Welcome to The Hip Replacement Podcast, where recovery meets motivation and healing leads to a whole new lifestyle.
I'm Chris Bystriansky, your host. I'm an author, athlete, and double hip replacement patient. I've been through the surgeries, the setbacks, and the comebacks. And I'm here to help you do the same.
Each week, I'll bring you tips, tools, expert advice, and inspiring stories to help you take back your life one step at a time.
Thanks for joining The Hip Replacement Podcast. New hips, new you. Let's go.
Welcome to The Hip Replacement Podcast. I'm Chris Bystriansky, your host. I'm also a two-time hip replacement patient. One more than 10 years ago and the other more than 12 years ago, and I'm here to share my experiences with you.
We all know intuitively that nutrition is important in our daily lives. Don't get enough of the right minerals and vitamins and your body starts reacting negatively and you're not able to be as sharp, as strong, or as capable as you really could be.
Not only is this important as we age to maintain our health, energy, and activity levels, but this is even more critical as we undergo surgery and the entire recovery process. The body needs the right nutrition to repair and recover itself.
But what are those right vitamins and minerals and how do we even know about them? Unfortunately, this is an area that often gets overlooked and even ignored.
When I was facing my surgeries more than a decade ago, I worked with a doctor who understood nutrition because I wanted to give myself every single advantage I could possibly get to prepare myself before surgery and also help me heal after. I wanted my body to have what it required to heal and stay strong and capable not only right after surgery but even years later.
When I recently saw that the same doctor, Dr. Osborne, posted a YouTube video discussing preparation for surgery with nutrition and supplements, I knew this was perfect for everyone tuning into The Hip Replacement Podcast.
So, in this episode, I'm replaying Dr. Osborne's full video on nutrition and recovering from surgeries, with his permission, of course.
Dr. Osborne is an expert in functional nutrition and is board certified with the American Clinical Board of Nutrition. You can watch or listen to the video right here or go to Dr. Osborne's YouTube channel and watch it there. The links to Dr. Osborne's website and his YouTube channel are below in the show notes.
And if you can try to watch the video, not only listen to it, listening to it is great, but if you can also watch it either here or on Dr. Osborne's YouTube channel, that would be exceptional because he uses charts and other visuals to help our understanding of the content.
Listening is great. Watching this particular video may be even better.
Any information that Dr. Osborne shares in the video such as his nutrition surgery protocol can be accessed through the link in the show notes, and the show notes can be found below. These will take you directly to this video on Dr. Osborne's YouTube channel.
I hope you enjoy his discussion on nutrition and supplements as you prepare for and recover from your surgery.
Most people think surgery is the hard part, but in reality, it's the beginning. The complicated part is what comes next. Increased risk for infections, complications, even failed surgery.
All provided you don't have the right nutrients in place before you go into the operation.
Today on the Dr. Osborne Zone, I'm going to be diving into how you can set yourself up before the surgery for success nutritionally. We're going to be talking about the lab tests you should ask your doctor to run. We're going to be talking about supplements you should take to enhance your healing and recovery. And we're also going to be talking about strategies postsurgically to enhance your recovery to reduce the risk of side effects, infections, or complications.
Stay tuned. We'll be right back.
You unlock this door with the key of compassion. Beyond it is another world, a world of science, a world of common sense, a world of sanity. You're moving into a land of both empathy and ethics, of nutritional knowledge and empowerment. You've just crossed over to Dr. Osborne's zone.
Welcome to Dr. Osborne Zone. Today we're diving into surgery. If you've got a surgery plan, this is a show you don't want to miss.
We're going to be talking about the nutrition, rather the malnutrition, that comes with guaranteed complications and guaranteed poor outcomes. So, let's talk about it for a minute.
One of the things that we know about people going into surgery, and this is especially true if you're going into surgery and you're overweight or obese, we know that people with obesity have much higher rates, sounds contraindicated, but higher rates of malnutrition.
Partly because obesity is an inflammatory condition and it drives nutritional load. So, we know that before surgery for many, malnutrition is something that actually can lead to needing surgery, right? Because when your body's malnourished, it's more prone to breaking. It's more prone to breaking down.
So, we've got preexisting malnutrition increasing the risk for surgery. Secondarily, you go into surgery. We know that surgeries can cause malnutrition. It's a very, very common consequence.
Remember that surgery, the trauma and the damage that it creates, leads to an increased demand for vitamins, minerals, amino acids, and other nutrients to heal and repair.
So we can get failed and botched surgeries as a result of malnutrition going into the surgery. We can get failed and botched surgeries because the surgical trauma itself sets the patient up for the potential of these complications.
Now I think one way we can define surgery, and this is not to say you're a bad person or you're bad because you need to have a surgery. Surgeries can be life-saving in many cases, life-altering.
But let's define what surgery is. It's scheduled trauma. Anytime you go under, you're going to be opened up. That is trauma. You're cutting through tissue. You're cutting through organs. Sometimes even removing organs. That's traumatic shock to the body. And in order to recover from that requires good nutrition.
So, let's talk about how you can prepare for surgery on the front end. Very, very important. Because surgeries are scheduled out, these things can be done months in advance to get you ready to have the most successful outcomes possible.
So, let's talk about some labs that you should request before surgery. Now, these labs are nutritional labs. Your doctor's already going to want to run certain labs, but again, these are the ones you want to request from a nutritional perspective.
Now, they're usually going to run a CBC. They're usually going to run a chemistry panel. That's often times where it stops. Because these are common labs and doctors will look at a CBC. They're looking to see whether you have anemia, which can affect your surgical outcome.
You know, your red blood cells, your white blood cells. If you have, for example, low white counts, it increases the risk of infection. So, they want to make sure your immune system's up and going.
If you have low red blood cells or low hemoglobin, then you're not going to heal very well. This is anemia in essence and your body requires oxygen to heal. Oxygen is delivered to your cells by your red blood cells. So without adequate quantities, it creates complications in a post-surgical situation.
They're also nutritionally going to look at protein and a type of protein called albumin. Those are found on a standard chemistry panel.
We already know from years of data and research that patients going into surgery with low albumin have greater complications, greater risk for infection. So these are some things that you're already going to get.
You generally don't have to request the top two.
But the nutrient panel, so iron panel, is typically not standard. Your doctor's not typically going to order it. You don't always have obvious anemias on a CBC. Sometimes the CBC doesn't show the anemia. So the iron panel sometimes is more sensitive to pick up on earlier iron deficiencies that might inhibit your ability to heal.
