Liver Health and Wellness


The outstanding performance of the new drugs to treat hepatitis c can overshadow the importance of liver health; also an important weapon in your arsenal to fight liver disease. While on HCV therapy a healthy diet, staying hydrated and getting the proper rest are all of great importance. Liver health should remain a priority, even if you are not on treatment, or have just finished. Hopefully the topics on the blog today will inspire the reader to consider healthy lifestyle changes.

The Bad News

Fatty liver disease, alcohol, certain medications and diet can accelerate the progression of liver disease.

The Warnings

Alcohol

Alcohol can damage or destroy liver cells. Liver damage can lead to the build up of fat in your liver (fatty liver), inflammation or swelling of your liver (alcoholic hepatitis), and/or scarring of your liver (cirrhosis).
For people with liver disease, even a small amount of alcohol can make the disease worse

Medicines
Different types of medicines are taken every day including over-the-counter and prescription medicines, vitamins, dietary supplements, and alternative medicines. Medicines can help you feel better. However, when medicines are taken incorrectly — by taking too much or the wrong type or by mixing — your liver can be harmed.

• Learn about your medicines and how they can affect your liver
• Follow dosing instructions
• Talk to your doctor or pharmacist often about all the medicines you are taking

Alcohol and Medicines
Mixing alcohol and medicines can be harmful even if they are not taken at the same time.

Avoid medications that may cause liver damage. Review your medications with your doctor, including the over-the-counter medications, in particular acetaminophen.

Acetaminophen
Acetaminophen is found in the following medications
Tylenol· Excedrin· Midol· NyQuil· Sudafed· Vicodin

Fatty Liver And HCV

There are two different forms of steatosis (Fatty Liver) that may be found in people with HCV: Metabolic steatosis and HCV-induced steatosis

Metabolic steatosis can result from obesity, raised blood fat levels (hyperlipidemia), insulin resistance and type II diabetes and is similar to the type of fatty infiltration caused by excessive alcohol consumption and that is also found in Non-Alcoholic Fatty Liver (NASH).

Metabolic steatosis is not triggered by the hepatitis C virus; however the combination of this form of steatosis and the presence of HCV can lead to a more rapid progression of scarring or fibrosis.

HCV-induced steatosis is fatty infiltration that is directly caused by the presence of the virus. It is possible for people with HCV to have both forms of steatosis simultaneously.

Genotypes and Fatty Liver Disease:
Although it seems that all genotypes can trigger steatosis, the risk of developing steatosis is significantly higher for people with genotype 3. There is a complex reaction between the genotype 3 virus and liver cells that is not seen in other genotypes that makes this group at much higher risk of developing the condition. Around 40% of people with hepatitis C have steatosis, compared to about 14% to 31% of the general population. However, 60% - 80% of people with genotype 3 have moderate or severe steatosis.

Liver Cancer And Fatty Liver

This week in a study led by Dr. Neeraj Bhala from the University of Oxford in the UK, researches reported that the incidence of liver cancer is lower in patients with nonalcoholic fatty liver disease, than in hepatitis C.

Liver cancer incidence lower in patients with nonalcoholic fatty liver disease than hepatitis C
"Our study reports on the long-term morbidity and mortality of NAFLD patients with advanced fibrosis or cirrhosis by prospectively following up cases from four international collaborating hepatology centers," explains lead author Dr. Neeraj Bhala from the University of Oxford in the UK. "Understanding the long term prognosis of NAFLD patients compared with patients affected by other liver diseases such as chronic HCV was an important aspect of our study." Medical evidence suggests that while HCV is currently the leading indication for liver transplantation, affecting more than 5 million individuals in the U.S, HCV incidence has plateaued, while that for NAFLD is on the rise.

In the largest prospective study of participants with advanced fibrosis or cirrhosis to date, the team recruited 247 patients with NAFLD and 264 patients with HCV infection who were not previously treated or were unresponsive to therapy from centers in Australia, Italy, the UK and the USA. Patients in both groups were Child-Pugh class A and had advanced fibrosis (stage 3) or cirrhosis (stage 4) confirmed by liver biopsy at the onset of the study. Follow-up in the NAFLD and HCV groups was a mean of 86 and 75 months, respectively.Of those patients in the NAFLD group, 19% had liver-related complications and 13% died (or received transplants). Liver-related complications and deaths (or transplants) in the HCV cohort were lower at 17% and 9%, respectively. However, after adjusting for age and gender, the incidence of liver-related complications, including liver cancer, was lower in the NAFLD group compared to the HCV cohort. Researchers found that cardiovascular complications and overall mortality were comparable between the groups, although moderate differences cannot be excluded, highlighting the need for even larger collaborative prospective studies.


