Healthier Eating Is Within Reach


Patients who optimize their pre-op nutrition are rewarded with better outcomes.

The surgeons at Excelsior Orthopedics in upstate New York understand that what patients eat and drink before surgery impacts how well they'll recover afterward. Their group, which owns and operates the Buffalo Surgery Center in Amherst, N.Y., recently hired Melinda Yoder, RDN, CDN, as manager of nutritional services to optimize the nutritional status of patients before they arrive on the day of surgery. The surgeons in the group used to cross paths with Ms. Yoder as she worked independently to ensure patients were physically prepared to endure the physical stress of surgery. They were intrigued, asked about her services and ultimately decided to make her an offer.

"We're aligned in our goals, so the relationship made sense," says Ms. Yoder.

Hiring a dedicated nutritional expert of your own would be ideal. At the very least, educate patients about the importance of eating and drinking right as they prepare for surgery.

Losing to gain

Patients in a suboptimal nutritional state are at increased risk of being hyperglycemic and experiencing insulin resistance brought about by the trauma of surgery, according to Elizabeth Goldenberg, MPH, RD, CDN, a registered dietician at Weill Cornell Medicine in New York, N.Y. "They're also more likely to have more GI symptoms and experience PONV," says Dr. Goldenberg. She points out optimizing pre-op nutrition puts patients in an anabolic state, during which the body builds lean muscle mass, instead of a catabolic state, which involves the loss of body mass.

As soon as possible after cases are scheduled (ideally 6 to 12 weeks before surgery), Ms. Yoder spends an hour with patients to review their medical histories, the medications and supplements they're taking, the average amount of sleep they get on a nightly basis. She asks about their cooking habits, stress levels and home life. She then creates interventions specific to their needs to help promote weight loss and manage existing comorbidities. "It's important to set realistic goals for patients, so they feel motivated to change their health status," says Ms. Yoder.

She prioritizes the care of patients with BMIs over 40 who are at higher risk for complications during and after surgery. Her goal is to help patients lose weight and build lean muscle mass, which helps support the body's structure. Lowering a patient's BMI also reduces pressure on joints and decreases the body's inflammatory response to surgery. Patients who lead healthier lifestyles and lose weight before surgery are better prepared to complete rehab exercises and often require lower dosages of prescribed medications that could increase risks of surgical complications. Some might even be able to stop taking drug therapies altogether.

Effective weight loss isn't about using fad diets for a quick fix, points out Ms. Yoder. After comprehensive assessments of patients, she modifies their lifestyles and nutrition plans based on evidence-based interventions. For that reason, most patients' insurance plans pay for her services. She teaches them how to recognize sensations of hunger and fullness, and gives them a deeper understanding of the physiological impact of specific foods and the overall importance of improving their nutrition.

Ms. Yoder instructs patients to eat nutrient-dense foods and emphasizes the importance of a back-to-basics approach to nutrition: Vegetables, grains, lean proteins and healthy fats provide the body with essential nutrients that increase metabolism and improve immune function, which increases the body's ability to fight infection and improve wound healing after surgery.

Patients with high blood pressure are instructed to monitor their sodium intake and eat more fruits and vegetables to increase the amount of potassium in their diets. Even a seemingly small reduction in body fat (3% to 5%) leads to improvements in blood pressure values, says Ms. Yoder.

She provides busy professionals with home recipes and offers tips for batch cooking, so they don't rely on the convenience of ordering out. Her goal is to work with patients to create sustainable lifestyle changes.

"We find the right amount of fuel for their bodies," says Ms. Yoder. "They have to be able to perform daily tasks and maintain immune function and health leading up to and after surgery."

New thinking in NPO
EXPERT ADVICE Melinda Yoder, RDN, CDN, meets with patients weeks before their scheduled procedures and suggests healthy lifestyle changes that prepare their bodies for the physical stress of surgery.

Dr. Goldenberg says research shows carbohydrate loading is an essential element of Enhanced Recovery After Surgery (ERAS) protocols. Instead of asking patients to fast beginning at midnight the night before surgery, permit them to drink clear liquids up to two hours before their scheduled procedure time. Simple carbohydrate drinks such as juices and sports drinks containing complex carbohydrates are effective, but not ideal, options. Specialty carbohydrate pre-op drinks, which contain immune-enhancing ingredients such as dextrin or oligosaccharides instead of more simple sugars, lead to a steadier release of carbohydrates instead of a more rapid spike, therefore providing a longer-lasting fuel reserve.

Dr. Goldenberg says consuming 110 g of carbohydrates the night before surgery and 50 g up to two hours before anesthesia induction releases insulin and shifts the body from a fasted to fed state. She points out those amounts can be achieved by following North American Surgical Nutrition Summit recommendations, which state that patients, when appropriate based on their health status, should drink 800 ml of a 12.5% carbohydrate drink the night before surgery and 400 ml the next morning two hours before anesthesia induction.

Many surgeons and anesthesia providers who are understandably concerned about aspiration risks still stick to mandating six to eight hours of preoperative fasting. Dr. Goldenberg points out, however, that current clinical evidence does not show fasting for two to three hours before surgery increases the risk of aspiration or morbidity compared with the traditional approach of going NPO after midnight.

We find the right amount of fuel for their bodies.
Melinda Yoder, RDN, CDN

Dr. Goldenberg thinks long-established assumptions about going NPO before surgery are beginning to change. When she helped launch an ERAS program at Weill Cornell Medicine that allows patients to drink clear fluids up to two hours before surgery, she received no pushback from surgeons or anesthesia providers.

There's still work left to be done, however. Dr. Goldenberg has spoken to peers across the country and has learned updated NPO protocols are having trouble gaining traction because of pushback from providers who are hesitant to change patient care.

Ready to recover

Excelsior's surgeons have negotiated bundled payments with local insurers, meaning they receive a single payment for managing an entire episode of care, which begins the day surgery is scheduled and ends at 90 days post-op. They're financially responsible for achieving positive outcomes, and therefore have a vested interest in making sure patients enter the OR in prime physical condition. Ms. Yoder helps to make sure that happens.

The surgeons are thrilled to have her onboard. She even helps the practice's staff make healthier eating choices. But it's Excelsior's patients who benefit the most from Ms. Yoder's work. "In order for patients to undergo complex surgery in the outpatient setting," she says, "they need to be as healthy and as physically prepared as possible." OSM

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