Ferritin is iron storage. So if your ferritin levels are very low, and who's at risk here are women, especially women of menstrual age. So if you have ladies, if you're on your cycle and you're prepping for surgery and you have heavy blood loss, this is going to set up the stage for a transient anemia going into a surgery that might complicate things.
So, you want your iron storage to be high enough so that you know when you do have your cycle, you've got some reserve in the gas tank, so to speak, to help you recover.
And then on the other side of that equation, so we got ferritin rather being if it's low, it's indicative of low iron levels. If your ferritin's elevated, it's indicative of inflammation. And if you've got active ongoing inflammation, this could also pose a complication for surgery as well.
This is why this test is recommended, the HSCRP test, and that stands for high sensitivity C reactive protein. It's also a marker of inflammation. And so, if you have inflammatory markers that are high before going into surgery, this could indicate a potential complication for you.
Now, understand these are markers of inflammation. So, if you're going in because you've had a hip fracture or you have severe pain, arthritic pain, and you're getting a joint replacement, it's not uncommon for those individuals to have high inflammation because of the damage from what they're about to have surgery for.
But if, let's say, for example, you're not going in for something like that, you're going in for something more elective, and you have pre-existing inflammation and don't know why, there's not an obvious source, you need to be concerned and communicate that with your surgeon about those potential risks.
Another test that should be measured is your vitamin D, 25, standard lab test, very easy to order. And vitamin D deficiencies have been shown to be present in many people with complicated outcomes in their surgery.
So this is low-hanging fruit. Very simple test. If it's low pre-surgically, you can supplement.
And this is especially true. Let's say your surgery is scheduled for winter. You're going into, you know, let's say a January surgery or February surgery. You haven't been getting adequate sunshine. You haven't had the opportunity because of the weather and your vitamin D stores have dropped as a result of that.
Now you're going into a surgery, complications, increased risk, etc. We want to be able to mitigate that. So supplementation when we know it's low is a very simple thing to do to prepare you for the surgery.
And then lastly, in my opinion, the most important test of all is something called an INA. And that stands for intracellular nutrient analysis. This is measuring vitamins, minerals and amino acids and other key nutrients involved in healing and repair.
And so this type of test you can request it from your doctor. Generally it's ordering or looking at 50 plus nutrients to determine whether or not you're low and need them.
And because this is what's going to set you up for success or failure.
Now, you should screenshot this. Take a picture of it. If you're planning surgery, go in and talk to your doctor about these things before you allow yourself to be put at risk nutritionally.
A lot of you may think, well, my surgeon knows about nutrition. He would tell me about these things if they were really a risk.
And so, let's look at what research has shown. This is actually a brand new publication that just recently published on medical students knowledge and perceptions about micronutrients in surgical care.
And what they found was that almost about 67%, 66.7% on average had correct or knowledge-based survey information.
They said initially 11 out of 12 students indicated significant comfort in identifying micronutrient imbalance in their patients. However, but once presented with actual patient scenarios, the discussion shifted to inadequate familiarity with micronutrient biology.
In other words, these physicians, even though they claimed to have the knowledge, when they started getting hit with patient scenarios and discussion, they had inadequate familiarity.
They had a lack of relevance to clinical cases during rotations. Meaning when they were going through their clinical rotations, most likely their attending physicians weren't talking about nutrition, weren't applying nutrition or implementing nutrition because they didn't have the relevance and the understanding of it.
And then they also had tremendous variables in education. Some schools, some hospitals teach it better, some don't teach it at all. So there's not like a standard of nutritional knowledge being taught in medical schools.
You can see here conclusion and implication. Students recognize micronutrient science as important in the care of the surgical patient, but most report low self-efficacy and lack of clinical integration.
In essence, we know about it. We just don't know what to do about the knowledge that we have. We don't have any clinical experience to implement this.
And this is where this is where I shine. And this is where you can use me. Take this information into your surgeon and demand respectfully.
So, demand that you have this conversation before just diving into surgery.
So, let's check this out. This is a roadmap to surgical success.
So if we're talking about pre-surgical prep and these are some general baselines, here's what we know. We know that protein is core. It's one of the most fundamental foundational things to prepare yourself for.
Now in this diagram talk about a 7-day protein load. You can go out further than that. You can go out 14 days, as well.
I actually like to prep in my office if somebody's going to have a surgery. If we have the time, I like to go out 30 days prior. I like to start doing several things 30 days prior surgery.
I like to increase their protein intake.
If you notice here, there's a reference dose of 1.2 to two grams of protein per kilogram of body weight. What this is ultimately going to equate to is about one gram of protein per pound of lean body mass.
So if you're 200 lb overweight, you don't take your total weight. You take what would be your lean body weight. And you would eat that many grams of protein a day for 30 days prior the surgery.
The other thing that you would want to do depending on where you're having the surgery, if it's an orthopedic surgery, a joint replacement, any particular area, you should start exercising around that area to tolerance.
Now, I know if you're getting a joint replacement, it's probably very painful and that's probably why you're getting the replacement, but you need to exercise around that. You need to be ideally in a PT program or some kind of monitored exercise program so that you can prepare the muscles for the surgery.
Because what happens after surgery is people can lose up to 1% of their muscle daily after the surgery. And the reason why is the trauma of the surgery, the inflammation usually leads to bed rest for a time at which point when you're resting and trying to recover, you're losing muscle mass in a big way.
So, we want a protein load on the front end. You can go seven, but I recommend 30 days if we're really trying to amplify this.
Now, you see down here, malnutrition doubles your risk. 47% complication rate for malnourished patients.
And when I'm talking about malnourishment, the main form of pre-surgical malnourishment is low protein. When we have patients in our clinic count their protein, from all walks of life, on average, they're usually sitting around 60 grams per day of protein.
Now, if you're 150 pound man and that's your lean weight, you need a gram of protein per pound. That's 150 grams.
So, going into a surgery with only 60 grams a day in your diet is it can be catastrophic.
Again, a 47% complication rate versus a 22% potential complication rate for well-nourished patients. Again, and this is defined with protein.
So when we talk about malnourished in this context, we're referring to protein.
The surgical procedure itself creates trauma and that leads to a major stress response and that cascade, right, that surgical stress response cascade causes inflammation as I mentioned before creates a 1% loss of muscle after the fact and you need amino acids for wound healing.
