Review: Nutritional support for the patient with wounds: food intake and supplementation

Nutritional support for the patient with wounds: food intake and supplementation

Greyling CP, BSc Dietetics, PU for CHE (North West University) Dietitian in Private Practice, Welkom Medi-Clinic, Meulen Street, Welkom Correspondence to: Christiaan Greyling, e-mail: cpgreyling@telkomsa.net Wound Healing Southern Africa 2010;3(1): 33-36

Introduction
The daily intake of food is an activity that is associated with life and the maintenance thereof. Unfortunately, there is more to food than meets the eye and what is eaten is not necessarily exactly what the body needs. When confronted with skin breakdown and wounds, evidence is mounting1,2,3,4 to support the notion that intake of food and additional nutritional supplementation in these individuals are paramount in facilitating the wound healing process. It is a well known fact that wounds heal the quickest in well-nourished patients.4,5 Supplementation can play a vital role as discussed later in this article, but it is important that basic nutrition should be in place. General Nutritional Guidelines5 and the South African food based dietary guidelines6: Use fresh foods as much as possible to elevate the intake of vitamins/minerals, and decrease the use of additives/ preservatives. Increase the intake of fish and white meats, nuts, beans and pulses since they are lower in saturated fat. Decrease the intake of red meat (23/week) to reduce saturated fat intake. Increase the intake of oily fish such as sardines, mackerel, trout, salmon, herring (23/week) to increase omega-3 polyunsaturated fats and natural intake of vitamin D. Use other poly- and mono-unsaturated fats/oils in moderation (sunflower oil, olive oil) rather than butter and hard fats. The Food Based Dietary Guidelines for healthy eating for South Africans older than seven years states that it is important to: Enjoy a variety of foods. Be active. Make starchy foods the basis of most meals. Eat dry beans, split peas, lentils and soya regularly. Chicken, fish, milk, meat or eggs can be eaten daily. Drink lots of clean, safe water. Eat plenty of vegetables and fruits every day. Eat fats sparingly. Use salt sparingly. Use food and drinks containing sugar sparingly and not between meals. If you drink alcohol, drink sensibly.

Nutrients that play a role in skin repair

Macronutrients Energy, Protein, Carbohydrates and Fat Energy (E) Total energy intake is most probably the most important aspect in the prevention of malnutrition and tissue breakdown. The basic energy requirements are normally: 2535 kCal/kg (105147 kJ/kg). Energy intake can be negatively influenced by a number of aspects such as difficulty to eat, taste and or texture preferences, social aspects, dysphagia, gastro-intestinal (GI) disorders and depression. Wounds and trauma or surgery can increase the basic need of energy. The first step to prevent malnutrition is to monitor if the patient consumes enough food by weighing the patient regularly. In this way unwanted or unmonitored weight loss can be identified quickly. Easy questions to ask a patient during a basic assessment should include the following5: Have you been eating less than usual? Have you experienced vomiting or diarrhoea recently? What is your normal weight? Have you lost weight recently? How tall are you? Have you noticed any change in appetite recently? Energy intake in the patient at risk for malnutrition can easily be increased to 3540 kCal/kg (147168 kJ/kg) to prevent weight loss or for those who are underweight2 to start out with. Energy intake is very dependent on maintenance of a balance as over-nutrition also has its own negative effects especially on immunity and possible re-feeding syndrome.1,2 The importance of glycaemic control cannot be emphasised enough. Protein Protein is required for the synthesis of new tissue. Deficiency adversely affects wound healing by blunting the fibroblastic response, new blood vessel formation, collagen synthesis, and wound remodelling processes.7,8 A minimum protein goal is normally in the range of 11.5 gram/kg/day (1220% of total E intake). Calculations should be based on actual body weight, which should be adjusted in the presence of oedema, chronic renal impairment (lower protein for conservative renal impairment treatment) and especially in the older patient, since too high protein intake can result in dehydration.7,8

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Review: Nutritional support for the patient with wounds: food intake and supplementation

