Nutrition after Shoulder Surgery

Many people who exercise regularly and those that are keen athletes (amateur and professional) ensure that they have a good diet and take the necessary supplements for their sport and training. However, after an injury or surgery the same people often neglect their diet when their body needs optimal nutrition most, to aid recovery and recuperation, as well as preventing muscle mass loss during the periods of inactivity.

Importance of Protein for Repair and Recuperation:

Injury to the body can result from either accidental injury or a surgical procedure. In either case, the injury is characterised metabolically by the breakdown of skeletal muscle tissue to harvest amino acids and transport of the muscular amino acids to the wound and also to visceral organs. The amino acids serve to enhance immune system function, support vital organ function, and promote wound repair. Healing requires that the body create new tissue and blood vessels, repair injured tissue, and step up the production of cells that repair wounds. These complex activities cannot occur efficiently if your diet is short on essential nutrients. Without proper pre and post-surgical nutrition, the post-surgical patient will experience slower recovery, a higher degree of complications, and a higher loss of skeletal muscle tissue. As proteins are made up of amino acids consuming extra protein is vitally important after surgery because the body must either get amino acids from food intake or it will produce its own supply of amino acids by breaking down muscle tissue. Protein is a major building block of human nutrition and it is necessary for tissue growth and repair. Protein requirements increase during the post-surgical recovery phase. The best single predictor of how well a person will heal after surgery is their protein status. If the protein status is inadequate, the body will heal more slowly.

Surgery places great metabolic stress on patients. A post-surgical patient requires more protein than a normal person because of the increased metabolic activity of wound healing and stress induced acute phase protein production. In addition, extra protein is required to repair injured muscle tissue and replace the skeletal muscle tissue that is being catabolised for strengthening the immune system and supporting vital organ function. Post-surgical patients tend to exhibit accelerated protein turnover and synthesis, but the increased rates seem to be inadequate to support required amino acid levels. Klein et. al. published a paper in 1996 that showed a significant reduction in post-operative complications when patients were in a satisfactory nutritional state (Two groups – one properly nourished and the other malnourished. Both groups underwent spinal surgery. Of the 26 post-surgery complications recorded, 24 complications – more than 90% of the total - came from the malnourished group.). In another study from 2001, Wilmore showed that supplementation with the amino acid glutamine decreased the rate of infection in post-surgical patients and decreased length of hospital stays (six different randomised blind trials). Protein supplementation may help to accelerate healing times, prevent loss of skeletal muscle tissue, and support immune system function.

What sort of protein supplementation would be best?

Micellar casein is a slow digesting protein and has been shown to release amino acids into the bloodstream many hours after consumption resulting in a prolonged period of elevated plasma amino acids (Boirie et. al. 1997). The elevated plasma amino acid levels maintain prolonged periods of body protein synthesis to help accelerate wound repair and muscle tissue repair. Just as important, micellar casein is also the only protein that has been scientifically shown to inhibit metabolic protein breakdown. Multiple studies since 1997 have shown that micellar casein provides better overall protein deposition, better retention of amino acids, and better utilisation of amino acids compared to whey proteins. While whey proteins are generally regarded as supporting the immune system, the only scientific studies that have indicated that whey proteins support immune system function were all performed with undenatured, native whey proteins. The original study, published in 1991 by Bounous and Gold, showed that a native, undenatured whey protein, Product X, significantly enhanced immune system function but that whey proteins manufactured from cheese whey did not enhance immune system function any better than the experimental control, casein (which was not thought to have immune system supporting properties at that time). Native undenatured whey protein is the only whey protein that has been shown to significantly enhance immune system function and should help prevent post-operative infection. Glutamine supplementation is well studied for people under stress. Numerous studies have shown that supplementation with glutamine (approximately 15 grams per day in doses of 3 to 5 grams) shortens hospital stays; decreases infection rates, improves overall nitrogen balance in patients and enhances net protein synthesis, especially for skeletal muscle. The problem with glutamine supplementation, however, is that glutamine is poorly absorbed when consumed as a free amino acid (L-Glutamine) - unless it is consumed on an empty stomach. Most glutamine supplementation is carried out in combination with consumption of other amino acids, proteins, or as part of a meal. In all such cases, absorption and utilisation of free glutamine (L-Glutamine) will be limited due to competitive uptake of free amino acids across the intestinal barrier. A study published in 2003, (Preiser et. al.) found that absorption and utilisation of peptide bonded glutamine (which is in ProPeptide & Pro MR), on the other hand, can be better than that of free glutamine (1.3 to 2 times better). For post-operative patients, peptide bonded glutamine would be the best form of glutamine supplementation.

