World Gastroenterology Organisation

Global Guardian of Digestive Health. Serving the World.


Nutrition in cirrhosis: recommend a bedtime snack

Review by Prof. Mark Topazian (USA)


Loss of muscle mass and strength, termed sarcopenia, is common in patients with cirrhosis and is associated with poor patient outcomes. Cirrhosis is a catabolic state, and patients may go into “starvation mode” overnight because of poor hepatic glycogen stores. This can result in muscle protein breakdown.


In this review, evidence-based practices that can improve muscle mass and/or strength in patients with cirrhosis were identified. This includes a bedtime snack of 50 grams carbohydrate, which has been shown to increase total body protein in patients with cirrhosis over time. A morning snack does not have the same benefit, as it does not protect against muscle catabolism overnight.  Frequent, high-protein meals throughout the day are also recommended. Other recommendations include routine assessment of sarcopenia in patients with cirrhosis by measurement of mid-arm circumference, assessment of grip strength (using a hand grip dynamometer) or chair stands (standing up from a chair repeatedly for 30 seconds) and recommending body-weight resistance and aerobic exercise to cirrhotic patients.


These nutritional assessments and recommendations are simple and can be implemented in most clinical settings, often without requiring much physician time. Prevention of sarcopenia is one low-cost method of improving outcomes for patients with cirrhosis.


Sarcopenia in cirrhosis: a practical review. Dhaliwal A, Armstrong MJ. Clin Med (Lond) 2020:20, 489-492.

Link to study

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