Diet and Hepatitis C
WHAT IS THE RELATIONSHIP BETWEEN DIET AND HEPATITIS C?
Hepatitis C (HCV) is a virus that infects the liver. Up to 85% of people exposed to this virus develop chronic liver disease. In general, chronic HCV appears to be a slowly progressive disease that may gradually advance over 10-40 years. While not as yet totally defined, many factors influence the rate of disease progression. Diet may play an important role in this process, as all foods and beverages that we ingest must pass through the liver to be metabolized.

General guidelines for individuals infected with HCV include maintaining a healthy lifestyle, eating a well-balanced, low-fat diet, and avoiding alcohol. A diet high in complex carbohydrates may be helpful in providing calories and maintaining weight. Since HCV infection may lead to loss of appetite, those individuals whose appetite is diminished may find frequent, small meals more easily tolerated. Adequate rest and moderate exercise can also contribute to a feeling of well-being.

Alcohol and Hepatitis C
Alcohol is a potent toxin to the liver. Excessive intake can lead to cirrhosis and its complications, including liver cancer. Heavy drinkers are not the only individuals at risk for liver diseases, as damage can occur in even some moderate "social drinkers." The hepatitis C virus has frequently been isolated from patients with alcoholic liver disease. In fact, these patients have been found to have a higher incidence of severe liver damage, cirrhosis, and a decreased lifespan, when compared to individuals without the virus. It is suggested that the combination of alcohol and HCV accelerates the progression of liver disease. The consensus statement concerning management of HCV released in March, 1997 from the National Institutes of Health further warned about the dangers of excessive alcohol use, and advised limitation of alcohol to no more than one drink per day. Therefore, patients with HCV would be unwise to drink alcohol in excess, and total avoidance of all alcohol intake is recommended.

Iron and Hepatitis C
The liver plays an important role in the metabolism of iron since it is the primary organ in the body that stores this metal. The average American diet contains about 10-20 mg of iron per day. About 10% of this iron is absorbed, in keeping with the body's need for 1 to 2 mg. of iron per day. Patients with chronic HCV sometimes have an increase in the iron concentration in the liver. Excess iron can be very damaging to the liver. Studies suggest that high iron levels reduce the response rate of patients with HCV to interferon. Thus, patients with chronic HCV whose serum iron level is elevated, or who have cirrhosis, should avoid taking iron supplements. In addition, these patients should restrict their intake of iron-rich foods, such as red meats, liver, and iron-fortified cereals, and should avoid cooking with iron-coated cookware and utensils.

Fat and hepatitis c
Overweight individuals are often found to have abnormalities related to the liver, ranging from fatty deposits in the liver (steatosis) to fatty deposits accompanied by inflammation (steatohepatitis). In overweight patients with a fatty liver who subsequently lose weight, liver related abnormalities improve. Therefore, patients with chronic HCV are advised to maintain normal weight. For those who are overweight, it is crucial to start a prudent exercise routine and a low fat, well balanced, weight reducing diet. Diabetic patients should follow a sugar restricted diet. A low cholesterol diet should be followed in those with hypertriglyceridemia. It is essential that patients consult with their physician before beginning any diet or exercise program.

Protein and Hepatitis C
Adequate protein intake is important to build and maintain muscle mass and to assist in healing and repair. Protein intake must be adjusted to one's body weight and medical condition. Approximately 1.0 to 1.5 gm. of protein per kilogram of body weight is recommended in the diet each day for regeneration of liver cells in non-cirrhotic patients.

In a small but significant number of individuals with cirrhosis, a complication known as encephalopathy, or impaired mental status, may occur. Affected individuals may show signs of disorientation and confusion. The exact cause(s) of encephalopathy is not fully understood. While some experts do not believe there is a link between dietary protein and encephalopathy, others believe in substantially reducing or even eliminating animal protein and adhering to a vegetarian diet, in order to help improve mental status. Patients who are at risk for encephalopathy may be advised to eat no more than .6 - .8 gm. of animal source protein per kilogram of body weight per day. (Animal source proteins are meat, fish, eggs, poultry, and dairy products. Each provides 7 gm. of actual protein per ounce of food.) There is no limit on vegetable protein consumption. Maintaining adequate protein intake and body weight should be considered a priority if vegetarian protein substitutes are not utilized .

The table below gives recommended grams of animal source protein intake per pound of body weight. (Note: The chart is intended to provide guidelines for patients with hepatitis C. For specific recommendations, consult your physician.)

