Beyond Liver Disease: The Hidden Role of Protein in CLD Recovery | Dr. Karan Jain & Ms. Reshma Aleem

Added: 2026-05-30

[00:00:00]A protein rich diet will ensure that the overall outcome of the patient is better. And once we educate them that this is what is going to actually help them in long run, I think the acceptance will be better. Especially when you take into consideration of alcohol related liver disease. Nutrition is the only proven treatment to actually reverse a disease which is at a reversible stage.

[00:00:18]What are the most commonest myths which you have encountered when you're counseling patients on taking some protein rich diet?

[00:00:24]>> Which is a non-vegetarian, the commonest myth is stop all the non-vegetarian foods, move on to vegetarian food which is very difficult for the quantity to achieve the protein. If I take protein, I will land up in the ICU. So here, the quality of the protein is important as you emphasized on weight. So in these obese patients, how do we counsel them and how do we educate?

[00:00:45]>> For them, weight loss is important in terms of losing fat. They should not lose muscle. Carbohydrates release energy in a quicker manner. Fats release energy slowly and proteins take longer time to release energy and they make the body utilize energy to digest it. So hence in that situation in obese individuals, ask them to reduce their calorie intake by reducing the carbohydrate intake and keeping the protein on the higher side. Patients in the ICU, how do you manage them?

[00:01:09]>> Patients in the ICU, their intake is already poor. We ask them at least to keep sipping on the supplements. At least if they are able to take nearing the 1 g is sufficient when they are in the ICU. So supplements which can have both calorie and protein are very important for our sarcopenic patients.

[00:01:25]For our obese, we need only protein.

[00:01:27]>> Also, that one education which we can give is not to mix the supplement along with the food. In the sense, they can break their meals six times in a day or eight times in a day. Take food, walk around, do some physical activity, have some protein supplement. Again, do the same. As a process if they can keep doing this repeatedly, they'll be able to meet their calorie requirement as well as their protein requirement.

[00:01:46]Because definitely with onset of liver disease and progression of liver disease, hunger is going to come down, appetite is going to come down. Both of them are slightly different and the desire to perform physically is going to come down. This is our duty to educate the patient that not all proteins are the same. They have to choose it rightly or what is prescribed they have to take it religiously.

[00:02:05]>> And as you said liver disease comes along with the metabolic parameter. So whether it's a diabetes or hypertension.

[00:02:11]So when it is diabetes we look into supplements which also do not elevate their sugar levels. Supplements either prescribed by a clinical dietitian or a doctor is very much specific disease specific. So it's better to go with these supplements.

[00:02:26]>> Basically the concept of liver disease is no fasting no feasting. So don't feast don't fast.

[00:02:31]>> [music] >> Hello and welcome all of you to the episode on chronic liver disease, malnutrition and why protein matters in malnutrition. So I'm dietitian clinical dietitian Reshma Ali. Today along with me I have Dr. Karan Jain who is a hepatologist.

[00:02:54]So today we are going to speak on the background of malnutrition in liver disease and why malnutrition occurs even in the starting stages of chronic liver disease when the patient is well nourished. So sir, I would like to ask you about how this chronic liver disease when the patients are diagnosed initially even at that time they find them very weak. So it is mostly like you say it is malnutrition where there is a muscle loss but the fat remains the same. So over the years so they find themself that the weight remains the same but they find they are very weak. Their appetite loss is there.

[00:03:36]They have nausea. So they have aversions to food which they like to use to eat before. So all these are contributing factors to malnutrition. And in our everyday scenario as an hepatologist you are very busy with the dealing with the medical side. Patient comes in with GI bleed, patient comes with ascites, patient comes in with sepsis. So, where you are targeting to address those issues first. And uh here I would like you to highlight the importance of nutrition and how nutrition can be bring these patients in a better in a longer way to handle their disease.

[00:04:15]>> Thank you, Reshma, for inviting me over here for this. So, uh as such if you see nutrition plays a very important role in health of an individual.

[00:04:25]So, rather it be a liver disease patient or a kidney disease patient or somebody who is otherwise well and just wants to build more nutrition and be more healthy.

[00:04:35]So, in that aspect the topic of nutrition is often missed when during a normal clinical conversation with the patient because they have a lot of more other uh clinical issues to discuss. Maybe as you said, person comes in with a GI bleed, patient comes with ascites. He is more worried about that. But, I think as a normal clinical conversation happens with the patient, a doctor should make sure that they talk and focus a lot more on nutrition.

[00:05:04]A good protein diet a diet which is rich in all essential amino acids. It's very important to build a good muscle mass.

