What foods are good for liver repair and liver regeneration

The liver is the largest gland (organ) in your body, weighing about 1.4 kg (3 pounds) in an average adult. Your liver is a football-sized organ that sits in the upper right portion of your abdomen, beneath your diaphragm and above your stomach. Your liver has many important functions, it performs over 500 functions, including digesting your food and processing and distributing nutrients. Everything that enters your body must pass through your liver to be processed before it can be absorbed into the blood stream. Your liver’s digestive function is to produce bile, a green alkaline liquid that is stored in the gallbladder and secreted into the duodenum. Bile salts emulsify fats in your small intestine; that is, they break up fatty nutrients into tiny particles, just as dish detergent breaks up a pool of fat drippings in a roasting pan. These smaller particles are more accessible to digestive enzymes from the pancreas. The liver also performs many metabolic functions. The liver:

• Picks up glucose from nutrient-rich blood returning from the alimentary canal and stores this carbohydrate as glycogen for subsequent use by the body.
• Producing bile, which helps the body absorb fats, cholesterol and fat-soluble vitamins
• Processes fats and amino acids and stores certain vitamins.
• Processes nutrients, medications and hormones
• Detoxifies many poisons and drugs in your blood.
• Removes bacteria and toxins from your blood
• Makes the blood proteins including proteins that help your blood clot.
• Preventing infection and regulating immune responses

Almost all of these functions are carried out by a type of cell called a hepatocyte or simply a liver cell. A normal, healthy balanced diet will help you recover and stay healthy.

There are many kinds of liver diseases and conditions. Some, like hepatitis, are caused by viruses. Others can be the result of drugs or drinking too much alcohol. Long-lasting injury or scar tissue in the liver can cause cirrhosis. Although your liver has a great ability to repair damage that is inflicted on it, with certain conditions like cirrhosis or chronic hepatitis, the liver can no longer function at its best. Jaundice, or yellowing of the skin, can be one sign of liver disease. If you suffer from some kind of liver disease it is advisable to be in touch with your dietician about the specific needs in your diet. Most people with liver disease find that eating several small meals a day helps. The liver can process these amounts more efficiently and it also maximises their energy levels.

If you’re a liver patient, your diet is adjusted to meet your individual needs. Talk to your doctor and dietitian about what’s best for you. Here are some general food tips for a healthy or healthier liver:

• What to avoid: Don’t eat foods high in fat, sugar and salt. Stay away from a lot of fried foods including fast food restaurant meals. Raw or undercooked shellfish such as oysters and clams are a definite no-no.
• Depending on the state of your liver, you should avoid alcohol. If you’re allowed alcohol, limit it to no more than one drink a day if you’re a woman and two drinks a day if you’re a man.
• Eat a balanced diet: Select foods from all food groups: Grains, fruits, vegetables, meat and beans, milk, and oil.
• Eat food with fiber: Fiber helps your liver work at an optimal level. Fruits, vegetables, whole grain breads, rice and cereals can take care of your body’s fiber needs.
• Drink lots of water: It prevents dehydration and it helps your liver to function better.

Nonalcoholic fatty liver disease (NAFLD) is one of the most common causes of liver disease in the United States. It is projected that 100 million people in the United States will have nonalcoholic fatty liver disease (NAFLD) by 2030, with direct medical costs of about $103 billion annually ¹. Nonalcoholic fatty liver disease (NAFLD) is a condition in which excess fat is stored in your liver. This buildup of fat is not caused by heavy alcohol use. When heavy alcohol use causes fat to build up in the liver, this condition is called alcohol-associated liver disease. NAFLD (nonalcoholic fatty liver disease) is more common in people who have certain conditions, including obesity and conditions that may be related to obesity, such as type 2 diabetes. Studies suggest that one-third to two-thirds of people with type 2 diabetes have NAFLD ². Research also suggests that nonalcoholic fatty liver disease (NAFLD) is present in up to 75% of people who are overweight and in more than 90% of people who have severe obesity, also called extreme obesity ³.

There are two forms of nonalcoholic fatty liver disease (NAFLD):

1. Nonalcoholic fatty liver (NAFL) is a form of NAFLD in which you have fat in your liver but little or no inflammation or liver damage.  Nonalcoholic fatty liver (NAFL) defined as 5% or greater hepatic steatosis without hepatocellular injury or fibrosis ⁴. Nonalcoholic fatty liver (NAFL) typically does not progress to cause liver damage or complications. However, NAFL can cause pain from enlargement of the liver.
2. Nonalcoholic steatohepatitis (NASH) is the form of NAFLD in which you have inflammation of your liver and liver damage, in addition to fat in your liver. Nonalcoholic steatohepatitis (NASH) is defined as 5% or greater hepatic steatosis plus hepatocellular injury and inflammation, with or without fibrosis. The inflammation and liver damage of NASH can cause fibrosis or scarring of the liver. NASH may lead to cirrhosis, in which the liver is scarred and permanently damaged. Cirrhosis can lead to liver cancer. Up to 10% of patients with NASH will eventually develop cirrhosis, which is the third most common causes of death in NAFLD after cardiovascular disease and cancer ⁵.

Experts are not sure why some people with NAFLD have nonalcoholic steatohepatitis (NASH) while others have nonalcoholic fatty liver (NAFL). NAFLD can affect people of any age, including children. Research suggests that close to 10% of U.S. children ages 2 to 19 have NAFLD ⁶. However, people are more likely to develop NAFLD as they age.

The majority of people with NAFLD have nonalcoholic fatty liver (NAFL). Only a small number of people with NAFLD have NASH. Experts estimate about 24% of U.S. adults have NAFLD and about 1.5% to 6.5% of U.S. adults have nonalcoholic steatohepatitis (NASH) ². By 2030, nonalcoholic steatohepatitis (NASH) is predicted to become the leading indication for liver transplantation in U.S. adults, surpassing hepatitis C.

You are more likely to develop nonalcoholic fatty liver disease (NAFLD) if you have the following health conditions:

• overweight or obesity
• insulin resistance or type 2 diabetes
• abnormal levels of fats in your blood, which may include:
  • high levels of triglycerides
  • abnormal levels of cholesterol—high total cholesterol, high LDL cholesterol, or low HDL cholesterol
• metabolic syndrome or one or more traits of metabolic syndrome. Metabolic syndrome is a group of traits and medical conditions linked to overweight and obesity. Doctors define metabolic syndrome as the presence of any three of the following:
  • large waist size
  • high levels of triglycerides in your blood
  • low levels of high-density lipoprotein (HDL) cholesterol is known as the “good” cholesterol, because it helps remove other forms of cholesterol from your bloodstream.
  • high blood pressure
  • higher than normal blood glucose levels or a diagnosis of type 2 diabetes

Other causes of excess fat in the liver include:

• disorders, called lipodystrophies, that cause your body to use or store fat improperly
• rapid weight loss or malnutrition
• some medicines, including corticosteroids, HIV treatment, estrogens, certain medicines used to treat cancer, and others
• exposure to some toxins
• rare genetic diseases, such as Wilson disease and hypobetalipoproteinemia

Researchers are studying whether diets high in fructose—a sugar that is part of table sugar and is also commonly added to sweeten drinks and foods—may increase the risk of NAFLD.

Scientists have also examined the relationship between NAFLD and the microbiome—the bacteria in your digestive tract that help with digestion. Studies have found differences between the microbiomes of people who have NAFLD and those who don’t. Experts are still studying how the microbiome may affect NAFLD.

People with nonalcoholic fatty liver disease (NAFLD) may develop liver complications or other health problems, including:

• Cardiovascular disease, which is the most common cause of death in people who have NAFLD ⁷
• Type 2 diabetes
• Metabolic syndrome
• Conditions that may be part of metabolic syndrome, such as high blood pressure and abnormal levels of fats—cholesterol and triglycerides—in the blood.

Weight loss through diet and exercise is the primary treatment for NAFLD ¹. If you have NAFLD, you should minimize alcohol use, which can further damage your liver. Other treatments, such as bariatric surgery, vitamin E supplements, and pharmacologic therapy with thiazolidinediones or glucagon-like peptide-1 analogues, have shown potential benefit; however, data are limited, and these therapies are not considered routine treatments. Bariatric surgery is surgery that affects your stomach and how food is digested. Bariatric surgery is designed to make your stomach much smaller, which causes the person to feel full after eating only a small amount of food.

If you have NAFLD, your doctor may recommend gradually losing weight if you are overweight or have obesity. Sometimes you might need extra help from a dietitian.

Your doctor may suggest changes to your diet such as:

• limiting your intake of fats, which are high in calories and increase your chance of developing obesity.
• replacing saturated fats and trans fats in your diet with unsaturated fats, especially omega-3 fatty acids, which may reduce your chance of heart disease if you have NAFLD.
• eating more low-glycemic index foods—such as most fruits, vegetables, and whole grains. These foods affect your blood glucose less than high-glycemic index foods, such as white bread, white rice, and potatoes.
• avoiding foods and drinks that contain large amounts of simple sugars, especially fructose. Fructose is found in sweetened soft drinks, sports drinks, sweetened tea, and juices. Table sugar, called sucrose, is rapidly changed to glucose and fructose during digestion and is therefore a major source of fructose.

Cirrhosis is scarring of the liver and it increases the risk of liver cancer. You can reduce your risk of cirrhosis if you:

• Drink alcohol in moderation, if at all. If you choose to drink alcohol, limit the amount you drink. For women, this means no more than one drink a day. For men, this means no more than two drinks a day.
• Maintain a healthy weight. If your current weight is healthy, work to maintain it by choosing a healthy diet and exercising most days of the week. If you need to lose weight, reduce the number of calories you eat each day and increase the amount of exercise you do. Aim to lose weight slowly — 1 or 2 pounds (0.5 to 1 kilograms) each week.