Weight Recommended average protein intake Maximum recommended protein intake for regeneration of liver cells in non-cirrhotic patients for patients at risk for encephalopathy

100 lbs. 45-68 gm. (6 -9 oz. meat or equivalent) 27 gm.
130 lbs. 59-87 gm. (8 - 12 oz. meat or equiv.) 35 gm.
150 lbs. 68-103 gm. (9.7-14 oz. meat or equiv.) 40 gm.
170 lbs. 77-116 gm. (11 -16 oz. meat or equiv.) 46 gm.
200 lbs. 91-136 gm. (13 -19 oz. meat or equiv.) 54 gm.

Sodium and Hepatitis C

Advanced scarring of the liver (cirrhosis) may lead to an abnormal accumulation of fluid in the abdomen, referred toas ascites. Patients with HCV who have ascites must be on sodium (salt) restricted diets. Every gram of sodium consumed results in the accumulation of 200 ml. of fluid. The lower the salt content of the diet, the better this excessive fluid accumulation is controlled. Sodium intake should be restricted to 1,000 mg. a day or less. This requires careful shopping and reading all food labels. It is often surprising to discover which foods are high in sodium. For example, one ounce of corn flakes contains 350 mg. of sodium; one ounce of grated parmesan cheese, 528 mg. of sodium; one cup of chicken noodle soup, 1,108 mg. of sodium; and one teaspoon of table salt, 2,325 mg. of sodium. Avoid fast food restaurants, because most fast foods are high in sodium. Meats, especially red meats, are high in sodium, so meat consumption may need to be reduced and vegetarian alternatives considered. Patients with chronic HCV without ascites are advised not to overindulge in salt intake, although their restrictions need not be as severe.

MEDICATIONS ARE NOT FOOD, BUT...

Like foods and beverages, medications also pass through the liver to be metabolized. Individuals with chronic liver disease should be careful about taking medications, even those sold over-the-counter. Read package labeling carefully before taking medications, and discuss any questions you may have with your physician and/or pharmacist.

Author: Melissa Palmer, MD

ALF Nutrition Education Subcommittee:
Bruce R. Bacon, MD, Kris V. Kowdley, MD, Francoise Ma

Nutrition and Hepatitis C

By Darlene Morrow, BSc

A special thanks to my friend, Smilin’ Sandi for her feedback and help with this paper. Please visit her excellent site at http://members.home.net/smking/index.htm

This entire document was typed using voice recognition software that was donated to me by Lernout and Hauspie. So a big thanks goes to them. If I missed any of the contextual errors, please excuse me. J

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.

First and foremost no changes should be made to do your routine without the consultation of the physician and/or naturopath. None of the advice given in this article is meant to be prescriptive. This information has been shared with me from other people with hepatitis c or that I've obtained through research.

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:

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 your doctor prescribes a new medication for you, and you feel sick because of it, 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 (supplemental)

[No] Beta Carotene (supplemental)

[No] Iron (supplemental)

[No] Niacin (supplemental)

[No] Raw or undercooked shellfish due to the high risk contamination from Vibrio vulnificus which is deadly for people with HepC.Sodium RestrictionProtein 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 reduces 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 at 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 has not been heated, the alcohol is still there. It depends on how radical you want to be about the alcohol.

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.

Natural sources of A: liver, eggs, a yellow fruits and vegetables, dark green fruits and vegetables, the whole milk and milk products, and fish liver oil.

Natural sources of D: salmon, vitamin D fortified milk and milk products, sardines and egg yolks.

Natural sources of calcium: Molasses, green leafy vegetables, milk and the products, and tofu.

Iron

People with hepatitis C often have a complication called hemochromatosis. 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 of the pot into the food.

Also watch for iron enriched cereals and other bread products.

Natural sources: fish and poultry, blackstrap molasses, cherry juice, dried fruits, and green leafy vegetables.

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.

Natural sources of cholesterol: egg yolks, meats, and butter.

Xenical- people taking xenical for weight loss need to be cautioned about the interference of the absorption of the fat soluble vitamins (A, D, E and K). Vitamin k is necessary for blood clotting.

Natural sources of vitamin k include green leafy vegetables, south lower oil, black strap molasses, cauliflower, and soybeans.

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, 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 do not seem to pose as big a problem for some people.

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 pre-packaged 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 whenever 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 caused 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 you have 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 synergistically i.e., together they have more power than individually.

Natural sources: Organ meats, fish and pork, eggs, cheese, milk and milk products.

Selenium

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

Natural sources: Tuna, herring, Brewer’s yeast, wheat germ and bran, broccoli and whole grains.