[00:05:13]Especially when patients of liver disease are concerned.

[00:05:16]A liver disease is a spectrum of illness.

[00:05:20]Where there is something which starts with just a fatty liver and progresses to inflammation in the liver. It can go towards fibrosis and can lead to as sick as cirrhosis.

[00:05:30]Which we usually call as chronic liver disease.

[00:05:33]It's a state of catabolism in the body.

[00:05:37]Where the body is now destroying its own muscle mass to develop energy.

[00:05:43]Because somewhere in the disease process energy requirements of the body increase, but energy utilization is poor.

[00:05:53]Hence, because of that, there is an imbalance in the amount of intake as well as the amount which is actually required.

[00:06:00]Hence, when the muscle starts breaking down, it leads to something called as sarcopenia.

[00:06:06]Sarcopenia is basically where there is a muscle mass leading to weakness leading to frailty, which eventually leads to poor outcomes.

[00:06:18]So, to improve that, we need to supplement patients with good protein-rich diet, where we educate them that protein is not only essential for maintaining health, but also it's important for improving the overall quality of life, reducing the risk of infections, improving the outcome to whenever they fall sick.

[00:06:42]So, with all these things, even I think in the era of uh patients who are just suffering from just fatty liver, the insult which the underlying chronic liver disease is giving to the muscle mass is significant and has to be addressed.

[00:06:59]>> Okay. So, when you say sarcopenia, frailty, ascites, so when the patient comes to OPD to us, the first thing we ask them is about the weight changes because uh they may say before 3-4 years they may might be 100 kg. Now, with ascites, they will be the same 100 kg. So, they have been progressively losing that weight of 30 kg over the 3 years.

[00:07:24]So, and when you look at them, some of them are able to walk, some of them come in a wheelchair to us. So, there itself the assessment is done. So, they are not able to walk, they have lost their muscle. They need somebody to support them or they have to come in a wheelchair. So, we calculate the protein requirements for them. So, when we see the protein requirements are very very high for them and it is not possible for them for a diet to cover up the protein requirements. So, already always they need a oral nutrition supplement to balance the protein and calorie what what they are not taking.

[00:08:01]>> Yes.

[00:08:02]>> So, some of them because of ascites they may feel very very heavy with the protein supplements because they've not taken protein over the years. Uh when they say jaundice itself the patient and family have a lot of myth. They would have stopped all the protein in the diet and they would have said that even the previous years what their ancestors or everybody used to say jaundice stop the protein. So, when they come to us they've already lost the muscle. So, how do we cope up this muscle? So, how much time does it take for us to bring in this and it along with nutrition we need them to do some of the exercises so that whatever protein we give to them uh helps to build the muscle and with such a heavier protein if they're not going to walk or if they're not going to move about then it's difficult for us to meet up the protein requirement every day.

[00:08:53]So, every day when there is a deficit so this deficit accumulates again to muscle lost.

[00:09:00]And with fluid restrictions and with salt restrictions for them to eat the food becomes very very difficult and so every day we try to counsel on these aspects as well. So, when when do you uh focus on the importance when you are doing your consultation?

[00:09:19]>> So, nutrition a protein rich diet is actually a therapy.

[00:09:26]It's not something which is optional.

[00:09:28]It's something which is mandatory.

[00:09:33]Problem with liver diseases as the liver disease progresses and the patient goes from a stage of fatty liver to inflammation and to cirrhosis.

[00:09:41]There is accumulation of excess of fluid inside the body.

[00:09:45]So when there is excessive accumulation of fluid in the form of fluid in the tummy called as ascites or pedal edema.

[00:09:51]So because of these things the weight may remain stable.

[00:09:56]But actually they are losing muscle mass.

[00:09:59]Which they are not really realizing about.

[00:10:03]Whatever said and done I think breaking the myth in a lot of fields of health care is very difficult and it's challenging and it's our duty as clinicians to help patients break these myths and come out of these barriers.

[00:10:18]Protein is necessary.

[00:10:22]Rich source of protein in a clean form of nutrition is what is mandatory.

[00:10:28]Educating them that in the liver disease the gut motility slows down, fluid accumulation happens.

[00:10:35]They're not going to be able to digest that amount of protein.

[00:10:39]The bowel movements are slow.

[00:10:41]They have erratic behaviors because of some amount of confusion which happens in liver disease.

[00:10:46]All of these is related to protein loss.

[00:10:51]Muscle mass depletion is responsible for all of this to happen.

[00:10:56]Hence it is our duty to educate them that they should come out of this myth and start taking in more amount of protein.