Essential amino acids are the bricks that repair tissue and prevent surgical infections.
If you want to know more about specific amino acids, I have an entire library of crash courses on individual ones. But for surgery, if you're trying to target specific amino acids more, there are two that probably outshine the rest.
One is L-arginine. L-arginine has been shown in many human studies to reduce surgical complications, reduce hospitalization time, and to enhance recovery.
The other one is L-glutamine.
And let me back up just a minute. Why L-arginine? Because it increases blood flow. It helps blood vessels in the microcirculation where the surgical trauma has occurred. It helps those vessels dilate and that helps get more vitamins, minerals, oxygen and nutrients into that tissue.
So, it's because arginine is necessary to make nitric oxide, an essential substance that opens up your blood vessels.
L-glutamine, in part, helps make L-arginine and some researchers believe the effect of L-glutamine is actually in part because of it improving or increasing L-arginine.
But L-glutamine has other functions as well. It's the most common amino acid, the most abundant amino acid in the body and in your muscle tissue. So, if you're going through an orthopedic surgery specifically where muscles are being cut, this is going to be critical for their repair and for the maintenance of those muscles and to prevent them from dwindling after the surgery.
But L-glutamine is also the fuel source for two key areas. One, it's the fuel source for enterocytes. What does that mean? Enterocytes are small intestine cells. They're the primary cells of your small intestine.
Why are they important? Because this is how you absorb nutrition from your food. These are how you get access to other vitamins and minerals.
So if your glutamine drops because of the surgery, the enterocytes in a sense starve and then your absorption of other nutrients reduces and so now your body has less coming in through the GI tract to heal and repair itself.
The second primary function of L-glutamine is that it's also a fuel source for lymphocytes.
And you really need your lymphocytes to be functioning on high speed postsurgically because poor lymphocyte function during surgery and after surgery increases the risk for surgical complications.
So your immune cells to fight the potential for you know hospital-acquired bacteria or viruses or other things you need your immune system on board.
Now the other function of glutamine that's extremely important is I said earlier surgery is scheduled trauma. Glutamine helps your body to produce one of the most powerful buffering antioxidants known to man which is called glutathione.
So part of glutamine's function is to help your body produce glutathione. And there have been studies that show that glutamine supplementation before the surgery and even IV glutamine during the surgery improves antioxidant function, reduces complications of the surgery.
So where do we get our arginine? Where do we get our glutamine? Predominantly from eating protein. So protein is the number one takeaway message here.
But if you want to do individual supplementation to get more of those is certainly not a bad idea.
I actually, my surgical protocol and if you guys would like specifics on my pre-surgery prep and then my post-surgery protocol, you can comment surgery or you can check out the link below where we have that information compiled for you.
It's a very detailed graphical walk through of how to think about how you should supplement before your surgery and after your surgery and you can get that clicking the link below this video.
So we have again the muscle loss, the amino acids are necessary to rebuild and we need recovery, right, so we need that recovery.
So if we look at adequate protein, average hospital stay for somebody with nutrition adequacy 6 and a half days. Average risk of infection 13.6. Average days to heal 10.
If we look at malnourished, it's almost 10 days in the hospital. It's at 36.3% risk of infection and it's a 14-day healing time.
And this is just the beginning stages. This is just the post op in the beginning. This isn't the long-term complications that sometimes arise when somebody has inferior protein intake.
So again, we got to get protein. If you do only one thing, it's make sure that your protein levels are one gram per pound.
Now, that's before you go into the surgery. I've given you lab tests that you can ask for. I've talked about getting more protein. You can start doing that right away.
Let's talk about supplementation.
One of the things that commonly comes up when you're getting ready to go to surgery, and I get this every week in my practice, is the doctor says, "Stop all supplements."
And I think it's important to point out what I just talked about in this context.
So if we look back over here, what do we say? We said surgical doctors lack understanding of clinical integration of nutrition and so they're just scared of it.
I'm not trying to pick on any doctors, but when a doctor says stop all your nutritional supplementation before your surgery, he's basically potentially setting you up for failure.
What he's worried about are supplements that could potentially thin your blood. And not all supplements thin your blood. There are certain ones that do. And I think it's probably a good idea to listen to that surgeon as it relates to those types.
The main supplements that can thin your blood, high dose omega-3, high doses of vitamin E, high doses of ginkgo biloba, so if you're using that as a brain supplement, and then high doses of blood thinning proteolytic enzymes like nattokinase, serrapeptidase, lumbrokinase, the family of proteolytic enzymes, all these things have the capacity to thin blood or to create a thinner blood.
So, in this regard, I don't disagree, but let's say for example that you're using a protein supplement, it's not going to thin your blood. You shouldn't stop taking it if it's helping you meet your required levels.
A high quality multivitamin, it's not going to thin your blood. It's going to get you extra micronutrients in your system ready for you so that when you do get cut on, you have the nutrients there to help your body recover and repair a lot more effectively.
Let's say you're using vitamin C. Vitamin C is necessary for collagen reformation. Vitamin C doesn't thin your blood. It's very important.
So, when you have a doctor that says stop all supplements, your question should be get more specific. Do I stop everything? And why? Why do you want me to stop all supplements?
Ask the question because if they have a very specific unique reason, honor it.
I mean, they may have an experience with certain supplements and certain patients and they may have a background to a certain degree where they don't want you to do certain things and they have a good reason, but ask because most of the time it's not a good reason.
Most of the time it's I don't know anything about this stuff. Just tell them to stop everything and we'll sort it out afterwards.
And pre-supplementation, pre-surgical supplementation can be very valuable in your recovery.
Okay. When you're done planning for the surgery, then you have to consider what medications are going to be used during the surgery. What are they going to be putting you on that might have potential complication?
And so the main things that we see typically in surgery you get an antibiotic. A lot of time and this is usually in an IV form. It's often times used preventatively but even postsurgically a lot of times they just prescribe the antibiotics to reduce the potential risk of infection which I'm not a fan of.
I don't think you take an antibiotic after every surgery to reduce the risk. I think if you have complications possibly if you're diabetic and you're uncontrolled blood sugar possibly but beyond that it should be a watch and see type of situation in my opinion.
Steroids can actually they're used a lot of times for pain reduction or inflammatory reduction.
