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Summary Background Preoperative starvation results in the development of insulin resistance. Measures to attenuate the development of insulin resistance, such as preoperative carbohydrate loading, lead to clinical benefits. However, the mechanisms that underlie the development of insulin resistance during starvation and its attenuation by preoperative carbohydrate loading remain to be defined. Insulin resistance associated with type 2 diabetes and ageing has been linked to mitochondrial dysfunction. The metabolic consequences of preoperative starvation and carbohydrate loading and mechanisms linking insulin resistance to impaired mitochondrial function are discussed. Methods Searches of the Medline and Science Citation Index databases were performed using various key words in combinations with the Boolean operators AND, OR and NOT. Key journals, nutrition and metabolism textbooks and the reference lists of key articles were also hand searched. Results Animal studies have shown that short-term energy deprivation decreases mitochondrial ATP synthesis capacity and complex activity, and increases oxidative injury. Furthermore, evidence from human studies suggests that the development of insulin resistance during starvation may be linked to impaired mitochondrial function. Conclusions There is evidence from animal studies that short-term starvation causes mitochondrial dysfunction. Future studies should investigate whether mitochondrial dysfunction underlies the development of insulin resistance in patients undergoing elective surgery.

Surgery elicits a series of metabolic stress reactions. Stress hormones and inflammatory mediators (i. e. cytokines) cause catabolism of glycogen, lipids and proteins. Glucose, free fatty acids, and amino acids are released for the tasks of healing and immune response. Thus, substrates are diverted from normal purposes such as physical activity. However, the patient requires anabolic metabolism to reach optimal recovery. Many stress-reducing measures have proven to minimize catabolism and support anabolism, and have led to faster and better rehabilitation, even after major surgical trauma. The so-called „Enhanced Recovery After Surgery” (ERAS) concepts focus on better preoperative preparation, anaesthesia, analgesia, and early mobilisation as well as improved supplies of nutritional substrates. This includes generally reduced preoperative fasting, preoperative carbohydrate loading, no interruption of oral nutritional intake after surgery, if possible, and a perioperative consumption of oral nutritional supplements. Studies have shown that such nutritional practices contribute to perioperative stabilisation of the organism by reducing postoperative insulin resistance, minimising protein catabolism, decreasing oxidative stress, and improving various organ functions. Further consequences are improved perioperative condition, attenuated depletion of muscle mass, reduction of postoperative complications, and reduced intensive care unit and hospital stays.

We studied the effect of three different fasting protocols on preoperative discomfort and glucose and insulin levels.Two hundred and ten ASA I-III patients undergoing general or gastrointestinal surgery were randomly assigned to three groups: overnight intravenous 5% glucose infusion (1000 ml), carbohydrate-rich drink (400 ml) at 6-7 a.m., or overnight fasting. The subjective feelings of thirst, hunger, mouth dryness, weakness, tiredness, anxiety, headache and pain of each patient were questioned preoperatively using a visual analogue scale. Serum glucose and insulin levels were measured at predetermined time points preoperatively.During the waiting period before surgery, the carbohydrate-rich drink group was less hungry than the fasting group (P = 0.011). No other differences were seen in visual analogue scale scores among the study groups. Trend analysis showed increasing thirst, mouth dryness and anxiety in the intravenous glucose group (P0.05). The carbohydrate-rich drink group experienced decreasing thirst but increasing hunger and mouth dryness (P0.05). In the fasting group, thirst, hunger, mouth dryness, weakness, tiredness and anxiety increased (P0.05). Both intravenous and oral carbohydrate caused a significant increase in glucose and insulin levels.Intravenous glucose infusion does not decrease the sense of thirst and hunger as effectively as a carbohydrate-rich drink but does alleviate the feelings of weakness and tiredness compared with fasting.

Objective : To evaluate the evidence for dietary recommendations in older adult athletes. Design : Interpretive review of the literature. Results : Regarding resistance training, a protein intake of slightly more than 0.8 g/kg/d is required to optimize gains in muscle strength. The early provision of protein and carbohydrate following a weight training session can enhance resultant strength and fat-free mass gains. Supplementation with creatine monohydrate (approximately 5 g/d) can potentiate some of the gains in strength and fat free mass attained through resistance exercise training. Regarding endurance exercise training, there are no studies evaluating carbohydrate loading, during-event, or postexercise carbohydrate/nutritional replacement in older adults. Conclusions : The amount and timing of dietary protein is important to maximize strength and gains in fat-free mass during resistance exercise training. Creatine monohydrate supplementation can potentiate some of these gains during the first 4 to 6 months of training. Older adults should consume adequate carbohydrates during endurance training (6-8 g/kg/d) and may benefit from the provision of carbohydrate and protein in the early recovery phase following endurance exercise to maximize glycogen re-synthesis for a subsequent exercise bout. There is no scientific reason to assume that older athletes will respond differently to the pre- and during-race fluid and carbohydrate replacement strategies suggested for younger athletes. The consensus guidelines outlined by the American College of Sports Medicine should therefore be followed for all athletes, regardless of their age.

It has been known for decades that low-fat, high-carbohydrate diets can increase plasma triglyceride levels, but the mechanism for this effect has been uncertain. Recently, new isotopic and nonisotopic methods have been used to determine in vivo whether low-fat, high-carbohydrate diets increase triglyceride levels by stimulating fatty acid synthesis. The results of a series of studies in lean and obese weight-stable volunteers showed that very-low-fat (10%), high-carbohydrate diets enriched in simple sugars increased the fraction of newly synthesized fatty acids, along with a proportionate increase in the concentration of plasma triglyceride. Furthermore, the concentration of the saturated fatty acid, palmitate, increased and the concentration of the essential polyunsaturated fatty acid, linoleate, decreased in triglyceride and VLDL triglyceride. The magnitude of the increase in triglyceride varied considerably among subjects, was unrelated to sex, body mass index, or insulin levels, and was higher when fatty acid synthesis was constantly elevated rather than having a diurnal variation. It was notable that minimal stimulation of fatty acid synthesis occurred with higher fat diets (>30%) or with 10% fat diets enriched in complex carbohydrate. Public health recommendations to reduce dietary fat must take into account the distinct effects of different types of carbohydrate that may increase plasma triglycerides and fatty acid synthesis in a highly variable manner. The mediators and health consequences of this dietary effect deserve further study.

