August 06, 2025
9 min read
Key takeaways:
- Good musculoskeletal health and nutrition are important for individuals undergoing surgical procedures.
- Nutrition should be optimized prior to surgery with a well-balanced diet, supplements and exercise.
Sarcopenia — a progressive loss of muscle mass, strength and function — has generally been associated with advanced aging, estimated to affect 10% to 16% of individuals aged 60 years and older worldwide.
However, natural loss of muscle mass can occur as early as 40 years and decreases by 8% every decade after, according to Reza Jazayeri, MD, orthopedic surgeon in sports medicine in Los Angeles.
Image: Grey Hunt
“We used to think [sarcopenia] was simply age related, which is not accurate,” Jazayeri told Healio. “What is more accurate is lifestyle. How much you exercise and what foods you eat contribute an important role.”
While exercise is the best way to keep muscle healthy, Katie R. Hirsch, PhD, EP-C, CISSN, said nutrition plays just as important a role, starting with optimizing protein intake and consuming the appropriate number of calories.
Katie R. Hirsch
“That can vary by the individual and by the goal, but we do want to make sure that we are getting both of those things to help support and maintain high-quality muscle,” Hirsch, assistant professor in the department of exercise science at the Arnold School of Public Health at the University of South Carolina, said.
Good musculoskeletal health and nutrition are especially important for patients undergoing surgical procedures. According to Paul E. Wischmeyer, MD, director of the parenteral nutrition/nutrition therapy team at Duke University Hospital, a patient’s body begins to break down muscle more rapidly after injury or surgery due to catabolic stress. If a patient is malnourished prior to surgery, Wischmeyer said they have a 3.5 times greater risk for complications, and a fivefold increased risk for mortality postoperatively compared with patients who are not malnourished.
Paul E. Wischmeyer
“Every patient having any surgery should be screened for malnutrition or, put more simply, no patient should ever have elective surgery without nutrition screening and optimization,” Wischmeyer, professor of anesthesiology and surgery at Duke University School of Medicine and co-director of the Duke Clinical Nutrition fellowship, said.
This can be done through the perioperative nutrition score, which he said uses validated questions that focus on BMI, unintentional weight loss, appetite and albumin levels to identify if a patient is malnourished.
“We ask patients have you lost meaningful weight that you were not trying to lose? Are you eating less than half of what you normally eat? Is your BMI less than 20 kg/m2? Low muscle mass and recent non-purposeful weight loss are major risk predictors for complications and death in the hospital and after surgery,” Wischmeyer said. “Then, do they show obvious signs of muscle wasting or fat wasting around the temporal part of their face or at their arms or legs? We think the future of surgical risk screening is using ultrasound or CT scan to assess for low muscle loss, which is a major predictor of mortality and complications after surgery.”
Optimize nutrition
For patients who are malnourished, sources who spoke with Healio said optimizing nutrition is key before, during and after surgery.
Connie Weaver
“Nutrition should be optimized your entire lifespan,” Connie Weaver, PhD, distinguished research professor at San Diego State University, told Healio. “You need it for growing the bone and muscle in the first place and then for holding on to it for as long as you can as you age after you have obtained peak bone mass.”
The best way to optimize nutrition is by having a high-quality, well-balanced diet that meets carbohydrate, fat and general protein recommendations, according to Hirsch.
“If we want to fine tune that and make sure we are hitting that skeletal muscle health, I tend to encourage a higher protein diet,” Hirsch said.
Hirsch said this involves consuming protein at amounts above the recommended dietary allowance of protein from 0.8 g/kg/day to 1.2 to 1.6 g/kg/day.
“We may even push more to 1.6 to 2 g/kg if it is going to be a higher stress surgical situation where we want to help maintain not just the muscle but then facilitate the recovery of that surgical procedure,” she said.
According to Wischmeyer, increasing intake of high-quality protein, such as whey protein, around the time of surgery has been shown to improve functional recovery, not just immediately postoperatively but for years following surgery.
“Patients who receive good nutrition around the time of surgery or the time of hospitalization have better quad strength and muscle function 2 years later,” Wischmeyer said. “It is not just the short time that they may take it around surgery where they are improving, but it seems to allow for maintenance of improvement of strength and function years later.”
Patients routinely consuming higher protein intakes at levels previously mentioned need to be sure they are not reducing their intake of essential carbs and fiber, according to Nancy R. Rodriguez, PhD, RD, FACSM, emeritus professor in the department of nutritional sciences at the University of Connecticut, Storrs.