Specific amino-acids may influence the healing process e.g. arginine appears to influence wound healing favourably by affecting microvascular and perfusion changes, enhancing collagen production via proline synthesis.1,2,7 Glutamine serves as a fuel source for cells with rapid turnover, such as enterocytes, epithelial cells, fibroblasts, macrophages and lymphocytes. In patients with burns, glutamine supplementation has resulted in faster wound healing rates.2,7,8,9 No studies have been conducted on glutamine and wound healing for pressure ulcers. Neither the NPUAP (National Pressure Ulcer Advisory Panel) nor the EPUAP (European Pressure Ulcer Advisory Panel) recommends routine glutamine supplementation for pressure ulcers.2 Carbohydrates Carbohydrate in the form of glucose is the major fuel source for collagen synthesis which is the building block of tissue.8 It should however be stated that it is not necessary to take in pure glucose since it can affect the blood glucose levels negatively. When carbohydrates are taken in, the body will break them down to glucose, therefore low glycaemic index (low GI) carbohydrates are recommended since they can be beneficial in controlling blood glucose levels and release glucose over a longer period of time to the body. Intake of a variety of carbohydrates is very important and emphasis should be placed on including whole grains in the diet since they contain all three layers of the grain (bran, germ, and endosperm).10 Examples of whole grains include brown rice, wheat (koring), barley (gort), oats, and whole mealies (corn on the cob/ green mealies). The general guideline is that carbohydrate intake should consist of 5060% of the total daily energy intake. Fats Except for normal fat intake for energy, omega-3 fatty acids play an important role in the immune functions and have been shown to be beneficial pre- and postoperatively in facilitating quicker recuperation of these patients.7 Trans-fats and hydrogenated oils should be avoided due to their negative health effects. Intake of olive oil may also play a role in decreasing inflammation and improving endothelial function.10 Fat is also responsible for the normal functioning of all tissue and helps transport nutrients across the cell membrane.4 Total fat intake 3035% of total energy intake. Saturated fat < 10% of total energy intake. Poly-unsaturated fat 410% of total energy intake. Mono-unsaturated fat should make up for the balance of the fat intake.11 Micronutrients Vitamin A, C, D, E, Zinc, Copper, Iron
Table I: Vitamin A guidelines2,14 Gender Age in years 3150 3150 Estimated average requirement (EAR) 625 g/2,083 IU 500 g /1,667 IU Recommended dietary allowance (RDA) 900 g/3,000 IU 700 g/233 IU

Vitamin A Vitamin A stimulates various aspects of wound repair by a number of mechanisms. It affects fibroplasia, collagen synthesis, epithelialisation, angiogenesis, and is involved in the inflammatory processes with specific stimulatory effects on macrophages, which play a dominant role in wound healing. Vitamin A is essentially beneficial in stimulating wound healing that has been retarded by the use of corticosteroids. It has also been demonstrated that it can reverse impaired wound healing caused by serious injuries, tumours, and radiation.12 Food sources Vitamin A Liver, kidney, milk fat (cream), fortified margarine, egg yolk, yellow and dark green leafy vegetables, apricots, cantaloupe (spanspek/ orange-fleshed melon), peaches, fish liver oil.5,13 Vitamin C Vitamin C plays a critical role in wound healing and collagen formation and a deficiency can have a crucial effect on wound healing. During vitamin C deficiency, fibroblasts produce unstable collagen which provides a weak structural framework for tissue repair. Vitamin C is also important for proline and lysine hydroxylation, collagen synthesis and cross-linkage. High dosages of vitamin C may however cause diarrhoea which may increase the risk factor for the development of decubitus ulcers (pressure sores).4,7,12,15,16 Food sources Vitamin C Citrus fruit, tomato, melon (orange/green), peppers, broccoli, brussel sprouts, raw cabbage (e.g. cole slaw), guava, strawberries, pineapple, potato, kiwi.5,13
Table II: Vitamin C guidelines2,14 Gender Age in EAR RDA UL LOAEL Recommended years mg/day mg/day mg/day mg/day serum levels Male 3150 75 90 2,000 3,000 Serum ascorbic acid 0.4-2.0 mg/dL* Female 3150 60 75 2,000 3,000
x NOAEL 2000 mg/day. * Please note that this is the values used in reference 2 and that local laboratory values may differ

Vitamin D Calcitriol, a metabolite of vitamin D has been shown to have an important regulatory function of cellular differentiation and proliferation.15 Many hospitalised and institutionalised patients might have a vitamin D deficiency due to low sun exposure. Food sources Vitamin D Milk fat (cream), liver, egg yolk, salmon, tuna fish, sardines, and sunlight converts 7-dehydrocholesterol to cholecalciferol.5,13
Table III: Vitamin D guidelines2,14 Gender Male Female Age in years 3150 3150 UL g/day 50 50 LOAEL g/day 95 95

