Broadly speaking, nutrition optimization (the core being protein supplementation and a pre-surgical carbohydrate drink) has been shown to improve speed of recovery, reduce
complications, lower pain, and lower length of hospital stay. Conversely, studies do not find a detriment to protein supplementation or a carbohydrate drink. Even people with diabetes have been shown to benefit from a pre-surgical carbohydrate drink for instance. Said another way, there are no apparent downsides of nutritional optimization which is why we advocate it for all
surgeries.

This is a very common problem! There are several reasons. First, surgeons get only very basic education about nutrition in medical school. They do not receive any education on nutrition in residency. They are taught to think about surgery alone. Second, most surgeons are under significant time pressures with decreased reimbursement and thus don’t take the time to discuss nutrition.

At a high-level data has shown the following with nutritional optimization:
Spine surgery – less pain and high rate of fusion
Joint replacement – quicker recovery and better outcomes 2 years after surgery
Trauma – lower complications and faster recovery
Shoulder – nutrition is more important than tear size and age in healing
Foot and ankle - Vitamin D has been associated with lower union

Generally speaking it is advised to begin protein supplementation 7-14 days prior to surgery. This provides a loading effect that can help prevent muscle breakdown after surgery.

The answer likely varies by the type of surgery and overall health. Data suggests that the most important period is the first couple of weeks after surgery. However, some data shows that up to 3 months of supplementation can be beneficial.

Total protein intake should be 1.2-2.0 grams per kilogram of body weight per day. For a person of 70 kg, or 154 lbs, this equates to 84 to 154 grams of protein per day. Typically this should occur with 20 to 40 grams of protein in one sitting. Our packs contain 25 grams of protein per day. Alone they do not meet all of your protein needs. We recommend people are consuming an additional 60 to 130 grams of protein per day via breakfast, lunch, and dinner.

Total protein intake should be 1.6-3.0 grams per kilogram of body weight per day. For a person of 70 kg, or 154 lbs, this equates to 112 to 210 grams of protein per day. Typically this should occur with 20 to 40 grams of protein in one sitting. Our packs contain 25 grams of protein per day. Alone they do not meet all of your protein needs. We recommend people are consuming an additional 90 to 180 grams of protein per day via breakfast, lunch, and dinner. One challenge is that appetite is often suppressed after surgery. Thus, protein shakes can be a good way to obtain needed protein despite a low appetite.

If you are doing physical therapy it is recommended to consume your protein shake 15-45 mins prior to physical therapy if possible.

Animal sources of protein have higher bioavailability. Whey protein is considered one of the highest quality sources because it is over 50% essential amino acids. Particularly important amino acids are Leucine and Glutamine which have been shown to be very important to prevent muscle breakdown.

Leucine is an essential amino acid that is a key mediator of muscle synthesis.

This is a difficult question to completely answer. There is increased evidence that loading should occur the night before surgery and can also occur 2 hours prior to surgery. However, at this time not all medical facilities and physicians are comfortable with intake 2 to 3 hours before surgery. It is standard practice to allow clear liquids to be consumed 6 hours prior to to surgery. Thus, we advise doing the carbohydrate loading just prior to bed the night prior to surgery or approximately 6 hours prior to surgery depending on your scheduled surgery time.

Vitamin B12 is a critical vitamin for the normal development and function of our nervous system. It is also required by our body’s enzymes that make many proteins as well as genetic material, including DNA and RNA. It is also critical for normal red blood cell formation. Vitamin B12 deficiency is associated with neuropathy, depression, and anemia.

Vitamin B12 is usually attached to proteins in foods, and must be released during digestion from natural foods. Dietary supplements are already in free form and ready for absorption from a specific region of the gut (terminal ilium). Intrinsic factor, a protein secreted by the stomach, is required for B12 absorption by the small intestine.

The Food and Nutrition Board at the National Academy of Sciences, Engineering, and Medicine (NASEM) has a recommended daily dietary intake of 2.4mcg for adult males and females.