[00:11:06]I think the ideal requirement I think you'll conquer with me is around 1.2 to 1.5 g per kg body weight per day.

[00:11:13]Which somehow for an individual who's around 80 kg comes to about 100 g of protein in a day.

[00:11:18]And for a vegetarian to meet 100 g of protein in a day is a big challenge.

[00:11:24]And for non-vegetarians, people who come especially from our background, they all are ones who already been told by their elders that stop taking non-veg, especially in the form of chicken, egg whites. All of these form actually a very good source and a clean source of protein, which is actually digestible.

[00:11:43]So, I think helping them with giving some prokinetics, helping them mobilize after each meal, all these things will help them empty their bowel little sooner, hence their appetite would increase.

[00:11:54]Because at the end of the day, a protein-rich diet will ensure that the overall outcome of the patient is better. And once we educate them that this is what is going to actually help them in long run, I think the acceptance will be better.

[00:12:10]Especially when you take in consideration of alcohol-related liver disease, nutrition is the only proven treatment to actually reverse a disease which is at a reversible stage. So, overall if you see, patients when they improve their nutrition, they themselves start feeling better. That they're doing day by day better. And their frequency of tapping the fluid from the tummy or the frequency of hospitalizations or the number of times they have undergone come from fusion episodes, all of them come down.

[00:12:43]Hence, overall they start feeling better, hence they start accepting to what we are saying.

[00:12:49]What are the most commonest myths which you have encountered when you're counseling patients on taking some protein-rich diet? What usually do you hear?

[00:12:57]>> So, if it is a non-vegetarian, the commonest myth is stop all the non-vegetarian food, move on to vegetarian food, which is very difficult for the quantity to achieve the protein.

[00:13:08]And as you said, patient have confusion.

[00:13:11]So, once they get admitted with one episode of HE, they say, "No, I will not take the protein. If I take protein, I will have to get admitted. I will have confusion." So, excess of extra protein, they don't say extra protein. If I take protein, I will land up in the uh ICU.

[00:13:29]>> ICU >> So, this myth was there.

[00:13:31]>> you know, for viewers, encephalopathy is basically a state of confusion where somebody is not able to calculate as swiftly as they were doing before or respond as swiftly as they're doing before, becoming slow in their actions.

[00:13:44]You know, liver disease and that to encephalopathy, one of the earliest signs can be just slowing down.

[00:13:53]>> So, when it is encephalopathy, uh people think it should be very, very uh low protein or don't give protein at all. But, the uh with the evidence-based uh medical nutrition therapy and with all the guidelines of ESPEN and ASPEN, they say, "Go on with giving at least 1 g protein in the initial stages and when HE reduces, then pick up on the protein." Because when you don't give the protein, the muscle wasting is still more aggravated. Anyway, that is going to lead to HE >> True.

[00:14:25]>> even if you're not going to give the protein. Yeah. So, when they are admitted with HE, so how do you do whether whether you start with branch chain amino acid giving the same dosage of protein?

[00:14:38]How do you do it?

[00:14:39]>> So, basically, hepatic encephalopathy, the confusion which happens in liver disease, actually a process of muscle mass loss because there is a product called ammonia in our body, which is a toxin.

[00:14:51]It's supposed to be managed by our body.

[00:14:56]And most important area of metabolism of ammonia is muscle.

[00:15:00]So, with ongoing liver disease, there is muscle mass loss and hence ammonia is not being metabolized well.

[00:15:07]Hence, that toxin reaches the brain and causes this confusion.

[00:15:11]So, treatment of hepatic encephalopathy is again building muscle mass.

[00:15:16]So, giving branch chain amino acids, giving agents called as L-ornithine-L-aspartate, they also play an important role.

[00:15:23]Branched-chain amino acids like leucine, isoleucine, and valine, they are three branched-chain amino acids, play very crucial part in muscle building.

[00:15:32]Why do they help in muscle building?

[00:15:33]Basically, leucine causes a shift in metabolism.

[00:15:37]It causes activation of a pathway called mTOR pathway and helps in building up more muscle mass.

[00:15:44]So, the trigger to build up muscle mass is got by branched-chain amino acids.

[00:15:48]So, hence, definitely, we should include branched-chain amino acids along with the usual protein source, which we usually say about a good whey isolate protein. Whey isolate protein is a better form of protein because it is it's complete.

[00:16:01]And we are talking about vegetarians to take increased protein. I would say that milk products play very crucial role in building up protein in the day-to-day requirement and achieving the goal which we want, which is around 1 1.2 to 1.5 g per kg body weight per day. Yeah.

