Nutritional Aspects of Healing a Diabetic Foot Wound...Medical nutrition therapy is part of the...

This is an essential but often overlookedaspect of wound healing.

NOVEMBER/DECEMBER 2003 • PODIATRY MANAGEMENTwww.podiatrym.com 199

principles and a systematic approachthat must include medical nutritiontherapy. In general, the clinical goalsof medical nutrition therapy in a dia-betic patient are to:

1. Achieve and maintainglycemic control by balancing foodintake with insulin (exogenous or en-dogenous) or oral glucose-loweringmedications and activity levels.

By Kenneth B. Rehm, DPM

Continued on page 200

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Following this article, an answer sheet and full set of instructions are provided (p. 210).—Editor

ObjectivesAfter reading this continuing education

article, the podiatric physician should beable to do the following:

1) Be familiar with the clinical goals ofmedical nutritional therapy.

2) Identify the eight principles of heal-ing a diabetic foot wound.

3) Be able to describe the basic princi-ples of nutritional management of pa-tients with diabetic foot wounds.

4) Describe a comprehensive nutritionalassessment.

5) Be able to relate the phases of woundhealing with basic nutritional needs.

6) To discuss the role of calories andweight loss in diabetic foot wound healing.

7) Understand the roles of proteins,fats, carbohydrates, vitamins, mineralsand trace elements in diabetic foot woundhealing.

8) To delineate the appropriate bloodtests needed to assess nutritional status ina patient with a diabetic foot wound.

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In a patient who has diabetes, heal-ing a foot ulcer, just like healing aproblem in any other part of the

body, requires incorporating basic

Nutritional Aspects of Healing

a Diabetic FootWound

Medical nutrition therapy is partof the systematic approach to healinga diabetic foot wound which incor-porates the following basic princi-ples:

1. There must be adequate circu-lation to the wound site.

2. A wound must be kept cleanand free from contamination.

3. Necrotic tissue must be elimi-nated or reduced to a minimum.

4. A wound must be free from in-fection.

5. Dermatologic disease must becontrolled or eliminated.

6. Shearing, friction and directpressure on a wound must be kept ata minimum.

7. The external wound healingenvironment must be controlled andkept free from excess dryness andmoisture.

8. The wound host must be nutri-tionally, metabolically and medically

stable. It is the nutritional aspects that

are to be discussed in this paper. The ability of a patient with a di-

abetic foot ulcer to heal is affected bythe baseline nutritional status andpre-existing nutritional deficiencies.A resultant suboptimal outcome andpoor healing prognosis is related toincreased susceptibility to the devel-opment of foot ulcers, increased timeneeded for wound healing, increasedlikelihood for reoccurrence, de-creased tensile strength of a closedwound, increased susceptibility to in-fection and post-surgical complica-tions in general. Providers of care fordiabetic foot wounds should closelyscrutinize the nutritional status ofthese patients, and consider poor nu-tritional status a major causal ele-ment, especially in cases where thewound is not healing and all of theother factors for appropriate woundhealing are in place. Basic principlesof nutritional management of pa-tients with diabetic foot wounds arethe following: correction of inappro-priate appetite, swallowing, as well aschewing and dentition abnormali-ties, control of serum glucose, hyper-lipidemia, hypertension, metabolicstatus, appropriate supplementationof vitamins and trace minerals, andascertaining and maintaining properdietary requirements. Before thesebasic principles of nutritional man-agement are implemented, propernutritional assessment and its com-ponents must be accomplished.

A comprehensive nutritional as-sessment evaluates macro- and mi-cronutrient intake, co-morbiditesthat could affect the actual ingestionof nutrients and/or the assimilationof nutrients, medications that affectwound healing and/or serum glucoselevels, and the overall medical, nutri-tional and metabolic status of the pa-tient. An optimal assessment shouldinclude relevant clinical and bio-chemical data, including the follow-ing blood tests: complete bloodcount with a differential, glycosylat-ed hemoglobin levels, hematocrit,hemoglobin, lipid levels, blood ureanitrogen levels, serum creatinine, al-bumin, prealbumin, sodium andpotassium levels, total protein andtransferrin levels. Urine tests includequantitative values for protein, urineglucose and urine acetone. Blood


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Nutrition...

2. Achieve optimal bloodlipid levels 3. Provide adequate calories to

maintain or attain reasonableweights for adults, normal growthand development rates in childrenand adolescents, metabolic needsduring pregnancy and lactation, orrecovery from illnesses that arecatabolic or to heal wounds.

4. Eliminate, prevent, delay orcontrol nutrition-related risk factorsand complications such as hypo-glycemia, short-term illnesses, exer-cise-related problems, renal disease,autonomic neuropathy, hyperten-sion, cardiovascular and peripheralvascular disease, and skin break-down.

5. Achieve, maintain or improveoverall health through appropriatenutrition.

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ESSENTIALS OF A NUTRITIONAL HISTORY

Weight Change

Appetite

Satiety level

Taste changes and aversions

Nausea and/or vomiting

Bowel habits including any diarrhea, constipation, or steatorrhea

Alcohol or recreational drug use

Smoking history

Chewing and swallowing ability

Pain while eating

Chronic diseases that affect the use of nutrients

Surgical resection or disease of GI tract

Usual meal pattern and dietary history

Dietary restrictions

Use of vitamin, mineral and nutritional supplements

Food allergies and intolerances

Medications

Level of Activity or Exercise

Ability to secure and prepare food


cells now begin to cover the surfaceof the wound until maturation oc-curs.

In order for these four phases ofwound healing to progress, certainbasic nutritional requirements mustbe met:

1. Proteins are required for tissuerepair

2. Glucose is required for energy 3. Lipids (fats) are required for

cellular integrity

4. Vitamins, minerals and traceelements are required for optimalmetabolic function.

The providers of care and thewounded individual must create ateam that provides the appropriatenutrients for healing through theproper intake of food and appropri-ate supplementation or tube feedingif needed.

