Malnutrition and Nutritional Support in Alcoholic Liver Disease: a Review


Malnutrition is associated with alcoholic liver disease (ALD) and related complications such as hepatic encephalopathy and increased rate of infections. Avoidance of prolonged fasting and overly restrictive diets is important to avoid poor nutrition. Adequate intake of calories, protein, and micronutrients via frequent small meals and evening supplements and/or enteral and parenteral nutrition when indicated has been associated with reduced mortality and morbidity in patients with ALD. Modification of protein/fat sources and composition in addition to probiotic supplementation are promising interventions for decreased progression of ALD and its complications.

This is a preview of subscription content, access via your institution.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Rossi RE, Conte D, Massironi S. Diagnosis and treatment of nutritional deficiencies in alcoholic liver disease: overview of available evidence and open issues. Dig Liver Dis. 2015;47(10):819–25.

    Article  PubMed  Google Scholar 

  2. 2.

    Patek AJ. Alcohol, malnutrition, and alcoholic cirrhosis. Am J Clin Nutr. 1979;32:1304–12.

    CAS  PubMed  Google Scholar 

  3. 3.

    Iwasa M, Iwata K, Hara N, Hattori A, Ishidome M, Sekoguchi-Fujikawa N, et al. Nutrition therapy using a multidisciplinary team improves survival rates in patients with liver cirrhosis. Nutrition. 2013;29(11–12):1418–21.

    Article  PubMed  Google Scholar 

  4. 4.

    O’Shea RS, Srinivasan D, McCullough AJ. Alcoholic liver disease. Hepatology. 2010;51:307–28.

    Article  PubMed  Google Scholar 

  5. 5.

    Plauth M, Cabré E, Riggio O, Assis-Camilo M, Pirlich M, Kondrup J, et al. ESPEN guidelines on enteral nutrition: liver disease. Clin Nutr. 2006;25:285–94.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    ••Fialla AD, Israelsen M, Hamberg O, Krag A, Gluud LL. Nutritional therapy in cirrhosis or alcoholic hepatitis: a systematic review and meta-analysis. Liver Int. 2015;35(9):2072–8. This systematic review and meta-analysis included 13 randomized controlled trials evaluating the effects of enteral and intravenous nutrition therapy vs. no intervention in patients with cirrhosis or alcoholic hepatitis and suggests that nutrition therapy can lead to reduced mortality, overt encephalopathy and infection.

    Article  PubMed  Google Scholar 

  7. 7.

    Koretz RL, Avenell A, Lipman TO. Nutritional support for liver disease. Cochrane Database Syst Rev. 2012;5:CD008344.

    Google Scholar 

  8. 8.

    Ney M, Vandermeer B, van Zanten SJ, Ma MM, Gramlich L, Tandon P. Meta-analysis: oral or enteral nutritional supplementation in cirrhosis. Aliment Pharmacol Ther. 2013;37(7):672–9.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Krenitsky J. Nutrition update in hepatic failure. Nutrition issues in gastroenterology, series #128. Practical Gastroenterology [Internet]. 2014 apr [47–55]. Available from: http://www.medicine.virginia.

  10. 10.

    Roe DA. Nutritional concerns in the alcoholic. J Am Diet Assoc. 1981;78(1):17–21.

    CAS  PubMed  Google Scholar 

  11. 11.

    Mendenhall CL, Roselle GA, Gartside P, Moritz T. Relationship of protein calorie malnutrition to alcoholic liver disease: a reexamination of data from two Veterans Administration Cooperative Studies. Alcohol Clin Exp Res. 1995;19(3):635–41.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    Marsano L, McClain CJ. Nutrition and alcoholic liver disease. JPEN J Parenter Enteral Nutr. 1991;15(3):337–44.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Mendenhall CL, Anderson S, Weesner RE, Goldberg SJ, Crolic KA. Protein-calorie malnutrition associated with alcoholic hepatitis. Veterans Administration Cooperative Study Group on Alcoholic Hepatitis. Am J Med. 1984;76:211–22.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Singal AK, Kamath PS, Francisco Ziller N, DiCecco S, Shoreibah M, Kremers W, et al. Nutritional status of patients with alcoholic cirrhosis undergoing liver transplantation: time trends and impact on survival. Transpl Int. 2013;26(8):788–94.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Hade AM, Shine AM, Kennedy NP, McCormick PA. Both under-nutrition and obesity increase morbidity following liver transplantation. Ir Med J. 2003;96:140.

    CAS  PubMed  Google Scholar 

  16. 16.

