Nutritional Aspects of Healing a Diabetic Foot Wound

MedicalContinuing Education

Objectives After reading this continuing education article, the podiatric physician should be able to do the following: 1) Be familiar with the clinical goals of medical nutritional therapy. 2) Identify the eight principles of healing a diabetic foot wound. 3) Be able to describe the basic principles of nutritional management of patients with diabetic foot wounds. 4) Describe a comprehensive nutritional assessment. 5) Be able to relate the phases of wound Nutritional healing with basic nutritional needs. 6) To discuss the role of calories and Aspects of Healing weight loss in diabetic foot wound healing. 7) Understand the roles of proteins, a Diabetic Foot fats, carbohydrates, vitamins, minerals and trace elements in diabetic foot wound Wound healing. 8) To delineate the appropriate blood This is an essential but often overlooked tests needed to assess nutritional status in aspect of wound healing. a patient with a diabetic foot wound.

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By Kenneth B. Rehm, DPM principles and a systematic approach 1. Achieve and maintain that must include medical nutrition glycemic control by balancing food n a patient who has diabetes, heal- therapy. In general, the clinical goals intake with insulin (exogenous or en- ing a foot ulcer, just like healing a of medical nutrition therapy in a dia- dogenous) or oral glucose-lowering Iproblem in any other part of the betic patient are to: medications and activity levels. body, requires incorporating basic Continued on page 200 www.podiatrym.com NOVEMBER/DECEMBER 2003 • PODIATRY MANAGEMENT 199 Nutrition... Medical nutrition therapy is part stable. of the systematic approach to healing It is the nutritional aspects that Continuing 2. Achieve optimal blood a diabetic foot wound which incor- are to be discussed in this paper. lipid levels porates the following basic princi- The ability of a patient with a di- Medical Education 3. Provide adequate calories to ples: abetic foot ulcer to heal is affected by maintain or attain reasonable 1. There must be adequate circu- the baseline nutritional status and weights for adults, normal growth lation to the wound site. pre-existing nutritional deficiencies. and development rates in children 2. A wound must be kept clean A resultant suboptimal outcome and and adolescents, metabolic needs and free from contamination. poor healing prognosis is related to during pregnancy and lactation, or 3. Necrotic tissue must be elimi- increased susceptibility to the devel- recovery from illnesses that are nated or reduced to a minimum. opment of foot ulcers, increased time catabolic or to heal wounds. 4. A wound must be free from in- needed for wound healing, increased 4. Eliminate, prevent, delay or fection. likelihood for reoccurrence, de- control nutrition-related risk factors 5. Dermatologic disease must be creased tensile strength of a closed and complications such as hypo- controlled or eliminated. wound, increased susceptibility to in- glycemia, short-term illnesses, exer- 6. Shearing, friction and direct fection and post-surgical complica- cise-related problems, renal disease, pressure on a wound must be kept at tions in general. Providers of care for autonomic neuropathy, hyperten- a minimum. diabetic foot wounds should closely sion, cardiovascular and peripheral 7. The external wound healing scrutinize the nutritional status of vascular disease, and skin break- environment must be controlled and these patients, and consider poor nu- down. kept free from excess dryness and tritional status a major causal ele- 5. Achieve, maintain or improve moisture. ment, especially in cases where the overall health through appropriate 8. The wound host must be nutri- wound is not healing and all of the nutrition. tionally, metabolically and medically other factors for appropriate wound healing are in place. Basic principles of nutritional management of pa- ESSENTIALS OF A tients with diabetic foot wounds are the following: correction of inappro- NUTRITIONAL HISTORY priate appetite, swallowing, as well as chewing and dentition abnormalities, control of serum glucose, hyper- Weight Change lipidemia, hypertension, metabolic Appetite status, appropriate supplementation of vitamins and trace minerals, and Satiety level ascertaining and maintaining proper dietary requirements. Before these Taste changes and aversions basic principles of nutritional man- Nausea and/or vomiting agement are implemented, proper nutritional assessment and its com- Bowel habits including any diarrhea, constipation, or steatorrhea ponents must be accomplished. A comprehensive nutritional as- Alcohol or recreational drug use sessment evaluates macro- and mi- Smoking history cronutrient intake, co-morbidites that could affect the actual ingestion Chewing and swallowing ability of nutrients and/or the assimilation of nutrients, medications that affect Pain while eating wound healing and/or serum glucose Chronic diseases that affect the use of nutrients levels, and the overall medical, nutritional and metabolic status of the pa- Surgical resection or disease of GI tract tient. An optimal assessment should Usual meal pattern and dietary history include relevant clinical and bio- chemical data, including the follow- Dietary restrictions ing blood tests: complete blood count with a differential, glycosylat- Use of vitamin, mineral and nutritional supplements ed hemoglobin levels, hematocrit, Food allergies and intolerances hemoglobin, lipid levels, blood urea nitrogen levels, serum creatinine, al- Medications bumin, prealbumin, sodium and potassium levels, total protein and Level of Activity or Exercise transferrin levels. Urine tests include Ability to secure and prepare food quantitative values for protein, urine glucose and urine acetone. Blood Continued on page 201