5 g = 200 IU NOAEL 60 g/day for both males and females of this age group

Tolerable upper intake level (UL) 3,000 g/10,000 IU 3,000 g/ 10,000 IU

Lowest observed adverse effect level (LOAEL) a* + b** a* + b**

Recommended serum levels Serum retinol 0.31.2 mg/L***

Male Female

* a LOAEL was established at 14 000 g/day/46667IU, which excludes women of childbearing age. **b No observed adverse effect level (NOAEL) was established at 4500 g/15000IU *** Please note that this is the values used in reference 2 and that local laboratory values may differ

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Vitamin E Vitamin E through its anti-inflammatory properties may enhance wound healing.16 Additional research is however needed and routine supplementation in the patient with pressure ulcers is not recommended unless a clinical deficiency is present.2 Vitamin E comprises eight naturally occurring forms (tocopherols and tocotrienols) of a fat soluble antioxidant that is present in plasma, membranes, and tissues. 12 Their functions as chain-breaking antioxidants come from their ability to rapidly scavenge lipid-peroxyl radicals before they can react with other lipids, thereby ending the propagation of lipid peroxidation in membranes. Excessive amounts of vitamin E may be detrimental to wound healing, as it increases the risk for fibroses and spontaneous hemorrhage.7 Vitamin E should not be taken for at least a week before surgery due to its anti-platelet effect.17 Patients taking anti-platelet medication should as a rule be careful when taking vitamin E as added supplementation. Vitamin E deficiency is rare but can occur with fat malabsorption as seen with short bowel syndrome, chronic diarrhoea, cystic fibrosis, coeliac disease and patients who have had gastrectomy surgery. Food sources Vitamin E Wheat germ, vegetable oils, green leafy vegetables, milk fat (cream), egg yolks, nuts, vegetable oils.5,13
Table IV: Vitamin E guidelines2,14 Gender Male Female Age in years 3150 3150 EAR mg/day 12 12 RDA mg/day 15 15 UL mg/day 1,000 1,000 Recommended serum levels Serum -tochopherol 5.518 mg/L*

zinc, on the other hand, can impair copper levels in the body and are negatively associated with wound healing.2 Food sources Zinc Oysters, animal flesh particularly red meat, beef liver and poultry, fish, toasted wheat germ, pecan nuts, wild rice, milk, walnuts, egg, dry beans, and whole grains.5,13
Table V: Zinc guidelines2,14 Gender Male Female
a

Age in years 3150 3150

EAR RDA ULa LOAEL Recommended mg/day mg/day mg/day mg/day serum levels 9.4 11 40 Serum zinc 60120 g/dL* 6.8 8 40 60

UL was based on the adverse effect of excess zinc on copper metabolism; it applies to total zinc intake from food, water and supplements (including fortified food). The UL is not meant to apply to individuals who are being treated with zinc under close medical supervision.14 * Please note that this is the values used in reference 2 and that local laboratory values may differ

Copper Copper is necessary for the formation of enzymes involved in connective tissue cross-linking2,8 and is thus essential for wound healing. Food sources Copper Beef liver and kidneys, cashew nuts, black-eyed peas, blackstrap molasses, sunflower seeds, beans, cocoa powder, dried prunes, and salmon.13
Table VI: Copper guidelines2 Gender Male Female Recommended serum levels 70140 g/dL* 80155 g/dL*

* Please note that this is the values used in reference 2 and that local laboratory values may differ

