Calcium, Sodium, Iron and Liver Disease/Hepatitis

Calcium (Ca) 

Calcium  is essential for healthy teeth and bones, for normal muscle contraction and for blood clotting.  Almost all of the calcium in the body resides in the bones.  Without an adequate amount of calcium  the bones become soft and brittle.  Osteoporosis is characterized by a reduced bone mass and the resulting increased risk for bone fractures.    Since people with chronic liver disease are at increased risk for the development of osteoporosis, it is important to consume foods rich in calcium and/or to  supplement their diets with calcium.  However, it is important to remember that calcium supplementation alone will not prevent osteoporosis. Other factors, such as cigarette smoking, lack of exercise, excessive alcohol consumption and abnormal hormone levels also play roles in the development of bone loss. Alcohol has been shown to be directly toxic to bone cells, and may impair calcium absorption. Thus, it is especially important for patients with alcoholic liver disease to take calcium supplementation.   In fact,  it is a good idea for all people with chronic liver disease to take a calcium and vitamin D supplement.

     Good sources of calcium include dairy products, leafy dark green vegetables ( except spinach), tofu, canned sardines with bones, or salmon with bones. Excessive calcium consumption may interfere with the absorption of iron, in addition to causing many medical problems such as kidney stones, constipation, and fatigue.  Furthermore, as with all supplements, regardless of how much is consumed, the body will only utilize the amount needed. Any surplus will be eliminated from the body unused, or will accumulate and perhaps cause medical problems. If calcium supplementation is taken, it should be limited to no more than 1000-2000 milligrams /day, and should be taken with a vitamin D supplement (which is usually included in the calcium tablet).  Since stomach acid is needed to properly absorb calcium, antacids such as Tums, which reduce stomach acid, are a poor source of this mineral.

     Blood tests, by themselves, are an insufficient means to measure calcium requirements.  People with chronic liver disease, especially women over the age of fifty, should have their bone density measured.  If found to be low, in addition to taking a calcium and vitamin D supplement, these individuals are strongly advised to start on medication aimed at inhibiting bone loss, such as Fosamax ( alendronate sodium ).

Sodium ( Na)

Sodium is a mineral that the body requires to maintain precise water balance.  Sodium occurs in nature only in combination with chloride another mineral (sodium chloride or salt).  The body requires only about 50 to 400 mg of sodium per day.  Yet, the average American consumes about twenty -five -to- thirty -five times that amount!   While this over- consumption of salt is not necessarily dangerous for most healthy individuals, it can create problems for someone with advanced liver disease.  

      Cirrhosis may lead to ascites (an abnormal accumulation of fluid in the abdomen).  If not treated in a timely manner, this ascitic fluid may become infected, a condition known as subacute bacterial peritonitis or SBP. Patients with ascites must be placed on a severely salt-restricted diet.  For every gram of sodium consumed, the accumulation of 200 milliliters of fluid results. The lower the consumption of sodium in the diet, the better controlled this excessive fluid accumulation is. For people with ascites, sodium intake should be restricted to under 1,000 milligrams(mg) each day, and preferably under 500 mg.  This goal is difficult, yet attainable.

     Remember - the lower the salt content in the diet, the better the fluid accumulation will be controlled and the less need there will be for water pills (diuretics).  Strive to avoid the vicious cycle of eating foods high in sodium content, leading to worsening of ascitic fluid  accumulation, leading to increasing dosages of diuretics, or, even worse, to having the fluid drained with a  needle (paracentesis) . Wouldn’t it be easier to refrain from excessive salt consumption in the first place?

      In order to successfully adhere to a salt-restricted diet, it is important to become a knowledgeable food shopper and must diligently read all food labels.  People are often surprised to discover which foods are high in sodium content (see table below for the sodium contents of some common foods). General guidelines are as follows : the amount of sodium in fresh foods is significantly less than that in the same foods after they have been processed, cured, canned or frozen; therefore, one should choose fresh foods whenever possible. Table salt and salt used for cooking should be totally eliminated from the diet.  One teaspoon of table salt contains 2,325 mg of sodium!  All canned foods and fast food restaurants should be avoided. Some over- the- counter medications have high sodium contents.  For example, one tablet of Rolaids contains 53 mg of sodium, 2 tablets of Alka-Seltzer contains 567 mg of sodium, and one serving of  Bromo-Seltzer contains 717 mg of sodium.  These medications should be substituted with ones having a lower sodium content. If the label on a medication or other product does not clearly state the sodium content, a pharmacist should be able to supply such information or offer a way to obtain it. Meats, especially red meats, have a high sodium content.  Consequently, adherence to a vegetarian diet may become necessary for individuals who develop severe ascites.  Spices such as basil, dill pepper, and vinegar, to name a few, may be used in place of salt to season one’s food.  Salt substitutes containing  potassium chloride should be avoided.  These substitutes tend to raise potassium levels in the body.  This can be especially dangerous to people taking spironolactone (Aldactone), a potassium-sparing water pill (diuretic) used in the management of ascites.