    Figueiredo F, Dickson ER, Pasha T, et al. Impact of nutritional status on outcomes after liver transplantation. Transplantation. 2000;70:1347.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Shahid M, Johnson J, Nightingale P, Neuberger J. Nutritional markers in liver allograft recipients. Transplantation. 2005;79:359.

    Article  PubMed  Google Scholar 

  18. 18.

    Spengler EK, Dunkelberg J, Schey R. Alcoholic hepatitis: current management. Dig Dis Sci. 2014;59:2357–66.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Liu Y, Xue X. Systematic review of peri-operative nutritional support for patients undergoing hepatobiliary surgery. Hepatobiliary Surg Nutr. 2015;4(5):304–12.

    PubMed  PubMed Central  Google Scholar 

  20. 20.

    DiCecco SR, Francisco-Ziller N. Nutrition in alcoholic liver disease. Nutr Clin Pract. 2006;21(3):245–54.

    Article  PubMed  Google Scholar 

  21. 21.

    Halsted CH. Nutrition and alcoholic liver disease. Semin Liver Dis. 2004;24:289–304.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Losowsky MS, Walker BE. Liver disease and malabsorption. Gastroenterology. 1969;56:589–600.

    CAS  PubMed  Google Scholar 

  23. 23.

    Halsted CH, Robles EA, Mezey E. Intestinal malabsorption in folate deficient alcoholics. Gastroenterology. 1973;64:526–32.

    CAS  PubMed  Google Scholar 

  24. 24.

    Mezey E, Jow E, Slavin RE, et al. Pancreatic function and intestinal absorption in chronic alcoholism. Gastroenterology. 1970;59:657.

    CAS  PubMed  Google Scholar 

  25. 25.

    Arky RA. The effect of alcohol on carbohydrate metabolism: carbohydrate metabolism in alcoholics. In: Kissin B, Begleiter H, editors. The biology of alcoholism, vol. 1. New York: Plenum Press; 1977. p. 197.

    Google Scholar 

  26. 26.

    Israel Y, Salazar I, Rosenmann E, et al. Inhibitory effects of alcohol on intestinal acid transport in vivo and in vitro. J Nutr. 1968;96:499.

    CAS  PubMed  Google Scholar 

  27. 27.

    Muller MJ, Lautz HU, Plogmann B, Burger M, Korber J, Schmidt FW. Energy expenditure and substrate oxidation in patients with cirrhosis: the impact of cause, clinical staging and nutritional state. Hepatology. 1992;15:782–94.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Israel Y, Videla L, Bernstein J. Liver hypermetabolic state after chronic ethanol consumption: hormonal interrelations and pathogenic implications. Fed Proc. 1975;34:2052–9.

    CAS  PubMed  Google Scholar 

  29. 29.

    Jhangiani SS, Agarwal N, Holmes R, et al. Energy expenditure in chronic alcoholics with and without liver disease. Am J Clin Nutr. 1986;44:323–9.

    CAS  PubMed  Google Scholar 

  30. 30.

    Pirola RC, Lieber CS. Hypothesis: energy wasting in alcoholism and drug abuse: possible role of hepatic microsomal enzymes. Am J Clin Nutr. 1976;29:90.

    CAS  PubMed  Google Scholar 

  31. 31.

    Amodio P et al. The nutritional management of hepatic encephalopathy in patients with cirrhosis: International Society for Hepatic Encephalopathy and Nitrogen Metabolism Consensus. Hepatology. 2013;58(1):325–36.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Singal AK, Charlton MR. Nutrition in alcoholic liver disease. Clin Liver Dis. 2012;16(4):805–26.

    Article  PubMed  Google Scholar 

  33. 33.

    Purnak T, Yilmaz Y. Liver disease and malnutrition. Best Pract Res Clin Gastroenterol. 2013;27(4):619–29.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Rothschild MA, Oratz M, Schreiber SS. Serum albumin. Hepatology. 1988;8(2):385–401.

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Matos C et al. Nutrition and chronic liver disease. J Clin Gastroenterol. 2002;35(5):391–7.

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Moctezuma-Velazquez C et al. Nutritional assessment and treatment of patients with liver cirrhosis. Nutrition. 2013;29(11–12):1279–85.

    Article  PubMed  Google Scholar 

  37. 37.

    Frisancho AR. New norms of upper limb fat and muscle areas for assessment of nutritional status. Am J Clin Nutr. 1981;34(11):2540–5.

    CAS  PubMed  Google Scholar 

  38. 38.

    Romeiro FG, Augusti L. Nutritional assessment in cirrhotic patients with hepatic encephalopathy. World J Hepatol. 2015;7(30):2940–54.

    Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Selberg O, Selberg D. Norms and correlates of bioimpedance phase angle in healthy human subjects, hospitalized patients, and patients with liver cirrhosis. Eur J Appl Physiol. 2002;86(6):509–16.

    CAS  Article  PubMed  Google Scholar 

  40. 40.

    Kohrt WM. Body composition by DXA: tried and true? Med Sci Sports Exerc. 1995;27(10):1349–53.

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Madden AM, Morgan MY. The potential role of dual-energy X-ray absorptiometry in the assessment of body composition in cirrhotic patients. Nutrition. 1997;13(1):40–5.

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Alvares-da-Silva MR, Reverbel da Silveira T. Comparison between handgrip strength, subjective global assessment, and prognostic nutritional index in assessing malnutrition and predicting clinical outcome in cirrhotic outpatients. Nutrition. 2005;21(2):113–7.

    Article  PubMed  Google Scholar 

  43. 43.

    John WJ, Phillips R, Ott L, Adams LJ, McClain CJ. Resting energy expenditure in patients with alcoholic hepatitis. JPEN J Parenter Enteral Nutr. 1989;13(2):124–7.

    CAS  Article  PubMed  Google Scholar 

  44. 44.

    Dugum M, McCullough A. Diagnosis and management of alcoholic liver disease. J Clin Transl Hepatol. 2015;3(2):109–16.

    Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Mouzaki M, Ng V, Kamath BM, Selzner N, Pencharz P, Ling SC. Enteral energy and macronutrients in end-stage liver disease. JPEN J Parenter Enteral Nutr. 2014;38(6):673–81.

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    McClain CJ et al. Alcoholic liver disease and malnutrition. Alcohol Clin Exp Res. 2011;35(5):815–20.

    Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Manne V, Saab S. Impact of nutrition and obesity on chronic liver disease. Clin Liver Dis. 2014;18(1):205–18.

    Article  PubMed  Google Scholar 

  48. 48.

    Leevy CM, Moroianu SA. Nutritional aspects of alcoholic liver disease. Clin Liver Dis. 2005;9:67–81.

    Article  PubMed  Google Scholar 

  49. 49.

    Roongpisuthipong C, Sobhonslidsuk A, Nantiruj K, Songchitsomboon S. Nutritional assessment in various stages of liver cirrhosis. Nutrition. 2001;17:761–5.

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    Medici V, Peerson JM, Stabler SP. Impaired homocysteine transsulfuration is an indicator of alcoholic liver disease. J Hepatol. 2010;53:551–7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Fragasso A et al. Holotranscobalamin is a useful marker of vitamin B12 deficiency in alcoholics. Sci World J. 2012;2012:128182.

    Article  Google Scholar 

  52. 52.

    de Carvalho SC et al. Plasmatic higher levels of homocysteine in non-alcoholic fatty liver disease (NAFLD). Nutr J. 2013;12:37.

    Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Medici V, Halsted CH. Folate, alcohol, and liver disease. Mol Nutr Food Res. 2013;57(4):596–606.

    CAS  Article  PubMed  Google Scholar 

  54. 54.

    Herbert V, Zalusky R, Davidson CS. Correlation of folate deficiency with alcoholism and associated macrocytosis, anemia, and liver disease. Ann Intern Med. 1963;58:977–88.

    CAS  Article  PubMed  Google Scholar 

  55. 55.

    Fernando OV, Grimsley EW. Prevalence of folate deficiency and macrocytosis in patients with and without alcohol-related illness. South Med J. 1998;91(8):721–5.

    CAS  Article  PubMed  Google Scholar 

  56. 56.

    Halsted CH et al. Folate deficiency disturbs hepatic methionine metabolism and promotes liver injury in the ethanol-fed micropig. Proc Natl Acad Sci U S A. 2002;99(15):10072–7.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    Halsted CH et al. Ethanol feeding of micropigs alters methionine metabolism and increases hepatocellular apoptosis and proliferation. Hepatology. 1996;23(3):497–505.

    CAS  Article  PubMed  Google Scholar 

  58. 58.

    Wani NA, Kaur J. Reduced levels of folate transporters (PCFT and RFC) in membrane lipid rafts result in colonic folate malabsorption in chronic alcoholism. J Cell Physiol. 2011;226(3):579–87.

    CAS  Article  PubMed  Google Scholar 

  59. 59.

    Eichner ER, Hillman RS. The evolution of anemia in alcoholic patients. Am J Med. 1971;50(2):218–32.

    CAS  Article  PubMed  Google Scholar 

  60. 60.

