Primary Sclerosing Cholangitis (PSC) is a chronic liver disease characterized by inflammation and scarring of the bile ducts. This can lead to a buildup of bile in the liver, causing damage and potentially leading to cirrhosis or liver failure. While there is no specific cure for PSC, dietary modifications can play a crucial role in managing the condition and alleviating symptoms. Individuals with PSC have expressed a desire for more information on food, diet, and supplements, emphasizing the importance of investigating dietary factors and possible associations between diet and disease progression.
Understanding PSC and Its Impact on Nutrition
PSC is often associated with inflammatory bowel disease (IBD), with approximately 70% of PSC patients also having IBD. The disease can progress from early stages, where patients may feel generally healthy or fatigued, to advanced stages with symptoms like jaundice, abdominal pain, weight loss, and vitamin deficiencies. As PSC progresses, the liver's ability to process nutrients and toxins may be compromised, necessitating dietary adjustments. Living with PSC, which carries a risk of malabsorption and malnutrition as it progresses, may increase the need for a high-quality diet that meets the nutritional requirements for energy, vitamins, and minerals.
Alterations in the intestinal microbiome may play a role in the pathogenesis of both IBD and PSC. Dietary habits, potentially impacting the human microbiome, are speculated to be relevant to PSC pathogenesis, yet their influence on the disease remains unclear. It remains unknown if dietary patterns affect the progression of PSC, and descriptions of dietary intake in patients with PSC are scarce.
Key Dietary Considerations for PSC Management
Dietary advice for PSC generally aims to reduce stress on the liver and alleviate symptoms of liver disease. Here are several key considerations:
Macronutrient Balance
A cross‐sectional assessment of dietary intake was performed using a food‐frequency questionnaire among 120 individuals with PSC from five regions across Sweden. Median energy distribution included 36% from fat (15% saturated, 4.6% polyunsaturated), 17% from protein and 43% from carbohydrates, highlighting an imbalanced diet with low carbohydrate, fibre and polyunsaturated fat intake and high saturated fat consumption. The average fibre intake was 18 g (IQR 18), below the recommended 25-35 g/d for both men and women. It's essential to maintain a balanced diet with adequate carbohydrates, fiber, and healthy fats. PSC-IBD individuals had a higher intake of total fat (36.8 (IQR 7) vs. 33.8 (SD 8) E%, p = 0.025) and saturated fat (14.9 (IQR 4) vs. 13.6 (IQR 4) E%, p = 0.018). There was a tendency for a lower carbohydrate intake in PSC-IBD individuals (42.5 E% (IQR 6) vs. 45.2 E% (IQR 10) (p = 0.095).
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- Carbohydrates: Choose complex carbohydrates like whole grains, fruits, and vegetables over simple sugars.
- Fiber: Increase fiber intake through whole grains, fruits, vegetables, and legumes to support liver function and protect against fatty liver disease.
- Fats: Prioritize unsaturated fats found in fish, avocados, nuts, and olive oil over saturated and trans fats.
Micronutrient Sufficiency
More than half reported suboptimal intake of zinc, selenium and vitamins C, D and K and > 30% suboptimal intake of vitamins A, B6, E, niacin, folate, potassium, magnesium and iron. Many individuals with PSC do not reach the recommended levels of various micronutrients, especially fat‐soluble vitamins and report a poor dietary quality. Inadequate intake for vitamins C, D and K was reported by more than 50% for both sexes. In addition, greater than 30% reported suboptimal intakes of other micronutrients such as vitamins A, B6, E, niacin and folate. For vitamin D, 59% reported intakes below the average requirement of 7.5 μg/day. For vitamin C, 55% reported intakes below the average requirements of 75/90 mg/day. Eighty‐nine percent reported vitamin K intakes below the provisional average requirement of 50/60 μg/day respectively. Forty percent reported intakes of vitamin A below the average requirement of 540/640 retinol equivalents/day.
- Fat-Soluble Vitamins (A, D, E, K): PSC patients are often at risk of deficiencies in fat-soluble vitamins due to impaired bile flow. Eating five or more servings of fruits and vegetables every day can help you get what you need.
- Other Micronutrients: Ensure adequate intake of other essential vitamins and minerals through a balanced diet or supplementation as recommended by your healthcare provider.
Sodium Reduction
Sodium/salt reduction will help to reduce fluid build-up in the abdomen (ascites). You may also need to restrict your fluid intake. As PSC progresses, your body’s ability to process sodium and remove it from your body declines. Therefore, we usually recommend a low-sodium diet, particularly as PBC advances. Processed foods are typically high in sodium.
- Limit processed foods, which are often high in sodium.
- Avoid adding salt to meals.
- Use salt-free seasonings and herbs to flavor food.
