Management of Lifestyle Factors in Individuals

with Cirrhosis: A Pragmatic Review

Puneeta Tandon, MD, PhD1 Annalisa Berzigotti, MD, PhD2

1 Division of Gastroenterology (Liver Unit), University of Alberta, Address for correspondence Annalisa Berzigotti, MD, PhD,
Edmonton, Alberta, Canada Hepatology, University Clinic for Visceral Surgery and Medicine,
2 Hepatology, University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, MEM F807, Murtenstrasse 35, CH - 3010
Inselspital, University of Bern, Switzerland Bern, Switzerland (e-mail: annalisa.berzigotti@insel.ch).

Semin Liver Dis

Abstract Lifestyle-related factors are major determinants/modifiers of prognosis in patients with

cirrhosis. Accumulating evidence indicates that malnutrition, obesity, sedentary
lifestyle, alcohol and smoking habits, and likely poor oral hygiene can increase the
risk of progression of the disease, and some of them are linked to higher risk of
hepatocellular carcinoma. Importantly, lifestyle-related factors can be largely cor-

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rected, and as such they represent an attractive approach to be added to etiological
Keywords and pharmacological therapy in patients with cirrhosis. Nonetheless, lifestyle is often
► obesity neglected in this population. In this concise review, the authors present evidence
► sarcopenia supporting lifestyle changes in patients with cirrhosis—including, but not limited to,
► physical activity nutrition and physical activity in malnourished and obese patients. They also discuss
► exercise some elements of motivational interviews as a tool to support a better interaction
► portal hypertension between hepatologists and patients in this field.

Liver cirrhosis is a frequent cause of death worldwide. Until
recently, cirrhosis was considered an irreversible disease
invariably carrying a dismal prognosis. However, thanks to
improved noninvasive diagnostic methods, cirrhosis is now
increasingly diagnosed in a fully compensated stage lacking
clinical complications and with relatively good prognosis,
where effective therapeutic measures to prevent progression
to decompensation and reduce the risk of hepatocellular
carcinoma (HCC) can be implemented. In this compensated
stage, the removal of the cause of liver injury can lead to
complete histological regression of cirrhosis.1,2 Importantly,
epidemiological and cohort studies have identified several
cofactors of liver damage related to lifestyle and as such
modifiable. Some have been proven to be important risk
modifiers in promoting further increase in portal pressure
and progression of cirrhosis from the compensated to the
decompensated stage (e.g., obesity), or to further decompen-
sation and death (e.g., sarcopenia).3,4 Furthermore, some
lifestyle factors promote comorbidities that prevent the re-
gression of portal hypertension and cirrhosis once the major
etiological agent has been removed.5 Since pharmacological
strategies to induce fibrosis regression are still lacking, non-
pharmacological strategies to prevent cirrhosis progression
and complications and to facilitate its regression in case the
main etiological factor has been cured should be considered as
an important part of the management of patients with cirrho-
sis. Since large enough lifestyle adaptation studies testing the
effect of all the major risk modifiers of prognosis in cirrhosis
are lacking and unlikely to be performed in the near future, we
performed a pragmatic review summarizing the existing evi-
dence in this field (►Fig. 1).
Addressing Nutritional Aspects
The Dietary Management of Malnutrition in Cirrhosis
Protein energy malnutrition has been described in 20 to 60%
of patients with cirrhosis, increasing with worsening disease
severity.6 Defined by a reduction in muscle mass or function,
sarcopenia is recognized as a key objective feature of malnu-
trition. The vast majority of recent literature in cirrhosis has
utilized cross-sectional imaging for the assessment of sarco-
penia,6,7 associating it with adverse outcomes including

