Semin Liver Dis 2020; 40(01): 020-028
DOI: 10.1055/s-0039-1696639
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Management of Lifestyle Factors in Individuals with Cirrhosis: A Pragmatic Review

Puneeta Tandon
1   Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
,
Annalisa Berzigotti
2   Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
› Author Affiliations
Further Information

Publication History

Publication Date:
30 August 2019 (online)

Abstract

Lifestyle-related factors are major determinants/modifiers of prognosis in patients with cirrhosis. Accumulating evidence indicates that malnutrition, obesity, sedentary lifestyle, alcohol and smoking habits, and likely poor oral hygiene can increase the risk of progression of the disease, and some of them are linked to higher risk of hepatocellular carcinoma. Importantly, lifestyle-related factors can be largely corrected, and as such they represent an attractive approach to be added to etiological and pharmacological therapy in patients with cirrhosis. Nonetheless, lifestyle is often neglected in this population. In this concise review, the authors present evidence supporting lifestyle changes in patients with cirrhosis—including, but not limited to, nutrition and physical activity in malnourished and obese patients. They also discuss some elements of motivational interviews as a tool to support a better interaction between hepatologists and patients in this field.

 
  • References

  • 1 Wanless IR, Nakashima E, Sherman M. Regression of human cirrhosis. Morphologic features and the genesis of incomplete septal cirrhosis. Arch Pathol Lab Med 2000; 124 (11) 1599-1607
  • 2 Hytiroglou P, Theise ND. Regression of human cirrhosis: an update, 18 years after the pioneering article by Wanless et al. Virchows Arch 2018; 473 (01) 15-22
  • 3 D'Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 2006; 44 (01) 217-231
  • 4 Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017; 65 (01) 310-335
  • 5 Marcellin P, Gane E, Buti M. , et al. Regression of cirrhosis during treatment with tenofovir disoproxil fumarate for chronic hepatitis B: a 5-year open-label follow-up study. Lancet 2013; 381 (9865): 468-475
  • 6 Plauth M, Bernal W, Dasarathy S. , et al. ESPEN guideline on clinical nutrition in liver disease. Clin Nutr 2019; 38 (02) 485-521
  • 7 Eslamparast T, Montano-Loza AJ, Raman M, Tandon P. Sarcopenic obesity in cirrhosis—the confluence of 2 prognostic titans. Liver Int 2018; 38 (10) 1706-1717
  • 8 van Vugt JL, Levolger S, Coelen RJ, de Bruin RW, IJzermans JN. The impact of sarcopenia on survival and complications in surgical oncology: a review of the current literature. J Surg Oncol 2015; 112 (06) 681-682
  • 9 Nardelli S, Lattanzi B, Merli M. , et al. Muscle alterations are associated with minimal and overt hepatic encephalopathy in patients with liver cirrhosis. Hepatology 2019 (e-pub ahead of print). Doi:10.1002/hep.30692
  • 10 Bhanji RA, Montano-Loza AJ, Watt KD. SARCOPENIA IN CIRRHOSIS: Looking beyond the skeletal muscle loss to see the systemic disease. Hepatology 2019 (e-pub ahead of print). Doi:10.1002/hep.30686
  • 11 Montano-Loza AJ, Angulo P, Meza-Junco J. , et al. Sarcopenic obesity and myosteatosis are associated with higher mortality in patients with cirrhosis. J Cachexia Sarcopenia Muscle 2016; 7 (02) 126-135
  • 12 Kim G, Kang SH, Kim MY, Baik SK. Prognostic value of sarcopenia in patients with liver cirrhosis: a systematic review and meta-analysis. PLoS One 2017; 12 (10) e0186990
