Cholestasis and Low-Fat Diet: Essential Tips for Effective Management

When dealing with cholestasis, whether during pregnancy or due to other causes, understanding the role of diet, particularly a low-fat approach, is crucial. This article provides a comprehensive overview of cholestasis, its causes, symptoms, and how a low-fat diet can be incorporated into its management, especially during pregnancy.

Understanding Cholestasis

Cholestasis happens when bile acids build up in a person’s blood. Bile acids are substances that help the body process fat. Cholestasis is defined as the impairment of bile production or an obstruction of bile flow. Bile is a yellow-green fluid that helps digest fat. It mainly consists of cholesterol, bile salts, and the pigment bilirubin. The liver produces bile, and the gallbladder stores it. From the gallbladder, it passes through the common bile duct into the duodenum. When food is present in the enteric tract, bile travels from the gallbladder into the duodenum to aid in the digestion of fats. In the setting of cholestasis, the flow of bile is halted between the liver and the duodenum.

Types of Cholestasis

There are two main types of cholestasis:

Intrahepatic Cholestasis: This happens when there is a problem with eliminating bile salts from the liver. This is the kind of cholestasis that occurs during pregnancy.
Extrahepatic Cholestasis: Sometimes, a blockage outside the liver prevents the bile from leaving it, leading to a condition known as extrahepatic cholestasis.

Cholestasis of Pregnancy

Cholestasis of pregnancy is the most common liver disorder associated with pregnancy. It happens when a pregnant person’s bile acid levels become elevated. It usually occurs late in the second trimester or during the last trimester of pregnancy. Pregnancy hormones, and especially the additional estrogen, may affect the proper functioning of the gallbladder and the liver.

Causes of Cholestasis

Cholestasis has many causes. In general, two types of problems may be going on. It may be a problem with your liver that inhibits its ability to secrete bile into your bile ducts (intrahepatic cholestasis). Or it may be a problem in your bile ducts that’s physically restricting the flow of bile through the ducts (extrahepatic cholestasis).

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Intrahepatic Causes

Causes affecting your liver (intrahepatic causes) include:

Chronic Liver Disease: Chronic liver disease that lasts a long time can cause scarring of the liver tissues (cirrhosis), including the intrahepatic bile ducts. Scarring causes them to narrow, which restricts the flow of bile. Specific diseases may also damage the cells that produce bile in more specific ways.
Acute Hepatitis: Acute liver inflammation (from a recent, temporary condition) can cause your liver to swell, inhibiting bile flow. Various toxins and infections may also cause the cells that produce bile to malfunction in different ways.
Pregnancy: Cholestasis of pregnancy (also called obstetric cholestasis) occurs in some people during the third trimester, when estrogen levels are at their highest. High estrogen inhibits bile secretion in your liver. Obstetric cholestasis goes away by itself after you’ve delivered your baby.
Total Parenteral Nutrition: Being fed through an IV in your vein bypasses your entire digestive system, including the hormonal signals that trigger your biliary system. If there’s no food in your small intestine that needs bile to help break it down, your liver might not get the message to keep delivering bile. This can cause bile to back up in your liver.
Medications: Certain medications can also cause bile stasis in your liver. If your liver is having trouble metabolizing these medications, they can have a toxic effect.

Extrahepatic Causes

Causes affecting your extrahepatic bile ducts include:

Biliary Stricture: Chronic inflammation in your bile ducts can cause scarring and narrowing of the ducts, restricting bile flow.
Bile Duct Obstructions: Physical obstructions may affect your bile ducts from the inside or outside, including:
- Gallstones in your common bile duct (choledocholithiasis).
- Gallstones in your cystic duct or Hartmann’s pouch (Mirizzi syndrome).
- Pancreatic cysts and pseudocysts.
- Extrahepatic bile duct tumors.