A liver-healthy eating plan includes:

• Vegetables and fruits
• Beans or other legumes
• Lean meats and fish
• Low-fat or fat-free dairy foods
• Whole grains
• Healthy fats, such as olive oil

The following foods are the foundation of a liver-healthy eating plan:

• Vegetables such as leafy greens (spinach, collard greens, kale, cabbage), broccoli, and carrots
• Fruits such as apples, bananas, oranges, pears, grapes, and prunes
• Whole grains such as plain oatmeal, brown rice, and whole-grain bread or tortillas
• Fat-free or low-fat dairy foods such as milk, cheese, or yogurt
• Protein-rich foods:
• Fish high in omega-3 fatty acids (salmon, tuna, and trout)
• Lean meats such as 95% lean ground beef or pork tenderloin or skinless chicken or turkey
• Eggs
• Nuts, seeds, and soy products (tofu)
• Legumes such as kidney beans, lentils, chickpeas, black-eyed peas, and lima beans
• Oils and foods high in monounsaturated and polyunsaturated fats:
• Canola, corn, olive, safflower, sesame, sunflower, and soybean oils (not coconut or palm oil)
• Nuts such as walnuts, almonds, and pine nuts
• Nut and seed butters
• Salmon and trout
• Seeds (sesame, sunflower, pumpkin, or flax)
• Avocados
• Tofu

Research shows that the best foods that protect your heart and blood vessels, include the following:

• Fruits and Vegetables. Current World Health Organization (WHO) recommendations for fruit intake combined with vegetable intake are a minimum 400 g/day ⁸. A recent meta-analysis indicated that the intake of 800 g/day of fruit was associated with a 27% reductions in relative risk of cardiovascular disease ⁹.
• Fatty fish (Omega-3 fatty acids). Omega-3 fatty acid is a polyunsaturated fatty acid that must be obtained through dietary intake from fish as well as other types of seafood as it is not produced naturally in the human body ¹⁰. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are essential fatty acids present in omega-3 ¹¹. Fatty fish such as salmon, sardines and mackerel are abundant sources of omega-3 fatty acids, healthy unsaturated fats that have been linked to lower blood levels of beta-amyloid—the protein that forms damaging clumps in the brains of people with Alzheimer’s disease. Omega-3 fatty acids are thought to help keep your blood vessels healthy and to help to reduce blood pressure. Research into this style of eating has shown a reduced risk of developing problems such as type 2 diabetes, high blood pressure and raised cholesterol, which are all risk factors for heart disease ¹². The American Heart Association recommends eating 2 servings of fish (particularly fatty fish) per week. A serving is 3.5 ounce cooked, or about ¾ cup of flaked fish. Fatty fish like salmon, mackerel, herring, lake trout, sardines and albacore tuna are high in omega-3 fatty acids ¹³. Eating oily fish is a nutritious choice which can form part of the Mediterranean diet (more bread, fruit, vegetables, fish and less meat, and replacing butter with unsaturated fat spreads). Researchers have also found that people who closely follow a traditional Mediterranean style diet are more likely to live a longer life and also are less likely to become obese. Try to eat fish at least twice a week, but choose varieties that are low in mercury, such as salmon, cod, canned light tuna, and pollack. If you’re not a fan of fish, ask your doctor about taking an omega-3 supplement, or choose terrestrial omega-3 sources such as flaxseeds, avocados, and walnuts. Plant sources of omega-3 fatty acids include flaxseed, oils (olive, canola, flaxseed, soybean), nuts and other seeds (walnuts, butternut squash and sunflower). Replacements for vegans/vegetarians exist that are not supplements, but the evidence is not as robust for plant sources of omega-3 fatty acids.
• Berries. Researchers credit the high levels of flavonoids in berries with the benefit ¹⁴. Flavonoids, the natural plant pigments that give berries their brilliant hues, also help improve memory, research shows. Berries contain a particularly high amount of flavonoids called anthocyanidins that are capable of crossing the blood brain barrier and localizing themselves in the hippocampus, an area of the brain known for memory and learning. Epidemiological evidence has established strong inverse associations between flavonoid-rich fruit (e.g. strawberries, grapefruit) and coronary heart disease mortality in cardiovascular disease-free postmenopausal women after multivariate adjustment ¹⁵. In a 20-year study of over 16,000 older adult women (aged ≥70 years), those who ate the most blueberries and strawberries had the slowest rates of cognitive decline by up to two-and-a-half years ¹⁴.
• Walnuts. Nuts are excellent sources of protein, fat-soluble vitamin E and healthy fats, and one type of nut in particular might also improve memory. A 2015 study from UCLA linked higher walnut consumption to improved cognitive test scores. Walnuts are high in a type of omega-3 fatty acid called alpha-linolenic acid (ALA). Diets rich in alpha-linolenic acid and other omega-3 fatty acids have been linked to lower blood pressure and cleaner arteries. That’s good for both the heart and brain.
• Meat-free meals. Heart-healthy eating encourages consuming meat sparingly. Beans, lentils and soybeans, which pack protein and fiber, make a worthy substitute. They’ll keep you full and are rich in B vitamins, which are important for brain health. In one study analyzing the diets of older adults, those who had the lowest intakes of legumes had greater cognitive decline than those who ate more.

Foods good for the liver

You need food to power your body, giving it energy and the material it needs to grow and repair itself. When you eat food, it is broken down in your stomach and intestine (gut) and three main nutrients are extracted:

• carbohydrates
• fat
• protein

These nutrients are then absorbed into your bloodstream and carried to your liver. Here they are either stored, or changed in such a way that your body can use them at once.

At the same time your liver is also working to detoxify substances which may harm your body such as alcohol, other drugs and some of your body’s waste products. If you have a liver problem, then your liver may not be able to do these jobs as efficiently as it should.

Carbohydrate

Carbohydrate (starch) is the body’s main energy (fuel) source. Starch is broken down to produce glucose which is used by your body for energy. A healthy liver makes glycogen from carbohydrates. The glycogen is then broken down and used when your body needs energy. All carbohydrates – simple or complex are broken down into glucose to produce the energy molecule known as ATP (adenosine triphosphate). People with liver disease should have a diet which consists of approximately 60-70% carbohydrates. Legumes, whole grains, vegetables, brown rice etc. are good sources of complex carbohydrates.

Starchy foods are an important part of the healthy diet. They should make up about a third of all the food that you eat. You don’t have to avoid or restrict them because they are ‘fattening’. Instead, be aware of the total amount of starch that you eat. Cutting out one food group, such as carbohydrate can cause dietary imbalance. Starchy foods include bread, potatoes, rice and pasta. Wholegrain options are healthier choices.

Fiber rich foods help your gut to function properly and have many other health benefits. Studies have shown that people who are overweight or obese tend to lose weight if they include plenty of high fiber, starchy carbohydrate in their diets.

Sugar

Sugar is a type of carbohydrate. Like starch, it breaks down into glucose, to provide energy for your body. ‘Free’ sugars are often added to foods during manufacture and include refined sugars such as sucrose (table sugar). This kind of sugar is also found naturally, in unsweetened fruit juices, and in syrups and honey.

Excess consumption of free sugars is linked to the risk of obesity, type 2 diabetes and tooth decay. Many of the free sugars that you consume, are in sugary drinks. A regular can of cola for instance, can contain the equivalent of seven teaspoons of sugar (35g). The guidance about free sugar consumption suggests a daily limit of 30g. This is equivalent to six teaspoons.

The natural sugars found in milk and in whole fruits and vegetables are not free sugars and do not need to be restricted in the same way.

Managing hyperglycemia (high blood sugar) and diabetes

Blood sugar levels may be particularly difficult to control in people with cirrhosis. It is important that you have regular monitoring with your specialist diabetes team if you have fluctuating blood glucose levels. And careful monitoring of body weight is essential.

This is because the liver plays a major role in controlling blood sugar levels. People with cirrhosis may develop high blood sugar levels or hyperglycemia. And many people with cirrhosis have underlying type 2 diabetes.

As well as following the general dietary advice given to all patients with cirrhosis you may also be advised to eat a diet that is:

• High in starchy carbohydrates such as potatoes, bread, pasta and rice. Wholegrain options are healthiest.
• Low in red meat such as beef, pork and lamb. Choose chicken, turkey, fish, dairy or plant-based options such as beans, pulses or tofu.
• Higher in monounsaturated fats than saturated fats. Aim to have less than 10% of your energy intake from saturated fats. Try using oils such as vegetable, olive or sunflower oil and spreads made from them instead of butter, lard, or solid oils such as coconut and palm.

Fruit and vegetables

Fruit and vegetables contain high levels of ‘micronutrients’. These include vitamins, minerals and antioxidants. Micronutrients are essential to the body’s many biochemical processes.

Fruit and vegetables are often high in fiber. They are generally low in calorie and they taste good. The current Dietary Guidelines for Americans recommends at least five portions of different fruit and vegetable per day ¹⁶. Like carbohydrate, fruit and vegetable should account for about one third of what you eat, per day. Dried, frozen, tinned, as well as fresh, fruit and veg are all included. One portion of pulses (baked beans, lentils, dried peas) can also count towards your five a day.

Dietary fiber

Fiber comes from plant-based foods, including fruits, vegetables and wholegrains. Dietary fiber is the part of plants that you eat but which doesn’t get digested in your small intestine. Instead, it is completely or partially broken down (fermented) by bacteria in your large intestine. Once broken down in your large intestine, it has been suggested that dietary fibers increase the beneficial bacteria in your gut. This improves your immune system. Fibre includes carbohydrates called polysaccharides and resistant oligosaccharides. Recent research suggests that fiber should be categorized by its physical characteristics; how well it dissolves (solubility), how thick it is (viscosity) and how well it breaks down (fermentability). Some commonly known terms are described below:

• Soluble fiber including pectins and beta glucans is found in foods like fruit and oats.
• Insoluble fiber including cellulose is found in wheat bran and nuts.
• Resistant starch is a soluble fiber that is highly fermentable in the gut. It gets broken down by good bacteria to produce short chain fatty acids (SCFAs). Resistant starch is naturally present in some foods such as bananas, potatoes, grains and pulses.
• Prebiotics are types of carbohydrate that only our gut bacteria can feed upon. Some examples are onions, garlic, asparagus and banana

Fibre is essential for your gut to work normally. It increases good bacteria which supports your immunity against inflammatory disorders and allergies. A high fiber diet seems to reduce the risk of chronic diseases such as heart disease, type 2 diabetes and bowel cancer.

Eating a range of dietary fiber can:

• Improve the diversity of your microbiota
• Improve constipation and lactose intolerance
• Enhance immunity
• Reduce inflammation in your gut

For example, high quality randomized controlled trials have shown that eating oat bran leads to lower blood pressure and lower total cholesterol.

