Nutrition and Hepatitis C

Nutrition and Hepatitis C

 Diet and Exercise

Nutrition and Hepatitis C

By Darlene Morrow, BSc

www.hepcsg.org

You might ask how I come to write a nutrition article?  I have my bachelor's degree from Simon Fraser University in biological sciences. I studied nutrition there and went on to study at St. John’s College of Naturopathic Medicine for one year.  During that year I took courses on nutrition, herbal medicine, homeopathy, and Chinese medicine. 

Throughout this article I will mention that there are things that you should watch.  By that I mean that these items can cause an elevation in liver enzymes in sensitive individuals.  The best thing for you to do is to consult your physician, tell him/her that you are interested in adding a particular item or product, and that you would like to monitor your liver enzymes before and after to make sure that everything is all right.   

Don't add more than a one new thing at a time.  You won’t know what worked or caused a problem.  If something happens, it is usually in the initial phase or after prolonged use.   

Rules of thumb:

1.         You need to take something for 3 months before you know if it works.

2.         Take a week off every 3 months.   

How long I stay on something depends on the product but it is usually never longer than 3 months and can be as little as a month.  In the case of Echinacea I never take it for more than 2 weeks.  

You need to remember that you are an expert on your own body.  You just have to learn to listen to the signs.  That means that anytime you feel nauseated or uncomfortable or pain when you have added something new to your regime, you should stop.   

If you're doctor prescribes a new medication for you, and you feel sick because of it, contact your doctor immediately and stop taking the medication until you see him. But never abruptly stop taking a medication that you have been on for a period of time. If you think the medication is a problem, go see your doctor immediately. 

What Might Hurt You and What You Should Watch 

• No Alcohol
• No Vitamin A
• No Beta Carotene
• No Iron
• No Niacin
• No raw or undercooked shellfish due to the high risk contamination from Vibrio vulnificus which is deadly for people with HepC.
• Sodium Restriction
• Protein Observation

Alcohol 

Alcohol should be avoided.  Studies have shown that alcohol can accelerate the damage caused by the hepatitis c virus. The studies have been inconclusive as to the amount of the alcohol that causes this to happen.  However all studies agree that regular alcohol consumption is a large problem. Personally I would avoid all alcohol. 

Alcohol also reduces the rate of metabolism and the secretion of fat.  This can contribute to fatty liver and cirrhosis. 

You might also want to watch the alcohol in cough syrup, in herbal tinctures like Echinacea and in chocolates that contain liquor like cherries. Most of these products are now available without alcohol but you might have to ask that the pharmacy counter to get them.   

Alcohol is often used in cooking in restaurants.  This is fine it if it's cooked because the alcohol boils off but if it's not been heated, the alcohol is still there. 

Vitamin A, Precursor Beta Carotene and Vitamin D

Fat soluble vitamins (vitamins A, D and E) are stored in the liver.  Vitamin A, one of the fat soluble vitamins should not be taken by people with hepatitis c.  That includes its precursor beta carotene.  Studies have shown that there is an increase in the damage of the liver particularly when these compounds are taken with alcohol. 

Vitamin D is necessary for bone metabolism however there have been some reports of caution with higher doses in people with hepc.  This would include the dosage of 1,000 IU that is recommended for people that suffer from osteopenia (pre osteoporosis). As women enter into menopause the complications due to hepatitis c compound treatment.

Iron 

People with hepatitis c often have a complication called hematochrosis.  This is iron deposits in the liver tissue itself.  This is a very dangerous condition and patients are often treated with phlebotomies (the removal of a portion of blood).  Furthermore there is speculation that the virus uses iron in its life cycle.  For these reasons iron should be avoided.  If you suffer from this condition, I would also avoid cooking in iron pots as the iron is leached out into the food.

 Also watch for iron enriched cereals and other bread products. 

Fats 

Reduction of saturated fats in the diet is a good recommendation regardless of disease state.  Because of the alteration in bile production and its necessity for the metabolization of fats many people find they feel better when they monitor their fat intake.  

Steatosis (fatty deposits in the liver) is seen in hepatitis c and although the relationship between dietary fat and fatty liver has not been conclusively proven the average Canadian diet could safely be reduced in fat (particularly saturated fat). In addition high cholesterol values are sometimes seen as a result of interferon therapy. 

