Introduction so my name is Paul wishm and I am a professor of anesthesiology and surgery at the Duke University School of Medicine and I work here as the associate Vice chair of clinical research for anesthesiology I'm the director of The Nutrition Therapy team and the parental nutrition team here at Duke for the hospital and I'm the director and founder of the Duke clinical nutrition online Fellowship um Fellowship we use to train Physicians and other providers all over the world in in clinical nutrition to get to the question of where we stand right now with the role that nutrition plays in preparation and Recovery is is it it's a role that's far underutilized and I I think the critical reason for that is is Physicians are not taught nutrition in medical school s 95% Why is clinical nutrition underutilized of our medical schools have no clinical nutrition training required at all and so our physicians and our healthc care providers aren't taught the critical role of nutrition in the preparation and recovery and health in general of their patients and when you survey new Physicians somewhere between 10 and 15% of them as all will say they have any ability to discuss nutrition with their patients so that means about 90% of our physicians feel no confidence in their ability to talk about nutrition with their patients must lets give them the best routes by which they can optimize their nutrition care or even take basic nutrition care of themselves when they're not sick much less when they are and so I think we have an enormous deficit in nutrition teaching and knowledge um in our physicians that exist but it that creates an enormous opportunity because the research is robust for the incredible benefit and role nutrition can play in recovery and in preparation for illness and surgery and so I think it provides a unique opportunity for a very lowcost very safe intervention that we can teach our physician colleagues and teach our healthc care provider colleagues to employ um and is not being utilized almost at all now and so I think it creates a huge opportunity especially for Unique Products like what men makes to really now have a high quality product that is evidence-based science-based and has extensive clinical research trials behind it to give Physicians the tools to meet the nutrition needs of our patients who are preparing and recovering from surgery and other illness the populations we're seeing now clearly are changing in the people we see coming to surgery so the the population of patients coming to surgery is clearly a different population in the last 10 or so years especially last five or so years where now I would say a majority of the patients coming for major operative procedures are obese and many many of them perhaps even a majority at times also have significant coexisting medical conditions or complicating medical conditions like diabetes um like other metabolic diseases uh the Obesity plus the diabetic patient is is a particular Challenge and then those patients although they look well-nourished because they're perhaps overweight or people would say well they've had too many calories they've been taking in the challenges the important parts of their body mass that helps people really recover and prepare for surgery is their muscle mass and so while they may look well-nourished they are actually by definition malnourished because their muscle mass is very low and the patients are sarcopenic and so you know we we classically know who the malar patients are the very thin CTIC looking wasted patient who's lost a lot of weight those patients we know perhaps we need to intervene with nutrition on but I I would say probably more than half to two-thirds of the patients coming for major operations are obese patients who are actually probably just as much at risk because they have the same low muscle mass and sarcopenia problems that our very thin patients have that are obviously malnourished and again your muscle mass is your body's metabolic Reserve kind of your armor that you have that allows you to recover and and sustain yourself when you undergo a major injury like a surgery and and that's true whether you know a tiger bites you a car hits you or the surgeon hits you um your body has really one way to respond to that and that is by breaking down muscle to mobilize amino acids and glucose to run away from the tiger run away from the surgeon and fuel your immune system to prevent infection and and to allow you to recover not just healthwise but functional wise so that you can walk down the street with the people you love and hold your children and grandchildren again um all that is really dependent on the amount of muscle that you enter a surgical event with and and our obese patients we believe and our data would show are just as challenged as our thin patients and perhaps even more in some cases because of the other concom illes like diabetes they often have which creates other organ dysfunction say in the kidneys or in the blood vessels or in other areas and so our populations have changed and I feel like the majority of patients coming for surgery are at very high nutrition risk and would benefit enormously from very straightforward nutrition optimizations like the new interventions that that I was honored to work with you at men together to build using the science that exists Evidence for clinical nutrition in surgery I think it's exciting to say that there is a robust amount a large amount of evidence for the role of nutrition in preparing patients for surgery uh and and other illnesses but in particular surgical interventions and and I think this goes back now many years and many thousands of patients studied we have large metaanalyses showing the benefit of of nutrition on surgical interventions and I think a few key facts from the from the evidence are really important for anyone who cares for surgical patients to know and the the first is for instance two out of every three patients coming for colar rectal or major GI surgery are malnourished and so we already have robust evidence that in some of