How to Prevent Hospital Malnutrition Easily

How to Prevent Hospital Malnutrition Easily

Surgery is one of those things we like to think usually happens to somebody else. However, operations are becoming more frequent instead of less, so chances are pretty good there's a scalpel out there with your name on it.

If and when that time comes, is there anything you can do to better your chances of a successful, uncomplicated operation and a speedy recovery?

Yes. Figure that your surgeon, however, expert he or she is with a scalpel, is a rank amateur when it comes to nutritionally preparing your body for surgery.

It's the rare surgeon who checks a patient carefully for pre-operative vitamin deficiencies. And after the operation, the surgeon expects an intravenous solution to supply all your nutritional needs. A popular handbook for American doctors reads :

The well-nourished and reasonably healthy patient, who is subjected to a single and relatively uncomplicated major surgical procedure, or who suffers moderately severe trauma, does well in the immediate postoperative period with a relatively simple program of parenteral infusion.

What that means is that all the surgeon has to worry about is if the sugar water is plugged into your vein. What follows this introduction is a discussion of the finer points of intravenous cuisine.

Now, intravenous feeding may be a lifesaver in cases where the patient is unconscious or otherwise unable to take food by mouth. But gadgets such as the IV feeding bag have a way of flooding over the boundaries between use and overuse. And that's a dangerous trend, because 'parenteral nutrition, ' as doctors call it to give it the official sound of high technology, is often malnutrition.

The use of parenteral feeding regimens 'can only satisfy a small portion of the nutritional requirements of a debilitated patient,' says Michael Brenner in the Journal of Oral Surgery. Dr. Bresner goes on to calculate how many calories a patient could be expected to receive during a day of intravenous feeding. Arriving at a total of 600, he says,

This is about a quarter of the needs of a healthy individual and far less than the convalescing, debilitated patient requires. It, therefore, becomes apparent that an adequate or concentrated nutritional diet should be resumed as soon as possible. In light of this, the established pathway of prolonged parenteral fluids, clear-liquid diet, full-liquid diet, soft diet and regular diet may not be adequate for the increased nutritional demands.

Problems with IV feeding

Intravenous feeding can cause other problems. Worthington G. Schenk, Jr. , professor of surgery at the State University of New York at Buffalo School of Medicine, warns that 'amino acid imbalances in patients with multiple injuries have been aggravated by the inappropriate use of intravenous glucose. ' Dr. Schenk says that critically ill patients should not be maintained on intravenous feedings for long periods. (Journal of the American Medical Association. ).

Doctors at St Joseph's Hospital, McMaster University, Hamilton, Ontario, found deficiencies in both folic acid and vitamin B12 in four of their patients maintained on intravenous feeding. They recommended that 'all patients receiving TPN [total parenteral nutrition] for more than three weeks should probably receive folic acid and vitamin B12 supplements routinely' (Canadian Medical Association Journal).

Although intravenous feeding may be more convenient to the nursing staff and more technologically satisfying to the surgeon, it definitely hasn't resulted in better nutrition for surgical patients. Quite the opposite — a series of recent studies has uncovered widespread serious malnutrition among surgical patients.

One report of surgeons' neglect of their patient's' nutrition comes from a group of doctors at the General Infirmary in Leeds. All 105 patients in the surgical wards were examined for protein-calorie malnutrition, anemia, and vitamin deficiencies. Abnormally low values in all these nutritional standards were found to be common. But what is even more interesting is that the worst nutritional levels were found in the patients who had undergone major surgery and were in the hospital more than a week afterward. More than half of these people had lost too much weight and were suffering from protein — calorie malnutrition. Blood levels of vitamin C were too low in 46 percent, riboflavin in 36 per cent, folic acid in 27 percent, and vitamin B6 in 18 per cent; 37 per cent were anemic. G. L. Hill and seven other colleagues found that only 22 of the surgical patients had any mention at all of the nutrition in their notes, that all but five of these comments were merely short ones, that only 17 patients had ever been weighed during their hospital stay, and that only five patients had any record of any kind of nutritional therapy at all.

So, as Dr. Hill concluded, 'these abnormalities had gone almost entirely unrecognized, even in patients with sepsis [toxins in their blood or tissues] after major surgery who would benefit from improvement in nutritional state' (Lancet).