  • 13 Sinclair M, Gow PJ, Grossmann M, Angus PW. Review article: sarcopenia in cirrhosis--aetiology, implications and potential therapeutic interventions. Aliment Pharmacol Ther 2016; 43 (07) 765-777
  • 14 van Vugt JL, Levolger S, de Bruin RW, van Rosmalen J, Metselaar HJ, IJzermans JN. Systematic review and meta-analysis of the impact of computed tomography-assessed skeletal muscle mass on outcome in patients awaiting or undergoing liver transplantation. Am J Transplant 2016; 16 (08) 2277-2292
  • 15 Tandon P, Raman M, Mourtzakis M, Merli M. A practical approach to nutritional screening and assessment in cirrhosis. Hepatology 2017; 65 (03) 1044-1057
  • 16 Belarmino G, Gonzalez MC, Torrinhas RS. , et al. Phase angle obtained by bioelectrical impedance analysis independently predicts mortality in patients with cirrhosis. World J Hepatol 2017; 9 (07) 401-408
  • 17 Ruiz-Margáin A, Macías-Rodríguez RU, Duarte-Rojo A, Ríos-Torres SL, Espinosa-Cuevas Á, Torre A. Malnutrition assessed through phase angle and its relation to prognosis in patients with compensated liver cirrhosis: a prospective cohort study. Dig Liver Dis 2015; 47 (04) 309-314
  • 18 Tandon P, Low G, Mourtzakis M. , et al. A model to identify sarcopenia in patients with cirrhosis. Clin Gastroenterol Hepatol 2016; 14 (10) 1473.e3-1480.e3
  • 19 Lai JC, Sonnenday CJ, Tapper EB. , et al. Frailty in liver transplantation: an expert opinion statement from the American Society of Transplantation Liver and Intestinal Community of Practice. Am J Transplant 2019; 19 (07) 1896-1906
  • 20 Lai JC, Covinsky KE, McCulloch CE, Feng S. The liver frailty index improves mortality prediction of the subjective clinician assessment in patients with cirrhosis. Am J Gastroenterol 2018; 113 (02) 235-242
  • 21 European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu; European Association for the Study of the Liver. EASL Clinical practice guidelines on nutrition in chronic liver disease. J Hepatol 2019; 70 (01) 172-193
  • 22 Amodio P, Bemeur C, Butterworth R. , et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism consensus. Hepatology 2013; 58 (01) 325-336
  • 23 Tsien CD, McCullough AJ, Dasarathy S. Late evening snack: exploiting a period of anabolic opportunity in cirrhosis. J Gastroenterol Hepatol 2012; 27 (03) 430-441
  • 24 Plank LD, Gane EJ, Peng S. , et al. Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: a randomized 12-month trial. Hepatology 2008; 48 (02) 557-566
  • 25 Everhart JE, Lok AS, Kim HY. , et al; HALT-C Trial Group. Weight-related effects on disease progression in the Hepatitis C Antiviral Long-Term Treatment against Cirrhosis trial. Gastroenterology 2009; 137 (02) 549-557
  • 26 Berzigotti A, Garcia-Tsao G, Bosch J. , et al; Portal Hypertension Collaborative Group. Obesity is an independent risk factor for clinical decompensation in patients with cirrhosis. Hepatology 2011; 54 (02) 555-561
  • 27 Carias S, Castellanos AL, Vilchez V. , et al. Nonalcoholic steatohepatitis is strongly associated with sarcopenic obesity in patients with cirrhosis undergoing liver transplant evaluation. J Gastroenterol Hepatol 2016; 31 (03) 628-633
  • 28 Choudhary NS, Saigal S, Saraf N. , et al. Sarcopenic obesity with metabolic syndrome: a newly recognized entity following living donor liver transplantation. Clin Transplant 2015; 29 (03) 211-215
