Nutritional status is a strong predictor of postoperative outcomes and is recognized as an important component of surgical recovery programs. Adequate nutritional consumption is essential for addressing the surgical stress response and mitigating the loss of muscle mass, strength, and functionality. This article highlights oral nutrition strategies that can be implemented leading up to and following major surgery to minimize atrophy and the resultant loss of functionality.
The Importance of Nutrition After Surgery
After any type of surgery, it's important to eat healthy foods that will help your body heal. Getting the right nutrients can speed up your recovery and help you avoid complications. Eating well before surgery builds up nutritional reserves, providing micro- and macronutrients that serve as building blocks for every cell in the body. Eating enough calories, protein, vitamins, and minerals may help make recovery from surgery quicker and smoother. Continuing a healthy diet after surgery is important for a swift recovery.
Nutritional Status and Postoperative Outcomes
Malnourished patients have longer lengths of stay, higher readmission rates, a greater number of complications, and higher mortality risks. An estimated 24-65% of surgical patients, ranging from young adults to the elderly undergoing major surgery, are malnourished or at risk of malnutrition, a percentage that only increases over the course of a hospital stay. Nutrition is recognized as an important component of enhanced recovery after surgery (ERAS), which is designed to minimize stress and facilitate the return of functionality after surgery.
The Surgical Stress Response and Muscle Atrophy
For a patient in a non-stressed, clinical state, surgery stimulates a cascade of inflammatory, immune, and metabolic responses that result in a hypermetabolic-catabolic state. Stimulated by the upregulation of glucagon, cortisol, and proinflammatory cytokines, significant catabolism of hepatic and muscle glycogen occurs to meet the energy demands of wound healing. The elevation in catabolic hormones also interferes with insulin secretion, preventing blood glucose clearance, causing an insulin resistant, hyperglycemic state. Depending upon the degree of surgical invasiveness, this response can last for a few hours to several days, and in some cases up to 2-4 weeks. Protein catabolism is elevated during the stress response. Due to the hypercortisolemia that occurs with surgery, protein synthesis is reduced, and protein breakdown increases. The net result is an efflux of amino acids from skeletal muscle to provide amino acid precursors for gluconeogenesis, wound healing, and immune function. When the muscle catabolism associated with the stress response to surgery is coupled with the general state of immobility that accompanies major surgery, significant skeletal muscle loss can occur. In older individuals, the rate of post-surgical atrophy is higher compared to young adults. Following total knee arthroplasty, atrophy has been estimated to be about 1% per day in older adults (65 years), with decreases of up to 18% in the quadriceps and hamstring of the surgical leg in six weeks. Loss of strength and functionality follows from muscle atrophy.
The Role of Carbohydrates
Nutritional intake around the operative period is aimed at supporting increased nutritional needs during the hypermetabolic and inflammatory state, managing post-surgical insulin resistance, and reducing muscle atrophy. Initial strategies have emphasized carbohydrate/glucose intake, in efforts to reduce post-surgical insulin resistance and the rise in gluconeogenesis. Compared to fasting conditions, pre-operative glucose intake (8-10 oz containing 50 g, 2 h before surgery) has been shown to reduce post-operative insulin resistance by up to 50%. In addition, pre-operative glucose intake has been shown to positively impact lean body mass maintenance and muscle function. Oral ingestion of 125 mg/mL of carbohydrate consumed the night before and up to 3 h before surgery was effective in maintaining whole-body protein balance 24 h after surgery. It was also beneficial in reducing the loss of quadricep strength one-week post-surgery (−11% vs. −16%), while also increasing the rate of return to pre-surgical strength values at one (−5% vs. −13%) and two months post-surgery (+4% vs.
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The Role of Protein and Amino Acids
Protein intake is especially important for modulating surgical stress and supporting recovery, yet surgical patients significantly under-consume protein, taking in about 22-36% of estimated requirements. When protein intake is inadequate, skeletal muscle serves as the primary source of essential amino acids needed to maintain whole-body protein synthesis. Thus, there is an increased need for dietary protein post-surgically, in order to meet the body’s elevated amino acid needs and reduce the risk of muscle catabolism. Post-surgical amino acid supplementation has been shown to effectively reduce whole-body and muscle catabolism, stimulating a 40% increase in whole-body protein synthesis and 20% reduction in whole-body protein breakdown. Twelve weeks of essential amino acid supplementation has been shown to reduce muscle atrophy and enhance functional outcomes in low physical functioning older adults. Following total knee arthroplasty, essential amino acid supplementation reduced quadriceps and hamstring atrophy in the operated leg at two weeks and six weeks post-surgery compared to placebo. Muscle atrophy in the non-surgical leg was also reduced. Essential amino acid supplementation seems to be effective for maintaining muscle strength, even when some atrophy occurs.
