HHeeppaattiittiiss CC:: NNuuttrriittiioonn CCaarree QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ QQ CCaannaaddiiaann GGuuiiddeelliinneess ffoorr HHeeaalltthh CCaarree PPrroovviiddeerrss Endorsed by: ♦ Canadian Association for the Study of the Liver ♦ Canadian Association of Hepatology Nurses ♦ Canadian Hemophilia Society ♦ Canadian Liver Foundation ♦ Hepatitis C Society of Canada Funding for the development and Copyright 2003, Dietitians of Canada. dissemination of these guidelines was All rights reserved. provided by Health Canada, Community Acquired Infections Division: This document, as well as an online <www.healthcanada.ca/hepc>. professional education program and patient education handouts, are available from the These guidelines are designed to serve as a Dietitians of Canada website at general framework to assist decision <www.dieteticsatwork.com>. making for nutritional management of Permission is granted to download and patients infected with the hepatitis C virus reproduce the documents in their entirety. and are based on the best information available at the time of publication. The particular needs of individuals infected with Également disponible en français sous le the hepatitis C virus will determine how titre, Hépatite C : Soins nutritionnels – these guidelines are used. The skill and Lignes directrices canadiennes pour les judgement of the health care provider is intervenants de la santé. important in making health care decisions. The opinions expressed in this document do not necessarily reflect the official policies or views of Health Canada. Table of Contents Acknowledgements ............................................................................................ i Executive Summary........................................................................................... ii Practice Essentials............................................................................................ iv Introduction ....................................................................................................... 1 Target Audience for the Guidelines Rationale for the Guidelines Results of Needs Assessment How the Guidelines Were Developed Chapter 1: A Primer on Hepatitis C ................................................................. 3 Description of the Issue Who Is at Risk Diagnosis of HCV Current Treatment Strategies How HCV Affects the Liver Stages of Liver Disease Factors Implicated in Progression of Liver Damage The Role of the Liver in Nutrition How HCV Affects Nutritional Status Chapter 2: Healthy Lifestyle Overview ........................................................... 7 Proven Benefits of Nutrition Healthy Eating for Persons Infected with HCV Healthy Eating Guidelines in Canada Alcohol and Hepatitis C Importance of a Healthy Body Weight Importance of Physical Activity Chapter 3: Nutrition Intervention in Hepatitis C......................................... 10 Guidelines for Nutrition Intervention in Hepatitis C Nutrient Guidelines Overview Oxidative Stress Vitamin and Mineral Supplements Stage of Hepatitis C — Nutrition Considerations Enteral and Parenteral Nutrition Chapter 4: Assessment of Nutritional Status .............................................. 24 Factors to Consider in Clinical Nutrition Evaluation Counselling Guidelines and Recommendations Chapter 5: Dealing with Symptoms and Treatment Side Effects.............. 29 Common Symptoms and Treatment Side Effects Associated with Hepatitis C Strategies for Coping with Symptoms and Treatment Side Effects Chapter 6: Complementary and Alternative Therapies .............................. 30 The Naturopathic Approach Vitamin/Mineral Supplements Herbal Products Chapter 7: Nutritionally At-Risk Groups....................................................... 35 Concomitant Medical Conditions At-Risk Population or Lifestyle Groups Chapter 8: Skills for Healthy Eating.............................................................. 38 Ability to Plan, Shop and Cook Nutrition Labelling Food Safety References and Resources ............................................................................. 40 References by Chapter Resources — Organizations and General Useful Resources Resources — by Chapter Glossary of Terms and Acronyms .................................................................. 56 Appendices ....................................................................................................... 