Nutritional Support (1)

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

2010 Volume 3 No 1Wound Healing Southern Africa

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: [email protected]

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 guidelines

6

: 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 sh 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 sh 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

(sunower 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, sh, 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 inuenced by a number of aspects such

as difculty 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 rst 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 identied quickly. Easyquestions 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 underweight

2

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. Deciency

adversely affects wound healing by blunting the broblastic

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

Wound Healing Southern Africa 2010;3(1): 33-36


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Specic amino-acids may inuence the healing process e.g. arginine

appears to inuence wound healing favourably by affecting micro-

vascular 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, broblasts, macrophages andlymphocytes. 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 benecial 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 benecial 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 inammation 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

Vitamin A

Vitamin A stimulates various aspects of wound repair by a

number of mechanisms. It affects broplasia, collagen synthesis,

epithelialisation, angiogenesis, and is involved in the inammatory

processes with specic stimulatory effects on macrophages, which

play a dominant role in wound healing. Vitamin A is essentially

benecial 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), fortied margarine, egg yolk, yellow

and dark green leafy vegetables, apricots, cantaloupe (spanspek/

orange-eshed melon), peaches, sh liver oil.5,13

Vitamin C

Vitamin C plays a critical role in wound healing and collagen formation

and a deciency can have a crucial effect on wound healing. During

vitamin C deciency, broblasts produce unstable collagen whichprovides 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

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 deciency due to low sun exposure.

Food sources Vitamin D

Milk fat (cream), liver, egg yolk, salmon, tuna sh, sardines, and

sunlight converts 7-dehydrocholesterol to cholecalciferol.5,13

Table I: Vitamin A guidelines2,14

Gender Age in

years

Estimated average

requirement (EAR)

Recommended dietary

allowance (RDA)

Tolerable upper intake

level (UL)

Lowest observed

adverse effect level

(LOAEL)

Recommended serum

levels

Male 3150 625 g/2,083 IU 900 g/3,000 IU 3,000 g/10,000 IU a* + b** Serum retinol

0.31.2 mg/L***Female 3150 500 g /1,667 IU 700 g/233 IU 3,000 g/ 10,000 IU a* + b**

* 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

Table II: Vitamin C guidelines2,14

Gender Age in

years

EAR

mg/day

RDA

mg/day

UL

mg/day

LOAEL

mg/day

Recommended

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

Table III: Vitamin D guidelines2,14

Gender Age in years UL g/day LOAEL g/day

Male 3150 50 95

Female 3150 50 95

5 g = 200 IU

NOAEL 60 g/day for both males and females of this age group


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Vitamin E

Vitamin E through its anti-inammatory 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 deciency is present.2 Vitamin

E comprises eight naturally occurring forms (tocopherols andtocotrienols) 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 broses 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 deciency is rare but can occur

with fat malabsorption as seen with short bowel syndrome, chronic

diarrhoea, cystic brosis, coeliac disease and patients who have hadgastrectomy surgery.

Food sources Vitamin E

Wheat germ, vegetable oils, green leafy vegetables, milk fat (cream),

egg yolks, nuts, vegetable oils.5,13

Zinc

Zinc is most probably the nutrient where the importance of

maintaining a balance is demonstrated the best since excess and

deciency 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 deciency 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 highdensity lipoprotein (HDL) cholesterol, and poor copper status.14 A rich

food source of zinc for patients not allergic to shellsh is oysters.10

Zinc deciency, as mentioned earlier, impairs wound healing and

supplementation appears to be benecial in patients with wound-

healing impairment secondary to zinc depletion. However, whether

zinc supplementation will increase the rate of wound repair in

patients who are not zinc decient 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 deciency that can caution further

investigation are white spots on the nails for prolonged time periods

(months or years). Zinc deciency is also a common occurrence

seen in patients with alcohol and tobacco use, trauma, HIV, burns,

pancreatic insufciency, vegetarian diets, chronic diarrhoea, short

bowel syndrome and high output GI-stula.2 Excessive amounts of

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 esh particularly red meat, beef liver and poultry,

sh, toasted wheat germ, pecan nuts, wild rice, milk, walnuts, egg,

dry beans, and whole grains.5,13

Copper

Copper is necessary for the formation of enzymes involved inconnective 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, sunower seeds, beans, cocoa powder, dried prunes, and

salmon.13

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 IV: Vitamin E guidelines2,14

Gender Age in

years

EAR

mg/day

RDA

mg/day

UL

mg/day

Recommended

serum levels

Male 3150 12 15 1,000 Serum -tochopherol

5.518 mg/L*Female 3150 12 15 1,000

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

Table V: Zinc guidelines2,14

Gender Age in

years

EAR

mg/day

RDA

mg/day

ULa

mg/day

LOAEL

mg/day

Recommended

serum levels

Male 3150 9.4 11 40 Serum zinc

60120 g/dL*Female 3150 6.8 8 40 60

a 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 fortied food). The UL is not meant to apply to individuals

who are being treated with zinc under close medical supervision.14


Table VI: Copper guidelines2

Gender Recommended serum levels

Male 70140 g/dL*

Female 80155 g/dL*


Table VII: Iron guidelines14

Gender Age in

years

EAR

mg/day

RDA

mg/day

UL LOAEL

Male 3150 6.0 8.0 45 70 mg/day x

Female 3150 8.1 18 45 70 mg/day x

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 uid must be done carefully, as elderly patients may suffer

from impaired homeostasis mechanisms and may not be able to

regulate uid 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 uids for individuals consuming high levels of

protein, those with an elevated temperature, uncontrolled vomiting,

profuse sweating, diarrhoea or heavily draining wounds.8

Other actors

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 benecial 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 sufcient

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

Nutritional status and wound healing: current bestevidence

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 conrmed micronutrient deciency should be

treated at an early stage by providing a minimum 100% RDA of

micro nutrients. 7

In the absence of deciency, supplemental intakes of micro-

nutrients such as vitamin C or zinc provide no clinical benet.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 signicantly

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 inuenced with a few dietary adaptations or maybe

supplementation.

Acknowledgements

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

Confict o interest

The author of this article is an independent GNLD distributor and

thus believes in the benets of possible nutritional supplementation.

Reerences: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 benet 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 Heal ing 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, Ka tsambas 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 vitamin s 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 patie nts. 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.

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