[00:16:19]>> So, when you >> you are saying 1.2 and 1.5. So, we have seen one side of the coin is sarcopenia.

[00:16:26]Okay, so of the one side of the other coin is obesity. You have a lot of chronic liver disease patient who are obese, 140 kg, 150 kg. So, for them, the protein requirements are higher. So, we usually say when they are obese, go on with a protein of 2 to 2.5.

[00:16:46]So, is that what you also recommend for for obese patient, lower calorie and higher protein?

[00:16:53]>> True.

[00:16:54]>> So, and here when we think of protein, we also link think about the quality of protein. So, whether we have to look into the quality, like pulses are again, we can't think them to ask them to take so much of quantity. So, here the quality of the protein is important as you emphasized on whey. Whey is still more easier to digest and when it's going lower down in the GI tract, the absorption is slower so that it's getting good absorbed than the case in which is available or the soya protein which are available. So in these obese patients, so how do we tackle to put up if it's too then it's really high. So how do we counsel them and how do we educate?

[00:17:40]>> The most important pathway of educating them is that for them weight loss is important in terms of losing fat.

[00:17:49]>> Yes.

[00:17:50]>> They should not lose muscle.

[00:17:52]So when that is being concentrated on, ask them to reduce their carbohydrate intake in that. So hence the calorie becomes on the lower side.

[00:18:01]The energy source, so when you say about carbohydrates, fats and proteins, all of them are source of energy.

[00:18:08]>> Yes.

[00:18:08]>> Ultimately at the end of the day all of them are source of energy.

[00:18:12]Carbohydrates release energy in a quicker manner.

[00:18:15]Fats release energy slowly and proteins actually take longer time to release energy and they make the body utilize energy to digest it.

[00:18:26]So hence in that situation in obese individuals, it's always advisable to ask them to reduce the calorie intake by reducing the carbohydrate intake and keeping the protein on the higher side.

[00:18:38]So that is one thing which we can advise.

[00:18:41]And coming to be the quality and the quantity of the protein in a sick serotic individual or a person who is having advanced liver disease, my first aim will be to improve the quantity first.

[00:18:55]First take good amount of protein in good amount of quantity and once you're able to achieve that, I think slowly start concentrating upon the quality of the protein.

[00:19:06]So like as you said, there are different types of protein which are usually available. One is the whey protein which is basically from milk. It's a base basically it's a part of milk. And then comes the plant-based proteins which are there. And then I think now there is also fermented yeast as a source of protein. So, different forms of protein are available. All of them have individual characteristics of their own.

[00:19:28]Going into too much of details about them is actually not necessary for a patient.

[00:19:32]For them, if they're able to meet the quantity of the protein first, and then slowly we can start educating them about the quality of the protein and start making them take better forms of protein accordingly.

[00:19:45]And when coming to weight loss, so you must have seen a lot of people losing weight by just cutting down on calories, not exercising much, not giving too much of concentration about the aerobic and resistance exercise. You know, to educate our viewers, there are two types of exercises. One is called the resistance exercise, the other is called aerobic exercise.

[00:20:06]Aerobics is basically like running, swimming, jogging, or just walking.

[00:20:11]Brisk walking is also an aerobic exercise.

[00:20:13]And coming to resistance exercise, one of the resistance exercises is basically muscle building or strength training, which we usually call. So, both of them are important when you're losing weight.

[00:20:24]When you lose weight, it is both muscle and fat which you're going to lose.

[00:20:29]Hence, you should be aware of it and start taking protein in adequate quantity so that you don't lose protein much. You don't lose your muscle mass much. And you only lose fat.

[00:20:43]You can never only lose fat. So, at least you'll have a good proportion of it.

[00:20:48]And once you're slowly building up on muscle in the form of resistance exercises, your bones become stronger, your muscles become stronger, and you have a more productive weight loss, which is good for reversing fatty liver disease. Because again, when you talk about fatty liver disease or fatty liver disease with some inflammation in the liver, the again, the only proven therapy is weight loss and muscle building.

[00:21:12]Once the patient is able to achieve these, overall outcome will be better and they'll start feeling better. The risk of progression of the disease is reduced.

[00:21:22]And the frequency of hospitalizations is reduced.

[00:21:26]The overall quality of life and productivity improves.

[00:21:30]So, that is one thing which we can concentrate on.

[00:21:33]Whenever we're educating patients about weight loss.

[00:21:36]And you know, with uh patients in the ICU, how do you manage them, doc?