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 from NAC for glutathione production.

For 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 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 neurogenic 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, as does vitamin c.

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

Natural sources: potatoes, carrots, beets, yams, kohlrabi and others root vegetables.

Zinc

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

Natural sources: pumpkin seeds, sunflower seeds, organ meats, mushrooms, soybeans, and Brewer’s yeast.

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.

Natural sources: Mackeral, salmon, and sardines.

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.

Natural sources: Dark green leafy vegetables, organ meats, Brewer’s yeast, root vegetables, whole grains, oysters, salmon and milk.

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 condition seen in people with hepatitis C and associated with excess iron.

Special caution: people that have a tendency toward kidney stone formation should not take high doses of vitamin C.

Natural sources: Citrus fruits, rose hips, acerola cherries, sprouted alfalfa seeds, canteloupe, strawberries, broccoli, tomatoes and green peppers.

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. However supplementation with superdioxide mutase has not been shown to help. Adding the other antioxidants may give support to this area.

Natural source: Barley grass, broccoli, Brussels sprouts, cabbage, wheatgrass and most green plants.

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

activation in chronic hepatitis. C. Houglum K, Venkataramani A, Lyche K, Chojkier M. Gastroenterology, 1997;113:1069-1073.

Milk Thistle

Milk thistle is a powerful antioxidant. In addition to this it has antifibrotic effects i.e., 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 are 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 B₁₂. 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 deficiency has been linked to immune response, mild dementia, and peripheral neuropathy.

Natural sources: organ meats, fish and pork, eggs, cheese, tofu, milk and milk products.

Essential Fatty Acids (formally called vitamin f)

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 have an 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. Interestingly, avocados are very high in monounsaturates. Another good source is olive oil. However, one problem with monounsaturates is that they exclude vitamin E, found in polyunsatured fats.

Natural sources: flaxseed (58%) and canola oils, pumpkin, walnuts, and soybeans. Fish oils, such as salmon, cod, and mackerel. Primrose oil, black current seed oil, and borage oil.

SAMe

SAMe provides indirect 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 that 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 synthetase so adding methionine won’t increase the SAMe and therefore there is 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 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 500 mg which is equal to 1g.

Should Methionine Be Added to Paracetamol (Tylenol) Formulations?

- Caution in Patients with Liver Disease!

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

Adverse effects associated with methionine include nausea, vomiting, drowsiness and irritability. [8] Moreover, methionine should be used with caution in patients with severe liver disease as this agent may aggravate hepatic damage and this drug should not be used in patients with acidosis. [8] Although methionine (an amino acid) is an essential dietary constituent, studies have shown that methionine may cause reduced serum folate levels, leucocytosis, changes in serum pH and potassium and increased urinary calcium excretion when given at dosages of 8 to 13.9 g/day for 4 to 5 days. Moreover, functional psychoses have been seen in schizophrenic patients receiving higher dosages of 10 to 20 g/day for 2 weeks, and single doses of 8g have precipitated hepatic encephalopathy in patients with cirrhosis. [3] Although there is no evidence in humans, animal studies indicate that methionine may have adverse effects on the cardiovascular and coagulation systems. [3,4]

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: 301-44.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. 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 levels.

Natural sources: cold pressed oils, eggs, wheat germ, organ meats, molasses, sweet potatoes, leafy vegetables and dessicated liver.

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 the dosage needs to be monitored. Use with caution in cases of diabetic retinopathy. Those suffering from diabetes, rheumatic heart disease, or an overactive thyroid should not use high doses.

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 vet that deals with horses. Try phoning the pharmacies too. Sue A. was a great detective and tracked down the product at Kripp’s Pharmacy at 990 Granville Street ($13.45) and I have also ordered it from the London Drugs in West Vancouver. It is also known as udder cream.

You can buy this from Lee Valley as well. They are on the net at www.leevalley.com and are located here in Vancouver. 1.800.267.8767

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.

Sleep

As simple as it sounds, your best medication is 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 periodic limb movement disorder. While there has been no association of these 2 conditions with hepatitis C, I can't help but wonder if there 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.

Natural Interferon Boosters

by Zoltan P. Rona MD, MSc

http://www.naturallink.com/homepages/zoltan_rona/interferon/index.html

Interferon is a substance produced by the body's white cells to fight Infections, cancer, allergies and toxic chemical poisoning. Interferon can be made artificially and injected for some cancers and viral infections like hepatitis C. Studies indicate that many natural substances can activate the body's own production of interferon. Some better known natural interferon boosters are:

invaders of all types including cancer.

properties used for the treatment of colds and flus, coughs, fevers,indigestion and pain.

leafy vegetables and algae like spirulina, chlorella and barley green.

needed for all energy dependent processes in the body. CoQ10 increases helper T-cells and reduces infection risk.