And then pain meds and NSAIDs are probably one of the more common used here. Although sometimes, you know, it's not just NSAIDs, it's also opiates, oxycontin, morphine, depending on the surgery type, depending on the doctor, and sometimes Tylenol would be another option or acetaminophen.
And so, what do we have to think about in this regard?
There's actually one more. It's the anesthesia that's used.
So, you need the anesthesia. I'm not saying don't take the anesthesia, but a lot of times anesthesia will interfere with vitamin B12.
Vitamin B12 is critical for oxygen delivery to your tissues and healing and repair. So, this is something that, you know, talk to your doctor, your anesthesiologist about whether or not that particular medicine they're using is going to deplete B12 and whether or not you need to consider pre-supplementing and post-supplementing after the fact.
Antibiotics, of course, this is a judgment call, but you should be considering a probiotic post-surgically right away. If you were given antibiotics, you want to remember that antibiotics wipe out your flora.
And one of the side effects of antibiotic use is a leaky gut. And why that's important is you need your gut after surgery. You need your gut to absorb, to digest, to do the things it's supposed to do to help you get quality nutrition.
But also antibiotics deplete nutrients like biotin and vitamin K. These nutrients about half of the daily need of these two nutrients comes from healthy flora and when you're taking antibiotic you wipe out the potential here.
And vitamin K is very important for remineralization of the tissue that was damaged during the surgery. Biotin is very important for how your body utilizes fat to make energy to heal and repair.
So you want those nutrients present and taking the antibiotics can deplete those.
We know that steroids deplete many different types of nutrients. Calcium, magnesium, vitamin C, zinc can be depleted as a result of steroid use. And of course these are all necessary for wound healing and wound repair.
And of course, NSAIDs cause damage to the GI tract. So NSAIDs can also cause leaky gut, especially when they're combined with a steroid. The effect is about seven times greater.
NSAIDs also will block folate and iron and vitamin C. So, if you're using those for pain relief, you've got to consider how it's impacting these nutrients.
If you're especially like an orthopedic surgery, folate, you need it to make new cartilage. And without it, you're not going to heal as effectively.
You also need folate for many other things.
If you're having GI surgery, you need folate to basically to make enough DNA quick enough to heal and repair GI tract cells from that surgery. So very key nutrients here.
And then of course opiates, aside from the known consequences of opiates, opiates deplete nutrients as well.
But one of the biggest longer term used side effects is that constipation really just hammers your gut and it leads to problems with digestion and absorption as well.
Tylenol depletes glutathione which is one of the most important recovery nutrients as it relates to surgery because of the free radical and tissue damage production.
So understand which medicines your doctors are going to be needing to use for you. Understand their nutritional complications.
Understand how those complications might impede your ability to heal when you get home.
And also understand are there alternatives? Are there things that you could do differently?
Like do you actually need the antibiotic or is that just a just in case kind of prescription?
Are there other things you could do? Like could you apply other natural antiseptics to the wound if you're doing wound care?
If your surgery, if it's an open scar, you know, could you use hydrogen peroxide to clean that wound?
Are there other things that you could use at home?
We like to use hydrated silver for many people.
Some I've seen some surgeons even use like honey preparations. Honey is a very effective surgical wrap to reduce the potential risk of infection.
But these are just would be alternatives.
And then, you know, are there alternatives to pain medication?
I have a couple. One of my favorite alternatives is white willow. We have a product at Gluten-Free Society called White Willow Complex.
And you know, it's this is where aspirin comes from. It's not aspirin. Aspirin is a synthetic derivative of white willow.
But white willow has extremely powerful anti-inflammatory effects and works really, really well for pain and inflammation reduction.
We also know that mixing vitamin C and quercetin can be very effective postsurgically.
There are number of research studies showing that vitamin C reduces the need for analgesics or for pain medications after surgery.
This has actually been researched in humans.
So I recommend about five grams a day. And with quercetin when you combine quercetin and vitamin C they have a synergism and I like to see four to five grams of quercetin a day as well.
And this is just mainly as needed, right?
So, you don't necessarily need to do this every day after your surgery, but if you're in that pain and you're wanting to reach for pain meds, you should be, in my opinion, if you're looking for a natural alternative, reach for these first as an alternative to taking those medications that drive nutritional deficit.
So, now let's talk about some surgeries independently.
Many of you have had these surgeries. Many of you maybe are looking at having these surgeries, but you need to understand a few things.
So, there are common surgeries that can cause lifelong malnutrition.
I think it's important that you understand that because part of when you go in to do surgery, part of what's supposed to happen is you're supposed to get informed consent where your doctor says, "Hey, for the rest of your life after this surgery, you're going to need to understand."
For example, bariatric surgery, for the rest of your life, you need to have your nutrition levels checked twice a year. The research states this. We know it's a complication.
So, if you had a gastric sleeve or a Roux-en-Y gastric bypass or any of the other kind of stomach stapling type surgeries, you're at risk for lifelong malnutrition because of that.
And so you need to understand these things so that you can prep yourself because you can't take the surgery back.
But what you can do is you can offset some of the nutritional problems associated with it.
So these four are some of the biggest: tooth extractions, bariatric surgeries, bowel resections and gallbladder removal or what's called cholecystectomy.
Now, tooth extraction probably the least detrimental of these three groups.
And where the tooth extraction, where that comes into play is that if you have a tooth removed, let's say you have an upper tooth removed, and then below it, you've got the teeth on the underside.
Well, as you're chewing, what keeps your teeth really strong and mineralized is the opposing force.
So, like your bite, when you bite down, this tooth hits this tooth and there's pressure, right? There's pressure going both ways. And that's what in part keeps those back teeth mineralized really, really well.
Well, when you have a tooth removed now, when you're chewing, unless you have a plate here, but if you don't, now when you're chewing, this tooth doesn't get adequate force and it can start to demineralize. It can start to deteriorate.
And of course, when you lose your teeth, you lose your ability to chew. When you lose your ability to chew, we're talking about mechanical digestion suffers.
Mechanical digestion is very important for overall nutrition. It's a big way in which we start breaking our food down to get our vitamins and minerals from it.
So where you have a tooth removal or tooth extraction, especially if you have multiple teeth out, you're using dentures, it is a lot harder to chew when you have multiple missing teeth and that can long-term affect a lot of how you eat.
Now you're choosing and selecting soft foods versus hard.