Calories and Weight Loss In a patient that has diabetes and

foot ulcers, the caloric requirementsare merely a function of metabolical-ly active tissue, especially lean bodymass, and may vary significantlyamong patients. The requirementsare not different from those of astressed patient without diabetes. Ac-curately measuring energy expendi-ture, and therefore needs, is criticalin the patient who requires aggres-sive nutritional support by way oftotal parenteral nutrition or enteraltube feedings, a surgical procedure,or has a significant wound to heal.The most commonly used formulafor determining basal energy expen-diture (BEE) is the Harris-Benedictequation.

Weight as a percentage of idealbody weight or weight loss comparedwith the patient’s usual weight aremarkers used to identify patients

pressure readings are important. Determining the dietary prescrip-

tion, restrictions, and level of compli-ance is essential information to beable to create proper nutritional sta-tus. It should be noted that poor nu-tritional status can be due to a poorappetite, a metabolic problem, or in-ability to digest or swallow appropri-ately. A close evaluation of food in-take vs. caloric require-ments should be per-formed, paying closeattention to proteins,fats, carbohydrates, keyvitamins, folic acid,and key minerals, traceelements and micronu-trients. Because of allof these factors, it isimperative that a regis-tered dietitian be in-volved in the assess-ment process.

Healing Phases With the nutritional assessment

made, the correction or preventionof malnutrition is critical in optimiz-ing wound healing. Nutritional sta-tus is the reserve from which the pa-tient will draw upon to close the skindefect. With the other principles ofwound healing in place, if the pa-tient is well nourished, and not chal-lenged again, the wound is likely toclose. If the patient is malnourishedat the start of the healing process, thewound cannot be expected to closein a timely manner. The nutritionalsubstrate is essential for tissue forma-tion because nutrients are importantto the appropriate completion of thefour phases of wound healing.

These four phases are separateand overlapping. They are:

1. The hemostatic phase. This isthe phase where platelet aggregationbegins the process of blood coagula-tion in the wound.

2. The inflammatory phase. Thisphase is characterized bymacrophage proliferation and theiringestion of bacteria and debris.

3. The connective tissue phase. Thisis when fibrous tissue and collagenforms to create a lattice work thatsupports new blood vessels. Thewound now begins to contract andclose.

4. The epithelial phase. Epithelial

Nutrition... with pre-existing compro-mised nutritional status.Marasmus is a type of undernu-trition associated with chroniccaloric deprivation. Depletion of so-matic proteins and subcutaneous fatcauses a decrease in body weight. Sig-nificant marasmus is indicated by aweight that is less than 85% of a per-son’s ideal weight. Weight loss that isless than 10% of a person’s usualweight is considered mild, moderate

if it ranges from 10% to20%, and severe if theweight loss is 20% orgreater. Mild to moder-ate weight loss may, infact, improve serumglucose levels even ifdesired weight is notreached. The problemis that without beingable to bear weight, asis the case in manywound patients, it isdifficult to achieveweight loss. In fact, it isoften necessary to

avoid purposeful weight reductionuntil the foot wound is closed.

Protein Requirements In detailing the basic nutritional

requirements, the first considerationis the protein and calorie require-ments. The provision of sufficientcalories is a priority so that proteinwill be spared for its critical roles inthe stimulation of fibrin formation,cell multiplication, connective tissueformation, collagen formation anddeposition, increasing of enzyme ac-tivity, diminishing catabolism, en-hancing immunity and improvingoverall wound healing. Protein defi-ciency suppresses the immune re-sponse, inhibits angiogenesis, de-creases fibroblast formation and re-modeling of collagen and impairsoverall wound healing.

A review of the componentswe’ve identified in the four phases ofwound healing reveals that skin for-mation, white blood cell activity, im-mune function and collagen forma-tion are all protein-based. The pres-ence of all essential amino acids is re-quired for protein synthesis. All as-pects of wound healing are delayedunder conditions of protein deficien-cy. Therefore, adequate protein in-take is absolutely essential for wound


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BASAL ENERGY EXPENDITURE (BEE)

Basal energy requirement is based upon the following:

Women: 655 + (9.6 x W) + (1.7 x H) - (4.7 x A)

Men: 66 + (13.7 x W) + (5 x H) – (6.8 x A)

W = actual weight in Kg (2.2 lb = 1 kg)

H = height in cm (1 in. = 2.54 cm.)

A = age in years

stress. It is usually associated with acatabolic stress situation without nu-tritional support. It is important todifferentiate the type of protein-calo-rie malnutrition because each has adifferent effect on wound healing.

Clinical studies have shown thatany protein-calorie malnutritionleads to compromised wound heal-ing and a greater risk for developingpressure-related ulcerations.

Various diseases can lead to allforms of protein-calorie malnutri-tion. Common diseases linked withthis form of malnutrition include:

• cancer• chronic illness• protein loss in the gastrointesti-

nal tract• anorexia and other eating disor-

ders• multiple traumas• liver disease• obesity

• pancreatitis• burns over 30% or more of your

body Overt signs of malnutrition may

exist and include severe wasting, ex-treme weight loss, weakened resis-tance to infection, being unable tothink clearly, or hair becoming brittleor falling out. In addition, the skinmay be dry or yellowish, musclesmay feel weak, and fainting spellsmay occur. In younger women, men-strual periods may stop.

Protein-calorie malnutritionposes a severe danger to the patientbecause it can occur very rapidly andwithout overt signs of malnutrition.Therefore it is important to appropri-ately monitor the nutritional statusby examining serum levels of pre-al-bumin, albumin, total protein, andtransferrin levels and by performinga CBC with a differential, hematocrit



Nutrition...

healing to occur. Adequate pro-tein consumption is so vital that

even a mild depletion has a negativeimpact on the wound healing pro-cess.

