Nutrition in wound healing WOUND• Metabolism alters• Extra nutrients need to be supply to the injured area for healing Catabolic phase• If the catabolic phase is prolonged and/or the body is not provided with adequate nutrient supplies, then the body can enter a protein energy malnutrition (PEM) state.
Protein-energy Malnutrition (PEM)• Inadequate or impaired absorption of both protein and energy.• Causes body to break down protein for energy, reducing the supply of amino acids needed to maintain body proteins and healing, and causing loss of lean body mass.• Defined as low Body Mass Index (BMI) or unintentional weight loss (> 5%) with loss of subcutaneous fat and/or muscle wasting.
Protein-energy Malnutrition (PEM)• Malnutrition Increases the chances of infection Decease wound strength Prolonged healing time• Malnutrition is especially prevalent in the elderly• Lean Body Mass (LBM) loss ≥ 20%: Wounds compete with muscles for nutrients• Lean Body Mass (LBM) loss ≥ 30%: Body often prioritize the rebuilding of body over wound healing with available protein.
Nutritional Recommendations for Wound Healing• Nutritional status influences wound healing therefore special attention must be focused on diet• After an injury, the metabolism of macronutrients and micronutrients alters• Healing of wounds involves blood cells, tissues, cytokines, growth factors and metabolic demands for nutrients. (Sylvia Escott-Stump, 2006)• Protein, carbohydrate, fats, vitamins, and minerals are needed for proper wound healing• The ability of a wound to heal may be determined by the individuals nutrition status
PROTEIN• Protein is responsible for: repair and synthesis of enzymes involved in wound healing cell multiplication collagen and connective tissue synthesis component of antibodies needed for immune system function.• A deficiency of protein can impair capillary formation, fibroblast proliferation, proteoglycan synthesis, collagen synthesis, and wound remodeling.• EXTRA protein is needed for wounds, burns and hemorrhage. Major wounds can cause a loss of >50g protein/ day. (Sylvia Escott-Stump, 2006)• SOURCES: red and white meats, fish, eggs, milk, dairy products, soybeans, legumes, seeds, nuts and grains
PROTEIN• In a non injured state, adults require approximately 0.8 g dietary protein/kg body weight/day• However, in injured state, a minimum protein goal is 1–1.5 g/kg/day. (Clark M. J Wound Care 2004)• Major surgery and multiple trauma may need additional protein (1.2-2.0 g/kg BW/day) Protein requirements should be calculated on an INDIVIDUAL BASIS , and they should be monitored closely This needs to happen along with the provision of calories, because if energy needs aren’t met the body will use protein for energy rather than for wound healing
PROTEIN : 14 g/ serving1 piece 2 piece chicken 2 match box 2 piecesdrumstick breast lean meat tempe1 fish 2 match box 2 medium 1 ½ piece( 6inches) fish eggs (hen) tauhu
Milk & Dairy products: 7 g PROTEIN 1 glass milk 4 rounded tablespoon (250ml) powdered milk¾ cup yogurt 2 thin slices cheese
NUTRITIONAL SUPPLEMENTS Standard 1 scoop : 36-38kcal : 1.4-1.7 g proteinFibresupplemented Glucose Gluc Intolerance
Protein Powder : Myotein 1 scoop : 5 gram protein
QUESTIONS ?????Patient A, weight 50kg, protein requirement1.2-1.3 g /kg body weight.How much the protein that patient needs?
ANSWER……60 gram-65 gram protein / dayHow to get 60-65gram protein??
Amino Acid: L- Arginine• Involved in wound healing pathways: Enhance protein metabolism (decrease muscle loss and improve collagen synthesis) Essential for the stimulation of the nitric oxide pathway for collagen deposition in wound healing. Trigger anabolic hormones (insulin, growth hormone) speed up wound healing (Zaloga et al, 2004)• A type nonessential amino acids become conditionally essential during trauma (Endogenously synthesized, plasma arginine levels tend to reflect dietary supply) (Stechmiller JK, Nutr Clin Pract 2005)• Average dietary intake: 4g L-Arginine/d
Amino Acid: L- Arginine• Supplemental maximum safe dosage of arginine not yet established.• If renal /hepatic function is impaired, suggested arginine supplementation be eliminated• A dose of 17 g to 24 g of supplemental arginine has been shown to improve both collagen formation and wound healing. (Barbul A. Surgery 1990)• Although arginine is present in a variety of protein rich foods , the amount is not sufficient for above• Supplements have been developed that provide 4.5g of arginine per serving.
Sources of ArginineSource Amount of Arginine (g)Endogenous Arginine production ~ 15-20g/dDietary protein 1g 54mg arginineOral diet, dependent upon intake ~3-6g/dOral liquid supplements ~4.5g/240mlEnteral tube feeding formulas: ~12.5-18.7g/Larginine enrichedEnteral tube feeding formulas: ~1-2g/LstandardParenteral amino acid solutions ~10-12g/L(10%)
Glutamine• Used by inflammatory cells within the wound for proliferation and as a source of energy. Primary oxidative fuel for rapidly dividing cells, including enterocyte (through uptake by kidney and intestine)• As precursor to a potent antioxidant (glutathione), glutamine participates in reducing oxidative damage• Positive impact to reduce wound infection and healing in experimental studies. (Robert H et al.,2009)• Conditionally essential amino acid during critical illness• Supplementation may be contraindicated in patients with severe renal or hepatic failure (Thompson, C.W., 2003)
ENERGY• Main sources of energy for the human body and for wound healing (collagen synthesis) are protein, carbohydrates and fats.• Energy goals will vary, many guidelines recommend a minimum of 30–35 kcal/kg/day for patients with pressure ulcers. (Clark M et al.,2004)• Vary according the gender, age, activity and clinical status• Small and frequent meal is necessary to ensure adequate energy intake
CARBOHYDRATES• Major source of calories• Glucose is the major source of fuel used to create the cellular ATP that provides energy for angiogenesis and deposition of the new tissues (Shepherd, 2003).• Approximately 55% to 60% CHO of their calories To ensure enough carbohydrate calories are provided to spare protein from being oxidized for energy. (Arnold and Barbul, 2006).