200 PODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2003 www.podiatrym.com MedicalContinuing Education Nutrition... cells now begin to cover the surface with pre-existing compro- of the wound until maturation oc- mised nutritional status. pressure readings are important. curs. Marasmus is a type of undernu- Determining the dietary prescrip- In order for these four phases of trition associated with chronic tion, restrictions, and level of compli- wound healing to progress, certain caloric deprivation. Depletion of so- ance is essential information to be basic nutritional requirements must matic proteins and subcutaneous fat able to create proper nutritional sta- be met: causes a decrease in body weight. Sig- tus. It should be noted that poor nu- 1. Proteins are required for tissue nificant marasmus is indicated by a tritional status can be due to a poor repair weight that is less than 85% of a per- appetite, a metabolic problem, or in- 2. Glucose is required for energy son’s ideal weight. Weight loss that is ability to digest or swallow appropri- 3. Lipids (fats) are required for less than 10% of a person’s usual ately. A close evaluation of food in- cellular integrity weight is considered mild, moderate take vs. caloric require- if it ranges from 10% to ments should be per- 20%, and severe if the formed, paying close BASAL ENERGY EXPENDITURE (BEE) weight loss is 20% or attention to proteins, greater. Mild to moder- fats, carbohydrates, key ate weight loss may, in vitamins, folic acid, Basal energy requirement is based upon the following: fact, improve serum and key minerals, trace glucose levels even if elements and micronu- Women: 655 + (9.6 x W) + (1.7 x H) - (4.7 x A) desired weight is not trients. Because of all Men: 66 + (13.7 x W) + (5 x H) – (6.8 x A) reached. The problem of these factors, it is is that without being imperative that a regis- W = actual weight in Kg (2.2 lb = 1 kg) able to bear weight, as tered dietitian be in- is the case in many volved in the assess- H = height in cm (1 in. = 2.54 cm.) wound patients, it is ment process. A = age in years difficult to achieve weight loss. In fact, it is Healing Phases often necessary to With the nutritional assessment 4. Vitamins, minerals and trace avoid purposeful weight reduction made, the correction or prevention elements are required for optimal until the foot wound is closed. of malnutrition is critical in optimiz- metabolic function. ing wound healing. Nutritional sta- The providers of care and the Protein Requirements tus is the reserve from which the pa- wounded individual must create a In detailing the basic nutritional tient will draw upon to close the skin team that provides the appropriate requirements, the first consideration defect. With the other principles of nutrients for healing through the is the protein and calorie require- wound healing in place, if the pa- proper intake of food and appropri- ments. The provision of sufficient tient is well nourished, and not chal- ate supplementation or tube feeding calories is a priority so that protein lenged again, the wound is likely to if needed. will be spared for its critical roles in close. If the patient is malnourished the stimulation of fibrin formation, at the start of the healing process, the Calories and Weight Loss cell multiplication, connective tissue wound cannot be expected to close In a patient that has diabetes and formation, collagen formation and in a timely manner. The nutritional foot ulcers, the caloric requirements deposition, increasing of enzyme ac- substrate is essential for tissue forma- are merely a function of metabolical- tivity, diminishing catabolism, en- tion because nutrients are important ly active tissue, especially lean body hancing immunity and improving to the appropriate completion of the mass, and may vary significantly overall wound healing. Protein defi- four phases of wound healing. among patients. The requirements ciency suppresses the immune re- These four phases are separate are not different from those of a sponse, inhibits angiogenesis, de- and overlapping. They are: stressed patient without diabetes. Ac- creases fibroblast formation and re- 1. The hemostatic phase. This is curately measuring energy expendi- modeling of collagen and impairs the phase where platelet aggregation ture, and therefore needs, is critical overall wound healing. begins the process of blood coagula- in the patient who requires aggres- A review of the components tion in the wound. sive nutritional support by way of we’ve identified in the four phases of 2. The inflammatory phase. This total parenteral nutrition or enteral wound healing reveals that skin for- phase is characterized by tube feedings, a surgical procedure, mation, white blood cell activity, im- macrophage proliferation and their or has a significant wound to heal. mune function and collagen forma- ingestion of bacteria and debris. The most commonly used formula tion are all protein-based. The pres- 3. The connective tissue phase. This for determining basal energy expen- ence of all essential amino acids is re- is when fibrous tissue and collagen diture (BEE) is the Harris-Benedict quired for protein synthesis. All as- forms to create a lattice work that equation. pects of wound healing are delayed supports new blood vessels. The Weight as a percentage of ideal under conditions of protein deficien- wound now begins to contract and body weight or weight loss compared cy. Therefore, adequate protein in- close. with the patient’s usual weight are take is absolutely essential for wound 4. The epithelial phase. Epithelial markers used to identify patients Continued on page 202 www.podiatrym.com NOVEMBER/DECEMBER 2003 • PODIATRY MANAGEMENT 201 Nutrition... stress. It is usually associated with a • pancreatitis catabolic stress situation without nu- • burns over 30% or more of your Continuinghealing to occur. Adequate pro- tritional support. It is important to body tein consumption is so vital that differentiate the type of protein-calo- Overt signs of malnutrition may Medical Education even a mild depletion has a negative rie malnutrition because each has a exist and include severe wasting, ex- impact on the wound healing pro- different effect on wound healing. treme weight loss, weakened resis- cess. Clinical studies have shown that tance to infection, being unable to any protein-calorie malnutrition think clearly, or hair becoming brittle Protein-Calorie Malnutrition leads to compromised wound heal- or falling out. In addition, the skin There are basically three types of ing and a greater risk for developing may be dry or yellowish, muscles protein-calorie malnutrition: (1) pressure-related ulcerations. may feel weak, and fainting spells Marasmus involves decreased calories Various diseases can lead to all may occur. In younger women, men- and protein. It is usually associated forms of protein-calorie malnutri- strual periods may stop. with prolonged starvation, anorexia, tion. Common diseases linked with Protein-calorie malnutrition chronic illness and the elderly. It this form of malnutrition include: poses a severe danger to the patient takes months to years to develop. (2) • cancer because it can occur very rapidly and Kwashiorkor involves decreased pro- • chronic illness without overt signs of malnutrition. tein intake alone and is usually a re- • protein loss in the gastrointesti- Therefore it is important to appropri- sult of fad diets, liquid diets, or long nal tract ately monitor the nutritional status term dextrose-containing IV fluid • anorexia and other eating disor- by examining serum levels of pre-al- supplementation with nothing by ders bumin, albumin, total protein, and mouth. It takes weeks to months to • multiple traumas transferrin levels and by performing develop. (3) Combined is a result of • liver disease a CBC with a differential, hematocrit decreased calories, protein intake and • obesity Continued on page 203