It should be noted here that there are concerns about high cholesterol associated with other diseases seen with hepatitis c.  Problems with low thyroid, diabetes and a decrease in estrogen (also compounded by aging) can all contribute to high cholesterol.   

Hypoglycemia? The liver breaks down hormones.  If insulin is not broken down quickly enough hypoglycemia can occur.   

A little nasty?  Failure of the liver to break down adrenaline can lead to chronic irritability and temper explosions. 

Protein metabolism- Brain Fog?

Physicians believe that cognitive difficulties, poor short-term memory, and confusion only occur in patients with cirrhosis.  I think that this information is incorrect.  I believe that these problems (which are commonly referred to as brain fog by hepc’ers) can occur at much earlier stages. I know too many people that have a lesser stage of disease and a big problem with this.  It seems to be transient in nature.

If you notice this problem, you might consider restricting the amount of protein that you eat.  Protein contains an ammonia molecule.  In cirrhosis protein metabolism is affected and the body is not able to clear this molecule.  It is usually removed by conversion to urea which is synthesized in the liver.  If it is not taken out of the blood it can accumulate and lead to hepatic coma.  As it builds it causes many cognitive problems and it is common for people with cirrhosis to be restricted in their protein intake in addition to being prescribed lactulose, which reduces the circulating ammonia. 

It is important to note that you must have a minimum of 20-30 grams of protein in your diet to prevent protein loss from muscle tissue.  And in a newly released study this week it was noted that between 45-55% of Canadian women do not meet the daily minimum requirements for protein.

Another thing to keep in mind is that we want the liver tissue to regenerate. To make new tissue you must have protein. So too much or too little protein is a problem. 

If you become aware of an increase in cognitive difficulties, try reducing your protein.  Many people feel better when they do not eat red meat. Chicken and fish does not seem to be as big a problem.

 Special note: A lack of insulin production (diabetes) also leads to a reduction in protein synthesis. 

Sodium Restriction 

The usual salt restriction is 2 grams per day. People with hepatitis c often have a problem with fluid balance.  This is especially true in the case of cirrhosis but is also seen in earlier stages.  Watch for sodium added to canned goods and prepackaged foods.  One ounce of corn flakes contains 350 mg of sodium; one ounce of grated parmesan cheese - 528mg of sodium; one cup of chicken noodle soup - 1108 mg of sodium; and one teaspoon of table salt - 2,325 mg of sodium! Also watch your salt intake when you are eating out in restaurants.

Niacin

Niacin can be really hard on the liver.  It should be avoided by people with chronic liver disease.  This is Vitamin B3.  It is also available in a form that you can take and that is called niacinamide.

A Word About Multivitamins 

You will need to check your multivitamin for the inclusion of iron because it is commonly added. It is possible to get a multivitamin without iron however I have not been able to find a multivitamin without vitamin A, beta carotene and iron. Keep an eye out for niacin but it is not usually in the multivitamin because it causes flushing and itching. 

Warnings 

The liver cleanses the blood by metabolizing chemicals, and by neutralizing and destroying poisonous substances. This means that you have to be very careful about anything then goes into your mouth. This includes herbal medicines and prescriptions. 

People often make the mistake in believing that natural is good when in fact there are many natural products that are harmful to the liver. A basic rule of thumb should be to consult your physician or practitioner when ever you add something new to your regime. I'll do a separate paper based on herbs because the topic is very big.  The list of herbs that have caused liver problems or death include valerian root, germander, asafetida, hops, skullcap, gentian, senna fruit extracts, chaparral, mistletoe, Jin Bu Huan and Ho-shou-wu.  This list is far from conclusive.   

Prescription medications that have cause problems for people with liver disease include the diabetes drug Rezulin, Tylenol, Methotrexate, Paxil, Ibuprofen, Diclofenac and many others.  If you see a drug that you're taking on this list, please do not panic.  Problems usually developed with the initial doses. Never stop taking a prescription that youhave been on for awhile without seeing your doctor first. 

Poor nutrition and its effect on hepatitis C 

The Canadian Journal of Gastroenterology, W Siriboonkoom, L Gramlich. Nutrition and chronic liver disease. Can J Gastroenterol 1998;12(3):201-207.  

Malnutrition frequently occurs in patients with chronic liver disease, and may influence both short and long term clinical outcome in these patients. Therefore, nutritional intervention may play an important role in the management of chronic liver disease patients.

