In this presentation Dr. Patrick Denard, an orthopedic shoulder surgeon and co‑founder of the THRIVE Protocol, argues that peri‑operative nutrition is a high‑impact, low‑risk lever to improve surgical outcomes and reduce costs for hospitals and surgery centers. He begins by highlighting the prevalence of malnutrition—affecting roughly half of all elective surgery patients, including young athletes—and its strong association with doubled length of stay, higher complication, readmission, infection, and mortality rates across specialties, especially total hip and knee arthroplasty. He then outlines three core nutritional pillars: (1) protein, emphasizing leucine and amino‑acid supplementation to counteract the rapid post‑operative muscle loss; (2) pre‑operative carbohydrate loading (≈100 g the night before and 50 g a few hours before surgery) to blunt insulin resistance and shorten stay; and (3) targeted micronutrients (vitamin D, vitamin C, collagen, curcumin, omega‑3s) that support bone, tendon, wound healing, and inflammation control. Dr. Denard cites multiple randomized trials and systematic reviews demonstrating measurable benefits of each pillar, including reduced muscle wasting, lower pain scores, fewer infections, and improved long‑term function. He discusses implementation options—universal nutrition kits versus selective screening—arguing that kits simplify delivery and avoid resource‑intensive screening. A case study from Allegheny Health Network shows a $7.8 million net saving from a $250 k nutrition program across 4,000 patients. Finally, he describes the THRIVE Protocol’s evidence‑based nutrition kits (protein‑rich, leucine‑high, vitamins, omega‑3s, curcumin, collagen, and a carbohydrate‑electrolyte drink), third‑party testing for quality, and patient education resources. The overarching message is that systematic nutrition optimization benefits patients (better recovery, satisfaction) and health systems (shorter stays, lower costs, improved metrics).
Chapters
Hi, I'm Dr. Patrick Denard, an orthopedic shoulder surgeon who's been in practice for over 14 years. I'm co-founder of the THRIVE Protocol, and here I'm talking about nutrition in surgical patients, clinical outcomes, and cost savings for surgery centers and for hospital systems. So hospitals and surgery centers have a lot of metrics they have to pay attention to: quality, patient satisfaction, length of stay, and complications. And all of this puts a lot of pressure on the healthcare system because Patient demands are increasing. We have these metrics that we're faced with, and on top of this, margins are going down because labor costs and drug costs as well as implant costs are rising. And my proposition here is that nutrition is one thing that can be optimized to help alleviate some of this pressure. So by background, nutritional deficiency is a very common problem in patients undergoing elective surgery. It's estimated it's approximately 50% of all elective surgeries. And at least 50% of total joint replacements, uh, and even over 90% of bariatric surgery patients, that is stomach surgery. And this isn't just the elderly, it's actually young athletes as well. So the common, uh, sort of belief oftentimes that it's an older patient that has malnutrition, but actually athletes who are undergoing surgery for a variety of orthopedic injuries have a lot of malnutrition as well. So it's all ages. And nutrition has a huge impact on outcomes. So this is a study from Germany, and they looked at elective surgery all across different specialties, and they found essentially that those who had some malnutrition had about double the risk of the length of stay— that is, double the length of stay— and a 1.4 times increased risk of complication. Now, if you get specifically into total hip and total knee arthroplasty, where there's a big emphasis on trying to improve outcomes and metrics. You see this study here, the systematic review of total hip arthroplasties showed that there was a big association with malnutrition outcomes. So increased rate of non-home discharge, pulmonary complication, reoperation, readmission, transfusion, and mortality is actually 105% that you can't, uh, see there because my head's covering it up, but it's a big number. Another study here actually looked at total hip and total knee from a large claims database, and they looked at modifiable risk factors. So this is a population of nearly 1,000, or sorry, 1 million arthroplasties, and the key finding was that malnutrition had the highest association with readmission. This was higher than tobacco use, type 2 diabetes, and opioid dependence. So it's a big factor. Malnutrition also increases the risk of infection in total joints, 260% increased risk surgical site infection and a 340% increased risk of periprosthetic joint infection. These findings are consistent across all types of surgical populations. It's not just hip and knee arthroplasty. We see this in hip fracture patients, lumbar spine fusion patients, colorectal surgery, etc. So it's a, it's a big factor that can be controlled, and nutrition can be optimized. The principles here are threefold. It's protein, carbohydrate loading prior to surgery, and micronutrients. And even in nutritionally normal patients, they face stress that their body undergoes through surgery. We often underestimate this. We take the athlete who's going through a big event and we don't— we prime them and do all this work, but we take a patient who is probably less primed and we do not provide them the resources to get