PROTEIN-CALORIE MALNUTRITION

Marasmus Kwashlorkor Combined

Nutritional setting Decreased calories Decreased protein intake Decreased calories, and protein intake decreased protein intake and increased stress Clinical setting Prolonged starvation, Fad diets, liquid diets, long- Catabolic stress without anorexia, chronic term dextrose-containing nutritional support illness, elderly IV fluid supplementation with nothing by mouth Time course to Months to years Weeks to months Days to weeks develop Clinical features Starved appearance May look well-nourished Moderately to severely or obese. Edema, ascites starved appearance may be present. Normal Decreased anthropometrics. anthropometrics Laboratory findings Normal visceral Decreased visceral Decreased immune proteins proteins, Decreased function values lymphocyte count, Decreased visceral Anergic proteins Clinical course Reasonably preserved Diminished wound Diminished wound and responsive to healing, Diminished healing, Increased short-term stress immunocompetence, overall complications Increased infections, and slower recovery Increased overall complications Mortality rate Low unless High High complications of underlying disease process

202 PODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2003 www.podiatrym.com MedicalContinuing Education Nutrition... androgens, and prednisolone. of protein in serum, pro- Recent research has shown that duced by the liver, which is and a hemoglobin. the pre-albumin test can predict poor only present during episodes The pre-albumin test measures a outcomes for hemodialysis patients. of acute inflammation. The most protein that reflects nutritional sta- A low initial reading (baseline level) important role of CRP is its interac- tus. Pre-albumin most often is used of pre-albumin predicts that a patient tion with the complement system, to help diagnose protein-calorie mal- may have problems, and steadily which is one of the body’s im- nutrition. In this condition, which dropping pre-albumin values are as- munologic defense mechanisms.) can affect more than 30% of physio- sociated with low survival. Diabetics also had lower albumin logically stressed or wounded pa- Pre-albumin is the best marker of levels when compared to two tients, the body breaks down muscle, malnutrition because it has a short groups of control patients, those protein, and body fat. This type of serum half-life, it is less affected by with diabetes and no foot ulcers malnutrition can lead to complica- liver disease than other proteins and and those with neither diabetes nor tions and even death if not treated. is not affected by hydrations status or foot ulcers. The decreased albumin The test also is used to monitor vitamin deficiency (except zinc). levels results from a shift in the changes in patients who are receiving Serum albumin levels measure hepatic synthesis of proteins that parenteral nutrition (nutrition from visceral protein levels and therefore result in an increase in acute-phase outside of the gastrointestinal tract, the body’s ability to manufacture proteins and decreased production such as nutrients given through in- protein. It is an adequate indicator of homeostatic proteins. It is im- travenous treatment). The test also is of this ability for stable patients portant to note that vascular per- used to monitor changes in nutrition with a chronic medical condition, meability is increased because of status for patients who are receiving such as diabetes. If the patient is this shift and proteins escape from hemodialysis. being evaluated during an acute ill- the vascular space. Depending on the exact levels, if ness, the urinary creatinine height A common mistake made by clin- pre-albumin is low, minor nutrition- index should be used. Serum albu- icians in treating patients with dia- al deficiencies can be the only prob- min levels are often used to test for betes and foot ulcers is to interpret lem or if pre-albumin is very low, liver or kidney problems, or to hypoalbuminemia as a sign of mal- then protein-calorie malnutrition has learn if there is a lack of amino acid nutrition. When hypoalbuminemia to be considered. absorption. Because turnover time shows up, calories are often increased Conditions that may lead to for albumin is 14 days, it is less sen- significantly, leading to hyper- lower levels of pre-albumin are the sitive than other measures. For in- glycemia and weight gain, both of following: stance, pre-albumin changes more which interfere with wound healing. • Severe or chronic illness, such quickly, making it more useful for Total protein measurements can as cancer detecting changes in short-term nu- reflect nutritional status. In addition, • Hyperthyroidism tritional status than albumin. low total protein levels can suggest a • Liver disease liver disorder, a kidney disorder, or a • Serious infections Albumin disorder in which protein is not di- • Digestive disorders Albumin is the major protein gested or absorbed properly. More • Inflammatory disorders synthesized by the liver. It main- specific tests, such as albumin and When inflammation and malnu- tains plasma oncotic pressure and liver enzyme tests, must be per- trition are both present, pre-albumin transports nutrients in the blood formed to identify which protein levels fall very far, very quickly. stream. Low albumin levels may fraction is abnormal, so that a specif- Higher levels of pre-albumin are lead to edema in the lower extremi- ic diagnosis can be made. High total common in patients with: ties, skin breakdown and open protein levels can indicate dehydra- • high-dose corticosteroid thera- wounds and increased infection, as tion or some types of cancer (e.g., py well as increased morbidity and multiple myeloma) in which an ab- • hyperactive adrenal glands mortality. Decreased albumin levels normal protein is accumulated, and • high-dose non-steroidal anti-in- correlate with poor clinical out- further tests must be performed. flammatory medications comes, increased length of hospital Total iron binding capacity • Hodgkin’s disease stay, increased risk for complica- (TIBC) is an indirect measurement If a patient is in renal failure, pre- tions and death. It should be noted of transferrin, a protein that binds albumin results may be falsely higher that hypoalbuminemia is an excel- and transports iron. It quantifies than they actually are. lent marker for the stress response, transferrin in terms of the amount Inflammation can interfere but is considered to be a poor mark- of iron it can bind and is reported with the results of your pre-albu- er for overall nutritional status even as percent saturation. Transferrin min test, causing it to be lower though albumin levels are often levels are generally depressed in pa- than it would be. Certain drugs can used to monitor nutritional status. tients who are malnourished or also lower your pre-albumin level, According to a recent study, those who have chronic disease states; including amiodarone, estrogens, patients with diabetes and foot ul- however, it may be normal in many and oral contraceptives (birth con- cers had significantly higher levels patients who are iron deficient. trol pills). Drugs that can cause of fibrinogen and C-reactive pro- Patients who are malnourished or your pre-albumin level to rise in tein. (This is a test that measures protein-depleted benefit by early your blood are anabolic steroids, the concentration of a special type Continued on page 204 www.podiatrym.com NOVEMBER/DECEMBER 2003 • PODIATRY MANAGEMENT 203 Nutrition... 1. the size of the wound result in improved nitrogen balance 2. the nutritional and physiologic in malnourished patients. Obtaining Continuingfeeding with a high protein for- state of the patient positive nitrogen balance is impor- mula. Some evidence exists that 3. complications associated with tant to counter the effects of nitro- Medical Education protein supplements (T) improve the protein absorption and/or protein gen losses, common in diabetics and healing process in any physiological- metabolism patients under physiologic stress, ly or metabolically stressed individu- It should be noted, however, that and maximize the retention of nitro- al. This has a positive impact on all most wound healing patients, espe- gen. At least 1 1/2-2 grams of protein phases of wound healing, especially cially diabetics, require an increase in and 25-30 calories per Kg. of body the critical initial phases. It should be protein in their diet in conjunction weight is recommended. For severely noted that every patient’s needs are with adequate calories. Research sug- stressed or injured patients, as in different. Protein requirements vary gests that increasing protein intake burn patients, up to 2 1/2 grams of according to to 20% or more of total calories may Continued on page 205