    Williams JA, Manley S, Ding WX. New advances in molecular mechanisms and emerging therapeutic targets in alcoholic liver diseases. World J Gastroenterol. 2014;20(36):12908–33.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  61. 61.

    Friedrich K, Baumann C, Brune M, Wannhoff A, Rupp C, Scholl SG, et al. Association of serum zinc levels with liver function and survival in patients awaiting liver transplantation. Langenbeck’s Arch Surg. 2015;400(7):805–11.

    Article  Google Scholar 

  62. 62.

    ••Mohammad MK, Falkner KC, Song M, Craig J, McClain CJ, Cave MC. Low dose zinc sulfate (220mg) supplementation for three months normalizes zinc levels, endotoxeima, pro-inflammatory/fibrotic biomarkers & improves clinical parameters in alcoholic cirrhosis- a double-blind placebo controlled - (ZAC) clinical trial. Hepatology. 2015;62:851A. This single center double blind placebo controlled trial is the first to provide evidence for the safety and efficacy of zinc supplementation for improvement of endotoxemia, inflammatory biomarkers and clinical status in patients with alcoholic cirrhosis.

    Google Scholar 

  63. 63.

    Wiegand J, van Bömmel F, Duarte-Rojo A, Altamirano J, Abraldes JG, Villanueva A, et al. Clinical trial watch: reports from the liver meeting®, AASLD, San Francisco, November 2015. J Hepatol. 2016;64(6):1428–45.

    Article  PubMed  Google Scholar 

  64. 64.

    •Bémeur C, Butterworth RF. Nutrition in the management of cirrhosis and its neurological complications. J Clin Exp Hepatol. 2014;4(2):141–50. This review summarizes the nutritional deficiencies commonly encountered in chronic liver disease and the impact that malnutrition can have on disease outcome, incidence and severity of complications such as hepatic and Wernicke’s encephalopathy and post-transplant mortality and morbidity.

    Article  PubMed  Google Scholar 

  65. 65.

    Anastácio LR, Correia MITD. Nutrition therapy: integral part of liver transplant care. World J Gastroenterol. 2016;22(4):1513.

    Article  PubMed  PubMed Central  Google Scholar 

  66. 66.

    Kim MS, Ong M, Qu X. Optimal management for alcoholic liver disease: conventional medications, natural therapy or combination? World J Gastroenterol. 2016;22(1):8–23.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  67. 67.

    Bruha R, Dvorak K, Petrtyl J. Alcoholic liver disease. World J Hepatol. 2012;4(3):81–90.

    Article  PubMed  PubMed Central  Google Scholar 

  68. 68.

    Chayanupatkul M, Liangpunsakul S. Alcoholic hepatitis: a comprehensive review of pathogenesis and treatment. World J Gastroenterol. 2014;20(20):6279–86.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  69. 69.

    Tsien CD, McCullough AJ, Dasarathy S. Late evening snack: exploiting a period of anabolic opportunity in cirrhosis. J Gastroenterol Hepatol. 2012;27(3):430–41.

    CAS  Article  PubMed  Google Scholar 

  70. 70.

    Kirpich IA, Miller ME, Cave MC, Joshi-Barve S, McClain CJ. Alcoholic liver disease: update on the role of dietary fat. Biomolecules. 2016;6(1):1.

    Article  PubMed  PubMed Central  Google Scholar 

  71. 71.

    •Wang Y, Liu Y, Kirpich I, Ma Z, Wang C, Zhang M, et al. Lactobacillus rhamnosus GG reduces hepatic TNFα production and inflammation in chronic alcohol-induced liver injury. J Nutr Biochem. 2013;24(9):1609–15. This animal study evaluated the effects of probiotic administration on hepatic epatic tumor necrosis factor-α (TNFα) production and inflammation in response to chronic alcohol ingestion in mice. The results demonstrated that probiotic Lactobacillus rhamnosus GG treatment reduced alcohol-induced hepatic inflammation by attenuating TNFα production by inhibiting TLR4 and TLR5-mediated intestinal gram-negative bacterial endotoxin activation.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  72. 72.

    Huynh DK, Selvanderan SP, Harley HA, Holloway RH, Nguyen NQ. Nutritional care in hospitalized patients with chronic liver disease. World J Gastroenterol. 2015;21(45):12835–42.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  73. 73.

    Thursz MR, Richardson P, Allison M, Austin A, Bowers M, Day CP, et al. Prednisolone or pentoxifylline for aloholic hepatitis. N Engl J Med. 2015;372(17):1619–28.

    CAS  Article  PubMed  Google Scholar 

  74. 74.