Protein-Calorie Malnutrition There are basically three types of

protein-calorie malnutrition: (1)Marasmus involves decreased caloriesand protein. It is usually associatedwith prolonged starvation, anorexia,chronic illness and the elderly. Ittakes months to years to develop. (2)Kwashiorkor involves decreased pro-tein intake alone and is usually a re-sult of fad diets, liquid diets, or longterm dextrose-containing IV fluidsupplementation with nothing bymouth. It takes weeks to months todevelop. (3) Combined is a result ofdecreased calories, protein intake and

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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 withoutanorexia, chronic term dextrose-containing nutritional supportillness, elderly IV fluid supplementation

with nothing by mouth

Time course to Months to years Weeks to months Days to weeksdevelop

Clinical features Starved appearance May look well-nourished Moderately to severelyor obese. Edema, ascites starved appearancemay be present. Normal Decreased anthropometrics. anthropometrics

Laboratory findings Normal visceral Decreased visceral Decreased immuneproteins proteins, Decreased function values

lymphocyte count, Decreased visceralAnergic proteins

Clinical course Reasonably preserved Diminished wound Diminished woundand responsive to healing, Diminished healing, Increasedshort-term stress immunocompetence, overall complications

Increased infections, and slower recoveryIncreased overall complications

Mortality rate Low unless High Highcomplications of underlying disease process


androgens, and prednisolone. Recent research has shown that

the pre-albumin test can predict pooroutcomes for hemodialysis patients.A low initial reading (baseline level)of pre-albumin predicts that a patientmay have problems, and steadilydropping pre-albumin values are as-sociated with low survival.

Pre-albumin is the best marker ofmalnutrition because it has a shortserum half-life, it is less affected byliver disease than other proteins andis not affected by hydrations status orvitamin deficiency (except zinc).

Serum albumin levels measurevisceral protein levels and thereforethe body’s ability to manufactureprotein. It is an adequate indicatorof this ability for stable patientswith a chronic medical condition,such as diabetes. If the patient isbeing evaluated during an acute ill-ness, the urinary creatinine heightindex should be used. Serum albu-min levels are often used to test forliver or kidney problems, or tolearn if there is a lack of amino acidabsorption. Because turnover timefor albumin is 14 days, it is less sen-sitive than other measures. For in-stance, pre-albumin changes morequickly, making it more useful fordetecting changes in short-term nu-tritional status than albumin.

Albumin Albumin is the major protein

synthesized by the liver. It main-tains plasma oncotic pressure andtransports nutrients in the bloodstream. Low albumin levels maylead to edema in the lower extremi-ties, skin breakdown and openwounds and increased infection, aswell as increased morbidity andmortality. Decreased albumin levelscorrelate with poor clinical out-comes, increased length of hospitalstay, increased risk for complica-tions and death. It should be notedthat hypoalbuminemia is an excel-lent marker for the stress response,but is considered to be a poor mark-er for overall nutritional status eventhough albumin levels are oftenused to monitor nutritional status.According to a recent study, thosepatients with diabetes and foot ul-cers had significantly higher levelsof fibrinogen and C-reactive pro-tein. (This is a test that measuresthe concentration of a special type

and a hemoglobin. The pre-albumin test measures a

protein that reflects nutritional sta-tus. Pre-albumin most often is usedto help diagnose protein-calorie mal-nutrition. In this condition, whichcan affect more than 30% of physio-logically stressed or wounded pa-tients, the body breaks down muscle,protein, and body fat. This type ofmalnutrition can lead to complica-tions and even death if not treated.

The test also is used to monitorchanges in patients who are receivingparenteral nutrition (nutrition fromoutside of the gastrointestinal tract,such as nutrients given through in-travenous treatment). The test also isused to monitor changes in nutritionstatus for patients who are receivinghemodialysis.

Depending on the exact levels, ifpre-albumin is low, minor nutrition-al deficiencies can be the only prob-lem or if pre-albumin is very low,then protein-calorie malnutrition hasto be considered.

Conditions that may lead tolower levels of pre-albumin are thefollowing:

• Severe or chronic illness, suchas cancer

• Hyperthyroidism• Liver disease• Serious infections• Digestive disorders• Inflammatory disorders When inflammation and malnu-

trition are both present, pre-albuminlevels fall very far, very quickly.

Higher levels of pre-albumin arecommon in patients with:

• high-dose corticosteroid thera-py

• hyperactive adrenal glands• high-dose non-steroidal anti-in-

flammatory medications• Hodgkin’s diseaseIf a patient is in renal failure, pre-

albumin results may be falsely higherthan they actually are.

Inflammation can interferewith the results of your pre-albu-min test, causing it to be lowerthan it would be. Certain drugs canalso lower your pre-albumin level,including amiodarone, estrogens,and oral contraceptives (birth con-trol pills). Drugs that can causeyour pre-albumin level to rise inyour blood are anabolic steroids,

Nutrition... of protein in serum, pro-duced by the liver, which isonly present during episodesof acute inflammation. The mostimportant role of CRP is its interac-tion with the complement system,which is one of the body’s im-munologic defense mechanisms.)Diabetics also had lower albuminlevels when compared to twogroups of control patients, thosewith diabetes and no foot ulcersand those with neither diabetes norfoot ulcers. The decreased albuminlevels results from a shift in thehepatic synthesis of proteins thatresult in an increase in acute-phaseproteins and decreased productionof homeostatic proteins. It is im-portant to note that vascular per-meability is increased because ofthis shift and proteins escape fromthe vascular space.

A common mistake made by clin-icians in treating patients with dia-betes and foot ulcers is to interprethypoalbuminemia as a sign of mal-nutrition. When hypoalbuminemiashows up, calories are often increasedsignificantly, leading to hyper-glycemia and weight gain, both ofwhich interfere with wound healing.

Total protein measurements canreflect nutritional status. In addition,low total protein levels can suggest aliver disorder, a kidney disorder, or adisorder in which protein is not di-gested or absorbed properly. Morespecific tests, such as albumin andliver enzyme tests, must be per-formed to identify which proteinfraction is abnormal, so that a specif-ic diagnosis can be made. High totalprotein levels can indicate dehydra-tion or some types of cancer (e.g.,multiple myeloma) in which an ab-normal protein is accumulated, andfurther tests must be performed.