What Might Help- The Antioxidant Cocktail 

Antioxidants protect cells from damage by free radicals.  They work against the process of oxidation which is the robbing of electrons from substances.  The following antioxidants are either decreased in hepatitis c or offer protection to the liver.  Alpha lipoic acid, selenium (zinc), folic acid, Vitamin C, Vitamin E, milk thistle, N-Acetyl Cysteine (NAC), Coenzyme Q and (B₁₂).

I would consider choosing from this group if you’re strapped for cash.  These antioxidants work synergically ie  together they have more power than individually. 

Selenium

This antioxidant is lowered in liver disease and is dependent on zinc.

NAC (N-acetyl cysteine)

N-acetyl cysteine is a powerful antioxidant and a stable form of glutathione.  Glutathione is very active in liver detoxification. It is an important free radical deactivator offering protection against cataract formation, as well as immune enhancement, liver protection, cancer protection and heavy metal detoxification.

NAC is given intravenously in hospitals to patients with Tylenol overdoses.  Tylenol destroys the liver in overdoses and immediate administration of NAC may help.

Immune responses are mediated by small chemicals like cytokines and lymphokines. One of the best researched is the amino acid cysteine. The activation and proliferation of T cells normally requires oxidizing substances such as superoxide and hydrogen peroxide, and  lymphocytes contain a limited amount of reducing substances such as cysteine. Lymphocytes can utilize cysteine for NAC for glutathione production.

For a maximal absorption  NAC is taken on an empty stomach.  Do not take with garlic. 

Please see the article by A.S. Gissen on NAC for more info.  

A word of caution:  Some people have experienced nausea with this product.

Alpha Lipoic Acid

Alpha lipoic acid is found in potatoes, carrots, beets, yams, kohlrabi and others. It is typically reduced in liver disease. It is a potent supplier of glutathione and has been shown to increase immune function.

It facilitates the metabolism of glucose to energy.  It has been very successful in the treatment of diabetes and diabetic neuropathies.  It is helpful in neurogenetive disorders.

It has also been found to be protective in the case of cataracts.

Neuropathy from the Combo? Try alpha lipoic acid to reduce symptoms of tingling and numbness in the hands and feet. 

Lipoic acid also helps with bruising along with vitamin c. 

For more info please see the article Alpha Lipoic Acid by Beth M. Ley.

Zinc

Zinc is necessary for the metabolism of selenium.  Both selenium and zinc found to be reduced in patients with hepatitis c.

Coenzyme Q

Coenzyme Q is an integral part of the mitochondria which is the energy producing unit in your cells.  Many hepc’ers find an increase in energy when they take this supplement.  A common dosage would be 60 mg per day.

Folic Acid

Folic acid is typically reduced in people with hepatitis c. A decrease in folate has been linked to mental confusion, depression and fatigue. 

Special caution:  High doses of folate can cause a decrease in zinc absorption.

Too much methionine can cause a decrease in folate. 

Vitamin C

J. Clin. Invest. Volume 102, Number 1, July 1998, 67-71, Dietary Supplement with Vitamin C Prevents Nitrate Tolerance, Eberhard Bassenge, Nelli Fink, Mikhail Skatchkov, and Bruno Fink, Institute of Applied Physiology, University of Freiburg, Hermann-Herder-Str 7, D-79104 Freiburg, Germany 

In this study they concluded that it is possible to increase platelets and decrease platelet breakdown by supplementation with vitamin C. Vitamin C also helps with bruising. 

A decrease in vitamin c has been seen in Porphyria Cutanea Tarda (PCT),  a skin conditions seen in people with hepatitis c and associated with access iron. 

Special caution: people that have a tendency to kidney stones should not take high doses of vitamin c.

Superdioxide Mutase

Superoxide dismutase in patients with chronic hepatitis C virus infection was found to be decreased in the liver.  A study suggested that it could be this oxidative stress that is initiating a fibrogenesis cascade in the liver of patients with chronic hepatitis C.

A pilot study of the effects of d-alpha-tocopherol on hepatic stellate cell

Milk Thistle

Milk thistle is a powerful antioxidant.  In addition to this it has antifibrotic effects ie it can slow the scarring within the liver. There are many scientific papers that support this finding. 

