The liver is one of the vital organs of our body; its weight is about 1.44-1.66 kg in an adult, which is essential for one’s health and wellbeing of an individual. One cannot survive in life without the liver as it performs everyday physiological functions in human life. So it is the job of an individual in maintaining his or her own health and wellbeing by protecting and nurturing the liver. The word “Cirrhosis” derives from the Greek word Kirrhos which means yellowish orange colour of diseased liver of patient. Liver cirrhosis is the final stage of liver disease which leads to obstruction and liver failure. In other sense, the active liver tissue is replaced by inactive tissue incapable of normal functioning. Such cells get filled with fibrous tissue and fat [1]. The cirrhosis is caused by various factors across the world like: Hepatitis B virus, hepatitis C virus, alcoholic liver disease, fatty liver, jaundice, non-alcoholic steatohepatitis, haemo-chromatosis, autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis [2]. Liver cirrhosis is characterized by poor life expectancy and is a leading cause of mortality and morbidity. Cirrhosis is the 3^rd most common cause of death in people aged between 45-65 years behind heart disease and cancer. Non-alcoholic fatty liver disease is a serious liver disease and cause serious and dangerous health problem in Kashmir valley. It is reported that, to stop liver disease caused by non-alcoholic fatty liver disease, we need to be on roads and in gyms rather than sedentary life style and driving luxurious cars [3]. Moreover, according to studies alcoholism in the western countries and HBV infection in India are the most common causes of cirrhosis [4-6]. HBV infection is one of the major causes of liver cirrhosis and affects an estimated 400 million people worldwide. It has been estimated that one million people die annually from HBV-related liver diseases [7,8]. Recently, Tahira et al. reported that adolescents in Pulwama district of Kashmir valley follow unhealthy eating habits thus increase the risk factors for chronic non communicable diseases in a later age such as coronary heart disease, diabetes, hypertension, obesity and cancer. In view of the literature discussed above, we choose this study with the aim to determine the patient's life style and dietary habits of liver cirrhotic patients.

It was a prospective cross sectional study conducted among 500 liver cirrhotic patients who visited or were admitted in Gastroenterology Department of SKIMS Soura and SMHS hospital Srinagar during the periods of 2014-2015. The tool used in the present study was essentially a questionnaire. This was pre-tested on 10 liver cirrhotic respondents in order to ensure the validity and feasibility of questionnaire before administering it on the entire sample. The patients were explained about the purpose of the study, and on obtaining their consent; data were collected from the participating patients. All data were statistically analysed through statistical package for social science (SPSS) software version 20.00 and Microsoft excel. Metric data was described as mean ± SD. Non parametric data was expressed and described as percentages. The intergroup comparison for such data was done by Chi-square analysis, Mean, SD, odds ratio were used. Significance was evaluated as follows:

• P-value: >0.05 (Non-significant)

• P-value: <0.05 (Significant)

• P-value: <0.01 (Highly significant)

The total respondents were 500 out of which 300 were from rural area and 200 were from urban area. It was observed that out of 300 rural respondents 222 (44.4%) were males and 78 (15.6%) were females as shown in Table 1. Statistically distribution of male and female respondents is not uniform (P<0.01). Further, it was observed that out of 200 urban respondents 147 (29.4%) were males and 53 (10.6%) were females (p<0.01). The results of our study are in agreement with the studies conducted by Singh et al., Teiusanu et al., Ullah, Chalasani, Arguedas and Nevens. Thus, it is concluded that males were more affected than females’ patients with this disease [9-14].

Table 1: Distribution of studied respondents.

Figure 1 shows that the disease is more prevalent in the age group of 46-60 years (30.8% were males and 13.4% were females) followed by the age group of 30-45 years (28.8% were males and 9.8% were females). In a study conducted by Ullah [11] on 95 cirrhotic patients at Peshawar revealed that the disease was more common in the age group of 40-60 years. Other studies conducted by Teiusanu, Heron, Najman, Leyland, Lewis revealed that the disease is more occurring in the age group of 46-60 years of age [10,11,15-18]. Thus our results are in agreement with these studies.

Figure 1: Distribution of patients as per age group.

Socioeconomic status of the liver cirrhotic patients is presented in Table 2. It was observed that 96.93% (71.6% males and 25.33% females) rural patients were married and in urban area 98.5% (73% males and 25.5% females) studied respondents were married. Most of the patients investigated were illiterate 62.66% rural and 58% urban respondents. Regarding occupation of the studied respondents, in rural area majority of the male patients were labourers (66.33%), 4.33% males were employed, 3.33% males were unemployed and 24.66% females were housewives.

Table 2: Socioeconomic status of respondents (n=500).