    Hébuterne X, Vanbiervliet G. Feeding the patients with upper gastrointestinal bleeding. Curr Opin Clin Nutr Metab Care. 2011;14(2):197–201.

    Article  PubMed  Google Scholar 

  75. 75.

    •Cabré E, Rodríguez-Iglesias P, Caballería J, Quer JC, Sán-chez-Lombraña JL, Parés A, et al. Short- and long-term outcome of severe alcohol-induced hepatitis treated with steroids or enteral nutrition: a multi-center randomized trial. Hepatology. 2000;32:3–42. This multicenter randomized compared the short and long term effects of total enteral nutrition vs. steroid therapy for 28 days in severe alcoholic hepatitis. Mortality was similar for both those treated with nutritional therapy and those treated with steroids during therapy, but occurred earlier in those treated with nutritional therapy. However, overall mortality at 1 year was higher in the group treated with steroids largely due to infection.

    Article  Google Scholar 

  76. 76.

    Papastergiou V, Burroughs AK, Tsochatzis EA. Prognosis and treatment of patients with acute alcoholic hepatitis. Expert Rev Gastroenterol Hepatol. 2014;8:471–86.

    CAS  Article  PubMed  Google Scholar 

  77. 77.

    Moreno C, Deltenre P, Senterre C, Louvet A, Gustot T, Bastens B, et al. Intensive enteral nutrition is ineffective for patients with severe alcoholic hepatitis treated with corticosteroids. Gastroenterology. 2016;150(4):903–910.e8.

    CAS  Article  PubMed  Google Scholar 

  78. 78.

    Figueira ERR, Rocha Filho JA, Nacif LS, D’Albuquerque LC, Waitzberg DL. Nutritional support for fulminant hepatitis. Nutr Hosp. 2015;32(n06):2427–32.

    Google Scholar 

  79. 79.

    Metcalfe EL, Avenell A, Fraser A. Branched-chain amino acid supplementation in adults with cirrhosis and porto-systemic encephalopathy: systematic review. Clin Nutr. 2014;33:958–65.

    CAS  Article  PubMed  Google Scholar 

  80. 80.

    Gluud LL, Dam G, Les I, Córdoba J, Marchesini G, Borre M, et al. Branched-chain amino acids for people with hepatic encephalopathy. Cochrane Database Syst Rev. 2015;9:CD001939.

    Google Scholar 

  81. 81.

    Irimia R, Stanciu C, Cojocariu C, Sfarti C, Trifan A. Oral glutamine challenge improves the performance of psychometric tests for the diagnosis of minimal hepatic encephalopathy in patients with liver cirrhosis. J Gastrointestin Liver Dis. 2013;22(3):277–81.

    PubMed  Google Scholar 

  82. 82.

    Hammad A, Kaido T, Uemoto S. Perioperative nutritional therapy in liver transplantation. Surg Today. 2015;45:271–83.

    CAS  Article  PubMed  Google Scholar 

  83. 83.

    Zhu X, Wu Y, Qiu Y, Jiang C, Ding Y. Effects of ω-3 fish oil lipid emulsion combined with parenteral nutrition on patients undergoing liver transplantation. JPEN J Parenter Enteral Nutr. 2013;37:68–74.

    Article  PubMed  Google Scholar 

  84. 84.

    Puri P, Thursz M. Intensive enteral nutrition in alcoholic hepatitis: more food for thought. Gastroenterology. 2016;150(4):803–5.

    Article  PubMed  PubMed Central  Google Scholar 

  85. 85.

    Kumar M, Panda D. Role of supportive care for terminal stage hepatocellular carcinoma. J Clin Exp Hepatol. 2014;4 Suppl 3:S130–9.

    Article  PubMed  PubMed Central  Google Scholar 

  86. 86.

    Mifflin MD et al. A new predictive equation for resting energy expenditure in healthy individuals. Am J Clin Nutr. 1990;51(2):241–7.

    CAS  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Valentina Medici.

Ethics declarations

Conflict of Interest

Drs. Chao, Waitzberg, Passos de Jesus, Bueno, Kha, Allen, Kappus, and Medici declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the author.

Additional information

This article is part of the Topical Collection on Nutrition and Obesity

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Chao, A., Waitzberg, D., de Jesus, R.P. et al. Malnutrition and Nutritional Support in Alcoholic Liver Disease: a Review. Curr Gastroenterol Rep 18, 65 (2016).

Download citation


  • Alcoholic liver disease
  • Diet
  • Nutrition
  • Enteral nutrition
  • Parenteral nutrition