- What is nutritional optimization?
- Can surgical outcomes be influenced by nutrition?
- Protein supplementation improving surgical outcomes
- Preoperative carbohydrates for metabolic stress
- How to implement nutrition optimization in practice
Nutrition is an important, yet often overlooked component of surgery. Did you know that optimizing patients through nutrition can help mitigate the risks of surgery, improve outcomes and promote recovery?
Orthopedic surgery puts significant stress on your patients’ bodies, which can impede recovery. While there are several medical interventions that are used to minimize this stress, nutrition is a high-impact, low-risk intervention that is often under-utilized. The right nutrition in the perioperative period can lead to a better surgical recovery. ERAS (Enhanced Recovery After Surgery) guidelines highlight a peri-operative care standard that is designed to lead to a better and earlier recovery and emphasize the use of perioperative nutrition 1–4.
What is nutritional optimization?
Nutritional optimization refers to using nutrition to optimize patients’ metabolic state prior to surgery to improve outcomes1. Before and after surgery, orthopedic patients have alterations in metabolism that impacts the body’s ability to recover2,3; nutrition optimization improves outcomes by addressing these metabolic changes2–4.
Can surgical outcomes be influenced by nutrition?
The stress of surgery can lead to catabolism, a breakdown of the body’s tissues. These losses of body proteins result in detriments to strength, mobilization, immune function, and wound healing7–9. Surgical stress can be worsened by poor nutrition in the perioperative period and lead to worse outcomes. Poor nutrition and nutrition status in orthopedic surgery is associated with:
- Increased risk of surgical site infection10,11.
- Increased risk of readmission12
- Longer length of stay12
- Delayed mobilization13
- Increased risk of revision14
- Increased risk of overall complications13–15
- Increased risk of postoperative infection 14
In the context of orthopedic surgery, two nutrients have been shown to have a benefit: protein and carbohydrate 1–3,16,17. Specifically, protein supplementation and presurgical carbohydrates are interventions that minimize catabolism in the perioperative period to preserve muscle mass and function and accelerate healing 6,17.
Protein supplementation improving surgical outcomes
In orthopedic surgery, perioperative protein and amino acid supplementation have been shown to:
- Improve markers of malnutrition 16,17
- Reduce muscle atrophy 18–21
- Attenuate markers of inflammation17,18
- Increase promoters of bone regeneration 17
- Reduce pain scores21
- Reduce disability scores21
- Accelerate wound healing17
Protein is important for maintaining body tissues like muscle, rebuilding tissue injury during surgery, and maintaining healthy immune function5,7,8. Inadequate protein intake surrounding orthopedic surgery, which can impair mobility, delay wound healing, and increase the risk of surgical site infection10.
Protein requirements double in the perioperative period from 0.8g/kg of bodyweight per day to over 1.6g/kg of bodyweight per day4,22. Most patients cannot get this amount of protein from diet alone, especially with reduced appetite as a common side effect of surgery3,23. High quality protein supplements like ISOlution can help your patients meet their elevated protein needs, to have better outcomes, and get back to what they love doing faster6.
Protein supplements taken before and after surgery are recommended for nutrition optimization. Taking protein before surgery stimulates muscle protein synthesis, so that function is maximized in advance of the stressful event of surgery20. This is important as many of the conditions that lead to orthopedic surgery often involve inflammation, which increases the body’s protein requirements24. This means that many of your patients are going into surgery at a protein deficit. Low levels of mobility due to injury or disease leading up to surgery exacerbates this problem as patients go into surgery with sub-optimal muscle mass, further limiting function and recovery 25,26.
Preoperative carbohydrates for metabolic stress
Preoperative carbohydrate loading in the form of complex carbohydrate drinks taken before surgery have been shown to reduce post operative insulin resistance, which the body’s natural response to stress29. The benefits of preoperative carbohydrate loading are:
- Reduced postoperative catabolism29,30
- Reduced muscle loss29,30
- Reduced length of hospital stay29,30
- Improved wound healing29–31
- Perioperative glucose control29,30
Not only that, but these complex carbohydrate drinks can give your patients a better surgery experience and improve patient satisfaction by decreasing patient discomfort before and after surgery29,31,32.