our most common surgical types like GI and abdominal surgery there is an enormous number of people two out of every three already are malnourished and that probably doesn't include the obese patients with low muscle mass who were also malnourished and so a majority of our patient are coming not at all ready for surgery and the the most important thing that predicts is we know that patients who have surgical interventions who are malnourished will die five times more often than patients who are well- nourished who have had their nutrition addressed again you're five times more likely to die from an operation if you have that operation and you haven't had your nutrition needs addressed and you're three times more likely to have a complication and I and I always say to both my patients and my surgical colleagues I think if more of our patients knew that none of them would want to go to surgery without having the nutrition optimized and and I don't know any surgeon who would want to operate on someone with a five-fold increased risk of dying when the thing that they're having that risk from could be treated in one to two weeks in many cases and we could significantly modify and reduce that risk with just a few weeks of intervention and when we survey surgeons they all tell us that more than 80% of them tell us they believe clearly nutrition would clearly improve the outcomes of their patients if it could be optimized for all of their patients but when we survey the large say cancer and and GI surgery Fellowship training programs the big academic in the US that are supposed to be the best at the Forefront of practice only one out of five of those major universities even have any nutrition screening programs at all for their patients coming for these major operations with this major risk if nutrition treatment isn't given and if Mal nutrition isn't treated so even though the surgeons believe it no one's seeing it and and what what is even more amazing perhaps is they could save a lot of money if they did it we know that every dollar that has spent on these oral nutrition drinks or or the nutrition kinds of interventions like the kind that men has developed we've developed together with men for every dollar you spend in those you save $52 on Hospital costs and that's from a multi-million patient study that was published and so the saddest part of it all is of all the patients that come with malnutrition for these major operations only one in five less than 20% are getting these simple straightforward interventions that a are inexpensive and B are highly effective and how effective are they well we know for instance that if you treat a patient coming for a major GI surgery with a formula that contains some Arginine in particular and perhaps some fish oil in addition along with some other protein content you can reduce the risk of infection by 40% with just five days of treatment before the operation five days not five weeks not five months five days 40% reduction and this is in thousands of patients studied these stud are in good journals U they're in a wide group of patients and this effect this benefit actually doesn't depend on the patient being malnourished this data is the same whether the patient's well-nourished or malnourished so our bodies have evolved a mechanism by which when we get injured whether it's a tiger that bites us or a surgeon that hits us about three days after that surgery or that trauma our immune cells begin to deplete Arginine and our spleen and lift nodes to keep our own immune system from attacking us and possibly injuring us further but that's of course from many many years ago where if you didn't get up off the ground and start eating again after three days after the tiger bit you you didn't live well now of course after 3 days we we don't want your body to shut down your immune system and we obviously want you to live more than 3 days and so by giving back Arginine we can prevent this Arginine depleting effect that all of us as humans have and improve immune response to infection and prevent infections dramatically like I said by 40% with this simple intervention and so just by giving Arginine for five days before or if let's say it's a surgery we don't have a lot of time to repair for like an emergent surgery you can give the Arginine and fish oil after the surgery and get the same benefit so it works if you give it before before and after or just after and so that's why this is one of the essential components of the men's repair and recover product that we wanted to be sure was in the right amounts that have been studied that could easily be administered and utilized by surgeons and patients to optimize their recovery so I think that's one example of a simple nutrition intervention that any patient having major surgery whether I was having it whether you were having it or your grandma was having it or your son was having it or daughter anyone and everyone that's been studied well-nourished or not benefits this is not a malnutrition related effect so all patients having major surgery should undergo it I would never let anyone in my family have surgery without taking this and when I have surgery and I've had many of them I always take these Arginine containing um interventions before and so I think that's one piece of this new men formula that I think is crucial that has a great deal of evidence and really should be standard of care and and needs to be education Ally promoted more to our surgery and and to our patients as well so they know what to ask for so I think what makes What makes Mend unique repair and recover a unique and exciting formula that I think our patients and our our caregiving process desperately needed was that it's the first formul that really incorporates a range of the new science and evidence for the nutritional intervention ions that most benefit the preparation and recovery of our patients both in how we prevent infection using Arginine and fish oil and how we correct vitamin D which has been shown to reduce complications if patients have low vitamin D coming into