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The perioperative period is the time before, during and after an operation. Dietitian Amanda Igel shares her recommendations on how to best manage nutritional debt during the surgical journey, as well as choice foods that can provide optimal recovery.

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What Should I Eat During The Perioperative Period?

Podcast Transcript

Scott Steele:  Butts and Guts, a Cleveland Clinic podcast, exploring your digestive and surgical health from end to end.

Welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And we're very pleased to have Amanda Igel here today with us, a registered dietitian within the Digestive Disease and Surgery Institute. Amanda, welcome to Butts and Guts.

Amanda Igel:  Thank you for having me.

Scott Steele:  So we're going to talk a little bit about nutrition today, and specifically we're going to talk about a little bit different type of nutrition and that's the nutrition that's associated with the perioperative period. But before we go on that, tell us a little bit about yourself. Where are you from, where did you train and how did it come to the point that you're here at the Cleveland Clinic?

Amanda Igel:  Well, I'm a local gal. So I grew up on the East side, I live on the West side now. I've done all my training and my education in Cleveland, so I did my Bachelor's and my Master's of Science and Nutrition at Case Western Reserve University. I did my internship at the Louis Stokes VA in Cleveland, Ohio. Before I came to the main campus, I was at a hospital in Lakewood, Ohio. And then in 2014 I came to the Cleveland Clinic.

Scott Steele:  Well, we're absolutely lucky to have you here. And today again, we're going to talk about, a little bit about the nutrition in the perioperative period. So let's just start with some kind of some baseline definitions here. First, talk a little bit about the perioperative period. What's a general overview of what that time period is all about, and then how does that factor into nutrition into that perioperative period?

Amanda Igel:  So mainly as a dietitian, what I'm mostly concerned about is malnutrition. And when we talk about malnutrition, it's protein calorie malnutrition, not a vitamin deficiency or anything like that. It is not getting enough nutrition before the surgical procedure. The problems with malnutrition or under nutrition is that it can increase your postop complications, increase your length of stay at the hospital, and then also delay your wound healing and immunity.

Scott Steele:  So when we have that perioperative period before the surgery, during the surgery and after surgery, one of the things that I hear you saying is we want to prepare these patients for surgery. Can every patient be prepared for surgery from a nutritional aspect to it, and how long of a process is that normally take?

Amanda Igel:  Well, as a dietitian, what we tend to look at is your nutritional health. So, what I do in the hospital is I assess the severity of your nutritional debt. I like to tell my patients, it's kind of like managing a bank account, so you're putting money in as deposits and then you're also making withdrawals. And these deposits can be from anywhere. Basically with nutrition, it's the deposits of food and energy. With withdrawals, you're using your finances to pay your bills, finance your house, things like that. With nutrition, it's the same way. So you use withdrawals to make the body function better, to repair. When this gets out of hand, what happens is you're going into nutritional debt. So it's harder and harder to heal and it's harder to get better when you don't have that proper nutrition.

There's different ways that you can do it. So a lot of the times with oral intake, you know you can do something like a nutrition drink, small frequent meals to try to optimize your nutrition beforehand. But if sometimes when the gut doesn't work or the gut's not functioning, which I see a lot of the times, we can use other alternative methods like enteral nutrition, which we put a tube through your nose or into your stomach to feed you that way. Or we use IV nutrition to try to help optimize your nutritional intake before surgery.

Scott Steele:  Yeah, there's no question that there's a lot of different variations out there depending on the urgency of the surgery and what's the underlying problem that requires surgery. But walk me through a little bit about just the overall dietitian's role during this perioperative period, and does the patient meet with you? Do you follow them through their entire period, and then what is the role for the nutrition in the dietitian specifically regarding that after the surgery?

Amanda Igel:  Well, beforehand you have the option to meet with a dietitian. Usually we have a role of outpatient nutrition, or if you need some pre-op surgery, you may come into the hospital where we would help you optimize your nutrition. Whether it would be through aggressive feeding, using supplements, or sometimes you get pre-admitted to the hospital to start on IV nutrition, also called parenteral nutrition, for about a week before surgery.

The best way to determine your nutritional risk is we do a screening tool, basically it's two questions. So you can ask yourself, have I lost weight without trying, and have I been eating poorly because of a decreased appetite? So those are the two questions that usually we will ask you postoperatively when you're in the hospital, but you can think about those before you have your surgery. The best time to start basically loading up on your nutrition is as early as you can, but ideally at least a week before. If you take some kind of protein supplements or eat high-protein foods, then your chances of postoperative recovery are usually better.

