A high energy and high protein diet are essential in the management of malnutrition in liver cirrhosis. Protein energy malnutrition (PEM) occurs in approximately 60% of decompensated cirrhotic patients and 20% of compensated cirrhotic patients. A high-protein diet is a requirement to help reduce the incidence of sarcopenia and help increase lean body mass, thus preventing fatigue and thereby improving the quality of chronic liver disease patients.
ESPEN (European Society for Clinical Nutrition and Metabolism) guidelines recommend a caloric intake of 25 to 30 kcal/kg body weight per day and a protein intake of 1 to 1.5 grams per kg body weight per day in patients with chronic liver disease. Whereas in cirrhotic patients with malnutrition, the guidelines recommend an intake of 35 - 40 kcal/kg/day along with a protein intake of 1.2 - 1.5 g/kg/day.
Muscle loss in chronic liver disease needs to be managed with strategies that involve dietary intake of adequate energy and protein and micronutrients combined with regular and structured physical activity. Malnourished patients have lower health-related quality of life (HRQOL) and they report increased symptoms of nutritional impact such as pain, poor appetite, dysgeusia, and faster satiety.
The following study, named PROTONS [Protein enriched Oral Nutrition Supplement on improving Nutrition], was a prospective, non-comparative, multi-center, interventional study conducted on 76 chronic liver disease patients. Participants received 2 - 3 servings of high-protein, BCAA-enriched Oral Nutrition Supplement (ONS), for three months as an adjunct to the daily diet according to ESPEN guidelines. Changes in nutrient intake, liver enzyme levels, muscle mass, handgrip strength, and chronic liver disease-related quality of life (CLDQOL) were evaluated. Before-and-after data were analysed using a paired t-test at a 5% significance level.
The results were as follows:
· Significant improvements were seen in nutrient intake, serum albumin, and liver enzymes {Aspartate Amino Transferase (AST), Alanine Transaminase (ALT)}.
· Hand grip strength increased significantly, indicating improved muscle function.
· Changes in muscle mass were seen on Bioelectrical Impedance (BIA) and Dual Energy X-ray Absorptiometry (DEXA) scans although the results were not statistically significant.
· The overall CLDQOL score as well as individual domain scores such as fatigue/fatique, emotional functioning and worry also showed significant improvements after the intervention.
· ONS effectively increased protein and BCAA intake, which is crucial for overcoming malnutrition in patients with chronic liver disease.
Conclusion:
This study concludes that supplementation with high protein and BCAAs can help improve nutritional status, muscle strength, liver function parameters and quality of life in patients with chronic liver disease. Further research is needed to explore the long-term effects of ONS on the progression and improvement of chronic liver disease.
Image: Illustration (Source: master1305-Freepik)
Reference:
Bhoite R, Kedarisetty bCK, Yandamuri N, Satyavrat V, Bhatte S, et al. Effect of high protein BCAA-enriched oral nutrition supplement (ONS) on malnutrition in Indian chronic liver disease (CLD) patients: PROTON study. Food and Nutrition Sciences 2025;16:255-68.