And where we really see a tooth extraction or multiple tooth extraction kick in is with protein. People will self-select away from protein.
If you've got multiple teeth missing and you don't chew animal meat because it's just a pain, consider liquid proteins like a shake, a protein shake because you got to get your protein in.
But I understand the complication there.
If we're talking about some of these other surgeries, let's do a deeper dive on some of these other things.
So here we have was a major research review on bariatric surgery and long-term nutritional issues which you can see here.
This alteration makes these patients more susceptible to developing nutritional complications namely deficiencies of macro that's carbs, fats, proteins and micronutrients that's vitamins, minerals which could lead to disabling diseases.
It's very important that you understand that malnutrition causes disease such as anemia, bone loss or osteoporosis and protein malnutrition.
Down here the summary. Nutritional complications associated with bariatric surgery can be prevented by lifelong nutritional monitoring with the administration of multivitamins and mineral supplements according to the patients needs.
This goes back to what I was saying a moment ago, the pre-nutritional workup, the labs, and I mentioned there's a test called an INA.
If you've had bariatric surgery, you should be doing this two times a year as a standard of your care, knowing that if you don't, you're going to run the risk of long-term complication.
Here's another paper published on a similar topic.
This particular paper was looking at specific types of bariatric gastric surgeries.
One being the sleeve gastrectomy and the other being the Roux-en-Y gastric bypass surgery and then also the jejunoileal bypass.
So these are common types of surgeries done for people who have a morbid obesity and the risk of the morbid obesity outweighs the risk of the surgery and so many of these cases the surgery is the right move.
But what's the consequence?
What they found is certain surgeries affected the absorption of iron, selenium and vitamin B12.
They found nutritional deficiencies in vitamins, minerals and trace elements may follow bariatric surgery and are associated with clinical manifestations and diseases including anemias, ataxia, which is loss of balance and dizziness caused by often times by B12 deficiency, hair loss, and something called Wernicke encephalopathy, which is basically a degradation of your nervous tissue leading to neuropathies.
So, don't trade your obesity for clinically life-threatening malnutrition.
Bottom line, you can see here another study done on gastric bypass.
Specifically, we know that the surgery affects the absorption of B12 and also vitamin D, as well as fat soluble vitamins and other nutrients.
Although both surgical methods induce only a mild protein deficiency. It's a mild one, but it's still a protein deficiency leading to osteoporosis.
So if you look at what they're saying here is that you've got a person with peak bone mass, a woman goes through menopause and you get this curve, menopause and then you get a dip in bone density that kind of follows.
But then if you have somebody with bariatric surgery here, they get a stronger dip.
Look at that dip in bone loss. It goes down and so they're losing bone mass.
And so the research is showing in part that it's vitamin D deficiency as a result of the surgery itself.
So you're at risk. What I'm trying to tell you is you're at risk for bone loss as well as a result of nutritional deficiency calcium, vitamin D, etc.
So here's a nice flowchart that you can think about.
So in the morbid obese, one of the things I mentioned is when you're overweight, you already have vitamin mineral deficiencies.
Part of being overweight is that you have chronic inflammation and malnutrition and so you're going into the surgery malnourished.
So you do the bariatric surgery. If you have a poor diet and most of these people do and you have damage you've got malabsorption and then you also have insufficient supplementation it's going to lead to post-operative risks.
So even though you might get thin you're also your bones are getting thin and there's other risks involved.
Bottom line bariatric surgeries cause malnutrition. You should talk to your doctor about that.
If your doctor doesn't understand that you should talk to a doctor like me where you can get set up on a regular basis to have your nutrition checked.
Now one of the other common surgeries, this one of the most common surgeries performed on people is removal of the gallbladder. So cholecystectomy.
So if you've had your gallbladder taken out you should know there's a risk of metabolic syndrome.
Now maybe you're scheduled to have your gallbladder taken out. Listen closely.
We know post gallbladder removal, so cholecystectomy what happens next?
Well one thing that happens you see this arrow here is we get an increase a doubling of enterohepatic bile acid dumping and this extra bile acid recycling causes a direct impact on the gut flora on the microbiome causing dysbiosis.
We know that it leads to an increased risk of inflammatory compounds, cytotoxic pro-inflammatory bile acids which lead to cytotoxicity and damage to the liver.
So this is a consequence of this surgery.
So when your doctor says you don't need your gallbladder, it's not about whether or not you need it, it's about what's going to happen when they remove it.
What are the complications long-term post-surgery?
So this is one of them.
Now, one of the other complications that I want to point out is we get a reduction in GLP-1.
Now, any of you taking Ozempic or these other weight loss drugs in the same class, you know, what are you taking? You're taking medicines that actually give you that protein.
And when you get a gallbladder surgery, your ability to make it is reduced.
So, you can actually increase your risk potentially of weight gain.
We also know that we get increases in inflammation and macrophage activation which are inflammatory cells and that leads to epigenetic changes or can contribute to them.
Changes in your ability to methylate which is partly how we do detoxification.
We also know if you follow this all the way down to the end these surgeries increase the risk of insulin resistance in a big way.
And part of that has to do with the damage to the liver and the fatty liver component, but also part of that has to do with the reduced availability of glucose.
And so you're increasing a process in the liver called gluconeogenesis which dumps a bunch of extra glucose into your bloodstream driving up your insulin over time that equates to an increased risk of insulin resistance.
So again the title of this is cholecystectomy and the risk of metabolic syndrome because that surgery increases your risk.
Just something you should be aware of.
If you've had the surgery, don't lose sleep. Don't go home and cry about, you know, life is hopeless. There's plenty that you can do here.
If you've had the surgery, but if you're thinking about having the surgery, these are questions you should ask the surgeon about complications.
We also know there's other risks with this surgery, cholecystectomy and subsequent risk of Parkinson's disease.
Here was a nationwide study.
See growing evidence has suggested that the gut brain axis plays a role in the development of Parkinson's disease and that this role is mediated by interactions between your bile acids which are made by your liver and secreted by your gallbladder and your intestinal microbiota.
Given that cholecystectomy can lead to alterations in bile acids and gut you see down here our results provide evidence that cholecystectomy is associated with increased risk of developing Parkinson's disease.
This was especially true in men more than it was in women in this particular study.
So there is a risk. Know it so that you can weigh your decisions more effectively.
Here's the effect of cholecystectomy on your vitamin D levels and bone mineral density. This is in men postmenopausal women.
