Liver Dinner

HIV.

The minute your physician uttered these three letters, your world started to spin. Doctors, possibly medications, diet, exercise -- the list goes on and on. But that was then, and now you've finally got it under some sort of control. But wait! What are these other three letters everyone is buzzing about?

HCV, shorthand for hepatitis C virus, is getting a lot of press these days, and for very good reason. It is estimated that HCV, often referred to as "the silent epidemic" or "the silent killer," has infected 3.9 million Americans, and 2.7 million of those infected have chronic HCV. According to the Centers for Disease Control and Prevention, each year there are approximately 36,000 new infections in the United States alone. Unlike its cousins hepatitis A and hepatitis B, hepatitis C cannot be prevented by a vaccine.

The Silent Killer

Hepatitis C is a viral infection that causes damage to the liver cells. Over the long term, HCV can lead to cirrhosis (irreversible scarring of the liver), liver cancer, or liver failure. According to the CDC, approximately 70 percent of chronically infected individuals will eventually develop some form of liver disease.

Hepatitis C is a blood-borne disease, which means that it can be contracted through contact with the blood of an infected person. The most common way this occurs is by the use of shared needles, for IV drug use and to a lesser extent for tattooing. Although such transmission is rare, the virus may also be spread through unsafe sex. The likelihood of spreading the virus through unprotected sex increases, however, if the person with HCV is also infected with HIV. HCV can also be passed from mother to infant.

This lethal disease is often referred to as "the silent killer" because its early symptoms are difficult to notice and no symptoms at all may appear for as long as thirty years. Once the first warning signs do appear, the mild, flu-like symptoms characteristic of the early stages of the disease may not be recognized as symptoms of a deadly disease. Thus a person may have the virus for decades before he or she realizes it. In fact, as many as 45 percent of those infected are unaware that they have the virus. As the disease progresses, more pronounced symptoms may develop. These include fatigue, loss of appetite, muscle weakness, lingering fever, diarrhea and/or pale stools, abdominal pain, nausea, itchy skin, and, in the later stages jaundice (yellowing of the skin and eyes) and dark yellow urine.

Hepatitis C and HIV

Co-infection with HIV and HCV is fairly common because they are transmitted along similar routes (needle sharing and the like). In fact, nearly one of every two HIV-positive individuals is co-infected with HCV. In New York City alone, 40 percent of the HIV-infected population is also infected with hepatitis C.

The good news is that there is no significant evidence demonstrating that having the hepatitis C virus will accelerate the progression of HIV. There have, however, been studies showing that HIV can accelerate the progression of HCV and HCV-related liver disease. While some infected with HCV alone may develop cirrhosis twenty years after becoming infected, a person who is co-infected with both diseases may develop cirrhosis within seven years of infection.

The Liver

So why is all of this so important? We can sum it up in one word: the liver. As stated above, HCV has the potential to ravage the human liver, and many of those chronically infected with the virus will develop cirrhosis, liver cancer, or liver failure. This is extremely significant because the liver is one of the largest (about the size of a football) and most important organs in the human body and is absolutely vital to human survival. Damage to the liver can lead to a wide variety of serious problems. The liver is responsible for thousands of body functions essential to life. Any type of disease or trauma can greatly reduce the liver's ability to carry out its functions thoroughly and efficiently.

Disease is not the only factor to affect the liver. The environment, diet, and drugs or alcohol can also harm the liver. Additionally, a stressed-out liver may exacerbate the side effects of HIV medications. Because so many different forces have the potential to cause damage to the liver, humans have more liver than they actually need. In fact, research indicates that we only need 10 to 20 percent of a functioning liver to survive. (While this may be true, I would not be want to test this statistic by losing 80 to 90 percent of my liver.)

Functions of the Liver

The easiest way to understand the liver is to envision a filter. Most of what we take into our bodies is filtered and detoxified by the liver. If ingested toxins are not processed by the liver, they will be stored in the fat tissues and cell membranes and released during exercise and stress, causing negative effects like nausea and stomach pain. In addition, substances that are not detoxified by the liver can accumulate in the blood, increasing the workload for the immune system.

Detoxification is performed in two main phases. The general purpose of the whole detoxification process is to convert fat-soluble toxins into water-soluble substances that can be excreted from the body. Phase I consists of a series of chemical reactions by which the liver essentially converts toxic chemicals into less harmful chemicals. This process produces free radicals, which, if produced in excess, can harm the liver cells. Antioxidants can reduce some of the damage caused by these free radicals. Phase II detoxification converts the less harmful substances of Phase I detoxification into water-soluble substances that the body can excrete. To work efficiently, Phase II detoxification requires certain sulfur-containing amino acids (taurine and cysteine) as well as substances like glycine and glutamine.