Nancy R. Rodriguez
“Patients need fiber and should stay hydrated. Eating fiber routinely before surgery and, certainly, after surgery is recommended since medications for various procedures may also have effects on the gut,” Rodriguez said.
Supplementation
Although patients should aim to get nutrients from whole foods to support musculoskeletal health, Jazayeri said this can be difficult to achieve through diet alone.
“The caloric load required is significant,” Jazayeri said. “We do not want patients gaining excess weight or fat, we are targeting specific amino acids essential for tissue healing and muscle recovery. We have now identified these key amino acids and can deliver them through targeted supplementation, offering a more efficient and practical approach.”
Sources who spoke with Healio said nutrition supplementation can help improve musculoskeletal health in patients who are unable to consume enough nutrients through whole foods. According to Weaver, patients who do not consume enough dairy, nuts or whole grains may need supplementation of calcium, magnesium and potassium.
“If your diet excludes dairy or provides minimal amounts of dairy and dark green leafy vegetables, whole grains, nuts and legumes … you probably need additional supplements,” Weaver said.
Because 40% to 70% of the population is deficient in vitamin D, Wischmeyer said physicians should have patients screened for vitamin D deficiency, which significantly increases complications.
“If people are deficient, then you need to replete them with 50,000 units a week probably for 6 weeks,” Wischmeyer told Healio. “If you are really low on vitamin D, taking 2,000 or 4,000 units a day is not going to replete you for a long time. You want to get 50,000 units. In the hospital, we even use 100,000 units and that does not make anyone toxic.”
Rodriguez said vitamin B12 is also important, especially among older patients or patients who choose to eat less meat.
“[Vitamin B12] also works in concert with iron. It does different things for the red blood cells,” Rodriguez said. “If I were picking micronutrients … I would say vitamin D, calcium, check iron and B12. Those would be the ones.”
Repopulate nutrients
As patients are being phased off antibiotics after surgery, Hirsch said a probiotic can help repopulate the gut to promote absorption of proper nutrients and proteins to recover from surgery. In addition, she said omega 3 supplements can help moderate the body’s inflammatory response so it can be repaired efficiently.
Even patients who are well-nourished will benefit from an arginine-containing formula before and/or after surgery, which will reduce their risk for infection, according to Wischmeyer.
“We do not have as much data in orthopedics as we do in cancer, cardiac or [ear, nose and throat (ENT)], but we have no reason to believe the data would be different because the mechanism is the same — that it reduces infection risk by 40% in completely healthy young people,” Wischmeyer said.
Hirsch also said supplementation with essential amino acids can help rebuild, repair and protect muscle. According to Hirsch, essential amino acid supplements mix clear in liquid, are easy to drink and digest fast to “give us our strongest muscle-stimulating response.”
“It also has less of an appetite-suppressing effect,” Hirsch told Healio. “Protein is satiating. People feel more full when they eat it, especially in a whole food form. Using a supplement form is not as filling, especially if you use the essential amino acid supplement. It helps facilitate making sure we are still getting good calorie intake and good nutrition from all the other foods we are eating, especially our older individuals where appetite and eating enough is already a struggle.”
Rebuild muscle
One supplement that has received a lot of attention is creatine, which Hirsch said is naturally stored in the muscle and facilitates muscle gain and strength. During times of disuse, such as after injury or surgery, Hirsch said creatine supplementation helps with muscle preservation and decrease muscle loss.
Source: Data were derived from Jacques A, et al. OTA Int. 2025;doi:10.1097/OI9.0000000000000402
“Where [creatine] can be beneficial is on the back end as we start to go through rehab and try to build back muscle strength and any muscle loss that we had during that time,” she said. “It can help with muscle adaptation and regaining strength. What it is going to do is help you get a few more reps out of that physical therapy workout you are doing, which, over time, helps you gain more and get more back.”
Hirsch also said there is growing research on the benefits that creatine has on the brain and cognition.
“If there is anything with concussions, [traumatic brain injuries] or sometimes depression, symptoms can get worse during these times when you are injured or having surgery, all of those can benefit from creatine,” Hirsch said.
Similarly, she said beta-hydroxy beta-methylbutyrate (HMB) has been found to have unique benefits among patients in muscle stress situations.