Risk Factors for Cholestasis of Pregnancy

Factors that may increase a person’s risk of developing cholestasis of pregnancy include:

Having a close relative who had the condition.
Having had cholestasis of pregnancy before, as the risk of recurrence during subsequent pregnancies is 60-70%.
A multiple pregnancy, for example, if a person is having twins or triplets.
A history of liver damage.
Being pregnant as a result of in vitro fertilization.

Symptoms of Cholestasis

The most typical symptoms include:

Jaundice: A yellow tint to your skin and in the whites of your eyes is usually one of the first signs that your liver isn’t functioning properly. Jaundice is caused by the buildup of bile in your blood. Specifically, the yellow comes from bilirubin, one of the ingredients in bile. Some bilirubin also comes out in your pee, which may give it a darker color.
Light-Colored Poop: You may also notice poop changes due to the absence of bile in your intestines. When bile can’t flow to your intestines to help break down fats, these fats come out in your poop. Fatty stools are whitish or clay-colored. Their light color comes from the absence of bilirubin, which usually makes them brown. They may also float and may be extra smelly.
Pruritus: Skin itching (pruritus) is another common symptom of cholestasis. Bile-related pruritus is caused by the buildup of bile salts in your blood. The bile salts (or bile acids) irritate nerves in your peripheral nervous system, causing itching. There’s no rash with this type of pruritus. Some people seem to be more sensitive to bile salts than others, and pruritus may be mild to severe.

As well as intense itching, a person may have some problems with absorbing fat-soluble vitamins, which are vitamins A, D, E, and K. However, within a few days after giving birth, the problems should resolve. There will not usually be any further liver problems.

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Complications of Cholestasis of Pregnancy

The condition does not always pose a serious risk to a pregnant person’s long-term health, but it may cause severe complications for the fetus. The risk of stillbirth is higher in people with cholestasis of pregnancy, and may increase with very elevated bile salt levels in the blood. There is also a significantly higher risk of preterm birth for the fetus if the pregnant person has cholestasis, although the reasons for this are unclear.

An infant born preterm may have breathing difficulties if the lungs are not yet fully developed. The risk of fetal death is also higher. During gestation, the fetus depends on the pregnant person’s liver to remove bile acids from the blood. If their liver has too much bile acid, they can pass this on to the fetus.

The baby also has a higher risk of inhaling meconium during childbirth, resulting in breathing difficulties. Research suggests that cholestasis of pregnancy may increase the risk of cardiovascular disorders and metabolic disorders such as obesity when the child reaches adulthood.

Diagnosing Cholestasis of Pregnancy

To diagnose cholestasis of pregnancy, a doctor will consider an individual’s signs and symptoms, such as itchiness and the color of their urine and stool. The person may also need to tell the doctor about any personal and family medical histories. Next, the doctor will do a physical examination.

If a doctor suspects cholestasis of pregnancy, they will test for the condition by looking at a person’s total serum bile acid. This is determined through a blood test. There are also some additional blood tests a doctor can order to see how well the liver is functioning. This includes an alanine aminotransferase test, a bilirubin test, and an aspartate aminotransferase test.

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Ultrasound scans may be used to look for abnormalities in the individual’s liver. If a person is diagnosed with cholestasis of pregnancy, a doctor may also recommend more frequent ultrasound scans of the fetus. This is to monitor fetal health and development on a regular basis. The doctor may also request regular “non-stress” tests to check how often the fetus moves in a given period and measure the fetal heartbeat in relation to body movements.

To prevent complications before they occur, a person will also need ongoing blood tests to monitor their liver function and blood bile levels.

Management and Treatment of Cholestasis

Treatment normally aims to relieve symptoms, mainly the itching, and prevent potential complications. The primary treatment is ursodeoxycholic acid, which relieves itching and increases bile flow. A person will typically start on a dose of 300 milligrams (mg) daily and go up to 300 mg three times daily until delivery.

They will usually experience fewer symptoms within 2 weeks. If not, the dose can increase to a maximum of 21 mg per kilogram a day. Doctors often recommend induced labor before 39 weeks if cholestasis is severe.