surgery their complication risk is much higher and so I think we're all beginning to believe that it's essential to replete vitamin D and our surgical patients to the recovery components or Key nutrients for Mend the pre op optimization components that we believe increase muscle mass which we think is our key metabolic reserve for surgery and allow for us to recover from the operation so we can walk again so we can do the activities we want to do and live the life we want to lead and that's where key nutrients like creatine creatine is one of the most widely and best studied of all the legal therapeutic nutrients you can take um 90% of high school athletes take it it's been studied and sh safe when given for years to patients and people uh it doesn't have any adverse effects on the kidney or any other organ and we know it increases strength and increases the ability of muscle to do what our patients want to do like get up out of a chair walk down the street walk up the stairs creatine improves the ability of people's muscles to do those basic activities as well as build strength in athletes and so it does the things we want our patients to be able to do there also seems to be some evidence that may have some benefits for the brain on cognition and more research is being done there but there's a wide variety of effects on many organs where creatine may have benefit but I think in particular for the surgical patient improving muscle mass before surgery which we know improves outcomes and recovering muscle strength and mass and function after surgery which is always our goal for our patients to recover and then the other nutrient that's really crucial here is hmbb or hydroxy methylate which is another nutrient that is critical to muscle building and Muscle Recovery it's an mtor Agonist that stimulates muscle to grow there is a growing and large body of evidence for its benefits in the elderly and in young athletes as well but especially in the elderly improving their recovery say from hip fracture improving their recovery from orthopedic surgery um improving the ability to heal wounds and be able to walk distances after injuries like hip fractures it's been studied in many different Surgical subtypes and had multiple studies that show benefit and I think one of the most exciting studies was a study that showed that hmbb has a big effect on the muscle we lose from bed rest so for instance if I lay a 21y old down in a bed for 28 days they won't be able to walk um they will lose so much muscle mass and NASA did those experiments with astronauts but if I take a 70-year-old and I lay them down in bed for just 10 days they'll lose as much three times more muscle mass than the 21y old that laid down for 28 days and if I take a 70-year-old and I lay them down for three days they'll lose as much muscle mass when they're sick as the 7-year-old did in 10 days when they're well so just three days in a bed for a 70-year-old who has an illness or an injury is a massive insult to their muscle and we've thought up until now there was no way to prevent that well a really excellent study from Mick deuts who's the editorinchief of clinical nutrition one of the most respected muscle physiology researchers with nutrition in the world he showed you could virtually entirely reverse or prevent the loss of muscle from bed rest by giving hmbb to elderly people who were laid in bed and so that is enormously exciting for the potential of this nutrient being added to this formula because again when someone has a major operation Orthopedic operation or say Falls and fractures their hip or fractures some ribs one of the major insults that leads to in their life is the muscle loss they experience not just from the injury but from laying in bed and not being mobile and when we're 70 years old those this three to five to seven days in bed can lead to muscle loss that will never be recoverable and lead to the patient getting pneumonia or blood clots that will take their life hip fractures and other injuries and Falls are major cause of morbidity and death in elderly people it's a common way sadly that so many of our elderly patients and elderly family members ultimately meet the end of their life and it doesn't have to be that way interventions like hmbb can prevent that muscle loss and allow that elderly person or our grandmothers or our grandfathers or our our our friends who as they age it allowed them to stay strong enough to get back out of bed to do Rehabilitation to get their lives back and continue to have a meaningful life and so I think what is truly unique about repair and recover is it takes all of these nutrients that for years after years now we've had exciting evidence that they change the outcome both in the short term and the long term for our surgical patients and they've been put into one simpl to use formula that anybody can use that is made of the highest quality ingredients I think one of the things that really impressed me and really motivated me to want to collaborate and consult with men to build these formulas is these are the same nutrients that I take every day of my life and again I've had 27 surgeries so I could have surgery tomorrow I'm always at risk of going to the operating room and when I looked at what you had in mind at M and I thought what are the things I take every day that I have to have 12 or 15 pill bottles and powder bottles in my house to take this was an exciting chance to put all those into one thing so that the person off the street could say where can I get all the things that have the science to help me recover best from surgery or help me prepare best for surgery and where can I get it all in one place I've spent a lifetime learning how to take all these different things I take every day and then I encourage my patients to take now you can get it all in one place in a trusted set of ingredients that has the science and we know will change the outcomes of our patients and have had the science for that for many years and now you can get get it all in one place so I think another key opportunity Carloading