fresh or lightly cooked vegetables and fruits
raw or lightly toasted nuts and seeds
whole grains such as brown rice and barley
whole-wheat breads, pastas, cereals, and crackers
mixed grain/nut/seed/bean combinations, eggs, poultry, fish, and lean meat for good quality protein

Many people find the mathematical formulas that give standard diet directions using "percentages of this" and "grams of that" too difficult to follow. Therefore, many experts recommend a simpler approach for designing your meals: the food pyramid. Picture a pyramid with layers made up of food groups. Just like any pyramid, the base is the largest and each level above that decreases in size. The idea is to eat from the bottom up, with the largest amount of your food coming from the base layer, the second largest amount from the second level up and so on.

USDA Food Pyramid

The food pyramid is reprinted courtesy of the U.S. Department of Agriculture ant the U.S. Department of Health and Human Services.

The pyramid base is the bread, cereal, rice, and pasta group. This group contains primarily complex carbohydrates that provide a substantial portion of the energy you need every day. It is recommended that you eat 6-11 servings from this group each day. Some examples of an average serving from this group would be one slice of bread, one-half of a bagel or English muffin, one cup of most flaky cereals, six crackers, two corn tortillas, one-half cup of cooked pasta, or three squares of graham crackers.

The next level up is split in half. One side is the vegetable group, and the other side is the fruit group. It is recommended that you eat 3-5 servings of vegetables and 2-4 servings of fruit each day. Eating the recommended amounts of fruits and vegetables will help you get all the nutrients and fiber needed for healthy body functions, especially immune function. One serving of vegetables is approximately one cup of raw vegetables or one-half cup of cooked vegetables. One serving of fruit is approximately one-half cup of fresh, chopped, or canned fruit.

The third level is the protein level, and it is also split. One side is the meat, poultry, fish, dry beans, eggs, and nuts/seeds group. The other side is the milk, yogurt, and cheese group. Most people need to eat at least 2-3 servings per day from each of these groups in order to get an adequate amount of protein.

The top level of the pyramid is the fats, oils, and sweets group. It is recommended that you eat the least from this group. Although a moderate amount of good fats is healthy, keeping the overall fat content of the diet low is important. Researchers have shown that high fat intake is tied to an increased risk of progression to cirrhosis in those with chronic hepatitis C.² Although an occasional sweet treat can be fun, most sweets contain few nutrients and often substitute for more healthy foods you might otherwise be eating. Limiting your intake of sweets is a good way to improve your chances for a total daily intake of nutrients that is supportive of your good health.

Another important and easy way to increase your daily nutrient intake is to go for variety and color. Each food is rich in certain nutrients, but not in others. Choosing a wide variety of foods at each pyramid level will help ensure intake of all the nutrients nature can provide. You run the risk of limiting your nutrient intake if you tend to eat the same foods over and over. Emphasizing color when you select a wide variety of foods is additional nutritional insurance. Think of it as, "the rainbow theory of shopping." When you are in the bread, pasta, cereals, and cracker aisles, choose brown, whole-grain varieties instead of white. White varieties contain processed grains, and processing removes most of the important nutrients found in the whole grain. When you are in the produce section, pick up a variety of colors: red, purple, green, orange, yellow, blue, etc. Any time you see natural color, you are seeing nutrients. The more your shopping basket looks like a rainbow of color, the better your diet will be.

Adjusting the Food Pyramid to Your Individual Needs

The food pyramid is a simple way to look at your overall diet. Its guidelines provide a basic approach to eating. However, some of the recommendations might need to be modified based on your individual needs.

One possible modification is adjusting the number of servings from the food groups that will be required to meet your calorie or energy needs. Both your metabolism, the rate at which your body uses energy, and your lifestyle can significantly affect your calorie requirements. These individual characteristics make it difficult to come up with generic recommendations on how many calories someone needs each day. You may have a high rate of metabolism and an energy-demanding job such as construction work or an intensive daily exercise schedule, which increase your calorie needs. On the other hand, you may have been born with a very low rate of metabolism and have a sedentary desk job or a lifestyle that does not include much exercise, which lessen your calorie needs. However, regardless of these individual variables, the total intake of food that you need daily is somewhat increased by chronic hepatitis C. Your immune system has an ongoing response to the virus and this response is constantly burning up calories.

