Hepatitis C: Nutrition Care
Canadian Guidelines for Health Care Providers
Chapter 7 - Nutritionally At-Risk Groups
According to the population health model, broad determinants of
health can influence nutritional health.1 It is important
to assess the medical, social and food security profile of the patient
with hepatitis C and modify nutrition advice to support the individual's
needs. This chapter describes two categories of patients with hepatitis
C that would be considered nutritionally at risk, either due to
concomitant medical conditions or as a member of an at-risk population
or lifestyle group.
Concomitant Medical Conditions
Human Immunodeficiency Virus (HIV)
Coinfection with HIV results in increased morbidity and mortality
in the HCV population.2 Because of the similar transmission
routes, coinfection with HCV and HIV is common,3,4 with
a prevalence of between 50% and 90%.3,5 As of December
1999, an estimated 11,194 persons in Canada were co- infected with
HCV and HIV.3 Of these, the vast majority (85%) represented
injection drug users, including those with and without same sex
exposure.3 Guidelines for nutrition care of persons with
HIV infection are available.6,7
The immunodeficiency associated with HIV infection appears to accelerate
the course of HCV,4,8,9 with a more rapid progression
from active hepatitis to cirrhosis, to ESLD.4,5,10 Coinfection
is associated with higher hepatitis C viral loads,5,10,11
and HCV infection mimics opportunistic diseases.12
In turn, chronic HCV infection may accelerate the clinical and
immunological progression of HIV disease;12 however,
reports are conflicting. A recent prospective cohort study did not
detect evidence that HCV infection substantially alters the risk
of dying, developing AIDS, or responding immunologically to highly
activated antiretroviral therapy (HAART), especially after accounting
for differences in its administration and effectiveness.13,14
Impact on Treatment
As new antiviral treatments for HIV are allowing patients to live
decades longer, many more will have to face hepatitis C treatment
decisions. HIV/AIDS therapies affect the liver, and hepatitis C
therapies affect the immune system. The impact of treatment of
either
virus on the natural history of the co- infected patient remains
speculative.4 The potential hepatotoxic effects of
antiretroviral therapy may be enhanced in the co-infected patient,
particularly
if cirrhosis is present, and could have a negative impact on the
liver disease due to HCV.4 As the pathogenesis of
hepatitis C depends on the host immune response, improvements
in immunity
following the introduction of HAART could cause a flare-up in hepatitis
C-related liver disease.4
Diabetes
Diabetes mellitus is a metabolic disease characterized by hyperglycemia
and associated with short- and long-term complications.15
A higher prevalence of diabetes is seen among persons infected with
HCV,16-18 and chronic hepatitis C may contribute to the
development of diabetes. Diabetes mellitus has been reported to
be more prevalent in patients with HCV compared to those with hepatitis
B19 and those with other types of liver diseases, usually
in the absence of predisposing factors.18
A cross-sectional national survey in the US found that HCV-infected
persons were at least three times more likely to have type 2 diabetes
than those without HCV infection, after adjustment for confounding
variables including age, BMI, poverty level and history of drug
and alcohol use.17 Others have confirmed that among HCV-infected
patients with cirrhosis, the increased risk of diabetes is not explained
by cofactors (age, sex, BMI, hepatitis G virus coinfection, hepatitis
C virus genotype).20 This increased risk exists even
in HCV-infected persons without liver cirrhosis and may be related
to fat and iron depositions in the liver, which are common features
among patients with HCV infection.20 (See hemochromatosis section below.)
Impaired glucose tolerance with accompanying insulin resistance
and hyperinsulinemia occurs commonly in cirrhotic patients.21-24
It usually precedes the development of diabetes mellitus in 10%
to 20% of these patients.16,20,25,26 (Alterations
in carbohydrate metabolism in HCV, see Chapter 3.)
Appropriate food choices consistent with CFGHE, along with slow,
steady weight loss where necessary, can aid in achieving and maintaining
optimal blood glucose control. Medical nutrition therapy, blood
glucose monitoring, medication and physical activity are integral
components of diabetes care and management. Blood glucose and insulin
response are influenced by both the source and the amount of carbohydrate
consumed, with priority given to the total amount of carbohydrate
consumed at each meal or snack. Including more foods and food combinations
that include cereal fibre with low glycemic index may be helpful
in optimizing health outcomes for persons with diabetes or at risk
for diabetes.27 Guidelines for nutrition care of persons
with diabetes are available.15,27
Hemochromatosis
Hemochromatosis is a disease in which there is an inappropriate
absorption of iron from the intestine. The excessive iron then accumulates
in the liver, pancreas and other organs in the body, causing damage.
Patients with this disease should not be given iron supplements.
Manifestations can include diabetes mellitus, hepatic dysfunction,
arthritis, skin pigmentation changes and congestive heart failure;
if damage appears in other organs, further dietary recommendations
may be indicated. Aside from these precautions, those with hemochromatosis
may follow a normal diet. Treatment is achieved by frequent removal
of blood from a large vein. Iron deposits in the liver are common
among patients with HCV infection, suggesting that those who also
have hemochromatosis would be at additional risk for liver damage
due to excess iron.