Benefits of a high-fiber diet:

• Normalizes bowel movements. Dietary fiber increases the weight and size of your stool and softens it. A bulky stool is easier to pass, decreasing your chance of constipation. If you have loose, watery stools, fiber may help to solidify the stool because it absorbs water and adds bulk to stool.
• Helps maintain bowel health. A high-fiber diet may lower your risk of developing hemorrhoids and small pouches in your colon (diverticular disease). Studies have also found that a high-fiber diet likely lowers the risk of colorectal cancer. Some fiber is fermented in the colon. Researchers are looking at how this may play a role in preventing diseases of the colon.
• Lowers cholesterol levels. Soluble fiber found in beans, oats, flaxseed and oat bran may help lower total blood cholesterol levels by lowering low-density lipoprotein, or “bad,” cholesterol levels. Studies also have shown that high-fiber foods may have other heart-health benefits, such as reducing blood pressure and inflammation.
• Helps control blood sugar levels. In people with diabetes, fiber — particularly soluble fiber — can slow the absorption of sugar and help improve blood sugar levels. A healthy diet that includes insoluble fiber may also reduce the risk of developing type 2 diabetes.
• Aids in achieving healthy weight. High-fiber foods tend to be more filling than low-fiber foods, so you’re likely to eat less and stay satisfied longer. And high-fiber foods tend to take longer to eat and to be less “energy dense,” which means they have fewer calories for the same volume of food.
• Helps you live longer. Studies suggest that increasing your dietary fiber intake — especially cereal fiber — is associated with a reduced risk of dying from cardiovascular disease and all cancers.

Good sources of dietary fiber include:

• Pulses (like lentils and peas) and beans and legumes (think navy beans, small white beans, split peas, chickpeas, lentils, pinto beans)
• Fruits and vegetables, vegetables such as carrots, broccoli, green peas, and collard greens; fruits especially those with edible skin (like pears and apples with the skin on) and those with edible seeds (like berries)
• Nuts—try different kinds (pumpkin seeds, almonds, sunflower seeds, pistachios and peanuts are a good source of fiber and healthy fats, but be mindful of portion sizes, because they also contain a lot of calories in a small amount!)
• Whole grains such as:
  • Quinoa, barley, bulgur, oats, brown rice and farro
  • Whole wheat pasta
  • Whole grain cereals, including those made from whole wheat, wheat bran and oats

Choose fiber rich foods from a variety of sources including wholegrains, fruit and vegetable, nuts and seeds, beans and pulses. When you read food labels check for the grams of fiber per serving or per 100g. Foods that are naturally high in fiber and contain at least 3 grams per 100 gram are often labeled as a “good source,” and foods labeled as “excellent source” contain more than 5 grams of fiber per serving.

Depending on your age and sex, adults should get 25 to 31 grams of fiber a day ¹⁷. Older adults sometimes don’t get enough fiber because they may lose interest in food.

• Men over the age of 50 should get at least 38 grams of fiber per day.
• Women over the age of 50 should get 25 grams per day.
• Children ages 1 to 3 should get 19 grams of fiber per day.
• Children between 4 and 8 years old should get 25 grams per day.
• Girls between 9 and 18 should get 26 grams of fiber each day. Boys of the same age range should get between 31 and 38 grams of fiber per day.

You may wish to see a dietitian if you:

• are unsure about how much and/or what types of fiber you currently have in your diet
• suffer with constipation or diarrhea (e.g. irritable bowel syndrome [IBS])
• have a condition which can restrict your fiber intake (e.g. inflammatory bowel disease)

Keep in mind that if you haven’t been eating a lot of foods high in fiber on a daily basis, it’s important to increase your intake slowly to allow your body to adjust. A sudden increase in eating foods high in fiber (especially foods with added fiber or when using supplements) can cause gas, bloating or constipation. Be sure you are drinking enough water too, because fiber needs water to move through your body.

Protein

Protein is vital. It is your body’s main building block. Proteins help build and maintain muscle, bone, skin, connective tissue, internal organs, and blood. They help fight disease and heal wounds. Protein is found in foods from plants and animals. Animal products such as meat, fish, eggs and dairy are good sources of dietary protein. Meat and fish also provide your body with a form of iron (heme), which is easy to absorb. Fish also contains essential fatty acids (e.g, Omega-3).

Protein also comes from foods of plant origin. Pulses, nuts, and seeds are all high in protein. Pulses are a very good meat alternative, whether or not you are vegetarian or vegan. Most people eat both types of protein. Talk to your dietitian about how to choose the right combination of protein foods for you.

The body’s protein needs tend to increase when a person has some form of liver disease. But this does not mean that you can consume as much meat, fish or poultry as your heart desires. Again your dietician will be your best guide. A very high intake of protein can increase the amount of ammonia in your blood. This can lead to a condition called hepatic encephalopathy (mental confusion).

Cutting back on consumption of red meat (beef, lamb, goat, pork) especially, is better for your health and for the environment: current advice is to have no more than 300g of red meat per week. Try to avoid processed meats such as bacon, salami, hot dogs, ham. Consumption of these cured meat products has been linked to a much higher risk of certain gut cancers.

All protein isn’t alike. Protein is built from building blocks called amino acids. Your body makes amino acids in two different ways: Either from scratch, or by modifying others. A few amino acids (known as the essential amino acids) must come from food.

Food protein containing all 9 amino acids in adequate amounts is called complete or high-quality protein.

• ANIMAL FOODS with complete protein include liver (chicken, pork, beef), goose, duck, turkey, chicken, lamb, pork, most fish, rabbit, eggs, milk, cheese (cottage, gjetost, cream, swiss, ricotta, limburger, gruyere, gouda, fontina, edam) and certain beef cuts. Animal foods with incomplete protein include certain yogurts and beef cuts.

• PLANT FOODS with complete protein include spinach, beans (black, cranberry, french, pink, white, winged, yellow), soy, split peas, chickpeas, chestnuts, pistachios, pumpkin seeds, avocado, potatoes, quinoa, a seaweed spirulina, tofu and hummus. Common plant foods with incomplete protein: rice (white and brown), white bread (including whole-wheat), pasta, beans (adzuki, baked, kidney, lima, pinto, snap), peas, lentils, nuts (walnuts, peanuts, hazelnuts, almonds, coconut), sunflower seeds, kamut.

In determining the effectiveness of a protein is accomplished by determining its quality and digestibility. Quality refers to the availability of amino acids that it supplies, and digestibility considers how the protein is best utilized. Typically, all dietary animal protein sources are considered to be complete proteins. That is, a protein that contains all of the essential amino acids ¹⁸. Proteins from vegetable sources are incomplete in that they are generally lacking one or two essential amino acids. Thus, someone who desires to get their protein from vegetable sources (i.e. vegetarian, vegan) will need to consume a variety of vegetables, fruits, grains, and legumes to ensure consumption of all essential amino acids. As such, individuals are able to achieve necessary protein requirements without consuming beef, poultry, or dairy ¹⁸. Protein digestibility ratings usually involve measuring how the body can efficiently utilize dietary sources of protein. Typically, vegetable protein sources do not score as high in ratings of biological value, net protein utilization, protein digestibility corrected amino acid score and protein efficiency ratio as animal proteins.

Vegetarians need to be aware of this. People who don’t eat meat, fish, poultry, eggs, or dairy products need to eat a variety of protein-containing foods each day in order to get all the amino acids needed to make new protein.

1. Animal Protein Foods : Animal sources of protein tend to deliver all the amino acids we need. Meat, such as pork, beef, chicken, turkey, duck / Eggs / Dairy products, such as milk, yogurt, cheese / Fish
2. Plant (Vegetable) Protein Foods : Other protein sources, such as fruits, vegetables, grains, nuts and seeds, lack one or more essential amino acids.
   

• High Protein Plant Foods: Beans, peas, lentils / Soy foods, such as soy milk, tofu / Nuts and nut spreads, such as almond butter, pea
  / nut butter, soy nut butter /Sunflower seeds ¹⁹
• Low Protein Plant Foods: Bread, tortillas  / Oatmeal, grits, cereals  / Pasta, noodles, rice / Rice milk (not enriched).

Finding balance, choosing the right kind and amount of protein.

• When choosing protein, opt for low-fat options, such as lean meats, skim milk or other foods with high levels of protein. Legumes, for example, can pack about 16 grams of protein per cup and are a low-fat and inexpensive alternative to meat.

Choose main dishes that combine meat and vegetables together, such as low-fat soups, or a stir-fry that emphasizes veggies.

• Some high-protein foods are healthier than others because of what comes along with the protein: healthy fats or harmful ones, beneficial fiber or hidden salt. It’s this protein package that’s likely to make a difference for health. For example, a 6-ounce broiled porterhouse steak is a great source of protein—about 40 grams worth. But it also delivers about 12 grams of saturated fat ²⁰. For someone who eats a 2,000 calorie per day diet, that’s more than 60 percent of the recommended daily intake for saturated fat.
• Watch portion size. Aim for 2- to 3-ounce servings.
• If you’re having an appetizer, try a plate of raw veggies instead of a cheese plate. Cheese adds protein, but also fat.
• A 6-ounce ham steak has only about 2.5 grams of saturated fat, but it’s loaded with sodium—2,000 milligrams worth, or about 500 milligrams more than the daily sodium max.

6-ounces of wild salmon has about 34 grams of protein and is naturally low in sodium, and contains only 1.7 grams of saturated fat ²⁰. Salmon and other fatty fish are also excellent sources of omega-3 fats, a type of fat that’s especially good for the heart. Alternatively, a cup of cooked lentils provides about 18 grams of protein and 15 grams of fiber, and it has virtually no saturated fat or sodium ²⁰.

The Vegetarian Society’s Vegetarian sources of protein include ²¹:

• Nuts, beans and pulses, such as quinoa – these have very high levels of protein
• Cheese
• Eggs – have the perfect balance of amino acids
• Soya is very versatile and found in soya milk, tofu, miso and ready made products such as burgers and sausages
• Quorn is a form of myco-protein and sold in a range of forms
• Rice, grains, pasta, bread and potatoes, although not generally known for their protein, play an important part in your protein intake

Vegetarian food of animal origin such as cheese, milk and eggs have a good balance of essential amino acids. However, food groups such as cereals, rice and legumes (peas, lentils and beans) have an imbalance of 2 of the essential amino acids. To provide a ‘complete’ protein, containing a balance of all 8 essential amino acids, it is recommended to consume a combination of cereals and legumes in your diet e.g. beans on toast.

