Although an uncommon problem in American adults,1 malnutrition can markedly affect outcomes in total hip and knee arthroplasty, collectively referred to as total joint arthroplasty (TJA).2-7 It is important to diagnose and treat malnutrition before TJA and recognize where inequities exist in malnutrition and food security.
Malnutrition can be classified under two different umbrellas: undernutrition and overweight. Undernutrition includes stunting, wasting, low body mass index (BMI), and vitamin and mineral deficiencies.8,9 The focus here will be undernutrition (overweight is addressed in the obesity articles in this publication). Currently, 1.9% of American women and 0.6% of American men are considered underweight (defined as BMI < 18.5).1 Albumin, vitamin D, transferrin, and total lymphocyte count (TLC) are important benchmarks of a patient's nutrition status and can reflect malnutrition at any BMI.10 Food security plays an important and complex role in nutritional status. Currently, 10.5% of American households are food insecure.11
Rates of undernutrition and food insecurity are not equitably spread within the American population. Rates of food insecurity are two times higher in Hispanic and African Americans,12 as compared with their non-Hispanic White counterparts. Rates of food insecurity are also higher for women,13 those of lower socioeconomic status,11 and those in rural areas.14 Many individuals and families lack the means (eg, financial, transportation, and geographic) to procure healthy, nutritious foods such as fresh fruits and vegetables.11 This lack of access is exacerbated in rural areas.14 The food environment (e.g., food deserts, food swamps, and access to physical activity–promoting recreational areas) has been shown to play an important role in nutrition status15 and is not equitably distributed. Food swamps (neighborhoods with fast food/junk food outlets and liquor stores outnumbering healthy food stores) and food deserts (neighborhood that lack access to affordable, healthy foods) are more likely to be in geographic areas that are of low income, have high levels of unemployment, have low levels of public transportation, and have high proportions of people of color.15,16 There is a paradox of food insecurity in rural areas because a large portion of fresh food is grown in these regions, but many rural communities are still classified as food deserts or swamps.17 Communities of color in rural locations that are already marginalized in the American society face the greatest burden of malnutrition and have the greatest barriers to address this nutritional gap.12,15,17
Rates of osteoarthritis and its subsequent management with TJA also have notable disparities which mirror the areas of most predominant malnutrition. Rates of osteoarthritis are disproportionately higher in communities of color, specifically individuals who identify as African American or Hispanic18-21 and women of all races and ethnicities.22 However, it has been shown that TJA is underutilized by African American and Hispanic individuals,19,23 women,24,25 and those of low socioeconomic status.26 In addition, undernutrition disproportionately affects the elderly community, a demographic with a high burden of osteoarthritis and notable need for TJA.6 Therefore, the elderly, women, and communities of color are more likely to be malnourished and considered inappropriate surgical candidates for elective TJA procedures. These patients may not receive the benefit of TJA, which is known to dramatically improve quality of life,27,28 further exacerbating current disparities.
Clinical Implications of Malnutrition Related to Total Hip/Knee Arthroplasty
Malnutrition plays a role in a complex pattern of perioperative complications. Under its two buckets—undernutrition and overweight—malnutrition is associated with many postoperative complications.2-7 Because it pertains specifically to undernutrition, one study by the US department of Veterans' Affairs found that serum albumin (<3 g/dL) was the single most valuable predictor of poor surgical outcomes and increased morbidity.5 In addition, patients with low BMI were found to have increased length of stay and eightfold increased 2-year mortality after TJA.6 Although there are no strictly imposed universal cutoffs for nutrition status, the observed wide variability in institutional guidelines may restrict access to surgery for groups who already have shown underutilization of this quality-of-life improving procedure. Preoperative optimization of nutritional status for patients is a unique opportunity to improve postoperative outcomes.
Strategies to Optimize
Various proposals for preoperative assessment and management of malnutrition are currently being conducted by experts in the field of arthroplasty. We conducted 10 qualitative interviews with 14 members of the orthopaedic surgical care team across seven institutions: New York University, OrthoVirginia, Hospital for Special Surgery, Yale New Haven Health, Louisiana State University, Brigham and Women's Hospital, and Penn Medicine. These institutions and individuals were chosen because of their national reputations and peer-reviewed publications focused on improving access for vulnerable populations. They provided both evidenced-based and individualized optimization protocols. Importantly, there was wide variability in optimization protocols and members of the surgical care team, both within and across institutions.
