Hip fracture – why muscles really matter

Strategies for healthcare professionals dealing with hip fracture patients

Introduction

Hip fracture is the most common serious injury in older people, the most frequent reason for surgery, and shockingly the most widespread cause of death following an accident. Each year, hip fractures account for one and a half million hospital bed days (with an average length of hospital stay of 20 days) and, at any one time, more than 3,600 hospital beds across the country are used by patients recovering from hip fractures.¹

Only a minority of patients will completely regain their previous physical abilities following a hip fracture. The need for long term care, due to the increased dependency on others, means hip fractures cost health and social services more than £1 billion per year, or the equivalent of one per cent of the annual NHS budget.²

Targeted nutrition for muscle health plays a critical role in preventing hip fractures and improving recovery rates in hip fracture patients. It is therefore vital we understand it and take action.

Why do muscles really matter?

Loss of muscle mass is associated with increased rates of falls and fractures. While muscle loss is an inevitable part of ageing (muscle mass decreases by 8% per decade from the age of 40, and by almost double for individuals over 70)³, people remain worryingly unaware that good nutrition remains key to maintaining muscle health and slowing the rate of muscle loss.³

Further reading: Patient and system specific variables and mortality post hip fracture
Further reading: Imaging and opportunistic identification of fractures
Further reading: Post-operative cognitive dysfunction in fractured neck of femur surgery

Metabolic stress, caused by inflammation, injury and illness can lead to loss of muscle and strength as muscle is used as a major source of energy.⁴ To compound this, inactivity or bed rest can also lead to the loss of muscle, which is more marked in older people compared to their younger peers.⁵

The role of nutrition in prevention

As we age, a higher intake of protein and vitamin D is recommended to maintain healthy muscles. Protein is part of every tissue and plays a major role in building, repairing and maintaining muscle tissue, while vitamin D deficiency is associated with decreased muscle strength in older men and women.⁶Despite this, many adults aged over 65, already at risk of muscle loss, do not meet the Reference Nutrient Intake for protein.⁷

When it comes to vitamin D requirements, the Scientific Advisory Committee on Nutrition recommends all adults over 65 years receive at least 400 IU/day⁸but the majority of our vitamin D comes from exposure to sunlight, which can be an issue for those who are house bound. Despite being limited in food sources, vitamin D is found in oily fish, eggs and fortified foods such as margarines and breakfast cereals.

A daily intake of 400 IU vitamin D from food consists of:

2-3 eggs
1 portion of sardines

Interestingly, research has indicated that higher intakes of 800 – 1000 IU/day may help improve skeletal muscle function, reduce the risk of falls and fractures, and improve mobility.⁹

As shown in the table below, the daily recommended protein requirements increase depending on the person’s state of health.

	Healthy older adults	Older adults with acute/chronic illness	Older adults with severe disease or malnutrition
Recommended protein intake (g/kg/day)¹⁰	1.0 – 1.2	1.2 – 1.5	Up to 2.0

For a 60kg individual with a chronic illness, the recommended intake is 90g of protein a day which is equivalent to a daily intake of all of the following:

1 pint of milk
4 eggs
2 yoghurts
1 portion of salmon

When it comes to patients with hip fractures, studies find that 90% have insufficient vitamin D levels¹¹and 80% have protein malnutrition.¹²And yet, according to a meta-analysis by Bischoff-Ferrari, taking vitamin D supplements is proven to reduce the risk of hip fractures by 18% in individuals aged over 65.¹³Targeted nutrition in order to preserve muscle health therefore has an important role in preventing hip fractures.

However, it may be difficult for older people to meet their protein and vitamin D requirements when they are ill or undernourished solely through food due to higher requirements, poor dietary intake, limited exposure to the sun, or if the care setting is unable to meet requirements through food alone. If this is the case, specialised oral nutritional supplements (ONS) are available to help address the needs of these patients.

The role of nutrition in recovery

Most of us associate muscles with the ability to move and retain balance. However, there is limited awareness that healthy muscles are essential for physical strength, organ function, skin integrity, immunity and wound healing. Good muscle health therefore also has an important role in helping patients recover from hip fracture surgery.

Studies looking at the effects of high protein supplements given to patients have shown:

a 30% reduction in hospital readmissions
a decrease in complications such as infections
an improvement in weight and hand grip strength⁷

Further research looking specifically at the effects of oral nutritional supplement in patients undergoing surgery for hip fractures has found that those undernourished patients receiving specialised ONS high in protein, additional vitamin D and HMB*:

are three times more likely to be mobile after surgery
enjoy better muscle strength (they are over 34% stronger than those who do not take supplements)
see the duration of their wound healing decrease by more than 8%.¹⁴

Strategies for healthcare professionals dealing with hip fracture patients

Conduct nutritional screening on a regular basis using the Malnutrition Universal Screening Tool (‘MUST’) or other locally validated tools
Address any nutritional deficits by offering nutritional support tailored to the individual, which could include offering foods rich in protein and vitamin D, food fortification and specialised oral nutritional supplements^15-17
Measure and monitor changes in muscle function. For example, hand grip strength can be measured using a dynamometer. Grip strength values of <27kg in men and <16kg in women indicate low strength¹⁸
Ensure any care plans initiated in hospital are continued across healthcare settings to achieve maximum benefit

Hip fracture and subsequent surgery have a major impact on the body and patients need attentive support and aftercare to get back to their previous physical abilities. There are steps people can take to help alleviate the pressures placed on their hips as they age, and steps they can take post-surgery to spearhead their recovery. The right nutrition is one element in this arsenal; it’s an important part that is too often overlooked.

*HMB or ꞵ-hydroxy ꞵ-methylbutyrate is a metabolite of leucine. HMB has been shown to have anti-catabolic properties and contribute to the preservation of muscle through increased protein synthesis and decreased protein degradation.^16-18

References

Royal College of Physicians, 2018: https://www.nhfd.co.uk/files/2018ReportFiles/NHFD-2018-Annual-Report-v101.pdf Accessed 24th September 2019.
Leal J et al. Osteoporos International 2016;27:549€“558.
Flakoll P et al. Nutrition 2004;20(5):445-451.
Argiles J et al. JAMDA 2016; 17:789-796.
Paddon-Jones D. 110^th Abbott Research Conference, 2009
Dawson-Hughes B, et al. Osteoporosis Int, 2010;21:1151-1154.
Cawood A L et al. Ageing Res Rev 2012;11(2):278€“296.
Scientific Advisory Committee on Nutrition, 2016: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/537616/SACN_Vitamin_D_and_Health_report.pdf. Accessed 20th September 2019.
European Food Safety Authority, EFSA Journal 2011;9(9):1-18.
Volkert D et al. Clinical Nutrition. DOI 10.1016/j.clnu.2018.05.024 Published on-line May 2018.
Bryson DJ et al. Acta Orthop Belg 2013;79(4):470€“473.
Diaz de Bustamante M et al. Eur J Clin Nutr DOI:10.1038/ejcn.2017.72 Published May 2017
Bischoff-Ferrari HA et al. J. Arch Intern Med 2009;169 (6), 551-561.
Ekinci O et al. Nutr Clin Pract 2016;31(6):829-835.
Cruz-Jentoft A et al. Age & Ageing 2019;48(4):16-31.
Wilson GJ et al. Nutr Metab (Lond) 2008;5:1.
Manzano M et al. Presented at 31^st ESPN Congress. 29 August €“ 1 September 2009. Vienne, Austria
Eley H L et al. Am J Physiol Endocrinol Metab 2008;295(6):E1417-1426.