Dairy

Dairy products and calcium-fortified alternatives are your body’s main source of calcium, which is necessary for the growth, development and maintenance of healthy bones and teeth. Dairy products and alternatives are also a source of protein. Milk, cheese, cream and milk-based sauces and yogurts can have a high saturated fat content. Fat reduced options are recommended, and small quantities.

Fats

Fats also known as lipids, is an essential nutrient (a primary storage form of energy, a kilojoule-dense nutrient) your body need for energy and to help your gut absorb vitamins A, D, E and K from foods. Fat has twice as many calories as proteins or carbohydrates. There are nine calories (37kJ) in every gram of fat, regardless of what type of fat it is. Fats are more energy-dense than carbohydrates and proteins, which provide four calories (17kJ) per gram. Dietary fat also plays a major role in your cholesterol levels. You need some fat in your diet but not too much. There are different types of fats, some are “good” and some are “bad”, however, you should try to avoid “bad” fats. When it comes to dietary fat, what matters most is the type of fat you eat. Contrary to past dietary advice promoting low-fat diets, newer research shows that healthy fats are necessary and beneficial for health. To cut down on the amount of fat in your diet, you should grill, bake, boil, steam or casserole your meals instead of frying. Trim visible fat off meat and remove skin from poultry. Be aware of hidden fats in your food.

Healthy fats are unsaturated. They keep cholesterol levels within a healthy range, reduce your risk of heart problems and may be good for the skin, eyes and brain. Unsaturated fats are the best choice for a healthy diet.

Unhealthy fats are saturated and trans fats, which can raise levels of ‘bad’ cholesterol and increase the risk of heart disease. Multiple studies have linked high levels of saturated fat with cognitive decline. A diet that is higher in unsaturated fats and lower in saturated fats is linked to better cognition.

• Saturated fats such as butter, solid shortening, and lard. Eating foods that contain saturated fats raises the level of cholesterol in your blood. High levels of LDL cholesterol (low-density lipoprotein or “bad” cholesterol) in your blood increase your risk of heart disease and stroke. The American Heart Association recommends aiming for a dietary pattern that achieves 5% to 6% of calories from saturated fat. For example, if you need about 2,000 calories a day, no more than 120 of them should come from saturated fat. That’s about 13 grams of saturated fat per day ²².
• Trans fats also known as trans fatty acids or “partially hydrogenated oils”. These are found in vegetable shortenings, some margarines, crackers, cookies, snack foods, and other foods made with or fried in partially hydrogenated oils. By 2018, most U.S. companies will not be allowed to add partially hydrogenated oils to food.

“Bad” fats, such as artificial trans fats and saturated fats, are guilty of the unhealthy things all fats have been blamed for—weight gain, clogged arteries, an increased risk of certain diseases, and so forth. Large studies have found that replacing saturated fats in your diet with unsaturated fats and omega-3 fatty acids can reduce your risk of heart disease by about the same amount as cholesterol-lowering drugs. Since fat is an important part of a healthy diet, rather than adopting a low-fat diet, it’s more important to focus on eating more beneficial “good” fats and limiting harmful “bad” fats. For good health, the majority of the fats that you eat should be monounsaturated or polyunsaturated. Eat foods containing monounsaturated fats and/or polyunsaturated fats such as canola oil, olive oil, safflower oil, sesame oil or sunflower oil instead of foods that contain saturated fats and/or trans fats.

For years you’ve been told that eating fat will add inches to your waistline, raise cholesterol, and cause a myriad of health problems. When food manufacturers reduce fat, they often replace it with carbohydrates from sugar, refined grains, or other starches. Your body digests these refined carbohydrates and starches very quickly, affecting your blood sugar and insulin levels and possibly resulting in weight gain and disease ²³. But now scientists know that not all fat is the same. Research has shown that unsaturated fats are good for you. Healthy fats play a huge role in helping you manage your moods, stay on top of your mental game, fight fatigue, and even control your weight. These fats come mostly from plant sources. Cooking oils that are liquid at room temperature, such as canola, peanut, safflower, soybean, and olive oil, contain mostly unsaturated fat. Nuts, seeds, and avocados are also good sources. Fatty fish—such as salmon, sardines, and herring—are rich in unsaturated fats, too. You should actively make unsaturated fats a part of your diet. Of course, eating too much fat will put on the pounds too. Note also that by swapping animal fats for refined carbohydrates—such as replacing your breakfast bacon with a bagel or pastry—won’t have the same benefits. In fact eating refined carbohydrates or sugary foods can have a similar negative effect on your cholesterol levels, your risk for heart disease, and your weight. Limiting your intake of saturated fat can still help improve your health—as long as you take care to replace it with good fat rather than refined carbs. In other words, don’t go no fat, go good fat.

Healthy-eating tips:

• Use olive oil in cooking.
• Replace saturated fats with unsaturated fats; for example, use avocado, tahini, nut or seed butter instead of dairy butter.
• Eat fish, especially oily fish, twice a week.
• Consume legume- or bean-based meals twice a week.
• Snack on nuts or add them to your cooking.
• Throw avocado in salads.
• Choose lean meats and trim any fat you can see (including chicken skin).
• Use table spreads that have less than 0.1g of trans fats per 100g.

Saturated fats

Saturated fats are fat molecules that are “saturated” with hydrogen molecules. Saturated fats are normally solid at room temperature. Saturated fats occur naturally in many foods — primarily meat and dairy foods (butter, cream, full-fat milk and cheese). Beef, lamb, pork on poultry (with the skin on) contain saturated fats, as do butter, cream and cheese made from whole or 2% milk. Plant-based foods that contain saturated fats include coconut, coconut oil, coconut milk and coconut cream, cooking margarine, and cocoa butter, as well as palm oil and palm kernel oil (often called tropical oils). Saturated fats are also found in snacks like chips, cakes, biscuits and pastries, and takeaway foods. Consuming more than the recommended amount of saturated fat is linked to heart disease and high cholesterol.

The American Dietary Guidelines recommend that:

• men should not eat more than 30g of saturated fat a day
• women should not eat more than 20g of saturated fat a day
• children should have less

For people who need to lower their cholesterol, the American Heart Association recommends reducing saturated fat to less than 6% of total daily calories. For someone eating 2,000 calories a day, that’s about 11 to 13 grams of saturated fat ²².

Examples of foods with saturated fat are:

• fatty beef,
• lamb,
• pork,
• poultry with skin,
• beef fat (tallow),
• meat products including sausages and pies,
• lard and cream,
• butter and ghee,
• cheese especially hard cheese like cheddar,
• other dairy products made from whole or reduced-fat (2 percent) milk,
• cream, soured cream and ice cream,
• some savory snacks, like cheese crackers and some popcorns,
• chocolate confectionery,
• biscuits, cakes, and pastries

In addition, many baked goods and fried foods can contain high levels of saturated fats. Some plant-based oils, such as palm oil, palm kernel oil, coconut oil and coconut cream, also contain primarily saturated fats, but do not contain cholesterol.

Unsaturated Fats

If you want to reduce your risk of heart disease, it’s best to reduce your overall fat intake and swap saturated fats for unsaturated fats. Unsaturated fats are in fish, such as salmon, trout and herring, and plant-based foods such as avocados, olives and walnuts. Liquid vegetable oils, such as soybean, corn, safflower, canola, olive and sunflower, also contain unsaturated fats.

There are 2 types of unsaturated fats: monounsaturated and polyunsaturated. Unsaturated fats help reduce your risk of heart disease and lower your cholesterol levels.

• Polyunsaturated fats such as omega-3 and omega-6 fats are found in fish, nuts, and safflower and soybean oil.
• Monounsaturated fats are found in olive and canola oil, avocado, cashews and almonds.

Monounsaturated fats have one (“mono”) unsaturated carbon bond in the molecule. Polyunsaturated fats have more than one (“poly,” for many) unsaturated carbon bonds. Both of these unsaturated fats are typically liquid at room temperature.

Eaten in moderation, both kinds of unsaturated fats may help improve your blood cholesterol when used in place of saturated and trans fats.

Polyunsaturated fats

Polyunsaturated fats are simply fat molecules that have more than one unsaturated carbon bond in the molecule, this is also called a double bond. Oils that contain polyunsaturated fats are typically liquid at room temperature but start to turn solid when chilled. Olive oil is an example of a type of oil that contains polyunsaturated fats.

There are 2 main types of polyunsaturated fats: omega-3 and omega-6. Oils rich in polyunsaturated fats also provide essential fats that your body needs but can’t produce itself – such as omega-6 and omega-3 fatty acids. You must get essential fats through food. Omega-6 and omega-3 fatty acids are important for many functions in the body. A deficiency of essential fatty acids—either omega-3s or omega-6s—can cause rough, scaly skin and dermatitis ²⁴.

Polyunsaturated fats can help reduce bad cholesterol levels in your blood which can lower your risk of heart disease and stroke. Polyunsaturated fats also provide nutrients to help develop and maintain your body’s cells. Oils rich in polyunsaturated fats also contribute vitamin E to the diet, an antioxidant vitamin most Americans need more of.

Foods high in polyunsaturated fat include a number of plant-based oils, including:

• soybean oil
• corn oil
• sunflower oil

Other sources include some nuts and seeds such as walnuts and sunflower seeds, tofu and soybeans.

Omega-6 fats are found in vegetable oils, such as:

• rapeseed
• corn
• sunflower
• some nuts

Omega-3 fats are found in oily fish, such as:

• kippers
• herring
• trout
• sardines
• salmon
• mackerel

The American Heart Association also recommends eating tofu and other forms of soybeans, canola, walnut and flaxseed, and their oils. These foods contain alpha-linolenic acid (ALA), another omega-3 fatty acid.

Polyunsaturated fats (PUFAs) are frequently designated by their number of carbon atoms and double bonds. Alpha-linolenic acid (ALA), for example, is known as C18:3n-3 because it has 18 carbons and 3 double bonds and is an omega-3 fatty acid. Similarly, eicosapentaenoic acid (EPA) is known as C20:5n-3 and docosahexaenoic acid (DHA) as C22:6n-3. Omega-6 fatty acids (omega-6s) have a carbon–carbon double bond that is six carbons away from the methyl end of the fatty acid chain. Linoleic acid (LA) known as C18:2n-6 and arachidonic acid (AA) known as C20:4n-6 are two of the major omega-6s.