NUTRITIONAL ASSESSMENT NORMAL REFERENCE LABORATORY VALUES

Determination Blood, Plasma, or Serum Values Reference Range Comment

Cholesterol 120-220 mg/100 mL(serum) Fasting Triglyceride 40-150 mg/100 mL (serum) Fasting Creatinine 0.6-1.5 mg/100 mL (serum) Fasting Glucose 70-100 mg/100 mL(plasma) Fasting Glucose (1 hr postprandial) 180 mg/dL (plasma) Values above this number are considered diagnostic for diabetes and require confirmation by other determinations.

Hemoglobin A1c 3.8-6.4% (plasma) Potassium 3.5-5.0 mEq/L (serum) Hematocrit Male: 45-52% Female: 37-48% Hemoglobin Male: 14-18 g/dl Female:12-16 g/dl Ferritin-iron deficiency 0-12 ng/mL 13-20 borderline (serum) Prealbumin 16 to 35 mg/dl (serum) Sensitive measure of nutritional status Albumin 3.5-5.0 g/100 mL (serum) Blood Urea Nitrogen 8-25 mg/100 mL (serum) Urine Tests Acetone plus acetoacetate Quantitative 0 Protein Quantitative <150 mg/24 h May require more information in diabetes Glucose Quantitative 0 24 hour or other timed specimen

