Optimizing Surgical Outcomes with Nutrition: Why and How
Nutritional deficiency affects up to 50% of rotator-cuff patients and increases re-tear risk 400-600%. Specific interventions like protein with leucine, pre-op carbs, and vitamin D reduce complications by 38% and improve healing, with high patient uptake when offered as a simple supplement packet.
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Nutrition, I'll tell you, nutrition's overlooked. The impact actually is on par with a lot of these things that we're doing that are more expensive. We talked a lot about Allograft yesterday. I don't think you can talk about biology without considering this. Implementation is easy. So what do most people tell nutrition? They usually say, I don't know, eat well. And what's wrong here is, you know, if you look at the athlete who's highly primed, they have all these resources, and yet we take somebody who is less optimized We give them no advice, and yet they're going through a stressful event, right? They have increased demands. They're more active than they used to be, from the young athlete to the older patient. And we're putting them through something that's really a challenge. To— going through surgery is no joke. Nutritional deficiency is very common. You can see numbers here. It's 21% of arthroplasty patients. I showed you the data yesterday on rotator cuff, and again, if you look at this, you have half the patients at risk And when you look at the odds ratio, you're talking about a 400 to 600% increase of retear. Now that's larger than even tear size and age, so this is a really important thing. And it's not just the elderly. Young patients who are having ACL, etc., have a very high risk profile. So large studies show that if you give nutritional guidance across all specialties, you reduce complication by 38%. What else can we do that's so simple that reduces complications by 38%? And patients report that they don't know what to take. But if you direct them, the vast majority will do something. So I'm going to go over protein, carb loading, vitamins, and other kind of things that are an option, and talk a little bit about the delivery. So let's talk about protein first. What happens here is protein requirements double after surgeries. Patients only get about 30% of their requirements. If any of you had surgery, you know you get disuse atrophy very rapidly. 7 days of mobilization decreases strength by 20 80%. 5 days of bed rest is 5 years of aging in terms of muscle loss. You put people in a sling, they get muscle loss rapidly. So the concept here is to modify by increasing their protein, and the real key is to be high in leucine. Leucine is the most important amino acid in muscle synthesis, and a variety of studies have shown that if you supplement with leucine— this is healthy patients, so pretty much everybody in this audience— you bed rest them they get muscle atrophy. If you give them leucine, 3 grams, you reverse that. And the key is that leucine that you get in an over-the-counter protein product is typically 1 to 2 grams, and you need a 3-gram dose. This is an example of another study, uh, showing the same thing. You see mobility was much higher day 15 after surgery when they were supplemented with leucine. Another important one is glutamine. Glutamine is the most important amino acid in the body. It's very important in immunity as well. So let's look at some trials on amino acids supplementation. This is total knee arthroplasty. There's no studies currently in the shoulder. We're currently starting a randomized prospective trial, but this is the data we have. And you see here that if patients were supplemented, they just gave that 4 weeks afterwards, you see that strength was much better. Uh, what's interesting here is that when you look at the change, it wasn't just short-term, but it's at 2 years later they were doing better. So what this suggests is there's a critical window that if you can modify by just giving them a little bit of guidance, they do better, not just short-term but long-term. Spine fusion data here. I know it's not shoulder, but this is really compelling. You look at fusion rate, 70% versus 30% at 6 months by giving them 4 weeks of amino acids with protein. Huge differences. Trauma literature, massive reduction in complications, 44% dropping to 30%. Look at the mortality, 4% down to 0.5%. Huge differences. So carb loading, we'll talk about this here. What happens when we tell somebody MPO after midnight? The reality is that they don't eat on average for about 14 hours, okay? And what happens is if you would never go run a marathon or do any, even a 5-mile run not eating for hours, right? We all know carb loading's important for performance. What happens from a physiological standpoint is you get increased catabolic effect because you have no immediate energy stores. This actually increases insulin resistance further. If you give people pre-surgery carbohydrate drink, the 100 gram— 100 grams the night