Nutrition
For many patients, the notion of undergoing orthopedic surgery can be a nervewracking process to work through. Our goal at the Shoulder and Elbow Center is to provide patients with the education and resources to optimize outcomes and ultimately get patients back to to living life. On this page, you will find information regarding perioperative nutrition, supplementation and hormonal regulation. Keeping this factors in mind, along with proper postoperative recovery practices, will optimize the body’s ability to recover from surgery or injury.
In addition, you will find a couple of links to various regenerative medicine and wellness specialists within the Knoxville area. These businesses can serve as fantastic resources to patients who are unsure where to start on some of the recommended practices in this page. A simplified, “bullet point” version of these recommendations is included at the bottom of this page.
Operative Nutrition
There are many things we can do to make sure that we recover from injury and/or surgery:
- First and foremost, smoking cessation is one of the most important factors in postoperative recovery.
- Additionally, among diabetic patients, achieving and maintaining a Hemoglobin A1C < 7 has been shown to significantly improve patient outcomes following surgery.
- Medication optimization is another important aspect of surgical preparation that you and your primary care physician can evaluate.
- In addition, physical prehab can aid in maintaining joint mobility and muscle mass through something as simple as isometric exercises.
- The final component is nutritional readiness which the following will address.
Both injury and surgery are huge stressors on the body. This stress increases cortisol levels in the body. Cortisol, known as the “stress hormone”, prompts the body to enter a catabolic state, where the body is breaking down fuel stores and thus loosing mass. The body is basically using all of its energy stores (carbohydrates, fats and protein) as fuel in this heightened metabolic state. This in contrast to an anabolic state where the body is building muscle mass.
Therefore, carb loading prior to surgery is a good idea. This is similar to what athletes do before a big race or competition. From a metabolic standpoint, surgery or injury is very similar to such a race or competition from a metabolic standpoint. The main way that we store glucose is through a molecule called glycogen, which is one of the fuels we burn for energy. Carbohydrate loading will thus increase glycogen stores in your muscles and liver, ensuring the body has plenty of fuel to aid in the recovery process following surgery or injury. It has been shown that carb loading 3 days prior to surgery resulted in reduced loss of muscle strength and a quicker return to pre-operative energy levels.[1}. The main nutritional focus during this time should be high carb and low-fat foods such as bananas, Quinoa, sweet potatoes, rice, fruit smoothies, pasta and cereals. There are apps available to count the carbs and calories, such as MyFitnessPal.
- ERAS (Enhanced Recovery After Surgery) recommends 100 grams of carbs the day prior to surgery. Athletes will often consume 4grams per pound 3 days prior to a competition.
- If you have diabetes this carb loading will need to be done carefully to not increase your blood glucose level- your primary care physician can provide guidance in this regard.
A high protein diet is critical. The increased cortisol levels seen after surgery or injury results in reduced protein synthesis and an increase in protein breakdown. When increased protein breakdown is coupled with immobility, skeletal muscle loss will occur. An example is total knee replacement but this happens in almost all orthopaedic surgeries. It has been demonstrated that this muscle mass loss is measurable within 5 days averaging 1% per day in total knee replacement [2]. To combat this and provide your body with the protein and amino acids needed to heal from an orthopaedic or musculoskeletal surgery, you need to be on a high protein diet a week before and at least 6 weeks after surgery. I would actually advocate 3 months after surgery.
The following is a guideline for a high protein diet:
- At least 1.5 grams of protein per kg of bodyweight. If you know your weight in pounds, just divide that by 2.2 and you will have your weight in kilograms. Considering that an egg is about 6 grams of protein and a chicken breast is about 50 grams, you will probably need to supplement with extra protein. This extra protein can come from powder collagen or whey protein isolates which can be mixed in a smoothie. The fruit smoothie will also provide you with low-fat carbs. These protein supplements are available at bulk stores such as Costco and Sam’s but also at nutrition stores. There are also great protein supplement drinks such a Fairlife which are lactose free.
There are several other important supplements for surgery that include the following:
Vit D– At least 60-70% of Americans are deficient in vitamin D. Everyone is familiar with the importance of vitamin D in bone health but it is also a very important immunomodulator. There are receptors for vitamin D on both T cells and B cells, crucial players in the body’s immune response, and this affects both the innate and adaptive immune functions. The importance of vitamin D in immune function was highlighted with the COVID 19 pandemic where deficiency was associated with disease severity and supplementation with recovery. The healthy range of vitamin D is 30-80ng/ml. You need to be sure that you are well within the normal range:
- In general, 3000-5000units of Vit D3 daily will get you in the normal range but you need to have a blood test to determine your actual level before you start supplementing.
Vitamin C is critically important in musculoskeletal healing as it is integral to the crosslinking of collagen. Various types of collagen form bone, tendon and ligament tissue and cartilage. One thousand milligrams per day after surgery is recommended. Vitamin C is a water soluble vitamin so that which you don’t use will be expelled by the body.
Consider other supplements that can increase lean muscle mass:
- These include branch chain amino acids or BCAA’s. There are 20 amino acids that make up all of the proteins in our bodies. Valine, leucine and isoleucine are the 3 BCAA’s. Consuming BCAA’s (especially at night) can increase your lean muscle mass.
- Hydroxymethylbutyrate, or HMB, has also been shown in a 3 gram dose to increase lean muscle mass.