The human body can only form carbon–carbon double bonds after the 9th carbon from the methyl end of a fatty acid ²⁵. Therefore, alpha-linolenic acid (ALA) and linoleic acid (LA) are considered essential fatty acids, meaning that they must be obtained from the diet ²⁶. Alpha-linolenic acid (ALA) can be converted into eicosapentaenoic acid (EPA) and then to docosahexaenoic acid (DHA), but the conversion (which occurs primarily in the liver) is very limited, with reported rates of less than 15% ²⁷. Therefore, consuming EPA and DHA directly from foods and/or dietary supplements is the only practical way to increase levels of these fatty acids in the body.

Alpha-linolenic acid (ALA) is present in plant oils, such as flaxseed, soybean, and canola oils ²⁷. Docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) are present in fish, fish oils, and krill oils, but they are originally synthesized by microalgae, not by the fish. When fish consume phytoplankton that consumed microalgae, they accumulate the omega-3s in their tissues ²⁷.

Some researchers propose that the relative intakes of omega-6s and omega-3s—the omega-6/omega-3 ratio—may have important implications for the pathogenesis of many chronic diseases, such as cardiovascular disease and cancer ²⁸, but the optimal ratio—if any—has not been defined ²⁹. Others have concluded that such ratios are too non-specific and are insensitive to individual fatty acid levels ³⁰. Most agree that raising eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) blood levels is far more important than lowering linoleic acid (LA) or arachidonic acid levels.

Currently, most clinicians do not assess omega-3 status, but it can be done by measuring individual omega-3s in plasma or serum phospholipids and expressing them as the percentage of total phospholipid fatty acids by weight ³¹. Experts have not established normal ranges, but mean values for serum or plasma phospholipid eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) among U.S. adults not taking omega-3 supplements are about 3%–4% ³¹. Plasma and serum fatty acid values, however, can vary substantially based on an individual’s most recent meal, so they do not reflect long-term dietary consumption ³².

It is also possible to assess omega-3 status via analysis of erythrocyte fatty acids, a measurement that reflects longer-term intakes over approximately the previous 120 days ³³. The “omega-3 index” proposed by Harris and von Schacky reflects the content of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) in erythrocyte membranes expressed as a percentage of total erythrocyte fatty acids ³⁴. This index can be used as a surrogate for assessing tissue levels of eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) ³⁵. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) typically comprise about 3%–5% of erythrocyte fatty acids in Western populations with low fish intakes. In Japan, where fish consumption is high, erythrocyte eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) levels are about twice those of Western populations ²⁷.

Table 1. Alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) content of selected foods

Food	Grams per serving
	ALA	DHA	EPA
Flaxseed oil, 1 tbsp	7.26
Chia seeds, 1 ounce	5.06
English walnuts, 1 ounce	2.57
Flaxseed, whole, 1 tbsp	2.35
Salmon, Atlantic, farmed cooked, 3 ounces		1.24	0.59
Salmon, Atlantic, wild, cooked, 3 ounces		1.22	0.35
Herring, Atlantic, cooked, 3 ounces*		0.94	0.77
Canola oil, 1 tbsp	1.28
Sardines, canned in tomato sauce, drained, 3 ounces*		0.74	0.45
Mackerel, Atlantic, cooked, 3 ounces*		0.59	0.43
Salmon, pink, canned, drained, 3 ounces*	0.04	0.63	0.28
Soybean oil, 1 tbsp	0.92
Trout, rainbow, wild, cooked, 3 ounces		0.44	0.4
Black walnuts, 1 ounce	0.76
Mayonnaise, 1 tbsp	0.74
Oysters, eastern, wild, cooked, 3 ounces	0.14	0.23	0.3
Sea bass, cooked, 3 ounces*		0.47	0.18
Edamame, frozen, prepared, ½ cup	0.28
Shrimp, cooked, 3 ounces*		0.12	0.12
Refried beans, canned, vegetarian, ½ cup	0.21
Lobster, cooked, 3 ounces*	0.04	0.07	0.1
Tuna, light, canned in water, drained, 3 ounces*		0.17	0.02
Tilapia, cooked, 3 ounces*	0.04	0.11
Scallops, cooked, 3 ounces*		0.09	0.06
Cod, Pacific, cooked, 3 ounces*		0.1	0.04
Tuna, yellowfin, cooked 3 ounces*		0.09	0.01
Kidney beans, canned ½ cup	0.1
Baked beans, canned, vegetarian, ½ cup	0.07
Ground beef, 85% lean, cooked, 3 ounces**	0.04
Bread, whole wheat, 1 slice	0.04
Egg, cooked, 1 egg		0.03
Chicken, breast, roasted, 3 ounces		0.02	0.01
Milk, low-fat (1%), 1 cup	0.01

Footnotes: *Except as noted, the U.S. Department of Agriculture (USDA) database does not specify whether fish are farmed or wild caught. **The USDA database does not specify whether beef is grass fed or grain fed.

Essential Fatty Acids

Essential Fatty Acids such as omega-3 oils are ‘essential’ because your body can’t make them and you have to obtain them from your food. Essential Fatty Acids are found in the skin of white fish but also in the flesh of oily fish such as fresh and tinned salmon, mackerel, sardines and fresh tuna. Advice for fish eaters is to have one portion of oily fish, and one portion of white fish per week.

Essential Fatty Acids can also be found in some plant oils such as flaxseed, rapeseed and soya but there is not as much in these oils as there is in fish and seafood.

Omega-3 fatty acids

Omega-3 fatty acids (omega-3s) are a type of polyunsaturated fat and have a carbon–carbon double bond located three carbons from the methyl end of the chain (see Figure 6). Omega-3 fatty acids, sometimes referred to as “n-3s,” are present in certain foods such as flaxseed and fish, as well as dietary supplements such as fish oil. Omega-3 fatty acids are especially beneficial to your health. Omega-3s play important roles in the body as components of the phospholipids that form the structures of cell membranes ²⁴. There are different types of omega-3s: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are found in fish and algae and have the most health benefits, while alpha-linolenic acid (ALA) comes from plants and is a less potent form of omega-3, although the body does convert ALA to EPA and DHA at low rates. Alpha-linolenic acid (ALA) contains 18 carbon atoms, whereas eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) are considered “long-chain” omega-3s because EPA contains 20 carbons and DHA contains 22 ³⁵.

Docosahexaenoic acid (DHA), in particular, is especially high in the retina, brain, and sperm ²⁷. In addition to their structural role in cell membranes, omega-3s (along with omega-6s) provide energy for the body and are used to form eicosanoids. Eicosanoids are signaling molecules that have similar chemical structures to the fatty acids from which they are derived; they have wide-ranging functions in the body’s cardiovascular, pulmonary, immune, and endocrine systems ²⁵. Higher concentrations of EPA and DHA than arachidonic acid tip the eicosanoid balance toward less inflammatory activity ³⁶.

Research has shown that a diet rich in omega-3 fatty acids may help to:

• Prevent and reduce symptoms of depression, ADHD, and bipolar disorder.
• Protect against memory loss and dementia.
• Reduce the risk of heart disease, stroke, and cancer.
• Ease arthritis, joint pain, and inflammatory skin conditions.
• Support a healthy pregnancy.
• Battle fatigue, sharpen your memory, and balance your mood.

Fish the best source of omega-3 (high in EPA and DHA):

• Anchovies
• Herring
• Salmon
• Mackerel
• Sardines
• Trout
• Tuna
• Mussels
• Oysters
• Halibut

Vegetarian sources of omega-3s (high in ALA):

• Algae such as seaweed (high in EPA and DHA)
• Eggs (small amounts of DHA)
• Flaxseeds and flaxseed oil
• Chia seeds
• Canola and soybean oil
• Walnuts
• Mayonnaise
• Edamame
• Beans (refried, kidney, etc.)
• Brussels sprouts
• Kale
• Spinach

Fish is a good source of protein and omega-3 fatty acids, which are good for your heart. Research has shown that omega-3 fatty acids can reduce your risk of heart disease and stroke. A 2020 Cochrane review ³⁷ of 86 randomized controlled trials published between 1968 and 2019 found that 0.5 g/day to more than 5 g/day omega-3 fatty acids for 12 to 88 months in a total of 162,796 participants reduced serum triglyceride levels by about 15% and slightly decreased rates of cardiovascular mortality and coronary heart disease events. However, the omega-3 fatty acids supplements did not affect all-cause mortality, cardiovascular events, stroke, or arrhythmia. The authors of several earlier meta-analyses and systematic reviews, as well as a 2016 report from the Agency for Healthcare Research and Quality, concluded that omega-3 fatty acids supplements do not appear to significantly reduce the risk of most cardiovascular events ³⁸. Many of these analyses ³⁹, however, but not all ⁴⁰, did find that omega-3s reduce the risk of cardiac death.

The American Heart Association recommends eating 2 servings of fish (particularly fatty fish) per week. A serving is 3.5 ounce (100 g) cooked, or about ¾ cup of flaked fish. Fatty fish like salmon, mackerel, herring, lake trout, sardines and albacore tuna are high in omega-3 fatty acids. For people with existing coronary heart disease, such as a recent heart attack (myocardial infarction), the American Heart Association recommends approximately 1 gram/day EPA plus DHA, preferably from oily fish; however, supplements could also be considered under the direction of a physician ⁴¹. The American Heart Association does not recommend omega-3 supplements for people who do not have a high cardiovascular disease risk.

While omega-3s are best obtained through food, there are many omega-3 and fish oil supplements available. A typical fish oil supplement provides about 1,000 mg fish oil, containing 180 mg EPA and 120 mg DHA, but doses vary widely ⁴². If you need to substantially lower your triglycerides, your doctor may recommend prescription fish oil, which has been concentrated to contain about 900 mg of EPA plus DHA per capsule. Cod liver oil supplements provide vitamin A and vitamin D in addition to omega-3s. For strict vegetarians or vegans, as well as obtaining ALA from food sources, look for capsules containing DHA and EPA extracted from algae, the original source of omega-3s for fish. Although seafood contains varying levels of methyl mercury (a toxic heavy metal) ⁴³, omega-3 supplements have not been found to contain this contaminant because it is removed during processing and purification ⁴⁴.