Vitamin B12 is usually obtained naturally from meat, fish, eggs, dairy products, as well as fortified breads or cereals. Most people consume sufficient amounts of Vitamin B12, but older patients, women, vegetarians, and those with stomach (“pernicious anemia”) and intestinal disorders (disease of the terminal ilium) have been shown to be at increased risk for deficiency. Fortunately, the body can store Vitamin B12

OptiFuel contains XX amounts of Vitamin B12. We believe that this amount is ideal for most people to safely support healing after surgery. Vitamin B12 is critical during recovery to maintain energy, endurance, and normal neurological function.

Sufficient Vitamin B12 levels are critically important for healing and recovery after surgery. While the surgical recovery is different for every patient, the healing phase of surgery, including tissue repair and remodeling, extends a minimum of 3 months after most surgical procedures. Fortunately, the body can store 1 to 5mg of vitamin B12, providing sufficient stores for several days before the symptoms and challenges of deficiency impact healing and recovery.

Vitamin D, also known as calciferol, is a critical vitamin for the body that is made from exposure to sunlight and absorbed from foods and dietary supplements. Vitamin D must be activated in the body the kidneys and the liver to be converted into is active form.

Vitamin D has many critical functions in the body. It is critical for calcium and phosphate absorption from our gut, which are critical to maintain bone and muscle health. A lack of Vitamin D and calcium are well-known causes of brittle bones and abnormal muscle contractions. Vitamin D also plays critical roles in many critical anti-inflammatory, immune, and metabolic pathways throughout the body.

Sufficient Vitamin D levels are critically important for bone and muscle health and healing after surgery. Deficiency of Vitamin D due to inadequate dietary intake and/or sunlight exposure is associated with rickets in young patients and poor bone health and osteoporosis in older patients. Lower time and length of sunlight exposure and darker skin are risk factors for reduced Vitamin D production.

The Food and Nutrition Board at the National Academy of Sciences, Engineering, and Medicine (NASEM) has a recommended daily dietary intake of 15mcg for adult males and females under the age of 70, and 20mcg for adult males and females over the age of 70. However, because Vitamin D must be converted to an active form by the patient’s own body, the necessary dietary intake to achieve ideal serum levels in the blood may be different for every patient.

Few foods, such as fish, naturally contain Vitamin D. The vast majority of dietary Vitamin D is obtained from the fortified dairy foods like milk and cheese in the U.S. Unfortunately, most people still consume less than the recommended amounts of Vitamin D in their diet.

Sufficient levels of Vitamin D are very important for healing after surgery, particularly with orthopedic procedures. Elderly patients with darker skin, gut absorption disorders, and smokers are at greater risk and may need even greater dietary supplementation.

OptiFuel contains 12.6 mcg of Vitamin D. We believe that this amount is ideal for most people to safely support healing after surgery. Excess dietary Vitamin D can be toxic secondary to excessive calcium, increasing the risk of calcification, kidney stones, and other problems. In fact, 100mcg daily for adult males and females has been defined as a safe and tolerable upper limit of intake.

Sufficient Vitamin D levels are critical important for healing and recovery after surgery, particularly orthopedic procedures that affect muscle and bone. While the surgical recovery is different for every patient, the healing phase of surgery, including tissue repair and remodeling, extends a minimum of 3 months after most surgical procedures. Accordingly, having sufficient levels of Vitamin D for one month before surgery and 3 months after surgery, if not longer, is highly recommended.

It is always best to avoid sugary foods. But especially for at least 2 weeks after surgery it is advisable to avoid high sugar foods such as soda, candy, and desserts.

It is advised to limited alcohol consumption after surgery. In addition to the negative effects on the body, alcohol increases protein catabolism and reduces sleep, which are very important in the recovery phase.

Water intake is important. Frequent hydration helps support the body during rehabilitation. After surgery is NOT a time to restrict calories, be on a ketogenic diet, intermittently fast. The latter has been shown to decrease athletic performance for instance.