Scott Steele:  Let's talk about a little myth or reality here. So first one, a patient that is overweight or heavier, big and bulky, they got good nutrition. Is that a myth or reality?

Amanda Igel:  It's a total myth. Oftentimes I see malnutrition in all various sizes. A lot of the times when people come into the hospital and they are in a larger body, usually they have more muscle wasting. So when you don't have those muscle stores, a lot of the times you can't heal properly. So it's important for everybody to at least try to maintain some kind of nutritional intake, regardless of what body size you're in.

Scott Steele:  Let's go to the other extreme. Somebody who's thin, they're an optimal nutritional status.

Amanda Igel:  We do something called a nutrition focused physical exam. So we're looking at fat muscle loss. We're taking a detailed history of your intakes, any kind of GI issues, and then also your functional status as well. So that's how we determine what kind of nutritional state that you're in. You can be in a thinner body, and especially if that's what you live in, a lot of the times you're able to recover. However, the lower body mass index you are, the more likely you are to have poor recovery or lower stores of those fat and muscle reserves.

Scott Steele:  So one of the things that you said is that you want to prepare patients for surgery if indeed they are able to be prepared. How long of a time period is that? And let's say that there's a patient that doesn't have access to some of these high-quality foods or anything. What can they go to the store and look for?

Amanda Igel:  High-nutrient dense foods, I usually include something that is nuts, seeds. If you can't eat that, smooth peanut butters. My favorite is the cheese and crackers. So, have a little party with your cheese and cracker plate. Other things that I like to recommend are any kind of meats, dairy, eggs, nuts and seeds are all great sources of protein.

The other thing to think about is also caloric density. So you can be pounding away at protein all day long, but if you're not meeting your overall caloric needs to maintain your weight, you're not doing any justice as far as putting yourself in nutritional surplus, you're still going to be in that nutritional debt. So other calorically dense foods can be things like oils, butters, higher-fat dairies, those types of things. Especially if you're struggling with eating, large volumes of food can also be helpful.

Scott Steele:  Take a typical patient that undergoes an abdominal operation or a major thoracic operation in the chest. Do they lose weight after that? How long does it take them to get back to that nutritional status where they're status quo?

Amanda Igel:  In the postop period I usually like to tell my patients, your body's going through fight-or-flight mode. So you've got to think about it like if a bear is chasing you, for example. You're fighting for your life, you're using up your energy reserves, and the last thing you think about is, "Oh, I'm going to sit down and have a hamburger." You're trying to run for your life, so that's a state called catabolism. Oftentimes, nutrition is usually not as effective in that postoperative state immediately after surgery, but usually once the body kind of calms down and comes back to an equilibrium, that's when nutrition can help you build back up and start repairing those reserves.

Scott Steele:  You mentioned this briefly earlier but I want to focus in on, what are the consequences of patients eating quote, unquote incorrectly around the time of an operation or going into an operation with nutritionally depleted stores.

Amanda Igel:  Oftentimes we see longer length of stay because calories and carbohydrates are particularly important for things like immune cell development. Your immune stores are less, so you're more likely to have postoperative infections and then also non-infectious complications as well. Delayed wound healing is another issue that can happen if you're not nutritionally optimized before surgery.

Scott Steele:  So I'm a patient, I'm going to go see a nutritionist. Walk me through what that visit is going to be like. Are they getting blood drawn or are you pinching me, poking me? Are we going through my diet? What's happening during that visit?

Amanda Igel:  Usually in the preoperative phase, we take a little history about how long you have or have not been eating well. So we take a diet intake history that could vary as far as what tools they like to use, whether it's a food frequency questionnaire or we're just getting a recall of the last 24 hours of your day. And then we take into account how long you've been losing weight, whether it's months or days or years, or if it's a very long time ago that you lost weight but now are stable again. We take a look at how frequently you're eating, whether it's a breakfast, lunch and dinner, or you're a grazer or any of those types of different things, any kind of fad diets that you may be on. A lot of the times with GI issues, there's a lot of controversy around, "Well, I got to go gluten-free or," those types of things. So we take a look at those.

And then we do our nutrition focused physical exam. So basically it's a head-to-toe exam where we're evaluating for fat stores, muscle stores, and then also any kind of micronutrient deficiency. So we may be tugging a little bit on the hair. I'm looking at your nails, looking at your tongue, looking at your skin to try to decide whether there's any protein calorie malnutrition in those areas. And then also if there's any vitamin deficiencies that are underlying.

Scott Steele:  So what's on the horizon for the future of perioperative care, specifically in regards to nutrition? Is there something that we're aiming towards or is there new supplementation? What's the latest research on this?