In a Boston, Massachusetts municipal hospital, Dr. Bruce R. Bistrian, and three colleagues found that half of the surgical Patients were malnourished in the two most basic nutrients: protein and calories. 'This report,' concluded the researchers, 'confirms recent studies suggesting that nutritional support of hospitalized patients has been neglected' (Journal of the American Medical Association).

Both Dr. Bistrian and Dr. Hill, in lamenting the sorry state of nutritional care in modern hospitals, suggest that medical schools should pay a lot more attention to nutrition. That's a good idea, but it's not going to help you if you need surgery before a new crop of doctors trained in nutrition reaches the hospitals. Until then, you're on your own. Since your doctor probably doesn't know, and may not even care, which nutrients you need to heal fast and free of complications, you're going to have to take some extra measures with your diet. And in case you have to explain them to your doctor, you're also going to need to know why you're taking these extra measures.

Your body needs help to heal itself

The surgeon's knife is going to make extra demands on your body's ability to heal itself, so you have to hustle some super-nutrition into your life. Since the circumstances that lead to surgery often rob you of nutrients, you might be entering the hospital with a deficiency in one or more vital food elements.

For example, pain or discomfort may keep your appetite down so you don't eat as well as you should. Vomiting, diarrhea, and bleeding can also rob your system of important nutrients. Simply worrying about your operation can put your nerves into overdrive and raise your requirements. Finally, just lying in bed for a few days waiting for your turn in the operating theater speeds up the rate of protein breakdown in your tissues. If you're not replacing it in your diet, you'll go into that operation with a dangerous protein deficit.

And don't forget that surgery itself is an injury, too, as far as your body is concerned. The only difference is that the surgical wound is made under sterile conditions, which lessen the chances of infection.

However, even under ideal operating conditions, healing a wound demands an enormous effort. You may be using up nutrients twice as fast as normal. New tissue must be manufactured and laid down in just the right places. Infection must be kept at bay. Your nutrient requirements, as Dr. Bresner says, 'should be greater than the minimum requirements to provide a ready reserve against variations in health and disease.' He says a surgeon should examine the state of a patient's nutrition and delay operating until any deficiencies can be corrected through dietary changes and supplements.

That's good advice if your surgeon knows which nutrients are especially important to healing, but as we pointed out, the chances of that happening are about as great as a plumber knowing how to take out your appendix. So you're going to have to do it yourself. And the time to start is now, because if you ever need emergency surgery, there won't be time to build yourself up nutritionally.

We're not suggesting you start now taking all these nutrients in the quantities needed by surgical patients. Don't do that until the time comes to prepare for surgery and to speed healing after your operation. But you will want to start right now looking at your diet and seeing whether or not you're adequately supplied with these nutrients for the everyday strains and stresses and the little bumps and bruises that might not call for anesthesia and stitches but none the less still make some extra effort on the part of your healing machinery.

Getting enough calories

First, you should know how to avoid the form of malnutrition that seems to be most common in surgical wards — protein — calorie malnutrition.

Calories are the most basic element of your diet. Modern Nutrition in Health and Disease (1964 edition) states, 'The ideal minimum requirement for a patient postoperatively or a patient with trauma [injury] or infection should be 3000 calories.' Dr. Bresner says that a feverish, 'severely injured patient may use as many as 4000 calories per day. ' A severely burned patient, because of the enormous amount of tissue that must be repaired, might require as many as 5000 calories a day.

If you don't get enough calories in your diet, your body will break down protein for energy. But your body also needs that protein to use as raw material for healing. So a deficiency of calories can lead to some real problems during convalescence.

Since calories are so fundamental, all food contains calories. So if calories were all you had to worry about, getting the right foods would be a simple numbers game and this entry could end here.

Naturally, there's more to it. Your body needs the fuel that calories provide, but which foods those calories come from can make the difference between a speedy recovery and a long, painful convalescence. So you should choose your calories in terms of the other nutrients you need. Of course, that's true even when you're not scheduled for surgery, but now the game is a lot faster, and the stakes are a lot higher. You will want as many odds as possible in your favor before you're wheeled into the operating theater.

The critical need for protein

Your body is going to need all the protein it can get for ready use in healing and infection fighting. Low protein levels make infection a more likely possibility, delay healing of fractures and wounds, cause anemia and poor tissue repair, and disturb the function of the heart and the liver.