Zinc Zinc is most probably the nutrient where the importance of maintaining a balance is demonstrated the best since excess and deficiency give almost the same symptoms. Zinc plays a role in over 200 enzymes that are important for immune function and with catalytic and structural roles. It is also involved in protein synthesis, DNA/RNA replications and cell division. Zinc deficiency results in poor wound healing, reducing the work capacity of respiratory muscles, immune dysfunction, anorexia, diarrhoea, hair loss, dermatitis, and depression.12,18 Adverse effects of excess zinc might however have similar results which may clinically present with epigastric pain, nausea, vomiting, loss of appetite, abdominal cramps, diarrhoea, headaches, suppression of immune response, a decrease in high density lipoprotein (HDL) cholesterol, and poor copper status.14 A rich food source of zinc for patients not allergic to shellfish is oysters.10 Zinc deficiency, as mentioned earlier, impairs wound healing and supplementation appears to be beneficial in patients with woundhealing impairment secondary to zinc depletion. However, whether zinc supplementation will increase the rate of wound repair in patients who are not zinc deficient remains controversial.12 If zinc and iron supplements are being used it is better to use them at different times since they can interfere with each others absorption. Other signs of possible zinc deficiency that can caution further investigation are white spots on the nails for prolonged time periods (months or years). Zinc deficiency is also a common occurrence seen in patients with alcohol and tobacco use, trauma, HIV, burns, pancreatic insufficiency, vegetarian diets, chronic diarrhoea, short bowel syndrome and high output GI-fistula.2 Excessive amounts of

* Please note that this is the values used in reference 2 and that local laboratory values may differ

Iron As iron is an important component to ensure adequate haemoglobin levels and oxygen-carrying capacity in the body, it should be monitored and assessed in the patient with severe malnutrition and those with a non-healing wound history. It is important to keep a close observation on haemoglobin levels (Hb) as that may serve as a point of reference regarding iron status in patients with infection or major wounds, since iron biochemical markers may be low during infection. Blood products are rarely given unless the Hb falls below 8 g/dL.7 Food sources Iron Liver, red meats, baked beans, blackstrap molasses, oysters, baked potato with skin, toasted wheat germ, spaghetti with tomato sauce, apricots, spinach, cocoa powder, wholewheat bread, and dried fruits.5,13

Hydration
The adequate intake of water is directly related to the effectiveness
Table VII: Iron guidelines14 Gender Male Female
x

Age in years 3150 3150

EAR mg/day 6.0 8.1

RDA mg/day 8.0 18

UL 45 45

LOAEL 70 mg/day x 70 mg/day x

LOAEL of 70 mg/day was established from data in studies on adult men and women.

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of blood perfusion in a body. The role of perfusion in studies of nutritional support in persons with wounds needs increased attention. Oxygen to tissue is vital in wound healing and is dependent on blood perfusion. Impaired oxygen tension to tissues can result from haemorrhage, haemodyalisis and dehydration.9 Patients at risk for perfusion problems also include those with renal failure, congestive heart failure and the elderly. Hospitalised patients are at risk of being inadequately hydrated and under-perfused. However administrations of extra fluid must be done carefully, as elderly patients may suffer from impaired homeostasis mechanisms and may not be able to regulate fluid balance as effectively as younger persons.19 Monitoring of hydration status is therefore vital for proper wound healing. Signs and symptoms of dehydration include rapid changes in weight, skin turgor, urine output and elevated serum sodium. Make sure to provide extra fluids for individuals consuming high levels of protein, those with an elevated temperature, uncontrolled vomiting, profuse sweating, diarrhoea or heavily draining wounds.8

In the absence of deficiency, supplemental intakes of micronutrients such as vitamin C or zinc provide no clinical benefit. 7 Attention should be paid to controlling physiological aspects detrimental to wound healing, such as dehydration, anaemia, hyperglycaemia and mobility, and 7 Involuntary weight loss and poor oral intakes significantly increase pressure ulcer risk.7

Conclusion
Practical implications for the wound practitioner are that any patient with a non-healing or a slow-to-heal wound should be screened properly for possible malnutrition. By adding a dietitian to the interdisciplinary team, the wound outcome for a patient can be positively influenced with a few dietary adaptations or maybe supplementation.

Other factors
Factors not discussed in detail in this article but which can adversely affect and subsequently delay timeous healing of wounds are discussed below. 1. Wound management should be in place and should include proper wound cleansing, debridement of callus or necrotic tissue, of loading of pressure and appropriate antibiotic therapy for infection.20 2. Diabetes and metabolic syndrome Hyperglyceamia increases the risk of wound infection and may seriously delay wound healing rates.7 The role of HbA1C in monitoring glucose control is becoming more important and it might be beneficial to test this during the initial baseline assessment not only in diabetics, but also in obese patients and patients suffering from the metabolic syndrome. Merely relying on fasting glucose or random glucose levels is no longer sufficient in measuring glycaemic control. New guidelines, however, suggest that HbA1C should not be too low in elderly patients; for the rest of the diabetic population an HbA1C level < 7 is the currrent cut off point.21 3. Obesity 4. Smoking 5. Acid Base balance (pH) 6. Cardiovascular risk including cholesterol and hypertension 7. HIV/Aids

Acknowledgements
I thank Hiske Smart for her assistance and contribution to the article.