- There are other supplemental protein drinks mainly found in health food stores that can increase your protein intake. Those that contain arginine are especially beneficial as arginine has been shown to increase blood flow by converting to nitric oxide but it also boosts your immune system and can help decrease the risk of infection which has been demonstrated in the general surgery literature.
Maximizing your hormonal ability to heal is also important. Androgens like testosterone work in conjunction with growth hormone to potentiate your ability to heal. If you are low in testosterone, then supplementation is an option. There are many ways to boost your native ability to produce testosterone and I encourage you to explore those options. One can also directly supplement testosterone via either transdermal creams, injection or pellets. It is not advised to become supra-therapeutic with testosterone. Instead, you just want to be within your normal age specific range. Supplementation should be discussed with your primary care physician as your past medical history will help determine the safety profile of supplementation.
There are also a number of more intensive methods of improving healing and rate of recovery, including intravenous administration of amino acids and supplements. It has been demonstrated that amino acid supplementation can stimulate protein synthesis by 40% and decrease muscle breakdown by 20%. [3]
Other options include the use of peptides. Peptides are simply chains of amino acids that are less than 100 amino acids long. Typically, peptides are molecules that bind to receptors on target cells and signal that cell to perform an action or produce a bioactive molecule. These peptides can also “turn off” the action of a specific cell. An example would be the reduction in the production of inflammatory mediators, which is beneficial to the recovery process. Additionally, some of these peptides can affect the function of a structure called the mitochondria. The mitochondria are the “energy factories” in each cell that take molecules like glucose and pyruvate and convert them into adenosine triphosphate or ATP. ATP is the currency of energy. Just like the dollar is the currency of the world, ATP is the currency on which our bodies run. We have a few podcastswhere you can learn about these peptides and much more. There are experts in town that can set you up with and appropriate peptide regimen designed for you.
Anti-Inflammatory Diets
I’m frequently asked about other things that can be done to reduce inflammation. Some patients can not take traditional anti-inflammatory medications such as NSAID’s, or they do not want to take a pill, or they are already taking medication that prevents NSAID use, or they might have a systemic inflammatory condition such as rheumatoid arthritis. There are many reasons to be on an anti-inflammatory diet if for nothing else but to feel better.
There are many sites to review that will promote different anti-inflammatory diets. I will try to distill some of them to more condensed actionable nutritional hacks and try to provide some science behind it.
The first is omega 3 fatty acid supplementation. These naturally come from deep water cold fish such as salmon. Nuts (especially almonds), flaxseed oil and soybean oil are also good sources but not as good as salmon. The essential fatty acids are ALA (Alpha linolenic acid), DHA (Docosahexaenoic acid), and EPA (Eicosapentaenoic acid). The omega fatty acids are actually made by microalgae and consumed by phytoplankton which are consumed by smaller fish and then larger fish and the concentration increases up the food chain.
Omega 3 fatty acids are polyunsaturated. This means that they have 2 or more of the carbon atoms in their sequence connected through a double bond. In contrast saturated fats have all single carbon-carbon bonds which means that the carbons can be “saturated” with hydrogen. The unsaturated fats are healthier and are essential for health. The fatty acids are chains of carbons with a carboxyl end and methyl end. The position of the double bond with respect methyl end determines the name. Omega 3 means there is a double bond 3 positions away from the methyl end while omega 6 fatty acids have a double bond 6 positions away from the methyl end.
The way that this works is that both omega 3 and 6 fatty acids are used to synthesize eicosanoids. The eicosanoids that are created from omega 6 (Arachidonic acid) are prostaglandins which promote inflammation. Therefore, having a relatively increased amount of omega 3 relative to omega 6 can reduce inflammation. In addition the American Heart Association recommends 1gm/day of DHA and EPA as they also lower triglyceride levels.
Increasing soluble fiber in your diet. We should shoot for 50-60 grams of soluble fiber daily. There is really no upper limit but more than that can be tough to tolerate by the gut. The soluble fiber is a “prebiotic”. Meaning that the soluble fiber is fermented by the gut microbiome to create short chain fatty acids (SCFA). These include acetic acid, propionic acid and butyric acid.
The benefits of soluble fiber are many. From an inflammatory standpoint, high fiber diets have been shown to have reduced CRP (C reactive protein), TNF (tumor necrosis factor) and IL-6 (interleukin 6) which are all pro-inflammatory. These mediators are also elevated in cardiovascular disease. Mechanistically, these mediators seem to inhibit nuclear factor kappa delta.
In addition to being anti-inflammatory, the SCFA propionic acid inhibits HMG CoA reductase in the liver. HMG CoA reductase synthesizes cholesterol in the liver and is the target for all the statin drugs. Therefore, you can naturally reduce your cholesterol through the same mechanism as the statin drugs by ingesting more soluble fiber.
Soluble fiber also reduces cholesterol by binding it in the gut. It also slows the absorption of glucose and reduces insulin sensitivity.
Furthermore, a metanalysis of 31 papers found that every 10gram increase in soluble fiber was associated with a 10% reduction in cardiovascular disease and stroke. The highest fiber diets were associated with a 24% decrease in cardiovascular disease.
The best forms of soluble fiber are fresh fruit and vegetables. A smoothie in the morning can be loaded with these as well as protein powder. There are also supplements such as psyllium and glycan.
There are supplements that can reduce inflammation which will be discussed in a different section.
Peptides
See Dr. Spencer’s article in CityView Magazine for an in-depth discussion on peptides and their role in optimizing health!