Some types of fish may contain high levels of mercury, PCBs (polychlorinated biphenyls), dioxins and other environmental contaminants. Levels of these substances are generally highest in older, larger, predatory fish and marine mammals.

The benefits and risks of eating fish vary depending on a person’s stage of life.

Children and pregnant women are advised by the U.S. Food and Drug Administration (FDA) to:

• Avoid eating those fish with the potential for the highest level of mercury contamination (such as shark, swordfish, king mackerel or tilefish).
• Eat a variety of fish and shellfish that are lower in mercury (such as canned light tuna, salmon, pollock, catfish).
• Check local advisories about the safety of fish caught by family and friends in local lakes, rivers and coastal areas.

For middle-aged and older men and postmenopausal women, the benefits far outweigh the potential risks when the amount of fish eaten is within the recommendations established by the FDA and Environmental Protection Agency.

Eating a variety of fish will help minimize any potentially adverse effects due to environmental pollutants. Five of the most commonly eaten fish or shellfish that are low in mercury are shrimp, canned light tuna, salmon, pollock, and catfish. Avoid eating shark, swordfish, king Mackerel, or tilefish because they contain high levels of mercury.

Cholesterol

Dietary fat plays a major role in your cholesterol levels. Cholesterol is a type of fat, a wax-like substance that your body needs to function properly that comes from foods such as eggs and is also found in your blood mostly made by your body in your liver. In and of itself, cholesterol isn’t bad. But when you get too much of it, it can have a negative impact on your health. The 2 main types of cholesterol are:

1. “Good” cholesterol or HDL (high-density lipoprotein) cholesterol. “Good” HDL cholesterol has a positive effect by taking cholesterol from parts of the body where there’s too much of it to the liver, where it’s disposed of.
   
2. “Bad” cholesterol or LDL (low-density lipoprotein) cholesterol.

High levels of LDL cholesterol (low-density lipoprotein or “bad” cholesterol) can increase your risk of heart disease. The key is to keep your LDL levels low and HDL high, which may protect against heart disease and stroke. High levels of LDL cholesterol (low-density lipoprotein or “bad” cholesterol) can clog arteries and low HDL (high-density lipoprotein or “good” cholesterol) can be a marker for increased cardiovascular risk. However, eating foods that contain any type of cholesterol won’t actually raise your body’s cholesterol levels. Rather than the amount of cholesterol you eat, the biggest influence on your cholesterol levels is the type of fats you consume. Eating saturated or trans fats is far more likely to give you high cholesterol. So instead of counting cholesterol, it’s important to focus on replacing bad fats with good fats.

LDL (bad) cholesterol

LDL (low-density lipoprotein) cholesterol is considered the “bad” cholesterol, because it contributes to fatty buildups in arteries (atherosclerosis). This narrows the arteries and increases the risk for heart attack, stroke and peripheral artery disease. Your body naturally produces all the LDL cholesterol you need. Eating foods containing saturated fats and trans fats causes your body to produce even more LDL — raising the level of “bad” cholesterol in your blood.

HDL (good) cholesterol

HDL (high-density lipoprotein) cholesterol can be thought of as the “good” cholesterol because a healthy level may protect against heart attack and stroke. HDL carries LDL (bad) cholesterol away from the arteries and back to the liver, where the LDL is broken down and passed from the body. But HDL cholesterol doesn’t completely eliminate LDL cholesterol. Only one-third to one-fourth of blood cholesterol is carried by HDL.

Trans fats

Avoid trans fat. Trans fats also known as trans fatty acids or “partially hydrogenated oils”, are created in an industrial process that adds hydrogen to liquid vegetable oils to make them more solid, so they ‘behave’ like a saturated fat. There are two broad types of trans fats found in foods: naturally-occurring and artificial trans fats. Naturally-occurring trans fats are produced in the gut of some animals and foods made from these animals (e.g., milk and meat products) may contain small quantities of these fats. Artificial trans fats (or trans fatty acids) are created in an industrial process that adds hydrogen to liquid vegetable oils to make them more solid.

Trans fats increase the levels of ‘bad’ LDL cholesterol and decreases the levels of ‘good’ HDL cholesterol in your body, which increases your risk of developing heart disease and stroke. Trans fats is also associated with a higher risk of developing type 2 diabetes. Trans fats can be found in many foods such as in butter, margarine (in small amounts), deep-fried and processed foods like doughnuts, cakes and pastries. Baked goods, such as pastries, pizza dough, frozen pizza, pie crust, cookies, biscuits, and crackers also can contain trans fats.

Since 2006, the FDA has required trans fat content to be listed on the Nutrition Facts panel of packaged foods. In recent years, many major national fast-food chains and casual-dining restaurant chains have announced they will no longer use trans fats to fry or deep-fry foods.

The American Heart Association recommends that adults who would benefit from lowering LDL cholesterol eliminate trans fat from their diet.

To find the amount of trans fats in a particular packaged food, look at the Nutrition Facts panel. Companies must list any measurable amount of trans fat (0.5 grams or more per serving) in a separate line in the “Total Fat” section of the panel, directly beneath the line for “Saturated Fat.” This means if a food package states 0 grams of trans fats, it might still have some trans fats if the amount per serving is less than 0.5 g. You can also spot trans fats by reading ingredient lists and looking for the ingredients referred to as “partially hydrogenated oils.”

Salt

Salt or sodium is a mineral that’s essential for life. Table salt is a combination of two minerals — about 40% sodium and 60% chloride. Salt or sodium is regulated by your kidneys, and it helps control your body’s fluid balance. It also helps send nerve impulses and affects muscle function. Your body needs only a small amount of sodium (less than 500 milligrams per day) to function properly. That’s a mere smidgen — the amount in less than ¼ teaspoon. Very few people come close to eating less than that amount. High levels of salt in your diet can increase blood pressure. High blood pressure is known as the “silent killer” because its symptoms are not always obvious. It’s one of the major risk factors for heart disease, the No. 1 killer worldwide. Ninety percent of American adults are expected to develop high blood pressure over their lifetimes. Because high blood pressure is an important risk factor for stroke, and strokes are detrimental to cognitive health, excessive salt intake is harmful for your brain health. There is a well-established relationship between consuming high levels of sodium and risk of stroke. In Japan, a public health education intervention in the 1960s showed the effectiveness of dietary interventions to reduce sodium intake. A 50% reduction in salt in the diet was associated with an 85% reduction in mortality caused by stroke.

The liver (in addition to your kidney) also plays a major role in regulating the balance of water and sodium (salt) in your body. When cirrhosis develops, the liver may lose this ability, leading to ‘fluid retention’. This can result in swelling of the feet and legs (oedema) and in a build-up of fluid in the abdomen (ascites). The presence of ascites may cause abdominal discomfort and make it difficult to eat without feeling bloated and uncomfortable.

Fluid retention is generally managed with diuretics (water pills) and in certain circumstances, by the drainage of fluid from your abdomen (paracentesis). Your health professional might also advise you to cut down on salt for example by following a ‘no added salt’ diet.

Most of the salt that you eat is added to processed foods. More than 70% of the sodium you consume comes from packaged, prepared and restaurant foods. The rest of the sodium in the diet occurs naturally in food (about 15 percent) or is added when we’re cooking food or sitting down to eat (about 11 percent). Current recommendations from the Dietary Guidelines for Americans are to limit sodium intake to 2,300 milligrams (mg) a day, which amounts to about one teaspoon of salt. The American Heart Association recommends an ideal limit of no more than 1,500 mg per day for most adults. On average, Americans eat more than 3,400 milligrams of sodium each day — much more than the American Heart Association and other health organizations recommend. While this over consumption is mostly harmless in a healthy individual, it can have negative consequences for someone with advanced liver disease. Liver disease patients often suffer from a condition called ascites (accumulation of fluid in the abdomen). Ascites must not be neglected as it can lead to a condition called subacute bacterial peritonitis. Such patients must be on a severely salt restricted diet. Even a gram of sodium consumed can result in 200ml of fluid build-up. It is therefore, important to read the labels on food packaging to monitor the salt content. Often condiments/spices such as dill pepper, vinegar, basil etc. can be used as salt substitutes to enhance the flavour of food.

Here are the approximate amounts of sodium in a given amount of salt:

• 1/4 teaspoon salt = 575 mg sodium
• 1/2 teaspoon salt = 1,150 mg sodium
• 3/4 teaspoon salt = 1,725 mg sodium
• 1 teaspoon salt = 2,300 mg sodium

If you are cutting down on salt, it is very important that you receive advice from a registered dietitian about the foods you can eat and those you should avoid. Some foods can surprise you and be much higher in salt than you would expect. And some products labelled as low-salt can have other ingredients that you should not have too much of. For example potassium can increase the risk of heart problems.

Tips to reduce the amount of salt you eat:

• Do not add salt to meals at the table. Add a small amount during cooking if need be.
• Avoid very salty foods such as ham, bacon, sausages, frankfurters, salami and other cold cuts, Bovril, Marmite, other yeast extracts, sardines and anchovies.
• Avoid smoked fish.
• Avoid fish tinned in brine, including salmon, tuna and pilchards. Look for products tinned in oil or water.
• Check food labels – anything with more than 1.5g salt per 100g (or 0.6g sodium) is high in salt. Salt is included in traffic light labelling, avoid products with a red light for salt.
• Some bottled waters are high in sodium – check the labels carefully.

It is also important to be aware that some prescription and over the counter medications have a high salt content. If the sodium content on the labelling of your medication is not clear, or you are unsure if it is suitable, your pharmacist or doctor should be able to advise you.

If you are struggling for how to add flavour to your food without salt then ground pepper, vinegar, herbs and spices can work well. Alternatively, try:

• Lemon juice on fish or meat
• Olive oil and vinegar with salad and vegetables
• Mustard powder or nutmeg with mashed potato

Fresh herbs, lime, garlic, chilli and ginger with pasta, vegetables and meat dishes

Iron in the diet

Iron in the diet is another important ingredient to look out for in people with liver disease. Excessive iron in the body of a liver patient can be extremely dangerous. Although iron is an essential component of hemoglobin which is responsible for delivering oxygen to red blood cells, in excess iron can be toxic to the liver. If you are a liver patient, your doctor will continually monitor your iron levels. Do not take iron supplements without your doctor’s knowledge if you are feeling fatigued or weak. Even herbal medications, known to be good for the liver like dandelion or milk thistle may have concentrations of iron. Avoid foods high in iron content like red meats, and cereals enriched with iron.