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Management of Lifestyle Factors in Individuals with Cirrhosis
Fig. 1 Schematic view of the main lifestyle adaptations required in cirrhosis. Alcohol cessation and diet optimization should be seen as key
steps. These should be complemented by progressively increased physical activity, smoke cessation, and improved oral health.
functional limitations, impaired quality of life, health care
associated infections, higher rates of hepatic encephalopathy
(HE), and mortality.7–9 Many reviews have detailed the
morbidity and mortality associated with sarcopenia and its
functional correlate frailty, most recently drawing a link
between the loss of skeletal muscle with cardiopulmonary
muscle impairment.10 Notably, sarcopenia and obesity can
coexist in an estimated 35% of patients awaiting liver trans-
plantation, the combination associated with higher rates of
morbidity and mortality above either condition alone.11
The diagnosis and prognostic implications of sarcopenia
have been expanded in great detail in the recent litera-
ture.7,10,12,13 Computed tomography (CT)-based cross-sec-
tional imaging is accepted as the most commonly utilized
tool in the research setting. It is a robust independent
predictor of both pre- and posttransplant morbidity and
mortality.14 In the clinical setting, mid-arm muscle circum-
ference is available for use, with recognized limitations of
high interobserver variability.15 Novel data are emerging
around the use of the bioelectrical impedance phase
angle6,16,17 and muscle ultrasound in patients with cirrho-
sis.18 There is also a growing literature on the use of
measures of physical frailty.19 As described by the recent
Frailty in Liver Transplantation guideline from the American
Society of Transplantation,19 a diverse range of frailty tools
have also been associated with both morbidity and mortality
and can be incorporated into clinical practice. These include
performance-based measures such as the Karnofsky Perfor-
mance Status, Clinical Frailty Scale, and activities of daily
living, and more objective tools such as the 6-minute walk
test, hand grip, and the Liver Frailty Index. Notably, the latter
more objective tools are more likely to be sensitive to change
related to intervention.19
The tenets for managing obesity in cirrhosis will be covered
in the subsequent section. Underlying these tenets are three
basic pieces of a nutritional prescription that can be provided
to all patients with cirrhosis.20 First, patients should be given a
Seminars in Liver Disease
Tandon, Berzigotti
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target caloric intake. As per recent European Association for
the Study of the Liver (EASL) and International Society for
Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN)
guidelines, this target varies according to the patient’s body
mass index (BMI).21,22 As per EASL guidelines, in nonobese
individuals (BMI  30), at least 35 kcal/kg of actual body
weight per day is recommended. Second, all patients should
be provided with a target protein intake—guidelines have been
consistent in the recommendation of 1.2 to 1.5 g/kg per day.
This can be achieved using multiple sources including meat,
dairy, and vegetable proteins, with some support from the
literature that the latter two sources may have additional
benefit against HE.21 Third, all patients should be counseled
on the need to reduce their fasting time. A late evening snack
before night sleep with 50 g of complex carbohydrates (e.g.,
1–2 slices of bread, 7–8 crackers) and approximately 15 g of
protein content (e.g., yoghurt, cheese, one glass of milk) is
acceptable and significantly increases muscle mass and may
also have beneficial effects on HE.22–24 On the same line,
patients should be counseled on the need to eat breakfast.
Although not always possible, ideally, this information would
be provided by a dietitian who could simultaneously carry out
a more comprehensive assessment of nutritional status and
management of barriers around nutritional intake.15,21
Obesity in Cirrhosis: Is It Frequent? Does It Have an
Impact on Liver-Related Outcomes?
In patients with compensated cirrhosis, overweight and
obesity are as frequent as in the general population, ranging
from 20 to 40% in the published studies.25,26 In addition,
since obesity is almost invariably present in patients with
nonalcoholic steatohepatitis-related cirrhosis, and due to the
changing epidemiology of chronic liver disease (CLD), this
comorbidity is expected to further increase in the next years.
Not surprisingly, and despite the concomitant loss of muscle
mass,11,27,28 obesity is frequently observed also in patients
with decompensated cirrhosis.
 Management of Lifestyle Factors in Individuals with Cirrhosis
Whether obesity in cirrhosis should be considered an
innocent bystander or whether it is a relevant comorbidity
worsening the prognosis was until recently unclear. In the