The Good News

Studies have revealed that diet, coffee, foods or spices such as artichokes, blueberries, curcumin and turmeric could have a protective effect on the liver.

Coffee

Researchers suggest that coffee consumption may improve response to standard HCV therapy and have an effect on liver cancer and fibrosis.



A Warning

Acetaminophen And Caffeine
According to consumer affairs , a 2007 study from the University of Washington in Seattle, scientists reported a potentially harmful interaction while taking acetaminophen in combination with caffeine.

While the studies are preliminary findings conducted in bacteria and laboratory animals, they suggest that consumers may want to limit caffeine intake -- including energy drinks and strong coffee -- while taking acetaminophen.

Researchers from the University of Washington in Seattle tested the effects of acetaminophen and caffeine on E. coli bacteria genetically engineered to express a key human enzyme in the liver that detoxifies many prescription and nonprescription drugs.Toxic byproductsThey found that caffeine triples the amount of a toxic by product, N-acetyl-p-benzoquinone imine (NAPQI) that the enzyme produces while breaking down acetaminophen.

This same toxin is responsible for liver damage and failure in toxic alcohol-acetaminophen interactions, they say.In previous studies, the same researchers showed that high doses of caffeine can increase the severity of liver damage in rats with acetaminophen-induced liver damage, thus supporting the current finding.“People should be informed about this potentially harmful interaction,” chemist Sid Nelson says. “The bottom line is that you don’t have to stop taking acetaminophen or stop taking caffeine products, but you do need to monitor your intake more carefully when taking them together, especially if you drink alcohol.”MegadosesNelson points out that the bacteria used in the study were exposed to ‘megadoses’ of both acetaminophen and caffeine, much higher than most individuals would normally consume on a daily basis.

Most people would similarly need to consume unusually high levels of these compounds together to have a dangerous effect, but the toxic threshold has not yet been determined, he says.Certain groups may be more vulnerable to the potentially toxic interaction than others, Nelson says. This includes people who take certain anti-epileptic medications, including carbamazepine and phenobarbital, and those who take St. John’s Wort, a popular herbal supplement

The Research

Coffee and the response to HCV Therapy

ScienceDaily (June 8, 2011) — Advanced hepatitis C patients with chronic liver disease may benefit from drinking coffee during treatment, according to a new study in Gastroenterology, the official journal of the American Gastroenterological Association (AGA) Institute. Patients who received peginterferon plus ribavirin treatment and who drank three or more cups of coffee per day were two times more likely to respond to treatment than non-drinkers.

"Coffee intake has been associated with a lower level of liver enzymes, reduced progression of chronic liver disease and reduced incidence of liver cancer," said Neal Freedman, PhD, MPH, of the National Cancer Institute and lead author of this study. "Although we observed an independent association between coffee intake and virologic response to treatment, this association needs replication in other studies."

Among non-drinkers, 46 percent had an early virologic response; 26 percent had no detectable serum hepatitis C virus (HCV) ribonucleic acid at week 20; 22 percent had no detectable serum at week 48; and 11 percent had a sustained virologic response. In contrast, the corresponding proportions for those who drank three or more cups of coffee per day were 73 percent, 52 percent, 49 percent and 26 percent, respectively.

Approximately 70 to 80 percent of individuals exposed to HCV become chronically infected. Worldwide, these individuals are estimated to number between 130 and 170 million. Higher coffee consumption has been associated with slower progression of pre-existing liver disease and lower risk of liver cancer. However, the relationship with response to anti-HCV treatment had not been previously evaluated. Treatment with peginterferon and ribavirin resolves chronic hepatitis C in about half of patients. It is unknown whether coffee will improve response with the addition of new drugs that were recently approved for use in the U.S.

Because patients in the Hepatitis C Antiviral Long-term Treatment against Cirrhosis Trial also had previously failed interferon therapy, it is not clear whether the results can be generalized to other patient populations. Future studies among patients with less advanced disease, those who are treatment-naïve to prior therapy, or who are being treated with newer antiviral agents are needed.