A word of caution: some people find that milk thistle causes nausea and discomfort and cannot take it for this reason.

B₁₂

Problems with malabsorption for possible. B₁₂ is stored in the liver and problems with this can lead to fatigue. B₁₂ is necessary for some energy metabolism and some patients with hepatitis c have noted an increase in energy when they take this. It is possible to get B₁₂shots from your doctor however recent studies have shown that sublingual B₁₂ has about the same absorption as the injection. You can get sublingual B₁₂ from the health food store 100 for $10.00.  These lozenges should be placed under the tongue and allowed to slowly dissolve.  The B₁₂ is absorbed through the sublingual vein under your tongue directly into your blood.

B₁₂ has been linked to immune response, mild dementia, and peripheral neuropathy. 

Sleep

As simple as it sounds, your best medication as sleep.  It is critical for people with hepatitis c to get enough rest.  That means rest  whenever you feel tired or try scheduling an afternoon nap.  It doesn't have to be a long time.  20 minutes often is enough but take more if you feel you need it.

We live in a society where we have learned to push past fatigue and to ignore how we feel.  You have to train yourself to learn to listen.  You can get much more done this way even if it takes a little bit longer.  And at the end of the day you might not feel so bad.

I have seen a surprising number of people that suffer from sleep disorders.  Many of them suffer from restless leg syndrome or periodically movement disorder.  While there has been no association with these 2 conditions to hepatitis c, I can't help but wonder if there's isn't a relationship. If your sleep patterns are severely disrupted, consider asking your family doctor for a referral to the UBC Sleep Disorders Clinic.  A good part of your fatigue could stem from lack of restful sleep.

Essential Fatty Acids 

The primary omega-3 oil is called alpha-linolenic acid (ALA) and is found in flaxseed (58%) and canola oils, pumpkin, walnuts, and soybeans. Fish oils, such as salmon, cod, and mackerel, contain the other important omega-3 oils, DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid). Omega-3 oils help reduce the risk of heart disease and impact the brain and immune system.

In addition, the study in Scand J Gastroenterol 1997 Apr;32(4):350-356  called "Steatosis and collagen content in experimental liver cirrhosis are affected by dietary monounsaturated and polyunsaturated fatty acids" by Fernandez MI, Torres MI, Gil A, Rios A  found that fibrosis and steatosis may be influenced by dietary fat, and monounsaturated fat appears to influence favorably the histologic recovery of the damaged liver.

 SAMe  

SAMe provides both glutathione. It has been advocated for use in depression and in liver disease.  It works in many ways and is too extensive to cover here. Please see the accompanying article on SAMe by Life Extensions. It's packed with information. 

SAMe has been shown to reduce ALT and cholesterol. 

The reason that people want to add methionine to their diets is because it increases glutathione, a powerful antioxidant and liver detoxifier. Methionine gets turned into SAMe by an enzyme called SAMe synthetase.  People with cirrhosis and liver disease often have an impaired synthestase so adding methionine won’t increase the SAMe and therefore no subsequent increase in glutathione.   Taking the supplement bypasses the problem.

 Some people have noticed nausea when they take SAMe.  It is possible to get an enteric coated form. This prevents the SAMe from dissolving in the stomach and the resulting nausea.  Nature Made makes this product.  You can call them to ask questions about SAMe at 1-888-898-1151 or visit their website at:  www.naturemade.com 

Special caution:  Too much methionine can cause a decrease in folate. 

Methionine and Liver Disease- A Word of Caution by Darlene Morrow, BSc

Methionine has been recommended to people with HCV as a liver protectant particularly in conjunction with tylenol (500mg twice a day). While it is generally accepted that methionine is a liver protectant, the evidence is not conclusive as to the recommended dosage and possible to side effects.  Extreme caution is necessary in individuals with severe liver disease because drugs/substances are processed in the liver.  The effects of Hepatitis C and liver disease vary from individual to individual.  The extent of damage and your particular condition (fibrosis, cirrhosis, etc.) will all have a bearing on your body's ability to deal with outside substances. The following excerpt demonstrates the possible dangers of self medicating. We strongly recommend that all supplements be approved for your use by your physician. 

Please keep in mind when reading this article that the suggested dosage of methionine was 2 x 500mg which is equal to 1g.

Should Methionine Be Added to Paracetamol (Tylenol) Formulations? - Caution in Patients with Liver Disease!