There are over a dozen more natural interferon boosters available at most

health food stores and pharmacies alone or in combination. For more

information about safe and effective natural ways to boost immunity, see

your health care practitioner.

Chinese Medicine

http://www.europa.com/~itm/hepcnew.htm

Hepatitis C: Recent Treatment Strategies

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

VIRAL HEPATITIS BACKGROUND

Viral hepatitis has been a major human disease for at least 2,000 years. It is estimated that 15% or more of persons living in Southeast Asia and Japan are infected by hepatitis B, a retrovirus that frequently leads to chronic infection. The high incidence of viral infection is the most likely reason that liver cancer and liver cirrhosis have been two of the leading causes of death in China during recent decades (when records were kept). In Japan, hepatitis is cited as the primary reason that medical doctors prescribe Chinese herbs. Minor Bupleurum Combination (Xiao Chaihu Tang) as well as numerous other traditional prescriptions for treating symptoms characteristic of viral hepatitis have been administered and claimed to alleviate symptoms.

When persons who die from liver disease in S.E. Asia are checked for hepatitis B, the virus is found in about 80–85% of cases, indicating that fatal liver diseases mainly arise from chronic infection by hepatotropic viruses. Most of the investigation of hepatitis B has been undertaken for specific research projects, evaluating the role of the disease in China’s overall health problems, or the efficacy of various treatments. Until recently, it was relatively rare to test patients for hepatitis B as a matter of course in evaluating health complaints, and it is still not frequent practice.

It is only very recently that Chinese doctors began checking patients for hepatitis C, a virus that was isolated only a decade ago. It is now found to be a common viral infection in China, though not as prevalent as hepatitis B. A substantial proportion of patients with chronic liver disease who are tested are found to harbor both hepatitis B and hepatitis C. As with hepatitis B, testing for hepatitis C is mainly undertaken for specific research projects, not general health care.

The infection is also fairly common in the United States: hepatitis C is currently estimated to infect at least 3.5 million in the U.S., perhaps having been a factor in the death of 100,000 Americans already (mainly during the past decade). Hepatitis C now accounts for an estimated 150,000 newly diagnosed cases of viral hepatitis each year, while many cases continue to go undiagnosed. Approximately 10,000 people die annually from liver disease that is attributed to hepatitis C (liver diseases of all types kill about 40,000 people per year in the U.S. and much of this is now understood to be due to the presence of chronic viruses). About 1,000 people each year receive a liver transplant because of cirrhosis caused by hepatitis C, and the numbers would be higher if there were more livers made available for transplant.

Hidden Epidemic

The hepatitis C virus was not detectable until a test for it was developed in 1989. Prior to that, cases of hepatitis that could neither be explained by the then-known viral strains (A and B) nor as an evident result of drug side effects were described as non-A, non-B hepatitis. Hepatitis C (as well as numerous other hepatic viruses) is now known to be the main cause of non-A, non-B hepatitis. This virus has been spread by blood transfusions for at least three decades (see below), persisting in the blood supply for several years after hepatitis B was removed. The hepatitis B test was applied to all collected blood since the 1970’s; hepatitis C is no longer in the donated blood supply, having been eliminated by routine testing since 1990.

Hepatitis C is thought to be transmitted almost solely by direct blood . However, surveys of hepatitis C patients indicate that up to one in six cases might be caused by sexual with an infected person, and there appear to be cases where people living in the same home but having no sexual intimacy with an infected person can pick up the disease (accounting for up to one in ten infections). Most of the unexplained cases of hepatitis C transmission might actually involve some kind of less evident blood to blood transmission. It is suspected that blood s occur more often than people realize—sexual when there are lesions caused by other infections, tattooing or ear piercing under less than sanitary conditions, sharing of razors or toothbrushes, and during treatment of minor wounds.

The practice of sharing contaminated needles during illicit IV drug use is presently the main route by which the hepatitis C virus is efficiently spread. There have been three decades of increasing levels of IV drug use in the U.S., mainly in the inner cities, and more heavily among African-Americans. Despite increased attention to the health hazards involved with sharing needles, the practice continues. Recent reports indicate that more than 85% of IV drug users are now infected by hepatitis C. About one-third of all people coming to inner-city hospitals have hepatitis C, though the disease is found to some extent in all social classes, all geographic locations, and in all age groups. From the large pool of infected IV drug users it may be spread by sexual s as explained above. It is also transmitted from mother to child.

