Here’s a topic that is seldom discussed with a patient and the family after a hip fracture: nutrition. The fact is that what we eat has an enormous effect on how well we recover from major illnesses, and hip fractures are no exception. The elderly have pretty poor appetites to begin with, and their dietary intake is such that in England they are frequently referred to as “tea and toasters”, meaning that all they eat and drink is the occasional slice of toast and a cup of tea. Fracture healing requires a large number of calories, there is a lot of protein synthesis that needs to take place, and after the fracture, an already anemic patient is often even more so. Also, we know that the elderly tend to have chronically low Vitamin D levels and this has a negative effect on bone health and vitality. To make matters even worse, the narcotic pain medications that are given to help with post-operative pain decrease appetite, cause constipation as a side effect, and make it even harder to get the patient properly nourished. The picture below shows a common sight on morning rounds. Post-operative day #2, and the patient is sound asleep with an untouched breakfast tray at their bedside. The patient doesn’t have much of an appetite and a box of cereal isn’t terribly nutritious either.
Here are some simple recommendations:
1. Vitamin D supplementation. I try to get everyone on 5,000 IU of vitamin D3 a day for 6 months after a hip fracture. If the patient has already been taking Vitamin D supplements then I will check their Vitamin D level with a blood test. If they haven’t already been on large doses of D3, I’ve never seen someone with a hip fracture who wouldn’t benefit from an increase in their Vitamin D3 level. Costco sells Vitamin D3 relatively cheaply; recently they had a bottle of D3 in soft gel caps with 5,000 IU per dose for $8.99 for 500 tablets.
2. Calcium tablets. From what I have read in the medical literature, there is already plenty of calcium in the normal diet of someone who lives in the United States. Most Americans already consume more than 2,000 mg of calcium a day so I don’t think that calcium supplementation is that necessary. I do think that a healthy Vitamin D3 level — above 50 micrograms per milliliter — will help get the calcium out of the diet and into the bones.
3. Protein shakes. I like the Odwalla Chocolate Protein Monster drink. It tastes a lot better than a medical protein shake and it has 18g of protein per bottle and the protein comes from soy, which is presumably a healthy place to get your protein. Most of the ingredients look organic enough and it tastes pretty good. I drink these drinks after exercise myself. When I’ve suggested to families that they make sure that the patient gets one or two of these per day, they seem to be popular, well tolerated, and easy to find.
4. Sunshine. The elderly do not get enough! There is a lot of medical literature from northern European countries like Norway and Finland that suggest that sun exposure can improve the chances of a good recovery after a hip fracture. These countries have a lot of elderly patients, they have short days and cold climates during the winter, and their studies show that getting 30 minutes of sunshine a day is extremely beneficial. The skin on the face and the hands loses its ability to synthesize Vitamin D after the age of about 40, so if possible, I like patients to get some sun exposure on the parts of their body that don’t normally see the sun — like the abdomen, low back, tops of the thighs, etc. The theory is that 30 minutes of sunshine on these parts results in an increase in Vitamin D of about 50,000 units.
5. Balanced Diet of Fresh Food. I’m lucky enough to live in coastal California where there is a farmer’s market with fresh organic produce on nearly every corner. There is no doubt in my mind that patients that eat a balanced diet with fresh vegetables, fish and meat for protein, and nuts and protein shakes for snacks, bounce back much faster than someone who is stuck eating institutional food at a care center. The most common complaint that I hear from families is that even if they take good food and snacks when they visit, its hard to get the patient to eat them. I think the culprit is usually the pain medication. If pain medication is minimized to the point where the patient is taking just what is needed to keep them comfortable, they tend to have a better appetite, better bowel function, and its easier to get quality nutrition in!