Hepatitis B
The prevalence of the combination of both hepatitis B and hepatitis
C infections in Canada is unknown.5 Published reports
indicate that the worldwide prevalence ranges between 3.4% and 18.3%
in various series of patients with hepatitis C.5,28 Coinfection
appears to result in more severe disease.5,29-32 The
risk of HCC is increased compared to the risk with hepatitis B or
hepatitis C alone.5
Renal Disease
The person with renal disease is already at higher nutritional
risk. Hepatitis C is particularly difficult to treat in patients
with co-existing renal insufficiency because the therapy may exacerbate
renal disease or complicate management of dialysis or kidney transplantation.
Chronic renal failure results in increased morbidity and mortality
in the HCV population.33 Guidelines for nutrition care
of persons with renal disease are available.34
At-Risk Population or Lifestyle Groups
Children and Adolescents
Compared to adults, knowledge of HCV infection in children is limited
because there are many fewer children infected with HCV,35
and they are less likely to have symptoms from their HCV infection.
In general, childhood liver disorders have modes of presentation
distinct from those in adults.36
Children with chronic liver disease should undergo periodic nutritional
assessment.37 Because of the increased risk for growth
failure and developmental delay, children should be referred for
full nutrition evaluation as soon as possible after diagnosis. A
combination of anthropometric, dietary intake and medical data can
be an indicator of nutritional risk in the HCV-infected child and
may be useful for measuring more subtle changes in nutrition status.
Psychosocial and economic issues may become barriers to appropriate
food intake and should also be considered.
Aboriginal Peoples
The rate of HCV infection among Canada's Aboriginal peoples may
be seven times higher than for non-Aboriginal Canadian-born people.38
Cross-cutting issues Aboriginal people may be facing include poverty,
food insecurity, violence and difficult living conditions. Many
of the communities are remote and have limited access to local health
services and qualified health professionals.39 They also
face higher rates of other diseases. Among First Nations people,
the prevalence of diabetes is at least three times the national
average.39 Unlike the overall AIDS epidemic where the
annual number of new cases has levelled off, the number of AIDS
cases among Aboriginal people has increased steadily over the last
decade.40 The increase can be attributed in part to the
fact that Aboriginal people are over represented in high-risk groups
such as injection drug users and prison inmates. Because of the
high mobility of many Aboriginal people, the HIV risk found in the
inner city can be transferred to even remote Aboriginal communities.
Injection drug use has not traditionally been a topic of discussion
in most Aboriginal communities.
Alcohol and Substance Use
For a person with hepatitis C, substance use may have an important
negative impact on disease outcome.31,32,41 Substances
used may include alcohol, illicit drugs, inhalants, and prescription
and over-the-counter medications. The prudent choice for persons
infected with HCV is to abstain from drinking alcohol or taking
illicit drugs. Avoidance at diagnosis is best, but decreasing or
stopping at any time should also be encouraged. Only medication
prescribed by or on the advice of a physician should be used.
Health care providers should detect the use of harmful substances
through screening and assessment procedures and refer to appropriate
services and programs. Information is available on nutrition care
for individuals undergoing treatment for chemical dependency, including
dietary suggestions that have proven useful for treating the symptoms
associated with withdrawal.42
Sustained substance use is common among certain subgroups of the
population. Anyone who is addicted to alcohol or other substances
may be living a chaotic lifestyle compounded by many stress factors,
and place healthy eating low on their list of daily priorities.
A comprehensive prevention and harm reduction approach would address
the psychosocial factors associated with injection drug use, the
environment in which unsafe behaviour occurs, and the provision
of basic life necessities.
Poverty and the Link with Nutrition
Poverty is related to nutritional vulnerability. The number of
people using food banks in Canada has almost doubled since 1989,43
and 20% of those with incomes below $25,000 say they cannot afford
a healthy diet.44 Poverty is frequently interrelated
with other factors.45 Those with lower household income
levels tend to rate their knowledge of nutrition lower than those
with higher income levels, and perceived knowledge of nutrition
correlates with the overall importance attributed to nutrition.46
Attitudes and knowledge toward nutrition are important underpinnings
to action.
Violence and the Link with Nutrition
Scientific research is limited that directly links the negative
effects of family violence to the outcome of persons infected with
HCV. However, people who live in constant fear of physical, psychological,
verbal, sexual or financial abuse may consider planning meals, shopping
and cooking low priorities. They may eat irregularly or erratically
and have difficulty eating at all. For some abused persons, alcohol,
drugs and medication may replace healthy eating. In a national survey,
one quarter of the women who reported that they had lived with violence
said they had turned to these substances to help them cope with
their situation.47 Taking drugs or medications to help
themselves sleep, calm down and/or get out of depression was also
commonly reported in another national survey, with women twice as
likely as men to report doing so.48
For more information, consult...
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