Evidence for hepatitis C infection is not obtained as part of routine medical screening. Even the liver enzyme tests that would indicate some degree of liver inflammation are still not standard in the CBC (complete blood count) ordered by many physicians during medical visits, so asymptomatic patients may go undiagnosed for years. While some people experience an acute hepatitis syndrome upon infection, which might lead one to be tested, that is not the usual situation. Acute hepatitis may manifest as a digestive disturbance that can be taken for "stomach flu," so that testing during the initial phase of disease is still not common. Even when measured, elevated liver enzymes are sometimes attributed to drinking of alcohol, which is a very common practice; in fact, the elevation might be caused by a virus and only exacerbated by the alcohol. Furthermore, some persons with active hepatitis C show only very mild elevations of liver enzymes, at levels for which doctors usually don’t express concern. In some cases the disease is not detected until there is need for a liver transplant (a similar situation existed with HIV infection, in which some individuals were unaware of the infection until experiencing a life-threatening case of pneumonia).

It is estimated that the interval from time of infection to time of significant liver cirrhosis, if that is to occur at all, is 20 to 30 years. The delayed expression of the disease is one reason why hepatitis C seems to be a sudden epidemic; another reason is the recent introduction of testing and the new awareness by medical doctors of the importance of testing (now that there are treatments available to administer when the virus is detected).

How the epidemic came about

A likely explanation for the current epidemic of hepatitis C in the U.S. is that the virus was brought to the U.S. primarily from Vietnam, mainly during the period 1964–1973. It may have been brought home by just a few hundred American soldiers (among the hundreds of thousands who served there) and then spread, silently, in the absence of diagnostics and with the normal delay in causing obvious liver disease.

A number of Vietnam veterans had blood transfusions during the war, were exposed to blood on the battlefield or at medical stations, had sexual relations with the Vietnamese, and/or used IV drugs (while in Vietnam or with other veterans after returning). Therefore, opportunities for transmission of a virus that existed in Vietnam were certainly present. Once the virus arrived in the U.S., there were opportunities for it to spread to non-veterans.

Blood transfusions in standard surgical practice were often administered without the patient ever being aware of the fact, or, at least, concerned about it. Thus, an individual diagnosed today with hepatitis C may not realize that they could have been infected when, for example, they had an operation 20 years ago and received blood from someone who carried the virus. Individuals who experimented with non-IV illicit drugs and tried an IV drug even once long ago may have been infected by the virus then; these individuals do not consider themselves IV drug users and may not regard the old incident as an actual example of IV drug use.

During the 1960’s and thereafter there was a "sexual revolution" in the United States that led to a large percentage of the teen and adult population having numerous sexual partners within a short period of time. This situation produced waves of STD’s, including herpes simplex, gonorrhea, chlamydia (the most frequently reported STD today), and HIV. A person who was infected by hepatitis C virus in the 1960’s or 1970’s might not easily associate a currently diagnosed case of chronic hepatitis C with sexual behavior of recent memory. Since it appears that sexual transmission of hepatitis C is very inefficient (it does not occur with notable frequency between marriage partners), it is most likely that this virus was only transmitted when there was unrecognized blood transmission, for example if there was an STD that caused lesions, permitting transmission to and from broken blood vessels. Many times, lesions are not obvious (especially in women), but they nonetheless serve to promote viral disease transmission. The rate of hepatitis C among unmarried persons with multiple sexual partners is about twice as high as that of the general population, implying a role for other STD’s in hepatitis C transmission via sex, though this increased infection rate may also be due to a higher prevalence of IV drug use among these individuals, with little role of sexual transmission.

