Good Outcomes Require Good Nutrition, and Good Nutrition Rests Upon Sound Policy

Commentary Dr. I. Leah Gitajn and her colleagues are to be commended for their investigation of whether living in a region with limited access to healthy food has a negative impact on patient outcomes following a fracture. The authors creatively employed existing, high-quality datasets that were generated from the PREP-IT trials1. The datasets were constructed prospectively, were very detailed, and included the information necessary for the authors to reach meaningful conclusions. The benefit of using the PREP-IT data is the breadth of elements that was collected prospectively, which included many important psychosocial variables that have been associated with complications and delayed healing 1. Although the PREP-IT trials were designed to compare different skin preparation solutions in the care of open and closed fractures, the PREP-IT data, combined with the overlay of census tract and ZIP code information, along with the presence or absence of a grocery store within proximity to the patient residence, established a strong foundation for this study. It is important to highlight that the criteria for the PREP-IT trials excluded patients who were deemed too unreliable for follow-up; as such, patients who were homeless and patients with severe mental illness were not enrolled, which could have biased this secondary analysis toward a more “privileged” population. Food deserts, i.e., neighborhoods with barriers to high-quality nutrition, are a major public health issue, and this investigation highlights the economic and social costs created by limited access to healthy food. The paper clearly demonstrates that living in a food desert increases the rate of unplanned reoperations following fracture surgery, and the authors believe that the negative impact stems from poor nutrition. It is reasonable to assume that patients living in a food desert are beset with limited access to healthy nutrition, and the authors contend that poor nutrition likely contributed to the problems involving wound complications and osseous healing. Unfortunately, the PREP-IT trials did not include complete sets of nutritional laboratory values nor any assessment of serum micronutrient levels, which would have further reinforced the causal impact of nutrition. Amidst the turbulence and uncertainty of our society, science remains the best method to inform public policy. We need more studies such as this one that offer evidence to support approaches for reducing the complications and the increased costs of care related to injury. Imagine a future in which patients are discharged with non-narcotic pain medications, a deep vein thrombosis (DVT) prophylactic regimen, outpatient therapy instructions, and a bag of fresh produce as a best practice—a future in which spinach, green beans, fresh fruit, eggs, and protein drinks are offered as critical adjuncts to the traditional therapies following fracture surgery. What was good for Popeye the Sailor, spinach, will be great for patients.