[00:21:42]>> Patients in the ICU, their intake is already poor. First thing when they enter into ICU, they have an ICU psychosis where they are very very afraid of everything over there. So, for them motivating and uh mostly we concentrate apart from food, we at least ask them to drink the supplements. We've seen some of the patients, they don't like drinking the supplements. They like to eat it as such. So, we have patients who said we when we mix it with water, it's uh it's a different taste. Eating it with curd or something, they find it really uh equal to like eating with their meal. So, they are more comfortable with that way. We ask them at least to keep sipping on the uh supplements. At least if they are able to take nearing the 1 g is for us it's more sufficient when they are in the ICU because every day in the ICU, it is muscle loss. Over the week, they might lose at least 7-8 kg of muscle if they are there in the ICU for 1 week or so.

[00:22:41]So, and mostly if it's GI bleed, it's again >> procedures, endoscopies. So, we get a uh we we actually make a little uh more focused on even if we are giving a clear liquid, we make it a clear liquid a little bit of high protein and calorie so that 1 ml gives 1 kcal. So, we try to focus on that, but we often speak with the doctors and the hepatologist at least to move it to a liquid diet so that our supplements can be given at least a 50 ml second hourly, something like that, so that they can cope up with the protein and calories in the ICUs. And we don't move or give them a lot of restrictions. We try to give them a little bit of their favorite food, what they eat at home, so that a little bit comfortable in the ICUs. And if they are not eating, we would also encourage the attenders to be at their mealtime with them. We would request the staff to just allow the attender during the mealtime so that they can We have a lot of patients who don't eat at all.

[00:23:45]>> True.

[00:23:46]>> So, at least that 5-10 minutes of visit of the attenders make them eat at least 10 spoons or like that. But oral nutrition supplements have a greater impact in the ICU because in the ward they are with the family.

[00:23:59]>> Yeah.

[00:23:59]>> They eat a lot.

[00:24:00]>> Yeah.

[00:24:00]>> They try to at least cover up 50%, but in the ICUs it is a it's a difficult task.

[00:24:06]>> Yeah, so ICU management of a patient of liver disease is a different ballgame altogether.

[00:24:10]>> So, we have a lot of supplements now currently. So, we There are huge range of supplements if you say, and all are not specific to the liver disease, to the chronic liver disease. Like how you we need a little less of sodium, a little lesser of potassium in some cases. And we need a water restriction. So, although our patients have a restriction of maximum when they have ascites might be less than 1 is the fluid requirement. So, we need supplements which are tailor-made to the liver disease so that it dissolves in a lesser volume giving us nutrient-dense product because patient do not want to take it repetitive again and again. If you say you have to take the supplements five to six times a day, that's not possible. So, something which which is like their three meals, they have a three supplements extra. And in that three supplements in a lesser quantity, they can meet their protein requirements. So, supplements need to be designed in such a way that we get all the aspects of chronic liver disease into that supplement to meet their their requirement, whether it be quality of protein, whey base protein, uh the addition of branch chain amino acids, and the volume which has to be lesser for them. And obviously, yes, the taste matters to them a lot.

[00:25:40]Some of them we have good flavors right now.

[00:25:44]I think we have supplements which have chocolate flavor, which a little bit masks the taste of the branch chain amino acid, and patients are able to take. Because when you see liver disease, they don't have uh the salt option. So, for them food is less tasty.

[00:26:00]So, when supplements are a little bit tastier and comes with lot of flavors, they're very happy to take it. So, sometimes they may want to take a vanilla supplement in the morning, and they might have to have a chocolate in the evening. So, they feel very much better when the supplements are tailor-made to the disease. And this is where the role of medically supervised products give a good aim fact, and gives a good adequate nutrition is met in these products. And there yes, of course, there are lot of varieties of supplements which are available, which can give us only protein.

[00:26:37]>> Mhm.

[00:26:38]>> But for these patients, we need little calories, and we need protein. So, when we are emphasizing on the protein, we cannot say that calorie is not important. Because when you say when you're targeting only protein, patient still loses weight.

[00:26:54]>> True.

[00:26:55]>> Because protein is not playing its specific role of building the muscle. It is going on to giving up what the nutri- requirements of the patient for the calories. So, so supplements which can have both calorie and protein are very important for our sarcopenic patients. And some of the supplements for our obese, we need only protein.

[00:27:19]So, that would be really apt if only protein is there for these patients so that they do achieve their calories a little bit. And so that 100 g protein or 120 g protein or 140 what we what we need can be targeted in in four meals at least for them.

[00:27:37]So, when you prescribe, how do you look into all these aspects?

[00:27:42]Because it's a it's a fast-moving OPD.