Further, it was observed that in urban area 63.5% male patients were labourers, 7.5% males were employed, 2.5% males were unemployed and 26% females were housewives. 91.33% rural and 95.5% urban had nuclear type family and only 8.66% rural respondents and 34.5% urban patients had joint type family system. Further, it was observed that majority 95.33% of rural studied respondents (73% males and 22.33% females) and 94.5% urban studied respondents (72% males and 22.5% females) belonged to lower socioeconomic class whose monthly income is <5000 INR. It was observed that majority (65%) of rural male respondent sand 11.33% female respondents were smokers. Further, it was observed that majority of urban males (69.5%) and females (14%) were smokers and remaining 4% males and 12.5% females were non-smokers. Statistically, it was observed that there is a no-significant difference between socio demographic characteristics of studied liver cirrhotic respondents (P>0.05). Idris and Ali [19] in their study on 28 liver cirrhotic patients observed that out of 28 study respondents 54% were married ones. So our result competes with this observation. Ahsan [20] in their study on lifestyle, nutritional status and seroclinical profile of liver cirrhotic patients in Bangabandhu observed that the liver cirrhosis is more prevalent in low income family groups. A study conducted by Debakey et al. [21] on liver cirrhosis mortality in USA revealed that cirrhosis is more prevalent in individuals belonging to low economic group [22].

The data presented in Table 3 reveals that non-alcoholic fatty liver was the predominant underlying cause of respondents and was seen in 66.32% rural (48.66% males and 17.66% females) and 67% urban (48% males and 19% females) respondents. Statistically, it was observed that there is a highly significant difference between male and female respondents in chronic alcoholism as a causative agent from both areas (P<0.01). Further, it was observed that in rural respondent so their infection was present in 19.99% (14.33% males and 5.66% females), alcohol in 15.32% (14.66% males and 0.66% females) and hepatitis B in 17.99% (14.33% males and 3.66% females). But in case of urban respondents infection was present in 22% (18.5% males and 3.5% females), hepatitis in 15.56% (11.56% males and 4% females), and alcohol in 12.5% (12% males and 0.5% females) as a causative agent. Statistically highly significant difference between male and female respondents was seen in urban respondents with non-alcoholic fatty liver and infection (P<0.01).

Table 3: Repartition of respondents as per aetiology.

The data presented in Table 4 shows that the majority of the male respondents 58.33% rural and 59.5% urban and in case of female respondents 20% rural and 22% urban take salt tea in comparison to consumption pattern of sweet tea which is much low in both genders. Further, it was observed that in case of type of tea there is a nonsignificant difference between rural and urban consumers (P>0.05). It was also observed that majority of respondents 93.33% (69% males and 24.33% females) rural and 90.5% urban respondents (67% males and 23.5% females) consume fried foods or street foods. Our results are in partial agreement with the study of Idris and Ali [19] who found that all of the studied respondents were dependent on junk foods in the form of street fatty foods. They showed lack of interest in nutrition.

Table 4: Pattern of tea and fried foods consumption in respondents.

The data presented in the Table 5 reveals that majority 50.66% (36% males and 14.66% females) of rural and 46.5% (39.5% males and 7% females) urban respondents use Kashmiri masala tikki (wur ) in some foods followed by 32.33% (25.33% males and 7% females) rural and 37.5% (23% males and 14.55 females) urban respondents using kashmiri masala tikki (wur ) weekly. Further, it was observed that only 15.66% (11.66% males and 4% females) rural and 18% (11% males and 7% females) urban respondents use Kashmiri masala tikki (wur ) daily in their food preparation. Statistically, there is a significant difference between rural and urban consumers of kashmiri masala tikki (wur ) weekly in their food items (P<0.05). It was also observed that majority of the respondents i.e., (69.33% rural and 72% urban) males and (25% rural and 26.5% urban) females were using spicy foods. Further, it was observed that only 4% rural respondents and 1% urban respondents use moderate spices in their diet. Statistically it was observed that there is non-significant difference between male and female consumption of spicy foods (P>0.05). further, it was observed that in case of smoked meat and fish consumers there was no significant difference between rural and urban respondents (P>0.05). It was found that majority 93.32% (70.66% males and 22.66% females) of rural respondents consumed smoked meat and fish. While as 54% of urban males and 19.5% females didn’t consume smoked meat and fish. Only 26.5% (19.5% males and 7% females) urban respondents consumed smoked meat and fish. Further, it was observed that 48.99% (36.33% males and 12.66% females) rural and 8% urban respondents consume smoked meat and fish monthly. 32% rural respondents (25% males and 7% females) and 3.5% urban respondents (1.5% males and 2% females) consumed smoked meat and fish daily and 12.33% rural respondents (9.33% males and 3% females) and 15% urban respondents (10% males and 55 females) consumed smoked meat and fish weekly.

Table 5: Dietary habits of respondents.

Our research indicated that liver cirrhosis in Kashmir valley is more seen in males from rural areas having nuclear type of family system and belonged to low socioeconomic group. The main etiology of this disease in Kashmir valley is fatty liver and hepatitis B. Smoking habit was also seen in both male and female respondents in terms of cigarette, hookah, naas, bidi also alcohol consumption was observed. The respondents showed poor eating habits, faulty dietary habits, lack of interest in the nutritional side and dependence on junk foods, spicy foods, and dried vegetables which significantly influence the level of treatment on the nutritional side. Malnutrition is common in end stage liver disease and adversely affects prognosis.

The most common and difficult to handle myth about liver disease is that there should be almost complete restriction of dietary fat and protein intake in diet, which is in contrast to the actual scientific dietary advices for such patients. Hence it is recommended that we should regularly and persistently convince the patient and relatives to give high protein and fat diet with less of salt, as decided upon degree of decompensation.