Unlike HIV infection, which has been spread in the U.S. since 1976, hepatitis C does not appear to occur with much greater frequency in the male homosexual population than among others in the U.S. This surprises some researchers, and is sometimes explained by the low rate of sexual transmission of the virus, but it can be explained by several factors. If hepatitis C was originally acquired by and spread among a mainly heterosexual population (U.S. armed forces) and brought to the U.S. where it was transmitted primarily by blood transfusion, and to a lesser extent by sexual (initially being primarily heterosexual) and within households, then the disease would be seen with considerable frequency outside the male homosexual community. Of course, it could spread easily within that community as well, but if it were already in the other population subgroups, then there would be a more even distribution (as occurs with HIV infection in Africa). This distribution would seem reasonable with the relatively higher level of transmission via medical blood transfusion and IV drug use compared to sexual or other routes of transmission. Further, since hepatitis C was not detectable until recently, and since a large portion of the homosexual men who were involved with multiple sexual partners or with IV drug use experienced HIV infection and its symptoms, testing of these individuals for hepatitis C may simply not have occurred. Hepatitis C testing has not been a priority among medical doctors dealing with AIDS. Already, over 350,000 people have died of AIDS, the majority being homosexual men, most of them not tested for hepatitis C because the focus of testing and treatment was elsewhere. Further, HIV infection is often fatal within 15 years; less time than it usually takes for hepatitis C to cause obvious liver disease.

It is not yet reported whether hepatitis C is unusually prevalent in Vietnam, but it is known that the prevalence is fairly high in nearby Taiwan, and it is evidently fairly widespread in mainland China. Significantly, hepatitis C is frequently found in Vietnam veterans who visit the VA hospitals (although this high rate could be the result of IV drug use after returning to the U.S.) The rate of hepatitis C infection in France is nearly twice that of the U.S,. or of neighboring Germany and about four times that of Australia: French soldiers fought in Vietnam during the 1950’s, just prior to American involvement (giving more time for it to spread), which might explain this apparent anomaly.

In a study of stored American blood samples from World War II, hepatitis B—but not hepatitis C—was found. While hepatitis C probably existed at that time (and troops stationed in S.E. Asia may have been exposed), it was probably not as prevalent then and there may have been less chance to either pick it up or to transmit it to others.

Variable manifestation of disease

At this time, little is known about its pathogenesis following initial infection, except that the infection may remain without presenting evident symptoms for many years. The virus may impact quality of life, but the signs are not taken as evidence of a problem of hepatitis. Whether or not hepatitis C leads to significant liver disease in an individual may depend on secondary factors, such as the presence and activation of other viruses, especially herpes viruses (e.g., EBV, CMV, herpes simplex, HHV-6, HHV-7). Also the action of liver stressors, such as exposure to toxic chemicals in the work place, consumption of alcohol and/or drugs (prescribed or otherwise), or emotional disturbance, might stimulate the viral activity. It is known that for HIV infection, activation of a herpes virus can cause the viral load (amount of virus in the blood) to increase by up to five times (and then decline some time after the herpes returns to dormancy); it is possible that hepatitis C viral load (levels under 100,000/ml are considered low at this time) is also affected by transactivation (one virus activating another). Herpes viruses generally influence the retroviruses.

In the absence of effective treatments, the number of deaths due to advanced liver disease is likely to increase markedly as a result of the spread of both hepatitis B and hepatitis C viruses during the past couple of decades (as with hepatitis C, there is often a twenty year gap between infection by hepatitis B and manifestation of a life-threatening disease). One reason that there are not more deaths by liver disease is that many of those infected by hepatitis viruses succumb first to cardiovascular diseases or to cancers that start somewhere other than the liver. Much of this death is attributed to such common practices cigarette smoking and consuming high levels of dietary fat. It is possible that, since viral hepatitis can alter blood coagulation properties and reduces immune functions, the viral disease actually enhances the chance of death by these other diseases without being formally recognized as a cause.

It has been suggested that nearly all persons exposed to hepatitis C virus become chronically infected (rather than having an acute disease that resolves entirely) and that up to 60% develop chronic liver disease marked by elevated liver enzyme levels if they live through other hazards long enough. However, there are estimates that as few as 9% of hepatitis C infections will become serious (life-threatening), taking all factors into account. Liver cirrhosis and liver cancer are two major disease outcomes. Hepatitis B causes premature death in about 20% of those chronically infected and this is probably about the rate at which hepatitis C will prove fatal. For the other 80%, the consequence of infection is either minor or overshadowed by other diseases.