Reprinted with permission from [Drugs & Ther Perspect 10(11): 11-13, 1997. (c) 1997 Adis International Limited]

source: http://www.medscape.com/adis/DTP/1997/v10.n11/dtp1011.04/dtp1011.04.html

References:

3.Jones AL, Hayes PC, Proudfoot AT, et al. Should methionine be added to every paracetamol tablet? No: the risks are not well enough known. BMJ 1997 Aug 2; 315: 301-4

4.Krenzelok EP. Should methionine be added to every paracetamol tablet? Yes: but perhaps only in developing countries. BMJ 1997 Aug 2; 315: 303-4

8.Martindale. The Extra Pharmacopoeia, 31st ed. London: Pharmaceutical Press, 1996: 683-4

Vitamin E 

Studies have shown that people with hepatitis c have a decrease in this antioxidant. It is possible that vitamin E can be a useful adjunct to interferon therapy.  1 study found that the addition of vitamin E Some studies have confirmed a lowering in the liver enzymes in response to antioxidant supplementation.   Furthermore patients with rheumatoid arthritis were found to be deficient in Vitamin E and it may be possible that supplementation could help reduce the aches and pains that are common in hepatitis c.   

Vitamin E has been associated with a decrease in fibrogenesis (the scarring). It is also effective in reducing cholesterol and in increasing T-cell function. Fragility of  red blood cells (RBCs) has been associated with low vitamin E.  

Vitamin E is found in a couple of different forms and the effectiveness of the forms may differ.  The best thing to do is to buy the mixed vitamin E.   

Vitamin E absorption is influenced by low zinc.

Special note: Dosages of 800 IU coupled with 1,000 mg of vitamin C were found to relieve the hemolytic anemia associated with combination therapy. it may also help with the peripheral neuropathy.  

Caution:  Sudden supplementation in unaccustomed individuals may raise blood pressure.  Vitamin E also increases the effect of cyclosporine and dosage the need to be monitored. 

SKIN PROBLEMS

Topical vitamin e as been shown to help with some skin problems. I would also recommend that you try a product called Bag Balm.  You get it from Buckerfield's or a horse place. Try phoning the pharmacies too.  Sue was a real great detective and tracked down the product at Krupp’s Pharmacy on Granville Street and I have also ordered it from the London Drugs in West Van.  It is known as udder cream. 

Nausea 

Weight loss is common in hepatitis c and often stems from the constant nausea.  Something that I have found very helpful is ginger.  Now there are several ways of getting the ginger.  First of all you can buy the standardized organic ginger in 500 mg capsules at the health food store. Take 3 capsules at the first sign of nausea. The ginger has a wonderful effect and it is also an appetite stimulant and an anti-inflammatory.  Many people enjoy ginger tea. Grate a one inch piece of ginger and place it in a tea strainer. Add boiling water and cover for 5 minutes. You can sip this drink throughout the day. 

References and articles used in the writing of this paper:

Alpha Lipoic Acid by Beth M. Ley  

AKIRA NAGITA1 AND MITSUO ANDO2.Assessment of Hepatic Vitamin E Status in Adult Patients With Liver Disease,  The American Association for the Study of Liver Diseases. 

José García de la Asunción*, Maria L. del Olmo*, Juan Sastre*, Arantxa Millán*, Antonio Pellín, Federico V. Pallardó*, and José Viña*.  AZT Treatment Induces Molecular and Ultrastructural Oxidative Damage to Muscle Mitochondria- Prevention by Antioxidant Vitamins. Clin. Invest. Volume 102, Number 1, July 1998, 4-9

Sally P Stabler, John Lindenbaum, and Robert H Allen. Vitamin B-12 deficiency in the elderly: current dilemmas. The American Journal of CLINICAL NUTRITION. Volume 66 Number 4 October 1997 

Henry D. Janowitz, MD. Good Food for Bad Stomachs. Oxford University Press, 198 Madison Ave., New York, New York 10016 USA 1997 

NORIFUMI KAWADA,1 SHUICHI SEKI,1 MASAYASU INOUE,2 AND TETSUO KUROKI1.  Effect of Antioxidants, Resveratrol, Quercetin, and N Acetylcysteine, on the Functions of Cultured Rat Hepatic Stellate Cells and Kupffer Cells.  Hepatology, Vol. 27, No. 5 (May 1998).