  • 29 Ayala R, Grande S, Bustelos R. , et al. Obesity is an independent risk factor for pre-transplant portal vein thrombosis in liver recipients. BMC Gastroenterol 2012; 12: 114
  • 30 Rui R, Lou J, Zou L. , et al. Excess body mass index and risk of liver cancer: a nonlinear dose-response meta-analysis of prospective studies. PLoS One 2012; 7 (09) e44522
  • 31 Chen Y, Wang X, Wang J, Yan Z, Luo J. Excess body weight and the risk of primary liver cancer: an updated meta-analysis of prospective studies. Eur J Cancer 2012; 48 (14) 2137-2145
  • 32 Sundaram V, Kaung A, Rajaram A. , et al. Obesity is independently associated with infection in hospitalised patients with end-stage liver disease. Aliment Pharmacol Ther 2015; 42 (11–12): 1271-1280
  • 33 Sundaram V, Jalan R, Ahn JC. , et al. Class III obesity is a risk factor for the development of acute-on-chronic liver failure in patients with decompensated cirrhosis. J Hepatol 2018; 69 (03) 617-625
  • 34 Karagozian R, Bhardwaj G, Wakefield DB, Baffy G. Obesity paradox in advanced liver disease: obesity is associated with lower mortality in hospitalized patients with cirrhosis. Liver Int 2016; 36 (10) 1450-1456
  • 35 LaMattina JC, Foley DP, Fernandez LA. , et al. Complications associated with liver transplantation in the obese recipient. Clin Transplant 2012; 26 (06) 910-918
  • 36 Terjimanian MN, Harbaugh CM, Hussain A. , et al. Abdominal adiposity, body composition and survival after liver transplantation. Clin Transplant 2016; 30 (03) 289-294
  • 37 Sánchez-Garrido MA, Brandt SJ, Clemmensen C, Müller TD, DiMarchi RD, Tschöp MH. GLP-1/glucagon receptor co-agonism for treatment of obesity. Diabetologia 2017; 60 (10) 1851-1861
  • 38 Hanipah ZN, Punchai S, McCullough A. , et al. Bariatric surgery in patients with cirrhosis and portal hypertension. Obes Surg 2018; 28 (11) 3431-3438
  • 39 Macías-Rodríguez RU, Ilarraza-Lomelí H, Ruiz-Margáin A. , et al. Changes in hepatic venous pressure gradient induced by physical exercise in cirrhosis: results of a pilot randomized open clinical trial. Clin Transl Gastroenterol 2016; 7 (07) e180
  • 40 Zenith L, Meena N, Ramadi A. , et al. Eight weeks of exercise training increases aerobic capacity and muscle mass and reduces fatigue in patients with cirrhosis. Clin Gastroenterol Hepatol 2014; 12 (11) 1920.e2-1926.e2
  • 41 Berzigotti A, Albillos A, Villanueva C. , et al; Ciberehd SportDiet Collaborative Group. Effects of an intensive lifestyle intervention program on portal hypertension in patients with cirrhosis and obesity: the SportDiet study. Hepatology 2017; 65 (04) 1293-1305
  • 42 Saló J, Guevara M, Fernández-Esparrach G. , et al. Impairment of renal function during moderate physical exercise in cirrhotic patients with ascites: relationship with the activity of neurohormonal systems. Hepatology 1997; 25 (06) 1338-1342
  • 43 Willen SS, Knipper M, Abadía-Barrero CE, Davidovitch N. Syndemic vulnerability and the right to health. Lancet 2017; 389 (10072): 964-977
  • 44 Vaughn-Sandler V, Sherman C, Aronsohn A, Volk ML. Consequences of perceived stigma among patients with cirrhosis. Dig Dis Sci 2014; 59 (03) 681-686
  • 45 Bazhan N, Zelena D. Food-intake regulation during stress by the hypothalamo-pituitary-adrenal axis. Brain Res Bull 2013; 95: 46-53
  • 46 Clemmensen C, Müller TD, Woods SC, Berthoud HR, Seeley RJ, Tschöp MH. Gut-brain cross-talk in metabolic control. Cell 2017; 168 (05) 758-774