Summary Triathlon is a sport consisting of sequential swimming, cycling and running. The main diversity within the sport of triathlon resides in the varying event distances, which creates specific technical, physiological and nutritional considerations for athlete and practitioner alike. The purpose of this article is to review physiological as well as nutritional aspects of triathlon and to make recommendations on ways to enhance performance. Aside from progressive conditioning and training, areas that have shown potential to improve triathlon performance include drafting when possible during both the swim and cycle phase, wearing a wetsuit, and selecting a lower cadence (60–80 rpm) in the final stages of the cycle phase. Adoption of a more even racing pace during cycling may optimise cycling performance and induce a “metabolic reserve” necessary for elevated running performance in longer distance triathlon events. In contrast, drafting in swimming and cycling may result a better tactical approach to increase overall performance in elite Olympic distance triathlons. Daily energy intake should be modified to reflect daily training demands to assist triathletes in achieving body weight and body composition targets. Carbohydrate loading strategies and within exercise carbohydrate intake should reflect the specific requirements of the triathlon event contested. Development of an individualised fluid plan based on previous fluid balance observations may assist to avoid both dehydration and hyponatremia during prolonged triathlon racing.

Background: Post-operative insulin resistance and hyperglycaemia are associated with an impaired outcome after surgery. Pre-operative oral carbohydrate loading (CHO) reduces post-operative insulin resistance with a reduced risk of hyperglycaemia during post-operative nutrition. Insulin-resistant diabetic patients have not been given CHO because the effects on pre-operative glycaemia and gastric emptying are unknown.Methods: Twenty-five patients (45-73 years) with type 2 diabetes [glycated haemoglobin (HbA1c) 6.2 +/- 0.2%, mean +/- SEM] and 10 healthy control subjects (45-72 years) were studied. A carbohydrate-rich drink (400 ml, 12.5%) was given with paracetamol 1.5 g for determination of gastric emptying.Results: Peak glucose was higher in diabetic patients than in healthy subjects (13.4 +/- 0.5 vs. 7.6 +/- 0.5 mM; P

Marathon runners can uniquely benefit from nutritional strategies that support their training responses and/or maximize their performance during the actual race. Promising strategies during marathon training include the adequate provision of dietary energy, macronutrients (carbohydrates, protein), and selected micronutrients (e.g., iron) to meet the increased requirements of prolonged distance running. Nutritional and training approaches aimed at increasing fat oxidation rates or facilitating weight loss may be associated with negative effects and should therefore be conducted with care. During the actual marathon race, runners can benefit from carbohydrate loading strategies that serve to maximize pre-race muscle glycogen storage capacity. Consumption of carbohydrates, fluid, and sodium can prevent preemptive fatigue due to nutrient depletion, and caffeine supplementation can provide ergogenic effects during prolonged running. Because the responses to these nutritional interventions can vary substantially among individuals and require fine tuning depending on factors such as performance level, environmental conditions, designated running pace, propensity for gastrointestinal discomfort, and availability of aid stations during the race, marathon runners are highly encouraged to familiarize themselves with these strategies prior to utilizing them in a competitive setting.

We read with interest the study by Rouillier et al. [1,] which reported that a carbohydrate (CHO)-loading strategy (3 days of high intake of CHO) in physically active men was associated with an increase in DXA estimates of lean body mass (LBM), thus confounding the ability of DXA to measure true changes in LBM (muscle mass) that might be of interest to an athlete. It is an intuitive hypothesis that increases in muscle glycogen and associated water might be considered within LBM estimates and thus represents an artefact of true changes in body composition. Indeed, we have recently conducted a study in which we manipulated the muscle content of creatine, glycogen and water in various combinations and found substantial changes in DXA estimates of LBM [2]. However, we would like to comment on the apparent issues (or lack of information) in the current investigation that preclude its ability to truly confirm that CHO loading is responsible for the observed changes in DXA estimates of LBM. First, although the dietary treatment was likely to be associated with increased muscle glycogen stores, this was not independently verified. More importantly, however, it appears from the methodology described in the paper, that the DXA measurements were made under nonstandardized conditions that could themselves create ‘noise' in the LBM estimates. The paper states that DXA measurements were undertaken on 2 occasions, with the first measurement being undertaken ‘just before the start of the diet on day 1' and the second ‘after the diet on day 3'. From this we conclude that some measurements were made in the morning, while others were made later in the day. Our group has undertaken a series of studies on the reliability of DXA estimates of body composition in athletes, and has shown that there are substantial changes in estimates of body composition over the course of the day, with changes in LBM of similar magnitude to that seen in this study [3,4]. These changes are associated with the intake of food and fluid, as well as body fluid shifts, which occur during exercise [3,4]. We have proposed that standardized conditions, with subjects having fasted and rested overnight, and positioned on the scanning bed in an identical protocol with use of positioning aids, be undertaken to minimise the errors of measurement [5,6]. It is uncertain from the description provided in the current paper that these protocols were followed. We not only encourage researchers and practitioners to follow best practice protocols for the use of DXA to undertake body composition measurements, but to state clearly that such protocols have been followed when reporting such research. This will help to promote confidence in the findings of their specific investigation as well as to promote the importance of these protocols in general athletic practice and scientific research.

Middle-distance athletes implement a dynamic continuum in training volume, duration, and intensity that utilizes all energy-producing pathways and muscle fibre types. At the centre of this periodized training regimen should be a periodized nutritional approach that takes into account acute and seasonal nutritional needs induced by specific training and competition loads. The majority of a middle-distance athlete's training and racing is dependant upon carbohydrate-derived energy provision. Thus, to support this training and racing intensity, a high carbohydrate intake should be targeted. The required energy expenditure throughout each training phase varies significantly, and thus the total energy intake should also vary accordingly to better maintain an ideal body composition. Optimizing acute recovery is highly dependant upon the immediate consumption of carbohydrate to maximize glycogen resynthesis rates. To optimize longer-term recovery, protein in conjunction with carbohydrate should be consumed. Supplementation of beta-alanine or sodium bicarbonate has been shown to augment intra- and extracellular buffering capacities, which may lead to a small performance increase. Future studies should aim to alter specific exercise (resistance vs. endurance) and/or nutrition stimuli and measure downstream effects at multiple levels that include gene and molecular signalling pathways, leading to muscle protein synthesis, that result in optimized phenotypic adaptation and performance.

Throwers, jumpers, and combined events athletes require speed, strength, power, and a wide variety of technical skills to be successful in their events. Only a handful of studies have assessed the nutritional needs of such athletes. Because of this, recommendations for nutritional requirements to support and enhance training and competition performances for these athletes are made using research findings from sports and exercise protocols similar to their training and competitive events. The goals of the preparation cycle of nutrition periodization for these athletes include attaining desirable body weight, a high ratio of lean body mass to body height, and improving muscular power. Nutritional recommendations for training and competition periods include: (1) meeting energy needs; (2) timing consumption of adequate fluid and electrolyte intakes before, during, and after exercise to promote adequate hydration; (3) timing consumption of carbohydrate intake to provide adequate fuel for energy demands and to spare protein for muscle repair, growth, and maintenance; (4) timing consumption of adequate protein intake to meet protein synthesis and turnover needs; and (5) consuming effective nutritional and dietary supplements. Translating these nutrient and dietary recommendations into guidelines these athletes can apply during training and competition is important for enhancing performance.