Sugar Limitation
Carbohydrate metabolism is also altered in liver disease, which can lead to increased blood sugar. You may be told to cut down on simple sugars in your diet. When we absorb these sugars, it can lead to fat building up in the liver.
- Reduce intake of sugary beverages like sodas and fruit juices.
- Limit consumption of sweets, candies, and baked goods.
Alcohol Avoidance
Alcohol is a definite stressor for your liver. Less is always better if you have PSC. It can raise your risk for developing cirrhosis if you already have inflammation in your liver.
- Avoid alcohol consumption to minimize liver stress.
Embracing a Mediterranean Diet
Although there is no specific diet for people with PSC, we recommend a diet with plenty of fruits and vegetables, low-fat proteins and whole grains, specifically the Mediterranean diet. The pillars of the Mediterranean diet typically work well for most people with PBC, especially given the anti-inflammatory properties of many of the foods.
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The Mediterranean diet is often considered the gold standard when it comes to preventive medicine through food. It emphasizes:
- Fruits and Vegetables: Aim for at least five servings per day to obtain essential vitamins and minerals.
- Whole Grains: Choose whole-grain bread, oatmeal, and brown rice for their fiber content and complex carbohydrates.
- Unsaturated Fats: Incorporate sources like fish, avocados, nuts, and olive oil for their beneficial fats.
- Plant-Based Proteins: Include more plant-based sources of protein into your diet. Examples include legumes, grains, nuts, nut-butters, seeds, tofu and edamame. It is important to note that PSC patients should not necessarily avoid animal-based protein altogether.
The Role of Gut Health
Consume prebiotic fiber, found in foods such as bananas, legumes, and potatoes, and probiotics, found in foods such as kefir, yogurt, kimchi, miso, and tempeh. It’s even better for your gut if you consume prebiotics and probiotics together. The same type of bad bacteria (Bacteroides) that has been discovered to be increased in people with PSC has been found to be increased in people who consume a lot of animal protein. This bacteria and other types of bad bacteria are also found to be increased in individuals who consume a westernized diet.
Maintaining a healthy gut microbiome is crucial for overall health and may play a role in managing PSC.
- Prebiotics: Consume foods like bananas, legumes, and potatoes to nourish beneficial gut bacteria.
- Probiotics: Include fermented foods like kefir, yogurt, kimchi, miso, and tempeh to introduce beneficial bacteria to the gut.
Dietary Supplements: A Word of Caution
Some PSCers say they find relief from symptoms if they take certain dietary supplements. If you decide to try supplements, you ought to research them thoroughly and ask your doctor before taking them. Formal research on dietary supplements and PSC is limited. Some supplement manufacturing practices may not be consistent or safe. Some supplements can be toxic to the liver, and you can inadvertently harm it further.
While some PSC patients find relief from dietary supplements, it's essential to exercise caution:
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- Research Thoroughly: Investigate supplements before taking them, as manufacturing practices may vary.
- Consult Your Doctor: Discuss supplement use with your healthcare provider to avoid potential harm to the liver.
The Importance of Professional Guidance
Diet issues can be confusing because patients are generally not trained to sort out the complexities, especially with regard to PSC and its related diseases. Well-meaning information from non-professionals, such as friends, other patients, advertisements, etc., should be checked with your doctor or nutritionist/dietitian. You may need assistance working through and understanding the importance of certain diet changes.
- Consult a Nutritionist: Seek guidance from a registered dietitian or nutritionist with experience in liver disease. Ask your specialist to recommend a nutritionist who is knowledgeable about the technical aspects of liver disease. Generally, these specialists are found in large and/or teaching hospitals, and are registered/licensed dietitians who are certified in medical nutrition. Dietary advice from a hospital-related professional will likely be the most precise for PSC.
- Personalized Plans: Work with your healthcare team to develop a diet plan tailored to your specific needs and disease stage. Your specific diet, if you need one, may not be the same as another PSC patient's. Each person is unique.
Study on Dietary Intake in PSC Patients
A cross-sectional study assessed dietary intake among 120 PSC patients in Sweden using a food-frequency questionnaire. The study revealed that many individuals with PSC do not reach the recommended levels of various micronutrients, especially fat-soluble vitamins and report a poor dietary quality. The median dietary index score was 5.0 (95% CI 4.6-5.2) points, ranging from 1 (poor quality) to 10 (high quality). Dietary quality was classified as fair for 58% of the participants, while 40% had poor dietary quality and 2% had high-quality diets.
- Key Findings: The study highlighted suboptimal intake of several micronutrients, particularly fat-soluble vitamins, and a generally poor dietary quality among PSC patients.
- Factors Influencing Dietary Quality: Older age increased dietary quality with 0.32.