Nutrition and Wound HealingJemma Corrigan
Accredited Practising Dietitian (APD)
Nutrition Department, The Canberra Hospital
Overview• Role of nutrition in wound healing• Identifying patients at nutritional risk• Key nutrients in wound healing• Improving nutritional status
NUTRITION IN WOUND HEALINGRole of
Stages of Wound Healing
Nutrition plays a vital role throughout all stages of wound healing• Regeneration (Inflammatory Phase)• Repair (Proliferative Phase)• Revascularisation (Proliferative Phase)• Re‐epithilialisation (Remodelling or Maturation Phase)
Nutrition in wound healing• Delayed or impaired wound healing may occur if nutritional status is inadequate
• A nutritionally complete diet provides the optimum environment for recovery and healing– wounds heal faster– strengthens immune system– prevents development of further wounds e.g. Pressure wounds
Inadequate nutrition +/‐malnutrition= poor wound healing/breakdown
Malnutrition
Increased Nutritional
Requirements
Wound breakdown
Wound infection
Nutrition Impact
Symptoms
Poor Oral Intake
IDENTIFYING PATIENTS AT NUTRITIONAL RISK
Nutrition Screening
TTDWCG recommend:• Nutrition screening, using a validated tool for the appropriate clinical setting, should be undertaken on all adults with pressure injuries to identify those at risk of poor healing due to nutritional problems.
NHMRC Grade of recommendation: B
Identifying patients at nutritional risk
Clinical information‐Type of wound‐Compounding medical conditions‐Nutrition impact symptoms‐Social historyAnthropometric data
– Height and weight– Weight history– BMI– Physical examination
Identifying patients at nutritional risk
Blood tests/biochemistry‐ e.g. serum albumin, status, hydration, BGL, trace elements (zinc, selenium, iron)
Nutritional Intake– Overall oral intake of food and fluids– Nutritional adequacy
Special populations
• Malnourished: ↑ rate of wound degradation, dehydration, vitamin and mineral deficiencies, muscle loss. Prone to development of pressure sores.
• Elderly:↑ risk malnutrition, ↑ risk of pressure sores and skin tears.
Special populations
• Diabetic: poor glycaemic control/ hyperglycaemia, delays wound healing
• Obese: malnutrition is often masked, weight loss is not beneficial as muscle stores, not fat can be lost. Poor vascular supply to skin, ↑ risk infection 2° ↑subcutaneous fat
KEY NUTRIENTS IN WOUND HEALING
Macro‐nutrientsEnergy (kJ/kcal)
• Main sources of energy are:– Carbohydrates– Fat – Protein
• Adequate energy intake is required to prevent muscle loss, protein deficiency and unintentional weight loss
• Energy requirements are higher for patients with wounds (up to 45% higher)
Macro‐nutrientsCarbohydrate• Source of cellular energy
– Glucose– Short Chain Fatty Acids (colon health)
• Dietary sources: wholegrain breads & cereals, fruits, starchy vegetables, rice, pasta & dairy foods
Fat• Source of energy• Key role in structure and function of cell membranes• Omega 3’s – inflammation reduction• Dietary sources: meat, nuts & seeds, dairy products,
avocados, plant oils, oily fish.
MacronutrientsProtein
• Aids re‐vascularisation andcollagen synthesis• Involved in synthesis of enzymes for wound healing
• Hypoproteinaemia delays wound healing– Decreases skin and fascial tensile strength– Increases wound infection rates
MacronutrientsProtein• Type & severity of wound and protein losses influence protein requirements
• Requirements:Chronic Wounds
• 1.25 – 1.5 g/kg actual wt/day
Catabolic Patients• 1.5 – 2.0 g/kg actual wt/day
• Good dietary sources: meat, chicken, fish, eggs, dairy products, nuts, seed legumes and grains
Macro‐nutrientsWater
• Adequate hydration is essential• Dehydration can delay wound healing by:
– blood volume – blood circulation– O2 and nutrients to tissues
• How much is enough?– 30‐35ml/kg/day
Zinc
• Role in cell proliferation, Deficiency = wound strength• A low protein diet is often inadequate in Zinc• Hypoalbuminaemia will affect interpretation of serum levels
(false negative)• Over supplementation will interfere with Cu & Fe absorption
Adequate protein = Adequate Zinc
• Dietary sources: eggs, seafood, red meat, poultry, milk products and nuts
Vitamin C
• Essential for collagen synthesis and fibroblast formation
• Deficiency results in capillary fragility
• Deficiencies can cause breakdown of already healed wounds
• Should only be supplemented in patients with deficiency
• Dietary sources: citrus fruits, berries, capsicum, tomato, green leafy vegetables
Vitamin
• Encourages skin growth and skin strength• Deficiency delays wound healing, risk of infection
• Hypoalbuminaemia will affect interpretation of serum levels
• Dietary sources: dairy products, eggs, fish, oranges, dark green vegetables and red fruit and vegetables
Copper
• Influences wound healing• Role in maturation of collagen • Impaired wound healing seen in deficiency• Dietary sources: shellfish, whole grains, nuts, seeds, dark green leafy veg, dried fruit.