Dietary adjustments may also be needed in those people with a significant level of liver damage from the virus. Since adequate protein is generally so important, it is easy to jump to the conclusion that more is better. However, in the presence of serious liver disease, too much protein can actually be dangerous. A damaged liver cannot process protein as well as a healthy liver. Too much protein can result in protein overload that may lead to encephalopathy, a brain condition that causes mental confusion, and, in advanced stages, coma. If you have significant liver damage, it is very important for you to discuss your dietary needs with your health care provider to ensure that your nutritional needs are met without placing undue stress on your liver.

Another dietary change that may be very important for some people is salt reduction. Ascites is a complication of cirrhosis in which fluid accumulates in the abdomen. Too much salt in the diet can significantly worsen ascites.

People coinfected with HCV and human immunodeficiency virus (HIV), may have additional problems that require dietary changes. For example, many people living with HIV suffer from lactose intolerance, an inability to properly digest the milk sugar lactose. This results in gas and/or diarrhea when dairy products are eaten. People with lactose intolerance often need to reduce or eliminate milk and milk products (cheese, yogurt, ice cream, etc.) from their diet. A reduced ability to digest and absorb fats, is also common in HIV disease. This can be another cause of gas and/or diarrhea. Therefore, people living with both viruses may need to keep the fat content of their diets even lower than those who have HCV alone. Finally, some of the drug regimens taken by many coinfected people require additional dietary adjustments.

For all these reasons, it is very important to discuss the details of your personal situation with your health care provider, and ask for advice about dietary adjustments that may be needed. You and your health care provider will need to consider your health history, laboratory results, the state of your liver, and any other conditions such as diabetes or heart disease that may require dietary adjustments. For those who are coinfected, you will also want to discuss all aspects of your HIV disease. Your health care provider may want you to make an appointment with a nutritionist or dietitian who specializes in hepatitis C. A qualified nutrition counselor can help you create an individualized dietary program. Just make sure your counselor is truly knowledgeable about the nutritional needs of people living with HCV.

All that can be offered to you in this book is a generalized look at what we know about nutrition for those living with hepatitis C. Consider the information in this book to be a base of knowledge that absolutely must be modified by your health care provider based on all aspects of your current health status. A diet that has been adjusted to precisely meet your current health status and individual needs is ideal.

With this in mind, we will now go back to the food pyramid and provide some specific suggestions on healthy choices for each of the food layers.

The Bottom of the Pyramid: Carbohydrates

Carbohydrates are the main source of your body's energy and should be the largest part of your diet. Carbohydrates are classified according to their structure as either simple or complex. Simple carbohydrates are found in sweet foods and sweeteners such as fruit, fruit juice, sugar, and honey. Complex carbohydrates are found in potatoes, root vegetables such as carrots, beans, peas, winter squashes, and grains such as wheat, rice, corn, and oats. Most of the carbohydrates you eat should be the complex variety, although a reasonable amount of simple carbohydrates, mostly from fruit, is acceptable.

Whole grains (those that are largely unrefined) provide vitamins, trace minerals, and fiber, all of which are important to the immune system and your overall health. One of the best ways to increase your nutrient intake is to substitute whole grains for the "white" foods that are common in our society. For example, use brown rice instead of white. Eat whole grain bread instead of white bread. Be sure to read the label and make sure your bread is all or mostly whole grain, such as whole wheat or whole rye. If the label says, "enriched flour," "white flour," or "wheat flour," be aware that this really means nutrient-poor white flour. Use whole-grain pasta instead of spaghetti, macaroni, or noodles made from white flour. Eat whole-grain rye, wheat, or rice crackers instead of white flour saltines. Again, do not be tricked by the name on the box; read the label carefully. Whole grain flaked cereals and whole grain hot cereals such as oatmeal have far more nutrients than the usual cold breakfast cereals.

Beans of all varieties are also excellent sources of complex carbohydrates and low-fat protein. Do not think of beans as a boring side dish. Make up a spicy bean dip, add them to a pasta dish, or sprinkle a tasty variety on your salad. And do not forget about corn and winter squashes. They are loaded with nutrients and can be a tasty source of complex carbohydrates from breakfast (whole corn grits) to dinner (baked spaghetti squash used in place of pasta in your favorite Italian dish).