Other treatments that doctors may use to treat cholestasis of pregnancy include:

1% menthol cream
The antibiotic rifampicin
Plasmapheresis

People with cholestasis will have low levels of vitamin K, increasing the chance of hemorrhage, so a person will often need Vitamin K supplements before and after delivery.

Research also discusses using antihistamines as a treatment. However, these do not appear to help with itching.

Home Remedies

In addition, a person can try soaking the affected areas of skin in lukewarm water to get some temporary relief. Dabbing with baking soda or apple cider vinegar may also help, and people may try applying coconut oil after a bath.

Lotion may help with skin itching. Some sources also recommend oatmeal baths. People should speak with a doctor before trying any alternative treatments to check their effects during pregnancy.

Natural remedies that are sometimes suggested for liver health include dandelion root and milk thistle. But there is no evidence that these are safe or effective for cholestasis of pregnancy. Home remedies are not a replacement for medications prescribed by a doctor. It is very important to check with a doctor beforehand to make sure any natural remedy is safe and to consult a doctor if symptoms get worse.

Diet and Cholestasis

Some believe that eating a balanced diet may help a person with cholestasis of pregnancy reduce the condition’s severity, or prevent the condition. However, there is no research to support this. In general, it is important to follow a healthy, balanced diet with plenty of whole fruits and vegetables to reduce the risk of complications during pregnancy.

While there is little evidence to link dietary choices with the development of cholestasis, eating a health-promoting diet is one of the best ways to help ensure a healthy pregnancy. It is important to follow a doctor’s instructions regarding treatment and diet. Also, diet is not an alternative to medication that a doctor prescribes.

General Dietary Recommendations

Fill half of your plate with fruits and vegetables for every meal: Fresh, canned, frozen and dried fruits and vegetables are all good options.
Eat a range of protein sources: Choose from foods such as meats, poultry, fish and seafood, eggs, beans and peas, tofu and soy products, nuts, and seeds.
Focus on whole grains such as oats, whole wheat, and brown rice: Look for “whole grain” on the label when selecting breads, cereals, and bakery products.
Include healthy fats and oils: Try to reduce fats from animal sources. Replace them with liquid oils like olive oil or grapeseed oil, and foods like nuts and avocados.

Since the condition interferes with nutrient absorption, eating as many nutrient-rich foods as possible is important.

Low-Fat Diet and Cholestasis

When you eat, the gallbladder releases bile, which helps you digest the fat in food. If you have an inflamed gallbladder, this may cause pain. A low-fat diet may give your gallbladder a rest so you can start to heal.

Due to insufficient bile release in patients with cholestasis, fat malabsorption is common. Temporarily following a fat-restricted diet can help manage these symptoms. Foods containing <3 g per serving are considered low fat, and fat restriction to <20 g/day is encouraged to manage symptoms of fat malabsorption.

Nutritional Recommendations for Cholestasis of Pregnancy

Pregnancy puts added stress on your liver, which partly explains why cholestasis of pregnancy develops. Following some simple dietary recommendations can help your liver function better during the stress of pregnancy and cholestasis.

