Overview

Research Article Title: Consensus-based recommendations for optimizing perioperative nutritional support and muscle health in major surgery in India
Authors: Adarsh Chaudhary et al.
Published in: Frontiers in Nutrition
Date of Publication: 05 June 2025
Link to Article →

Summary

Background: Malnutrition is identified as a modifiable preoperative risk factor and these recommendations highlight the importance of nutritional support for surgical patients not only for muscle health optimization but also for improving patient outcomes.

Key Findings:

• The consensus recommendations help to provide a clear framework for effective nutritional care in surgical care to address malnutrition and sarcopenia to improve patient outcomes and reduce healthcare costs.
• The consensus statements were divided into four sections.

1. 1. Nutrition status of surgical patients.
   2. The etiopathogenesis of sarcopenia.
   3. Nutrition assessment: when, which tool, and why.
   4. Benefits of nutrition intervention.

• Key recommendations:
  • Use of oral nutrition supplements.
  • Multimodal prehabilitation to include exercise, nutritional optimization smoking and alcohol cessation, and psychological stress reduction.
  • Targeted postoperative interventions to enhance recovery, maintain muscle mass, and reduce complications.
    
    

Methodology 

This study used a modified Delphi-based approach to collect expertise through iterative feedback with a panel of experts.

• Nine panel members, including a moderator, who were all clinicians based in India.
• Domains of surgery included oncology, gastrointestinal, and hepatobiliary.
• Recommendations based on a comprehensive review of the current evidence.
  
  

Why It Matters

This initiative to develop consensus-based recommendations for optimizing perioperative nutritional support and muscle health in patients undergoing major surgery provides actionable strategies to integrate effective best practices into protocols.

1. Nutrition Status in Surgical Patients

• Sarcopenia, progressive and global decline in skeletal muscle mass and strength, is a significant predictor of poor outcomes after surgery.
  • Higher mortality, complications, and lower survival rates.
  • Influences length of hospital stay.
• Malnutrition is an independent predictor of sarcopenia.
  • Increased risk of postoperative complications such as surgical site infection, delayed wound healing, bleeding, and delayed ambulation.

2. Etiopathogenesis of sarcopenia

• Chronic inflammation is closely linked with sarcopenia. 

3. Nutritional Assessment: When, Which Tool, and Why

• Malnutrition is a modifiable risk factor.
• Perioperative malnutrition is linked with higher mortality rates, increased complications, and elevated healthcare costs.
• Validated tools for assessing nutritional risk:
  • Subjective Global Assessment (SGA) - preferred by the expert panel
  • Nutritional Risk Screening (NSR)
  • Malnutrition Universal Screening Tool (MUST)
  • Mini Nutritional Assessment (MNA)

4. Benefits of Nutritional Interventions

a. Prehabiliation in Surgical Patients 

• • Prehabiliation: process of enhancing an individual’s functional capacity to withstand a stressful event better
  • Preoperative nutritional supplementation has been shown to improve clinical outcomes 
    • High energy, high protein drinks
    • Immunonutrition
    • Enteral & parenteral nutrition
    • Preoperative carbohydrate-rich drinks

b. Postoperative Nutrition Interventions for Recovery

• • Early feeding is a key component of early recovery.
  • Patients receiving oral nutrition supplements had less weight loss, higher BMI and SMI, lower incidence of sarcopenia, fewer chemotherapy modifications, and improved quality of life (fatigue and appetite).
  • Patients receiving a combination of enteral and parenteral nutrition experience the lowest calorie and protein deficits.
  • Enteral nutrition is preferred but there are situations where it is not feasible (gut intolerance, surgical complications, etc) and parenteral nutrition is a critical alternative to ensure nutritional needs are met to support recovery.

c. Types of Nutrition Recommendations and Clinical Evidence 

• • Assessment of nutritional status is recommended both before and after major surgery. 

d. Role of Certain Nutrients in Postoperative Recovery

• • Malnutrition is consistently associated with poor outcomes, especially after discharge.
  • Recommendation: balanced oral nutritional supplementation with adequate calories, high-quality protein, and vitamins and minerals to help improve BMI and SMI.
  • Depletion of macro-and micro-nutrients can make patients susceptible to sarcopenia, cachexia, surgical trauma and infection.
  • Perioperative supplementation with L-glutamine, HMB, and L-arginine has been shown to reduce inflammation, improve immune function, and promote muscle preservation.

Limitations

• There is a need for a simplified algorithm for developing and implementing nutrition practices. A large barrier noted is the lack of standard operating procedures to monitor and audit nutritional interventions.
• Specific to India, the prevalence of the vegetarian diet poses a challenge to ensuring adequate protein intake.
• Global Leadership Initiative on Malnutrition (GLIM) criteria is a comprehensive tool designed to build a global consensus around core diagnostic criteria but many of the required parameters are not routinely assessed in surgical patients in Indian settings.
• Financial barrier: insurance does not cover nutritional support

Final Thoughts

Nutrition support is critical to address malnutrition and sarcopenia to improve surgical outcomes. Providing perioperative nutrition support through nutrition screening, utilization of oral nutritional supplementation, and tailored postoperative interventions should be the standard of care for patients undergoing major surgery.

Remember, nutrition is not one size fits all.  Continue efforts need to be made to promote best practices and optimize these strategies for various conditions such as chronic kidney disease or sarcopenic obesity. Utilization of Registered Dietitians and continued education is vital for continuing to provide patient-centered care and improve clinical outcomes.

This article was written by Katie Frushour, MS, RD, CSSD, a dietitian at Mend.