before surgery we have to improve the outcome of patients having operations having surgeries is the role of car load the car loading before the operation and so we have robust evidence that if you give about 50 grams of moltex and a complex carbohydrate 2 hours before the operation as a clear liquid you can reduce rce complications and length of stay significantly in fact you can reduce the length of stay of a patient having a major abdominal operation by one and a half days again these are little drinks or little little little drinks that cost a few dollars that could save days in the hospital and thousands of dollars in costs to the hospital and to the patient and so just on that alone this is enormous effect but it has to be done correctly so all the studies that have been done to this point have used a certain amount of a complex carbohydrate called melto dextran existing in the right concentration and the right osmolarity um to be safe for someone to take two hours before surgery our anesthesia guidelines I'm an anesthesiologist by training say that you can take clear liquids up to two hours before surgery safely and so we often hear people concerned about the carblow saying we don't want our patients drinking something 2 hours before surgery but our guidelines that have existed since before I was a resident so more than 20 years now say it is entirely safe and reasonable to take a clear liquid up to two hours before an operation without worrying about aspiration when you send people off to sleep and induce them and have to put a breathing tube in and so I think that's the first hurdle that we've had is I think anesthesiologists and surgeons have said oh I don't know about giving patients things to drink like that two hours before surgery but our guidelines have always said that was safe so that is not an issue and that should never be thought of as an issue but I think what is critical is this has to be done correctly and unfortunately what's happened with this new literature showing these exciting benefits that that go beyond actually just the length of stay people who take these carb loads also have less nausey and vomiting after surgery less thirst less pain they feel better they eat sooner they go home sooner there's lots of benefits to this but what's happened unfortunately is people have said well why don't we just give them any kind of carbohydrate sugar containing drink before surgery why don't we give them Gatorade or a sports drink or orange juice and wouldn't that be the same well it's not the same a they haven't been studied and so we don't know if they benefit the patient because the key of the maltodextrin is it was formulated that way because it induces reductions and insulin resistance when given that precise way and we don't have any evidence that the other carbohydrate loading Solutions have that same benefit or have any benefit the other problems with the simple sugars of Gatorade and orange juice and other sports drinks is is they don't empty the stomach the same way and they could increase the risk of aspiration right all the research has been done with a complex carbohydrate malod dextran and all the research it shows it's safe to do the patients don't aspirate and they have better outcomes have been done with only that specific carbohydrate mixture if your patient or a patient was to aspirate and have a comp ation because they had Gatorade or orange juice you couldn't really defend yourself because there's no evidence to say it's safe we know that simple sugars and the osmolarity of those drinks is not the same and don't enter the stomach perhaps as successfully or as efficiently and and why would you use something that is's no evidence for and could create risk I think the other key feature that needs to go into doing these correctly is these drinks need to be taken over about 5 to 10 minutes they need to be taken in quickly and so we have to instruct our patients to do that they can't be sipped over hours and then I think the other thing that has kind of begun to permeate into some of the commercially available Carlo drinks is people have thought it was a good idea to add amino acids like argine or citrine or some of the other amino acids that may benefit surgical patients in other settings the problem is we know amino acids especially things like Arginine and citruline that generate nitric oxide can delay gastric emptying and so they can slow the stomach empty they could potentially lead to increased risk of aspiration and complications for the patient so again none of us that have studied this literature for a long time or does research in this area which suggests using drinks that also contain amino acids as a attractive an idea that may have been and so I think what's important and unique about carb ready is it uses the carbohydrate content and concentration that exactly mimics the one that has been studied for years to be beneficial and safe and I think that's what's critical anyone who's trained for a marathon knows that you don't into a marathon or a major stress which a marathon is without carbohydrate loading the night before and the morning of and that's how we suggest our patients do it they should take two amounts of the carb load or 100 grams of of the of the sugar the complex carbohydrate the night before surgery before midnight and then one car Lo um carb ready drink the morning of surgery just like someone running a race or a marathon would do again the body doesn't do well it doesn't tolerate stress well when it's fasted immediately before the stress and that's what our fasting guidelines often make our patients do but now we've overcome that through the safe use of these cool liquid carbohydrate loading drinks but it's critical that the right concentration and right content which is what carb ready delivers is what's used because that's the only thing we have evidence for safety and benefit from and I think that's essential and that's why this product is so important it provides patients with exactly what has been studied and what they need in a simple to use formulation