[00:27:44]You have a lot of patients every day. I think you might see around uh greater greater than 50 to 60 patients a day.

[00:27:52]So, the quality of time you have to spend with each patient uh doing your medical aspect and then the nutrition aspects. And if it is you're not able to cover up, still we have a lot of patients in our OPD as well sent by our hepatologist to look into the most of the malnourished cases who need a lot of time for consultation on how to take the proteins, when to take the proteins.

[00:28:17]Uh because some of them might take it before their meals and they get a satiety and meal is not done.

[00:28:23]>> done.

[00:28:24]>> So, we want them we often tell them first give your meal a priority and then anyway it's half eaten and then we want the supplement to come in to that way.

[00:28:35]Uh so, we try to educate the family in that way.

[00:28:39]Uh so, I also want you to elaborate on little bit how you say this this fits the this supplement fits the patient.

[00:28:47]>> Okay.

[00:28:49]>> So basically when you talking about patients coming to the OPD and meeting us like this, so talking about nutrition is important, but I think we need to have separate clinical nutritionist like you are there at you know. So basically what happens over here is um patient comes, walks into the OPD with some symptoms, with some problems. We help them give some medications for the same and we ask them that this what are you taking? So what is your diet? So they say that you know somebody has told them that this is good, this is good.

[00:29:21]They are taking some they eating healthy. People consider just you know that I'm taking a lot of fruits and vegetables. I'm taking a very healthy diet.

[00:29:29]The problem is that does not suffice the amount of protein they supposed to take.

[00:29:33]So hence meeting a clinical nutritionist taking advice from them in a tailor-made fashion for each patient that what they need at that particular given point of time, at that particular point in their liver disease phase which they are going through becomes crucial.

[00:29:53]Like for example if there is somebody who is very sick in the ICU as you were we were talking before the nutrition is again going to be tailor-made based upon something more of clear liquids, clear liquid based proteins calorie dense liquids which are going to be given to the patient. So this decision or this calculation is going to be done by a very good clinical nutritionist. Hence the role of them is so important in managing a sick patient. Similarly in the OPD when you're talking about these patients the protein intake which comes from varied sources will overall collaborate and still fall deficit of the amount of protein which they need per day.

[00:30:34]Hence understanding which protein supplements are calorie dense as well as protein dense and that smaller quantities will give them a larger quantity of protein.

[00:30:44]So, in the amount of the food content which is there, it's going to be on the lower side, but the amount of protein in that food is going to be on the higher side is what we want them to take.

[00:30:53]Because of this the fullness in the stomach which they have, the reduced appetite which they have, they'll be able to overcome all these barriers. Educating the patient that simple walking every before every meal, walking after every meal, a 10 minutes of walk before a meal, and a 15 minute walk after a meal will go in a long way to stimulate the bowel movements.

[00:31:16]Lead to faster gastric emptying, and there is a desire, there is a hunger to eat.

[00:31:24]So, when this happens automatically our supplements also go in along with the food which they are taking.

[00:31:31]Also, that one education which we can give is not to mix the supplement along with the food.

[00:31:36]>> Yeah.

[00:31:36]>> In the sense, they can break their meals six times in a day or eight times in a day.

[00:31:42]Take food. Give a gap. Walk around. Do some physical activity. Have some protein supplement. Again, do the same.

[00:31:50]As a process, if they can keep doing this repeatedly, they'll be able to meet their calorie requirement as well as their protein requirement.

[00:31:59]Because definitely with onset of liver disease and progression of liver disease hunger is going to come down.

[00:32:06]Appetite is going to come down. Both of them are slightly different.

[00:32:10]And the desire to perform physically is going to come down.

[00:32:16]So, tackle all of these is where the role of a very good physiotherapist, a very good clinical nutritionist comes into play about what basic physical activity which they can do, which will again help them burn some calories so that they again they can build some muscle accordingly, and also eat well.

[00:32:35]Once we are able to focus on their day-to-day activities and concentrate on them and get feedback from the patient.

[00:32:43]Once they have listened to what we are saying, once let them go back home for a week or 10 days maybe and repeatedly keep seeing them and getting feedbacks from them that what changed in the last 10 days which resulted in a better food intake, which resulted in a better protein intake. What really helped them?

[00:33:02]To understand that as a feedback mechanism from them will help us again in educating that particular individual in a better manner.

[00:33:10]Because diet and nutrition I would say is something which is a personal choice.

[00:33:15]It's something which is personalized to each patient. What I say for one particular patient cannot be same applicable for another patient.