Amanda Igel:  So we are part of the enhanced recovery after surgery protocol. A lot of the studies that have been done in enhanced recovery after surgery, and this is something that was discussed in Dr. Delaney's podcasts, a few podcasts aback, nutrition was also incorporated into that protocol. Some of the things that we're looking at right now is there are specific supplements that can be used, particularly surgical nutrition drinks that are on the market now that we use in the hospital after recovery that contains specific ingredients to help improve your vascular flow, and then also decrease inflammation.

The most important thing is to limit the amount of fasting, or what we call no per os or NPO, which just means nothing by mouth. We found that, many moons ago when I started, we used to wait until bowel function came back, and you had a bowel movement and now that is no longer the truth. You go in, you have your surgery. Day one, you're on clear liquids, and then we try to advance your diet to solid foods literally that day, basically to stimulate the return of the bowel function. We're also looking at preoperative carbo loading. So it's kind of like in a marathon, when you're about to run a marathon, you know you may eat those high-starch foods. We have specific nutrition drinks that cater to basically giving you this drink two hours before surgery that may help with some of the postoperative insulin spikes afterwards, and to help improve recovery.

Scott Steele:  So for the patients that are listening out there, if you could have a take-home message for them, if they're preparing on a surgical journey coming up. What is the message that you really want to make sure that we get through to them?

Amanda Igel:  I would say start early, know your nutritional risk. So if you know that you're losing weight without trying, or if you're not having the greatest of appetite, seek out help or guidance from a healthcare professional. And then just be prepared as far as getting the nutrition that you need and focusing on that as early as you can before surgery.

Scott Steele:  And for our providers that are listening to this and regarding the nutrition, "If you would just do this," what is that message?

Amanda Igel:  Screening practices can be enhanced, so asking your patients about any kind of weight loss or appetite loss before surgery, and then referring to a nutrition professional. Or making a recommendation of how somebody can increase their nutrition intake, whether that be through protein drinks or through just eating more throughout the day.

Scott Steele:  And kind of along those lines, what are the nutritional therapy or support programs that are offered here at the Cleveland Clinic?

Amanda Igel:  We have our outpatient nutrition department and they specialize in all areas. We've got one for gastrointestinal transplants, you name it. I belong to the inpatient nutrition department, so I focus mainly on medical and surgical, regular nursing floors. We have an ICU dietitian group, a nutrition support team that specializes in IV nutrition. And then we also have a center for gut rehab, so they do intestinal transplants and trying to get your gut back into working order and getting you off of that IV nutrition. And then as far as that, we have regional hospitals that also provide outpatient nutrition educations and assessments.

Scott Steele:  That's fantastic stuff. And as we finish up here we always like to end with our guests, a couple of quick hitters. So what's your favorite food?

Amanda Igel:  Anything Asian cuisine.

Scott Steele:  Okay.

Amanda Igel:  You name it. The spicier, the better.

Scott Steele:  Spoken like a true nutritionist. What's your favorite sport?

Amanda Igel:  Right now it's golf.

Scott Steele:  Fantastic. What's your handicap?

Amanda Igel:  I knew you were going to ask this. It's unestablished, so I'm guessing it's 36.

Scott Steele:  I like it. I like it. And a trip that's memorable or one of the nicer places that you have been to?

Amanda Igel:  Oh, it's got to be Hawaii. That's where I got married. So we got married in Maui.

Scott Steele:  Fantastic. And what's the last nonmedical book that you've read?

Amanda Igel:  It's more about body politics, it's called Body Respect by Linda Bacon and Lucy Aphramor.

Scott Steele:  And then finally, tell our listeners something that you like about living here in Northeast Ohio and Cleveland.

Amanda Igel:  I think it's the lakeside living. I love being able to walk my dog on the lake and wake up in the morning and see the lake.

Scott Steele:  That's fantastic. So for more information on nutrition therapy and support programs here at the Cleveland Clinic, please visit clevelandclinic.org/nutrition. That's clevelandclinic.org/nutrition. N-U-T-R-I-T-I-O-N. And to speak with a specialist in the Center for Human Nutrition, please call 216-444-5957. That's 216-444-5957. Amanda, thanks for joining us on Butts and Guts.

Amanda Igel:  Glad to be here.

Scott Steele:  That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.

Butts & Guts

Butts & Guts

A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. You’ll learn how to have the best digestive health possible from your gall bladder to your liver and more from our host, Colorectal Surgeon and President of the Main Campus Submarket, Scott Steele, MD.
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