Strategies for optimization begin with a holistic assessment of the patient's nutritional status. Patients should have a BMI >18.5 kg/m2, vitamin D level >30 ng/dL, albumin level >3.5 g/dL, transferrin level >200 mg/dL, and TLC of >1,500 cells/mm3. Even one abnormal metric of malnutrition can predispose a patient to poor perioperative outcomes.10 Patient screening can be accomplished by a nurse navigator, or any member of the care team, depending on institutional ability. Identifying patients with malnutrition should be accomplished early because levels of these key nutrients may take weeks to rise markedly.29 Patients who are identified as having any concerns for malnutrition should immediately be followed up with screening for food security, including geographic and resource-oriented ability to procure healthy food. Depending on institutional ability, patients with identified undernutrition should be referred to a nutritionist or weight management specialist. Ideally, this referral would be intrainstitutional, accept all forms of insurance including Medicaid, and be able to tailor highly individualized plans to surgical candidates with differing levels of food security. In those who have identified food insecurity, social work should be consulted to incorporate community partners to leverage available mechanisms for access to healthy food. These include, but are not limited to, government support programs (eg, Supplemental Nutrition Assistance Program); local organizations, such as churches, local nonprofits, and neighborhood management teams; local food shelters; Meals on Wheels; and the Medicaid Escalation Unit. In addition, identified malnourished surgical candidates can be instructed to take preoperative supplements of omega-3 fatty acids and arginine and protein shakes. These have been shown to decrease infectious morbidity, length of stay, and hospital-related expenses30-32 (Table 1).
Table 1 -
Malnutrition Optimization Strategies
| Optimization Strategy |
| Screening personnel |
| Surgical care team, such as Nurse navigators |
| Physician associates |
| State-wide case managers |
| Social workers |
| Orthopaedic surgeon |
| Screening |
| BMI < 18.5 kg/m2
|
| Nutrition status |
| Albumin (<3.5 g/dL) |
| Vitamin D (<30 ng/dL) |
| Transferrin (<200 mg/dL) |
| TLC (<1,500 cells/mm3) |
| Food security |
| Resources (eg, finances and transportation) to access healthy food |
| Social support system |
| Ability to exercise |
| Referrals |
| Nutritionist consult |
| Weight loss programs |
| Social work |
| Community partners |
| Institutional funding for food procurement |
| Meals on Wheels |
| Local food shelters |
| Government social support programs (eg, SNAP) |
| Local organizations (eg, churches, community organizations, and neighborhood management teams) |
| Medicaid Escalation Unit (if available in your state) |
| Short-term preoperative options |
| Well-balanced meals |
| Preoperative supplementation with omega-3 fatty acids and arginine and protein shakes |
BMI = body mass index, SNAP = Supplemental Nutrition Assistance Program, TLC = total lymphocyte count
Across the seven institutions interviewed, there was no consistent approach toward optimization or retesting malnourished patients. Most consistent across institutions was monitoring albumin level and proceeding with elective TJA when albumin was in the normal range.
Summary Take-home Message
We recommend that orthopaedic surgeons screen for malnutrition for all elective total hip/knee arthroplasty patients with blood tests (albumin, vitamin D, transferrin, and TLC). Malnutrition can occur at any BMI and is an important reversible risk factor for postoperative complications.
Acknowledgments
This article is part of a series on optimizing underserved patients for total hip and knee arthroplasty. The series was coordinated in collaboration with Movement is Life, a group of healthcare professions focused on the elimination of musculoskeletal health disparities. The authors thank Daniel H. Wiznia, MD, Assistant Professor of Orthopaedics and Rehabilitation at Yale University and member of the Movement is Life Steering Committee, as well as Kelsey Rankin, BA, Yale University medical student, for their assistance in preparing the background for this article.
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