Selenium
• Essential for activity of glutathione peroxidase “first line” anti‐oxidant defence
• Deficiency may alter immune function• High proportion of deficiency in Australian population (deficient soils)
• Dietary sources: Fish and seafood, nuts, whole grains, meat and poultry, eggs.
Immuno‐nutrientsArginine (Amino Acid/Protein)• Essential during wound induced stress• Works at cellular level to promote wound healing• Dosage difficult to elucidate (study variances)• Supplementation may be most beneficial in the first 3 days of wound healing
TTDWCG Recommendations:• “may be considered” for patients with stage II or above Pressure Ulcers, improvements should be seen within 2‐3 weeks if will be of benefit.
• Important to optimise energy and protein intake first and if minimal improvements on wound healing seen, Argininesupplementation can be considered
Immuno‐nutrientsGlutamine (Amino Acid/Protein)• Essential during wound induced stress• Fuel for cell populations that participate in
inflammatory response• Energy for gut and immune cells, gut barrier• Supports antioxidant function• Needs to be given with adequate protein from other
sources –supplementary to protein requirements
EnergyProteinArginineGlutamineVitamin CVitamin AZincCopperSelenium
EnergyProteinArginineGlutamineVitamin CVitamin AZincCopper
EnergyProteinVitamin C
NUTRITION GOALS FOR WOUND HEALING
Nutrition Goals for Wound Healing
• Adequate energy and protein for metabolic support + wound healing
• Restoration of a well balanced diet– Ensure adequate micronutrient intake
• Prevent/Improve malnutrition
IMPROVING NUTRITIONAL STATUS
Methods of Improving Nutritional Status
Identifying those at nutritional riskReferral to the Dietitian for counseling and education
– Educating patients regarding identified nutrition requirements
• Nutrition and wound healing• Managing nutrition impact symptoms e.g. poor appetite, nausea, vomiting
Methods of improving nutritional status
Food and nutrients– Ensuring requirements for macro and micronutrients are met
– High protein, High energy advice and food fortification
– Nutrition support• Supplements• Enteral feeding
Supplements
• Commercial supplements for wound healing include;• Arginaid (Nestle), Cubitan (Nutricia)
Before recommending you need to consider: • Evidence for use • Dose • Cost • Patient tolerance/ compliance
If in doubt , consult your friendly Dietitian!
Supplements - a comparisonSupplement Cubitan Fortisip Resource
Fruit Bev.Full cream
milk
Volume/serve 200ml bottle 200ml bottle 237ml tetra 250ml glass
Energy (kcal/kJ) 250/1050 300/1254 360/1505 170/705
Protein (g) 20(3g arginine)
12 13.1 8.5
Fat (g) 7 10.7 10
Vitamin A (g RE) 238 246 282 127.5
Vitamin C (mg) 250 30 23.5 5
Zinc (mg) 9 3.6 3.6 1Copper (g) 1350 540 550 traceSelenium (g) 64 17.5 21.8 2.5Cost per serve ($) 2.03 1.30 1.44 0.25
Summary: • Complete nutrition screening – identify malnutrition or risk• Make appropriate referral to the Dietitian where risk is
identified• Optimise nutritional intake (energy and protein)• Where concerns regarding Micronutrients, but no deficiency –
recommend a daily multivitamin• Supplement where micronutrient deficiencies are identified • Monitor progress closely • If no improvement, consider Arginine supplementation.
References• The Role in Nutrition in Wound Healing, Education in Nutrition webinar, R. Kurmis,
Nov 2013• Foundation Concepts of Pathophysiology, Sherman & Barkley, Nutrition & Wound
Healing, Journal of Wound Care, 2011• Stechmiller, JK. Nutrition in Clinical Practice, 2010. 25(1):61‐68• Trans Tasman Dietetic Wound Care Group (DNZ/DAA), Evidence based practice
guidelines for the dietetic management of adults with pressure injuries. 2011• Meyer, NA et al. Nutrient support of the Healing Wound, New Horizons
1994;2(2):202‐213
Any Questions?