Late evening snack: Exploiting a period of anabolic opportunity in cirrhosis

Background and Aim: Cirrhosis is a state of accelerated starvation with impaired protein synthesis. Increased rate of gluconeogenesis and alterations in skeletal muscle signaling pathways result in anabolic resistance and consequent loss of muscle mass or sarcopenia in cirrhosis. Late evening snack (LES) is an intervention to reduce the postabsorptive (fasting) phase with the potential to improve substrate utilization and reverse sarcopenia. Published reports were evaluated to examine the effect of LES on regulation of substrate utilization (short-term studies) and nutritional outcomes (long-term studies). Methods: PubMed, EMBASE, Google scholar and OVID databases were searched. All studies published on LES in cirrhosis were included. Studies that included few ( n < 3) subjects and patients with hepatocellular carcinoma were excluded. Results: Late evening snack decreased lipid oxidation and improved nitrogen balance, irrespective of the composition or type of formulation used. Daytime isocaloric isonitrogenous snacks did not have the metabolic or clinical benefit of LES. LES decreased skeletal muscle proteolysis. No studies have examined its effect on muscle protein synthesis. There was inconsistent translation into an increase in lean body or skeletal muscle mass. Improved quality of life occurs but decreased mortality or need for transplantation has not been reported. The optimal composition of LES has not been defined, but based on mechanistic considerations, a branched chain supplemented LES holds most promise. Conclusions: Late evening snack holds the most promise as an intervention to reverse anabolic resistance and sarcopenia of cirrhosis with improved quality of life in patients with cirrhosis. Long term benefit and improved survival need critical evaluation.