through surgery appropriately and deal with that stress. So targeted optimization can improve recovery and reduce complication rates. One of the things that's really important is muscle loss after surgery is very high. So if you have immobilization for 7 days, strength decreases by 8 to 21%. That can be from casting, that can be recovered from surgery such as total hip and total knee, or it could be being in bed because of a GI surgery. And 5 days of bed rest equals 5 days of— 5 years, that is, of aging on muscle tissue. So there's an opportunity to improve. You're trying to offset this muscle loss. And it's important to know that protein requirements double after surgery, yet on average surgical patients only consume about 30% of their protein requirements. If you look at this specifically, one of the biggest keys is leucine, and data shows that a 3-gram dose of leucine really helps offset muscle wasting that occurs. So this is people who are middle-aged in this study. They were not undergoing surgery, they simply just got them to bed rest for 2 weeks and have a regular diet versus with leucine. And when they had leucine supplementation, they had far less muscle wasting. This study here in older patients with hip fracture showed that mobility was much higher when the supplementation was done with leucine. 81% of patients were mobile at day 15 after surgery compared to 20%— 26% on a normal diet, and wound healing was also shorter. So So leucine is key because it's the most important amino acid in muscle synthesis. Now supplementing with amino acids has been shown across multiple studies to provide benefit. This is one of these examples. This is a randomized controlled trial, uh, published in 2023 in the Journal of Bone and Joint Surgery, one of the higher, uh, prominent orthopedic journals. And they looked at amino acid supplementation right after surgery and they found that strength strength not only was improved initially in term, in the patients, but also they had a better outcome at 2 years. And that went along with less muscle wasting in the quadriceps. Now what's really interesting about that is it suggests that there's this critical period in which people, if they have supplementation, you can offset this muscle loss and they get better in the end. It's not just that they're gonna get there eventually, seems that this alters their overall outcome. Another study here out of Oregon, actually randomized controlled trial, showed that amino acid supplementation led to less decrease in muscle volume at 6 weeks post-op. Yet another study here out of Japan looking at total knee arthroplasty, randomized controlled trial, where they did 5 days prior of supplementation, 4 days after total knee arthroplasty. The supplementation group had no muscle loss. Uh, compared to the other group that had 36% loss. So these are big differences. Now, in addition to protein, one of the key components of nutrition is carbohydrate loading prior to surgery. And with a traditional approach, we tell people not to eat or drink after midnight, but the reality is they don't really eat or drink for 12 to 16 hours. This prolonged fasting leads to a catabolic state, and then the stress of surgery comes along, which leads to increased insulin resistance because the body is already in a stress response. Leading to free radicals. Cochrane review data has shown that length of stay is lower when you give carbohydrate loading prior to surgery. And it's important to do this in a non-sugar manner, so you wanna give a complex carbohydrate, particularly 100 grams prior to surgery the night before, and some centers also allow an additional 50-gram dose a couple hours prior to surgery. This decreases insulin resistance. It may even decrease muscle loss. Data in hip arthroplasty randomized controlled trial here shows that carbohydrate loading prior to surgery led to a reduced length of stay, lower pain scores, and even lower need for narcotics. Another study here on carbohydrate intake showed essentially the same thing. Patients had improved quality of recovery, they had decreased hunger and anxiety levels, and moved their bowels earlier and had reduced duration of a hospital stay. So these are big impacts with a very simple intervention. In addition to protein and carbohydrate, several micronutrients and vitamin supplements can impact the outcome. Vitamin D plays a big role in tendon and bone health, and there's been— it's been shown that there's an association of vitamin D deficiency with poor outcomes. So about 76% of patients undergoing a total joint arthroplasty are vitamin D deficient. This worsens seasonally, and this review here, this systematic review of 150,000 total knee arthroplasties, showed that there was an increased length of stay when there was vitamin D deficiency, and vitamin D supplementation improved outcomes. Vitamin C has been shown to play a role in impact and outcomes in arthroplasty. Vitamin C, or ascorbic acid, has been associated with lower blood loss. It's been associated with improved outcomes and also in terms of having decreased pain and decreased inflammation. It's also been shown to lower the risk of complex regional pain syndrome after surgery, which is devastating complication once it can occur. So supplementation of vitamin C is very important. Additional studies show that other supplements may be beneficial. These are not direct hip and knee, but collagen has actually been shown, basic science studies, increase tendon thickness and improve wound healing. Curcumin is an anti-inflammatory