Table 1.

Overview of risk factor prehabilitation strategies. Screening tools can be employed by multiple clinicians at the earliest opportunity in the preoperative pathway. Further assessment may need to be conducted by specialist healthcare professionals such as a dietician or nutritionist. Prehabilitation interventions should follow similar key principles aiming to achieve meaningful risk factor modification in the available time before surgery.

Risk factor	Screening (all patients)	Assessment (at risk patients)	Intervention principles	Prehabilitation goals
Physical activity	Assess against chief medical officer recommendations for healthy adults: 150 minutes moderate intensity exercise per week or 75 minutes vigorous intensity exercise per week plus muscle strengthening exercise on 2 or more days per week. Patients failing to meet one or both criteria should be offered exercise prehabilitation.	Objective assessment of physical fitness eg cardiopulmonary exercise test 6 minute walk test incremental shuttle walk test.	Combined aerobic and resistance training programme. Prescribed based on objective fitness assessment. Monitored and modified to account for improvements in fitness.	Improve aerobic capacity Develop lean muscle mass
Inspiratory muscle training	ARISCAT score. Consider IMT in ‘intermediate-’ and ‘high-’ risk patients.	n/a	Structured IMT programme.	Develop muscles of respiration and reduce risk of perioperative pulmonary complications.
Smoking	Establish smoking status. All smokers should be offered cessation support.	Support access to cessation services for assessment. Fagerström score used to titrate nicotine therapy.	Gold-standard cessation programme (combines counselling and nicotine replacement therapy).	Preoperative cessation.
Alcohol	Establish weekly intake in units. Patients with a ‘hazardous’ intake (>14 units per week) should undergo further assessment.	AUDIT/AUDIT-C questionnaires in those with higher intakes.	Patients with features of dependence will require input from specialist alcohol services. Those with ‘hazardous’ intakes may respond to the ‘brief alcohol intervention’.	Modify intake to non-hazardous levels.
Nutrition	MUST (Can be adapted for preoperative setting). 39	Dietician/nutritionist assessment.	Identify macro- and micronutrient deficiencies (ensure total protein intake 1.5–2.0 g/kg daily). ‘Food first’ approach to correction. Consider protein supplementation following exercise training sessions.	Correct preoperative malnutrition. Support exercise training.
Psychological factors	HADS	Assessment for poorly controlled depression and anxiety and low self-efficacy to engage with prehabilitation.	Build self-efficacy through other risk factor interventions. Education programmes. Specialist input for psychological intervention.	Improve control of anxiety and depression. Develop self-efficacy for prehabilitation and surgery.

ARISCAT = assess respiratory risk in surgical patients in Catalonia; AUDIT/AUDIT-C = alcohol use disorders identification test; HADS = hospital anxiety depression scale; IMT = inspiratory muscle training; MUST = malnutrition universal screening tool; n/a = not applicable.