Pyramid Level 2: Fruits and Vegetables

Fruits and vegetables are nature's most abundant source of most vitamins and minerals, including antioxidant nutrients that are particularly important for protecting the liver. In addition, they provide a great deal of fiber that is important for your health. Including a variety of vegetables and fruits in your diet every day is one of the most important things you can do for good health. Most experts recommend eating 5-9 servings of fruits and vegetables every day, but many people do not even come close to that amount. That makes fruits and vegetables an important area to emphasize for improving nutrient intake.

Fresh fruits and vegetables, lightly steamed or sautéed vegetables, and fresh-squeezed fruit and vegetable juices (made with a juicer that retains pulp) are the most nutrient-rich choices in this group because there has been little or no processing to degrade the nutrients. These fruit and vegetable options contain all of the vitamins and minerals nature intended. Cooking at high temperatures destroys enzymes and some nutrients. Therefore, including fresh or lightly cooked fruits and vegetables in your daily diet can be a particularly potent source of nutrients.

Whether raw, steamed, sautéed, or cooked into soups or sauces, the greater the variety of vegetables you eat, the better your chances are for getting all the important nutrients you need. Thus, do not eat the same vegetables day after day. Choose from the entire produce section and include several helpings each day. Your choices are many and include such things as carrots, zucchini, yellow summer squash, broccoli, cauliflower, red and green cabbage, green beans, peas, snow peas, kale, mustard and collard greens, spinach, red, yellow and green peppers, celery, Brussels sprouts, red and green lettuce, and so on. If you cook these with onions, garlic, ginger, peppers, and tomatoes, you will add the healing nutrients of these ingredients to your body's health store, too.

Several helpings of fruit each day are also important for your diet. Take advantage of the wide variety of fruits available in modern supermarkets. Choices include apples, bananas, oranges, grapefruits, tangerines, red and green grapes, peaches, plums, apricots, melons, pineapples, papayas, mangoes, and so on. It is important to eat fresh fruit rather than just drinking fruit juice since juice often does not contain the fiber and pulp that provide many of the fruit's most important nutrients. Do not forget that fruit is the best and most healthy dessert you can eat. Fruit is also a far healthier snack food than the common sugar-loaded variety.

Increasing your fruit and vegetable intake to reach the recommended 5 to 9 servings daily can seem impossible to some people, but it may not be as difficult as you think. For one thing, the amounts of these foods that make up a serving are rather small. One serving of fruit equals one-half cup of fresh chopped fruit. To reach the recommended 2 to 4 servings of fruit, just think in terms of trying to have 1 to 2 cups of fruit each day. One serving of vegetables equals one cup of raw vegetables or one-half cup of cooked vegetables. Therefore, to get your 3 to 5 servings of vegetables, think in terms of a mixture of raw and cooked vegetables that equals about one quart per day. Eating the recommended amount of fruits and vegetables is not very difficult if you concentrate your food choices appropriately. Have a piece of fresh or stewed fruit as a dessert and for some of your between-meal snacks. Eat a couple of servings of vegetables with your main meal of the day, and include at least one or two other vegetable servings at another meal or as a snack. In the morning, sauté a mixture of vegetables such as onions, spinach, mushrooms, tomatoes, and potatoes and stir them into an omelet for a nutrient-loaded breakfast. Add a variety of vegetables to rice, barley, couscous or any other grains you are cooking. Bake some carrots or winter squash along with your baked potato.

Vegetables cooked into soup count as a serving or two, depending on how many vegetables you put into the soup and how much of it you eat. Making up a big pot of hearty vegetable soup can help provide vegetables for a number of meals. You can eat the soup over several days or freeze individual portions to use when other vegetable preparation feels too difficult. If you add beans, chicken, or fish to your soup, you will also be getting lots of protein. For days when eating seems like a difficult chore, getting good nutrition can be made easier by pureeing or blending soup in a blender or food processor so that it becomes an easily drinkable, liquid meal.

If you can purchase organic fruits and vegetables, you will limit your exposure to the pesticides that are used when growing non-organic produce. If you cannot purchase organic fruits and vegetables due to budgetary constraints or lack of availability, be sure to carefully wash your produce with a mild soap and water solution for two minutes.