last few years several studies have clarified its role as an
aggravating prognostic factor both in compensated and in
decompensated cirrhosis.
In patients with compensated advanced CLD (cACLD)/
compensated cirrhosis due to chronic hepatitis C included
in the Hepatitis C Antiviral Long-term Treatment against
Cirrhosis (HALT-C) trial,25 each BMI quartile increase was
associated with a 14% increase in the risk of further histo-
logical progression or clinical decompensation; furthermore,
patients showing a body weight increase over 5% at 1 year of
inclusion had an additional 35% risk of progression of liver
disease. In a study conducted in patients with liver cirrhosis
due to chronic hepatitis B treated long-term with Tenofovir,
obesity and obesity-related factors (diabetes) were the only
independent factors related to lack of regression of cirrhosis
on liver biopsy after 5 years of treatment initiation.5
In another retrospective evaluation of patients with com-
pensated cirrhosis of any etiology and portal hypertension
(hepatic venous pressure gradient [HVPG]  6 mm Hg)
included in a randomized controlled trial on timolol versus
placebo to prevent the onset of esophageal varices, obesity
(and BMI taken as continuous variable) was associated with a
marked increase in the risk of clinical decompensation,
independent of portal hypertension and albumin.26
Newer data suggest that obesity is also a robust indepen-
dent risk factor for portal vein thrombosis (hazard ratio:
13.1).29 HCC risk is also increased in patients with obesity,30,31
even if a large part of the effect seems to be explained by the
coexistence of diabetes mellitus.
In decompensated cirrhosis the overall long-term effect of
obesity is less clear. On one side, obesity (and in particular
severe obesity) has been associated with a higher risk of serious
bacterial infections requiring intensive care unit (ICU) admis-
sions,32 and to acute on chronic liver failure,33 but on the other
hand, some authors reported a lower risk of death during the
ICU stay in obese versus nonobese patients with cirrhosis.34
Nonetheless, obesity increases the risk of major complications
of liver transplantation,35 and morbid obesity is considered a
contraindication to liver transplantation in many centers.36
Taken together, these data outline a strong rationale for
considering obesity as a potentially modifiable target for achiev-
ing an improvement of prognosis in patients with cirrhosis.
Novel drugs improving the metabolic efficiency (e.g., GLP-
1 agonists) improve body weight in patients with diabetes
type 2 and obesity.37 There are limited data available in
patients with obesity and cirrhosis. Furthermore, bariatric
surgery is restricted to patients with compensated disease
without severe portal hypertension,38 and lifestyle changes
remain the cornerstone of obesity treatment in cirrhosis.
Correcting Obesity in Cirrhosis: Is It Useful? Is It
Dangerous? How Should We Achieve it?
An intentional reduction of body weight was associated with
improved outcomes (histological features; HVPG) in obese
patients with compensated cirrhosis in three studies.25,39,40
Tandon, Berzigotti
Both in the HALT-C trial25 and in the SportDiet study,41 a
weight decrease of at least 5% was sufficient to achieve an
effect, but the best results on liver histology and on the HVPG
were observed in patients achieving a weight loss of 10%, and
this should be likely considered the target of lifestyle inter-
ventions. As for feasibility, up to 50% of patients included in
intensive short-term (16–20 weeks) lifestyle intervention
studies achieved at least 5% body weight loss. Diabetic
patients were less likely to achieve this target in one study.41
As for safety, in the studies conducted so far in compen-
sated cirrhosis, weight loss obtained by supervised and
unsupervised exercise and moderate caloric restriction and
under monthly medical control was not associated with
clinical decompensation or other adverse outcomes.
Weight loss can be also achieved in patients with decom-
pensated cirrhosis; however, since weight loss can lead to
worsening of sarcopenia, ascites,42 and potentially HE, spe-
cial care in the management of decompensated patients
should be paid to ensure a slow weight loss and an adequate
protein intake.
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Regarding how to achieve a sufficient and long-lasting
weight loss, lifestyle changes remain the cornerstone, and as
in any other population of patients with chronic diseases, they
require an individualized and multidimensional approach.
Before prescribing calorie restriction and physical activity,
an achievable target should be agreed upon with the patient. As
above, a detailed nutritional assessment should be conducted
by a dietitian/nutritionist aware of the specificities of nutrition
in liver patients (high protein need; frequent coexistence of