The Study;
2011 June edition of American Gastroenterology , a study published online in March 2011 found;
High-level consumption of coffee (more than 3 cups per day) is an independent predictor of improved virologic response to peginterferon plus ribavirin in patients with hepatitis C.

In November 2010 at the AASLD meeting in Boston, a presentation evaluated the relationship between drinking coffee and the response to HCV anti-viral treatment .

From NATAP: Coffee is associated with virologic response in chronic Hepatitis C: Findings from the Hepatitis C Long - Term Treatment against Cirrhosis Trial (HALT - C)
The Conclusion: Pre-treatment coffee intake was independently associated with improved virologic response during peginterferon alfa-2a and ribavirin in the HALT-C trial. "daily coffee consumption of 3 or more cups was associated with 25.8% SVR vs 20.7% for 1- less then 3 cups and 12.7% for less then 1 cup and these are all statistically significant. Coffee increased EVR & week20 responses too"Check out full data.

Liver Cancer

In August of 2010 data from a case-control study showed that: moderate coffee consumption significantly reduced the risk of HCC by almost half in chronic HBV.

Liver Fibrosis

A study from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), published in the January 2010 issue of Hepatology; has shown that in people with chronic hepatitis C virus who drink about two and a quarter cups of coffee (with caffeine) daily had milder liver fibrosis. However, researchers found that other beverages containing caffeine did not have the same effects.
Full Text

Foods And Spices

Artichokes
Artichokes, have been shown to improve various digestive health disorders. They significantly lower blood cholesterol levels, prevent heart disease and atherosclerosis, enhance detoxification reactions, as well as protect the liver from damage. Artichokes are very concentrated in cyanarin, which may also help in regeneration of liver tissue.


Published in Biological Trace Element Research in June 2010 researchers investigated the effect of artichoke leaf extract on the liver in mice. In the study they found that artichoke leaf extract decreased fat and cholesterol levels in the liver.

In a study in "Journal of Functional Foods" in 2009, Vincenzo Lattanzioa and colleagues describe the properties of artichoke leaf extract as antibacterial, anti-carcinogenic, diuretic, bile-expelling and hepatoprotective, which means it protects the liver from toxin overload.

Blueberries
Consuming blueberries, a food source that contains high levels of antioxidants, may help prevent the development of liver disease.


Published in the 2010 issue of World J Gastroenterol (full text available) researhers Ming-Liang Cheng, MD, from Department of Infectious Diseases, Guiyang Medical College, Guiyang, presented some data from their research on the effectiveness of blueberries on liver fibrosis induced in laboratory animals.

Innovations and breakthroughs
The present study showed that blueberries have therapeutic effects on CCl4-induced hepatic fibrosis in rats, through inhibition of liver inflammation and lipid peroxidation. This protective effect may not be related to the activation of NF-E2-related factor 2 in rat livers.

Applications
Increasing consumption of blueberries is a reasonable strategy to increase antioxidant intake, and may lead to a reduced risk of hepatic disease.

Research frontiers
Reactive oxygen species and oxidative stress have an important role in the development of hepatic fibrosis. Blueberries have high cellular antioxidant activity. Recent reports have suggested that proanthocyanidin isolated from blueberry leaves can be used against hepatitis C virus by inhibiting viral replication.

Another study in 2009 lead by Hiroaki Kataoka and colleagues at the University of Miyazaki (U-M) in Japan researchers screened nearly 300 different agricultural products for potential compounds that suppress HCV replication and uncovered a strong candidate in the leaves of rabbit-eye blueberry (native to the southeastern US). They purified the compound and identified it as proanthocyandin (a polyphenol similar to the beneficial chemicals found in grapes and wine).

While proanthocyandin can be harmful, Kataoka and colleagues noted its effective concentration against HCV was 100 times less than the toxic threshold, said a U-M statement.
Similar chemicals are found in many edible plants, suggesting it should be safe as a dietary supplement. Researchers now hope to explore the detailed mechanisms of how this chemical stops HCV replication.

Curcumin

In a 2010 study from the Saint Louis University suggested that Curcumin held promise in preventing or treating liver damage in fatty liver disease.



"High levels of leptin activate hepatic stellate cells, which are the cells that cause overproduction of the collagen protein, a major feature of liver fibrosis. The researchers found that among other activities, curcumin eliminated the effects of leptin on activating hepatic stellate cells, which short-circuited the development of liver damage."