  • 47 Buganza-Torio E, Mitchell N, Abraldes JG. , et al. Depression in cirrhosis - a prospective evaluation of the prevalence, predictors and development of a screening nomogram. Aliment Pharmacol Ther 2019; 49 (02) 194-201
  • 48 Brewer JA, Ruf A, Beccia AL. , et al. Can mindfulness address maladaptive eating behaviors? Why traditional diet plans fail and how new mechanistic insights may lead to novel interventions. Front Psychol 2018; 9: 1418
  • 49 Hartmann-Boyce J, Johns DJ, Jebb SA, Summerbell C, Aveyard P, Behavioural Weight Management Review G. ; Behavioural Weight Management Review Group. Behavioural weight management programmes for adults assessed by trials conducted in everyday contexts: systematic review and meta-analysis. Obes Rev 2014; 15 (11) 920-932
  • 50 Dunn MA, Josbeno DA, Schmotzer AR. , et al. The gap between clinically assessed physical performance and objective physical activity in liver transplant candidates. Liver Transpl 2016; 22 (10) 1324-1332
  • 51 Villablanca PA, Alegria JR, Mookadam F, Holmes Jr DR, Wright RS, Levine JA. Nonexercise activity thermogenesis in obesity management. Mayo Clin Proc 2015; 90 (04) 509-519
  • 52 Nielsen K, Kondrup J, Martinsen L. , et al. Long-term oral refeeding of patients with cirrhosis of the liver. Br J Nutr 1995; 74 (04) 557-567
  • 53 McClave SA, Kushner R, Van Way III CW. , et al. Nutrition therapy of the severely obese, critically ill patient: summation of conclusions and recommendations. JPEN J Parenter Enteral Nutr 2011; 35 (5, Suppl): 88S-96S
  • 54 Bajaj JS, Idilman R, Mabudian L. , et al. Diet affects gut microbiota and modulates hospitalization risk differentially in an international cirrhosis cohort. Hepatology 2018; 68 (01) 234-247
  • 55 Salas-Salvadó J, Díaz-López A, Ruiz-Canela M. , et al; PREDIMED-Plus investigators. Effect of a lifestyle intervention program with energy-restricted mediterranean diet and exercise on weight loss and cardiovascular risk factors: one-year results of the PREDIMED-Plus trial. Diabetes Care 2019; 42 (05) 777-788
  • 56 Grosso G, Marventano S, Yang J. , et al. A comprehensive meta-analysis on evidence of Mediterranean diet and cardiovascular disease: are individual components equal?. Crit Rev Food Sci Nutr 2017; 57 (15) 3218-3232
  • 57 Schwingshackl L, Missbach B, König J, Hoffmann G. Adherence to a Mediterranean diet and risk of diabetes: a systematic review and meta-analysis. Public Health Nutr 2015; 18 (07) 1292-1299
  • 58 Schwingshackl L, Schwedhelm C, Galbete C, Hoffmann G. Adherence to Mediterranean diet and risk of cancer: an updated systematic review and meta-analysis. Nutrients 2017; 9 (10) E1063
  • 59 Sofi F, Abbate R, Gensini GF, Casini A. Accruing evidence on benefits of adherence to the Mediterranean diet on health: an updated systematic review and meta-analysis. Am J Clin Nutr 2010; 92 (05) 1189-1196
  • 60 Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score. Public Health Nutr 2014; 17 (12) 2769-2782
  • 61 Small DMD, DiFeliceantonio AG. Processed foods and food reward. Science 2019; 363 (6425): 346-347
  • 62 Cattoir L, Van Hoecke F, Van Maerken T. , et al. Clinical burden of hepatitis E virus infection in a tertiary care center in Flanders, Belgium. J Clin Virol 2018; 103: 8-11
  • 63 Layman DK, Walker DA. Potential importance of leucine in treatment of obesity and the metabolic syndrome. J Nutr 2006; 136 (1, Suppl): 319S-323S
  • 64 Cave MC, Hurt RT, Frazier TH. , et al. Obesity, inflammation, and the potential application of pharmaconutrition. Nutr Clin Pract 2008; 23 (01) 16-34
