formation and cellular differentiation, and stimulates the immune response. Prior to surgery, patients who are known to be de-pleted in vitamin A, are immune compro-mised, have been treated with steroids, or have fractures, tendon damage or sepsis, may all benefit from vitamin A supplemen-tation. Although there is some reluctance to supplement due to toxicity, most toxic-ity cases reported exceed dosing of 50,000 IU over a period of weeks to years. Using 25,000 international units (IU) for a short period of time, for most patients, does not appear to pose any risk of toxicity. at greatest risk of iron deficiency includes the elderly. This can be due to poor dietary intake along with reduced absorption due to low hydrochloric acid. Iron toxicity is rare and intakes of up to 75 mg/day are in most cases safe. Due to the possible con-nection between heart disease and high serum iron, it is best to have blood levels checked, including ferritin levels. Supple-menting with 30 mg twice daily is a safe and effective dose for bringing levels into the normal range. VITAMIN C This is a key component in the cellular matrix of skin, bone, capillaries, and con-nective tissue and is an essential cofactor in collagen formation. Vitamin C stimulates neutrophil function, increases angiogenesis and acts as a powerful antioxidant. Supple-mentation of one to two grams may posi-tively affect wound healing and collagen formation. Considering the safety profile of vitamin C, this dosing is conservative and may be increased based on the metabolic needs of the patient. COPPER Copper is an important mineral cofactor for the enzymes involved in the cross linking of collagen and elastin. It is also imperative for repair and maintenance of bone formation and influences fracture healing time. Plasma levels of copper drop rapidly after surgery. It is important to note both high levels of zinc and vitamin C can de-crease copper absorption. The optimal ra-tio of zinc to copper is 10:1. In most cases if zinc is supplemented at 30 mg, copper would be dosed at 3 mg. Although cop-per toxicity is rare and 10 mg is considered safe, it can cause nausea at doses of 60 mg or higher. It is best for the average person to stay close to the 3 mg/day for supple-mentation. IRON Iron is in every cell of the body and is pres-ent in many enzymes, acting as a catalyst especially in energy production. It also plays a vital role in immune function. De-ficiency interferes with wound healing due to tissue hypoxia and decreases the ability of leukocytes to kill bacteria, thus increas-ing the risk of wound infection. Restless leg syndrome is a common complaint in those with low iron levels. The population 28 • CaNaDIaN CHIROPRaCTOR | DECEMBER 2010 ZINC This is a necessary cofactor in more than 300 enzyme reactions in the body. It is re-quired for DNA synthesis, cell division, pro-tein synthesis and immune function. Poor wound healing has been associated with zinc deficiency. Supplementation with 15-30 mg of zinc is a safe and effective perioper-ative strategy to ensure adequate zinc levels. RECOMMENDING A MULTIVITAMIN From the nutrients already discussed, it would seem prudent to recommend, at the very least, a good comprehensive multiple vitamin-mineral supplement be used a few weeks to months leading up to surgery. There is a study in progress in the Neth-erlands addressing the nutrient status of elderly patients admitted for hip surgery. It is estimated that the prevalence of mal-nutrition is as high as 63 per cent in this population group. Poor nutrient status is associated with impaired muscle func-tion, disability, prolonged rehabilitation time, and increased mortality. The study will investigate the outcome of dietary in-tervention, consisting of a combination of dietetic counselling and oral supplementa-tion, upon admission for surgery and ex-tending up to three months post discharge. The results from this study are expected in early 2011. The study is limited truly to the perioperative patient and does not address a long preparatory pre-surgical strategy for nutritional status. It would be very interesting to further assess the effects of supplementation six months prior to and post surgery, compared to a placebo group. The rate of postoperative infection, heal-ing time and pain scale evaluation would be valuable outcome measures to consider. THE POWER OF PROTEIN Adequate protein intake is another very important macronutrient to consider in the surgical patient. Protein provides the key building blocks for so many structures in the body. In order to support a range of mechanisms that includes wound heal-ing, collagen formation, enzyme forma-tion, immune function, and provision of tensile strength in wound healing, protein intake must be maximized. The increased metabolic stress of surgery alone can in-crease the need from the average 0.8g/kg/ day by 10 per cent. Muscle strength and repair rely on adequate protein intake. – As post surgery muscle wasting is inevitable, this should be considered for periopera-tive patients, who should be doing all they can to ensure muscle strength and mass are at optimal levels prior to surgery. En-suring a good baseline going into surgery is prudent. Adding a quality source protein powder, such as whey, to the dietary re-gime to ensure protein intake is optimized is a good plan. Quality protein powders should also supply a beneficial amount of glutamine. This amino acid is lost from skeletal muscle with injury/surgery and needs to be replaced. PREVENTING ISCHEMIA A possible complication from any surgery that is not necessarily discussed per se, often, is myocardial and cerebrovascular ischemia. Badner et al. discusses mitigating the negative effects of increased nitrous ox-ide induced postoperative plasma homo-cysteine. Elevated homocysteine increases a patient’s risk of these ischemias. This risk may be mitigated by preoperative vitamin B supplementation. This study evalu-ated patients undergoing hip/knee arthro-plasty. The study group received a B vita-min containing folic acid, as well as B12, and B6 aimed at ensuring proper homo-cysteine management, and were compared to a placebo group. The results showed the supplemented group did not experience the increase in postoperative homocysteine compared to the placebo group. This result could be extrapolated to support the no-tion that vitamin B supplementation may reduce the risk of homocysteine-related ischemic events. GLUCOSAMINE Glucosamine is the key rate-limiting ingre-dient in the production of hyaluronic acid, which is an important component of the extracellular matrix and main glycosami-noglycans in tissue repair. A study in The Lancet already has demonstrated the role of glucosamine in the management of pain www.canadianchiropractor.ca
Chiropractic + Naturopathic Doctor December 2010: Page 28
