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Nutrition and the Injured
Patient
Diet Recommendations for Recovery
Kristi Veltkamp, MS, RDN
2/28/17
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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
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Goals for Nutrition in Recovery
Promote healing & boost immune system
Reduce inflammation
Prevent weight gain
Prevent muscle loss
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Healing Phases – Acute
Three Healing Phases
■ Phase 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.
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Phase 1: Inflammation
1.
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.
2.
Swelling. This is a result of fluid seeping through damaged
— and now hyper-permeable — blood vessels into the
damaged tissues.
3.
Redness and heat. Vasodilation up-stream of the injury and
constriction downstream shunts additional blood to the
injured area, producing heat and redness.
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Phase 2: Proliferation
1.
New vasculature developed with restoration of oxygen and
nutrient flow for collagen/fibronectin formation (scar tissue)
2.
Scar tissue formed in alignment of forces placed (PT!)
3.
Maturation of scar tissue from fibroblasts to myoblasts
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Phase 3: Maturation
1.
Scar tissue degraded and type I collagen formed
2.
Rehab and therapy needed to manage/arrange tissue
formation
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Chronic Wounds/Injury
Chronic 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
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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%
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Back to normal through rehab phase but may still need extra
depending on intensity of rehab (crutches, exercises, ect)
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Severe energy restriction will interfere with healing and
recovery
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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)
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Hindrances to Good Nutrition
Unable 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
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Dietary Strategies
Mediterranean Diet
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Olive oil
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Ample fruits, veggies,
legumes, whole grain
cereals, fish, nuts, plant
proteins
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Moderate red wine
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Low-fat dairy
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Low red meat intake
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Mediterranean Diet
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Higher n3:n6 ratio
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Reduction in CVD, cancer, Parkinson's, Alzheimer's, T2DM
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Reduces inflammatory markers (HS-CRP, IL-6/7/18, WBC,
finbrinogen), especially in those with more olive oil and nut
consumption
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Dietary Choices – Anti-inflammatory Diet
Fat (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
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Dietary Choices – Anti-inflammatory Diet
Carbohydrate
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Main energy source but needs are decreased during
recovery. Concern is more about type.
• White Stuff = Inflammation
• (LESS) Refined grains, anything with sugar, alcohol
•
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Fiber-Rich = Healing
• (MORE) Whole grains, baked potato, beans, fresh fruit,
milk/yogurt, squash
Glycemic Index
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Dietary Choices – Anti-inflammatory Diet
Protein
•
Injury repair requires more protein. Continues into rehab
phase.
• Normal requirements = .8g/kg
• Recovery requirements = 1.5-2g/kg
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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
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Dietary Choices – Anti-inflammatory Diet
Vegetables and Fruits = Antioxidants
•
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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.
Anti-inflammation “Superfoods”
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EVOO
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Flaxseeds
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Flavonoids: citrus (carotenoids), apple,
cocoa, onion, celery, tea, berries, red
wine
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Turmeric
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Fatty Fish – herring, salmon, mackerel,
tuna
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Magnesium-Rich Foods – Dark greens,
nuts, seeds, fish, whole grains, yogurt,
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Anti-Inflammatory/Healing Essentials
Micronutrients
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Vitamin A, C, D, copper, zinc, iron
Additional Nutrients
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Essential Amino Acids – Reduces muscle loss
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Arginine – Increase wound collagen accumulation
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Glutamine – Essential fuel for turning-over cells
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HMB – Increase LBM
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Glucosamine/chondroitin – Safe but mixed evidence
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Omega-3s – Anti-inflammatory – supplement chronic only
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Application
Encourage your patients to:
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Eat every 3-4 hours (include protein with each meal/snack)
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Follow the Mediterranean diet
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Take a multivitamin
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Make homemade shakes if no appetite (whey protein, fruits,
vegetables, milk/yogurt)
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Include fish, nuts/seeds, avocado, olive oils daily
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Eat the rainbow
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Lose weight if appropriate
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Spread the Word
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You are the gateway to helping your patients understand the
importance of nutrition in healing!
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Needed for better success and speedy recovery.
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For further help with diet and/or supplementation for healing,
refer to the experts! – Physician Referral
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Next Level
Perioperative Nutrition Program
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SH colorectal team started Impact nutrition supplement
(nucleotides, arginine, omega-3s) pre-op
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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
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Questions?
Thank you!
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References
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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
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Nutritional Support for Exercise Induced Injuries. Tipton, K.D. Sports Med (2015)
45(Suppl 1): 93. doi:10.1007/s40279-015-0398-4.
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http://oldwayspt.org/traditional-diets/mediterranean-diet
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Diet and Inflammation. L. Galland, MD. Nutrition in Clinical Practice. Volume: 25 issue:
6, page(s): 634-640.
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Schwingshackl L, Hoffmann G. Mediterranean dietary pattern, inflammation and
endothelial function: a systematic review and meta-analysis of intervention trials. Nutr
Metab Cardiovasc Dis. 2014 Sep;24(9):929-39. doi: 10.1016/j.numecd.2014.03.003.
Review. PubMed PMID: 24787907.
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Nutrition, Inflammation, and Disease. By Mary Franz, MS, RDN, LDN. Today’s Dietitian
Vol. 16 No. 2 P. 44
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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):4654-4666. doi:10.1172/JCI70160.
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References
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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 2002 - Volume 236 - Issue 3 - pp 369-375
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