Nutr in Wounds

Baseline Body Composition Matters

Micronutrients:

–Minerals

•Copper

•Iron

•Magnesium

•Selenium

•zinc

Copper is a catalyst that assists in the metabolism of hemoglobin, elastin, and collagen during the wound healing process. It also acts as an antioxidant to protect tissues against further damage.

Iron plays an important role in protein synthesis and in the oxygen capacity of the blood.

Magnesium acts as an enzyme co-factor and helps to stabilize body tissue levels of minerals.

Selenium acts as an antioxidant and supports immune functions.

Zinc is involved in tissue synthesis and a co-factor in a number of enzyme activities. It is involved in protein synthesis and can be lost in draining wounds.

It should be noted that nutrients tend to interact. For instance, to get the best impact from plant-based iron sources, a vitamin C source should be present to improve bioavailability. Copper intake should be balanced with iron and zinc due to their competition.

Supplemental Nutrition

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•During deficiency:

–Macronutrients:

•Calorie-containing supplements

•Protein modules and amino acid supplementation

•Enteral nutrition

•Parenteral nutrition

In some cases, supplemental nutrition may be required to meet the needs for wound healing and the maintenance of nutritional status. If not enough calories are consumed, patients can be counseled on how to add in appropriate calories. In addition, concentrated sources of calories are available in supplemental form. Some of the calorie-containing supplements will also provide a balance of protein and micronutrients.

If protein needs are not met, protein modules can be added to the diet and, in some cases, amino acid supplements may be used. For the purposes of healing, arginine and glutamine have been considered. Arginine has been touted for its role in protein synthesis and immune function support. Glutamine is a primary fuel for muscle tissues and may support anabolism.

Even fats have been explored for their effect on wound healing. Omega-3 fatty acids, found in fish and canola or flax seed oils, has been suggested. Some caution should be exercised in supplementation of these fats because of research that suggested weakening of wound strength in supplemented patients.

Enteral nutrition and parenteral nutrition may be used, if indicated by routine evidence of inability to meet needs with oral nutrition or significant impairment of the gastrointestinal tract that compromises the ability to consume and absorb nutrients enterally.

During deficiency:

–Micronutrients

•Vitamin A: 700-3000 IU

•Vitamin C: 60-200 mg/day

•Vitamin E: DRI

•Copper: 2 mg/25 mg supplemented zinc

•Iron: 20-30 mg/day

•Magnesium: DRI

•Selenium: 100-400 mcg/day

•Zinc: 25-50 elemental (up to 14 days)

While food is the best and safest source for nutrients, some micronutrients have been explored in cases of deficiency that can hamper wound healing. This slide shows some of the levels that have been explored and recommended. It is important to remember that caution should be taken in supplementing individual nutrients because of the potential for interactions, including competition. In the case of zinc, it is important to know that while adequate amounts are crucial for wound healing, excessive amounts can impair the same processes in wound healing. Therefore, it is recommended for only a short period of time.

Summary

•Review:

•Nutritional restoration and maintenance is a key factor in supporting wound healing

•Catabolic processes compromise lean tissues most

•Hormonal changes especially challenge glucose control in patients with diabetes

•Nutrient needs are increased

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Better nutrition = better wound healing

During today’s discussion we discussed the interaction between nutrition and wound healing. Malnutrition of any kind at baseline will impair and delay the wound healing process. Wounds can lead to compromised nutritional status in particular ways.

Unlike starvation or dieting, the acute phase or stress responses associated with wound healing more quickly depletes protein stores that are crucial to body functioning, including wound healing. As little as 10% loss of lean tissues puts a person at significant compromise and at 20% loss the body prioritizes survival over wound healing, significantly delaying the process. At 30% loss, wound healing is completely halted and at 40% loss a person experiences “nitrogen death” or inadequate protein stores to support life.

Catabolic hormones kick in and there is a decrease in anabolic hormones, such as sex hormones, growth hormone, and insulin. These changes can increase the challenges for glucose control in diabetic patients, making it even more crucial to implement dietary and other interventions.

We saw that wounds increase fluid, energy, protein, and micronutrient needs. These needs can be met through education about food-based sources of nutrients and supplemental nutrients.

Nutrition is one of the key factors in assuring adequate wound healing and reducing delays and complications. Therefore, both nutritional status and nutrient needs should be assessed and addressed in all patients with chronic and other wounds.