Monitoring treatment outcomes

The concept of cure in a case of an infectious disease, like hepatitis C, includes the complete elimination of the virus from the body, not just limitation of its action (remission). For this concept to be applied, one requires the modern knowledge of, and testing for, viral particles, something that has become common place only during the past few years. The PCR (polymerase chain reaction) test for hepatitis C viral RNA is, therefore, the current standard for measuring the status of the disease, and the determination method of a true cure. The test measures the "viral load," or the quantity of virus in the bloodstream. In someone who is cured, the viral load should be undetectable (technically, one cannot measure tiny amounts of virus, so one can only say below the limit of detection) and then continue to remain undetectable in the absence of any virus suppressing therapies for several years. At this time, it is not known whether hepatitis C can be cured according to this strict standard, partly because there hasn’t been enough time (since testing was developed) to determine whether any treatment has a long-term successful result. Interferon treatment produces an effective and prolonged response (up to about three years thus far monitored, but not necessarily a cure) in only 20–30% of those who try it, and it causes significant side effects in many. In fact, several participants in interferon studies withdrew during the first month of treatment (usual duration of treatment is six months). Recently, a combination of ribavirin and interferon has been offered; it appears more effective in lowering viral load than interferon alone (40% effective rate, with up to two years remission measured thus far), but the side effects are even greater, as ribavirin can cause significant bone-marrow suppression.

Currently, a viral load (before treatment) of below 100,000 is considered on the low side; this level is usually accompanied by few, if any, symptoms. A viral load of several million is possible and is usually found in persons with significant symptoms and signs of the hepatic disease. However, individuals who have undergone various treatments have reported alleviation of symptoms while viral load measurements remain quite high, so the viral load is not necessarily a good correlate to the symptomatology.

The immune system responds to viral hepatitis with, among other things, antibodies. These antibodies are generated, usually, when the virus is highly active, but may disappear when the virus is at low levels. Antibody tests are far less expensive than PCR tests, so one may measure whether the antibody test shows positive (indicating active virus with immune response to it) or negative (indicating less activity, with reduced immune response) as a cheaper evaluation tool. Converting from antibody positive to negative has been used in the past as a signal for "cure" of the disease, but we now know that this is not reliable.

Elevated liver enzymes, the signifier of liver inflammation, are caused by so many things (including recent use of the over the counter drug acetominophen) that unless the levels are quite high most physicians ignore them. However, given the extent of the viral hepatitis epidemic and its potential harm, it may be prudent to check for viral hepatitis when liver enzymes are found to be elevated. This viral assay can also be used to help confirm or refute the possibility that a drug or herb therapy is causing hepatic inflammation. In persons with viral hepatitis, elevated liver enzymes are usually a signal that the virus is replicating, destroying liver cells, and releasing the liver cell enzymes into the blood stream. The test for the enzymes (usually ALT, AST, and GGT, though other enzymes can be monitored) is less expensive and easier than antibody testing, and is used to monitor the health of the liver. If the liver enzyme levels in the blood are high and then become reduced after a treatment, this is taken as a sign of inhibition of the viral activity; still, the liver may become less inflamed while the virus remains active, so it is not a sure sign of viral inhibition. Normalization of liver enzymes will almost always correlate with freedom from symptoms of viral hepatitis, and may be interpreted as a "cure" only in the sense of freedom from clinical complaints. However, as with the antibody testing, this test only means that the viral activity is reduced, not that the virus is eliminated.

Liver biopsies are used to determine the extent of damage to the liver; in particular, this test will reveal the extent of fibrosis and fatty deposits. Such tests do little to indicate specific treatment strategies, with two exceptions: persons who have denied (due to limited health impact of the disease) that hepatitis C needs to be aggressively treated may change their minds if they find that their liver has been significantly damaged, and persons who show very extensive liver damage may be put on the list to receive a liver transplant (which is only warranted when the extent of liver damage is great).

Western medical interventions

The Western medical approach to hepatitis C follows the model used for hepatitis B: the main focus is to avoid infection in the first place, by screening the transfusion blood supply, determining transmission-risk behaviors and warning the population about them, and eventually developing a vaccine for those at risk (e.g., medical workers who may be exposed to blood). Development of a vaccine may be difficult because the hepatitis C virus mutates rapidly; so far, at least six subtypes have been identified. Further, within the blood of an individual patient, several different genome sequences are found, indicating that specific viral inhibitors—as well as vaccines—may be of limited value, similar to the situation with HIV. Post-infection treatment of hepatitis C mainly relies on various types of interferons (alpha interferon derivatives are common), alone or in combination with antiviral drugs (such as ribavirin). New drugs regimens are in various stages of research and development. In advanced cases, liver transplant becomes essential to saving the life of the patient.

Chinese medical analysis of hepatitis C

Physicians in China were alerted to hepatitis C mainly through the international medical literature. Due to the lesser availability of funds for testing compared to the situation for American and European doctors, Chinese physicians primarily investigate hepatitis C and its treatment in patients who are notably symptomatic for the disease and are seeking relief of symptoms. By contrast, many tens of thousands of Americans with asymptomatic disease may seek treatment simply because the virus showed up after routine examination indicated mildly elevated liver enzymes. Because Chinese doctors mainly deal with symptomatic patients and because testing of these patients is also limited, the analysis of symptoms and the alleviation of symptoms are a primary concern. For traditional doctors, the fact that the virus now involved is "C" rather than "B" has little significance in relation to treatment. Rather, the important factors are the symptom manifestation and the fact, known from modern science, that a virus is involved.