If you're deficient in protein, the normal stresses of surgery, such as minor blood loss and anesthesia, could put your body in a state of shock. And shock, which is a drastic, life-threatening, sudden lowering of the blood pressure to the point where blood almost stops circulating, is even more dangerous on the operating table.

How much protein do your need? Dr. Bresner says that a convalescing person needs about twice as much as a normal, healthy person. That means you're going to have to eat a lot more of the foods that provide protein.

For example, a medium-size egg supplies 6 g of protein; 8 fl oz of milk, 8 g; a small piece of chicken, 8 g; a 3 oz serving of calf's liver, 25 g; and 2 ½ oz peanuts, 19 g. If you ate all of these in one day, you would get 66 g of protein.

Since a healthy person requires about 1 g of protein for every 2.2 lb of body weight, 66 g of protein would be enough for a person who weighed about 10 stone. However, if that person had wounds to heal, he or she would need twice as much protein or about 132 g. So besides eating more of these particular foods, a convalescing person would have to find some other high-protein foods: 6 ½ oz of diced beef or mince, for example, supplies about 36 g of protein; 8 oz of cottage cheese supplies 30 g. These two foods alone would supply the additional 66 g of protein a person who weighs 10 stone would need.

Sometimes convalescing people don't have the appetite to get down high protein foods. Eggs, non-fat dried milk, and whole milk can be whipped up with a little honey and baked into a custard that even a person whose appetite isn't that strong will find palatable.

If you eat plenty of high-protein foods — e.g. milk, eggs, cottage cheese, fish, poultry, liver and wheat germ — before your operation, you won't need to correct a deficiency, only to maintain the high level of protein that's already in your blood, healing your injuries or surgical wounds and keeping them healed.

Vitamins in special demand

Protein and calories are not all that matter. As a surgeon, Harold A. Zittel says, 'The importance of vitamin therapy in seriously ill surgical patients might be emphasized in a simple analogy. It is, of course, useless to supply abundant amounts of lumber, steel, and bricks for the repair of a damaged building if hammers, nails, bolts and cement are not available to fashion the former materials into a functioning part of the building. It is just as foolish to provide carbohydrate, fat, protein and potential calories in the presence of subclinical vitamin deficiencies and expect the body to restore a functioning part or parts of the body efficiently. '

Vitamin A This heads the list of vitamins essential to healing. In order for your surgical wound to heal, collagen, — the 'cement' that holds tissue together — must be laid down between new cells. Vitamin A influences the rate at which the new collagen is linked, so your vitamin A status has a lot to do with how fast and how well you heal.

The wound healing of animals given vitamin A was better than that of non-supplemented animals in experiments performed by Eli Seifter and his colleagues at the Albert Einstein College of Medicine in New York.

Apparently, the worse your wound, the more vitamin A you need. Severely injured persons, such as burn and accident victims, can actually develop stress ulcers as a result of the trauma they are going through. An Arizona study found that, by giving burn, trauma and post-operative patients injections of from 50,000 to 100,000 IU of water-soluble vitamin A twice a day, the incidence of these ulcers could be cut to less than a third of what it was in an unsupplemented group (Journal of Trauma).

If your doctor gives you the steroid drug cortisone to suppress unwanted inflammation, you'll also need more vitamin A. Cortisone also inhibits wound healing, but vitamin A, taken internally or applied directly to the wound, can counteract this effect and restore normal healing.

Thiamin (vitamin B1) This is necessary for the utilization of carbohydrates. The more carbohydrates in your diet, the more thiamin you need. One study has shown that people on intravenous feeding can develop a thiamine deficiency in as short a time as four or five days. And long before a really severe deficiency develops, symptoms such as loss of appetite, irritability, pain and lack of interest in important matters show up — just the kind of things that can make convalescence agonizing.

Riboflavin (vitamin B2) This is necessary for the utilization of protein. Since protein is the raw material for wound healing, a riboflavin deficiency will keep you in that hospital bed longer than you have to be.

Niacin (nicotinic acid) This B vitamin is necessary for the utilization of both protein and carbohydrates. And, apparently, the first body function to suffer when there's a deficiency of niacin is the use of protein for repair. Later on in a deficiency, nervousness, depression, loss of appetite, redness of the tongue, ulceration of the gums and diarrhea develop.