before, data shows— Cochrane review data— you have decreased length of stay and you have less muscle loss. Here's an example of some of the other studies. This is a femur fracture, 2-point reduction in pain. Cardiac studies showing decreased use of insulin requirement as well. It's very simple to do. If you don't have one that you can give them, just simply at least tell them to take a Gatorade the night before. I think it can make a big difference. Okay, some of the other things that you can consider. Vitamin D— we talked about this before— retear rate 3 times higher in people who are deficient. So I think it really makes sense to supplement them. There's data across other joints as well. For instance, Looking at hip and knee arthroplasty and spine fusion also shows that vitamin D is effective. Very simple to do. Vitamin C is important for tendon healing. It's been linked to bone density. This study here out of France showed a half-fold less failure of healing. Now, this didn't meet statistical significance in this study that I show you on the bottom, but it does, you know, really look at— when you look at the magnitude of difference, it's super simple to do. And it's very clearly shown that if you give people 500 of vitamin C BID, they have less risk of CPRS in the upper extremity literature. But also other data shows improved spine fusion, improved outcomes with foot and ankle, and less pain. So I now advocate vitamin C as a way to reduce pain in my patients. Magnesium can be beneficial. Peter Attia is one of the— you know, if you're a health nut, he's pretty much the go-to for people. And data here shows that you have less pain afterwards, and you have improved sleep after, after giving this, which is really important in our patients who are having trouble sleeping after surgery. That's a really important part of recovery. What about creatine? We all know there's robust data on muscle strength and gains. There's some possible cognitive benefit and even possibly a nerve injury recovery. I'll give you some examples of some of that data. This is healthy individuals, 18 to 25. Put them in a long-arm cast, give them creatine, 81% less strength loss with giving them creatine supplementation. Another study here, just looking at older individuals, you can see the gains in strength were doubled by giving them creatine. So I personally take it every day, and I advocate it in a patient who is struggling to get their strength back. I say, give them— I say, take creatine. I've seen anecdotally a lot of positive impact with that. Some additional things you can think about— collagen. I was initially thinking this was a wonky idea, but actually the basic science data supports improved tendon thickness. We've now put this in our nutritional formula. Curcumin decreases inflammation. One study shows 50% reduction in pain at 2 weeks and decreased adhesions and lap chole. So I especially am giving this to my patients, patients with adhesive capsulitis at this point. There's good data with omegas as well. For instance, one study shows less muscle loss 43% muscle loss, in fact, in a casting scenario, again, in healthy young females. So these are huge magnitudes of difference that you can do with very simple things. So let's wrap up and talk about the delivery. How do we do this? If now what I'm doing is I'm telling, okay, people, you're taking all this sorts of stuff and it really kind of adds up. So what we've tried to do, and other companies have done the same, we're not the only one out there, but essentially give them all these things that are evidence-based in one daily packet. That they can take and give them a pre-surgery carbohydrate drink that has electrolytes as well. We advocate doing this a couple of weeks in advance, but even there's data that shows that if you just simply take it afterwards for 4 weeks, that's beneficial. Give them a carbohydrate drink and then continue afterwards. My experience, 25% of my patients, if I just give them an information on this, they order it. I haven't measured it, but I would estimate that another quarter percent do something, which is great. They go do protein, they do something to increase their carb load prior to surgery. And I would say at a minimum, my patients appreciate having information. Even some of them modify what they do afterwards in terms of their life. Because the reality is they're looking to you. And if you're not telling them something, they're not going to change. There is some financial gain. You can— if you're in a private practice, you know, you get some revenue back with this. This is all above board. This can add up over time. But I think that in summary, the big thing here is nutrition is overlooked. They're looking to us as surgeons to give them guidance. There's loads of data that shows that protein, carbs, and, and specific vitamins can improve outcomes. And I think implementation can be easy and also potentially ancillary revenue generator if that's something that interests you. Thank you.