In an article by Chen Lihua (1), a traditional Chinese medical analysis of hepatitis C was presented. The author makes these three points about the disease characteristics and treatments:

In a study reported by Jin Shi and Chen Quanliang (2), the researchers examined 85 patients with hepatitis C and 37 patients with hepatitis B and compared their general symptom profile. The differential categories used were the following five that have been standardized for all kinds of hepatitis since 1992 by the Liver Disease Committee of the Chinese Association for Traditional Chinese Medicine and Pharmacology:

A general comparison showed that hepatitis C patients were generally older and had a history of blood transfusion; hepatitis B patients often had a close relative afflicted with the same disorder. At the same time, symptoms were much less severe in patients with hepatitis C. A comparison of TCM symptom complex showed equal distribution between the two types in relation to liver qi stagnation, yin deficiency, and yang deficiency, but a markedly higher incidence of blood stasis among patients with hepatitis C, and a markedly higher incidence of damp-heat among patients with hepatitis B.

However, these results may not reflect much on the difference between hepatitis B and C disease. Those with hepatitis C tended to have a higher incidence of blood stasis, but were also older: the elderly tend to have blood stasis. Those with hepatitis B tended to have higher incidence of damp-heat, but damp-heat is probably the main manifestation of more severe hepatitis (see below), which was the condition of those in the study with hepatitis B.

In the opinion of the authors of that report, TCM treatment protocols for hepatitis C should focus on the following: 1) clear pathogens and resolve toxins; 2) remove toxins by strengthening the righteous qi; and 3) transform stasis to prevent cancer formation (liver cancer is a major cause of death from chronic hepatitis). These are, in fact, about the same treatment principles as are often applied to hepatitis B.

Comparing hepatitis B and C, Hong Huiwen and his colleagues (3) examined 100 chronic hepatitis B patients and 50 chronic hepatitis C patients. As noted previously, the patients with hepatitis B tend to be younger than those with hepatitis C (32.7 vs. 46.1 years, mean values in this study). These authors thought that hepatitis B tended to be transmitted more with "socializing"—-indulgence in illicit injected drugs and unsafe sexual activity, among other things—which not only accounts for the younger age, but also the tendency for it to affect males (in their group, 89 males and 11 females had hepatitis B; in China it is primarily young men who partake in high-risk "socializing"). Getting a blood transfusion due to diseases of old age was thought to be the reason that hepatitis C tended to involve older individuals and have less sexual differentiation in incidence rates (35 males, 15 females in the hepatitis C group). As to the categories of disorder:

Hepatitis B Hepatitis C

Damp-heat 41% 26%

Blood stasis 1% 12%

Liver and kidney yin deficiency 15% 8%

Liver qi stagnation with spleen qi deficiency 42% 54%

Spleen and kidney yang deficiency 1% 0%

These findings tend to confirm the previous report, which was that there were similarities in frequency of liver and kidney yin deficiency, liver qi stagnation, and spleen/kidney deficiency between the two groups, but that there was more damp-heat with hepatitis B and more blood stasis with hepatitis C. The authors also presented information on the tongue and pulse qualities. Generally, patients with hepatitis B tended to have a pale or dark tongue and a yellow greasy coating and a fine wiry pulse or a wiry slippery pulse; patients with hepatitis C tended to have a dark or dark purple tongue, with a thin white coating, and a fine wiry pulse. These findings lend further support to the contended differentiation into damp-heat and blood stasis categories for hepatitis B and C, respectively.

Without giving details of treatment, the authors state that of the recipes that were given to patients with hepatitis B, there was a higher proportion of heat-clearing herbs and dampness eliminating herbs, with the following ingredients being dominant: hu-chang, oldenlandia, wild chrysanthemum, dandelion, and coptis. For hepatitis C, heat-clearing and blood-cooling herbs were relied upon, mainly: lonicera, oldenlandia, hu-chang, dictamnus, duchesnia, solanum, and lithospermum. The formulas for hepatitis B tended to have more ingredients than those for hepatitis C. Some therapies relied on astragalus and other qi-tonic herbs. In general, hepatitis-C patients received larger doses of astragalus when that ingredient was included.