[00:33:26]This person may be comfortable with a particular brand of protein, with a particular composition of protein. The other individual may not be completely okay with that.

[00:33:35]So this adjustment has to be done. So this tailor-made approach to each to fit each patient is necessary.

[00:33:42]And that can be done by giving time to the patients, by sitting down with them, taking feedback from them about how things are happening and how better they are they feeling with whatever changes they have made.

[00:33:54]And talking about the various forms of protein which are available, we have previously also discussed about this that there are proteins which are whey isolates, there are proteins which are um fermented yeast based, there are proteins which are plant based. So all of them have some deficits in them.

[00:34:11]Mostly, when you take animal source of protein, they are usually complete.

[00:34:16]>> Yeah.

[00:34:16]>> Plant source of proteins are not very complete. They lack a few amino acids in them.

[00:34:20]But they can be supplemented by adding supplements again.

[00:34:24]And palatable proteins are basically proteins which have some added flavor to them.

[00:34:30]And when you talk about food as a good source of protein, again it comes as a routine diet for them. For example, when you're talking about vegetarians, asking them to take more of sprouts, asking them to make up soya, asking them to take more of paneer, all these things help them because it comes as a natural part of the diet. But only thing is you're supposed to educate them how much grams of paneer has how much amount of protein. Because to actually meet the amount of protein requirement, you have to take a little larger quantity of the paneer. If you take a little larger quantity of sprouts, which they may feel feeling of satiety much earlier. They may not be having that much of appetite to take that much large quantity of food.

[00:35:10]Hence, educating them that that's the reason that we need to add some supplements.

[00:35:15]And that's the role of the supplements which come from pharma industries, which basically is complete.

[00:35:22]It is tailor-made for the particular problem. For example, for liver disease patients, there are protein brands which are low in sodium. Because sodium is the biggest enemy of liver disease patients.

[00:35:34]We advise patients to take less than 2 g of table salt per day, added salt. The reason is the more the amount of salt, the more the amount of fluid retention in the body.

[00:35:44]The more derangement in renal function.

[00:35:48]Hence, more electrolyte disturbances.

[00:35:52]So, the person or the particular company which manufactures that particular protein has to keep in mind about why are they manufacturing? For whom are they manufacturing? Who is the recipient of this particular product? That has to be kept in mind when we are prescribing as doctors or when nutritionist is prescribing this to patients particularly.

[00:36:13]To keep in mind about the amount of salt, amount of sugar.

[00:36:17]Because all of these proteins may also have added sugar in them to make it more palatable. The company may just keep adding sugar to it. So, off late, I think you may be aware of a lot of other products which are available in the market which have again come in the negative light of having too much of sugar in it.

[00:36:32]Which is not what we desire.

[00:36:35]So, adjusting that is also important.

[00:36:38]As our This is our duty to educate the patient that not all proteins are the same.

[00:36:44]>> same.

[00:36:46]>> They have to choose it rightly or what is prescribed they have to take it religiously. So, that is what something which we can advise them.

[00:36:54]And overall follow up of all these things will ultimately result in better patient outcome.

[00:36:59]So, when the patient outcome is better, the physician is happy, the nutritionist is happy, and overall the patient is also happy because of that.

[00:37:07]So, that's what our goal is supposed to be when you're managing a patient holistically.

[00:37:11]Rather than not just concentrating only upon the medical aspect of the disease, the nutritional aspect of the disease, and the uh exercise aspect of the disease has also to be supposed to be addressed for completing a overall holistic health approach to the patient.

[00:37:27]And talking about uh you know, what is called as a healthy diet, an unhealthy diet, and all of these are too many food fats which are related to people.

[00:37:36]So, clearing the, you know, cloudiness in their uh understanding about how things really work is also a part of our duty to educate them that, you know, not all what is said as healthy diet is actually healthy.

[00:37:52]This example of that is basically consuming a lot of fruits and vegetables in a liver disease patient, which is not really going to be helpful.

[00:38:00]Definitely vegetables will provide a good amount of fiber which is important for bowel movement. It'll only act as a part of it.

[00:38:06]But, somehow they're supposed to meet their protein intake per day. So, for that we'll have to educate them that how else can they improve their protein intake?

[00:38:14]So, that is one thing which we are supposed to tell them about.

[00:38:17]And whatever over-the-counter is available or somebody just tells them that this is good, that is good. I think it should be verified once again. Take it from a trusted source, from a trusted a company which has a very clean source of protein. So, that another thing which is coming up in the market is is your protein clean enough?