The present study was undertaken to study the impact of nutrition education and carbohydrate supplementation on performance of high school kabaddi players of Dharwad, Karnataka. Players were divided in to two groups as control and experimental. Both the groups were assessed for physical measurements, physical performance, nutrient intake and nutrition knowledge, practice before the intervention. Experimental group received nutrition education for 12 contact hours. Later they were supplemented with carbohydrate rich snack (Carbohydrate –72gm) three days before the final match. On the day of competition experimental group received a carbohydrate (6.75%)electrolyte beverage before, during and after the competition. Physical performance was evaluated using AAHPERD physical fitness test. Real match was arranged between control and experimental group to evaluate the field performance. The findings of impact of nutrition education revealed that overall nutrition knowledge level increased significantly by 35% where as practice was improved only 13%. The knowledge improvement was better than practice. Carbohydrate intake after the nutrition education was 70%. This was further improved due to carbohydrate supplementation to 73%, which was significantly more than control group. The physical performance results revealed significant improvement in the selected fitness tests like strength by 12 cm, agility by 1.5 sec, endurance by 432 mts. There was significant improvement in the game performance as evaluated by coaches in experimental group (7.6) and in control group (4.2) and experimental group had won the match. Self-evaluation of performance by players showed intervention program was useful for their sports performance.

This study compared 3 d of carbohydrate loading (CHOL; 8.4 g·kg−1·d−1 carbohydrate) in female eumenorrheic athletes with 3 d of an isoenergetic normal diet (NORM; 5.2 g·kg−1·d−1 carbohydrate) and examined the effect of menstrual-cycle phase on performance, muscle-glycogen concentration [glyc], and substrate utilization. Nine moderately trained eumenorrheic women cycled in an intermittent protocol varying in intensity from 45% to 75% VO2max for 75 min, followed by a 16-km time trial at the midfollicular (MF) and midluteal (ML) phases of the menstrual cycle on NORM and CHOL. Time-trial performance was not affected by diet (CHOL 26.10 ± 1.04 min, NORM 26.16 ± 1.35 min; P = 0.494) or menstrual-cycle phase (MF 26.05 ± 1.10 min, ML 26.23 ± 1.33 min; P = 0.370). Resting [glyc] was lowest in the MF phase after NORM (575 ± 145 mmol·kg−1·dw−1), compared with the MF phase after CHOL (728 mmol·kg−1·dw−1) and the ML phase after CHOL and NORM (756 and 771 mmol·kg−1·dw−1, respectively). No effect of phase on substrate utilization during exercise was observed. These data support previous observations of greater resting [glyc] in the ML than the MF phase of the menstrual cycle and suggest that lower glycogen storage in the MF phase can be overcome by carbohydrate loading.

Muscle glycogen provides a key fuel for training and racing a marathon. Carbohydrate 'loading' can enhance marathon performance by allowing the competitor to run at their optimal pace for a longer period before fatiguing. For the well trained runner, this may be achieved by tapering exercise over the final days before the marathon and ensuring carbohydrate intakes of 10-12 g/kg/day over the 36-48 hours prior to the race. Sports nutrition guidelines recommend that the runner consumes sufficient carbohydrate to promote restoration of muscle glycogen between training sessions. This strategy should allow the runner to 'train harder' and recover optimally between workouts. A recent hypothesis suggests that runners might 'train smarter' by training with low glycogen stores, since this might promote greater stimulation of the training response. However, there is no evidence that a low carbohydrate diet enhances the outcomes of training or provides benefits as a depletion phase prior to carbohydrate loading. In fact, a low carbohydrate diet may even impair performance if carried out for extended periods. If there are benefits to manipulating glycogen stores for some workouts, this is likely to happen as the natural outcome of the periodisation of the high-volume programme of an elite runner.

ERAS programs are based on a combination of perioperative measures with a proven efficacy, that combined with each other lead to an enhanced recovery after surgery through a synergistic pathway. Such programs help to decrease postoperative morbidity and to reduce length of hospital stay. Beside immunonutrition, carbohydrate loading until 2 hours before surgery and early postoperative oral feeding are safe and allows enhanced recovery after surgery.

The purpose of this review is to present the basic principles of a healthy nutrition in female endurance runner enriched by the latest scientific recommendations. Female endurance runners are a specific population of athletes who need to take specifically care of daily nutrition due to the high load of training and the necessity to keep a rather low body mass. This paradoxical situation can create some nutritional imbalances and deficiencies. Female endurance athletes should pay attention to their total energy intake, which is often lower than their energy requirement. The minimal energy requirement has been set to 45 kcal/kg fat free mass/day plus the amount of energy needed for physical activity. The usual recommended amount of 1.2–1.4 g protein/kg/day has recently been questioned by new findings suggesting that 1.6 g/kg/day would be more appropriate for female athletes. Although a bit less sensitive to carbohydrate loading than their male counterparts, female athletes can benefit from this nutritional strategy before a race if the amount of carbohydrates reaches 8 g/kg/day and if their daily total energy intake is sufficient. A poor iron status is a common issue in female endurance runners but iron-enriched food as well as iron supplementation may help to counterbalance this poor status. Finally, they should also be aware that they may be at risk for low calcium and vitamin D levels.

Prior to endurance competition, many endurance athletes participate in a carbohydrate loading regimen in order to help delay the onset of fatigue. The "classic" regimen generally includes an intense glycogen depleting training period of approximately two days followed by a glycogen loading period for 3–4 days, ingesting approximately 60–70% of total energy intake as carbohydrates, while the newer method does not consist of an intense glycogen depletion protocol. However, recent evidence has indicated that glycogen loading does not occur in the same manner for males and females, thus affecting performance. The scope of this literature review will include a brief description of the role of estradiol in relation to metabolism and gender differences seen in carbohydrate metabolism and loading.