  • 65 Kennedy OJ, Roderick P, Buchanan R, Fallowfield JA, Hayes PC, Parkes J. Systematic review with meta-analysis: coffee consumption and the risk of cirrhosis. Aliment Pharmacol Ther 2016; 43 (05) 562-574
  • 66 Tandon P, Ismond KP, Riess K. , et al. Exercise in cirrhosis: translating evidence and experience to practice. J Hepatol 2018; 69 (05) 1164-1177
  • 67 Duarte-Rojo A, Ruiz-Margáin A, Montaño-Loza AJ, Macías-Rodríguez RU, Ferrando A, Kim WR. Exercise and physical activity for patients with end-stage liver disease: Improving functional status and sarcopenia while on the transplant waiting list. Liver Transpl 2018; 24 (01) 122-139
  • 68 Aamann L, Tandon P, Bémeur C. Role of exercise in the management of hepatic encephalopathy: experience from animal and human studies. J Clin Exp Hepatol 2019; 9 (01) 131-136
  • 69 Dietrich R, Bachmann C, Lauterburg BH. Exercise-induced hyperammonemia in patients with compensated chronic liver disease. Scand J Gastroenterol 1990; 25 (04) 329-334
  • 70 García-Pagàn JC, Santos C, Barberá JA. , et al. Physical exercise increases portal pressure in patients with cirrhosis and portal hypertension. Gastroenterology 1996; 111 (05) 1300-1306
  • 71 Aamann L, Dam G, Rinnov AR, Vilstrup H, Gluud LL. Physical exercise for people with cirrhosis. Cochrane Database Syst Rev 2018; 12: CD012678
  • 72 Moore KT, Kröll D. Influences of obesity and bariatric surgery on the clinical and pharmacologic profile of rivaroxaban. Am J Med 2017; 130 (09) 1024-1032
  • 73 Mathur S, Janaudis-Ferreira T, Wickerson L. , et al. Meeting report: consensus recommendations for a research agenda in exercise in solid organ transplantation. Am J Transplant 2014; 14 (10) 2235-2245
  • 74 Baar K. Training for endurance and strength: lessons from cell signaling. Med Sci Sports Exerc 2006; 38 (11) 1939-1944
  • 75 Monto A, Patel K, Bostrom A. , et al. Risks of a range of alcohol intake on hepatitis C-related fibrosis. Hepatology 2004; 39 (03) 826-834
  • 76 Diehl AM. Obesity and alcoholic liver disease. Alcohol 2004; 34 (01) 81-87
  • 77 Loomba R, Yang HI, Su J. , et al. Synergism between obesity and alcohol in increasing the risk of hepatocellular carcinoma: a prospective cohort study. Am J Epidemiol 2013; 177 (04) 333-342
  • 78 Mahli A, Hellerbrand C. Alcohol and obesity: a dangerous association for fatty liver disease. Dig Dis 2016; 34 (Suppl. 01) 32-39
  • 79 Luca A, García-Pagán JC, Bosch J. , et al. Effects of ethanol consumption on hepatic hemodynamics in patients with alcoholic cirrhosis. Gastroenterology 1997; 112 (04) 1284-1289
  • 80 Spahr L, Goossens N, Furrer F. , et al. A return to harmful alcohol consumption impacts on portal hemodynamic changes following alcoholic hepatitis. Eur J Gastroenterol Hepatol 2018; 30 (08) 967-974
  • 81 Powell Jr WJ, Klatskin G. Duration of survival in patients with Laennec's cirrhosis. Influence of alcohol withdrawal, and possible effects of recent changes in general management of the disease. Am J Med 1968; 44 (03) 406-420
  • 82 Louvet A, Labreuche J, Artru F. , et al. Main drivers of outcome differ between short term and long term in severe alcoholic hepatitis: a prospective study. Hepatology 2017; 66 (05) 1464-1473
  • 83 Altamirano J, López-Pelayo H, Michelena J. , et al. Alcohol abstinence in patients surviving an episode of alcoholic hepatitis: prediction and impact on long-term survival. Hepatology 2017; 66 (06) 1842-1853
