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2 Nutrition and the Injured PatientDiet Recommendations for Recovery Kristi Veltkamp, MS, RDN 2/28/17

3 Objectives Review healing process after injury Discuss healing and anti-inflammatory diet Identify key nutrients to promote recovery Explore ways you can help direct your patient in better nutrition

4 Goals for Nutrition in RecoveryPromote healing & boost immune system Reduce inflammation Prevent weight gain Prevent muscle loss Some injuries can take several years to fully recover. So nutrition is crucial to lessen the recovery time and return to full function.

5 Healing Phases – Acute Three Healing PhasesPhase 1: Inflammation – occurs immediately after surgery and continues up to 5 days post-op Phase 2: Proliferation – occurs at 5 days through 3 weeks post-op. Tissue rebuilding and repairing process. Phase 3: Maturation – occurs 3 weeks to 2 years post-op. Remodeling to build stronger tissue structures. Will Review Each Ref: Understanding the Role of Nutrition and Wound Healing Joyce K. Stechmiller, PhD, ACNP-BC, FAAN Nutrition in Clinical Practice. Volume: 25 issue: 1, page(s): 61-68

6 Phase 1: Inflammation Pain.  Chemicals involved in injury repair (substance P, calcitonin, histamines, cytokines) may interact with local pain receptors to cause the pain associated with inflammation as well as from swelling. Swelling.  This is a result of fluid seeping through damaged — and now hyper-permeable — blood vessels into the damaged tissues. Redness and heat. Vasodilation up-stream of the injury and constriction downstream shunts additional blood to the injured area, producing heat and redness. When these tissues are injured, they’re deprived of their normal flow of oxygen and nutrient-rich blood. Reduced blood flow, as well as the actual physical damage, leads to cell death. These chemicals take care of the cellular debris and attract plasma (fluid from the blood) and blood proteins to the site of injury. Although painful and irritating, we need the inflammatory process for repair. Without inflammation, injuries wouldn’t heal. So any attempt to eliminate inflammation is a mistake in the initial stages of an acute injury. 

7 Phase 2: Proliferation New vasculature developed with restoration of oxygen and nutrient flow for collagen/fibronectin formation (scar tissue) Scar tissue formed in alignment of forces placed (PT!) Maturation of scar tissue from fibroblasts to myoblasts Once the inflammation of stage 1 begins to subside (4-5 days), most of the damaged tissues will have been removed from the site of injury, and new vasculature will have developed. This restoration of oxygen and nutrient flow to the damaged area allows fibroblast proliferation/multiplication. Once this occurs, collagen and fibronectin are laid down. This forms what is commonly called “scar tissue.” Importantly, scar tissue will lay down in alignment with the forces being placed on the area. (That’s why rehab and therapy is so important.)  Further, this scar tissue will contract and shorten as it matures.  This is due to fibroblast differentiation into myoblasts, which are similar to smooth muscle cells.  This reduces the size of the injury.

8 Phase 3: Maturation Scar tissue degraded and type I collagen formedRehab and therapy needed to manage/arrange tissue formation Starting a few weeks from injury until up to several years. Eventually, the scar tissue (typically made up of type II collagen) will be degraded and type I collagen (much stronger) will be laid down in its place. Although this new tissue will never likely be 100% normal, it can become about 80% as strong as uninjured tissue. Since this tissue is created along tension lines, functional activity (rehab and therapy) is critical throughout the recovery process, as it helps to maintain the length of the scar tissue. It’ll also help arrange the tissue in an organized pattern, in line with adjacent soft tissue fibers. This predictable pattern of soft tissue healing can give us clues about how to manage injuries through the use of physical therapy, manual therapy, nutritional strategies, and drug interventions.

9 Chronic Wounds/InjuryChronic Inflammation/injury Excessive inflammation, especially if it’s prolonged, can lead to other problems, such as continued macrophage activity at the site of inflammation and ongoing tissue destruction. In this case, reduction of inflammation is key and of course, treatment of injury Treating acute injuries requires a tricky balance of managing inflammation while allowing it to do its important job. Chronic wounds are “stalled in the inflammation stage”. Impeded by DM, age, smoking, steroids, poor nutrition etc. Don’t try to avoid the inflammatory process in the acute phases of an injury. It’s critical for Stage 1 recovery. Rushing to eliminate inflammation (and pain) too soon may also reduce healing. This is why inflammation management is an important concept in injury recovery.

