Help patients organize a healthy approach to nutrition
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Surgical outcomes are affected by key factors that orthopedic surgeons assess before and during the episode of care.
Surgical factors are our primary focus. However, we are also responsible for understanding the healing process and guiding rehabilitation. Other perioperative concerns include anesthesia, postoperative pain management and preventative strategies, such as routine use of antibiotics and thrombosis prevention.
Patient-specific factors
Of increasing importance, yet often difficult to influence and manage, are patient-specific factors, such as age, overall patient fitness, social determinants of health, lifestyle choices and nutritional status. We provide realistic expectations of surgical care, which may also come with a sense of pessimism about achieving the ideal result given patient-specific factors. Certain patient characteristics may not be modifiable and are out of the surgeon’s control, which can significantly impact surgical outcomes. The overall duty of surgeons is to prioritize patients’ health, which includes a comprehensive approach to achieving ideal outcomes, including preoperative interventions known to impact surgical results.
The surgical team should incorporate a full preoperative patient assessment, as well as request preoperative clearance from primary care providers and medical specialists as indicated. Factors, such as age, cannot be modified and impact patient tolerance for the stress of surgery, ability to heal and ability to rehabilitate appropriately. Patient-specific factors also affect the choice of surgical intervention, such as soft tissue repair vs. arthroplasty.
Smoking and alcohol and drug use are modifiable social behaviors and should be discussed with patients. Unfortunately, resolution of the behaviors either takes months or years to make a difference or has already resulted in permanent damage. Patients should be offered referrals to cessation programs that can provide a pathway to healthier lifestyles.
Obesity
Recent CDC data indicate 41.9% of the U.S. population is obese (BMI 30 kg/m2), with 9.2% considered severely obese (BMI 40 kg/m2). With more than 50% of the U.S. adult population exceeding the recommended healthy weight, many patients have accepted overweight as the norm despite its impact on health and surgical care.
Orthopedic surgeons may not be experts iregarding diet and nutrition, however, we should have a basic understanding and appreciation for the impact of nutrition on surgical outcomes. We are ultimately held responsible for outcomes despite nutritional factors outside of our control. Concern for patients’ overall health should prompt discussion with patients who are overweight or obese. We should discuss the increasing collection of evidence on the importance of overall nutrition and and be willing to participate in screening programs to assess nutritional status.
The risks of surgical procedures are affected by malnutrition and should also be discussed as part of informed consent. For example, patients should be informed that the risk of postoperative infection, poor wound healing and delayed recovery from surgery have been related to low albumin levels, and they can take measures to mitigate their risk.
Establish dialogue
Respecting patients’ autonomy on decisions that affect their health is essential to ethical patient management. Establishing dialogue on perioperative nutrition is time-consuming, but essential to providing the highest standard of care for surgical management.
We cannot assume patients with obesity are well nourished. Obesity is one side of the burden of poor nutrition and may coexist in malnourished patients. Before the orthopedic evaluation, the patient can complete simple screening tools, such as the Subjective Global Assessment, a questionnaire that helps differentiate nutritional risks and screens for patients who would benefit from nutritional intervention. The Mini Nutritional Assessment also has been demonstrated to be an effective screening tool for joint replacement patients.
Serum albumin is associated with outcomes after joint replacement and hip fractures. Serum prealbumin has a shorter half-life and reflects current nutritional status. Levels of serum albumin less than 3.5 g/dL are indicative of malnutrition and are predictive of higher complication rates.
A comprehensive laboratory screening panel for malnutrition may include serum albumin, serum prealbumin, transferrin and total lymphocyte count. Vitamin D deficiency is a common finding in less sun-exposed environments and may affect patients of all ages and can be considered part of preoperative screening for malnutrition. Further investigation into a patient’s nutritional status may be warranted if any of these labs are abnormal.
Organize a healthy approach
Proper nutrition impacts outcomes in every patient population. Proper nutrition is essential for tissue healing, minimizing inflammation, bone health, preserving muscle function, the effectiveness of our immune system and reducing infection risk and other complications. In addition, nutrition should be considered as part of the pain management program, beginning with enhanced recovery after surgery (ERAS) protocols to reduce patient stress, stabilize physiological management of blood glucose and electrolytes, and provide rapid recovery from the effects of anesthesia. Nutraceuticals, such as omega-3 fatty acid supplements and other antioxidants, can reduce postsurgical inflammation and benefit pain relief.
Orthopedic surgeons should have informative preoperative discussions about nutrition with patients of all ages and orthopedic conditions. As part of our responsibility to patient well-being, especially when surgical intervention is considered, we should help organize a healthy approach to nutrition. Appropriate patient populations should be screened subjectively and objectively for malnutrition. Patients should be encouraged to follow a well-balanced diet and avoid smoking, alcohol and drug use.
Due to the stress of surgery and postoperative recovery, patients should be encouraged to increase protein intake 2 to 4 weeks before surgery and continue for 2 to 4 weeks postoperatively. Patients should be provided guidance on the supplements agreed upon with the anesthesia team using the ERAS approach. Patients should take a comprehensive multivitamin daily, which can be supplemented with additional nutrients and nutraceuticals depending on nutritional assessment.
Surgeons can suggest additional nutritional support with vitamin D and calcium for bone health, vitamin C for wound healing, iron for patients with anemia or when blood loss is expected, omega-3 fatty acids for anti-inflammatory support, and possibly collagen supplementation for joint, bone and skin health. Proper sleep and daily exercise are other valuable recommendations. Providing patients with this level of guidance helps develop patient engagement needed to achieve the most favorable outcomes and highest standard of care.
- References:
- Blevins K, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.04.027.
- Cross MB, et al. J Am Acad Orthop Surg. 2014;doi:10.5435/JAAOS-22-03-193.
- https://www.cdc.gov/obesity/data/adult.html.
- https://www.mna-elderly.com/sites/default/files/2021-10/mna-mini-english.pdf
- https://pt-global.org/pt-global/
- Phillips JLH, et al. J Am Acad Orthop Surg. 2023;doi:10.5435/JAAOS-D-22-01035.
- For more information:
- Anthony A. Romeo, MD, is the Chief Medical Editor of Healio | Orthopedics Today. He can be reached at Healio, 6900 Grove Road, Thorofare, NJ 08086; email: orthopedics@healio.com.
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