  • 84 Mann RE, Smart RG, Govoni R. The epidemiology of alcoholic liver disease. Alcohol Res Health 2003; 27 (03) 209-219
  • 85 O'Shea RS, Dasarathy S, McCullough AJ. ; Practice Guideline Committee of the American Association for the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. Alcoholic liver disease. Hepatology 2010; 51 (01) 307-328
  • 86 Tilg H, Cani PD, Mayer EA. Gut microbiome and liver diseases. Gut 2016; 65 (12) 2035-2044
  • 87 Mellinger JL, Winder GS. Alcohol use disorders in alcoholic liver disease. Clin Liver Dis 2019; 23 (01) 55-69
  • 88 Caputo F, Domenicali M, Bernardi M. Diagnosis and treatment of alcohol use disorder in patients with end-stage alcoholic liver disease. Hepatology 2019; 70 (01) 410-417
  • 89 Fuller RK, Branchey L, Brightwell DR. , et al. Disulfiram treatment of alcoholism. A Veterans Administration cooperative study. JAMA 1986; 256 (11) 1449-1455
  • 90 Addolorato G, Leggio L, Ferrulli A. , et al. Effectiveness and safety of baclofen for maintenance of alcohol abstinence in alcohol-dependent patients with liver cirrhosis: randomised, double-blind controlled study. Lancet 2007; 370 (9603): 1915-1922
  • 91 Dam MK, Flensborg-Madsen T, Eliasen M, Becker U, Tolstrup JS. Smoking and risk of liver cirrhosis: a population-based cohort study. Scand J Gastroenterol 2013; 48 (05) 585-591
  • 92 Altamirano J, Bataller R. Cigarette smoking and chronic liver diseases. Gut 2010; 59 (09) 1159-1162
  • 93 Azzalini L, Ferrer E, Ramalho LN. , et al. Cigarette smoking exacerbates nonalcoholic fatty liver disease in obese rats. Hepatology 2010; 51 (05) 1567-1576
  • 94 Marrero JA, Fontana RJ, Fu S, Conjeevaram HS, Su GL, Lok AS. Alcohol, tobacco and obesity are synergistic risk factors for hepatocellular carcinoma. J Hepatol 2005; 42 (02) 218-224
  • 95 Koh WP, Robien K, Wang R, Govindarajan S, Yuan JM, Yu MC. Smoking as an independent risk factor for hepatocellular carcinoma: the Singapore Chinese Health Study. Br J Cancer 2011; 105 (09) 1430-1435
  • 96 Pessione F, Ramond MJ, Njapoum C. , et al. Cigarette smoking and hepatic lesions in patients with chronic hepatitis C. Hepatology 2001; 34 (01) 121-125
  • 97 Kolly P, Knöpfli M, Dufour JF. Effect of smoking on survival of patients with hepatocellular carcinoma. Liver Int 2017; 37 (11) 1682-1687
  • 98 Ishida JH, Peters MG, Jin C. , et al. Influence of cannabis use on severity of hepatitis C disease. Clin Gastroenterol Hepatol 2008; 6 (01) 69-75
  • 99 Grønkjær LL. Periodontal disease and liver cirrhosis: a systematic review. SAGE Open Med 2015; 3: 2050312115601122
  • 100 Grønkjær LL, Holmstrup P, Schou S, Kongstad J, Jepsen P, Vilstrup H. Periodontitis in patients with cirrhosis: a cross-sectional study. BMC Oral Health 2018; 18 (01) 22
  • 101 Grønkjær LL, Vilstrup H. Oral health in patients with liver cirrhosis. Eur J Gastroenterol Hepatol 2015; 27 (07) 834-839
  • 102 Guggenheimer J, Eghtesad B, Close JM, Shay C, Fung JJ. Dental health status of liver transplant candidates. Liver Transpl 2007; 13 (02) 280-286
  • 103 Acharya C, Sahingur SE, Bajaj JS. Microbiota, cirrhosis, and the emerging oral-gut-liver axis. JCI Insight 2017; 2 (19) 94416
  • 104 Bajaj JS, Matin P, White MB. , et al. Periodontal therapy favorably modulates the oral-gut-hepatic axis in cirrhosis. Am J Physiol Gastrointest Liver Physiol 2018; 315 (05) G824-G837
  • 105 Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. New York, NY: Guildford Press; 2013