sarcopenia). Sarcopenia should be investigated, and we recom-
mend using simple and repeatable tests such as grip-strength
test and imaging-based measurements of muscle mass.
Anxiety and depression are common in cirrhosis and are
due to several factors including perceived stigma irrespective
of the cause of the disease and syndemic aspects (aggrega-
tion of concurrent or sequential disease clusters which
biologically interact in a population and which exacerbate
the prognosis and burden of disease), in this case alcohol
consumption, low income, and lack of social support.43,44
Anxiety and depression should be investigated and treated if
needed, due not only to their negative effects on food intake
(reduction of food reward mechanisms)45,46 but also to the
impact on quality of life and mortality.47 The partner and
family should be invited to take part to the patient’s lifestyle
change plan. Most cities will have either online or in-person
behavior change programs available for patients with obesi-
ty, including not only a focus on dietary restriction and
increasing activity but also a growing focus on strategies
to impact reward-related eating.48,49
Avoidance of sedentary behavior, which is extremely
frequent in cirrhosis (76% of waking hours spent in the
sedentary state),50 should be recommended even in patients
not willing to undergo a formal exercising program. Written
advice could be provided to the patient with guidance to
increase daily physical activity within the context of NEAT
(nonexercise activity thermogenesis).51 As opposed to
scheduled exercise, NEAT encourages patients to take oppor-
tunities to increase their activity within their day-to-day
Seminars in Liver Disease
Management of Lifestyle Factors in Individuals with Cirrhosis
routine (e.g., stepping in place while watching TV, climbing
the stairs instead of taking the elevator).
Diet: Achieving a negative total energy expenditure balance
in patients with obesity and cirrhosis (often complicated by
the presence of diabetes) without compromising the protein
stores and skeletal muscle mass is challenging, and requires
the support of nutritionists and experts in the management of
liver patients. Nonetheless, simple recommendations and
education regarding the avoidance of food particularly rich
in calories and sugar-containing drinks can be given in written
form even before the nutritionist visit. Nutritional manage-
ment should be aimed at a slow and progressive weight loss
aiming at a final decrease of 10% of body weight.
The resting energy expenditure, food-related thermogene-
sis, and energy expenditure related to physical activity should
be taken into account to achieve moderate caloric restriction
( 500 to 800 Kcal/day or not less than 70% of previous caloric
intake) with a tailored, individualized dietary plan. While the
standard protein intake in cirrhosis should not be lower than
1.5 g/kg/day,21 in patients undertaking increased physical
activity it should be increased accordingly, taking into account
that protein amounts up to 1.8 g/kg/day are proven safe in this
population.21,52 As previously stated, decompensated patients
require particular attention to avoid loss of lean mass. This
applies as well to patients in the acute setting. While specific
recommendations on caloric intake for the obese critically ill
cirrhotic patient cannot be given due to the lack of data, as for
the protein intake, attention should be paid to the coexistence
of renal insufficiency.53
Qualitative Content of Diet
Data supporting the benefit of Mediterranean diet—rich in
vegetables, fruit, and olive oil—in reducing the complication
risk in cirrhosis have been recently published, and it has been
linked due to improved microbiota diversity under this
dietetic regimen.54 In consideration of these data and con-
sidering that Mediterranean diet improves insulin resis-
tance55 (which is linked to higher risk of complications of
cirrhosis and HCC) and has proven favorable on cardiovascu-
lar risk, cancer risk, and on several chronic diseases inde-
pendent of weight loss,56–60 this seems a reasonable choice
also in patients with cirrhosis.
In the last few years, evidence has been accumulating
regarding the detrimental effects of processed food on the
gut–brain mechanisms of food reinforcement, leading to
perpetuation of obesity.61 Although there are no cirrhosis-
specific data to confirm this, in our view, patients should be
advised to avoid processed food and use fresh ingredients, to
favor weight loss.
In addition, in patients lacking immunity against hepatitis
E virus (HEV), the consumption of uncooked meat, wild game,
or wild boar should be avoided, since HEV infection can have a
severe course in patients with underlying liver cirrhosis.62
Vitamin and microelement deficit should be excluded,
and in particular vitamin D and zinc should be supplemented
in case of deficit.21 Branched chain amino acid supplements
and leucine-enriched amino acid supplements (6–8 g per
