0.8 grams of protein per kilogram (2.2 pounds) of body weight is recommended in the diet each day for someone with stable liver disease. People with unstable liver disease or decompensated cirrhosis need to lower the percentage of protein content in their diets so that it falls between approximately 10 to 15 %. And, they need to eat only vegetable sources of protein. A diet high in animal protein ( which typically contains alot of ammonia) may precipitate an episode of encephalopathy among these people. Vegetarian diets, on the other hand, have a low ammonia content and have been shown to be much less likely than animal protein diets to induce encephalopathy. It is important to keep in mind that some popular weight-loss diets involve the consumption of a very high animal protein content. People with cirrhosis are advised to avoid any such diets.

 

CARBOHYDRATES

The major function of carbohydrates is to provide a ready supply of energy to the body. The liver plays a crucial role in carbohydrate metabolism. Before sugars are able to supply energy to the body, they are routed to the liver, which is in charge of deciding their fate. Thus, it may immediately send sugar into the blood stream to provide an instant energy boost. Or, the liver may send glucose to the brain or muscles, depending upon what activities are being performed at the time, (for example, taking a test versus exercising). Or it may decide to store glucose ( in the form of the starch glycogen) for later use. Converting foods other than carbohydrates into energy is stressful, even to a normal liver. By eating an unbalanced diet that is low in complex carbohydrates, a person with liver disease will add to the stress that the disease has already caused the liver. In fact, this is one reason why so many people with liver disease feel fatigued. Simply put, their diets are working against them.

People with liver disease should strive for a diet consisting of approximately 60 - 70 % carbohydrates, with complex carbohydrates ( starches and fibers) predominating. A well-balanced diet will include at least 400 grams of carbohydrates. If there are too few carbohydrates in a person's diet, this will likely result in excessive protein and fat intake.

 

FAT

Fats are the body's most efficient means for storing excess energy. Gram for gram, fats contain more than double the amount of calories of other nutrients. That is why a diet high in fat is likely to result in more weight gain than a diet high in calories from protein or carbohydrates. It is important for people with liver disease to minimize their fat intake by avoiding foods that are high in fat content. Excess fat can result in a fatty liver or nonalcoholic steatohepatitis (NASH). Not only can a fatty liver cause liver disease, it may contribute to the worsening of other liver diseases. For example, it has been demonstrated that people with hepatitis C and a fatty liver are likely to develop scarring in the liver at an accelerated rate. Furthermore, although uncommon, it is possible for someone with NASH to develop cirrhosis and liver failure. In fact, fatty livers are felt to be so unhealthy that they are not even considered viable for use in transplantation.

As a general rule, no more than 30% of a person's caloric intake should come from fat. People who are overweight should aim for something in the neighborhood of 10%. While it is important to eat as little fat as possible.eating a small amount of the more healthy fats does have some benefit. For example, people need some fat in order to properly absorb the four fat-soluble vitamins - A,D,E, and K. Without some fat, these vitamins may become deficient in the body, even if they are taken in supplemental form. This type of vitamin deficiency sometimes occurs in people with cholestatic diseases such as primary biliary cirrhosis.

 

VITAMINS AND MINERALS

The liver is the body's main warehouse for storing nutrients. It absorbs and stores excess vitamins and minerals from the blood. If a person's diet does not supply an adequate amount of these nutrients on a given day, the liver releases just the right amount of them into the bloodstream. However, the liver has only a limited capacity for processing vitamins and minerals. Any excess amounts that the liver is unable to process are generally eliminated from the body. Yet, at some point, the liver can become damaged due to the strain of processing an overabundance of certain vitamins and minerals ( particularly iron, vitamin A and niacin).

If a person eats a healthy, well-balanced diet, all the vitamins and minerals for daily needs and activities should be amply supplied. Despite this, many people feel that they should take vitamin and/or mineral supplements "just to be on the safe side". While this may be fine for an overall healthy person, it may be downright dangerous for someone with liver disease. Thus, excessive doses of vitamin and mineral supplements may do much more harm than good to an already damaged liver.