Pyramid Level 3: Protein

The third level of the pyramid consists of proteins, without which your body cannot survive. Recall that one side of this level is the meat, poultry, fish, dry beans, eggs, and nuts/seeds group. The other side is the milk, yogurt, and cheese group. Eating 2-3 servings from each half of this pyramid level generally provides the protein needed each day.

You need protein to build and maintain cells, keep muscles and organs healthy, produce enzymes and hormones, make the hemoglobin that carries oxygen to your cells, and maintain your immune system. When your protein intake is too low to maintain your protein stores, the immune system cannot function normally. A loss of immune function created by protein deficiency can cause a lowered resistance to infections, improper wound healing, and a lessened ability to control viruses including HCV. Too little protein can also result in weight loss, fatigue, and a decreased ability to respond to drug therapy.

Proteins are made of building blocks called amino acids. When making protein choices, it is important to remember that we require all of the amino acids necessary for the body to build the proteins it needs. The eight so-called essential amino acids are those the body cannot make on its own. They must be obtained from your diet. The so-called nonessential amino acids are those your body can manufacture for itself, provided it has the necessary materials. To manufacture non-essential amino acids, the body uses other amino acids, vitamins, minerals, and enzymes. If any of these are in short supply, even the nonessential amino acids may become deficient.

Complete proteins contain all of the essential amino acids. Complete proteins are found in animal foods such as eggs, dairy products, meats, fish, and poultry. Essential amino acids can also be obtained through complementary proteins created by combining grains, nuts, seeds, and legumes such as beans, peas, and nuts. However, building tissue from complementary proteins requires more energy than building it from complete proteins. Therefore, if you have already experienced muscle loss and/or your appetite is low, it may be better for you to concentrate on eating animal foods that contain complete proteins.

On the other hand, plant foods are generally less expensive than animal foods. If cost is a concern, remember that including some combination of beans, peanut butter, peas, rice, corn, nuts, seeds, and other grains and legumes in your daily diet will give your body the protein it needs. Small amounts of animal proteins added to a mostly plant-based diet can ensure that such combinations work without increasing the cost too much. Always remember that eggs top the list for high quality, inexpensive protein.

Some good, concentrated sources of protein are listed below.

eggs
poultry - skinless to lower the fat content
fish - preferably deep-water, cold-ocean varieties since these are less likely to contain the liver-stressing toxins that fish from polluted waters may have
complementary proteins found in mixed grain/nut/seed/bean combinations
lean meat

Unless lactose intolerance is a problem, cheese and other dairy products can add to your protein intake. Adding things like alfalfa sprouts, chickpeas or other beans, or sesame seeds to your salad, or having beans as part of your meal can increase your protein intake substantially. Snacking on sunflower seeds will do the same. Just be careful not to overdo on seeds or nuts as they also contain substantial amounts of fat. With a reasonable combination of such protein foods in your three daily meals and occasional snacks, you should easily be able to eat the amount of protein you need.

Remember, this is a case where more is not necessarily better. A health care provider who knows the details of your health and liver status should prescribe the exact amount of protein you need to eat each day.

The Top of the Pyramid: Less is More

The top and smallest part of the food pyramid includes fats, oils, and sweets. Some fat is necessary for good health, but fat intake should be limited in people living with hepatitis C. Fats should come from healthy sources which means focusing on natural fats. The best fat choice is monounsaturated fat such as that found in extra-virgin, cold-processed olive oil or canola oil.

It is very important to eliminate partially hydrogenated fats from your diet. Hydrogenation is a process that uses heat and chemicals to change the structure of fatty acids in vegetable oils so that the oils are solid at room temperature. For example, hydrogenation is how liquid corn oil is converted into solid margarine. You will see partially hydrogenated fats referred to as trans fats. During hydrogenation, the normal chemical cis bond found in the fat is changed to a trans bond. This may sound complex, but just know that trans fatty acids may contribute to blocking some of the body's normal chemical processes, including those related to fat metabolism. Researchers who have studied this believe that artificially created trans fats have many negative health effects. In 1994, a group of Harvard researchers stated, "Federal regulations should require manufacturers to include trans fatty acid content in food labels and should aim to greatly reduce or eliminate the use of partially hydrogenated vegetable fats."³ The FDA recently acknowledged the importance of this. All foods are required to have the trans fat content listed on the nutrition label no later than January 2006.