Nutrient Timing Strategies
Similar to an athletic endeavor, nutrient timing strategies can be implemented during both the pre- and post-operative periods to prepare the body for the stress of surgery, support increased metabolic demands, and offset the catabolic consequences. The goal of pre-operative nutrition is to ensure adequate energy stores to meet the demands of the stress state. The goal of post-operative nutrition, on the other hand, is to promote nitrogen balance, reduce the loss of lean mass, and facilitate rapid healing and recovery. Starting 7-10 days prior to surgery, nutrition emphasizing both high-quality carbohydrate and protein intake would ensure optimal nourishment prior to surgery. Preoperative carbohydrate loading is highly recommended for surgical patients.
Essential Nutrients for Post-Surgical Healing
Several key nutrients play a vital role in post-surgical recovery:
- Protein: Essential for healing and repairing tissues, and for making new blood cells. Good sources include lean meats, poultry, fish, tofu, eggs, legumes, and nuts.
- Vitamin C: Important for wound healing and reducing the risk of infection. Good sources include citrus fruits, tomatoes, bell peppers, broccoli, and Brussels sprouts.
- Fiber: Helps improve digestion and prevent constipation, a common problem after surgery. Foods high in fiber include fruits, vegetables, whole grains, and legumes.
- Iron: Necessary for making new blood cells, which are needed for healing wounds. Foods high in iron include red meat, poultry, fish, beans, lentils, spinach, and iron-fortified foods.
- Calcium: Essential for strong bones and teeth, and also plays a role in blood clotting, muscle contraction, and the regulation of heart rhythm. Dairy products are a good source of calcium, as are soy milk and tofu.
- Antioxidants: Protect cells from damage and reduce inflammation. Foods high in antioxidants include berries, dark leafy greens, nuts, and seeds.
Each of these nutrients plays an important role in helping you heal. Eating a well-balanced diet can help you get all these nutrients. The foods that heal listed below are suggestions that are high in nutrients, but there are many other sources.
- Antioxidants: help the body to protect and repair itself. Top 3 foods: berries, grapes and spinach.
- Calcium: helps to build strong bones, as well as regulate nerve impulses, blood clotting, and muscle strength. Top 3 foods: kale, yogurt and almonds.
- Carbohydrates: provide energy for your muscles, brain and nerves. You’ll need this energy for healing. Top 3 foods: whole grains, carrots and sweet potatoes.
- Fiber: Constipation is a common risk after surgery. This can be caused by a lack of activity and pain medication. Fiber is a necessary bulking agent that keeps your system moving. Top 3 foods: raspberries, nuts, and beans.
- Iron: Most surgeries will involve an expected loss of blood. Iron is vital for the creation of new red blood cells. Top 3 foods: garbanzo beans, spinach and cashews.
- Magnesium: Magnesium provides a soothing, relaxing effect. Adequate amounts of magnesium can relieve sore muscles and promote better sleep quality. Top 3 foods: nuts, seeds, and avocado.
- Potassium: Potassium keeps your heart healthy, grows new cells, and helps your muscles with their work. Top 3 foods: squash, sweet potato and white beans.
- Protein (Amino Acids): The amino acids in protein help to rebuild the damaged tissue. Protein also speeds up how fast your incision will heal. Top 3 foods: eggs, poultry and beans.
- Vitamin A: Vitamin A will help your body to build up new bone, tissue, mucus membrane, or skin. This is especially important if you have had surgery on your bones. Top 3 foods: carrots, sweet potatoes and apricots.
- Vitamin B: Vitamin B is needed to create red blood cells and keep your brain functioning. Top 3 foods: meat, seafood and eggs.
- Vitamin C: Vitamin C provides the collagen protein that is responsible for repairing tendons, ligaments and healing both your incision and the repairs inside your body. Top 3 foods: oranges, strawberries and bell peppers.
- Vitamin E: Vitamin E belongs to the antioxidant group. These help your body to make healthy red blood cells and use vitamin K. Top 3 foods: sunflower seeds, swiss chard and asparagus.
- Vitamin K: Without vitamin K, your blood is not able to clot.