Eat Plenty of Protein: Your liver is responsible for making many blood proteins. You can help by making sure you get key amino acids found in foods high in protein.
Eat Foods with Medium-Chain Fatty Acids (MCFAs): Fats absorb very poorly when the bile flow has slowed or stopped. The only fats that absorb relatively easily are medium-chain fatty acids found in higher concentrations in coconut oil and palm kernel oil. Other types of fats should be reduced in your diet as they are poorly absorbed and contribute to GI upset.
Consume Extra Fiber: Toxins in your food can be absorbed by the gut, and because your liver is sluggish, it can’t break them down as easily. Fiber helps bind toxins so that you aren’t as affected by them.
Eat Foods High in Vitamin K: Vitamin K is a fat-soluble vitamin that needs bile to be absorbed. You need this vitamin for the effective clotting of blood. In order to get enough vitamin K absorbed when you have cholestasis, you should consume more than you normally would. Leafy greens like spinach and collard greens are great choices.
Eat Extra Omega-3 Fatty Acids: Omega-3 fatty acids will be more challenging to absorb with cholestasis of pregnancy. Do your best by eating foods that have mostly this type of healthy fat. These include fish, nuts, and seeds.
Load Your Diet with Vitamins A, C, and E: These are antioxidant vitamins that help your cells heal from stress. Vitamin C will be easily absorbed, but because vitamins A and E are fat-soluble, they are harder to get into your system. Nevertheless, when you eat more foods with these vitamins, the chances of some getting in are greater.
Make Phytonutrients Your Friend: Phytonutrients are plant-based nutrients known to have antioxidant effects or to help your cells heal in other ways. Highly-colored fruits and vegetables will be your go-to foods for phytonutrients.
Consume a Diet Higher in Calcium: Calcium and vitamin D are essential for bone health.
Remain Hydrated: Hydration helps your kidneys flush waste (including toxins). By drinking extra water, you can help your kidneys do their job.

Foods to Eat and Avoid

Foods to Eat

Whole Fruits and Vegetables: While all fruits and veggies are good for you, those on the Clean Fifteen list have the lowest pesticide content (even if not organic). These include carrots, mangoes, watermelon, sweet potatoes, mushrooms, cabbage, honeydew melon, kiwi, asparagus, sweet peas, papaya, pineapple, onions, sweet corn, and avocados.
Healthy Fats: Remember that most fats will be poorly absorbed when you have cholestasis. To get some of the healthiest fats into your system, eat mostly those foods high in good fat and avoid other types of fat. The best choices are fish, nuts, seeds, coconut oils, palm kernel oils, and low-fat dairy products.
Lean Protein Sources: The best lean proteins have all the amino acids you need and little of the fat you don’t. Good choices include fish, poultry, lean beef, lean pork, beans, and lentils. Beans and lentils are excellent sources of fiber and protein and have very little fat, making them excellent choices.
Whole Grains: Whole grains have the grain protein and carbs you need plus bran that serves to add fiber to your food. Whole grains include brown rice, whole grain bread, oats, or other baked products.

Foods to Avoid

High-Fat Foods: Foods high in fat may not harm you; however, they are poorly absorbed, leading to gastrointestinal upset and diarrhea.
High-Sugar Foods: There are many reasons to avoid these foods. They are often highly processed and offer no valuable nutrients.
Refined Complex Carbs: Things like pastries, crackers, and cookies that are high in fat, trans fats, and preservatives will be hard on your liver and GI tract.
Soy Products: Soy is good for you in most situations; however, it is currently difficult to find products made of soy that don’t contain a lot of pesticides or aren’t genetically modified (GMO) foods.
Alcohol: Alcohol is dangerous in pregnancy for many reasons. If your liver is compromised from cholestasis, alcohol will be even riskier to consume.
Foods from Dirty Dozen (unless organic): You can eat these foods during pregnancy (and should eat), but they must be carefully chosen. To reduce the pesticide content of your diet, select only organic foods from this list: strawberries, mixed greens, spinach, peaches, pears, nectarines, apples, grapes, and peppers (hot or green).

The "Dirty Dozen" and "Clean Fifteen"

The Environmental Working Group (EWS) is a global coalition designed to educate people on the use of pesticides in food. The EWS studied foods grown commercially and sold in stores for their pesticide content and developed the concept of the “Dirty Dozen” and “Clean Fifteen” foods.

Foods are included in the Dirty Dozen if they are particularly high in pesticides. If you have cholestasis, your liver will have trouble processing these excess pesticides, and they could harm you or your developing baby. Organic versions of these foods offer you a chance to avoid high levels of pesticides.