204 PODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2003 www.podiatrym.com MedicalContinuing Education Nutrition... heme iron. The need for an iron care as well as provide supplement should be assessed. fatty acids. The precise role protein and 35 calories per Kg. of A CBC with a differential will of fatty acids in wound healing body weight may be needed. If the give an indication as to if there is a is unknown. However, they are a patient has nephropathy, a range of high white cell count, common in key ingredient of triglycerides and 1.0 to 1.5 gm of protein per Kg. of malnutrition and in infections. Pro- phospholipids that are major compo- body weight is recommended. If this tein intake should be monitored in nents of cell membranes. Also, unsat- cannot be accomplished with in- clients at risk for renal disease. Modi- urated fatty acids are precursors to creasing the amount of food a per- fication of protein intake should be- prostaglandins and other regulators son eats, enteral formulas can be an come a decision reached by the phy- of the immune and inflammatory alternative. sician, dietitian and the patient. processes. Therefore, it is reasonable A standard enteral formula has 40 There is suggestive evidence that to assume that a deficiency in fatty grams of protein per 1000 calories. several amino acids, particularly argi- acids likely results in sub-optimal The high-protein formulation, which nine and glutamine, appear to pro- wound healing. is better equipped to meet the re- mote wound repair. Arginine’s effect A blend of fats has been shown to quirements of wound healing pa- is linked to enhanced wound colla- be more beneficial in wound healing tients, has 60 grams of protein per gen synthesis and pituitary hormone than fats that come from a single 1000 calories. Studies suggest that for secretion; glutamine improves gut source; and because various fats have those patients who need a dietary al- mucosal repair and serves as fuel for different benefits than others, a fat ternative, high protein formulations the immunocytes. No improvement blend can play an advantageous role have been recommended. This is be- in wound healing has been demon- in the healing of wounds where a cause they have lower calorie-to-ni- strated using high-dose supplements high metabolic or physiologic stress trogen ratios and therefore are associ- of branched chain amino acid infu- situation exists or in wound healing. ated with increased nitrogen reten- sions. For this reason, a lipid profile in- tion and balance, improved serum cluding essential fatty acids, especial- protein levels and improved im- Carbohydrate Requirements ly omega 3 fatty acids, is critical. munological function. Clinically, this The role of carbohydrates, as is Why “essential?” Omega-3’s (and leads to reduction in the size of large the case with fats, is less well-defined omega-6’s) are termed essential fatty wounds and improved healing of than protein’s role. It is known, how- acids (EFA’s) because they are critical smaller wounds. It is important to ever, that the role of carbohydrates for good health; and a deficiency in note that exceeding protein require- and fats is to provide the energy them has been shown to inhibit tis- ments will not cause the wound to needed for cell proliferation that oc- sue regeneration. However, the body heal faster. curs in all phases of wound healing. cannot make them on its own. For An elevated BUN in elderly pa- Leucocytes, which are white blood this reason, they must be obtained tients on a high-protein diet should cells that perform phagocytosis, uti- from food, thus making outside not be of concern given that the pa- lize glucose as their primary fuel. Fi- sources of these fats essential. tient does not have a pre-existing broblast proliferation, the key to col- Although the body needs both renal condition, has normal creati- lagen formation, also depends on omega-3’s and omega-6’s to thrive, nine levels and the state of hydration glucose as their primary source of en- most people consume far more 6’s on physical exam is normal. Urea is ergy. It is clear that an abnormality than 3’s. Hardly a day goes by, how- not a toxic molecule and the buildup in glucose metabolism would be ex- ever, without reports of another of urea in this patient is of no conse- pected to have an effect on these health benefit associated with quence; and in a patient with a functions and therefore wound heal- omega-3’s. For this reason, many ex- wound, the priority is healing the ing. perts recommend consuming a better wound and not a normal BUN. The balance between these two EFA’s. risk of underfeeding and sub-optimal Fat Requirements There are three key omega-3 fatty protein consumption is non-healing Fat in the diet is an absolute ne- acids which include eicosapentaenoic and non-function. In patients who cessity for wound healing in a diabet- acid (EPA) and docosahexanoic acid are adequately fed or fed slightly ic. However, because granulation tis- (DHA), both found primarily in oily above what’s needed, elevated serum sue is an obligate glucose consumer, cold-water fish such as tuna, salmon, urea is a result of an extra amino acid it follows that adherence to a high- and mackerel. Aside from fresh sea- being changed to glucose. carbohydrate diet can be of benefit. weed, a staple of many cultures, Hematocrit and hemoglobin val- Some evidence exists in animal mod- plant foods rarely contain EPA or ues can be used as a gross indicator els that low-fat diets may be more DHA. of iron status in individuals with di- beneficial to wound healing than an However, a third omega-3, called abetes. Low values are generally as- over-all higher fat intake. Reduction alpha-linolenic acid (ALA), is found sociated with chronic blood loss, in total fat intake, especially saturat- primarily in dark green leafy vegeta- heavy menstrual bleeding, or gas- ed fats, is therefore recommended. bles, flaxseed and canola oil. Al- trointestinal bleeding. Diets low in Less than 30% of the calories con- though ALA has different effects on saturated fat and cholesterol that are sumed should be from fat and less the body than EPA and DHA do, the routinely prescribed for persons than 10% should be from saturated body has enzymes that can convert with diabetes often contain inade- fats. Fats, however, do help provide ALA to EPA. All three are important quate supplies of foods high in the fuel for all the phases of wound Continued on page 206 www.podiatrym.com NOVEMBER/DECEMBER 2003 • PODIATRY MANAGEMENT 205 Nutrition... It is needed for the hydroxylation of tein synthesis. It is also a co-factor for lysine and proline, an essential step collagen synthesis and cross-linkage. Continuingto human health and have in collagen synthesis, as well as cross- Therefore, even though it is some- been shown to be beneficial in linking. Wounds are metabolically what pro-inflammatory, Vitamin A is Medical Education supporting the immune functions more active than healthy connective still needed in wound healing pri- necessary in metabolic stress and tissue; therefore, increased concentra- marily for: wound healing. A deficiency in es- tions of vitamin C are needed to cre- 1. Collagen formation sential fatty acids has been shown to ate and maintain wound integrity. 2. Epithelial integrity inhibit tissue regeneration. Studies suggest that pressure ulcer pa- 3. Immune function In addition, some of the omega-6 tients supplemented with very high Vitamin A deficiency may de- fatty acids which include linoleic doses of vitamin C had reduced pres- crease epithelialization, collagen syn- acid, also found in some vegetable sure sore areas when compared with thesis, production of macrophages, oils, may result in suppression of patients who had no vitamin C sup- and overall resistance to infection. some vital components related to the plementation. (T). A vitamin C defi- Beta-Carotene, improves serum normal immune response, a pro- ciency will cause the following com- retinol levels and enhances immune longed inflammatory response and plications: function. increased catabolism. These adverse 1. Increased capillary fragility responses may be antagonistic to the 2. Delayed wound healing The B Vitamins optimum wound healing response. 3. Decreased tensile strength of The B Vitamins also play a crucial wounds and poor scar formation role in wound healing. Generally, Vitamins, Minerals, Trace These three factors are associated they assist in white blood cell func- Elements and Micronutrients with a more common occurrence of tion and aid the body in resisting in- A number of vitamins, miner- all types of wounds as well as a high- fection. als, trace elements and micronutri- er incidence of wounds re-opening Thiamine, Vitamin B1, is impor- ents have been evaluated for their and reoccurring. tant in collagen formation and is a effect on wound healing. The in- cofactor in collagen cross-linking. Vi- creased need for these nutrients Vitamin A tamin B1 is found in Brewers yeast, has been documented in studies Vitamin A is a fat-soluble vitamin unrefined cereal grains, organ meats, where nutrient losses associated that occurs in two forms in nature. It pork, legumes, nuts and seeds. A defi- with wound healing and injury is found in its true form (also called ciency has been found to be associat- have been observed. retinol) in animal foods such as fish ed with peripheral neuropathy. oils and liver. The body readily uses Pantothenic Acid, Vitamin B5, is a Vitamin C this form. component of the coenzyme A Chief among these nutrients is vi- Vitamin A can be found in veg- molecule as well as being part of the tamin C because it is a water-soluble etables in the form of beta-carotene carrier proteins involved in fatty acid vitamin and not stored in the body. or provitamin A. This form is found metabolism. It helps release energy Therefore, a deficiency can occur in plants and is the precursor of the from fat, carbohydrate, and keto- very quickly in stressed or wound actual vitamin. Beta-carotene has to genic amino acids. It is essential for healing patients whose requirements be converted in the body in order to the functioning of fibroblasts, the are dramatically increased. Theoreti- be used by it. Fat and bile are needed collagen-producing cells. A deficien- cally, extensive wounds can exhaust for the conversion. cy is associated with poor immune vitamin C stores. The liver regulates the blood level function, compromised wound heal- The role of Vitamin C in wound of vitamin A. It needs a protein carri- ing and diminished graft take. care is to augment the speed and er to be transported throughout the Vitamin B2 is a co-factor in colla- strength of the healing. This is done body. An adequate protein and fat gen cross-linking. It is found in broc- through enhancing tissue regenera- intake is required for a good absorp- coli, spinach, asparagus, meat, poul- tion through three avenues: tion of vitamin A. try, fish, yeast, egg whites, dairy 1. Increased deposition of Vitamin A is an anti-oxidant, a products and fortified grain products. collagen compound that may protect against Vitamin B6 is a co-enzyme that 2. Fibroblast activity disease by neutralizing unstable oxy- stimulates wound healing and assists 3. The formation of granulation gen molecules, called free radicals, in activating protein synthesis. It is tissue. within the body. This vitamin is in- found in chicken, fish, kidney, liver, Also, because it is an anti-oxi- volved in cellular growth, moderates bananas, eggs, soy beans, oats, dant, Vitamin C protects tissues from cell differentiation and reproduction peanuts and walnuts. superoxide damage. as well as reverses the inhibitory ef- Vitamin B12 is a co-enzyme for Deficiencies promote collagen in- fects on growth and wound healing protein and DNA synthesis and also stability, decreased collagen forma- by corticosteroids. It also maintains stimulates wound healing and helps tion and decreased tensile strength of the health of the skin and surface tis- activate protein synthesis. It is found the wound. Profound deficiencies sues, especially those with mucous in meat, fish, poultry and eggs. may promote capillary fragility. If a linings, an important factor in Folic Acid (Vitamin B9) is needed deficiency exists, it must be supplant- wound healing and prevention of in- for the metabolism of amino acids and ed immediately because vitamin C is fection. Vitamin A enhances tissue in nucleic acid synthesis and thus for pivotal in the formation of collagen. regeneration by aiding in glycopro- Continued on page 207