[00:38:36]Because all these are manufactured in industry ultimately. So, there's a little problem of lot of additives in it. There's a problem of heavy metal poisoning because of it. So, a lot of things going on around that. So, take your protein from a trusted company, from a good source, a clean source protein is what should be given to our patients.

[00:38:55]>> So, as you said, over the counter proteins are a lot. So, we want something specific to the patient, specific to the liver disease, as I said before. And when we tell the patients, we tell the timings of the protein, when they need to take this protein, and we give importance to the late evening snack for them because these uh liver disease, end-stage liver disease particularly, are in a state of accelerated starvation. So, even in the night, we do not want that starvation process for them. So, maximum we try to push in to the starvation hours at least to less than 6 hours. So, we tell them, "Whenever you go to sleep, the last minute when you're going to sleep, have the supplement." So, we uh or if if in between you're going going for a washroom, getting up 3:00 a.m., again anyway you're going to feel hungry. So, we ask them, "Just mix it and keep it by your bedside instead of having water, drink the supplement." So, we want them to break this fast of accelerated starvation because the next day morning it'll be very late for them. They're going to consume their breakfast. It's very going to be late. Obviously, they won't have their sleep patterns are altered. They're going to sleep late.

[00:40:09]Breakfast is late again, and then supplement again is delayed. So, uh taking sp- proteins which is specific for them is very important. We always tell them not to avoid the carbohydrates and fat if it is a liver disease liver disease, we at least ask them to take 30% of fat as their requirement not to go on a fat-free or very very less fat diet. And as you said liver disease comes along with the metabolic parameter. So whether it's a diabetes or hypertension. So when it is diabetes, we look into supplements which also do not elevate their sugar sugar levels. And it's the supplements maximum are when it is a protein, it has a delayed satiety. So obviously it is not going to increase their sugar levels.

[00:40:59]But what happens is when they do when they do the liver I mean their sugar test, sometimes what happens is they take the breakfast, we tell them half an hour after half an hour have your supplement and what what do they do immediately test their sugars.

[00:41:14]>> Sugars.

[00:41:14]>> So obviously the sugar levels are are on the higher side because the main goal of protein itself is a delayed satiety.

[00:41:23]>> True.

[00:41:23]>> So that is going to be there for them throughout.

[00:41:27]So it is very important for them to make a gap and then have their sugars tested along with that. So try to avoid on these over-the-counter medications as well as the over-the-counter supplements which are lot available.

[00:41:42]Supplements either prescribed by a clinical dietitian or a doctor is very much specific and specifically medically prepared supplements are disease specific app for the disease. So it's better to go with these supplements as well.

[00:42:00]>> True. And what you said about overnight fasting, that's a very important point.

[00:42:04]So especially in liver disease patients, as I was telling you, break the meals.

[00:42:08]Have more frequent food so that you don't allow so there's basically the concept of liver diseases no fasting no feasting.

[00:42:15]>> Yeah.

[00:42:15]>> So don't feast don't fast. Have break your meals have it at frequent regular intervals.

[00:42:21]Educate and spread the awareness of increasing protein intake not only for patients with liver disease but as a general population as well. Protein intake requirements are definitely there and we as Indians are actually lacking on it. So we should improve our protein intake overall.

[00:42:42]And concentrate little more on strength training and aerobic exercises.

[00:42:47]>> Uh so today we had a good insightful uh discussion with Dr. Karan sir on highlighting the importance of malnutrition in liver disease and how this malnutrition can be progressive if it is not being rightly and timely done with uh the diet education and with the oral nutrition supplements. Uh so thank you Karan sir for being with me for this uh insightful session and it was a very uh meaningful one. And uh because importance of uh nutrition is very vital in liver disease. Without nutrition we cannot improve our patient outcomes. And we cannot have a long way through the liver disease because they will be having sarcopenia, they will be having obesity, they will be having frailty. So all this needs to uh be addressed as soon as possible and like how you said reviewing them is important. At least if we are not going into the full details in a review session uh we would always like to tell them please tell us a hi like how you're feeling better. That's more than sufficient and how you're doing with the diet and with the medications. So uh coming back to us reviewing with us is is very good for the patient as well. Uh so uh any last uh points you need to add?

[00:44:10]>> talking to you. So, yeah, so rich protein good protein diet better muscle mass and better liver disease outcomes is what I would like to conclude with that to fight liver disease good nutrition, increasing protein intake is what is basically required.

[00:44:30]And with overall with doing this, overall outcome of the patient is better.

[00:44:36]So, we should just create more awareness about increasing protein intake and improving quality of life.

[00:44:43]Thank you.

[00:44:49]>> [music]