Dirty Dozen: Strawberries, Spinach, Kale/Collard/Mustard Greens, Nectarines, Apples, Grapes, Cherries, Peaches, Pears, Bell and Hot Peppers, Celery, Tomatoes.

The Clean Fifteen foods are those that are generally considered to be safe because pesticides are not often a part of growing them commercially. If you can’t afford organic foods or don’t have access to them, you can eat these foods whether they are organically grown or not.

Clean Fifteen: Avocado, Sweet Corn, Pineapple, Onion, Papaya, Sweet Peas (Frozen), Eggplant, Asparagus, Broccoli, Cabbage, Kiwi, Cauliflower, Mushrooms, Honeydew Melon, Cantaloupe.

Additional Dietary Advice

Choose lean meats.
Many types of fish, such as salmon, lake trout, tuna, and herring, provide healthy omega-3 fat.
Drink or eat nonfat or low-fat milk, yogurt, cheese, or other milk products each day.
Eat low-fat ice cream, frozen yogurt, or sorbet.
Eat whole-grain cereals, breads, crackers, rice, or pasta.
Flavor your foods with herbs and spices (such as basil, tarragon, or mint), fat-free sauces, or lemon juice instead of butter.
Learn how to read food labels for serving sizes and ingredients.
A person should also drink 8-12 cups (64-96 ounces) of water every day and avoid alcoholic drinks and sodas, such as cola.
It is also a good idea to check that any product with an organic label is 100% organic. In addition, foods with a “natural” label are not necessarily organic or healthy.

Medium-Chain Triglycerides (MCTs)

Medium‐chain triglycerides (MCTs) should be recommended when initiating a fat‐restricted diet to prevent weight loss. MCTs, unlike long‐chain fatty acids, are water soluble and shorter in carbon length (8‐12 carbons). MCTs are absorbed by passive diffusion via the portal system, and therefore do not require formulation of micelles or bile salts for absorption. MCTs are calorically dense and are available as commercial oils. Coconut and palm kernel oils contain a high concentration of MCTs (>50%), although these two oils still contain long‐chain triglycerides, which can contribute to malabsorptive diarrhea.

Specific Considerations for Primary Biliary Cholangitis (PBC)

While this article primarily focuses on cholestasis and low-fat diets, it's important to briefly touch on Primary Biliary Cholangitis (PBC), formerly known as primary biliary cirrhosis, as it is a chronic cholestatic liver disease. While there isn’t a “one-size-fits-all” diet for everyone with PBC, there are general recommendations:

Mediterranean Diet: This diet is anti-inflammatory and beneficial for most people with PBC.
Avoid Saturated Fats: Limit cream, butter, beef, pork with visible fat, sausages, bacon, and deli meats.
Limit Sugary Foods: Stay away from foods high in sugar, especially sugar-sweetened beverages such as sodas, fruit drinks, and high fructose corn syrup.
Reduce Sodium: Cutting back on sodium is extremely important, especially if you have edema or ascites.
Moderate Alcohol Intake: People with PBC should either eliminate alcohol or drink very moderate amounts of it (no more than one glass of alcohol per day).

The Role of a Registered Dietitian

Nutritional needs can change as symptoms arise and the disease progresses. That’s why it’s important to see a registered dietician who can help tailor a diet to your individual needs.

How a Prenatal Nutritionist Can Help

Cholestasis of pregnancy is uncomfortable and scary. A prenatal nutritionist can provide both information and support. They are trained in advanced nutritional practices and have special training in nutrition for high-risk pregnancies.

Your prenatal nutritionist can evaluate your current diet. They will learn your likes and dislikes before working with you to develop a dietary plan that will carry you through your pregnancy. They can help you with meal planning and teach you the best foods to eat while pregnant and ways to eat with cholestasis to reduce your chances of suffering from this illness.

The nutritionist may meet with you once for a longer period to fully evaluate your diet and make recommendations. After that, you may reach out again to address concerns that may come up in implementing the dietary plan.

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