Best practice for preoperative carbohydrate loading is 800mL of a 12.5% maltodextrin carbohydrate drink taken the night before surgery and 400mL of a 12.5% maltodextrin carbohydrate drink taken 2-3 hours before surgery. Preoperative carbohydrate drinks like PREcovery help replete glycogen stores in the muscle and liver, provide hydration and reduce surgical stress.
How to implement nutritional optimization in practice
The Ortho Nutrition Bundle (ONB) was created with researchers and orthopedic surgeons to align with the principles of nutrition optimization for orthopedic surgery.
The Ortho Nutrition Bundle consists of:
- 2 weeks of preoperative protein supplementation (ISOlution) to give patients the protein they need to replenish and build body proteins like muscle;
- A preoperative complex carbohydrate drink (PREcovery) which improves post-operative metabolism and patient experience;
- 2 weeks of post-operative protein supplementation to maintain muscle mass and improve surgical healing.
The Ortho Nutrition Bundle takes the guesswork out of nutritional optimization and implements seamlessly into your practice's existing patient workflow. Get in touch with us at 1-800-619-0783 or firstname.lastname@example.org to know more.
Authored by: Leila Hammond, Registered Dietitian, MHSc.
Wainwright, T. W. et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. New Pub: Medical Journals Sweden 91, 3–19 (2019).
Debono, B. et al. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. The Spine Journal 21, 729–752 (2021).
Gillis, C. et al. Food Is Medicine: A Qualitative Analysis of Patient and Institutional Barriers to Successful Surgical Nutrition Practices in an Enhanced Recovery After Surgery Setting. Nutrition in Clinical Practice 34, 606–615 (2019).
Weimann, A. et al. ESPEN guideline: Clinical nutrition in surgery. Clinical Nutrition 36, 623–650 (2017).
Evans, D. C., Martindale, R. G., Kiraly, L. N. & Jones, C. M. Nutrition Optimization Prior to Surgery. Nutrition in Clinical Practice 29, 10–21 (2014).
Hirsch, K. R., Wolfe, R. R. & Ferrando, A. A. Pre- and Post-Surgical Nutrition for Preservation of Muscle Mass, Strength, and Functionality Following Orthopedic Surgery. Nutrients 13, (2021).
Gillis, C. & Carli, F. Promoting Perioperative Metabolic and Nutritional Care. Anesthesiology 123, 1455–1472 (2015).
Demling, R. H. Nutrition, Anabolism, and the Wound Healing Process: An Overview. Eplasty 9, e9 (2009).
Windsor, J. A. & Hill, G. L. Weight loss with physiologic impairment. A basic indicator of surgical risk. Ann Surg 207, 290 (1988).
Tsantes, A. G. et al. Association of malnutrition with periprosthetic joint and surgical site infections after total joint arthroplasty: a systematic review and meta-analysis. Journal of Hospital Infection 103, 69–77 (2019).
Tsantes, A. G. et al. Association of malnutrition with surgical site infection following spinal surgery: systematic review and meta-analysis. Journal of Hospital Infection 104, 111–119 (2020).
Bohl, D. D., Shen, M. R., Kayupov, E. & della Valle, C. J. Hypoalbuminemia Independently Predicts Surgical Site Infection, Pneumonia, Length of Stay, and Readmission After Total Joint Arthroplasty. J Arthroplasty 31, 15–21 (2016).
Nanri, Y. et al. Preoperative malnutrition is a risk factor for delayed recovery of mobilization after total hip arthroplasty. PM&R 13, 1331–1339 (2021).
Yi, P. H. et al. Is Potential Malnutrition Associated With Septic Failure and Acute Infection After Revision Total Joint Arthroplasty? Clinical Orthopaedics and Related Research® 2014 473:1 473, 175–182 (2014).