Total iron binding capacity(TIBC) is an indirect measurementof transferrin, a protein that bindsand transports iron. It quantifiestransferrin in terms of the amountof iron it can bind and is reportedas percent saturation. Transferrinlevels are generally depressed in pa-tients who are malnourished orwho have chronic disease states;however, it may be normal in manypatients who are iron deficient.

Patients who are malnourished orprotein-depleted benefit by early


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1. the size of the wound 2. the nutritional and physiologic

state of the patient 3. complications associated with

protein absorption and/or proteinmetabolism

It should be noted, however, thatmost wound healing patients, espe-cially diabetics, require an increase inprotein in their diet in conjunctionwith adequate calories. Research sug-gests that increasing protein intaketo 20% or more of total calories may

result in improved nitrogen balancein malnourished patients. Obtainingpositive nitrogen balance is impor-tant to counter the effects of nitro-gen losses, common in diabetics andpatients under physiologic stress,and maximize the retention of nitro-gen. At least 1 1/2-2 grams of proteinand 25-30 calories per Kg. of bodyweight is recommended. For severelystressed or injured patients, as inburn patients, up to 2 1/2 grams of


Nutrition...

feeding with a high protein for-mula. Some evidence exists that

protein supplements (T) improve thehealing process in any physiological-ly or metabolically stressed individu-al. This has a positive impact on allphases of wound healing, especiallythe critical initial phases. It should benoted that every patient’s needs aredifferent. Protein requirements varyaccording to

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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/dlFemale: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


heme iron. The need for an ironsupplement should be assessed.

A CBC with a differential willgive an indication as to if there is ahigh white cell count, common inmalnutrition and in infections. Pro-tein intake should be monitored inclients at risk for renal disease. Modi-fication of protein intake should be-come a decision reached by the phy-sician, dietitian and the patient.

There is suggestive evidence thatseveral amino acids, particularly argi-nine and glutamine, appear to pro-mote wound repair. Arginine’s effectis linked to enhanced wound colla-gen synthesis and pituitary hormonesecretion; glutamine improves gutmucosal repair and serves as fuel forthe immunocytes. No improvementin wound healing has been demon-strated using high-dose supplementsof branched chain amino acid infu-sions.

Carbohydrate Requirements The role of carbohydrates, as is

the case with fats, is less well-definedthan protein’s role. It is known, how-ever, that the role of carbohydratesand fats is to provide the energyneeded for cell proliferation that oc-curs in all phases of wound healing.Leucocytes, which are white bloodcells that perform phagocytosis, uti-lize glucose as their primary fuel. Fi-broblast proliferation, the key to col-lagen formation, also depends onglucose as their primary source of en-ergy. It is clear that an abnormalityin glucose metabolism would be ex-pected to have an effect on thesefunctions and therefore wound heal-ing.

Fat Requirements Fat in the diet is an absolute ne-

cessity for wound healing in a diabet-ic. However, because granulation tis-sue is an obligate glucose consumer,it follows that adherence to a high-carbohydrate diet can be of benefit.Some evidence exists in animal mod-els that low-fat diets may be morebeneficial to wound healing than anover-all higher fat intake. Reductionin total fat intake, especially saturat-ed fats, is therefore recommended.Less than 30% of the calories con-sumed should be from fat and lessthan 10% should be from saturatedfats. Fats, however, do help providethe fuel for all the phases of wound

protein and 35 calories per Kg. ofbody weight may be needed. If thepatient has nephropathy, a range of1.0 to 1.5 gm of protein per Kg. ofbody weight is recommended. If thiscannot be accomplished with in-creasing the amount of food a per-son eats, enteral formulas can be analternative.

A standard enteral formula has 40grams of protein per 1000 calories.The high-protein formulation, whichis better equipped to meet the re-quirements of wound healing pa-tients, has 60 grams of protein per1000 calories. Studies suggest that forthose patients who need a dietary al-ternative, high protein formulationshave been recommended. This is be-cause they have lower calorie-to-ni-trogen ratios and therefore are associ-ated with increased nitrogen reten-tion and balance, improved serumprotein levels and improved im-munological function. Clinically, thisleads to reduction in the size of largewounds and improved healing ofsmaller wounds. It is important tonote that exceeding protein require-ments will not cause the wound toheal faster.

An elevated BUN in elderly pa-tients on a high-protein diet shouldnot be of concern given that the pa-tient does not have a pre-existingrenal condition, has normal creati-nine levels and the state of hydrationon physical exam is normal. Urea isnot a toxic molecule and the buildupof urea in this patient is of no conse-quence; and in a patient with awound, the priority is healing thewound and not a normal BUN. Therisk of underfeeding and sub-optimalprotein consumption is non-healingand non-function. In patients whoare adequately fed or fed slightlyabove what’s needed, elevated serumurea is a result of an extra amino acidbeing changed to glucose.

Hematocrit and hemoglobin val-ues can be used as a gross indicatorof iron status in individuals with di-abetes. Low values are generally as-sociated with chronic blood loss,heavy menstrual bleeding, or gas-trointestinal bleeding. Diets low insaturated fat and cholesterol that areroutinely prescribed for personswith diabetes often contain inade-quate supplies of foods high in

Nutrition... care as well as providefatty acids. The precise roleof fatty acids in wound healingis unknown. However, they are akey ingredient of triglycerides andphospholipids that are major compo-nents of cell membranes. Also, unsat-urated fatty acids are precursors toprostaglandins and other regulatorsof the immune and inflammatoryprocesses. Therefore, it is reasonableto assume that a deficiency in fattyacids likely results in sub-optimalwound healing.

