Food as Medicine: What is the Impact on Foot and Ankle Surgery?

Preventable chronic diseases currently overwhelm the US health care system. Physicians experience this firsthand daily, yet Western medicine places little priority on lifestyle modification as a treatment modality. There is not the time nor a support system in place for physicians to prioritize these concepts with patients, least of all nutritional counseling. Even if we had the time, our general medical education system does not educate physicians in-depth on nutrition.¹ Instead, we must find the time to educate ourselves on these topics, and with widely available misinformation available on nutrition, we begin to question any resource.

Without appropriate knowledge of nutrition, are we as physicians in disservice to our patients? As foot and ankle surgeons, how does this affect us? Does this impact patient outcomes? And, if so, how can we help to change that dynamic?

Our nutritional intake as a human being affects everything about our daily life: energy levels, body habitus, metabolism, preventable disease, healing capabilities, mood, skin condition, bone metabolism, and the list goes on. As medical professionals we have a unique capability to self-educate and learn about macro- and micronutrients, the power of protein, and what has become available in our society that, although viewed as food, truly provides no nutritional benefit for fueling our bodies. Yet, as a society we continue to overconsume such items lacking in nutrition and are undernourished. This directly affects our daily life, and importantly, our patients' healing potential after surgery.

In recent years we have put more emphasis on the importance of optimizing Vitamin D for bone metabolism, yet we are not equally recommending optimizing protein intake.  For elective surgery, it is imperative to avoid preoperative malnutrition and consume appropriate amounts of protein to support anabolism. Most in the US are malnourished due to lack of protein intake and insulin resistance, this becomes increasingly relevant following surgery as a surgical stress response induces hyperglycemia and protein catabolism.² This catabolism yields loss of lean muscle mass in attempts to nourish the body due to the stress response from surgery. Maintaining lean muscle mass is essential to support wound healing, immunity and autonomy.³ Providing appropriate physiologic nutritional reserve preoperatively allows the body to meet functional demands of the stress response including increased cardiac output, delivery of oxygen, osseous and soft tissue healing. Malnourished surgical patients have worse clinical outcomes, greater risk for complications, mortality, readmission, and prolonged hospitalization.⁴ Nutritional management should continue postoperatively to maintain nutritional status for supporting wound healing, improving the immune response and enhancing functional recovery.

So why are we not talking about nutrition; the most powerful medication at our disposal? While recommendations vary individually, we would benefit from preoperative guidelines for our elective foot and ankle patients with basic information on macronutrients, the importance of eating whole, unprocessed foods, and prioritizing protein. Food is medicine and we should treat it as such.

Dr. Millonig is a fellowship-trained foot and ankle surgeon specializing in deformity correction and minimally invasive surgery. She practices at East Village Foot and Ankle Surgeons in Des Moines, IA. She is an Associate of the American College of Foot and Ankle Surgeons. Dr. Millonig has held multiple leadership positions in numerous national committees with the American College of Foot and Ankle Surgery, American Public Health Association, and the American Podiatric Medical Association.

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References

1.    Crowley J, Ball L, Hiddink GJ. Nutrition in medical education: a systematic review. Lancet Planet Health. 2019;3(9):e379-e389. doi: 10.1016S2542-5196(19)30171-8. PMID: 31538623.

2.    Gillis C, Carli F. Promoting perioperative metabolic and nutritional care. Anesthesiology. 2015;123:1455–1472.

3.    Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: an evidence-based approach to treatment. Wallingford, UK: CAB International Publishing, 2003.

4.    Tangvik RJ, Tell GS, Eisman JA, et al. The nutritional strategy: four questions predict morbidity, mortality and health care costs. Clin Nutrition. 2014;33:634–641.