206 PODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2003 www.podiatrym.com MedicalContinuing Education Nutrition... deficit, a wound will not heal. it influences affinity for Calcium, essential for collagen oxygen, thus affecting tissue the manufacturing of DNA. In wound synthesis, is required for both the re- oxygenation. It also is involved healing, this translates to being a key modeling process and the degrada- in the metabolism of carbohy- factor in resisting infection. tion of collagen through the action drates, protein and fat, and is essen- of collagenases. Calcium is found in tial for the maintenance of acid-base Vitamins E & K dairy products, sardines, oysters, kale, balance and required for normal Vitamin E has antioxidant proper- greens and tofu. nerve and muscle function. It is an ties that promote cell membrane in- Copper promotes the cross-link- essential component of many en- tegrity. Supplementation has been ing reactions of collagen and elastin zyme systems and many hormones shown in clinical studies to accelerate sythesis. It also is involved in free are dependent on phosphorylation. the healing of chronic stasis ulcers. It radical elimination. These are critical Milk is an excellent source of phos- is found in wheat and rice germ, veg- factors in wound healing. Also, cop- phorus. etable oil, dark green leafy vegetables, per is required for the maintenance Selenium is a necessary part of nuts and legumes. and repair of bones. Supplementa- collagen synthesis, as it protects the Vitamin K is essential for coagulation has been shown to potentially cell membrane lipids from oxidant tion, a necessary prerequisite for increase the rate of healing of bone damage. Selenium is found in seafood, wound healing and is found in green fractures. kidney, liver, meats and grains. leafy vegetables, dairy products, Copper is found in whole grain meat, eggs, cereals and fruit. breads and cereals, shellfish, organ Other Therapeutic Modalities meats, poultry, dried peas and beans, Pharmacologic modulation of cy- Trace Elements and dark leafy vegetables. A copper tokines, prostaglandins and the use Trace elements and micronutri- deficiency can show up as impaired of anabolic agents such as hormones ents are lost through wound exu- glucose tolerance and/or anemia. and growth factors may prove to fur- dates and must be replaced for prop- Iron is necessary for the hydrox- ther enhance wound healing. The er wound healing to occur. These in- ylation of lysine and proline in colla- use of growth hormone is the best clude zinc, calcium, copper, iron, gen synthesis and is needed to trans- studied to date, but remains contro- magnesium, chromium, phosphorus port oxygen to the wound bed. Iron versial. Recombinant growth hor- and selenium. Zinc is essential for deficiency results in tissue hypoxia mone has been found to support en- wound healing. Similar to Vitamin C, and therefore interferes with wound hanced wound healing, although zinc is not stored in significant healing. If the deficiency is pro- there is evidence of increased infec- amounts. It is found commonly in longed, anemia could develop, which tious morbidity and mortality in crit- oysters, dark meat turkey, liver, lima further interferes with the wound ical care and burn patients that have beans and pork. Zinc is an essential healing process. Iron is plentiful in used growth hormone. Alpha-lipoic trace element and important in egg yolk, red meats, dark green leafy acid is being researched as an antioxi- wound healing due to the following: vegetables, enriched breads and cere- dant potential with its effect on 1. It is a co-factor in about one als, legumes and dried fruits. glycemic control. hundred enzymatic reactions Magnesium is a co-factor for en- 2. It is essential for the transcrip- zymes involved in protein and colla- Malabsorption/Maldigestion tion of RNA gen synthesis. Low levels play a role The condition of malabsorption 3. It promotes protein synthesis, in carbohydrate intolerance and re- (or maldigestion) has to be discussed collagen formation and cellular repli- sistance to insulin. Deficiency is rare. as it can create a state of malnutri- cation Magnesium is found in nuts, tion. Malabsorption can be defined 4. It mobilizes retinol-binding legumes, unmilled grains, green veg- as impaired absorption of fat, carbo- protein and albumin etables and bananas. hydrate, protein, vitamins, elec- 5. It is essential in the synthesis Chromium potentiates the ac- trolytes, minerals, or water. Clinical of albumin tion of insulin and therefore inter- manifestations include unexplained 6. It plays a key role in tissue re- plays with glucose, protein, and lipid weight loss, steatoarrhea, diarrhea, pair metabolism. A chromium deficiency anemia, tetany, bone pain and Deficiency of zinc may occur sud- can lead to impaired glucose and pathologic fractures, bleeding, der- denly and quickly, especially in pa- amino acid utilization, increased matitis, neuropathy, glossitis, and tients that are medically, metaboli- plasma LDL-cholesterol levels, and edema. There are many tests avail- cally and/or physiologically compro- peripheral neuropathy. Carbohydrate able for determining the type and ex- mised. Serum zinc may already be intolerance and insulin resistance is tent of the malabsorption problem. low in wound patients as a result of related to chromium deficiency, The co-morbidities of diabetes, their being malnourished. When zinc which is rare. To date, the only which may potentiate malabsorption is deficient, collagen synthesis and chromium deficiency reported has of nutrients or accelerate their losses tensile strength of the wound is di- been in patients receiving parenteral include gluten-sensitive or diabetic minished and there are abnormalities nutrition without adequate chromi- enteropathy with bacterial over- in neutrophil and lymphocyte func- um replacement. growth, previous gastric surgery, tion. The end result is an increased Phosphorus is a critically im- large gaping wounds, Crohn’s dis- risk for infection and delayed wound portant element in every cell. A com- ease, diverticular disease, radiation healing. Generally, if there is a zinc ponent of membrane phospholipids, Continued on page 208 www.podiatrym.com NOVEMBER/DECEMBER 2003 • PODIATRY MANAGEMENT 207 