Calcium

Calcium is very important for your bone health especially in liver patients. People with liver disease can have high rates of hepatic osteodystrophy (a broad term that incorporates all the biochemical abnormalities and skeletal manifestations in patients suffering from chronic liver disease). Hepatic osteodystrophy is a common complication of cirrhosis ⁴⁵. This can lead to weak and porous bones (osteoporosis) which is not a good sign when patients are recovering post liver transplant. The main clinical relevance of hepatic osteodystrophy is the increased risk of fractures ⁴⁶, which adversely impacts morbidity, quality of life, and possibly even survival ⁴⁷. Studies across the world have reported a variable prevalence of osteoporosis (11–48%) and osteopenia (18–35%) in patients with cirrhosis ⁴⁸. The cause of hepatic osteodystrophy is not well understood. Studies suggest that, while both are at play, osteoblast dysfunction is probably more important than excessive bone resorption ⁴⁹. Dual‐energy X ray absorptiometry (DEXA) is the gold standard for diagnosing osteoporosis.

If you have established osteoporosis or are at risk, you should be given calcium and vitamin D supplements. Factors that contribute to bone loss need to be minimised, including alcohol and tobacco use. Alcohol is known to be directly toxic to bone cells and it can impede calcium absorption. Steroid medication should be reduced whenever possible. If you have questions about your medication speak to your doctor.

Calcium also plays an important role in blood clotting and muscle contraction. Again it is your doctor and dietician who will monitor your calcium intake because excessive calcium will impede iron absorption and can even cause severe constipation, fatigue and kidney stones.

Good sources of calcium include most leafy green vegetables, tofu, canned sardines with bones and salmon with bones.

Guidelines for physical activity

The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) Primary Physical Activity Recommendations ⁵⁰:

• All healthy adults aged 18–65 year should participate in moderate intensity, aerobic physical activity for a minimum of 30 minutes on 5 days/week or vigorous intensity, aerobic activity for a minimum of 20 minutes on 3 days/week.
• Combinations of moderate and vigorous intensity exercise can be performed to meet this recommendation.
• Moderate intensity, aerobic activity can be accumulated to total the 30 minutes minimum by performing bouts each lasting 10 minutes
• Every adult should perform activities that maintain or increase muscular strength and endurance for a minimum of 2 days/week
• Because of the dose-response relationship between physical activity and health, individuals who wish to further improve their fitness, reduce their risk for chronic diseases and disabilities, and/or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity.

Adults aged 18–65 years should aim for 150 minutes of moderate intensity activity in bouts of 10 minutes or more (that is, 30 minutes at least 5 days a week) ⁵¹. Comparable benefits can be achieved through 75 minutes of vigorous intensity activity spread across the week and at least 2 days of the week activity should be aimed at improving muscle strength. Although the guidelines for people over 65 years are similar, older adults are encouraged to include activities that improve balance and coordination, especially if at risk of falls. Similar guidance can also be found for children, including infants ⁵². Patients can obtain this ‘daily dose’ by addressing their sedentary lifestyle, for example, taking the stairs instead of a lift, and walking to work.

Physical activity guidelines for adults aged 19 to 65

Adults should do some type of physical activity every day. Any type of activity is good for you. The more you do the better ⁵²

Adults should:

• aim to be physically active every day. Any activity is better than none, and more is better still
• do strengthening activities that work all the major muscles (legs, hips, back, abdomen, chest, shoulders and arms) on at least 2 days a week
• do at least 150 minutes of moderate intensity activity a week or 75 minutes of vigorous intensity activity a week
• reduce time spent sitting or lying down and break up long periods of not moving with some activity.

You can also achieve your weekly activity target with:

• several short sessions of very vigorous intensity activity
• a mix of moderate, vigorous and very vigorous intensity activity

You can do your weekly target of physical activity on a single day or over 2 or more days. Whatever suits you.

These guidelines are also suitable for:

• disabled adults
• pregnant women and new mothers

Make sure the type and intensity of your activity is appropriate for your level of fitness. Vigorous activity is not recommended for previously inactive women.

All of these routines count towards the recommended guidelines for weekly physical activity.

Moderate aerobic activity

Moderate activity will raise your heart rate, and make you breathe faster and feel warmer. One way to tell if you’re working at a moderate intensity level is if you can still talk, but not sing.

For moderate-intensity physical activity, your target heart rate should be between 64% and 76% of your maximum heart rate ⁵³, ⁵⁴. You can estimate your maximum heart rate based on your age. To estimate your maximum age-related heart rate, subtract your age from 220. For example, for a 50-year-old person, the estimated maximum age-related heart rate would be calculated as 220 – 50 years = 170 beats per minute (bpm). The 64% and 76% levels would be:

• 64% level: 170 x 0.64 = 109 bpm, and
• 76% level: 170 x 0.76 = 129 bpm

This shows that moderate-intensity physical activity for a 50-year-old person will require that the heart rate remains between 109 and 129 bpm during physical activity.

Most moderate activities can become vigorous if you increase your effort.

Examples of moderate intensity activities:

• brisk walking
• water aerobics
• riding a bike
• dancing
• doubles tennis
• pushing a lawn mower
• hiking
• rollerblading

Vigorous activity

Vigorous intensity activity makes you breathe hard and fast. If you’re working at this level, you will not be able to say more than a few words without pausing for breath.

For vigorous-intensity physical activity, your target heart rate should be between 77% and 93% of your maximum heart rate ⁵³, ⁵⁴. You can estimate your maximum heart rate based on your age. To estimate your maximum age-related heart rate, subtract your age from 220. For example, for a 35-year-old person, the estimated maximum age-related heart rate would be calculated as 220 – 35 years = 185 beats per minute (bpm). The 77% and 93% levels would be:

• 77% level: 185 x 0.77 = 142 bpm, and
• 93% level: 185 x 0.93 = 172 bpm

This shows that vigorous-intensity physical activity for a 35-year-old person will require that the heart rate remains between 142 and 172 bpm during physical activity.

In general, 75 minutes of vigorous intensity activity can give similar health benefits to 150 minutes of moderate intensity activity.

Examples of vigorous activities:

• jogging or running
• swimming fast
• riding a bike fast or on hills
• walking up the stairs
• sports, like football, rugby, netball and hockey
• skipping rope
• aerobics
• gymnastics
• martial arts

Activities that strengthen muscles

To get health benefits from strength exercises, you should do them to the point where you need a short rest before repeating the activity.

There are many ways you can strengthen your muscles, whether you’re at home or in a gym.

Examples of muscle-strengthening activities:

• carrying heavy shopping bags
• yoga
• pilates
• tai chi
• lifting weights
• working with resistance bands
• doing exercises that use your own body weight, such as push-ups and sit-ups
• heavy gardening, such as digging and shoveling
• wheeling a wheelchair
• lifting and carrying children

Foods to eat for a healthy liver

The food you eat can have a significant impact on your liver.

• If your liver is healthy a well-balanced diet can reduce your risk of developing some types of liver disease in the future.
• If you have liver disease eating a good, balanced diet is essential to maintain strength and a healthy weight. You might also need to change the food you eat depending on:
  • the type of liver disease you have
  • the stage of the damage to your liver – people living with cirrhosis have special dietary needs
  • any eating difficulties you experience such as loss of appetite or feeling sick (nausea)

If you have already been given dietary advice you should not make changes without first talking to your doctor or dietitian.

If you have a liver condition, there are some special considerations you may need to make in your diet to stay nutritionally well and to help to manage your condition. Some of these are specific to certain liver diseases, others relate to how advanced your liver disease is.

If you are experiencing symptoms such as loss of appetite, nausea, low energy levels, fluid retention in the legs or accumulation of fluid in the abdomen (ascites), you will need to follow a more specialized diet. These, and other problems associated with advanced liver disease, require specialist dietary advice from a registered dietitian.

It is important that you talk to your doctor as well as reading this information. Your doctor will be able to refer you to a registered dietitian. If you have already been given dietary advice you should not make changes without first talking to your doctor or dietitian.

It is important to remember that your body’s nutritional needs may vary depending on the type and severity of your condition. Particularly, if you are unwell and losing weight you may need to vary your diet from the recommendations below.

Cirrhosis

Cirrhosis is the scarring and hardening of the liver. Having cirrhosis or advanced liver disease usually means you will need to make some changes to your diet. As well as generally eating healthily you may need to follow special advice to make sure you get enough energy (calories) and protein, and not too much salt. This is important to stop you from becoming malnourished and losing muscle mass.

Around 2 in 10 people with compensated cirrhosis are malnourished, but this increases to more than 5 in 10 people with decompensated cirrhosis.

For specific advice on your diet, ask your doctor to refer you to a dietitian. When you see a dietitian, the advice you receive will be specific for you. The guidance here is more general and you shouldn’t make any changes without first discussing them with the professionals looking after you.

When cirrhosis develops your liver is no longer able to store glycogen, a form of carbohydrate which it needs to meet your body’s energy demands. Your liver tries to make up for this but you often need more energy and protein in your diet.

Diet recommendations:

• Limit salt and foods that contain a lot of salt
• Talk to your doctor about how much protein to have in your diet

You can increase the amount of protein in your diet by eating:

• Beans and pulses such as lentils, kidney beans, or baked beans
• Nuts such as almonds or walnuts
• Eggs, cheese and other dairy products
• Fish such as cod, salmon, and tinned or fresh tuna, sardines or mackerel
• Meats such as turkey, chicken, or lean cuts of beef, pork and lamb

If you are underweight or malnourished then you will need to increase the amounts of energy and protein you eat even more. Regular snacking can top them up. There are also a number of high protein supplements that your dietitian may recommend and your doctor can prescribe.