A blend of fats has been shown tobe more beneficial in wound healingthan fats that come from a singlesource; and because various fats havedifferent benefits than others, a fatblend can play an advantageous rolein the healing of wounds where ahigh metabolic or physiologic stresssituation exists or in wound healing.

For this reason, a lipid profile in-cluding essential fatty acids, especial-ly omega 3 fatty acids, is critical.Why “essential?” Omega-3’s (andomega-6’s) are termed essential fattyacids (EFA’s) because they are criticalfor good health; and a deficiency inthem has been shown to inhibit tis-sue regeneration. However, the bodycannot make them on its own. Forthis reason, they must be obtainedfrom food, thus making outsidesources of these fats essential.

Although the body needs bothomega-3’s and omega-6’s to thrive,most people consume far more 6’sthan 3’s. Hardly a day goes by, how-ever, without reports of anotherhealth benefit associated withomega-3’s. For this reason, many ex-perts recommend consuming a betterbalance between these two EFA’s.

There are three key omega-3 fattyacids which include eicosapentaenoicacid (EPA) and docosahexanoic acid(DHA), both found primarily in oilycold-water fish such as tuna, salmon,and mackerel. Aside from fresh sea-weed, a staple of many cultures,plant foods rarely contain EPA orDHA.

However, a third omega-3, calledalpha-linolenic acid (ALA), is foundprimarily in dark green leafy vegeta-bles, flaxseed and canola oil. Al-though ALA has different effects onthe body than EPA and DHA do, thebody has enzymes that can convertALA to EPA. All three are important


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It is needed for the hydroxylation oflysine and proline, an essential stepin collagen synthesis, as well as cross-linking. Wounds are metabolicallymore active than healthy connectivetissue; therefore, increased concentra-tions of vitamin C are needed to cre-ate and maintain wound integrity.Studies suggest that pressure ulcer pa-tients supplemented with very highdoses of vitamin C had reduced pres-sure sore areas when compared withpatients who had no vitamin C sup-plementation. (T). A vitamin C defi-ciency will cause the following com-plications:

1. Increased capillary fragility 2. Delayed wound healing 3. Decreased tensile strength of

wounds and poor scar formation These three factors are associated

with a more common occurrence ofall types of wounds as well as a high-er incidence of wounds re-openingand reoccurring.

Vitamin A Vitamin A is a fat-soluble vitamin

that occurs in two forms in nature. Itis found in its true form (also calledretinol) in animal foods such as fishoils and liver. The body readily usesthis form.

Vitamin A can be found in veg-etables in the form of beta-caroteneor provitamin A. This form is foundin plants and is the precursor of theactual vitamin. Beta-carotene has tobe converted in the body in order tobe used by it. Fat and bile are neededfor the conversion.

The liver regulates the blood levelof vitamin A. It needs a protein carri-er to be transported throughout thebody. An adequate protein and fatintake is required for a good absorp-tion of vitamin A.

Vitamin A is an anti-oxidant, acompound that may protect againstdisease by neutralizing unstable oxy-gen molecules, called free radicals,within the body. This vitamin is in-volved in cellular growth, moderatescell differentiation and reproductionas well as reverses the inhibitory ef-fects on growth and wound healingby corticosteroids. It also maintainsthe health of the skin and surface tis-sues, especially those with mucouslinings, an important factor inwound healing and prevention of in-fection. Vitamin A enhances tissueregeneration by aiding in glycopro-

tein synthesis. It is also a co-factor forcollagen synthesis and cross-linkage.Therefore, even though it is some-what pro-inflammatory, Vitamin A isstill needed in wound healing pri-marily for:

1. Collagen formation 2. Epithelial integrity 3. Immune function Vitamin A deficiency may de-

crease epithelialization, collagen syn-thesis, production of macrophages,and overall resistance to infection.Beta-Carotene, improves serumretinol levels and enhances immunefunction.

The B VitaminsThe B Vitamins also play a crucial

role in wound healing. Generally,they assist in white blood cell func-tion and aid the body in resisting in-fection.

Thiamine, Vitamin B1, is impor-tant in collagen formation and is acofactor in collagen cross-linking. Vi-tamin B1 is found in Brewers yeast,unrefined cereal grains, organ meats,pork, legumes, nuts and seeds. A defi-ciency has been found to be associat-ed with peripheral neuropathy.

Pantothenic Acid, Vitamin B5, is acomponent of the coenzyme Amolecule as well as being part of thecarrier proteins involved in fatty acidmetabolism. It helps release energyfrom fat, carbohydrate, and keto-genic amino acids. It is essential forthe functioning of fibroblasts, thecollagen-producing cells. A deficien-cy is associated with poor immunefunction, compromised wound heal-ing and diminished graft take.

Vitamin B2 is a co-factor in colla-gen cross-linking. It is found in broc-coli, spinach, asparagus, meat, poul-try, fish, yeast, egg whites, dairyproducts and fortified grain products.

Vitamin B6 is a co-enzyme thatstimulates wound healing and assistsin activating protein synthesis. It isfound in chicken, fish, kidney, liver,bananas, eggs, soy beans, oats,peanuts and walnuts.

Vitamin B12 is a co-enzyme forprotein and DNA synthesis and alsostimulates wound healing and helpsactivate protein synthesis. It is foundin meat, fish, poultry and eggs.

Folic Acid (Vitamin B9) is neededfor the metabolism of amino acids andin nucleic acid synthesis and thus for



Nutrition...

to human health and havebeen shown to be beneficial in

supporting the immune functionsnecessary in metabolic stress andwound healing. A deficiency in es-sential fatty acids has been shown toinhibit tissue regeneration.

In addition, some of the omega-6fatty acids which include linoleicacid, also found in some vegetableoils, may result in suppression ofsome vital components related to thenormal immune response, a pro-longed inflammatory response andincreased catabolism. These adverseresponses may be antagonistic to theoptimum wound healing response.