that's really gained popularity in recent years. Many people are now taking this, but the data does show clinically that it decreases inflammation, may even decrease adhesions, and one study shows a 50% reduction in pain at 2 weeks after taking it. And then omegas, we all know the cardiac benefits, but they've also been shown to decrease inflammation and improve muscle preservation deprivation. One study in a casting scenario, actually, there was 43% less muscle loss when people were casted if they were supplementing with omegas. Now the question is, can you alter, uh, nutrition going in? And the data shows that yes, if you give people guidance, you can improve their outcomes. This is a systematic review of nearly 16,000 patients across multiple specialties And if you simply give people guidance prior to surgery, they have reduced complications about 38% and a reduced length of stay of even 1 day. And it's not just that you reduce complications, but patients are asking for this. This is a study out of the Journal of Arthroplasty in 2024. Uh, only about half of patients said they actually knew what to take. Most of the patients though would say if they were given guidance by their surgeon or a hospital system, they would even purchase a nutrition kit to help them get through the surgery. So patients are looking for the guidance, but they don't know what to take. Now the challenge, uh, this is complex because if you ask them to take a lot of things, that can be really overwhelming because we're telling them take vitamins, increase your protein intake, take omegas, etc. And on top of this, patients are having to deal with pain control. And then there's a question of should you screen everybody? And I think screening can be very valuable in some certain scenarios, but if you screen everyone, it actually leads to a lot of cost of, and resources that are time-intensive. So one solution is just provide nutritional kits in a simple manner that you can take, that patients can take, that has everything comprehensively placed in it, and then just offer that to all patients. And because the reality is there's no downside to doing this sort of approach. Approach. Um, taking this approach not only has no downside for the patients clinically, but it gives the, the pa— the physicians and the hospitals decreased burden because then they're not having to screen everyone, um, directly. An example of what this cost savings looks like, Allegheny Health Network did a study of, uh, over 4,000 patients in 8 surgical specialties. They did a preoperative nutrition program that included protein with vitamins, carb load and they didn't publish this yet, but they presented this American College of Surgeons in 2024. They decreased length of stay and complications as in other studies, and they calculated the financials on this, and for annually for this number of patients, it was a $250,000 cost but a $7.8 million savings that the facility actually achieved. So what we do with the THRIVE protocol is try to make this simple for the patients. We have a daily protein loaded with the vitamins, everything that's evidence-based that I showed you here, high in leucine, glutamine is another important amino acid, collagen as I mentioned, and then omegas, curcumin, vitamin C, vitamin D, magnesium, and then also have a pre-surgery carbohydrate drink that also in our case includes electrolytes to improve for hydration. So in the ideal scenario, a patient will begin this prior to surgery to prepare, then do their carb loading, and lastly continue afterwards to improves their outcome. There are some situations where patients will not obtain a kit for a variety of reasons, like they just didn't learn about this till later, and the data even says there that if they simply carb load and continue to take high protein vitamins afterwards, they will have a benefit. We just believe that preparing in advance is the ideal scenario. Now, all the products we do, it's important that, that they're third-party tested. We have our products tested by Informed Sport, which is a, a group that has very high standards, so we ensure quality, which is a big variable in supplements. So I think that's really important to measure. We also provide a lot of resources for our patients to offload to clinicians, from things like wellness preparation prior to surgery to commonly asked questions people have about nutrition, so it makes them very easy for them to go through and get information. So the bottom line here is nutrition optimization is really a win-win. For the patient, you have improved outcomes, you have improved satisfaction. I would tell you as a clinician, I see that patients really, really appreciate having this option, having a surgeon at least think about things holistically, even if they're not spending a lot of time on that. And many patients even change what they're doing. And then for the hospital and surgery center, you have decreased length of stay, it frees up valuable resources. You get cost savings, you improve metrics and improve marketing because the patients are having a better experience. For Thrive in particular, our value proposition is making it simple for patients. Providers or hospitals can purchase in bulk at a discount. We can ship those directly to the patients to make it very easy and decrease the burden. And the patient experience is simple with clear instructions and a lot of resources as well as social media outreach to give them information that they are looking for, as I showed you. Thank you very much.