day) should be considered, particularly in decompensated
Seminars in Liver Disease
Tandon, Berzigotti
patients at risk of HE and in sarcopenic patients.6,21 Leucine
might support fat mass decrease while improving lean
mass,63 given its anabolic action mediated by AMP-activated
protein kinase.63,64
In a systematic review and meta-analysis, coffee drinking
was associated with a decreased risk of cirrhosis and hepa-
tocellular carcinoma;65 although specific data are lacking in
obese patients with cirrhosis, in these authors’ view the
evidence points toward a protective effect of coffee on liver
disease, and patients should be encouraged to drink coffee.
Physical Activity and Exercise
Across healthy people and patients with chronic disease, exer-
cise has been associated with a wide range of health bene-
fits.66,67 Additional benefits in cirrhosis may link to an
improvement in insulin sensitivity, an increase in muscle
protein synthesis, and the use of muscle as an alternative route
for ammonia detoxification.68 Earlier studies suggested the
possibility of adverse events associated with exercise, second-
ary to ammonia generation, and short-term increase in portal
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pressure.69,70 Likely in part due to these concerns, the evidence
supporting the benefits of exercise in cirrhosis has been slower
to evolve than in other chronic disease populations; existing
studies are currently limited by a small sample size and
enrollment of patients with Child–Pugh A and B disease.
A recent Cochrane systematic review meta-analyzed the data
from six randomized controlled trials, 173 participants with
intervention duration ranging from 8 to 14 weeks.71 They
concluded that when aggregated, although there was no in-
crease in adverse events seen with exercise, there was insuffi-
cient evidence to support an impact on mortality, health-
related quality of life, exercise capacity, or anthropometric
measurements beyond mid-arm muscle circumference. Until
sufficient evidence can be accumulated, practitioners are sug-
gested to use the more general recommendations from the
American College of Sports Medicine (ACSM) developed for
people with chronic disease, supplemented by reviews of
clinical experience in exercise and cirrhosis.66,67,72,73 Prior to
recommending a moderate-intensity exercise program in
patients, a recent cirrhosis-specific review suggested three
categories of pre-exercise safety considerations, namely: cir-
rhosis specific considerations (e.g., surveillance and manage-
ment of high-risk varices in patients with a FibroScan score of
 20 kPA or platelet count  150,000); cardiopulmonary safety
screening (required in patients with signs, symptoms, or a
history of cardiovascular, metabolic, or renal disease wanting
to pursue more than moderate activity i.e., beyond the demand
of a brisk walk); and a consideration of physical comorbidities
(e.g., fall risk).66
Consistent with the ACSM guidelines, when recommending
exercise to patients, the most important tenet of any exercise
program is to “start low, progress slowly, and be alert for
symptoms.” The exercise prescription can be personalized per
patient following the FITT (frequency, intensity, time, and type
of activity) principles.66 Scheduled exercise programs gener-
ally start with a 5 to 10 minute warm-up, include a 10 to
40 minute exercise phase containing aerobic and resistance
components, and end with 5 to 10 minutes of flexibility and
 Management of Lifestyle Factors in Individuals with Cirrhosis
balance training.66 Consistent with ACSM guidelines, a rea-
sonable overall target for moderate aerobic activity is to
eventually reach to 150 minutes per week, incorporating
resistance activities on two or more days per week.66 In obese
patients with cirrhosis, increased physical activity has both the
aim of increasing energy expenditure facilitating weight
loss and of improving muscle mass and function. Although
high-quality data in this regard are still needed, preliminary
evidence suggests that aerobic and endurance exercises are
able to improve skeletal muscle function, but these are likely
insufficient for achieving increase in muscle mass. For this aim,
resistance training is needed.74 In a study specifically address-
ing patients with compensated cirrhosis and obesity, moder-
ate-intensity supervised and nonsupervised exercise added to
moderate caloric restriction for 16 weeks did not show any
detrimental effect.41 Quite to the contrary, patients who were
most adherent to the regimen showed a larger reduction in
body weight, which was associated with a decrease in portal
pressure. In this intervention study, resistance exercise was
allowed, except for specific abdominal work-outs which might
abruptly increase abdominal pressure.
Adherence is of key importance to maintain physical
exercise long term and a tailoring to patients’ skills and