The beneficial role of carbohydrate (CHO) supplementation in endurance exercise is well documented. However, only few data are available on the effects of CHO loading on resistance exercise performance. Because of the repetitive use of high-threshold motor units, it was hypothesized that the power output (power-endurance) of multiple sets of jump squats would be enhanced following a high-CHO (6.5 g CHO kg body mass(-1)) diet compared to a moderate-CHO (4.4 g CHO kg body mass(-1)) diet. Eight healthy men (mean +/- SD: age 26.3 +/- 2.6 years; weight 73.0 +/- 6.3 kg; body fat 13.4 +/- 5.0%; height 178.2 +/- 6.1 cm) participated in 2 randomly assigned counterbalanced supplementation periods of 4 days after having their free-living habitual diet monitored. The resistance exercise test consisted of 4 sets of 12 repetitions of maximal-effort jump squats using a Plyometric Power System unit and a load of 30% of 1 repetition maximum (1RM). A 2-minute rest period was used between sets. Immediately before and after the exercise test, a blood sample was obtained to determine the serum glucose and blood lactate concentrations. No significant difference in power performance existed between the 2 diets. As expected, there was a significant (p

In this study we examined the pacing strategy and the end muscle glycogen contents in eight cyclists, once when they were carbohydrate loaded and once when they were non-loaded.Cyclists completed 2 hours of cycling at approximately 73% of maximum oxygen consumption, which included five sprints at 100% of peak sustained power output every 20 minutes, followed immediately by a 1 hour time trial. Muscle biopsies were performed before and immediately after exercise, while blood samples were taken during the 2 hour steady state rides and immediately after exercise.Carbohydrate loading improved mean power output during the 1 hour time trial (mean (SEM) 219 (17) v 233 (15) W; p0.05) and enabled subjects to use significantly more muscle glycogen than during the trial following their normal diet. Significantly, the subjects, kept blind to all feedback except for time, started both time trials at similar workloads ( approximately 30 W), but after 1 minute of cycling, the workload average 14 W higher throughout the loaded compared with the non-loaded time trial. There were no differences in subjects' plasma glucose and lactate concentrations and heart rates in the carbohydrate loaded versus the non-loaded trial. Of the eight subjects, seven improved their time trial performance after carbohydrate loading. Finishing muscle glycogen concentrations in these seven subjects were remarkably similar in both trials (18 (3) v 20 (3) mmol/kg w/w), despite significantly different starting values and time trial performances (36.55 (1.47) v 38.14 (1.27) km/h; p0.05). The intra-subject coefficient of variation (CV) for end glycogen content in these seven subjects was 10%, compared with an inter-subject CV of 43%.As seven subjects completed the time trials with the same end exercise muscle glycogen concentrations, diet induced changes in pacing strategies during the time trials in these subjects may have resulted from integrated feedback from the periphery, perhaps from glycogen content in exercising muscles.

The purpose of this study was to examine the effect of carbohydrate (CHO) augmentation on endurance performance and substrate utilization in aerobically trained women. Eight endurance-trained women completed a 24.2-km (15 mile) self-paced treadmill performance run under three conditions: CHO supplementation (S), CHO loading and supplementation (L+S), and placebo (P). Dietary CHO was ∼75% of energy intake for L+S and ∼50% for both S and P. A 6% CHO-electrolyte solution (S and L+S) or placebo (P) was ingested preexercise (6 ml/kg) and every 20 min during exercise (3 ml/kg). Blood glucose was significantly higher at 40, 60, and 100 min during L+S, and at 60, 80, and 100 min during S compared with P ( P < 0.05). Blood lactate was significantly higher ( P < 0.05) during L+S than S and P. Blood glycerol was significantly lower ( P < 0.05) at 20, 80, and 100 min during L+S, and at 80 and 100 min during S than P. The proportion of CHO (%) utilized during exercise was significantly higher ( P < 0.05) during L+S (71.3 ± 3.8%) and S (67.3 ± 4.3%) than P (59.2 ± 4.6%). Performance times ( P > 0.05) were 132.5 ± 6.3 min (S), 134.4 ± 6.3 min (L+S), and 136.6 ± 7.9 min (P). In conclusion, it appears that when CHO availability in women is increased through CHO loading and/or CHO supplementation, there is a concomitant increase in CHO utilization. However, this may not necessarily result in significantly improved performance.

Vastus lateralis intramyocellular lipid (IMCL) content was assessed by1H-magnetic resonance spectroscopy before and after prolonged time trial cycling bouts of ∼3-h duration. Six highly trained male cyclists completed a double-blind, randomized, crossover design of two experimental trials after a strenuous exercise bout and 48 h of high (HC) (9.32 ± 0.08 g · kg−1 · day−1) and low (LC) (0.59 ± 0.21 g · kg−1 · day−1) dietary carbohydrate. Resting IMCL content was significantly higher after LC vs. HC ( P < 0.01) and was reduced during exercise by 64 and 57%, respectively. IMCL was not different between conditions after exercise ( P > 0.05). The approximately twofold increase in IMCL degradation in LC compared with HC suggests that higher rates of whole body lipid metabolism in LC were in part attributable to a greater IMCL utilization. Four subjects experienced reductions of IMCL in excess of 70% during exercise. To our knowledge, this is the first study to report near depletion of IMCL during prolonged cycling, indicating that IMCL, presumably the triacylglycerol component, may be exhausted by prolonged strenuous exercise.

The use and effects of selected performance-enhancing drugs and nutritional supplements are reviewed. Recent sports medicine studies are mostly double blind and placebo controlled but contain relatively small sample sizes. Their data appear reliable and are reported in reputable journals. Definitions and methods used in sports medicine are provided to enhance the understanding of this literature. The use of performance-enhancing substances is probably under-reported. Anabolic-androgenic steroids are reportedly used in 0% to 1% of women, 0.5% to 3% of high school girls, 1% to 5% of men, 1% to 12% of high school boys, and up to 67% of some groups of elite athletes. The use of combinations of performance-enhancing substances is common. Carbohydrate loading, adequate protein intake, creatine, blood doping, and erythropoietin (epoetin alfa) appear to enhance performance. Anabolic-androgenic steroids enhance performance, but health risks limit their use. Growth hormones and β2-selective adrenergic agonists may enhance performance, but additional studies are needed. Androstenedione, caffeine, amphetamines, and nonprescription sympathomimetics do not appear to enhance performance. Performance-enhancing drugs have shown some benefit in diseased patients with malnutrition and/or decreases in physical ability. Pharmacists and other health care providers have opportunities to improve the understanding, use, and monitoring of performance-enhancing substances.