Snacks to top up your energy and protein levels:

• Teacake with butter
• 3 crackers with butter and cheese
• Breakfast cereal with full cream milk
• Fruit scone with butter and jam
• 2 slices of toast with jam
• Milky drinks
• 2 slices of fruit loaf
• Hot chocolate and a banana

If you are overweight you may be advised to lose weight. This should be done by reducing your fat and carbohydrate intake, but keeping your protein intake high and increasing physical activity levels to ensure you do not compromise your muscle mass.

If you have cirrhosis, you should avoid eating and drinking

You should avoid eating raw or undercooked shellfish, fish, and meat. Bacteria or viruses from these foods may cause severe infections in people with cirrhosis.

Your doctor may recommend limiting salt in your diet and limiting your intake of fats or protein.

You should completely stop drinking alcohol because it can cause more liver damage.

Hepatic encephalopathy (brain fog)

People with hepatic encephalopathy should also follow the above guidance including to eat more protein. In the past, patients were advised to cut down on protein. Doctors now know this is wrong, but you may still see it in some information or hear it said by health professionals.

You might find it helpful to:

• Spread your protein intake out over the day. Avoid having all of your daily protein in one meal.
• Take as much of your protein from vegetable sources as possible. Vegetable protein is better tolerated than dairy or meat. Try lentils, beans, peas, nuts, oatmeal, wild rice, and soybean products such as soy milk, tofu and edamame.

Choose dairy sources of protein such as eggs and cheese over meat sources. Dairy can be better tolerated than protein from meat sources. Fish and poultry are better sources than red meat.

Fatty liver disease

Fatty liver disease is the build-up of fat in liver cells.

Diet recommendations:

• Limit foods that are high in calories
• Eat foods that have fiber
• See above for people who have nonalcoholic fatty liver disease (NAFLD)

Bile duct disease

Bile is a liquid made in the liver that helps break down fats in the small intestine. Bile duct disease keeps bile from flowing to your small intestine.

Diet recommendations:

• Use fat substitutes
• Use kernel oil (i.e. canola, olive, corn, sunflower, peanut, flax seed oils) because it needs less bile to break down fats than other types of oil

Hemochromatosis

Hemochromatosis is the build-up of iron in the liver.

Diet recommendations:

• Do not eat foods that have iron
• Do not use iron pots and pans
• Do not take pills with iron
• Do not eat uncooked shellfish

Hepatitis C

Hepatitis C is a disease of the liver caused by the hepatitis C virus (HCV).

Diet recommendations:

• Limit foods that have a lot of iron
• Do not use iron pots and pans
• Limit salt and foods that contain a lot of salt

Wilson disease

Wilson disease is the build-up of copper in the body.

Diet recommendations:

• Limit foods that have copper such as chocolate, nuts, shellfish and mushrooms
• Do not use copper pots

Best foods for liver cancer

Liver cancer is cancer that begins in the cells of your liver (hepatocytes). There are two main types of liver cancer — ‘primary liver cancer’, which means the cancer started in the liver, and ‘secondary liver cancer’, which means the cancer has spread into the liver from another part of the body. Most cancers that affect the liver have spread from elsewhere in the body. These are known as secondary cancer in the liver. These secondary cancers are named after the part of the body in which they started. Colon, breast, ovarian and lung cancers, as well as melanomas, are all cancers that can spread to the liver.

Several types of cancer can form in the liver. The most common type of liver cancer is hepatocellular carcinoma, which begins in the main type of liver cell (hepatocyte). Other types of liver cancer, such as intrahepatic cholangiocarcinoma and hepatoblastoma, are much less common.

If you have (or have had) liver cancer, you probably want to know if there are things you can do that might lower your risk of the cancer coming back, such as exercising, eating a certain type of diet, or taking nutritional supplements. Unfortunately, it’s not yet clear if there are things you can do that will help. Tobacco and alcohol use has clearly been linked to liver cancer, so not smoking and avoiding alcohol may help reduce your risk. Scientists don’t know for certain if this will help, but they do know that it can help improve your appetite and overall health. It can also reduce the chance of developing other types of cancer. Other healthy behaviors such as eating well, being active, and staying at a healthy weight might help as well, but no one knows for sure. However, scientists do know that these types of changes can have positive effects on your health that can extend beyond your risk of liver or other cancers.

Cancer prevention includes eating a variety of vegetables and fruits and limiting red meat consumption ⁵⁵. People with cancer need to keep a balanced diet, maintain a healthy weight and limit alcohol intake ⁵⁶. This is an important step in reducing risk of cancer recurrence, second primary cancers, and improving physical and emotional health ⁵⁷. Cancer type, stage, and treatment all need to be taken into consideration when deciding if any foods must be avoided. Consuming large doses of vitamins or antioxidant supplements is not recommended, as some vitamins and / or herbal supplements can interfere with cancer therapy ⁵⁶. Urgency and relevance of nutrition for cancer patients, has been clearly demonstrated. In a study performed among 907 people with cancer, 90% did not receive any information about cachexia (weight loss caused by cancer) from their health professionals. Whereas, almost 70% reported that they lost weight after the cancer diagnosis. More than 70% of the respondents didn’t know the meaning of the term ‘cachexia’ (weight loss caused by cancer) ⁵⁸.

So far, no dietary supplements (including vitamins, minerals, and herbal products) have been shown to clearly help lower the risk of liver cancer progressing or coming back. This doesn’t mean that no supplements can help, but it’s important to know that so far none have been proven to do so. Dietary supplements are not regulated like medicines in the United States – they do not have to be proven effective (or even safe) before being sold, although there are limits on what they’re allowed to claim they can do. If you’re thinking about taking any type of nutritional supplement, talk to your doctor. He/she can help you decide which ones you can use safely while avoiding those that might be harmful.

Cancer that spreads to the liver is more common than cancer that begins in the liver cells. Cancer that begins in another area of the body — such as the colon, lung or breast — and then spreads to the liver is called metastatic cancer rather than liver cancer. This type of cancer is named after the organ in which it began — such as metastatic colon cancer to describe cancer that begins in the colon and spreads to the liver.

Doctors don’t always know what causes primary liver cancer. Your risk of getting primary liver cancer is greatly increased if you have a chronic hepatitis B or hepatitis C infection which has caused permanent scarring or damage to your liver, known as cirrhosis.

You are also more likely to develop primary liver cancer than other people if you:

• have scarring of the liver (cirrhosis) or injury to the liver
• drink a lot of alcohol
• smoke
• have certain inherited diseases, such as hemochromatosis or Wilson’s disease
• have autoimmune disorders that damage the liver.
• have type 2 diabetes
• have nonalcoholic fatty liver disease (NAFLD)
• are obese
• have been exposed to some chemicals

Risk factors that increase your risk of primary liver cancer include:

• Chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV). Chronic infection with the hepatitis B virus (HBV) or hepatitis C virus (HCV) increases your risk of liver cancer. Getting treatment for hepatitis B or hepatitis C may help reduce damage to your liver that can increase liver cancer risk.
  • You can reduce your risk of hepatitis B by receiving the hepatitis B vaccine. The vaccine can be given to almost anyone, including infants, older adults and those with compromised immune systems.
  • There is no vaccine for hepatitis C yet, but you can reduce your risk of hepatitis C virus (HCV) infection.
    • Know the health status of any sexual partner. Don’t engage in unprotected sex unless you’re certain your partner isn’t infected with HBV, HCV or any other sexually transmitted infection. If you don’t know the health status of your partner, use a condom every time you have sexual intercourse.
    • Don’t use intravenous (IV) drugs, but if you do, use a clean needle. Reduce your risk of HCV by not injecting illegal drugs. But if that isn’t an option for you, make sure any needle you use is sterile, and don’t share it. Contaminated drug paraphernalia is a common cause of hepatitis C infection. Take advantage of needle-exchange programs in your community and consider seeking help for your drug use.
    • Seek safe, clean shops when getting a piercing or tattoo. Needles that may not be properly sterilized can spread the hepatitis C virus. Before getting a piercing or tattoo, check out the shops in your area and ask staff members about their safety practices. If employees at a shop refuse to answer your questions or don’t take your questions seriously, take that as a sign that the facility isn’t right for you.
• Cirrhosis. This progressive and irreversible condition causes scar tissue to form in your liver and increases your chances of developing liver cancer.
• Certain inherited liver diseases. Liver diseases that can increase the risk of liver cancer include hemochromatosis and Wilson’s disease.
• Diabetes. People with this blood sugar disorder have a greater risk of liver cancer than those who don’t have diabetes.
• Nonalcoholic fatty liver disease (NAFLD). An accumulation of fat in the liver increases the risk of liver cancer.
• Exposure to aflatoxins. Aflatoxins are poisons produced by molds that grow on crops that are stored poorly. Crops, such as grains and nuts, can become contaminated with aflatoxins, which can end up in foods made of these products.
• Excessive alcohol consumption. Consuming more than a moderate amount of alcohol daily over many years can lead to irreversible liver damage and increase your risk of liver cancer.

For some people with liver cancer, treatment can remove or destroy the cancer. For many people with liver cancer, the cancer may never go away completely, or it might come back in another part of the body. These people may still get regular treatments with chemotherapy, radiation therapy, or other therapies to help keep the cancer under control for as long as possible.

Exercise and physical activity should be a regular part of your life after a liver cancer to continue improving your overall physical and mental health.

Soon after your liver cancer treatment, you should walk as much as you can. Then, depending on your progress, you can start incorporating more physical activity into your daily life.

Walking, bicycling, swimming, low-impact strength training and other physical activities you enjoy can all be a part of a healthy, active lifestyle after liver cancer treatment. But be sure to check in with your healthcare team before starting or changing your exercise routine.

10 best foods for liver cancer

1. Pick out vegetables and fruits without high-calorie sauces or added salt and sugars
2. Choose fiber-rich whole grains
3. Pick up poultry and fish without skin prepared in healthy way
4. Decide over lean cuts of meat instead of those high in fat
5. Eat fish at least twice a week, especially fish containing omega-3 fatty acids (e.g. salmon, trout and herring)
6. Make sure your dairy is fat-free (skim) or low-fat (1%)
7. Avoid foods with partially hydrogenated vegetable oils to reduce trans fat
8. Limit saturated fat and trans fat by replacing them with the better fats (monounsaturated and polyunsaturated)
9. Cut back on beverages and foods with added sugars
10. Choose foods with less sodium and prepare foods with little or no salt

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