10 Metabolic Changes Basal Metabolic Rate (BMR)May increase by 15-50% based on severity of trauma Injury or minor surgery 15-20% Major surgery or burns 50% Back to normal through rehab phase but may still need extra depending on intensity of rehab (crutches, exercises, ect) Severe energy restriction will interfere with healing and recovery During immobilization, tendency to lose muscle mass. Protein needs are higher for repair. Caution energy restriction! Will interfere with wound healing and cause muscle loss. Keep in mind energy cost of ambulation: ie crutches, etc Ref: Tipton, K.D. Sports Med (2015) 45(Suppl 1): 93. doi: /s

11 Example Basal Metabolic Rate – 1611 kcal/day (mean of 3 predictive equations) Energy needs when sedentary – 1933 kcal/day (activity factor of 1.2) Energy needs with daily exercise activity – 2416 kcal/day (activity factor of 1.5) Energy needs during recovery – 2319 kcal/day (activity factor of 1.2 and a 20% increase in metabolism due to injury) You do not need to know how to calculate this but just know that depending on previous activity, they may need a little more than they would as sedentary. Do not encourage calorie deficit/wt loss in acute recovery phase – need adequate nutrition for healing - wt will fluctuate with fluids.

12 Hindrances to Good NutritionUnable to stand/move to cook No appetite due to pain/medications Convenience foods typically nutrient poor Fear of weight gain Previous poor eating habits Lack of understanding on importance of nutrition for healing

13 Dietary Strategies Mediterranean Diet Olive oilAmple fruits, veggies, legumes, whole grain cereals, fish, nuts, plant proteins Moderate red wine Low-fat dairy Low red meat intake

14 Mediterranean Diet Higher n3:n6 ratioReduction in CVD, cancer, Parkinson's, Alzheimer's, T2DM Reduces inflammatory markers (HS-CRP, IL-6/7/18, WBC, finbrinogen), especially in those with more olive oil and nut consumption Note, chronic low grade inflammation leads to insulin resistance = T2DM. Uncontrolled DM may impede healing as well. Diet and Inflammation. L. Galland. Nutrition in Clinical Practice. Volume: 25 issue: 6, page(s): Schwingshackl L, Hoffmann G. Mediterranean dietary pattern, inflammation and endothelial function: a systematic review and meta-analysis of intervention trials. Nutr Metab Cardiovasc Dis Sep;24(9): doi: /j.numecd Review. PubMed PMID:

15 Dietary Choices – Anti-inflammatory DietFat (Inflammation Control) Essential for healing. Type of fat critical. Balance of Each. Trans fat, omega-6 oil, saturated fats = PRO inflammation (LESS) Fried food, margarine, baked goods, corn oil, soybean oil, vegetable oil, butter, lard, full fat dairy, high fat meats Omega-3 and monounsaturated fats = ANTI inflammation (MORE) Fish, olive oil, canola oil, nuts/seeds, avocados Nutrition, Inflammation, and Disease By Mary Franz, MS, RDN, LDN Today’s Dietitian Vol. 16 No. 2 P. 44

16 Dietary Choices – Anti-inflammatory DietCarbohydrate Main energy source but needs are decreased during recovery. Concern is more about type. White Stuff = Inflammation (LESS) Refined grains, anything with sugar, alcohol Fiber-Rich = Healing (MORE) Whole grains, baked potato, beans, fresh fruit, milk/yogurt, squash Explain WHY to convince to make better choices What do most people crave when not feeling well? SUGAR ETOH prevents protein synthesis and increases muscle loss Low GI foods.

17 Glycemic Index

18 Dietary Choices – Anti-inflammatory DietProtein Injury repair requires more protein. Continues into rehab phase. Normal requirements = .8g/kg Recovery requirements = 1.5-2g/kg Best Choices (3oz = 21 grams): Baked/grilled chicken, fish, lean beef (limited), eggs, whey protein (if unable to get enough at meals), nuts/seeds, beans, low fat dairy During immobilization, tendency to lose muscle mass. Protein needs are higher for repair. Especially if no resistance exercise. Fish oil seems to help some as well. Muscle protein balance, i.e. the balance between the rate of muscle protein synthesis and muscle protein breakdown, is the metabolic mechanism responsible for changes in muscle mass. Negative net muscle protein balance results when the rate of muscle protein synthesis is exceeded by breakdown. Negative balance over any given time means that muscle protein is reduced resulting in muscle loss Nutritional Support for Exercise Induced Injuries. Tipton, K.D. Sports Med (2015) 45(Suppl 1): 93. doi: /s

19 Dietary Choices – Anti-inflammatory DietVegetables and Fruits = Antioxidants Each meal/snack should contain 1-2 servings of veggies and/or fruit (1/2 – 1 1/2 cups or 1-2 pieces) with a greater focus on veggies.