Background: Surgery is succeeded by long-lasting state of relative peripheral insulin resistance, which is reduced by giving glucose infusion or oral carbohydrate-rich drinks immediate before operating instead of fasting. The aim of the present study was to investigate whether oral carbohydrate or carbohydrate with peptide drinks preoperatively instead of fasting would improve postoperative voluntary muscle strength, nutritional intake and ambulation, decrease postoperative fatigue, anxiety and discomfort, and reduce the endocrine response to surgery. Methods: Forty-eight patients were included and randomized into three groups to receive 2 × 400 ml of carbohydrate-rich drinks or to fast overnight and allowed only water. Voluntary grip and quadriceps strength, body composition, pulmonary function, VAS-score of eight parameters of wellbeing, muscle biopsies and insulin, glucagon, IGF-1 and free fatty acids were measured before and after the operation. The basic postoperative regimen for all groups were immediate oral nutrition and early enforced mobilization. Results: Significant postoperative decrease in glycogen synthase activity in the muscle biopsies was reduced in the intervention groups, and in combination, the intervention groups had a less reduced quadriceps strength after one week (−10% vs. −16%, NS) and one month (−5% vs. −13%, P

As we look forward in 2015, attention to perioperative surgical nutrition continues to play a key role in optimizing outcomes and enhancing surgical recovery. Nutrition therapies for preoperative preparation include high protein intake combined with exercise, immune- and metabolic-modulating nutrients, carbohydrate loading, probiotic therapy and, occasionally, the need for specialized enteral or parenteral nutrition. Early enteral nutrition and probiotic therapy optimize gastrointestinal integrity and function in the postoperative setting. Some questions of who, when and how to optimally feed the surgical patient still exist. Despite these questions, the abundance of evidence supports a determined focus for nutrition optimization prior to major surgery.

We tested the hypothesis that a shift to carbohydrate diet after prolonged adaptation to fat diet would lead to decreased glucose uptake and impaired muscle glycogen breakdown during exercise compared with ingestion of a carbohydrate diet all along. We studied 13 untrained men; 7 consumed a high-fat (Fat-CHO; 62% fat, 21% carbohydrate) and 6 a high-carbohydrate diet (CHO; 20% fat, 65% carbohydrate) for 7 wk, and thereafter both groups consumed the carbohydrate diet for an eighth week. Training was performed throughout. After 8 wk, during 60 min of exercise (71 ± 1% pretraining maximal oxygen uptake) average leg glucose uptake (1.00 ± 0.07 vs. 1.55 ± 0.21 mmol/min) was lower ( P < 0.05) in Fat-CHO than in CHO. The rate of muscle glycogen breakdown was similar (4.4 ± 0.5 vs. 4.2 ± 0.7 mmol · min−1· kg dry wt−1) despite a significantly higher preexercise glycogen concentration (872 ± 59 vs. 688 ± 43 mmol/kg dry wt) in Fat-CHO than in CHO. In conclusion, shift to carbohydrate diet after prolonged adaptation to fat diet and training causes increased resting muscle glycogen levels but impaired leg glucose uptake and similar muscle glycogen breakdown, despite higher resting levels, compared with when the carbohydrate diet is consumed throughout training.

A well-balanced diet with appropriate training is the key to maximizing athletic performance. Nutritional counseling should be an essential part of anticipatory guidance, especially for certain teens, such as those who are vegetarians or those with low-calorie intakes. Other considerations for anticipatory guidance are listed in Box 8. Adequate hydration before, during, and after practice or a game is important to maintain hemodynamic balance, prevent heat disorders, and optimize performance. Cool water is adequate for short-duration activities, while carbohydrate-electrolyte fluids are more desirable for long-term activities, especially those lasting more than an hour. Such drinks are also more palatable and the athlete is more likely to consume them. Carbohydrates (meaning hydrates of carbon) are an important part of the athlete's diet; carbohydrates are rapidly broken down and their energy is quickly supplied to the body. The body stores only a small amount of carbohydrates in the form of glycogen in the liver, while muscle glycogen is an immediate source of energy. Thus, carbohydrate loading has been used to increase glycogen stores and aid the athlete involved in endurance events.

Background Trauma such as hip fracture initiates a neurohumoral stress response that changes the balance between anabolism and catabolism resulting in muscle breakdown and reduced mobilisation. Various studies have demonstrated a reduction in catabolism with pre-operative carbohydrate loading but only in an elective setting. Methods/Design This is a two-centre, randomised double-blinded trial in the United Kingdom. Sample size will be 30 patients (approximately 15 from each centre). Randomisation will be web based using computer-generated concealed tables. Both participants and investigators will be blinded to group allocation. Participants will be >70 years of age, cognitively intact (Abbreviated Mental Score ≥7), able to give informed consent, and admitted directly through the emergency department with fractured neck of femur requiring hemiarthroplasty. Intervention will consist of two carbohydrate drinks (Nutricia pre-Op) given the night before, and the morning of the surgery. The control will receive two placebo drinks of equal volume. All participants will receive standard hospital care at the discretion of the clinical team. The primary outcome is the difference between groups in insulin resistance calculated by a glucose tolerance test administered pre-operatively and 24 hours postoperatively. Secondary endpoints will be changes in muscle carbohydrate metabolism (biopsy), mobility (Cumulative Ambulation Score) and subjective measures of tolerability. Discussion This is a small-scale pilot study, investigating the benefits and tolerability of carbohydrate loading in an emergency setting in a frail elderly group with known high morbidity and mortality. Positive findings will provide the basis for a larger scale study. Trial registration Current Controlled Trials ISRCTN91109766 (7 April 2014); NRES ref: 13/EM/0214 Trial Sponsor: University of Nottingham Ref.13036.

For many years athletes have used carbohydrate loading to enhance endurance performance. This practice has been based on findings demonstrating that 1) exercise induced depletion of the muscle glycogen stores followed by the intake of a carbohydrate rich diet, resulted in muscle glycogen stores above normal values and 2) that the pre-exercise muscle glycogen content was the main determinant of the capacity to perform strenuous exercise to exhaustion. Lately it has been speculated whether a period of a high fat diet, followed by carbohydrate loading to restore or increase muscle glycogen levels above normal, would be of further advantage for exercise performance. From the discussed data it emerges, however, that varying periods offat adaptation followed by a carbohydrate rich diet prior to exercise is of no benefit for exercise performance. Despite an increased fat oxidation and a concomitant decrease in carbohydrate oxidation during submaximal exercise, no benefit in a subsequent time trial appeared. Data suggest that this dietary regimen impairs the ability to utilise carbohydrates.

We demonstrated that female endurance athletes did not increase their muscle glycogen concentration after an increase in the dietary carbohydrate intake (58 → 74%), whereas men did (Tarnopolsky MA, SA Atkinson, SM Phillips, and JD McDougall, J Appl Physiol 78: 1360–1368, 1995). This may have been related to a lower energy or carbohydrate intake by the women or due to an inherent gender difference in glycogen storage capacity. We examined whether well-trained men ( n = 6) and women ( n = 6) increased muscle glycogen concentration after an increase in both the relative (58 → 75%) and absolute energy and carbohydrate intake and whether potential gender differences were related to muscle hexokinase enzyme activity. Subjects were randomly allocated to three diets [Hab, habitual; CHO, high carbohydrate (75%); and CHO + E, extra energy + CHO (↑∼34%)] for a 4-day period before a muscle biopsy for analysis of total and pro- and macroglycogen and hexokinase activity. Total glycogen concentration was higher for the men on the CHO and CHO + E trials compared with Hab ( P < 0.05), whereas women increased only on the CHO + E trial compared with Hab ( P < 0.05). There were no gender differences in the proportion of pro- and macroglycogen or hexokinase activity. A low energy intake may explain the previously reported lower capacity for women to glycogen load compared with men.