Conflict of interest
The author of this article is an independent GNLD distributor and thus believes in the benefits of possible nutritional supplementation.

References:
1. Mechanick JI. Practical aspects of nutritional support for wound-healing patients. The American Journal of Surgery, 2004;188:(Suppl)52S56S. 2. Doley J. Nutritional Management of Pressure Ulcers. Nutrition in Clinical Practice, 2010;25:5060. 3. Raffoul W, Far MS, Cayeux M, Berger MM. Nutritional status and food intake in nine patients with chronic low-limb ulcers and pressure ulcers. Nutrition, 2006;22:8288. 4. Handel C. A review of the use and benefit of nutritional supplements in the wound healing of orthopaedic patients. Journal of Orthopaedic Nursing, 1997;1:179182. 5. Pattison D. Fed up with Nutrition. Journal of Orthopaedic Nursing, 1998;2:105115. 6. Department of Health (Republic of South Africa) South African Guidelines for healthy Eating Department of Health, Directorate: Nutrition, Pretoria, June 2004. Supported by: Association for dietetics in South Africa, Nutrition Society of South Africa. 7. Thomas B, Bishop J. Wound healing, tissue viability and pressure sores. Manual of Dietetic Practice. 4th ed. 1988:836844. 8. Dorner B, et al. The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. NPUAP Nutrition White Paper. 2009;115. 9. Whitney JD, Heitkemper MM. Modifying perfusion, nutrition, and stress to promote wound healing in patients with acute wounds. Heart and Lung 28;2:123133. 10. Myklebust M. The Healing Foods Pyramid: An Integrative Nutrition Tool. Explore. 2006;2;4: 352356. 11. Dippenaar N, Delport L. The South African Fat & Protein Guide. 2006;1153. 12. Nicolaidou E, Katsambas AD. Vitamins A, B, C, D, E, F, Trace Elements and Heavy Metals: Unapproved Uses or Indications. Clinics in Dermatology. 2000;18:8794. 13. Mahan LK, Escott-Stump S. Krauses Food, nutrition and diet therapy 10th edition. 2000;105106 and 131139. 14. Dietary Reference Intakes (DRIs). Nutrition Information Centre of the University of Stellenbosch (NICUS). 2003;1120. 15. Shapiro SS, Saliou C. Role of Vitamins in Skin Care. Nutrition, 2001;17:839844. 16. Keller KL, Fenske NA. Uses of vitamins A, C, and E and related compounds in dermatology: A review. Journal of the American Academy of Dermatology. 1998;39:611625. 17. Petry JJ. Nutritional Supplements and Surgery patients. AORN Journal. 1997;65;6: 11171121. 18. Strachan S. Trace elements. Current Anaesthesia & Critical Care. 2010;21:4448. 19. Stotts NA, Wipke-Tevis D. Nutrition, perfusion and wound healing: An Inseparable Triad. Nutrition, 1996;12:733734. 20. Widgerow AD. The Diabetic Foot Ulcer An Unique Wound Care Problem. SA Cardiology & Stroke Journal. 2008;2;1:4850. 21. SEMDSA Guidelines for Diagnosis and Management of Type 2 Diabetes Mellitus for Primary Health Care. 2009. 22. Position of the American Dietetic Association: Nutrient Supplementation. Journal of the American Dietetic Association. 2009;109;12:20732085.

Nutritional status and wound healing: current best evidence

Nutritional screening, support and regular monitoring should be commenced as early as possible to optimise outcome. 7 Adequate energy should be provided to maximise nitrogen retention and wound healing, including a source of omega-3 fatty acids. 7 Adequate protein should be provided based on age- and disease-related needs, arganine/proline-enriched feeds may be considered in the management of large surface area wounds. 7 Suspected or confirmed micronutrient deficiency should be treated at an early stage by providing a minimum 100% RDA of micro nutrients. 7

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