“HMB helps mitigate muscle break down and muscle loss,” Hirsch said. “There is growing evidence that HMB may assist with muscle preservation during periods of disuse, especially in older individuals whoare at higher risk for muscle loss. That is one we could consider right around surgery time and as we are going through those early stages of rehab and rebuilding back muscle strength.”
However, Rodriguez said physicians should be cautious about recommending HMB, as most benefits require increased protein intake and strength training.
“I am not sure of strong evidence using HMB alone to improve recovery of muscle health following orthopedic procedures,” Rodriguez said. “Even in the aging population, HMB alone is not effective.”
Dietician referral
Overall, the impact of nutrition on musculoskeletal health during and after surgery is an understudied space, with little data available on many of the recommendations, according to Hirsch.
“The whole space still has a ton of potential, a ton of room to apply this and how we streamline it and make it most feasible and most effective,” Hirsch said.
In the future, Jazayeri said physicians need to understand how long the duration of optimization should be, as well as the appropriate dosage of nutritional supplements.
“Then also looking at sarcopenia because, as we gain more awareness on this, we are going to have a much better impact on our patients,” Jazayeri said.
As physicians await more research and guidelines on optimizing nutrition prior to surgical procedures, Jazayeri said physicians should start looking at patient body composition with the use of bioimpedance analysis (BIA), which allows physicians to observe muscle volume in a patient.
“Instead of simply checking vitals, blood pressure and BMI, we can now use a BIA scale, which gives us more meaningful data, such as body composition, that helps us better guide and educate our patients beyond just their weight,” Jazayeri said.
Performing a nutrition assessment and referring patients to a registered dietician can aid in patient education and, therefore, improve clinically relevant outcomes in orthopedic patients, as well, according to Rodriguez.
“The burden of being a physician is they feel like they have to know everything, but at the end of the day they need to bring someone on board,” Rodriguez told Healio.
In addition, Rodriguez said dieticians need to “step up in terms of talking to surgeons.” If a physician has questions that a dietician is unable to answer, Rodriguez said the dietician should not just walk away.
“You want to be valid, you want to be respected and the way that you do that is if you do not know, you say let me look into it, and the biggest part of that is you have to follow up,” she said.
Movement is key
Physicians should also encourage patients to exercise, which is an important component to reduce muscle loss, according to Rodriguez.
“If they are not walking even before surgery, they need to walk,” Rodriguez said. “They need to find a way to become active, if it is swimming or if it is getting on a bike. Whether it is active aging, active recovery or doing something to offset muscle loss, movement is important.”
While movement is a good starting point, Wischmeyer said the ultimate goal is to have patients participate in resistance training or interval training, which provides distinct benefits for musculoskeletal health.
“The world needs to learn to use heart rate monitors to understand where they are exercising at and learn to do intervals even if they are just short 1-minute intervals,” Wischmeyer said. “Resistance training with weight at any age is life saving and everybody should do it, and elderly people need to do it more.”
Most importantly, Jazayeri said physicians should “look at the whole patient, not just their broken leg or their torn rotator cuff.”
“Given the rising cost of surgical complications, we cannot afford to rush into the operating room,” Jazayeri said. “Taking a moment to pause and optimize a patient’s nutritional status during the perioperative period offers a critical opportunity to improve recovery and long-term outcomes.”
References:
For more information:
Katie R. Hirsch, PhD, EP-C, CISSN, can be reached at khirsch@mailbox.sc.edu.
Reza Jazayeri, MD, can be reached at rezajazayerimd@gmail.com.
Nancy R. Rodriguez, PhD, RD, FACSM, can be reached at nancy.rodriguez@uconn.edu.
Connie Weaver, PhD, can be reached at cmweaver@sdsu.edu.
Paul E. Wischmeyer, MD, can be reached at paul.wischmeyer@duke.edu.
Sources/Disclosures
Source:
Healio Interviews
Disclosures:
Jazayeri reports being the founder of Xcelerated Recovery. Weaver reports receiving grants from the California Prune Board and the National Dairy Council. Wischmeyer reports receiving grant funding to Duke University from Abbott, Baxter, the Department of Defense, Fresenius Kabi and the NIH; being a consultant for Abbott, Baxter, Fresenius, Mend Nutrition and Nutricia; being a CME speaker for Abbott, Baxter, Fresenius and Nutricia; and being on the scientific board for MuscleSound. Hirsch and Rodriguez report no relevant financial disclosures.
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