Vitamins, Minerals, TraceElements and Micronutrients

A number of vitamins, miner-als, trace elements and micronutri-ents have been evaluated for theireffect on wound healing. The in-creased need for these nutrientshas been documented in studieswhere nutrient losses associatedwith wound healing and injuryhave been observed.

Vitamin CChief among these nutrients is vi-

tamin C because it is a water-solublevitamin and not stored in the body.Therefore, a deficiency can occurvery quickly in stressed or woundhealing patients whose requirementsare dramatically increased. Theoreti-cally, extensive wounds can exhaustvitamin C stores.

The role of Vitamin C in woundcare is to augment the speed andstrength of the healing. This is donethrough enhancing tissue regenera-tion through three avenues:

1. Increased deposition of collagen

2. Fibroblast activity 3. The formation of granulation

tissue. Also, because it is an anti-oxi-

dant, Vitamin C protects tissues fromsuperoxide damage.

Deficiencies promote collagen in-stability, decreased collagen forma-tion and decreased tensile strength ofthe wound. Profound deficienciesmay promote capillary fragility. If adeficiency exists, it must be supplant-ed immediately because vitamin C ispivotal in the formation of collagen.

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deficit, a wound will not heal. Calcium, essential for collagen

synthesis, is required for both the re-modeling process and the degrada-tion of collagen through the actionof collagenases. Calcium is found indairy products, sardines, oysters, kale,greens and tofu.

Copper promotes the cross-link-ing reactions of collagen and elastinsythesis. It also is involved in freeradical elimination. These are criticalfactors in wound healing. Also, cop-per is required for the maintenanceand repair of bones. Supplementa-tion has been shown to potentiallyincrease the rate of healing of bonefractures.

Copper is found in whole grainbreads and cereals, shellfish, organmeats, poultry, dried peas and beans,and dark leafy vegetables. A copperdeficiency can show up as impairedglucose tolerance and/or anemia.

Iron is necessary for the hydrox-ylation of lysine and proline in colla-gen synthesis and is needed to trans-port oxygen to the wound bed. Irondeficiency results in tissue hypoxiaand therefore interferes with woundhealing. If the deficiency is pro-longed, anemia could develop, whichfurther interferes with the woundhealing process. Iron is plentiful inegg yolk, red meats, dark green leafyvegetables, enriched breads and cere-als, legumes and dried fruits.

Magnesium is a co-factor for en-zymes involved in protein and colla-gen synthesis. Low levels play a rolein carbohydrate intolerance and re-sistance to insulin. Deficiency is rare.Magnesium is found in nuts,legumes, unmilled grains, green veg-etables and bananas.

Chromium potentiates the ac-tion of insulin and therefore inter-plays with glucose, protein, and lipidmetabolism. A chromium deficiencycan lead to impaired glucose andamino acid utilization, increasedplasma LDL-cholesterol levels, andperipheral neuropathy. Carbohydrateintolerance and insulin resistance isrelated to chromium deficiency,which is rare. To date, the onlychromium deficiency reported hasbeen in patients receiving parenteralnutrition without adequate chromi-um replacement.

Phosphorus is a critically im-portant element in every cell. A com-ponent of membrane phospholipids,

the manufacturing of DNA. In woundhealing, this translates to being a keyfactor in resisting infection.

Vitamins E & K Vitamin E has antioxidant proper-

ties that promote cell membrane in-tegrity. Supplementation has beenshown in clinical studies to acceleratethe healing of chronic stasis ulcers. Itis found in wheat and rice germ, veg-etable oil, dark green leafy vegetables,nuts and legumes.

Vitamin K is essential for coagula-tion, a necessary prerequisite forwound healing and is found in greenleafy vegetables, dairy products,meat, eggs, cereals and fruit.

Trace ElementsTrace elements and micronutri-

ents are lost through wound exu-dates and must be replaced for prop-er wound healing to occur. These in-clude zinc, calcium, copper, iron,magnesium, chromium, phosphorusand selenium. Zinc is essential forwound healing. Similar to Vitamin C,zinc is not stored in significantamounts. It is found commonly inoysters, dark meat turkey, liver, limabeans and pork. Zinc is an essentialtrace element and important inwound healing due to the following:

1. It is a co-factor in about onehundred enzymatic reactions

2. It is essential for the transcrip-tion of RNA

3. It promotes protein synthesis,collagen formation and cellular repli-cation

4. It mobilizes retinol-bindingprotein and albumin

5. It is essential in the synthesisof albumin

6. It plays a key role in tissue re-pair

Deficiency of zinc may occur sud-denly and quickly, especially in pa-tients that are medically, metaboli-cally and/or physiologically compro-mised. Serum zinc may already below in wound patients as a result oftheir being malnourished. When zincis deficient, collagen synthesis andtensile strength of the wound is di-minished and there are abnormalitiesin neutrophil and lymphocyte func-tion. The end result is an increasedrisk for infection and delayed woundhealing. Generally, if there is a zinc

Nutrition... it influences affinity foroxygen, thus affecting tissueoxygenation. It also is involvedin the metabolism of carbohy-drates, protein and fat, and is essen-tial for the maintenance of acid-basebalance and required for normalnerve and muscle function. It is anessential component of many en-zyme systems and many hormonesare dependent on phosphorylation.Milk is an excellent source of phos-phorus.

Selenium is a necessary part ofcollagen synthesis, as it protects thecell membrane lipids from oxidantdamage. Selenium is found in seafood,kidney, liver, meats and grains.

Other Therapeutic Modalities Pharmacologic modulation of cy-

tokines, prostaglandins and the useof anabolic agents such as hormonesand growth factors may prove to fur-ther enhance wound healing. Theuse of growth hormone is the beststudied to date, but remains contro-versial. Recombinant growth hor-mone has been found to support en-hanced wound healing, althoughthere is evidence of increased infec-tious morbidity and mortality in crit-ical care and burn patients that haveused growth hormone. Alpha-lipoicacid is being researched as an antioxi-dant potential with its effect onglycemic control.