Partially hydrogenated fats are found in countless foods. These include margarine, shortening, most standard breads, crackers, cookies and other baked goods, many condiments such as mayonnaise, most commercial salad dressings, and some processed meats and snack foods such as potato chips, corn chips, ice cream, and French fries. It is crucial to read labels carefully in order to eliminate these unhealthy fats from your diet. If the words "partially hydrogenated" appear anywhere on the label, do not eat that food. Seek out brands of foods that have eliminated these bad fats in favor of healthy, natural ones. Luckily, many whole-food companies manufacture fat-healthy foods of all kinds. When eating out, be aware that most fast-food establishments use partially hydrogenated oils in their cooking processes. If you just have to have burgers and fries, you are better off making them at home from healthy ingredients. Even in better restaurants, it is a good idea to ask what kinds of fats they use in cooking and what is in the bread they put in front of you.

In general, try to make sure that you are consuming fats that nature made. Green, cold-processed olive oil not only makes great salad dressing, it is also a wonderful spread on bread. You can even use it for sautéing garlic, onions, or vegetables, as long as you keep the temperature fairly low since it has a low smoke point. Nut and seed butters are another source of healthy and tasty fat, whether they are spread on bread or used in salad dressing. If you really want a more traditional fat for cooking or spreading on your toast, plain old-fashioned sweet cream butter is definitely preferable to a partially hydrogenated margarine. Just be careful not to eat too much of any of these foods since your overall fat level needs to be moderately low to help reduce your chance of disease progression to cirrhosis.

When looking at possible ways to reduce fat, remember that much of it is hidden. Most meats (other than very lean varieties) and dairy products (other than those made from skim milk) are loaded with fat. Bacon, sausage, hot dogs, luncheon meats, and other similar products are very high in fat content. Almost all snack foods are also loaded with fat. This includes most chips, peanuts, nuts, many types of crackers, cookies, granola bars, candy bars, and many others. The fats found in salad dressings, peanut butter or other nut butters, and many sauces can add huge amounts of fat calories to your diet. Fried foods of all kinds (such as hamburgers, French fries, fried chicken, fried fish, fried or deep-fried vegetables) are often incredibly high in fat. Finally, the addition of fatty products such as butter, vegetable oils, mayonnaise, whipping cream, and sour cream can dramatically increase the fat content of any dish.

Relatively simple dietary and food preparation changes can significantly reduce the fat content of your diet. Some useful tips are noted in the following list. Any one of these can go a long way in increasing both the appetite-stimulating smell and flavor of foods while at the same time reducing the fat in your diet.

Bake, broil, or grill your meats, poultry, and fish instead of frying.
Use skim milk and skim milk cheeses and yogurt instead of whole milk and whole milk products.
Avoid high-fat bread products like croissants, doughnuts, muffins, and most cornbread. Use whole-wheat pita bread or low-fat whole grain breads instead. If you are making your own baked goods or sauces, use unsweetened condensed skim milk in place of cream.
Avoid high-fat sauces, gravies, and butter. Substitute herbs and other seasonings to improve the flavor of foods.
Unfortunately, removing the fat from dishes often seems to remove a lot of the flavor to which we are accustomed. Try using salsas, roasted garlic or shallots, flavored vinegars, chicken broth, and various hot sauces to spice up low-fat dishes.
Thicken sauces or soups with pureed white beans, instant mashed potatoes, or cornstarch and skim milk instead of heavy cream.
Make mashed potatoes using fat-free chicken broth instead of butter and milk.
Avoid fried potatoes or other vegetables, substituting steamed or baked versions.
Sauté foods like onions, garlic, mushrooms and so on using water or poultry broth instead of butter or oil. Alternatively, just "sweat" such foods by placing the chopped onions or garlic in a frying pan. Use moderate heat just until they begin to brown around the edges, and then pour in stock or vinegar to deglaze the pan.
Prepare your own popcorn using grated skim-milk cheese and various seasonings instead of butter as the topping.
Use toasted sesame oil or other strongly flavored oils when you just have to have a little fat for flavor.