preference should be attempted, with a progressive increase
in intensity.
Acting on Other Detrimental Lifestyle
Factors
Alcohol
Alcohol consumption is per se one of the leading etiologies of
cirrhosis. In addition, alcohol is a major risk factor for the
progression of liver fibrosis in CLD due to other causes, e.g.,
viral causes.75
Obesity and alcohol have synergistic effects on liver
damage,76 and the presence of obesity in alcoholic patients
leads to a higher risk of cirrhosis and HCC.77,78
In cirrhosis even a moderate alcohol intake leads to a quick
increase in portal pressure and porto-collateral blood flow.79,80
In patients with cirrhosis, alcohol intake is undoubtedly
associated with worsening of prognosis. After a first decom-
pensating episode81 or after an episode of alcoholic hepati-
tis,82,83 patients who continue drinking show a higher
mortality as compared with patients abstaining from alco-
hol. Abstinence from alcohol can lead to histological regres-
sion of cirrhosis, improvement of portal hypertension and
reduction in the risk of clinical decompensation and HCC, and
improved survival, with over 20% drop in deaths at 5 years.84
In a small proportion of patients with alcoholic cirrhosis
(5–15%), the disease progresses even after successful alcohol
withdrawal, and this underlines that cofactors such as obe-
sity and/or sarcopenia/malnutrition should be taken into
account and treated as well85 and patients should be kept
under regular follow-up and screening for HCC. Interestingly,
there might be a common mechanism linking the benefits of
weight loss and those of alcohol abstinence in cirrhosis to the
recovery of gut integrity (improved diversity of the micro-
biota, reduced permeability).86
Tandon, Berzigotti
Patients with alcoholic cirrhosis and alcohol use disorders
require attention directed to both of these conditions. Specific
strategies aiming not only at achieving but also at maintaining
alcohol abstinence should be used, since recidivism is extremely
frequent, ranging from 67 to 81% within 1 year.85 As described in
a recent review, although practitioners can often feel ill-
equipped to impact alcohol use, the quality therapeutic alliance
that develops between patients and practitioners (hepatolo-
gists, primary care specialists) is one of the most important
predictors of a favorable outcome.87 Ideally a multidisciplinary
approach is required. By using a combination of motivational,
cognitive behavioral therapy, and drug therapy,88 the mainte-
nance of abstinence is increased.89,90
The survival benefit achieved by abstinence in alcoholic
cirrhosis has been proven for over 50 years.81 Given the above-
mentioned data, which are not specific to alcoholic etiology
only, complete abstinence from alcohol should be prescribed
to all patients with cirrhosis, irrespective of its cause.
Cigarette Smoking and Cannabis Smoking
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Cigarette smoking markedly increases the risk of liver cir-
rhosis independent of alcohol use,91 and is a recognized pro-
fibrogenic stimulus.92 In a murine model of obesity, cigarette
smoking induced oxidative stress, hepatocellular apoptosis,
and nonalcoholic fatty liver disease (NAFLD).93
In patients with alcoholic cirrhosis and viral cirrhosis,
cigarette smoking is a major synergistic risk factor for
HCC.94–96 In patients with HCC, cigarette smoking was
associated with worse survival in one study.97
Furthermore, cigarette smoking is associated with in-
creased nongraft related mortality after liver transplanta-
tion, mostly due to an increase in cardiovascular events and
de novo cancer onset.92
Taken together this evidence strongly suggests that smok-
ing cessation should be considered an important component
of lifestyle adaptations to be put in place in all patients with
cirrhosis.
Cannabis smoking enhances fibrogenesis in patients with
CLD and liver fibrosis due to chronic hepatitis C.98 Data in
cirrhosis are not available, but their use should be discouraged.
Poor Oral Health Habits
As compared with the general population, patients with liver
cirrhosis of any etiology often show poorer oral health
habits,99–101 and have a very high prevalence of periodonti-
tis.101,102 Recent data suggest that periodontitis might be an
additional risk factor for death in cirrhosis,100 and that an
oral health links to the gut–liver axis integrity.103 In a proof-
of-concept study, therapy of periodontitis led to improved
intestinal dysbiosis and improved HE.104 Hence, lifestyle
adaptations in cirrhosis should include a careful oral health
(teeth brushing at least twice per day; visit to the dentist at
least once per year).
Can We Integrate Some Principles of Motivational
Interviewing Into Our Clinical Encounters?
All of the items discussed above include behavior change
recommendations which require substantial lifestyle
Seminars in Liver Disease
Management of Lifestyle Factors in Individuals with Cirrhosis Tandon, Berzigotti