IMMUNE SYSTEM DISORDER NUTRITIONAL THERAPY. A Five Point Empowerment Plan Based on the Clinical Research of Joan Priestley, M.D. Omni Medical Center 615 East 82nd Avenue, Ancorage, AK 99518; 907-344-7775. 

W Siriboonkoom, L Gramlich .  The Canadian Journal of Gastroenterology. Nutrition and chronic liver disease. Can J Gastroenterol 1998;12(3):201-207. 

Oleg G. Khatsenko, Ram K. Sindhu, Yutaka Kikkawa. Undernutrition during hyperoxic exposure induces CYP2E1 in rat liver. Abstract Volume 71 Issue 11 (1997) pp 684-689  

LEVANDER OA, ARS, NUTR REQUIREMENTS & FUNCT LAB, BELTSVILLE HUMAN NUTR RES  CTR, USDA, BELTSVILLE, MD. VIRAL EVOLUTION AS DRIVEN BY HOST NUTRITIONAL SELECTIVE FACTORS - and INFLUENCE OF DIETARY OXIDATIVE STRESS. FOOD CHEMISTRY   1996 SEP;57(1):47-49. 

Olivieri O, Girelli D, Stanzial AM, et al. Selenium, zinc, and thyroid hormones in healthy subjects: low T3/T4 ratio in the elderly is related to impaired selenium status. Biol Trace Elem Res 1996;51:31-41. 

A.S. Gissen . N-Acetyl Cysteine. VRP's Nutritional News: April, May, June 1994. 

Carole Lemens and Craig Sterrit.  Antioxidants, Oxidative Stress, and NAC.  http://www.projinf.org/hh/alternative.html# Evaluating_New_or_Alternative_Treatments

Zoltan P. Rona MD, MSc.  NATURAL INTERFERON BOOSTERS. http://www.naturallink.com/homepages/zoltan_rona/interferon/index.html

Natural, Alternative and Complementary Therapies. http://www.ozemail.com.au/~acocacms/Page2.html

Dr. David Bayley, BScK., N.D. 1997 September hepc.bull. NATUROPATHIC TREATMENT OF HEPATITIS C. PART ONE: Clinical Indications for the use of Lipotrophic Factors. PART TWO: Vitamins and minerals. PART THREE: Homeopathic preparations.

Carl Germano, M.A., R.D., CNS. Nutritional Considerations In The Treatment Of Hepatitis.  http://www.solgar.com/nutrition_library/articles/hepetitus.html

Fernandez MI, Torres MI, Gil A, Rios A.  "Steatosis and collagen content in experimental liver cirrhosis are affected by dietary monounsaturated and polyunsaturated fatty acids".  Scand J Gastroenterol 1997 Apr;32(4):350-356.  

Carol A Seymour, Kevin Whelan.  Dietary management of hepatic encephalopathy.  BMJ 1999;318:1364-1365 ( 22 May ). 

Ken Babal, C.N. "Reversing Liver Damage: The body's largest detox organ needs repair work now and then" 

Editor's Correspondence - Leslie Olmstead Schulz, PhD.  August 11, 1997. Comments on the Safety of Antioxidant Vitamin Supplementation.

http://www.ama-assn.org/sci-pubs/journals/archive/inte/vol_157/no_15/letter11.htm 

SAMe The Liver Super-Nutrient.  June 1997 edition of "Life Extension" magazine. 

"Living with Hepatitis C: A Survivor's Guide" by Gregory T. Everson, M.D., and Hedy Weinberg. 1997, Hatherleigh Press. VIRAL EVOLUTION AS DRIVEN BY HOST NUTRITIONAL SELECTIVE FACTORS - INFLUENCE OF DIETARY OXIDATIVE STRESS 

H SIES, UNIV DUSSELDORF, INST PHYSIOL CHEM 1, POSTFACH .  DIMINISHED PLASMA-LEVELS OF VITAMIN-E IN PATIENTS WITH SEVERE VIRAL-HEPATITIS. FREE RADICAL RESEARCH 1996 ;25(6):461-466 

Willis C. Maddrey, MD.  Viral Hepatitis: Natural History and Treatment. Strategies for Reducing Ribavirin-Induced Nonimmune Hemolytic Anemia.  Digestive Disease Week Day 2 - May 17, 1999.  http://www.medscape.com/Medscape/CNO/1999/DDW/Story.cfm?story_id=623

Larrea E, Beloqui O, Munoz-Navas MA, Civeira MP, Prieto J.  Superoxide dismutase in patients with chronic hepatitis C virus infection. Free Radic Biol Med 1998 May;24(7-8):1235-1241. 