So you see here the influence of bile salts on vitamin D absorption is well known.
You need bile to absorb vitamin D from the food that you eat. It's part of bile's job is it emulsifies fat so that you can absorb fat. Vitamin D is a fat.
What we know in women after they've had a gallbladder removal that they have lower vitamin D levels across the board and they also have lower bone mineral density than women who didn't have their gallbladders removed.
So, direct impact on nutrition and bone health.
And vitamin D does more than that. You know, vitamin D is an immune regulator. It regulates autoimmune reactivity, regulates how white blood cells mature.
So it's more than just your bones that require vitamin D.
Here's another study on magnesium deficit caused as a result of cholecystectomy.
It was found that 60% of the operated patients suffered different digestive syndromes in association with magnesium deficiency while 40% of patients had the same complaints in association with magnesium and calcium deficiency.
And when the supplementation was given, their symptoms resolved.
And so the question mark there is is that surgery contributo to magnesium and calcium loss?
Here's another one. Association between the cholecystectomy and the risk for fracture.
Patients who underwent cholecystectomy showed an increased risk of all fractures including vertebral and hip fractures.
Individuals who underwent gallbladder surgery have an increased risk of fracture. In the younger population, the risk of vertebral fractures may be further increased following gallbladder removal.
So, kind of the theme here with a lot of this research is bone health, vitamin D, calcium, magnesium.
Now here's a study on micronutrient deficiencies after pancreaticoduodenectomy which is a different kind of surgery but it's a GI surgery specifically.
You can see micronutrient uptake is impaired after pancreaticoduodenectomy because of malabsorption reduced absorptive capacity and poor oral intake.
We established that iron zinc and vitamin D deficiencies are common.
Fat soluble vitamin deficiencies are rare and occurred in patients who discontinued pancreatic enzymes but are otherwise nutritionally well.
Whereas trace element and B vitamin deficiencies occurred as part of a more generalized malnutrition state.
So, malnutrition when you get part of your intestine removed, part of your pancreas removed.
Those of you who have had long bowel syndrome or rather short bowel syndrome where you've had part of your colon removed or part of your intestines removed, that doesn't come without a cost.
Now, sometimes it's an emergency surgery and it has to be done, but you should know the long-term nutritional consequences afterward.
So, again, surgeries that require lifelong nutritional monitoring.
So if you've had any of these, you need to have your nutrition values checked twice a year. Gallbladder removal, bariatric surgery, small bowel or colon resection.
So, you know, if you've had ulcerative colitis or Crohn's and you've had part of your bowel removed, if you've had a cancer and you've had a section removed, you need to make sure you're getting your nutrition levels checked.
What do you get checked? We talked about this earlier.
What do we get checked?
The CBC, the chemistry panel, especially protein and albumin, iron, ferritin, vitamin D, HSCRP, measuring the inflammation, and the INA, intracellular nutrition analysis to look at all the different vitamins, minerals, and amino acids to make sure that you know where you need to focus your time, effort, and attention as it relates to nutrition adequacy.
And so with these types of tests, you can adjust your diet to incorporate more foods that contain those nutrients if they're low or you can supplement.
In many cases, because of the surgery, supplementation becomes necessary.
Now, couple of supplements I want to speak on.
If you've especially if you've had a gallbladder removal. So, what should you consider taking if you've had your gallbladder removed?
One, you should definitely consider taking something with ox bile in it as a substitute.
Ox bile will put bile into your intestine at an appropriate time where you can then with your food, with your meal, you can better support absorption of fat soluble vitamins, vitamins A, D, E, and K.
But also omega-3 fatty acids are you know obviously those are fats as well as are some of the other fats like omega 9 become very critical and important.
So if you've had your gallbladder removed I highly recommend a supplementation to help you digest.
If you've had part of your bowels removed it's really up in the air depending on which part of the bowel you've had removed.
If you've had your stomach operated on or you've had stomach damage from an operation, I would highly strongly suggest either one of these two digestive enzyme, a broad-spectrum digestive enzyme formula just to help with breaking of your food down.
Because when you removed or bypassed part of your intestine, this is where you're going to struggle.
You're going to struggle with breaking that food down effectively.
And that's what you might be eating the right foods, but without the adequate digestive capacity, you're not breaking those foods down adequately enough to get to the nutrition.
Okay, let's talk about those of you who maybe are going into some kind of orthopedic surgery because we've been really focusing on GI tract surgeries, but many of you are having hip replacements.
Maybe you've had fractured hip and had a surgery. Maybe you're getting a knee arthropathy or a joint replacement. Maybe it's surgery on your ankle or just some type of trauma surgery.
Let's talk about needs in this case.
So this is a really good review published in the journal Nutrients on recovery following orthopedic surgery.
And so you can see here nutritional status is a strong predictor of postoperative outcomes and is recognized as an important component of surgical recovery programs.
I would argue that's false. I would say based on the information I've already shown you is not recognized as important because it's not practiced.
As a matter of fact, how many of you have sat down with an orthopedic surgeon before your surgery and they ran a bunch of nutritional tests and said, "I want you to take X, Y, and Z."
Now, it happens. I know there are doctors out there that do it. I know some of them. But I would argue that this is underrecognized. It's not standard of care.
Adequate nutritional consumption is essential for addressing the surgical stress response and mitigating the loss of muscle mass.
This is one of the big things that happens is because orthopedic surgeries typically lead to immobility and if you're sitting around trying to recover from the surgery, you're losing muscle very rapidly, especially in older patients.
Inadequate protein, we've talked about this, can lead to significant muscle atrophy leading to a loss of independence and increased mortality risk. So, increased risk of dying without adequate protein.
Very important.
Current nutritional recommendations for surgery primarily focus on screening and prevention of malnutrition, pre-surgical fasting protocols, and combating postsurgical insulin resistance.
I would say even that's limited in my experience. Most people I see their doctors aren't addressing it at all.
If you come down here again, it's a strong indicator of outcomes. Malnourished patients have longer lengths of stay in the hospital, higher readmission rates, a greater number of complications, and higher mortality risk.
An estimated 24 to 65% of surgical patients ranging from young to the elderly undergoing major surgery are malnourished or at risk of malnutrition. Look at that number. 24 to 65%.
So, I mean, that's pretty damn alarming when you think about it because not 100% of these people are being talked to about nutrition prior to their surgery.