However, there are exceptions to this rule. First, not everyone eats a healthy well-balanced diet. Also, some people follow strict vegetarian diets. Under these circumstances, vitamin and mineral supplementation may be necessary. People with certain liver diseases, especially cholestatic diseases, such as primary biliary cirrhosis, absorb some vitamins poorly. Thus, these people may also require supplementation. Moreover, people with alcoholic liver disease have a need for vitamin supplementation due to the nutrient-depleting effects of alcohol on the body. On the other hand, some liver diseases actually result in an overload of a certain vitamin or mineral. An example of this is hemochromatosis, which is a liver disease of iron overload. Alternatively, there are liver diseases that may be associated with iron deficiency. This may be due to internal bleeding, which can occur in people with bleeding esophageal varices due to decompensated cirrhosis. Therefore, the requirements of vitamins and mineral in the diet of a person with liver disease must be evaluated on an individualized basis.

An in-depth review of every vitamin and mineral is beyond the scope of this article, and the reader is referred to my book for a detailed discussion. However, in general it is important to keep in mind that excessive doses of iron, vitamin A and niacin have been found to be toxic to the liver. Thus, individuals with liver disease are generally advised to avoid these supplements. And, since osteoporosis ( a disease characterized by reduced bone mass resulting in an increased risk for bone fractures), is common to many liver diseases, it is a good idea for all people with chronic liver disease to take a calcium supplement. Calcium supplementation should be limited to no more than 1000 to 2000 milligrams per day and should be taken with a vitamin D supplement ( which is usually included in the calcium tablet). Since stomach acid is needed to properly absorb calcium, antacids, such as Tums, which reduce stomach acid, are poor sources of calcium. Finally. individuals suffering from ascites- a complication of cirrhosis resulting in an abnormal accumulation of fluid in the abdomen, need to limit their intake of sodium. For every gram of sodium consumed, the accumulation of 200 milliliters of fluid results. The lower the consumption of sodium in the diet, the better controlled this excessive fluid accumulation is. For people with ascites, sodium intake should be restricted to under 1,000 milligrams per day and preferably under 500 milligrams. This goal is difficult, yet attainable.

 

SOME TIPS ON DIET

Dining out can present a challenging situation for a person on a special or restricted diet. The fat, sodium, and calorie content of restaurant foods is not included on the menu. For this reason, it is best to steer clear of fast-food establishments completely. When dining out, food should be ordered cooked "dry", meaning it should be prepared without butter, margarine, or oil. Most people with liver disease find that eating multiple small meals throughout the day is the best approach, as it maximizes energy levels and the ability to digest and absorb food. Finally, it must be stressed that all alcohol consumption should be avoided. This includes hidden alcohol contained in desserts, especially cakes and certain coffees.

BASIC NUTRITION

Every body needs good basic nutrition. You know, having adequate nutritional resources is rather like having a lot of money in a current account. Most of the time you don’t need it there but when an emergency happens you have the resources to draw upon. When our health is challenged, having a good nutritional status gives you the best start to a full and fast recovery.

If you want more information ask us for a copy of a cassette on why we need good nutrition.

There are two other nutrients to take into consideration when talking about the body and they are water and oxygen.

Water is very important. Are you getting enough? Virtually all the biochemistry in the body takes place in an aqueous environment and is dependent upon the surface tension of the water. The greater the surface tension the more difficult it is for the biochemical processes to flow easily. The lower the surface tension the easier it is for them to flow. The more dehydrated you are the greater the surface tension is.

So you can see that it is very important that you drink enough water, and we do mean water. A lot of the things we drink are diuretics, that is they make you lose water. Things like tea, coffee, cola, carbonated beverages, alcohol and drinks containing sugar all dehydrate us.

Drinking water, then, is the key. Most authorities agree that we need approximately two litres of water a day. However, remember that this is a guide line only. Your requirements may be more or less than this. If you've not been used to drinking a lot of water then increase your intake gradually until you reach a level that feels right for you.

Oxygen is also very important, are you getting enough? A stupid question maybe because if you're not getting enough you wouldn't be reading this, but how much is enough? Well certainly you are getting enough so that you aren't suffocating but many people don't get optimum amounts for their biochemistry.

So what happens when there is a lack of oxygen? Simply put, the body doesn't burn it's fuel as efficiently. Incomplete combustion of the body's fuel can lead to an accumulation of toxic by products of metabolism which can have an adverse affect on your health.

There are two reasons why you may have reduced oxygen levels. The first is that the partial pressure of oxygen in the air that you are breathing is reduced, for example because you are somewhere where there is high levels of pollution. The second, and by far the most common, reason is that you breath too shallowly. This has the added disadvantage of not removing the waste gasses of respiration which can contribute to a condition of acidosis in the system.

The answer is to breath deeply and rhythmically which has the added benefit of "switching on" the parasympathetic nervous system so countering the stress response.