While detoxification is one of its primary functions, the liver is also responsible for a host of other actions. Other important responsibilities of the liver include creating bile, which is essential in the breakdown of fats; helping digestion by processing nutrients absorbed by the intestine; synthesizing cholesterol to help maintain cell membranes; removing bacteria from the blood; manufacturing proteins for the body to use in immune function; metabolizing alcohol; storing fat soluble vitamins (A, D, E, K), certain minerals, and sugars; regulating blood clotting; maintaining hormone balance; storing extra blood; and purifying the blood by removing toxic substances.

Diet for a Healthy Liver

Clearly, the liver is too important an organ to put in jeopardy. To this end, we must engage in activities that help to sustain and/or strengthen the liver. Nutrition can play a vital role in this area. A whole-foods diet that includes plenty of fruits and vegetables, whole grains, lean sources of protein, and good fats reduces stress on the liver. And drinking plenty of water is essential to detoxification. Here are some more specific nutrition guidelines:

Meal Size. Eat moderate-sized meals, and avoid overeating. Eating causes a certain amount of stress to the liver. As part of the digestive system, the liver must process all nutrients (and nonnutrients) derived from food. Overeating places added stress on the liver by making it work overtime to get the job done. Everyday meals shouldn't make you feel as though you've just finished Thanksgiving dinner.

Try eating your largest meal at lunchtime and a lighter meal for dinner. This will reduce the amount of work the liver has to do while you sleep. The sleep hours are when the body can concentrate on healing. During these "healing hours" the less work your body has to do, the more it can recover from its daily stresses.

Fruits and vegetables. Fruits and vegetables contain a wide variety of nutrients, including antioxidants, phytochemicals, and carotenoids, that can be beneficial to both general health and liver health. The greater the variety of fruits and vegetables you consume, the more disease-fighting nutrients you will absorb. Certain fruits and vegetables can aid in both the Phase I and II detoxification processes. Spinach, tomatoes, and beets contain antioxidants, B vitamins, and carotenoids that enhance the efficiency of Phase I detoxification. Cruciferous vegetables like broccoli, cabbage, Brussels sprouts, and cauliflower contain natural sulfur compounds that aid in the efficiency of Phase II detoxification. Green beans help to keep cell membranes (including liver cells) healthy. Shiitake mushrooms have antiviral properties and protect the liver. All mushrooms have strong immune-boosting effects are especially good for fighting HCV. Carrots, by way of their antioxidant and enzymatic properties, also offer protection to the liver. Try adding artichokes to your salad to benefit from their liver-protecting ability.

Fats. Although fats are a good energy source, they are difficult for the liver to process, and the total fat in your diet should be moderate. Avoid fried foods and any foods that are very fatty. A Big Mac and large order of fries would definitely fall into the list of foods to avoid. Concentrate instead on eating the "good" types of fat found in coldwater fish like salmon, tuna, sardines, flounder, trout, and mackerel. Avocados and certain nuts and seeds such as sunflower seeds, flaxseeds (or oil), pumpkin seeds, and legumes (beans, peas, and lentils) also contain these good fats, which are beneficial to liver regeneration.

It is always best to grill, broil, or bake your foods. Certain oils are better than others for cooking. The two best are canola oil, which contains omega-3 fats, and olive oil, which contains monounsaturated fats. Whenever possible, use cold-pressed oils, that is, oils processed at cooler temperatures. Heat processing produces trans fats, which can be harmful to both your liver and your cardiovascular system. Cold-pressed oils may be difficult to find, however, and are often more expensive. Whatever oil you use in cooking, cold-pressed or not, use it sparingly. And when looking to top that whole-grain toast in the morning, try using hummus or olive oil for a spread instead of margarine or butter.

Refined sugars. It is best to avoid refined, processed foods like cakes, cookies, white bread, and pasta, which can lower enzyme activity and add stress to the liver. These kinds of food turn into sugar very easily and contain trans fats that suppress important prostaglandins that protect the liver by reducing inflammation. Instead, introduce whole grains into your diet by eating brown rice, millet, amaranth, quinoa, and whole-grain breads and cereals. These less processed foods reduce stress on the liver.

Protein. Consume lean sources of protein like beans, nuts and seeds, fish, and white-meat chicken and turkey. Avoid fatty meats like sausage, salami, pepperoni, bacon, and hot dogs. Eggs too are a good source of protein. They supply B vitamins and sulfur-containing compounds, which help both Phase I and Phase II detoxification.

Other foods. To help maintain liver health, try using garlic when preparing meals. Garlic contains methionine, which is necessary for detoxification, and also contains selenium, which is an antioxidant that plays a role in Phase I detoxification. Garlic is also beneficial due to its allycin content and is especially good for the liver that has been assaulted by HCV. Just don't get too close to anyone right after eating!