The Mediterranean diet has shown many health benefits such as decrease in the risk of cardiovascular disease, cancer, and improved cognitive health.

The Mediterranean diet is a plant-based diet. it encompasses consumption of abundant seasonal vegetables, olive oil for cooking or seasoning (main fat source); fresh seasonal fruit consumed as a desert; regular consumption of nuts and seeds (either as art of the recipes or as healthy snacks); consumption of legumes several times weekly; whole cereals daily; consumption of moderate portions of fish two to three times weekly; dairy (yogurt, milk, cheese) only in limited amounts; spices and herbs to flavor recipes; infrequent consumption of sweets (a few times weekly); moderation of red processed meat; three to four eggs weekly; use plenty of water as a beverage; and drinking wine in moderation.

A hallmark of Mediterranean Diet is the inclusion of unprocessed foods, which are full of healthy nutrients, as opposed to Western dietary patterns, which are rich in processed and ultra-processed foods and full of calories, but very poor in nutrients ("empty calories"). The common Western diet is linked to a high risk of obesity, inflammatory disease, and worsening of cognitive function.

How much protein should I consume and how?

The stress response of surgery leads to protein breakdown or catabolism. Additionally, inactivity leads to loss of muscle tissue within 48 hours. This breakdown is higher in adults over the age of 45. Thus, of the most important things after surgery is to increase protein intake. However, appetite is often reduced after surgery, making it difficult to reach protein needs. Thus, a dietary strategy after surgery is to increase protein intake via the use of protein shakes, or smoothies with fruit, milk and yogurt.

Normally, total protein intake should be 1.2-2.0 grams per kilogram of body weight per day. For a person of 70kg, or 154 pounds, this equates to 84 to 154 grams of protein per day. After surgery, protein requirements increase by up to 50%. Thus, a person weighing 70kg should consume 112 to 210 grams of protein per day.

Useful nutritional advice to achieve this goal is as follows:

• Consume balanced meals starting from breakfast with protein sources at each point such as Greek yogurt, low fat milk, white eggs, scrambled eggs, turkey and chicken breast, or hummus.
• Consume a protein snack before and after the rehabilitation sessions.
• Have two snacks a day to increase your eating windows such as between breakfast and lunch and between lunch and dinner.

Several amino acids play a role in wound healing. Arginine is involved in pathways producing ornithine (important for cell proliferation), proline (important for collagen production), and nitric oxide (important for wound contraction). Glutamine is the most abundant amino acid in human blood plasma. It is used as a source of energy for cells to proliferate including fibroblasts and epithelial cells. Glutamine is also converted to ornithine and then arginine at the cell level. Several studies show that wound healing is related to amino acids.

Wound Healing
Arribas-Lopez E, Zand N, Ojo O, Snowden MJ, Kochhar T. The Effect of Amino Acids on Wound Healing: A Systematic Review and Meta-Analysis on Arginine and Glutamine. Nutrients. 2021;13.

• Meta-analysis of 5 studies on Arginine and 39 studies on Glutamine and
  wound healing
• Arginine significantly increased hydroxyproline levels
• Glutamine was associated with improved nitrogen balance, reduced
  mortality, and decreased length of stay.
• 2 studies reported decreased wound healing time
• 1 study report decreased infection
  

Diabetic Foot Ulcers
Armstrong DG, Hanft JR, Driver VR, Smith AP, Lazaro-Martinez JL, Reyzelman AM, et al. Effect of oral nutritional supplementation on wound healing in diabetic foot ulcers: a
prospective randomized controlled trial. Diabet Med. 2014;31:1069-77.

• RCT of 270 patients with diabetic foot ulcers who received twice daily
  amino acid complex (arginine, glutamine, HMB) or a control drink for 16
  weeks
• Those with low albumin or decreased ankle-brachial indexes were 1.7
  times and 1.67 times more likely, respectively, to heal in the amino acid
  group