Turmeric

In the 2010 issue of GUT researchers suggested that a major component of the Indian spice turmeric was found to decrease inflammation and fibrosis in vitro and in an animal model of chronic cholangiopathy. Chronic cholangiopathies, which are usually genetic or autoimmune in origin, cause inflammation and fibrosis and can lead to the need for liver transplantation. Primary biliary cirrhosis is one example of a chronic cholangiopathy.

From NHS
"Researchers in this animal study investigated how an extract of the spice protected mice that had been bred to have inflammation in their bile ducts from liver damage.
The results suggest that liver damage, jaundice and scarring were all reduced by the curcumin and that the underlying cellular pathways affected might, in time, become promising targets for new drug development. However, there is no suggestion from this study that eating turmeric will have the same effect or be a useful treatment for humans"


Conclusion
This well-conducted animal and laboratory study has identified cellular targets for new drug development. The theories are at an early stage and it is too soon to say that any new treatments might be developed from the spice. However, researchers will welcome these findings as they give a clear direction for new study into treatments for these severe and hard-to-treat conditions.
A variation of curcumin may be one of the drugs tested further; however, it is also possible that other related chemicals may have more effect. At this stage, it is not possible to say if the spice turmeric will be useful for treating liver disease in humans.


Diet

Dietary history and physical activity influence the risk of advanced liver disease in HCV, reports this month's issue of the Digestive Diseases & Sciences.

Dietary history and physical activity influence the risk of advanced liver disease in HCV, reports in the june issue of the Digestive Diseases & Sciences.

The role of customary diet and physical activity in development of advanced HCV-related liver disease is not well-established. Dr Donna White and colleagues conducted a retrospective association study in 91 male veterans with PCR-confirmed chronic HCV and biopsy-determined hepatic pathology.

Respondents completed the Block Food Frequency and the International Physical Activity questionnaires. The research team conducted 3 independent assessments based on hepatic pathology, including fibrosis, inflammation, and steatosis. Each assessment compared estimated dietary intake and physical activity in veterans with advanced disease to that in analogous veterans with mild disease.

Multivariate models adjusted for total calories, age, race/ethnicity, biopsy-to-survey lag-time, BMI, pack-years smoking, and current alcohol use.

Average veteran age was 52, with 48% African-American. The researchers found that advanced fibrosis was more prevalent than advanced inflammation or steatosis. The strongest multivariate association was the suggestive 14-fold significantly decreased advanced fibrosis risk with lowest dietary copper intake. The team observed that other suggestive associations included the 7-fold significantly increased advanced inflammation risk with lower vitamin E intake, and 6-fold significantly increased advanced steatosis risk with lower riboflavin intake.

The only physical activity associated with degree of hepatic pathology was a 2-fold greater weekly MET-minutes walking in veterans with mild compared to advanced steatosis. Dr White's team concluded, "Several dietary factors and walking may be associated with risk of advanced HCV-related liver disease in male veterans."

"However, given our modest sample size, our findings must be considered as provisional pending verification in larger prospective studies."
Dig Dis & Sci 2011: 56(6): 1835-47 21 June 2011

Vitamins, Diet and Nutrition
For most people, including those with hepatitis C, the best diet is one that is balanced, and contains the right amount of essential nutrients and calories.

In overweight patients with a fatty liver who subsequently lose weight, liver- related abnormalities improve. Therefore, patients with chronic hepatitis C are advised to maintain a normal weight. For persons who are overweight, it is crucial to start a prudent exercise routine and a low fat, well balanced, weight reducing diet. In diabetic patients, a sugar- restricted diet should be adhered to. A low cholesterol diet should be followed in those with hypertriglyceridemia. In individuals with NASH who are of normal weight, a low fat diet may be advantageous. It is essential that patients consult with their physician prior to the commencement of any dietary or exercise program.

Vitamins
The best way to get vitamins and minerals is through food. Food provides the greatest range of nutrients. However, a multivitamin/mineral supplement can be helpful, especially if you lose your appetite or can't eat a healthy diet. Folate is particularly important vitamin and is not obtained easily from food but is found in multivitamins.

Before taking any supplement, talk to a doctor or dietitian. If you take supplements, don't exceed the recommended doses. Some supplements in high amounts can be dangerous, particularly fat-soluble vitamins, such as A, D, E, and K.