     We are fortunate that in this day and age there are many foods on the market which have been specifically manufactured as low sodium products. Furthermore, as of 1986, the FDA has required the sodium content of all processed foods to be listed on the package label.  This regulation has been a boon to the consumer. People with liver disease without ascites, are advised to refrain from excessive salt intake, although they need not limit their consumption as severely.

Iron (Fe)

There are two types of dietary iron.  Heme, or animal iron  (i.e. red meat), is well absorbed from the diet.  Nonheme, or plant iron (i.e. spinach), is poorly absorbed into the body (Popeye was wrong - spinach is not a good source of iron).  In fact, only about fifteen percent of ingested animal iron, and only three percent of ingested plant iron, is actually by the body.  The average American  consumes about 10 - 20 mg of iron per day.   In order to increase the absorption of plant iron into the body a vitamin C supplement should be consumed at the same time. On the other hand, tea, which contains tannins ( a plant substance), inhibits the amount of iron absorbed from the diet. 

      The amount of iron in the body usually amounts to about 3-4 grams, ( 50mg per kg in men and 40 mg per kg in women). The body has a limited ability to eliminate excess iron from the body.  In fact, only about 1-2 mg of iron is capable of being excreted each day.  Therefore, if too much iron is ingested (whether in the form of food or supplements), any excess iron is stored in body tissues, primarily the liver.  As such, the liver is the part of the body that is most susceptible to the toxicity of iron.

      Iron is an essential component of hemoglobin, a protein responsible for delivering oxygen to the body’s cells and organs. ( One red blood cell carries approximately two-hundred and seventy hemoglobin molecules, each of which contains four iron molecules).  Iron is also a component of myoglobin, a protein responsible for delivering oxygen to the muscles. Finally, iron helps make ATP ( adenosine triphosphate), an important component of energy.  Thus, it is common to associate iron with energy and strength.  And, the link between fatigue and iron deficiency was pointed out to the American public via the Geritol commercials which aired during the 1960’s popularizing the term “iron poor blood”.   Individuals with liver disease often incorrectly assume that when they feel weak and tired, they need  to take iron supplements.  But, taking an iron supplement under such circumstances is not a wise move and may, in fact, be dangerous. The symptoms of iron deficiency and iron overload can be quite similar - fatigue, headaches, shortness of breath.  Also, the fatigue associated with liver disease is more likely to be due to something other than the amount of iron in the body.  Therefore, prior to taking an iron supplement, it is crucial that a person with liver disease get his or her blood tested for an iron profile ( iron, ferritin, and total iron binding capacity).

     Excessive iron in the body of a liver patient can be extremely dangerous.  In extreme excess, iron is toxic to the liver, and can lead to cirrhosis, liver failure and liver cancer. Furthermore, there is growing evidence that even mildly increased (or sometimes even normal amounts of iron) may cause or enhance the amount of injury to the liver in the presence of other liver diseases.  This applies especially to people with alcoholic liver disease and chronic hepatitis C.   In fact, iron overload is commonly seen in  patients with alcoholic liver disease and chronic hepatitis C, and has been found to worsen prognosis, and to decrease the responsiveness to treatment. Liver scarring and liver cell damage are directly related to the iron content of the liver cell.  Since a person’s body is unable to eliminate an overabundance of iron , neither iron supplements nor vitamins containing iron should be included in the diet of a person with liver disease, unless it has been determined that there is an iron deficiency.

    Patients with chronic hepatitis with high iron levels should avoid cooking with cast - iron laden cookware and should avoid eating with cast-iron laden utensils.  These individuals should consume only moderate amounts of those foods which are high in iron content, such as red meats and cereals or breads enriched with iron. ( see table below for the iron content of some common foods).  Furthermore, some herbal preparations commonly taken by patients with hepatitis( for example, milk thistle, dandelion, licorice) often contain iron.  Therefore, patients who are found to have an overload of  iron should avoid these herbs.

  IRON CONTENT OF SOME COMMON FOODS

By reading this article, you have acquired some useful knowledge about the relationship between minerals and the liver. For additional information on the broader subject of nutrition and the liver, you may wish to consult my book.  Until next time - continue to keep up the fight for a healthy liver.

All contents of this article are Copyright © Melissa Palmer, MD

Melissa Palmer, MD is the author of " Dr. Melissa Palmer's Guide of Hepatitis and Liver Disease". (Published 2004. Penguin Putnam).

The offices of Melissa Palmer, M.D. are located at:

1097 Old Country Road Suite 104

Plainview, Long Island N.Y 11803

or

500 Portion Road

Lake Ronkonkama, N.Y. 11779

To arrange an appointment with Dr. Palmer, call

(516) 939-2626

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