Pro MR and ProPeptide protein powder products contain the same unique blend of proteins and amino acids that will aid in recovery from injury and surgery. Both products contain micellar casein, truly undenatured, native whey proteins, and supplemented glutamine in an easily absorbable form – peptide bonded glutamine. Pro MR and ProPeptide are the only protein powders that combine almost equal levels of micellar casein and native, undenatured whey proteins in large quantities. The micellar casein provides prolonged periods of elevated plasma amino acids for increasing efficacy of muscle metabolism and the whey proteins improve immunological support. In addition, Pro MR and ProPeptide are supplemented with 4 grams of peptide bonded glutamine per serving - the optimum dose of glutamine for people under stress. A recuperating surgical patient will receive the recommended amount of supplemented protein and glutamine in 3 servings per day of either Pro MR or ProPeptide.

Additional glutamine can be obtained from L-Glutamine powder, but this must be taken on an empty stomach so that you get extra Glutamine to aid recovery.

In addition to protein/amino acids, the protein blend in Pro MR and ProPeptide also provides essential minerals that will assist in repairing and restoring damage to muscle tissue as well as the skeletal system. Micellar casein contains high levels of calcium and phosphorous, the building blocks of bone. Because the calcium and phosphorous are bound to the casein micelle, studies have shown that they are more efficiently absorbed into the bloodstream and better utilised for manufacturing skeletal tissue than other forms of calcium. The casein micelle also contains important levels of bound and easy-to-absorb zinc and magnesium. Studies have shown that depleted plasma levels of zinc and magnesium lead to low anabolic hormone levels, making recovery and repair more difficult.

Overall, the protein blend in Pro MR and ProPeptide has been custom designed to provide improved physiological response, promote enhanced nutrient bioavailability, and increase efficacy of muscle metabolism and repair. Pro Peptide is a protein only supplement that you would take with carbohydrates (porridge, Weetabix, Shredded Wheat etc.) normally for breakfast and Pro MR contains the same protein but with added carbohydrates and vitamins to make it a meal replacement.

Importance of Micronutrients: Essential Fatty Acids, Vitamins and Antioxidants in Repair and Recuperation:

Just as increased protein consumption is required for surgical patients, essential fatty acids, vitamins and antioxidants are valuable micronutrients that are crucial for healing. Fatty Acids such as omega 3, omega 6, and omega 9 polyunsaturated fatty acids (PUFA’s) are essential for repair of cell walls after a stressful event. PUFA’s have also been shown to have joint protecting, anti-inflammatory properties. PUFA’s have been shown to modulate pro-inflammatory cytokine production and speed wound healing. In addition, PUFA’s act to protect joints (less inflammation) as they heal from injury. Vitamins and antioxidants are essential nutrients that play a major role in the normal functioning of the human body. Vitamins act as coenzymes and work in conjunction with enzymes to enhance cellular function. Certain vitamins function very similar to enzymes in the brain that control normal body function and provide stability to emotional and cognitive processes. They work to stabilise parts of the brain when faced with stressful situations originating from both inside and outside of the body. Lowering of stress levels has a positive effect on every other part of the body and can help to speed healing. Certain vitamins have also been shown to have anti-inflammatory effects and to enhance cell repair and replication. Accelerated cell repair and replication leads to faster recuperation from injury. Antioxidants also play an important role in recovery from surgery. Immediate and persistent muscle dysfunction commonly follows the injury and surgical repair of skeletal and muscle tissue. Despite advances in orthopedic surgery, physical therapy, and medicine, muscle dysfunction, especially weakness, can continue for years in many people. It is well known that oxidative stress may play an important role in enhancing muscle degeneration. Both oxidative stress and pro-inflammatory molecules, called cytokines, will induce muscle dysfunction. Dietary antioxidants have been shown to modulate a wide range of inflammatory cytokines and, therefore, inhibit muscle dysfunction to a degree. A study performed by the Linus Pauling Institute found that antioxidants will lower the increase of anti-inflammatory cytokines and stabilize the depression of the pro-to-anti-inflammatory cytokine ratio immediately following surgery. The recovery of muscle strength following surgery is associated with adequate antioxidant levels in the blood prior to surgery and with elevated antioxidant plasma levels post-surgery. They concluded that greater muscle strength gains after surgery are associated with lower oxidative stress and a higher pro-to-anti-inflammatory cytokine ratio - but only in the subjects supplemented with antioxidants.
Micronutrients such as essential fatty acids, vitamins, and antioxidants can help in providing the optimal supply of nutrients that are crucial for healing. Pro Omega contains unique ratios of Omega 3, 6 and 9 fatty acids that have been blended with antioxidants and cutting edge ingredients, such as plant sterol esters, to help protect joints, modulate production of inflammatory cytokines, and speed repair. Pro Vital provides all of the essential vitamins, minerals, and antioxidants the body needs for enhanced metabolic function. Supplementation with both products post-injury or surgery may help to enhance healing and decrease healing times.