Iron and Vitamin C
Some people with hepatitis C, particularly those with cirrhosis, have above-average levels of iron in their body. Too much iron can damage organs. If these people take multivitamin/mineral pills, they should take the ones without iron. These pills usually are marketed as formulas for men or adults over 50. These people also should avoid taking large doses of vitamin C because vitamin C helps the body absorb iron.
You do not want to take iron supplements if you have hepatitis C, unless you are specifically told to take iron by your provider.

Vitamin A
Vitamin A, if taken in doses larger than the recommended 10,000 IU, can harm the liver. Vitamin A is even more toxic in someone who drinks alcohol.
You won't get too much vitamin A from food, but be careful taking routine dietary supplements with high doses. There's a non-toxic form of vitamin A, present in many fruits and vegetables, called beta-carotene. If you take vitamin A supplements, look for those with beta-carotene.

Vitamin D
Vitamin D is important for health in normal amounts (such as diets with plenty of milk). The body also can make vitamin D when exposed to sunlight. Taking supplements of 800 IU of vitamin D daily may help people with poor diets or long winter seasons, or those who are housebound.

Vitamin E
Vitamin E supplements do not have benefits, though it used to be believed that Vitamin E prevented heart disease. High doses (greater than 400 IU/day) can have be dangerous.

Vitamin K
Vitamin K is involved in blood clotting. It is present in the diet mostly in green vegetables. It also is produced by bacteria in the intestines. Vitamin K supplements generally are not taken, nor are they recommended.
http://www.va.gov/

What foods can improve liver health?
Your liver is the organ responsible for an enormous number of metabolic activities, and you'll need a plentiful supply of virtually all nutrients for your liver to be optimally healthy. In general, fruits and vegetables would be at the top of our list in the support category, since they contain such a wide range of nutrients that participate in liver function. Additionally, if you are focused on liver health, it is important to consume foods that are organically grown; the liver is an organ that detoxifies chemicals and therefore with organically grown foods you'll reduce your exposure to agricultural chemicals. In this same toxic exposure category, moderate consumption of alcohol (or less) would also be important to the health of your liver, since this organ postpones other important functions when it is trying to metabolize excess alcohol.

Fried foods and other high-fat foods (like processed foods containing hydrogenated oils) would also be particularly hard on your liver. Just as with alcohol, there is a limit to the total amount of fat than your liver can process while maintaining all of its other metabolic activities.
There are a couple of food groups that would also be especially helpful in supporting your liver's ability to detoxify chemicals. First are foods rich in sulfur. Sulfur-containing compounds are one of the primary types of molecules used to help the liver detoxify a wide range of prescription medications, pesticides, and other types of environmental toxins. Foods in this category would include onions, garlic, and egg yolks. (We'd caution against over consumption of egg yolks, however, due to their higher concentration of cholesterol and saturated fat. Two-to-four eggs per week would be a very reasonable amount for most persons).

Some additional sulfur-containing foods are worth mentioning as a category of their own - namely, the cruciferous vegetables. There are some unique sulfur compounds in these foods that may be especially beneficial in liver detoxification processes. Foods in this group include broccoli, cabbage, cauliflower, collard greens, kale, and Brussels sprouts.
To support your liver's immune function, we also feel obligated to mention some culinary spices that have extensive research with respect to their role in liver support. Those spices include turmeric, cinnamon, and licorice.

According to the American Liver Foundation here are some additional ways to keep your liver healthy: Eat a well balanced, nutritionally adequate diet. If you enjoy foods from each of the four food groups, you will probably obtain the nutrients you need. Cut down on the amount of deep-fried and fatty foods you and your family consume. Doctors believe that the risk of gallbladder disorders (including gallstones, a liver-related disease) can be reduced by avoiding high-fat and cholesterol foods.

Minimize your consumption of smoked, cured and salted foods. Taste your food before adding salt! Or try alternative seasonings in your cooking such as lemon juice, onion, vinegar, garlic, pepper, mustard, cloves, sage or thyme.

Increase your intake of high-fiber foods such as fresh fruits and vegetables, whole grain breads, rice and cereals. A high-fiber diet is especially helpful in keeping the liver healthy. Rich desserts, snacks and drinks are high in calories because of the amount of sweetening (and often fat) they contain. Why not munch on some fruit instead? Keep your weight close to ideal. Medical researchers have established a direct correlation between obesity and the development of gallbladder disorders.

For more information on this topic,
see:
Broccoli [Brussels sprouts [Cabbage [Cauliflower [Cinnamon [Collard greens [Eggs, hen [Garlic [Kale [Onions [Turmeric, ground

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