State of Perioperative Nutrition No Longer Acceptable, Experts Say
—By Ajai Raj
Perioperative nutrition in the United States is in dire straits and changes need to be made right away, according to leading researchers and clinicians.
A recent national survey of gastrointestinal (GI) and oncologic surgeons found that although surgeons acknowledge that perioperative nutrition can have positive effects on surgical outcomes, there has been “poor implementation of evidence-based nutrition practices in GI and oncologic surgery programs,” the researchers wrote (Ann J Surg 2017:213:1010-1018).
The results of the survey are unsurprising, said Paul Wischmeyer, MD, the director of perioperative research at Duke Clinical Research Institute and the co-director of the Nutrition Support Service at Duke University Hospital in Durham, S.C., who co-authored the study.
“This lack of awareness of the key role of nutrition begins, I think, in our medical training,” said Dr. Wischmeyer, who is also a professor of anesthesiology at the institution. “More than 75% of medical schools provide no meaningful training in clinical nutrition at all, which leads most physicians to believe it’s not important.
“Another survey, of residents finishing their training, found that less than 15% felt adequately trained to address nutrition with their patients in any meaningful fashion,” he added. “There’s a robust body of data that shows we’re not teaching our young physicians about the role of nutrition, nor are they comfortable talking about malnutrition, let alone diagnosing or treating it.”
Thomas Varghese Jr., MD, MS, the section head of general thoracic surgery at the University of Utah and program director of the cardiothoracic surgery residency at the Huntsman Cancer Institute, in Salt Lake City, agreed with Dr. Wischmeyer’s assessment.
“I’m aware of how bad things are, how a lot of surgeons know that nutritional status should be targeted for optimizing, but that it’s not given the importance that it should be prior to surgery,” said Dr. Varghese, who was not involved with the study. “Sadly, I wasn’t surprised at all by the survey.”
Dr. Varghese, who has a leadership position in the Surgical Outcomes Club, added that there are several reasons the status quo is what it is. “For one thing, nutrition is an area of universal confusion—you see it every day in popular culture, how one week coffee is bad for you and the next week it’s good for you, not to mention the sheer number of diets that are supposed to be ‘the best,’” he said.
“Another factor is that in many cases, nutritional interventions can be time-consuming, and people don’t want to take the time to do that. And a third reason is that historically, nothing we do in the preoperative setting has been well reimbursed,” he added. “Not to say it’s all about money, but if insurance companies aren’t paying attention to this area, then the health care system won’t either.”
The last piece of the puzzle, according to Dr. Varghese, is simple inertia. “Nutrition is not one of the topics physicians spend a lot of time on in medical school, so it hasn’t been given the attention it deserves,” he said, echoing Dr. Wischmeyer’s comments.
Nutrition Guidelines for Better Outcomes
Addressing this problem need not be expensive or overly time-consuming, both doctors emphasized. Dr. Wischmeyer, who led the creation of a set of guidelines for nutrition screening and therapy within a surgical enhanced recovery pathway released jointly by the American Society for Enhanced Recovery and the Perioperative Quality Initiative (Anesth Analg 2018:126;1883-1895), said the most important recommendations are also the simplest.
“The first key point is preoperative screening is essential,” Dr. Wischmeyer said. “We have to look for malnutrition to know that we’re treating patients who need intervention, and not letting people go to surgery with a massive fivefold increased risk of death. We can’t have that happen anymore.
“The second thing to know is that protein is more important than calories—when the body undergoes an operation, it can break down amino acids from muscle to use for energy,” he said. “More than two hours before surgery, patients should be drinking a complex carbohydrate loading drink that costs a few dollars.
“If you’re going to run a marathon tomorrow, you would never starve and dehydrate yourself 12 hours before the race,” Dr. Wischmeyer said, taking aim at prevalent practice. “We have patients coming to the biggest race of their life, and that’s what we’re telling them to do. That leads to longer length of stay, more vomiting after surgery, pain, anxiety. Administering a complex carbohydrate drink reduces all of these things that makes patients stay in the hospital, that makes them suffer.”
Similarly, he added, patients need to be fed much earlier in the recovery room. “The longer the stomach is left with nothing in it after surgery, the more likely it is to not work, leading to vomiting, longer hospital stays and other potential complications.”
Dr. Wischmeyer pointed to the success of a nutrition-focused quality improvement program at Advocate Health Care and supported by Abbott Nutrition, reported in an analysis published in the Journal of Parenteral and Enteral Nutrition (2018;42:1093-1098), which saw the 30-day readmission rate of 390 surgical patients fall by nearly half compared with historical controls (relative risk reduction, 46.9%; P<0.001).
“This really needs to be a team effort,” he said. “Your dietitians, nurses and surgeons all need to be onboard.”
Dr. Varghese said the survey findings and joint consensus statement are “a call to action. It’s 2018 right now, and we’re still talking about nutritional status and its importance around surgical outcomes. If you trace the evidence in the literature, it goes back 30 to 40 years, so there’s no excuse not to take action.
“The status quo doesn’t cut it anymore,” Dr. Varghese said. “We need to be using the best evidence-based practices for every patient, every single time.”
Dr. Wischmeyer reported that he is a health advisor for Abbott.