One caution in this discussion of fat is that you should not carry fat avoidance to an extreme. You want a whole-foods diet that includes moderate amounts of good fats. You do not want a diet with no fat at all. In our concern to educate people about the need to lower dietary fat content, it is sometimes forgotten that fat is necessary at appropriate levels and in appropriate forms. Essential fatty acids are just that, essential. Both the omega-3 and omega-6 fatty acids are very important for human health.

When fat intake drops so low that the levels of essential fatty acids in the body are compromised, many negative health consequences can result. These consequences include skin problems, neurological problems, energy problems, and suppressed immunity. Fat provides the body's storehouse of energy. Fat in the diet is required for the absorption of the fat-soluble vitamins A, D, E, and K. In your attempt to decrease your intake of unhealthy fats, be sure you do not eliminate the good ones in the process. Moderate amounts of healthy fats are essential for a nutritious diet. Too much or too little fat are both unhealthy.

A healthy diet involves limiting the amount of concentrated sweets you eat. Many people consume too many nutrient-poor snack foods and desserts that are often loaded with excessive sugar and fat. Then they are not hungry for all the nutrient-rich foods on the lower levels of the food pyramid. The end result is a diet loaded with empty calories that do not promote good health. Try to make both sweets and fatty foods occasional treats instead of a major part of your diet.

Healthy Liquids

Drinking plenty of healthy liquids is just as important as eating nutritious foods. Water is a dietary essential. Your diet must include plenty of water. The old adage about drinking eight large glasses of water per day (approximately two quarts) is actually a good beginning. However, because your size affects how much water you need, a better and simpler rule is to divide your body weight in pounds in half, and then drink at least that number of ounces of water every day. For example, if you weigh 140 pounds, divide that in half and drink at least 70 ounces of water (almost nine cups) each day. Many people drink far too little water thinking that they can substitute other water-based beverages like soft drinks and coffee. However, these drinks are not a substitute for pure water.

You need to drink plenty of fresh, pure water every day because without sufficient water, the body simply cannot function properly. Anytime you are running a fever, have diarrhea, are suffering from nausea and vomiting, or have daytime or nighttime sweats, you run the risk of dehydration. Dehydration describes the state your body is in when it does not have enough water. Under these circumstances, you should put drinking plenty of fluids at the top of your list of priorities.

It is especially important for those who are coinfected with HIV to remember that the water you drink must be free of all disease-causing organisms. You can ensure the safety of your water by boiling it or using a water purifier that is designed to kill or filter out bacteria, protozoa, and other disease-causing organisms. The risk of water-borne infections is too high to ignore this.

Many people find herbal teas to be an enjoyable addition to their list of healthy liquids. Make sure you consult with your pharmacist or health care provider to make sure the herbs you are drinking have no potential for liver toxicity and will not interact with any of your medications. Fresh fruit and vegetable juices are also healthy liquids. Remember, many of the nutrients in vegetables and fruits are in the pulp. If you are preparing fresh juice, it is best to use a juicer that retains the pulp so you get the most nutrient value from your juice

Bottled fruit juices are another source of good liquids and are widely available. Be sure to pick the varieties with no added sugar. There are also canned or bottled juice spritzers that are sweet, cold, and carbonated. They have no added sugar and none of the chemicals most sodas contain, but taste great and are just as fizzy as carbonated soft drinks. These spritzers are good alternatives to standard soft drinks or so-called sports drinks.

Soups, already mentioned as a good source of protein and vegetables, can also contribute to your fluid intake. Warm liquids such as soups, herbal teas, and roasted-grain coffee substitutes are not only nutritious, but are also less demanding on the body than icy cold drinks. Anything that is drunk icy cold requires some of your body's energy to warm it up. Drinking large quantities of very cold beverages can actually drain away calories your body needs.

Diet Dangers

There can be hidden dangers lurking in certain foods and liquids. Both alcohol and salt (especially if ingested in excess) are bad for people with hepatitis C. The facts are simple.