Nutrition... abetic patient, especially when plan- healing and the podiatric physician ning an operative procedure. Poorly is seemingly doing everything right: Continuingenteritis, enteric fistulas, HIV, controlled diabetes contributes to ruling out all skin diseases, assuring any pancreatic insufficiency, short poor wound healing and has deleteri- glycemic control, maintaining ade- Medical Education bowel syndrome, or prolonged use ous effects on outcomes, including quate circulation, controlling infec- of total parenteral nutrition, where skeletal, neural, smooth muscle and tion, off-loading the wound, keeping deficiencies of magnesium and/or immune dysfunction. Factors that the wound clean and free from con- chromium may become evident. may precipitate hyperglycemia, such tamination, debriding the necrotic These diseases may be associated as infection, overfeeding, volume de- and senescent tissue and using dress- with diarrhea which can precipitate pletion, medications, and inadequate ings that are creating an appropriate or exacerbate the malabsorption. The insulin or oral medications, should wound environment. In other words, patient with enteropathy complicat- be quickly addressed. Hypoglycemia the podiatric physician must not for- ed by bacterial overgrowth is at risk can be harmful to the healing process get about the patient’s nutritional for vitamin B12 and folate deficien- as well. Gastroparesis, hepatitis, sep- status. cies because the small bowel is un- sis associated with nephropathy, dis- In the final analysis, healing a able to incorporate these vitamins. continuation of nutritional support, wound in a person with diabetes can Gastric bypass surgery for obesity or a resolution of the stress response, or be as difficult as leading an orchestra partial gastrectomy for peptic ulcer weaning from steroid therapy can all made up of un-tuned instruments. disease may increase a patient’s risk contribute to a hypoglycemic re- Diabetes is a multi-system disease for vitamin B12, calcium and/or iron sponse. Maintaining glucose levels and all the systems have to be in har- deficiencies. Short bowel syndrome between 100 and 150 mg/dL is a rea- mony to achieve an optimal out- with resection of any portion of the sonable goal. come. These systems need the appro- terminal ileum increases the likeli- It is interesting to note that poor priate fuel. Nutrition supplies that hood of deficiency of any of the fat- control of postoperative hyper- fuel, and therefore nutrition is the soluble vitamins. Large gaping glycemia in a recent study predicted key to creating the energy that drives wounds can be a source of Vitamin C the likelihood of serious infection. the process of wound healing. ■ and/or zinc deficiency. Patients with blood sugar levels over Knowledge of the patient’s medi- 220 mg/dl on the first day following References for Additional cal history and selection of an appro- surgery had a 24.6% incidence of se- Information priate supplement or enteral product rious infection, compared with 4.2% 1. Powers, M. A., MS, RD, CDE : may help diminish the effects of the in patients with blood sugar levels Chapter 3: Medical Nutrition Therapy for malabsorption problem. However, under 220 mg/dl. Patients receiving Diabetes, Handbook of Diabetes : Medical Nutrition Therapy, Aspen Publishers, Inc depending upon the extent of the total parenteral nutrition had higher Guthersberg, MD, 1996. disease, parenteral nutrition may mean glucose levels and required 2. McClave, S A. and Finney, L S.: even be necessary in selected pa- more insulin to maintain optimum Chapter 8: Nutritional Issues in the Pa- tients. Formulations composed of serum glucose levels. tient with Diabetes and Foot Ulcers, Levin MCT’s (medium chain triglycerides) For any patient with diabetes on and O’Neal’s The Diabetic Foot sixth edi- may control the diarrhea and other an oral diet, nutritional manage- tion, John H. Bowker, M.D. Michael A. complications associated with malab- ment, whether or not a foot ulcer is Pfeifer, M.D., Mosby Publishers, Inc. St. sorption. present, should be founded on an in- Louis, MO, 2001. Medications the patient is taking dividualized meal plan based on rec- 3. Mayes, T, RD and Gottschlich, can affect wound healing and/or ommendations set forth by a dieti- MM, PhD, RD, CNSD: Chapter 19: Burns and Wound Healing The Science and control of glucose levels. Corticos- tian or the guidelines established by Practice of Nutrition Support, Michele teroids often inhibit wound healing the American Diabetes Association. Morath Gottschlich, PhD, RD, CNSD, by interfering with connective tissue Meals should be at consistent times Kendall/Hunt Publishing Company formation, collagen synthesis, and synchronized with the peak action of Dubuque, IA 2001. wound retraction. Non-steroidal anti- their insulin or oral medication. 4. Video by Clinitec Nutrition Com- inflammatory medication improves Focus on food choices and an opti- pany: Nutrition for Professionals: Nutri- wound strength but may adversely mal weight for the individual patient tional Aspects of Wound Healing, 1993. affect the rate of wound re-infection is recommended. Approximately 10 due to its effect on a patient’s immu- to 20% of calories should be from Dr. Rehm, board nity. Cyclosporins, sympathomimet- protein sources and less than 30% of certified in dia- ics, and corticosteroids may con- the calories as fat (less than 10% betic wound tribute to poor glycemic control. It is from saturated fat). The remaining care, practices important to investigate all medica- calories should be made up of carbo- in San Diego, tions and supplements that the pa- hydrates. Ethanol intake should be CA. He lectures tient is taking because of the pro- restricted, substituting alcohol calo- nationally and found effect that they may have. ries for fat exchanges and limiting in- offers seminars for podiatrists take to two alcoholic beverages a day and other pro- Control of Serum Glucose Levels to those on insulin. fessionals. Dr. Glycemic control is an essential In healing a diabetic foot wound, Rehm is Director of the Diabetic Foot component to nutritional therapy as nutritional therapy may be the miss- and Wound Treatment Centers in it applies to healing a wound in a di- ing link when the wound is just not San Diego.

