We appreciate Drs. Ianelli and Schiavo taking the time to comment on our recent review and to highlight the unique problem of developing weight loss recommendations for obese patients with cirrhosis.1 One of the critical points they emphasize is the importance of preserving fat-free mass (FFM) in patients with cirrhosis, arguing that the most important factor in preventing sarcopenia is the macronutrient composition of a diet. Although we agree that high-protein intake may decrease FFM loss in the setting of a calorie-restricted diet, we recommend using caution when applying outcomes in healthy individuals to the cirrhotic population.
Although sarcopenic obesity is a well-known problem in the general population, the drivers of malnutrition and FFM loss are different in cirrhotic patients. Hypermetabolism, accelerated starvation state, and alterations in amino acid profiles in cirrhosis all contribute to accelerated muscle loss.2 A review by Dasarathy et al2 notes that many studies aimed at increasing protein, calories, and activity in cirrhotic patients do not prevent sarcopenia and malnutrition, in part, because they do not address their underlying abnormalities in metabolism. Our ability to preserve FFM in cirrhotic patients in the setting of a very low-calorie diet (VLCD) is even less clear.
The small case series cited in the letter to the editor describes successful weight loss in 2 cirrhotic patients treated with a VLCD.3 This interesting proof of concept case series demonstrates that a VLCD may be feasible in very selected, closely monitored patients with compensated cirrhosis, but is too small and heterogeneous to draw any significant conclusions. Understanding the effects of VLCD on the metabolism and FFM of patients with cirrhosis is very important, particularly because it is a necessary component of bariatric surgery. At this time, however, we do not feel there is enough data to assess the safety of VLCD in cirrhotic patients and caution against using this approach outside of a closely monitored setting.
It should be noted that the studies cited by Ianelli and Schiavo share several other features that may have been key to their success. Most interventions used a multidisciplinary team approach that provided the patients with extensive education and close follow-up. In addition, the studies focused on FFM preservation, not only weight loss, when assessing the success of their intervention. Most importantly, all 3 studies used physical activity in conjunction with high protein intake to preserve FFM loss.3-5 Each of these factors should be considered when developing a weight loss program. Although these studies cannot be directly applied to our patients, they give us a foundation for future research to address the complex issues of obesity, malnutrition, and sarcopenia in cirrhosis.
1. Ianelli A, Schiavo L. Very low-calorie diet, the morbidly obese with liver cirrhosis and bariatric surgery. Transplantation
2. Dasarathy S, Merli M. Sarcopenia from mechanism to diagnosis and treatment in liver disease. J Hepatol
3. Temmerman JC, Friedman AN. Very low calorie ketogenic weight reduction diet in patients with cirrhosis: a case series. Nutr Diabetes
. 2013;3:e95. doi:10.1038/nutd.2013.36.
4. Weinheimer EM, Sands LP, Campbell WW. A systematic review of the separate and combined effects of energy restriction and exercise on fat-free mass in middle-aged and older adults: implications for sarcopenic obesity. Nutr Rev
5. Mettler S, Mitchell N, Tipton KD. Increased protein intake reduces lean body mass loss during weight loss in athletes. Med Sci Sports Exerc