Foods to Embrace for a Speedy Recovery
Here's a list of foods that can help you recover faster and more effectively:
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- Berries: Excellent source of vitamin C and antioxidants, which aid in rebuilding collagen and soft tissue, leading to quicker incision healing.
- Vegetables: Provide healthy carbohydrates for energy, along with vitamins A and C. Fiber in vegetables reduces constipation, a common side effect of pain medication and decreased mobility.
- Fats (nuts, oils, fish): Healthy fats help the body absorb vitamins, strengthen the immune system, and decrease the chance of infection.
- Dark Leafy Greens: Rich in vitamins A, C, E, and K, as well as B-complex vitamins, fiber, iron, magnesium, potassium, and calcium.
- Meat or Other Alternatives: Protein and iron are essential for repairing muscles and regaining energy.
- Eggs: Provide a complete package of nutrients, including protein, vitamins A, E, K, B complex, riboflavin, folic acid, calcium, zinc, and iron.
- Probiotics: Help regulate the digestive system, which can be disrupted by surgery, anesthetics, antibiotics, and painkillers.
- Brightly colored fruits: Offer a good dose of vitamins A and C, carbohydrates, fiber, antioxidants, and nutritious calories.
- Whole grains: Provide the brain with energy and stop muscles from breaking down, along with another dose of fiber.
- Water: Maintaining adequate levels of hydration is crucial for a quicker recovery.
Foods to Avoid After Surgery
It is just as important to look at which foods are slowing your body’s healing. Food can either be medicine or poison for your body. Although you might be desperately craving a sweet treat, remember that these foods can rob you of a quick healing time and increase your risk of infection.
- Alcohol: Can dehydrate the body and hinder the healing process. It also impairs the immune system, increasing the risk of infection.
- Processed foods: Can slow down your recovery or increase your risk of complications after surgery.
- Caffeine: Some surgeons recommend avoiding caffeine after surgery because it can interfere with the healing process.
- Foods that are high in sugar: Can slow down your recovery or increase your risk of complications after surgery.
Foods to Avoid After Surgery
It is just as important to look at which foods are slowing your body’s healing. Food can either be medicine or poison for your body. Although you might be desperately craving a sweet treat, remember that these foods can rob you of a quick healing time and increase your risk of infection.
- Added Sugars: Food and drinks with added sugar offer your taste buds a quick reward, but the added sugar is high in calories and gives your body no nutritional value. You may feel a short burst of energy and alertness but quickly feel more drained and tired. Bacteria and viruses thrive on sugar, which is one more reason to avoid sugary foods after surgery.
- Highly processed foods: After surgery, you may have a small appetite and be tempted to indulge in whatever sounds good. Highly processed foods are usually white, sweet and come in a package. Or they are artificially colored. These foods primarily provide your body with carbohydrates. This causes blood sugar spikes and high insulin levels. Both drain your body of energy and the ability to heal. Processed foods are also often stripped of fiber, which helps to keep your bowels moving. After surgery constipation can be a serious and uncomfortable condition. Counter this problem by adding extra vegetables and limiting processed foods in your diet.
- Alcohol: You might look forward to having a drink to unwind or relax post-surgery. But alcohol slows down the rate of blood clotting and makes your blood thinner. This can cause your incision to take longer to heal and you will also have an increased risk of bleeding. Alcohol also impairs your immune system, putting you at a higher risk for infection. Following surgery, you will heal faster when there is less swelling. Alcohol causes blood vessels to swell. One of the biggest reasons to avoid alcohol is how it affects your pain levels. You may think that a drink will help you feel better, but alcohol does not mix well with pain medication prescribed by your doctor. It can even be deadly to mix alcohol and pain pills.
Additional Tips for a Fast Recovery
Along with eating healthy with an after surgery diet, here are a few tips that can help you get back on your feet quicker.
- Manage your pain: You will experience pain after your surgery but following the pain medication plan that your doctor gives you can help. Make sure you are able to move comfortably. To help you sleep, you may want to ask your doctor if they recommend you take something before heading to bed.
- Get adequate rest: Sleep is when your body can repair and heal. Make sure that you set aside time each day for rest. Set up your night environment to be comfortable and calming and allow yourself regular rest periods throughout the day.
- Get moving: Physical activity is just as important as rest. Do not push yourself to the point of injury. Talk to your doctor or physical therapist about what activities you should be doing. Lying in bed all day can increase your risk of infection, pneumonia, and blood clots. Appropriate amounts of movement will help the flow of your blood, which can improve the healing process.
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