We examined the effects of a high-fat diet (HFD-CHO) versus a habitual diet, prior to carbohydrate (CHO)-loading on fuel metabolism and cycling time-trial (TT) performance. Five endurance-trained cyclists participated in two 14-day randomized cross-over trials during which subjects consumed either a HFD (>65% MJ from fat) or their habitual diet (CTL) (30 ± 5% MJ from fat) for 10 day, before ingesting a high-CHO diet (CHO-loading, CHO > 70% MJ) for 3 days. Trials consisted of a 150-min cycle at 70% of peak oxygen uptake (V̇O2peak), followed immediately by a 20-km TT. One hour before each trial, cyclists ingested 400 ml of a 3.44% medium-chain triacylglycerol (MCT) solution, and during the trial, ingested 600 ml/hour of a 10% 14C-glucose + 3.44% MCT solution. The dietary treatments did not alter the subjects’ weight, body fat, or lipid profile. There were also no changes in circulating glucose, lactate, free fatty acid (FFA), and β-hydroxybutyrate concentrations during exercise. However, mean serum glycerol concentrations were significantly higher (p < .01) in the HFD-CHO trial. The HFD-CHO diet increased total fat oxidation and reduced total CHO oxidation but did not alter plasma glucose oxidation during exercise. By contrast, the estimated rates of muscle glycogen and lactate oxidation were lower after the HFD-CHO diet. The HFD-CHO treatment was also associated with improved TT times (29.5 ± 2.9 min vs. 30.9 ± 3.4 min for HFD-CHO and CTL-CHO, p < .05). High-fat feeding for 10 days prior to CHO-loading was associated with an increased reliance on fat, a decreased reliance on muscle glycogen, and improved time trial performance after prolonged exercise.

Postoperative insulin resistance is a well-characterized metabolic state that has been shown to correlate with the length of postoperative stay in hospital. Preoperative intravenous or oral carbohydrate treatment has been shown to attenuate the development of postoperative insulin resistance measured 1 day after surgery. To study the effects of preoperative oral carbohydrate treatment on postoperative changes in insulin resistance and substrate utilization, in the absence of postoperative confounding factors, 15 patients were double-blindly treated with either a carbohydrate-rich beverage (12.5%) ( n = 8) or placebo ( n = 7) before undergoing total hip replacement surgery. Insulin sensitivity, endogenous glucose release, and substrate oxidation rates were measured before and immediately after surgery. Whole body insulin sensitivity decreased by 18% in the treatment group vs. 43% in the placebo group ( P < 0.05, Student's t-test for unpaired data). In both groups, the major mechanism of insulin resistance was an inhibition of insulin-induced nonoxidative glucose disposal after surgery. The better preservation of insulin sensitivity in the treatment group was attributable to a less reduced glucose disposal in peripheral tissues and increased glucose oxidation rates.

AIM: We investigated the effect of carbohydrate availability and euglycaemic hyperinsulinaemia on intramuscular and plasma amino acids in 14 healthy men (age 26.5 +/- 0.9 years, b.m.i. 22.9 +/- 0.5 kg/m2). METHODS: Insulin was infused (1.5 mU/kg/min) for 240 min both after a carbohydrate depleting exercise and after carbohydrate loading. Muscle samples were taken before and after hyperinsulinaemia. Plasma and intramuscular amino acid concentrations were measured. RESULTS: Insulin-mediated glucose disposal was similar after carbohydrate depletion (65.2 +/- 1.9 micromol/kg/min) and loading (66.9 +/- 2.8 micromol/kg/min). Carbohydrate depletion was associated with decreased alanine and increased branched chain amino acid (BCAA) concentrations in muscle and plasma. Blood lactate was lower after carbohydrate depletion (477 +/- 25 micromol/l) than loading (850 +/- 76 micromol/l, p < 0.001). In carbohydrate depletion, hyperinsulinaemia resulted in a greater increase in intramuscular (from 927 +/- 48 nmol/g muscle to 2029 +/- 104 nmol/g muscle, p < 0.001), than plasma (from 197 +/- 6.7 micromol/l to 267 +/- 11 micromol/l, p < 0.001) alanine. After carbohydrate loading muscle alanine did not rise significantly (from 1546 +/- 112 nmol/g muscle to 1781 +/- 71 nmol/g muscle) whereas plasma alanine decreased (from 339 +/- 26 micromol/l to 272 +/- 13 micromol/l, p < 0.05). CONCLUSIONS: (1) Carbohydrate availability has profound effects on the interrelationship between glucose and amino acid metabolism and on the form of storage for glucose-derived carbons. (2) For most amino acids changes in plasma levels of amino acids are not related to changes in concentrations of intramuscular amino acids during hyperinsulinaemia.

The de novo biosynthesis of glycogen is catalyzed by glycogenin, a self-glucosylating protein primer. To date, the role of glycogenin in regulating glycogen metabolism and the attainment of maximal glycogen levels in skeletal muscle are unknown. We measured glycogenin activity after enzymatic removal of glucose by α-amylase, an indirect measure of glycogenin amount. Seven male subjects performed an exercise and dietary protocol that resulted in one high-carbohydrate leg (HL) and one low-carbohydrate leg (LL) before testing. Resting muscle biopsies were obtained and analyzed for total glycogen, proglycogen (PG), macroglycogen (MG), and glycogenin activity. Results showed differences ( P < 0.05) between HL and LL for total glycogen (438.0 ± 69.5 vs. 305.7 ± 57.4 mmol glucosyl units/kg dry wt) and PG (311.4 ± 38.1 vs. 227.3 ± 33.1 mmol glucosyl units/kg dry wt). A positive correlation between total muscle glycogen content and glycogenin activity ( r = 0.84, P < 0.001) was observed. Similar positive correlations ( P < 0.05) were also evident between both PG and MG concentration and glycogenin activity (PG, r = 0.82; MG, r = 0.84). It can be concluded that glycogenin does display activity in human skeletal muscle and is proportional to glycogen concentration. Thus it must be considered as a potential regulator of glycogen synthesis in human skeletal muscle.