Pantothenic acid This B vitamin is important for the storage and utilization of protein. It also plays a role in the proper functioning of the adrenal glands, which govern the body's response to stress. An injury, burn or operation is probably the most highly concentrated stress anyone ever experiences. So you don't want your adrenal glands to become exhausted when you need them most.

Pyridoxine (Vitamin B6) This is also necessary for efficient use of protein. Pyridoxine is vital to the body's response to foreign invaders — which can include infecting organisms. So a deficiency can lead to a greater chance of developing an infection that will slow healing and keep you laid up longer.

Folic acid This B vitamin helps maintain and restore the red blood cells, and it aids in the development of white blood cells (leukocytes) which are the mainstay of the body's defense against infection.

Vitamin B12 This also has a vital role in the function of the red blood cells and keeps the body's utilization of protein as efficient as possible.

Biotin Another B vitamin, this may be important to the body's use of protein. One study which shows that biotin levels are low in the blood of children with burns and scalds suggests that the vitamin may be required for tissue repair (Journal of Clinical Pathology).

Vitamin C This should be at the heart of your 'nutrition under the knife'. The most important link in the healing chain of events is the formation of collagen, the glue that holds cells together and makes healing possible. If there's not enough vitamin C in your system, collagen production will be inadequate. Your wounds won't heal. And there's a good chance of that happening if you're not careful, because after any serious injury — surgical wounds included — the body's metabolism of protein and water-soluble vitamins gets jolted into high gear. You can quickly start needing a lot more than you have.

The consequences of running out of vitamin C can be disastrous. A study of over 1400 surgical patients with infections confirmed that their blood levels of vitamin C were as low as those of people with scurvy (Journal of the American Dietetic Association). If this happens to you, though, chances are your doctors won't write it down in your notes or tell you that you have scurvy. More likely, they'll just say — when your wound starts to fall apart and gets worse instead of healing — that you're not doing quite as well as expected, that there's nothing to worry about, and that you'll have to be in the hospital a week or so longer.

A vitamin C deficiency can let you go further 'down' under the anesthetic than either you or your surgeon is counting on. And you might end up staying 'down' longer, too. At the very least, getting enough vitamin C may help protect you from painful and persistent bedsores, the curse of long hospital stays. A British study found that by supplementing hospital patients with two 500 mg tablets of vitamin C each day, bedsores healed almost twice as fast. (Lancet).

We were not surprised, therefore, when surgeon Philip Thorek, medical director of Thorek Hospital and Medical Center in Chicago, wrote, 'Vitamin C is the surgeon's vitamin' (New Dynamics of Preventive Medicine).

Minerals for healing

Potassium Necessary for the utilization of protein.

Iron Important if there is the loss of blood.

Calcium Supremely important if there are broken bones to heal.

Zinc This is so critical to healing that its importance cannot be over-emphasized. Surgery, injury, burns and broken bones all call for zinc to perform its healing work. Zinc is vital to the production of collagen and the utilization of protein. It is necessary for normal growth and reproduction of cells. So without zinc, the new cells needed to form new tissue cannot be made.

And once these cells are made, zinc increases their ability to survive. Zinc is also important to the body's response to infection and inflammation. And vitamin A, the first vitamin we talked about, is not mobilized from body stores unless zinc levels are adequate.

With all these facts in mind, it's no wonder that the medical literature is overflowing with reports of how people given supplements of zinc heal much faster than people not given them. One study found that surgical patients given a zinc-supplemented diet appear to have pinker, cleaner, healthier-looking new tissue in their rapidly healing wounds. (Surgery, Gynecology, and Obstetrics).

The most remarkable of these reports, though, is one in which zinc supplements actually cut in half the number of days women had to remain in the hospital after gynecological surgery. We're not talking about cutting a three-day stay down to a day and a half: the average post-operative stay for the women not receiving the supplements was 37 days, but those who received zinc supplements for a week before their operation were able to go home after 18 days. The amount of zinc these women received was small: 150 mg spread out over each day.

If your doctor has you packing for the hospital, good nutrition should be the first thing you take along with you. And even if your horizon is clear of surgery right now, your diet should still be supplying adequate amounts of the important nutrients we've been talking about. There may not be a scalpel with your name on it. But, after all, that's what health is all about: keeping it that way.

(See also HEALING PROBLEMS.)