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The Role of Nutrition in Chronic Wound Care Management

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The Role of Nutrition in Chronic Wound Care Management THE DIABETIC FOOT The Role of Nutrition in Chronic Wound Care Management What patients eat affects how they heal. BY LELAND JAFFE, DPM AND STEPHANIE WU, DPM, MSC he multi-faceted approach tients who are malnourished may plying the body with glucose. During to the management of lack the necessary fundamental this stress response with increased chronic wounds can be a building blocks to promote tissue re- cortisol production, elevated levels daunting challenge. Treat- generation, leading to wound chro- of inflammatory cytokines, including 77 ment strategies for chronic nicity.1 Patients may be malnourished interleukin 1 (IL-1), interleukin 6 (IL- Twounds of the lower extremity often for a number of reasons, including 6), and tumor necrosis factor alpha entail a multidisciplinary approach limited financial resources, lack of will be elevated, contributing to a focusing on therapies, including off- family support, dietary constraints, delay in wound healing.4 loading modalities, serial wound anxiety, depression, and diminished This systemic inflammation will debridements, assessment of arte- appetite. Malnourishment ensues if a also cause a decrease in negative rial vascular inflow, and managing patient’s nutritional intake does not acute phase reactants including al- bacterial bioburden. While these do meet the body’s metabolic demands. bumin and pre-albumin.4 With con- represent the major pillars of chron- ic wound management, evaluation and optimization of nutritional sta- tus should be included as part of Evaluation and optimization of nutritional status the comprehensive treatment of the should be included as part of the comprehensive chronic wound patient. Hippocrates in 5th century B.C. treatment of the chronic wound patient. recognized the value of nutrition and the potential of certain foods for good health and said “Let food be thy Malnutrition tinual lack of nutritional intake, the medicine and medicine be thy food.” Malnutrition is defined as loss body will begin metabolizing fat for Wound healing requires the body to of body tissue and diminished body energy, sparing the sustained break- be in an anabolic state that necessi- functions caused by inadequate nutri- down of muscle tissue for protein.3 tates specific macro- and micronutri- tional intake.2 Firstly, during a period This transition from primarily pro- ents as well as proper hydration to of malnourishment the patient will tein to fat metabolism will minimize fuel the physiologic process. Since deplete the liver’s glycogen stores to muscle and overall weight loss. A dietary depletion may contribute to ensure glucose is continually sup- consequence of adipose tissue de- wound chronicity,1 proper assess- plied to vital body cellular functions. pletion, however, may contribute to ment of nutritional status is para- However, glycogen stores are often increased pressure on osseous prom- mount to predict healing potential. depleted within the first 24 hours inences leading to pressure ulcer for- The complex wound healing cas- following starvation. The continued mation. cade progresses from hemostasis, stress of starvation will increase the Following the depletion of fat inflammation, proliferation, and ul- metabolic rate and result in the re- stores, the body will again rely pri- timately tissue remodeling. Among lease of cortisol from the adrenal marily on skeletal muscle for energy other factors, this process relies on glands.3 This will improve the body’s demands, resulting in rapid weight adequate levels of macro-and mi- ability to mobilize amino acids from loss and overall cachexia. Clinically, cro-nutrients to ensure a timely pro- protein sources to support hepatic a malnourished status will contrib- gression through these stages. Pa- gluconeogenesis and continually sup- Continued on page 78 www.podiatrym.com NOVEMBER/DECEMBER 2017 | PODIATRY MANAGEMENT THE DIABETIC FOOT Nutrition (from page 77) and localized/generalized edema.11 inflammatory phase of healing are The prevalence of obesity, defined primarily protein-driven and include ute to impaired immunity,5 decreased as a body mass index (BMI) > 30, is macrophages, phagocytes, leukocytes, muscle mass leading to weakness on the rise in the United States and and lymphocytes.18 With a blunted and immobility,6 and an overall de- involves 36.5% of the adult popula- immune response and a diminished crease in wound healing potential.7 tion.12 Obesity should not rule out the inflammatory phase of wound healing possibility of a malnourished status, due to protein deficiency, clearing of Assessment of Nutritional Status as excess adipose tissue may conceal cellular and bacterial debris will be Nutritional status associated