Alcohol is highly toxic to the liver and can cause serious disease and/or death, even in those with no active viral infection. In people with HCV, alcohol intake has been linked to increased risk of cirrhosis, a more advanced degree of liver fibrosis, and a higher death rate. If you are considering interferon-based therapy, you should know that alcohol consumption has been associated with a decreased response to the drug.^{4, 5}

Another hidden dietary danger is the large amount of salt (sodium) contained in the typical American diet. High salt intake is not healthy for anyone, but for those with cirrhosis, it can be particularly dangerous since it can lead to or worsen ascites. Anyone with ascites must be on a salt-restricted diet. It is estimated that every 1,000 mg of sodium consumed can result in the accumulation of approximately 1 cup (200 mL) of ascitic fluid. The more the salt content of the diet can be reduced, the better the chances of avoiding this excessive fluid accumulation. For people with advanced disease, liver experts recommend limiting sodium intake to no more than 500-1,000 mg daily.⁶ This level of salt restriction requires careful shopping and scrupulous attention to food labels. Most fast foods and snack foods (especially chips, pretzels, and crackers) are dangerously loaded with sodium and must be avoided if you are on a salt-restricted diet. Even foods that might otherwise be considered healthy can be dangerously loaded with salt. For example, one cup of chicken noodle soup may contain an amazing 1,108 mg of sodium.

The only way to cut salt intake is to look at the sodium content of all the foods you are eating. Use food labels on prepared foods and a chart that shows sodium levels for other food ingredients to determine your total daily intake of sodium. One easy way to cut sodium intake is to avoid prepared foods. Since many people with high blood pressure are placed on low sodium diets, there are many cookbooks and dietary plans available to help you avoid salt. People with hepatitis C who have not developed ascites usually do not need severe sodium cutbacks, but moderating your salt intake is likely to be beneficial.

Another possible dietary danger is eating too many iron-containing foods. This is a particular concern for those who have had a liver biopsy showing an abnormal accumulation of iron. Iron is stored in the liver and is used by the body for many different processes such as producing red blood cells. Iron is also a very important component of the enzymes involved in energy production and the manufacture of DNA, the building block of life. Therefore, the human body requires some amount of iron. However, because of its ability to act as a source of substances called free radicals, iron can cause liver damage in people with hepatitis C. This damage can lead to inflammation and scarring. See Chapter 15, Naturopathic Medicine and Chapter 16, Nutritional Supplementation for discussions of free radical damage.

Studies have shown that iron appears to be much more likely to contribute to liver damage in people who have hepatitis C than in those who do not. A study in India with hepatitis B and C patients showed that a low-iron diet significantly lowered blood iron and ALT (a liver enzyme), especially in those who started with high iron levels.⁷ Many iron-rich foods are also high in protein. Although it is not a good idea to sacrifice protein for the sake of a low-iron diet, it is fairly simple to avoid foods that contain very high amounts of iron or are fortified with iron while still getting enough protein.

In general, dietary iron is poorly absorbed. The iron from meats is better absorbed (10-20%) than the iron from plants (2-5%). If you already have a high iron level in your liver, it may be advisable to decrease your animal protein intake as a way to lower your intake of iron. You can substitute plant proteins for the animal proteins. Be aware that many processed foods are fortified with iron and can significantly increase your iron intake. Unless your physician has recommended iron supplements because of iron-deficiency anemia, it is best to avoid iron supplements. While the exact role of iron in hepatitis C is still under study, eliminating excess iron from your diet appears to be a good idea.

As a final cautionary note, people with hepatitis C should avoid raw fish and shellfish. These foods can be contaminated with the hepatitis A virus. The chance of contracting hepatitis A from raw fish or shellfish is not worth the risk for people already infected with HCV, as the complications can be severe.

The Bottom Line

A summary of dietary guidelines for people living with hepatitis C is rather simple. Try to avoid junk food and fast food. Avoid other nutrient-poor foods that are made with white flour or white sugar, deep-fried in chemically altered oils, overcooked, or loaded with chemicals.

Create your meals from whole foods, using a wide variety of properly prepared fruits and vegetables, whole grains, and high-quality protein. Include plenty of healthy liquids.

Put care and thought into what you put into your body so that every mouthful adds nutrients and increases your capacity to heal. If you have created each cell in your body from healthy foods and liquids, then there is no question that you will have dramatically increased your body's ability to resist the assault of any disease, including hepatitis C.