58 Appendix A: Healthy Eating Checklist for Persons with Hepatitis C Appendix B: Canada’s Food Guide Principles Appendix C: Summary of Physical Activity Considerations Appendix D: Quick Protein Check Appendix E: Guidelines for Food Selection with Sodium Restriction Appendix F: Managing Common Discomforts and Treatment Side Effects Appendix G: Healthy Eating — Planning Tips Appendix H: Low-Cost Nutritious Choices Appendix I: Standard Nutrition Facts Label Appendix J: Tips for Safe Food Handling Acknowledgements Many people have contributed to the development of these guidelines and deserve recognition for their time, effort and dedication. Dietitians of Canada sincerely thanks the members of the national advisory committee for their expert advice and guidance. We also thank the organizations involved in the project, as well as the expert reviewers who provided valuable guidance on the technical and practical aspects of the guidelines. Production of the guidelines would not have been possible without the insights of those who participated in the key informant interviews for the needs assessment. We are also grateful to the participants in the focus groups conducted to test and refine the patient education material. National Advisory Committee Renée C. Crompton, M.Sc., RD Timothy J. McClemont Regional Nutritionist – Ontario Region Executive Director First Nations and Inuit Health Branch Hepatitis C Society of Canada Health Canada Billie Potkonjak Mary Giudici, RDN National Director of Health Promotion Vancouver Island Health Authority and Patient Services Royal Jubilee Hospital Canadian Liver Foundation Victoria, BC Jeff Rice Lynn Greenblatt Coordinator of Regional Resources and Community Acquired Infections Division Hepatitis C Programs Health Canada Canadian Hemophilia Society Kelly Kaita, MD, FRCP(C) Vera Simon, RN, M.Sc.N Director, Viral Hepatitis Investigative Unit President University of Manitoba Canadian Association of Hepatology Nurses Canadian Association for the Study of the Liver Jayne Thirsk, Ph.D., RD Professional Development and Support Dietitians of Canada Expert Reviewers—Dietitians of Canada Pauline Brazeau-Gravelle, RD Lori Hards, RD Perinatology Clinical Dietitian Dietitian/Nutritionist Ottawa Hospital, General Campus Southern Alberta Clinic Ottawa, ON Calgary, AB Alison Cummins, RD Janet Madill, Ph.D.(C), RD Clinical Dietitian–Medicine Program Transplant Dietitian, Research Practice Leader Health Sciences Centre University Health Network, Toronto General Winnipeg, MB Toronto, ON Marylynn Cutten, P.Dt. Tania Soutar, B.Sc., RD Dietitian, Food & Nutrition Services Clinical Dietitian Capital District Health Authority Regina Qu'Appelle Health Region Queen Elizabeth II Health Sciences Centre Regina, SK Halifax, NS Special thanks go to Mary Giudici for sharing her patient education tools, and to the additional expert reviewers: Diana Johansen, B.Sc., RD, Clinical Dietitian, Oak Tree Clinic, Children’s and Women’s Health Centre of British Columbia, and Adjunct Professor, Department of Family Practice, University of British Columbia; and Sian Hoe Cheong, RD, Supervisor, Food Services, Medicine Hat Regional Hospital, Palliser Health Region. Project Management Susan Morgan, M.Ed., RD Sheryl Conrad, RD Project Manager Consultant/Writer Jeane Ennis Consultant/Project Associate Hepatitis C: Nutrition Care — Canadian Guidelines for Health Care Providers i Executive Summary These guidelines are directed to all health care providers who are in a position to offer nutrition- related advice and guidance to persons infected with the hepatitis C virus (HCV), in all stages of the disease. The guidelines are based on the best information available at the time of publication; where scientific evidence is not available, best-accepted practice is presented. The prevalence of HCV infection in Canada is estimated to be about 0.8%, or 240,000 persons. Hepatitis C is one of the driving forces behind the increasing prevalence of chronic liver disease. Up to 85% of persons exposed to HCV develop chronic liver disease over a 10- to 40-year period. Associated morbidity and mortality are projected to increase dramatically over the next 10 to 15 years. An increase in chronic hepatic disease means potential problems with nutritional deficits in this population and an important role for nutrition in the outcome of the disease. A Primer on Hepatitis C HCV causes an inflammatory reaction that is localized within the liver, allowing the virus to gradually infect and destroy liver tissue, such that liver damage progresses slowly. It is not unusual for someone who feels well to have serious liver disease and for someone with severe symptoms to have only mild liver disease. Liver failure does not become obvious until most of the hepatocytes have been destroyed. At this point, it becomes difficult for the body to maintain nutritional homeostasis, utilize nutrients appropriately, synthesize plasma proteins, and detoxify noxious substances. The Liver and Nutrition The liver significantly influences nutritional status through