20 Anti-inflammation “Superfoods”EVOO Flaxseeds Flavonoids: citrus (carotenoids), apple, cocoa, onion, celery, tea, berries, red wine Turmeric Fatty Fish – herring, salmon, mackerel, tuna Magnesium-Rich Foods – Dark greens, nuts, seeds, fish, whole grains, yogurt, Polyphenols = flavanoids and lignans Only supplement if inflammation becomes a major/chronic problem.  This would likely be discussed with your physician first. Diet and Inflammation. L. Galland. Nutrition in Clinical Practice. Volume: 25 issue: 6, page(s): Nutrition, Inflammation, and Disease. By Mary Franz, MS, RDN, LDN. Today’s Dietitian Vol. 16 No. 2 P. 44 Diet and Inflammation. L. Galland, MD. Nutrition in Clinical Practice. Volume: 25 issue: 6, page(s):

21 Anti-Inflammatory/Healing EssentialsMicronutrients Vitamin A, C, D, copper, zinc, iron Additional Nutrients Essential Amino Acids – Reduces muscle loss Arginine – Increase wound collagen accumulation Glutamine – Essential fuel for turning-over cells HMB – Increase LBM Glucosamine/chondroitin – Safe but mixed evidence Omega-3s – Anti-inflammatory – supplement chronic only Be sure to discuss supplements with your physician first. Note HMB is in ensure enlive product and Juven or myoplex muscle armor EAA – 20g 2x/day 1 week before and 2 weeks after TKA enhanced recovery in older adults (Essential amino acid supplementation in patients following total knee arthroplasty Hans C. Dreyer ... Steven N. Shah, Brian A. Jewett Hans C. Dreyer ... Steven N. Shah, Brian A. Jewett Published November 1, 2013 Citation Information: J Clin Invest. 2013;123(11): doi: /JCI ) Combo of arginine, glutamine, HMB – 14 days post-op – best effect – especially in older adults - significant increase in collagen deposition (Effect of a Specialized Amino Acid Mixture on Human Collagen Deposition. Williams, Jeremy Z. MD; Abumrad, Naji MD, FACS; Barbul, Adrian MD, FACS. Annals of Surgery: September Volume Issue 3 - pp ) Glutamine – helps with infection and inflammation – not really wound healing Arginine – Collagen synthesis Vit A 10K IU 2-4 weeks Vit c 1-2K Cu 2-4mg Zn 15-30mg Nutritional Support for Exercise Induced Injuries. Tipton, K.D. Sports Med (2015) 45(Suppl 1): 93. doi: /s Essential amino acid supplementation in patients following total knee arthroplasty Hans C. Dreyer ... Steven N. Shah, Brian A. Jewett Hans C. Dreyer ... Steven N. Shah, Brian A. Jewett Published November 1, 2013 Citation Information: J Clin Invest. 2013;123(11): doi: /JCI70160.

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24 Application Encourage your patients to:Eat every 3-4 hours (include protein with each meal/snack) Follow the Mediterranean diet Take a multivitamin Make homemade shakes if no appetite (whey protein, fruits, vegetables, milk/yogurt) Include fish, nuts/seeds, avocado, olive oils daily Eat the rainbow Lose weight if appropriate

25 Spread the Word You are the gateway to helping your patients understand the importance of nutrition in healing! Needed for better success and speedy recovery. For further help with diet and/or supplementation for healing, refer to the experts! – Physician Referral

26 Next Level Perioperative Nutrition ProgramSH colorectal team started Impact nutrition supplement (nucleotides, arginine, omega-3s) pre-op SH ortho team starting planning on perioperative program for improved outcomes from surgery Impact 3 cartons/day 5 days pre-op and post-op Vitamin supplementation 2-4 weeks post-op HMB supplementation 2 weeks post-op

27 Questions? Thank you!

28 References Understanding the Role of Nutrition and Wound Healing. Joyce K. Stechmiller, PhD, ACNP-BC, FAAN. Nutrition in Clinical Practice. Volume: 25 issue: 1, page(s): 61-68 Nutritional Support for Exercise Induced Injuries. Tipton, K.D. Sports Med (2015) 45(Suppl 1): 93. doi: /s Diet and Inflammation. L. Galland, MD. Nutrition in Clinical Practice. Volume: 25 issue: 6, page(s): Schwingshackl L, Hoffmann G. Mediterranean dietary pattern, inflammation and endothelial function: a systematic review and meta-analysis of intervention trials. Nutr Metab Cardiovasc Dis Sep;24(9): doi: /j.numecd Review. PubMed PMID: Nutrition, Inflammation, and Disease. By Mary Franz, MS, RDN, LDN. Today’s Dietitian Vol. 16 No. 2 P. 44 Essential amino acid supplementation in patients following total knee arthroplasty Hans C. Dreyer ... Steven N. Shah, Brian A. Jewett Hans C. Dreyer ... Steven N. Shah, Brian A. Jewett Published November 1, 2013 Citation Information: J Clin Invest ;123(11): doi: /JCI70160.

29 References Effect of a Specialized Amino Acid Mixture on Human Collagen Deposition. Williams, Jeremy Z. MD; Abumrad, Naji MD, FACS; Barbul, Adrian MD, FACS. Annals of Surgery: September Volume Issue 3 - pp

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