The physical demands faced by soldiers of the U.S. Army are in many ways similar to those experienced by endurance-event athletes. Mission success, and even life itself, depend on physical stamina. This article examines the possibility that carbohydrate loading, as practiced by endurance athletes, may prove to be an ergogenic aid that enhances this endurance. Although the negative side effects of the classic carbohydrate-loading procedure would hinder the critical pre-mission activities, a modified carbohydrate-loading approach attains the same benefits without the adverse side effects. The mechanisms for implementing the modified carbohydrate-loading regimen are already in place within the current unit structure of the U.S. Army. A proposed pilot study would ascertain if the current research data on carbohydrate loading could be generalized to the deploying soldiers of the U.S. Army.

Background: The rate of absorption of glucose from carbohydrates is important in several aspects of health. We recently validated a noninvasive technique in pigs, euglycemic hyperinsulinemic clamp plus oral carbohydrate loading (OC-Clamp), to quantify the rate of net posthepatic appearance of glucose after ingestion of carbohydrates. Objective: The OC-Clamp procedure was performed in 8 healthy men to compare the net posthepatic appearance of glucose after ingestion of 1 of 3 carbohydrates. Design: Human volunteers underwent the OC-Clamp procedure at an insulin infusion rate of 1.5 mU.kg -1 .min -1 (n = 5). The oral carbohydrate load (1 g/kg) consisted of glucose, cornstarch, or mung bean starch. During the OC-Clamp procedure, the glucose infusion rate decreased during absorption to maintain plasma glucose steady state and the decrease reflected the net posthepatic appearance of glucose. In addition, carbohydrates were loaded without insulin infusion (n = 6) and glycemic indexes were calculated (with glucose as the reference). Results: The mean (±SEM) glycemic index of cornstarch was higher (95 ± 18) than that of mung bean starch (51 ± 13). In the OC-Clamp experiments, the posthepatic appearance of glucose and cornstarch did not differ significantly and represented 79.4 ± 5.0% and 72.6 ± 4.0%, respectively, of the load after complete absorption (within 3 h). In contrast, the net posthepatic appearance of glucose from mung bean starch was significantly lower (35.6 ± 4.6% of the load, P < 0.001) than that from glucose and cornstarch, even 4.5 h postprandially. Conclusions: The OC-Clamp technique allows a continuous assessment of net posthepatic appearance of glucose after ingestion of carbohydrates and significant discrimination between corn and mung bean starches.

This study examined the role of carbohydrate (CHO) ingestion on the resynthesis of two pools of glycogen, proglycogen (PG) and macroglycogen (MG), in human skeletal muscle. Nine males completed an exhaustive glycogen depletion exercise bout at 70% maximal O2 consumption on two occasions. Subsequent 48-h dietary interventions consisted of either high (HC, 75% of energy intake) or low (LC, 32% of energy intake) CHO diets. Muscle biopsies were taken at exhaustion (EXH) and 4, 24, and 48 h later. The total muscle glycogen (Gt) at EXH for the HC and LC conditions was not significantly different, and the MG represented ∼12% of the Gt. From EXH to 4 h, there was an increase in the PG only for HC and no change in MG in either diet ( P < 0.05). From 4 to 24 h, the concentration of PG increased in both conditions ( P < 0.05). Between 24 and 48 h, in HC the majority of the increase in Gt was due to the MG pool ( P < 0.05). The MG and PG concentrations for HC were significantly greater than for LC at 24 and 48 h ( P < 0.05). At 48 h the MG represented 40% of the Gt for the HC diet and only 21% for the LC diet. There was no change in the net rates of synthesis of PG or MG over 48 h for LC ( P < 0.05). The net rate of PG synthesis from 0 to 4 h for HC was 16 ± 1.68 mmol glucosyl units ⋅ kg dry wt−1 ⋅ h−1, which was threefold greater than for LC ( P < 0.05). The net rate of PG synthesis decreased significantly from 4 to 24 h for HC, whereas the net rate of MG synthesis was not different over 48 h but was significantly greater than in LC ( P< 0.05). The two pools are synthesized at very different rates; both are sensitive to CHO, and the supercompensation associated with HC is due to a greater synthesis in the MG pool.

Purpose: To evaluate patients with clinically diagnosed uveal melanoma Material and Methods: Forty-eight consecutive patients were examined with spin-echo (SE) and fast spin-echo (FSE) MR sequences that utilized glucosefructose enhancement together with a subtraction technique on a 1.5 T unit Results: Twenty-seven patients were enucleated and the eyes histologically examined for tumours (spindle cell, mixed cell, and epitheloid cell). The remaining patients were referred for other treatment. There were no significant differences in T2 although T2 was longer in the amelanotic lesions. Carbohydrate loading in combination with a subtraction technique gave: an increased signal intensity; a prolongation of T2; and an increased tumour size. The FSE sequences were as good as the SE sequences in the visualization of uveal malignant melanoma Conclusion: MR imaging performed with carbohydrate loading registers metabolic changes induced in the tumour. This gives the method great validity in the diagnosis of uveal melanoma. The method is especially useful in amelanotic tumours that have longer relaxation times than melanotic tumours. The SE technique can be replaced with the FSE technique

Introduction As an exercise physiologist, my research interests focus on the interactive role of both the training stimulus and nutrient availability in modifying the molecular pathways that regulate how skeletal muscle adapts to exercise training. I am interested in how we can maximize how our muscles respond to training simply by changing what we eat (e.g., carbohydrate, protein and fat) before, during and after each training session. In recent years, our laboratory has challenged existing beliefs in the field of sports physiology and nutrition by demonstrating that deliberately restricting carbohydrate availability actually enhances the oxidative adaptations of human skeletal muscle (Bartlett et al., 2013; Morton et al., 2009), as opposed to conventional wisdom that training should always be completed after carbohydrate loading and with the provision of sports drinks.

Goforth, Jr., Harold W., David A. Arnall, Brad L. Bennett, and Patricia G. Law. Persistence of supercompensated muscle glycogen in trained subjects after carbohydrate loading. J. Appl. Physiol. 82(1): 342–347, 1997.—Several carbohydrate (CHO)-loading protocols have been used to achieve muscle glycogen supercompensation and prolong endurance performance. This study assessed the persistence of muscle glycogen supercompensation over the 3 days after the supercompensation protocol. Trained male athletes completed a 6-day CHO-loading protocol that included cycle ergometer exercise and dietary manipulations. The 3-day depletion phase began with 115 min of cycling at 75% peak oxygen uptake followed by 3 × 60-s sprints and included the subjects consuming a low-CHO/high-protein/high-fat (10:41:49%) diet. Subjects cycled 40 min at the same intensity for the next 2 days. During the 3-day repletion phase, subjects rested and consumed a high-CHO/low-protein/low-fat (85:08:07%) diet, including a glucose-polymer beverage. A 3-day postloading phase followed, which involved a moderately high CHO diet (60%) and no exercise. Glycogen values for vastus lateralis biopsies at baseline and postloading days 1–3 were 408 ± 168 (SD), 729 ± 222, 648 ± 186, and 714 ± 196 mmol/kg dry wt, respectively. The CHO-loading protocol increased muscle glycogen by 1.79 times baseline, and muscle glycogen remained near this level during the 3-day postloading period. Results indicate that supercompensated muscle glycogen levels can be maintained for at least 3 days in a resting athlete when a moderate-CHO diet is consumed.