For a patient in nonstressed clinical state, so somebody in general good health, surgery stimulates a cascade of inflammatory, immune, and metabolic responses that result in hyper catabolic state.
Meaning it's now you've got inflammation and catabolic means that your tissues are being broken down.
So catabolic state, tissue breakdown stimulated by the upregulation of glucagon, cortisol and pro-inflammatory cytokines.
Remember, I've talked a number of times about cortisol drives breakdown of tissue and it causes an increased glucose level in your blood.
And if you're already diabetic, this is where it can get really complicated.
Now, when you have increased glucose, you know, your body tries to compensate by increasing insulin.
But if you're insulin resistant, this becomes problematic.
Why? Because glucose thickens the blood. It glycates the blood.
And so when your blood is struggling, now you can't deliver all that extra nutrition efficiently.
Glucose also it glycates. So it binds, glycation is just a fancy way of saying that it binds or ties up protein.
It basically sugarcoats the protein in your blood rendering it less effective.
So this is what happens when cortisol goes up.
Now acutely in just a short-term scenario it's not a big deal but if you're not healing and not recovering that elevation in cortisol really will affect your outcome in the long haul.
And so you can see here when the muscle catabolism associated with the stress response, heightened cortisol to surgery is coupled with the general state of immobility that accompanies major surgery, significant skeletal muscle loss can occur.
Loss of strength and functionality follows from muscle loss.
Exercise, specifically resistance training, is the most effective way to prevent muscle atrophy. However, surgery often requires a period of total or partial immobility.
After seven days of immobilization, a 5.5 decrease in high muscle volume was accompanied by significant decreases in leg extensor 19% leg press 21% and calf strength 8% in healthy young men.
In older adults, deteriorations even faster. They've been shown to experience up to 14% decrease in muscle volume within two weeks.
That's 1% per day in the first two weeks following total knee arthroplasty.
Following abdominal surgery, functionality was not fully regained for two months postoperatively while almost a third of hip arthroplasty patients continue to experience moderate to severe activity limitations up to five years.
These are the complications.
How many of you go into surgery and expect that now your life is going to be hindered for the next five years?
You don't have to have it that way. If you eat enough protein going in, key takeaway, one of the key takeaways that you should get out of today's show is protein.
You see here, this is kind of a timed series for needs of protein.
So if you want to do post-operative timing of protein, so during rehab, protein requirements range from 73 to 1.36 grams of protein per pound per day. And that's again this is lean body mass.
Beyond that so you can see here this general recommended schedule is soon after your surgery as quickly as you can.
The recommendation is 12 grams of essential amino acids in a powdered form with some carbohydrate as well. 50 grams of carbohydrate.
So essential amino acids, why? Because postsurgically you may not be hungry from the effects of medications, but this is relatively easy to get in.
And essential amino acids are free form amino acids that are predigested. So no tremendous amount of digestion is required but 12 grams gets your body flooded with key key amino acids to begin the healing process immediately after surgery or as close to immediately as possible.
As your appetite recovers, you see 30 grams of protein 24 hours after, at least 30 grams of protein.
And then on the days after, you can see on the days after, it's stacking protein.
This is 30 20 30 30 20. It's basically a 30-20 pattern of protein throughout the course of the day.
So like breakfast, snack, before you do physical therapy or rehab, after physical therapy or rehab.
And so you're getting well over a 100 grams of protein in those days as you're doing the rehab so that you recover better.
Protein, protein, protein.
Now let's take a look at a few things here.
So pre-operative malnutrition, so this is before the surgery, is associated with increased treatment failure and salvage procedures following surgical fixation of ankle fractures.
You see conclusion, patients with malnutrition undergoing surgical fixation for the ankle experience significantly higher rates of systemic complications and adverse surgical outcomes including infections, non-union and all cause return to the OR for staged removal of the hardware, debridements, arthrodesis and amputation.
Amputation. Let that sink in.
You go into surgery, you could lose your foot, you could lose your limb if you go in malnourished and don't take this seriously.
These findings should direct post-operative risk management and motivate study into interventions aimed at promoting nutrition and preventing complications at the at risk population.
Who's at risk? Pretty much everyone.
Everyone in our population is pretty much at risk for malnutrition. I mean, maybe not everybody, but 60% for sure of adults are obese. And so all of those people are at risk. So at least 60%. I'd argue much more than that though, the way most Americans eat.
Here's another one. Nutrition and vitamin D deficiencies are common in orthopedic trauma patients.
867 patients with lower extremity fractures treated with surgical fixation.
And then what did they find?
So they recorded albumin which is protein, pre-albumin which is a type of protein. They also recorded total protein, vitamins A, C, D, magnesium, phosphorus, transferrin, which is iron and zinc, as well as wound complications.
Nutritional deficiencies were found for pre-albumin, albumin, and transferrin at 50% and 23% and 48% respectively.
So depending on the type of fracture. Furthermore, a high prevalence of micronutrient deficiencies in vitamin A, vitamin C, and vitamin D and zinc were observed.
We also recorded statistically significant difference in wound healing complications in patients who were deficient in protein, deficient in pre-albumin versus those not.
And as well vitamin C surgical complications much greater in those with vitamin C deficiency.
Takeaway, get nutritionally measured before you get operated on.
Here's another one. Vitamin D deficiency during perioperative period increases the rate of hardware failure.
These results demonstrate that pre and/or post-operative vitamin D deficiencies independently correlated with risk for hardware failure and revision surgery single level lumbar fusion patients.
And that's a pretty nasty surgery. Lumbar fusions are pretty invasive. You don't want to have to go back and have that done again.
So check your vitamin D before you go in.
You can see in this one in the journal anesthesia and pain medicine addresses the oversight by providing key nutrients such as arginine, omega-3 fats, and glutamine and antioxidants to enhance immune function and support tissue repair.
Clinical studies and meta-analyses have demonstrated that immunutrition lowers the infection rate, shortens the length of hospital stay and accelerates recovery.
Takeaway: Get your nutrients measured. Get your nutrients in you.
I love this report. This was from an online news magazine called Orthopedic Today.
So they did a study and published it and then commented on it.
Glutamine supplementation reduces hospitalization discharge from the hospital an average of a day earlier if they gave them glutamine.
The surgeons who participated in this study are now making glutamine supplementation a standard part of their perioperative surgical protocol for general surgery to prevent oxidative stress and improve clinical outcomes.