Table 1 Motivational interviewing fundamentals

Four aspects of the spirit of motivational interviewing

Partnership Active collaboration where the patient is considered the expert in their own journey.
This is contrasted from the “top-down” expert-based recommendations given without consideration of the
patient’s personal situation
Acceptance Nonjudgmental acceptance which includes four aspects:
• Absolute worth—the potential and inherent worth of an individual is always recognized.
• Accurate empathy—an active willingness to see the world through the patient’s eyes.
• Autonomy support—honoring the patient’s right and ability to direct their care.
• Affirmation—acknowledging strengths and efforts.
Compassion A “deliberate commitment” to actively pursue the best interests of the patient, giving priority to their needs
Evocation A “strengths-based approach” that assumes that patients have within them the strengths and resources
needed to change. The focus of the interview is to evoke this information (including the patient’s strengths,
motivations, and resources) as opposed to lecture to the patient about what “should” be done and in what
way.

Source: Table adapted from information in reference by Miller and Rollnick.105

Table 2 A set of pragmatic actions for patients with cirrhosis and obesity

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• Empowerment of patients
Ideally utilizing some of the tenets of motivational interviewing to elicit behavior change66 (see also ►Table 2), on the first
visit work together with your patients to provide them with information that can be adapted into their own personal context:
– Obesity is associated to higher risk of adverse outcomes: he/she should understand why weight loss is important; provide
a minimal set of recommendations on the unhealthy (highly caloric; sugar drinks; processed food) and healthy
(vegetables; fruit; beans; olive oil) food.
– Sedentary behavior should be avoided as much as possible and promote the use of simple tools (log; step counting
through mobile devices or wearable devices) to set achievable goals to increase physical activity; encourage nonexercise
activity thermogenesis.
– Alcohol and cigarette smoke are detrimental in all patients with cirrhosis: they should be completely stopped.
– Oral health is important: support hygiene twice per day and recommend a visit to the dentist
• Prescription of nutritional support and exercise
Actively prescribe:
– Nutritional counseling to achieve a mild calorie deficit while supporting protein intake to avoid muscle mass loss while
exercising and dieting.
– Exercise counseling (aerobic and resistance training) in compensated patients, and consider it even for decompensated
patients, adapting to their situation.
Follow-up after 3 to 6 months to reassess the body mass index and if possible muscle mass.

adaptations. As many practitioners have experienced, it can
be frustrating when recommendations are made and no
changes are observed. Motivational interviewing is “a way
of being with a client” that can help to reduce ambivalence
and increase the likelihood of behavior change.87,105
Although many medical practitioners may find that time
pressures and lack of training make it challenging to imple-
ment the full motivational interviewing style into every
patient encounter, following some of its principles may
facilitate successful outcomes (►Table 1). Formal training
in motivational interviewing is available worldwide with
varying course durations, enhancing the practitioner’s abili-
ty to build on techniques such as patient engagement, focus
on the patient’s goals for change, evoke their reasons for
change, and plan steps toward change.
Conclusion
Lifestyle adaptations are an important component of the
management of patients with cirrhosis (►Table 2). Patients
should be educated to avoid behaviors that increase the risk of
further progression, and to adopt lifestyle changes fostering
improvements in their health. Complete alcohol and smoking
abstinence, and achievement of a healthy body weight and
body composition through an appropriate nutrition and physi-
cal activity should be suggested to all patients with cirrhosis to
improve prognosis and quality of life. These apparently simple
concepts are however limited in their application by an ex-
treme complexity, encompassing lack of transfer of knowledge
from the medical community to patients, and barriers to
lifestyle changes opposed by long-lasting behaviors and by
the society itself. Therefore, clinicians need to improve and
adapt the dialogue with patients regarding lifestyle adapta-
tions and the respective barriers, to increase the chance of
achieving adherence to the suggested changes. The implemen-
tation of lifestyle adaptation programs including nutritional
and physical activity support, and alcohol and cigarette smok-
ing withdrawal support when needed, requires a multidisci-
plinary approach that should be taken into account in the
future organization of activities in hepatology.

Seminars in Liver Disease

 Management of Lifestyle Factors in Individuals with Cirrhosis
Conflicts of Interest
All the authors declare that they have no conflict of
interest with respect to the content of the present article.
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