Optimizing Nutrition Prior to Surgery

Nutritional status is a major determinant of outcomes for any type of surgery, especially for high risk patients. Strong for Surgery is an initiative in Washington State aimed at identifying and improving evidence-based practices to help patients have better outcomes.

The Strong for Surgery nutrition initiative focuses on nutrition screening of patients prior to surgery to determine those at greatest risk for malnutrition. Good nutritional status is important to help patients heal better and fight infection.

The Strong for Surgery Nutrition Checklist addresses three separate components:

Screening for Malnutrition. Four specific questions help the clinician determine the patients’ current nutritional status.  Assessment of a Body Mass Index of less than 19, unintentional weight loss, decline in appetite, and inability to tolerate food due to dysphagia, vomiting, or diarrhea can all indicate that a patient is at risk of malnutrition. Once identified, at risk patients will be referred to a Registered Dietitian for a nutritional assessment and individualized nutrition care plan to improve nutrition status prior to surgery.

Lab Tests for Risk Stratification. The clinician may also check an albumin level to assess complication risk after surgery.[NEW1,2] SCOAP data collected between 2005 and 2011 indicates that there is a two to three fold increase in rates of re-operation and/or death in patients with an albumin level of <3.0 g/dL.  A low albumin level will provide clues to the clinician as to the general health of the patient and guide them to look for potentially modifiable factors such as fluid retention and medication changes. (Albumin is considered an unreliable indicator for determining nutritional status due to the variability caused by factors such as inflammation and edema and should not be used in isolation to determine the nutritional status of a patient. [3-5])

Screening for Use of Supplements. Major surgery can temporarily weaken the immune system making the body more prone to infection. Immune modulating formulas with special ingredients have been shown to help support the immune system, but only supplements with a blend of supplemental arginine, omega 3 fatty acids, and nucleotides have Level 1 evidence (data from randomized clinical trials, meta-analyses, and systematic reviews) showing a significant reduction in infectious complication rates after surgery. [6,7]


1. Hennessey DB, Burke JP, Ni-Dhonochu T, et al. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg. 2010; 252:325–329.
2. Gibbs J, Cull W, Henderson W, et al. National VA Surgical Risk Study. Arch Surg. 1999;134:36–42
3. Banh, Le. Serum Protein as markers of nutrition. What are we treating? “Practical Gastroenterology”. October 2006, Series #43 46-64.
4. Fuhrman MP, Charney P, Mueller CM. Hepatic proteins and nutrition assessment. J Am Diet Assoc 2004; 104: 1258-1264.
5. Mueller C, Compher C, Ellen D; and the A.S.P.E.N. Clinical Guidelines: Nutrition Screening, assessment, and intervention in adults. JPEN Volume 35, No 1 Jan 2011 16-24.
6. Drover JW, Dhaliwal R, Weitzel L, et al. Perioperative use of arginine-supplemented diets: a systemic review of the evidence. JACS 2011; 212(3):385-399.
7. Marimuthu K, Varadhan KK, Ljungqvist O, and Lobo DN. A meta-analysis of the effect of combinations of immune modulating nutrients on outcome in patients undergoing major open gastrointestinal surgery. Ann Surg 2012; 255:1060-1068.