Optimization of metabolic state prior to major surgery leads to improved surgical outcomes. Nutrition screening protocols should be implemented in the preoperative evaluation, possibly as part of a bundle. Strategies to minimize hyperglycemia and insulin resistance by aggressive preoperative nutrition and carbohydrate loading may promote maintenance of a perioperative anabolic state, improving healing, reducing complications, and shortening the time to recovery of bowel function and hospital discharge. Short courses of preoperative immune-modulating formulas, using combinations of arginine, ω-3 fatty acids, and other nutrients, have been associated with improved surgical outcomes. These immune-modulating nutrients are key elements of metabolic pathways that promote attenuation of the metabolic response to stress and improve both wound healing and immune function. Patients with severe malnutrition and gastrointestinal dysfunction may benefit from preoperative parenteral nutrition. Continuation of feeding through the intraoperative period for severely stressed hypermetabolic patients undergoing nongastrointestinal surgery is another strategy to optimize metabolic state and reduce prolonged nutrition deficits. In this paper, we review the importance of preoperative nutrition and strategies for effective preoperative nutrition optimization.

Aim To describe the atypical phenotype and genotype of an adolescent girl with symptomatic exercise-induced hyperglycaemia, responsive to sulfonylurea treatment. Methods Chart review, gene sequencing, and blinded continuous glucose monitoring (Medtronic iPro2) were used to characterise the case. Results A novel heterozygous mutation p.Q219x (c.655C>T) in exon 6 of the glucokinase gene (NM_000162.3) was confirmed in the patient and father. Initiation of gliclazide 20mg twice daily was associated with resolution of symptoms and normalization of haemoglobin A1C (5.6%). Blinded continuous glucose monitoring demonstrated significantly less time spent in the hyperglycaemic range (sensor glucose>8.0mmol/L) when on twice daily gliclazide versus intermittent or no gliclazide (mean minutes/day with sensor glucose>8mmol/L: 53.6±90.0 vs. 307.9±246.6; P =0.04). Conclusions This novel mutation in the glucokinase gene led to atypical symptomatic exercise-induced hyperglycaemia that was responsive to low dose sulfonylurea with self-reported additional benefit after reduction of carbohydrate intake. We postulate that her atypical clinical presentation was related to the intense elite-level physical activity combined with carbohydrate loading before exercise.

The aim of this study was to ascertain whether a high carbohydrate diet in the days before movement patterns simulating a squash match would increase carbohydrate oxidation during the match, and alter physical performance. Nine New Zealand level squash players were recruited to complete a simulated squash match on two occasions: 1) following a 48-hr high carbohydrate (11.1g·kg−1); and 2) following a calorie-matched low carbohydrate (2.1 g·kg−1) diet. The interventions were assigned in a randomized, single-blind, cross-over design. The match simulation was designed to mimic a five-game match lasting approximately 1 hr. Performance was measured as time to complete each game. Expired respiratory gases and heart rate were continuously collected throughout the trial using a portable gas analysis system. Capillary blood glucose and lactate samples were obtained during a 90 s rest period between each game. Rating of perceived exertion was also recorded after each set. Respiratory exchange ratio was significantly higher during exercise following the high CHO diet (0.80 vs. 0.76) p < .001) and this was associated with significantly faster time to complete the games (2340 ± 189 s vs. 2416 ± 128 s, p = .036). Blood glucose and lactate concentrations were also significantly higher in the high carbohydrate condition (p = .038 and p = .021 respectively). These results suggest that ingestion of a diet high in carbohydrate (>10 g/kg body weight) preceding simulated competitive squash produces increased rates of carbohydrate oxidation and maintains higher blood glucose concentrations. These metabolic effects were associated with improved physical performance.

after Surgery (ERAS) guidelines Percent compliance of urologists without clinical care pathway Percent compliance of urologists with clinical care pathway P value PRE-OPERATIVE Nutritional assessment 34 47 0.02 No pre-op fast greater than 2 hours for liquids or 6 hours for solids 8 12 0.2 Pre-op carbohydrate loading 11 13 0.6 No bowel prep 8 16 0.04 POST-OPERATIVE Nasogastric tube out immediately after surgery 26 42 0.004 Early diet initiation 21 34 0.01 Entereg use 6 15 0.005 No routine ICU for post-op care 60 64 0.42 *Diet initiated at post-op day 2 or sooner.

Oral carbohydrate-rich fluids are used preoperatively to improve postoperative recovery, but their effectiveness for reducing length of hospital stay is uncertain. We assessed the effectiveness of preoperative loading with carbohydrates on the postoperative outcomes of 44 patients scheduled for elective colorectal surgery who were randomly allocated to a carbohydrate-rich fluid group or a usual care group during their preadmission clinic visit. Our primary outcome was the time patients required to be ready for discharge. Patients in the control group spent an average of 4.3 days (95% confidence interval [CI], 3.2-5.7) in the hospital and patients in the carbohydrate-rich fluid group spent 4.1 days (95% CI, 3.2-5.4) in the hospital until they met discharge criteria (P = .824). We found that the safety of administering preoperative oral carbohydrate-rich fluids is supported, but we were unable to confirm or refute the benefit of this treatment regimen for contributing to shorter hospital stays after elective colorectal surgery.

Background Enhanced recovery protocols may reduce postoperative complications and length of hospital stay. However, the implementation of these protocols requires time and financial investment. This study evaluated the cost-effectiveness of enhanced recovery implementation. Methods The first 50 consecutive patients treated during implementation of an enhanced recovery programme were compared with 50 consecutive patients treated in the year before its introduction. The enhanced recovery protocol principally implemented preoperative counselling, reduced preoperative fasting, preoperative carbohydrate loading, avoidance of premedication, optimized fluid balance, standardized postoperative analgesia, use of a no-drain policy, as well as early nutrition and mobilization. Length of stay, readmissions and complications within 30 days were compared. A cost-minimization analysis was performed. Results Hospital stay was significantly shorter in the enhanced recovery group: median 7 (interquartile range 5–12) versus 10 (7–18) days (P = 0·003); two patients were readmitted in each group. The rate of severe complications was lower in the enhanced recovery group (12 versus 20 per cent), but there was no difference in overall morbidity. The mean saving per patient in the enhanced recovery group was €1651. Conclusion Enhanced recovery is cost-effective, with savings evident even in the initial implementation period.