N.R. Diluzio.  The Liver: Master Organ for Optimal Nutrition. http://www.itsnet.com/home/biosourc/liver.html 

Eberhard Bassenge, Nelli Fink, Mikhail Skatchkov, and Bruno Fink.  Dietary Supplement with Vitamin C Prevents Nitrate Tolerance.  J. Clin. Invest. Volume 102, Number 1, July 1998, 67-71. 

Vitamin C Deficit Linked To Skin Disease. http://www.pslgroup.com/dg/34fde.htm 

Bernadette M. Marriott, PhD.  Annals of Internal Medicine:EDITORIALS. Vitamin D Supplementation: A Word of Caution.  Annals of Internal Medicine 1 August 1997. 127:231-233. http://www.acponline.org/journals/annals/01aug97/bmdedit.htm 

Robert D. Utiger, M.D.  Editorial:  The Need for More Vitamin D.  http://www.nejm.org/public/1998/0338/0012/0828/1.htm 

Meydani SN, Meydani M, Blumberg JB, Leka LS, Siber G, Loszewski R, Thompson C, Pedrosa MC, Diamond RD, Stollar BD.  "Vitamin E supplementation and in vivo immune response in healthy elderly subjects. A randomized controlled trial".  JAMA 1997 May 7;277(17):1380-1386. 

C. Houglum K, Venkataramani A, Lyche K, Chojkier M. A pilot study of the effects of d-alpha-tocopherol on hepatic stellate cell activation in chronic hepatitis. Gastroenterology 1997;113:1069-1073. 

Huey-Mei Shaw and Ching-jang Huang.  Liver -Tocopherol Transfer Protein and Its mRNA Are Differentially Altered by Dietary Vitamin E Deficiency and Protein Insufficiency in Rats.  The Journal of Nutrition Vol. 128 No. 12 December 1998, pp. 2348-2354.

RONALD J. SOKOL,*,‡ JAMES M. McKIM, Jr.,*,‡ M. COLBY GOFF,* STEPHANIE Z. RUYLE,§ MICHAEL W. DEVEREAUX,*,‡ DERICK HAN, LESTER PACKER,  and GREGORY EVERSON‡.  Vitamin E Reduces Oxidant Injury to Mitochondria and the Hepatotoxicity of Taurochenodeoxycholic Acid in the Rat.  1998 by the American Gastroenterological Association. ( Ronald J. Sokol, M.D., Department of Pediatrics, The Children's Hospital, Box B290, 1056 East 19th Avenue, Denver, Colorado 80218. Fax: (303) 764-8025.)

Vitamin Toxicities http://www.projinf.org/hh/alternative.html - Evaluating_New_or_Alternative_Treatments 

von Herbay A; Stahl W; Niederau C; Sies H.  Vitamin E improves the aminotransferase status of patients suffering from viral hepatitis C: a randomized, double-blind, placebo-controlled study. Free Radic Res 1997

Mutlu-Turkoglu U, Ademoglu E, Turkoglu S, Badur S, Uysal M, Toker.  The effects of interferon-alpha on serum lipid peroxidation and total thiol content in patients with chronic active hepatitis-C.  Res Commun Mol Pathol Pharmacol 1997 Jun;96(3):357-361. 

Yamamoto Y, Yamashita S.  Plasma ratio of ubiquinol and ubiquinone as a marker of oxidative stress. Mol Aspects Med 1997;18 Suppl:S79-S84. 

What Does My Liver Do?  http://www.ozemail.com.au/~acocacms/Page2.html

What Is Fatty Liver? http://www.gastro.com/liverpg/fattyliv.htm 

Kralik A, Eder K, Kirchgessner M.  Influence of zinc and selenium deficiency on parameters relating to thyroid hormone metabolism.  Horm Metab Res 1996;28:223-226.  http://www.thorne.com/altmedrev/recent2-2.html

Diet & Exercise and Hepatitis C 

http://www.artistsagainsthepatitis.com/diet.htm