with underlying skeletal muscle atrophy.13 compromised. This could prolong the an increased risk for the develop- Moreover, adipose tissue is con- inflammatory phase of wound healing ment of ulcers include reduced body sidered poorly vascularized, causing a and limit the ability to progress to- mass index (BMI), low body weight, further delay in wound healing due to wards tissue proliferation. A decrease altered ability to dine independent- decreased oxygenated blood flow to a in protein availability will also de- ly, reduced food intake, low dietary wound bed. Anthropometric measure- crease fibroblastic activity and colla- protein intake, low serum albumin concentration (<3.5 mg/dL), and de- creased total lymphocyte count (< A thorough nutritional screening mechanism 1.8 x 109/L). While no cause-effect re- lationship can be established between is important to identify patients malnutrition and ulcer formation, a thorough nutritional screening mech- at risk of a potential nutritional deficit. anism is important to identify patients at risk of a potential nutritional deficit. 78 ments include patient’s BMI, recent gen production during the prolifera- The Mini Nutritional Assessment weight loss, and head circumference tive stage of healing.19 (MNA) (in children). Unintentional weight loss Protein malnutrition can pres- The Mini Nutritional Assessment of <5% in 6 months is defined as mild ent in a patient with decreased pro- (MNA) is a frequently referenced tool loss, 5-10% as moderate-severe loss, tein intake, absorption, or metabo- to assist in identifying malnutrition, and >10% as severe loss of weight.14 lism, contributing to insufficiencies particularly in the elderly popula- in LBM. Protein deficiency may also tion.8 The MNA screening tool eval- Macronutrients in Wound Healing stem from a deficiency in certain uates multiple parameters, including Wound healing is an anabolic amino acids such as arginine and food intake and decline, weight loss, event that requires adequate intake glutamine. Arginine is a condition- mobility, neuropsychological prob- of macronutrients, including carbo- ally essential amino acid, especially lems, BMI, and calf circumference hydrates, fats, protein, and water. during times of stress. It is acquired to define nutritional risk. Patients Fats provide about 9 kcal per gram, from diet and derived endogenous- frequently recognized as high risk carbohydrates about 4 kcal per gram, ly from citrulline in a reaction cat- for nutritional deficit include the el- and protein about 4 kcal per gram. alyzed by arginine synthetase. Ar- derly, patients with food intolerance Protein is a macronutrient that is ginine functions as a precursor to (chemotherapy), limited income, de- critically important during the entire collagen formation and production pression, lack of teeth/dentures, and cascade of the wound healing pro- of nitric oxide, thus promoting tis- inability to self-feed. cess. Protein stores within the body sue formation and oxygenation of the Patients with diabetes and ulcer- may be diminished due to overall wound.20,21 ations have also been recognized as decreased intake, or excessive daily Glutamine is another amino acid a cohort at risk of malnutrition, re- protein loss via wound exudate.15 The that has been suggested to serve sulting in a poor prognosis of heal- daily recommended protein intake a function during the cascade of ing.9 Zhang and colleagues identified for a healthy individual is 0.8 grams wound healing.16 As with arginine, that as the severity of the Wagner of protein per 24 hours. This number glutamine is conditionally essential diabetic foot ulceration classification may vary based upon activity level, during injury or disease as demand increased, the patient’s nutritional total caloric intake, and gender. outstrips supply. It is involved in status declined.9 Patients with open wounds, how- protein synthesis as a precursor for Assessment of nutritional status ever, may require an additional 1.25 nucleotides and glutathione and is es- also includes anthropomorphic data to 1.5 grams of protein per kilogram sential for immune system function. and an overall clinical assessment of of body weight to support the anabolic Glutamine serves as a fuel source for the patient. The physical examina- process of wound healing.16 The body fibroblasts, epithelial cells, lympho- tion includes findings such as coarse increases protein demand about 250% cytes, and macrophages, and indi- hair and reduced skin turgor.10 Other and caloric demand 50% to support rectly assists in the process of inflam- clinical findings suggestive of nutri- synthesis of new tissue and maintain mation and phagocytosis. Therefore, tional depletion include muscle at- lean body mass (LMB) stores.17 supplementation of glutamine has rophy, reduced subcutaneous tissue, Numerous factors involved
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