208 PODIATRY MANAGEMENT • NOVEMBER/DECEMBER 2003 www.podiatrym.com MedicalContinuing Education EXAMINATION

See answer sheet on page 211.

1) Nutritional Management of a abundant in alpha lipoic Acid ing T.V. diabetic patient with or without D) Choosing foods that are C) Never snack in between a foot ulcer should be based on: low in linoleic acid meals A) A high fat diet containing D) Correction of chewing Omega 3 fatty acids 5) Which of the following are abnormalities B) A low fat diet high in the least instrumental in healing Omega 6 fatty acids a diabetic foot wound? 10) The four phases of wound C) Recommendations set A) Vitamin C healing are the following: forth by the American Dia- B) Vitamin A A) Hemostatic, catabolic, an- betes Association C) Vitamin E abolic and reparative D) Meals that are consistent D) Trace boron B) inflammatory, reparative, with the patient’s appetite catabolic and remodeling 6) Zinc is an important trace ele- C) Catabolic, anabolic, home- 2) All of the following are true ment because: ostatic, maturation statements except: A) It is a co-factor in catabolic D) Hemostatic, inflammatory, A) Meals should be at consis- reactions connective tissue, epithelial tent times synchronized with B) It potentiates the action of the action of the patient’s DHA 11) A poor nutritional status in a medication C) It is essential for the tran- diabetic patient most likely is due B) Meals should be based on scription of RNA to all of the following except: an individualized meal plan D) It immobilizes the harmful A) Poor appetite C) Focus should be food effects of retinol-binding B) Steatorrhea choices and the ideal weight protein C) Metabolic problem for any person of the same D) Inability to digest or swal- height and weight 7) Vitamin K is essential for the low properly D) Ethanol intake should be following reason: limited to two alcoholic bev- A) It is needed for the metab- 12) Which of the following state- erages per day to those on in- olism of amino acids ments is the least accurate? sulin B) It has anti-oxidant proper- A) Boron is a critical element ties that promote cell mem- in wound healing 3) The basic principles of healing brane integrity B) Copper promotes the a diabetic foot wound include C) It is a coenzyme for DNA maintenance and repair of all of the following concepts synthesis bones except: D) It is essential for C) Calcium is involved in the A) Keeping a wound dry until coagulation degradation of collagen a scab is developed always al- D) Deficiency of zinc may lows optimal healing 8) A comprehensive nutritional occur suddenly B) A wound should be main- assessment should evaluate all of tained with little or no pres- the following except: 13) Which of the following state- sure insult A) The ratio of complex vs. ments is not true? C) Adequate circulation to simple carbohydrates A) Pharmacologic modulation the wound site is absolutely consumed of cytokines may enhance necessary B) Macro- and micronutrient wound healing D) Contamination in a heal- intake B) The use of growth hor- ing wound should be avoided C) Comorbidities mone has become part of the D) Medications standard of care 4) The ability of a patient to heal C) The use of growth hor- a foot ulcer is mostly affected by: 9) Basic principles of nutritional mone is associated with in- A) Hypoglycemia in the in- management of patients with di- creased risk of morbidity and flammatory phase of wound abetic foot wounds include the mortality in burn patients healing following: D) Alpha-lipoic acid is being B) Consuming foods that are A) Never force yourself to eat researched for its role in dia- high in DHEA beyond your appetite betes and wound healing C) Avoiding foods that are B) Never eat while watch- Continued on page 210 www.podiatrym.com NOVEMBER/DECEMBER 2003 • PODIATRY MANAGEMENT 209 EXAMINATION PM’s Continuing (cont’d) Medical Education CPME Program 14) Which of the following is the most likely Welcome to the innovative Continuing Education cause of malabsorption and maldigestion: Program brought to you by Podiatry Management A) Marasmus B) Kwashlorkor Magazine. Our journal has been approved as a C) Weight gain sponsor of Continuing Medical Education by the D) Pancreatic insufficiency Council on Podiatric Medical Education. 15) Vitamin A deficiency affects wound care in all of the following ways except: Now it’s even easier and more convenient A) Decreases epithelialization to enroll in PM’s CE program! B) Produces an increase in T- lymphocytes You can now enroll at any time during the year C) Decreases resistance to infection and submit eligible exams at any time during your D) Decreases collagen synthesis enrollment period. 16) All of the following are important trace PM enrollees are entitled to submit ten exams elements or micronutrients in wound published during their consecutive, twelve–month healing except: enrollment period. Your enrollment period begins A) Bismuth B) Zinc with the month payment is received. For example, C) Copper if your payment is received on September 1, 2001, D) Iron your enrollment is valid through August 31, 2002. 17) Which of the following is not used for If you’re not enrolled, you may also submit any the diagnosis of protein malnutrition? exam(s) published in PM magazine within the past A) Albumin twelve months. CME articles and examination B) Pre-albumin C) Total Protein questions from past issues of Podiatry Man- D) BUN agement can be found on the Internet at http://www.podiatrym.com/cme. All lessons 18) Which of the following is not likely to are approved for 1.5 hours of CE credit. Please read cause an elevation in pre-albumin levels: A) Corticosteroid therapy the testing, grading and payment instructions to de- B) Digestive disorders cide which method of participation is best for you. C) Hyperactive adrenal glands Please call (631) 563-1604 if you have any ques- D) Hodgkin’s disease tions. A personal operator will be happy to assist you. 19) All of the following are likely to Each of the 10 lessons will count as 1.5 credits; interfere with pre-albumin levels except: thus a maximum of 15 CME credits may be A) Inflammation B) Amiodarone earned during any 12-month period. You may se- C) Estrogens lect any 10 in a 24-month period. D) Beta Carotene

20) Patients with diabetes and foot ulcers The Podiatry Management Magazine CME are likely to have all of the following except: program is approved by the Council on Podiatric A) Higher levels of fibrinogen Education in all states where credits in instruction- B) Higher levels of C-reactive protein C) Higher levels of thyroid hormone al media are accepted. This article is approved for D) Lower albumin levels 1.5 Continuing Education Contact Hours (or 0.15 CEU’s) for each examination successfully completed.

PM’s CME program is valid in all states See answer sheet on page 211. except Kentucky and Pennsylvania.

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