Schwartz, A. M., Wilson, J. M., Farley, K. X., Bradbury, T. L. & Guild, G. N. Concomitant Malnutrition and Frailty Are Uncommon, but Significant Risk Factors for Mortality and Complication Following Primary Total Knee Arthroplasty. J Arthroplasty 35, 2878–2885 (2020).
Hirsch, K. R., Wolfe, R. R. & Ferrando, A. A. Pre-and Post-Surgical Nutrition for Preservation of Muscle Mass, Strength, and Functionality Following Orthopedic Surgery. (2021) doi:10.3390/nu13051675.
Burgess, L. C., Phillips, S. M. & Wainwright, T. W. What Is the Role of Nutritional Supplements in Support of Total Hip Replacement and Total Knee Replacement Surgeries? A Systematic Review. Nutrients 2018, Vol. 10, Page 820 10, 820 (2018).
Preoperative High-Protein Diet Can Improve The Serum Albumin Levels of Patients Undergoing Total Knee Arthroplasty. (2020) doi:10.21203/RS.3.RS-115657/V1.
Khalooeifard, R., Oraee-Yazdani, S., Keikhaee, M. & Shariatpanahi, Z. V. Protein Supplement and Enhanced Recovery after Posterior Spine Fusion Surgery: A Randomized, Double-blind, Placebo-controlled Trial. Clin Spine Surg 35, E356–E362 (2022).
Muyskens, J. B. et al. Cellular and morphological changes with EAA supplementation before and after total knee arthroplasty. J Appl Physiol 127, 531–545 (2019).
Muyskens, J. B., Winbush, A., Foote, D. M., Turnbull, D. W. & Dreyer, H. C. Essential amino acid supplementation alters the p53 transcriptional response and cytokine gene expression following total knee arthroplasty. J Appl Physiol 129, 980–991 (2020).
Dreyer, H. C. et al. Essential Amino Acid Supplementation Mitigates Muscle Atrophy After Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial. JB JS Open Access 3, E0006 (2018).
Khalooeifard, R. et al. Effect of Protein Supplement on Paraspinal Muscles in Spine Fusion Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial. Int J Spine Surg 15, 47 (2021).
Smith-Ryan, A. E., Hirsch, K. R., Saylor, H. E., Gould, L. M. & Blue, M. N. M. Nutritional considerations and strategies to facilitate injury recovery and rehabilitation. J Athl Train 55, 918–930 (2020).
Hope, K., Ferguson, M., Reidlinger, D. P. & Agarwal, E. “I don’t eat when I’m sick”: Older people’s food and mealtime experiences in hospital. Maturitas 97, 6–13 (2017).
Guadagni, M. & Biolo, G. Effects of inflammation and/or inactivity on the need for dietary protein. Curr Opin Clin Nutr Metab Care 12, 617–622 (2009).
Paddon-Jones, D. et al. The catabolic effects of prolonged inactivity and acute hypercortisolemia are offset by dietary supplementation. J Clin Endocrinol Metab 90, 1453–1459 (2005).
Paddon-Jones, D. et al. Atrophy and impaired muscle protein synthesis during prolonged inactivity and stress. J Clin Endocrinol Metab 91, 4836–4841 (2006).
Pogatschnik, C. & Steiger, E. Review of Preoperative Carbohydrate Loading. Nutr Clin Pract 30, 660–664 (2015).
Yuill, K. A., Richardson, R. A., Davidson, H. I. M., Garden, O. J. & Parks, R. W. The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively - A randomised clinical trial. Clinical Nutrition 24, 32–37 (2005).
Kratzing, C. Pre-operative nutrition and carbohydrate loading. Proc Nutr Soc 70, 311–315 (2011).
Bilku, D. K., Dennison, A. R., Hall, T. C., Metcalfe, M. S. & Garcea, G. Role of preoperative carbohydrate loading: A systematic review. Ann R Coll Surg Engl 96, 15–22 (2014).