The surgeons also plan to administer glutamine before elective procedures according to the press release.
So good for these guys.
They were involved in a study. They saw the effect of the amino acid glutamine on the outcomes in their patients and they got wise and said let's do right by them.
Glutamine is pennies on the dollar.
Okay. Let's talk about nutrients that are necessary to help your body heal from surgery.
So these are some of my priority lists here. I'm going to give you kind of a couple different lists.
And again, if you want the full details, dosing, timing, and everything else, click in that link in the video description below, and we'll make sure we get that to you if you're planning for surgery.
So, what's key is amino acids.
We're talking about branch chain amino acids, glutamine, and arginine.
So, if you're kind of limited to what you can take and what you can do, I would recommend because many what's going to happen for many of you is you don't eat enough protein, you're not used to it.
And so, if you try to eat 100 plus grams of protein in a day, you're going to be so full all day, you're going to be miserable.
But where a lot of people can get that level is they can do free form amino acids.
And so, that would be a smart play.
So, you could take BCAAs, branch chain amino acids. You could take L-glutamine individually and then you could take arginine, L-arginine also individually.
Now dosing wise, you're talking about a heavy amount here.
So with glutamine, if we're talking about pre-surgery prep, I mean, a lot of like I showed you that study, a lot of those were IVs. Those doctors were doing IVs.
So that's something you may want to talk to your doctor about is an IV glutamine during the surgery.
But 5 to 10 grams is not unheard of.
You have, but the thing here is you got to start low. Start low because if you take too much glutamine too quickly, it'll cause headache. It'll cause nausea. It'll cause potential diarrhea because it can act as osmotic in your gut.
With arginine, same thing here. Three to four, not quite as much, three to four grams. You can eat it as well if you're eating a lot of protein, but you got to be careful here.
If you have a history of fever blisters or herpetic outbreaks, high doses of arginine can make this worse, can cause a flare, and you don't want that right before surgery.
So, you got to be careful here.
In my opinion, if you're going to use a lot of arginine, you should also couple that with lysine. The two of them balance each other out and same dosing three to four grams so that you don't end up having a herpetic outbreak right before your surgery.
So coupling that just to prevent that piece from happening.
Branch chain amino acids. Ideally, these usually come in formula because branch chains refer to leucine, isoleucine and valine.
So they're three separate amino acids together. They commonly just abbreviate them as BCAAs, branch chain amino acids.
But critical for muscle regrowth especially if you're having orthopedic surgery those amino acids are going to be important.
Now again going back to you get them all if you eat protein.
So if you're eating 100 plus grams a day prior you're getting these things.
But if you're not and you don't have the stomach room to fit it you need to consider powders.
We have a blend something called Ultra Aminos which is a full blend of all the free form amino acids that you can take and just mix it in water and drink it.
We use that a lot for people getting ready to go into surgery combined with protein powders.
So protein powder is another great way to get this up.
We have something called Ultra Pure Protein which is a highly absorbable and highly nitrogen or high nitrogen high biological value protein designed predominantly for repair.
So those are options.
Some people also use collagen.
So one easy way to get collagen is if you drink a hot beverage in the morning is you just put a scoop in your hot beverage.
And a scoop of collagen. If you're using our collagen, Ultra Collagen, it's about 12 grams of protein in total.
But that's just one way to get it in without overfilling yourself because it doesn't really add bulk to the beverage that you're drinking.
Vitamin C becomes, in my opinion, one of the most essential.
If I were picking, if I could only pick from this list, if I could only pick a couple of things, it would be protein and vitamin C would be my top priority along with a high quality multivitamin.
A high quality multivitamin is going to give you a lot of the other things like copper and zinc in this list.
But, you know, if you're budgeting and you just don't have the bandwidth to buy high doses of all of these things, I would go with, number one would be protein, number two would be C, and number three would be the multi.
So, think of it that way.
And but if you can do the rest, ideally do the rest.
Copper and zinc are responsible for tissue healing and repair and mineralization of tissue to make it strong.
Copper is important for elasticity of tissue as well.
So again, if you're talking about an extensive invasive surgery, these are the things I recommend.
Now, if you just had a very minor surgery, like if you had a small mole removed or a small cancer from your skin removed, you don't necessarily need it in these amounts.
Although, I would still emphasize the protein, but you may not need quantities as much as you would need for something more invasive.
Okay. So after surgery, so that was all kind of before surgery, right?
So now we're going to talk about after the surgery. It's a very similar list.
Protein powder and this is your high ROI list, return on investment.
So, protein powder, vitamin D, vitamin C, the probiotics, as I mentioned before, the antibiotic offset, but also the support for your GI tract so that you absorb nutrients much more effectively after the surgery.
Because they're not going to want you to take omega-3s before because of the blood thinning effect, but as soon as the surgery's done, you need to get two to four grams a day in that first many weeks to get the tissue in the inflammatory process to what's called resolution.
Because what omega-3s do is they can contribute to the creation of something called resolvins, which are chemicals that help your body get into the final stage of healing and repair without staying chronically inflamed.
This is where a lot of complications come in when we see people low omega-3 and they never get to this resolutory state and they stay in a chronic inflammatory state so they have complications.
And then again the high quality. So it's two the lists are very similar in that regard.
So now you know a little bit more about the nutrition that's necessary for surgery, the importance of nutrition for surgery.
If you want my exact protocols, if you want what I use in my clinic, if you're getting ready for a surgery, or maybe you've just had one and you're trying to support yourself the best that you can, click the link below in the description, and we'll send you a detailed breakdown of all the nutrients, how you can take them, how you should take them, and get that help to you right away.
I hope you've enjoyed the show. Make sure you join us on Thursday for a live Q&A all about this very topic.
So, we'll be back here Thursday at 12:30 p.m. Central Standard Time. If you want to get a reminder, make sure you hit that like and subscribe button below.
Thanks so much and have a great evening.
I hope you enjoyed Dr. Osborne's video on nutrition and supplements to help you prepare for and recover from your surgery.
Remember, if you want any of the information Dr. Osborne mentioned in his video, go to the link below in the show notes, which will take you to Dr. Osborne's YouTube channel and this video specifically, and you can access the links in his show notes.
Thanks so much for tuning into The Hip Replacement Podcast. Until next time, I wish you the best recovery possible.
Take care.