Malabsorption/Maldigestion The condition of malabsorption

(or maldigestion) has to be discussedas it can create a state of malnutri-tion. Malabsorption can be definedas impaired absorption of fat, carbo-hydrate, protein, vitamins, elec-trolytes, minerals, or water. Clinicalmanifestations include unexplainedweight loss, steatoarrhea, diarrhea,anemia, tetany, bone pain andpathologic fractures, bleeding, der-matitis, neuropathy, glossitis, andedema. There are many tests avail-able for determining the type and ex-tent of the malabsorption problem.

The co-morbidities of diabetes,which may potentiate malabsorptionof nutrients or accelerate their lossesinclude gluten-sensitive or diabeticenteropathy with bacterial over-growth, previous gastric surgery,large gaping wounds, Crohn’s dis-ease, diverticular disease, radiation


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abetic patient, especially when plan-ning an operative procedure. Poorlycontrolled diabetes contributes topoor wound healing and has deleteri-ous effects on outcomes, includingskeletal, neural, smooth muscle andimmune dysfunction. Factors thatmay precipitate hyperglycemia, suchas infection, overfeeding, volume de-pletion, medications, and inadequateinsulin or oral medications, shouldbe quickly addressed. Hypoglycemiacan be harmful to the healing processas well. Gastroparesis, hepatitis, sep-sis associated with nephropathy, dis-continuation of nutritional support,resolution of the stress response, orweaning from steroid therapy can allcontribute to a hypoglycemic re-sponse. Maintaining glucose levelsbetween 100 and 150 mg/dL is a rea-sonable goal.

It is interesting to note that poorcontrol of postoperative hyper-glycemia in a recent study predictedthe likelihood of serious infection.Patients with blood sugar levels over220 mg/dl on the first day followingsurgery had a 24.6% incidence of se-rious infection, compared with 4.2%in patients with blood sugar levelsunder 220 mg/dl. Patients receivingtotal parenteral nutrition had highermean glucose levels and requiredmore insulin to maintain optimumserum glucose levels.

For any patient with diabetes onan oral diet, nutritional manage-ment, whether or not a foot ulcer ispresent, should be founded on an in-dividualized meal plan based on rec-ommendations set forth by a dieti-tian or the guidelines established bythe American Diabetes Association.Meals should be at consistent timessynchronized with the peak action oftheir insulin or oral medication.Focus on food choices and an opti-mal weight for the individual patientis recommended. Approximately 10to 20% of calories should be fromprotein sources and less than 30% ofthe calories as fat (less than 10%from saturated fat). The remainingcalories should be made up of carbo-hydrates. Ethanol intake should berestricted, substituting alcohol calo-ries for fat exchanges and limiting in-take to two alcoholic beverages a dayto those on insulin.

In healing a diabetic foot wound,nutritional therapy may be the miss-ing link when the wound is just not

healing and the podiatric physicianis seemingly doing everything right:ruling out all skin diseases, assuringglycemic control, maintaining ade-quate circulation, controlling infec-tion, off-loading the wound, keepingthe wound clean and free from con-tamination, debriding the necroticand senescent tissue and using dress-ings that are creating an appropriatewound environment. In other words,the podiatric physician must not for-get about the patient’s nutritionalstatus.

In the final analysis, healing awound in a person with diabetes canbe as difficult as leading an orchestramade up of un-tuned instruments.Diabetes is a multi-system diseaseand all the systems have to be in har-mony to achieve an optimal out-come. These systems need the appro-priate fuel. Nutrition supplies thatfuel, and therefore nutrition is thekey to creating the energy that drivesthe process of wound healing. ■

References for AdditionalInformation

1. Powers, M. A., MS, RD, CDE :Chapter 3: Medical Nutrition Therapy forDiabetes, Handbook of Diabetes : MedicalNutrition Therapy, Aspen Publishers, IncGuthersberg, MD, 1996.

2. McClave, S A. and Finney, L S.:Chapter 8: Nutritional Issues in the Pa-tient with Diabetes and Foot Ulcers, Levinand O’Neal’s The Diabetic Foot sixth edi-tion, John H. Bowker, M.D. Michael A.Pfeifer, M.D., Mosby Publishers, Inc. St.Louis, MO, 2001.

3. Mayes, T, RD and Gottschlich,MM, PhD, RD, CNSD: Chapter 19: Burnsand Wound Healing The Science andPractice of Nutrition Support, MicheleMorath Gottschlich, PhD, RD, CNSD,Kendall/Hunt Publishing CompanyDubuque, IA 2001.

4. Video by Clinitec Nutrition Com-pany: Nutrition for Professionals: Nutri-tional Aspects of Wound Healing, 1993.


Nutrition...

enteritis, enteric fistulas, HIV,any pancreatic insufficiency, short

bowel syndrome, or prolonged useof total parenteral nutrition, wheredeficiencies of magnesium and/orchromium may become evident.

These diseases may be associatedwith diarrhea which can precipitateor exacerbate the malabsorption. Thepatient with enteropathy complicat-ed by bacterial overgrowth is at riskfor vitamin B12 and folate deficien-cies because the small bowel is un-able to incorporate these vitamins.Gastric bypass surgery for obesity or apartial gastrectomy for peptic ulcerdisease may increase a patient’s riskfor vitamin B12, calcium and/or irondeficiencies. Short bowel syndromewith resection of any portion of theterminal ileum increases the likeli-hood of deficiency of any of the fat-soluble vitamins. Large gapingwounds can be a source of Vitamin Cand/or zinc deficiency.

Knowledge of the patient’s medi-cal history and selection of an appro-priate supplement or enteral productmay help diminish the effects of themalabsorption problem. However,depending upon the extent of thedisease, parenteral nutrition mayeven be necessary in selected pa-tients. Formulations composed ofMCT’s (medium chain triglycerides)may control the diarrhea and othercomplications associated with malab-sorption.