Wheat germ also helps with detoxification due to its vitamin E and selenium content.

Bitter foods are helpful to the liver. Endive, lemons, dandelion greens, romaine lettuce, and quinoa are all bitter foods that may help remove toxins from the liver.

Barley leaf and barley grass contain chlorophyll, which acts as a liver cleanser.

Drinking hot water and lemon in the morning can help to stimulate digestion. For a drink that will aid in liver detoxification, try blending a whole lemon (yes, pits, rind, and all) with 8 ounces of water or citrus juice and 1 tablespoon of olive oil. You will need to strain the concoction before drinking it. And don't forget to cut that lemon into pieces before placing it in the blender.

Alcohol. Alcohol is a very potent toxin for the liver to metabolize. Research indicates that alcohol consumption in those infected with HCV can accelerate the progression to liver disease. The National Institutes of Health advise a limit of one alcoholic drink per day.

Herbs. Herbs can be used to add flavor to your foods, and also to help take care of your liver.

Milk thistle (silymarin) has been shown to help chronic hepatitis by way of fostering cell renewal and repair. It helps to limit the entry of toxins into cells, and it works as a powerful antioxidant, neutralizing free radicals in the body. There have been many studies indicating its benefits. The Commission E, a German expert panel that assess the safety and efficacy of herbs for the German government, recommends up to 400 mg of silymarin daily. A rare side effect of milk thistle is stomach upset. A note of caution: One study suggested some effect of milk thistle on the cytochrome P450 system, which is part of Phase I liver detoxification and also responsible for metabolizing some of the HIV meds like protease inhibitors and NNRTIs. The study used high concentrations of milk thistle (<800 mg), however, and was done on animals. Other studies showed no effect with PIs. Taking between 200 and 400 mg is thought to be safe and beneficial. You may consider cycling the herb -- two weeks on and two weeks off -- taking it with meals, and avoiding taking it at the same time as PIs.

Another rather benign herb recommended for liver health is schisandra, which protects the liver from damage and accelerates liver detoxification. The recommended dose is 1 teaspoon of the dried herb steeped in 1 cup of water three times per day.

The following tea is recommended for chronic hepatitis by Christopher Hobbs, a well-known and respected herbalist, in his book Natural Liver Therapy (Interweave Press, 1986). Simmer milk thistle (35%) artichoke leaf (15%), turmeric (15%), schisandra (15%), shiitake (15%,) and licorice (5%) in a covered pot for twenty minutes. Remove from heat and let steep, covered, for ten minutes. Drink one cup in the morning, one in the evening, and one more at another time if desired. This tea can be used over the long term.

Remember, always alert your doctor to any herbs you may be using so as to avoid possible drug/nutrient interactions. Children and pregnant women should avoid herbal treatments in general except under the supervision of a healthcare provider.

Supplements. In promoting liver care, a healthy, balanced diet is always first and foremost. But beyond that, there are a few guidelines for taking supplements that may help you in combating liver disease.

Glutathione is the main detoxifier used by the liver to break down certain medications. It is also the most powerful antioxidant in the body. Increased glutathione levels may prove beneficial in dealing with HCV. It is usually best to take the building blocks of glutathione so they can be converted into the amino acid in the body.

N-acetyl cysteine (NAC) is a building block of glutathione and can help boost its levels in the body. In cases of severe liver disease, however, taking glutathione directly might be indicated since the body may not have the ability to convert NAC into glutathione. Another constituent of glutathione is glutamine. Along with helping to boost glutathione levels, this amino acid may be useful in the "leaky gut" syndrome also associated with liver disease. Combining NAC with glutamine and antioxidants like lipoic acid and vitamins C and E is sometimes recommended as a liver detoxification regimen.

While some supplements are beneficial, others may prove harmful. The liver plays an important role in the metabolism of iron. Individuals with HCV sometimes have an increase in the concentration of iron in the liver. Excess iron can damage the liver. According to the American Liver Foundation, high iron levels can reduce a patient's sensitivity to the drug interferon, which is used to treat HCV. It is recommended that people infected with HCV whose serum iron level is elevated or who have cirrhosis avoid taking iron supplements. In addition, they may need to restrict foods containing a lot of iron like liver and red meats.

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Once again, a healthy diet is the best way to a healthy liver. Beyond that, try to get plenty of rest, walk after meals, use a dry sauna to release toxins from the body, and drink lots and lots of water. Remember, take care of your liver so that your liver can take care of you.

Sandra Goldsmith is an HIV Nutrition Specialist at Gay Men's Health Crisis.