Medications the patient is takingcan affect wound healing and/orcontrol of glucose levels. Corticos-teroids often inhibit wound healingby interfering with connective tissueformation, collagen synthesis, andwound retraction. Non-steroidal anti-inflammatory medication improveswound strength but may adverselyaffect the rate of wound re-infectiondue to its effect on a patient’s immu-nity. Cyclosporins, sympathomimet-ics, and corticosteroids may con-tribute to poor glycemic control. It isimportant to investigate all medica-tions and supplements that the pa-tient is taking because of the pro-found effect that they may have.

Control of Serum Glucose Levels Glycemic control is an essential

component to nutritional therapy asit applies to healing a wound in a di-

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Dr. Rehm, boardcertified in dia-betic woundcare, practicesin San Diego,CA. He lecturesnationally andoffers seminarsfor podiatristsand other pro-fessionals. Dr.Rehm is Director of the Diabetic Footand Wound Treatment Centers inSan Diego.


abundant in alpha lipoic AcidD) Choosing foods that arelow in linoleic acid

5) Which of the following arethe least instrumental in healinga diabetic foot wound?

A) Vitamin CB) Vitamin AC) Vitamin ED) Trace boron

6) Zinc is an important trace ele-ment because:

A) It is a co-factor in catabolicreactionsB) It potentiates the action ofDHAC) It is essential for the tran-scription of RNAD) It immobilizes the harmfuleffects of retinol-bindingprotein

7) Vitamin K is essential for thefollowing reason:

A) It is needed for the metab-olism of amino acidsB) It has anti-oxidant proper-ties that promote cell mem-brane integrityC) It is a coenzyme for DNAsynthesisD) It is essential for coagulation

8) A comprehensive nutritionalassessment should evaluate all ofthe following except:

A) The ratio of complex vs.simple carbohydrates consumedB) Macro- and micronutrientintakeC) ComorbiditiesD) Medications

9) Basic principles of nutritionalmanagement of patients with di-abetic foot wounds include thefollowing:

A) Never force yourself to eatbeyond your appetiteB) Never eat while watch-

1) Nutritional Management of adiabetic patient with or withouta foot ulcer should be based on:

A) A high fat diet containingOmega 3 fatty acidsB) A low fat diet high inOmega 6 fatty acidsC) Recommendations setforth by the American Dia-betes AssociationD) Meals that are consistentwith the patient’s appetite

2) All of the following are truestatements except:

A) Meals should be at consis-tent times synchronized withthe action of the patient’smedicationB) Meals should be based onan individualized meal planC) Focus should be foodchoices and the ideal weightfor any person of the sameheight and weightD) Ethanol intake should belimited to two alcoholic bev-erages per day to those on in-sulin

3) The basic principles of healinga diabetic foot wound include all of the following conceptsexcept:

A) Keeping a wound dry untila scab is developed always al-lows optimal healingB) A wound should be main-tained with little or no pres-sure insultC) Adequate circulation tothe wound site is absolutelynecessaryD) Contamination in a heal-ing wound should be avoided

4) The ability of a patient to heala foot ulcer is mostly affected by:

A) Hypoglycemia in the in-flammatory phase of woundhealingB) Consuming foods that arehigh in DHEAC) Avoiding foods that are

ing T.V.C) Never snack in betweenmealsD) Correction of chewing abnormalities

10) The four phases of woundhealing are the following:

A) Hemostatic, catabolic, an-abolic and reparativeB) inflammatory, reparative,catabolic and remodelingC) Catabolic, anabolic, home-ostatic, maturationD) Hemostatic, inflammatory,connective tissue, epithelial

11) A poor nutritional status in adiabetic patient most likely is dueto all of the following except:

A) Poor appetiteB) SteatorrheaC) Metabolic problemD) Inability to digest or swal-low properly

12) Which of the following state-ments is the least accurate?

A) Boron is a critical elementin wound healingB) Copper promotes themaintenance and repair ofbonesC) Calcium is involved in thedegradation of collagenD) Deficiency of zinc mayoccur suddenly

13) Which of the following state-ments is not true?

A) Pharmacologic modulationof cytokines may enhancewound healingB) The use of growth hor-mone has become part of thestandard of careC) The use of growth hor-mone is associated with in-creased risk of morbidity andmortality in burn patientsD) Alpha-lipoic acid is beingresearched for its role in dia-betes and wound healing

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E X A M I N A T I O N

See answer sheet on page 211.


210

14) Which of the following is the most likelycause of malabsorption and maldigestion:

A) MarasmusB) KwashlorkorC) Weight gainD) Pancreatic insufficiency

15) Vitamin A deficiency affects wound carein all of the following ways except:

A) Decreases epithelializationB) Produces an increase in T-lymphocytesC) Decreases resistance to infectionD) Decreases collagen synthesis

16) All of the following are important traceelements or micronutrients in woundhealing except:

A) BismuthB) ZincC) CopperD) Iron

17) Which of the following is not used forthe diagnosis of protein malnutrition?

A) AlbuminB) Pre-albuminC) Total ProteinD) BUN

18) Which of the following is not likely tocause an elevation in pre-albumin levels:

A) Corticosteroid therapyB) Digestive disordersC) Hyperactive adrenal glandsD) Hodgkin’s disease

19) All of the following are likely tointerfere with pre-albumin levels except:

A) InflammationB) AmiodaroneC) EstrogensD) Beta Carotene

20) Patients with diabetes and foot ulcersare likely to have all of the following except:

A) Higher levels of fibrinogenB) Higher levels of C-reactive proteinC) Higher levels of thyroid hormoneD) Lower albumin levels

E X A M I N A T I O N

(cont’d)

See answer sheet on page 211.

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E N R O L L M E N T F O R M & A N S W E R S H E E T (cont’d)

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educational objectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

EXAM #10/03Debride a Wound

(Johnson, Nixon, and Armstrong)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educational objectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

Degree____________________________

Additional comments and suggestions for future exams:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

EXAM #11/03Nutrition(Rehm)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

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