CARBOHYDRATES• Chronic hyperglycemia can impair the transport of vitamin C into cells, including leukocytes and fibroblasts, and inhibits proliferation of fibroblasts.• Hyperglycemia increase susceptibility to infection and loss of nutrients through glycosuria (Hoogwerf, 2001)• Patient would benefit from improved glucose control with the value of HbA1c < 6.5%• Thus, a well distribution for CHO throughout the day and type of CHO is very important in control blood glucose level
FATS• Adequate fats are needed to prevent the body using protein for energy• Fat carries the fat-soluble vitamins (A, D, E, K)• Demands for essential fatty acids increase after injury.• Essential unsaturated fatty acids must be supplied in the diet as the body cannot synthesize enough for the needs of wounds.
FATS• The benefits of omega 3 fatty acid supplementation in wound healing are not conclusive.• Omega-3s are anti-inflammatory• The true benefit of omega-3 fatty acids may be in their ability to improve the systemic immune function of the host, thus reducing infectious complications and improving survival (Arnold and Barbul, 2006)
Vitamin C (Ascorbic Acid)• Antioxidant (immune system)• Increases the absorption of iron• Important after the wound has healed (wounds are metabolically active and previously healed scars can break down in states of vitamin C deficiency) (Leweson SM et al., 1992)• Recommended vitamin C is 60-200mg daily. (doses over 200mg/d are not necessary as tissue saturation occurs. (Levine et al, 1999)• In burn patient, daily intake of 1-2g is recommended (e- SPEN, 2009)• Tolerable upper limit of 2,000 mg/day should not be exceeded in order to avoid adverse effects (nausea, abdominal cramping and diarrhea). (Monsen E, 2000)
Vitamin A• Increases the inflammatory response in wounds, promotes wound healing by increasing fibroblast differentiation, collagen synthesis, wound strength and by reducing infection (Cohen IK et al.,1992)• SOURCES: Dark green and yellow fruits and vegetables, such as carrots, sweet potatoes, apricots, spinach, and broccoli• Recommended intake of vitamin A for wound healing is 20,000-25,000 IU for 10 days if there is a deficiency• It is not recommended to exceed the RDA for a prolonged period of time because it may be toxic (Nelms, M et al., 2007)
Vitamin E• Antioxidant responsible for normal fat metabolism and collagen synthesis• Vitamin E deficiency does not appear to play an active role in wound healing. No evidence to suggest supplemental vitamin E improves wound healing. (Waldorf H et al.,1995)• In fact, wound healing is delayed and the beneficial effects of vitamin A on wound healing are reduced when an excessive amount of vitamin E is given. (Clark SF. Nutr Clin Pract,2002)• Limited evidence for the benefits of vitamin E in decreasing scar formation
Vitamin K• Co-factor for clotting factors and is normally produced by bacteria in the large intestine.• If the patient is taking antibiotics, endogenous vitamin K production may be limited.• Adequate intake of vitamin K is important• SOURCES: green leafy vegetables• It is important to monitor the prothrombin time (PT), PT will increase with vitamin K deficiency (severe diarrhea/vomiting, anticoagulants and liver disease) (Cohen IK et al.,1992)
Zinc• Cofactor in protein and collagen synthesis, in tissue growth and healing• Wounds with increased drainage, excessive gastrointestinal losses, or inadequate dietary intake for long periods of time may trigger a zinc deficiency• Enteral nutrition products (for enhance wound healing) are enriched with zinc.• Those at risk of zinc deficiency include vegetarians, alcoholics, and those with digestive diseases (diarrhea, gastrointestinal fistula)• Zinc is abundant in protein foods such as meat, oysters, liver, milk products, poultry and eggs
Zinc• No clinical evidence supporting supplementation• Patients with wounds should not receive routine zinc supplements in excess of the tolerable upper limit of 40 mg/day, without measuring plasma zinc levels to assess zinc status. (Malone M, 2000)• Recommended intake of zinc: Non healing pressure ulcers is 15mg/day Larger non healing wounds, 25-40mg daily (limited to 14 days) Excess zinc can interfere with both iron and copper metabolism in wound healing (Otten JJ et al.Institute of Medicine. Dietary Reference Intakes, 2006)
Iron• Iron (haemoglobin) deficiency impaired wound healing and impaired collagen production.• Iron is required for hydroxylation of proline and lysine in collagen synthesis.• Severe anemia can impair wound healing through reduced peripheral circulation and oxygenation of the wound site.• SOURCES: red meat, offal, fish, eggs, wholemeal bread, dark green leafy vegetables, dried fruits, nuts and yeast extracts.• Iron absorption from non meat sources can be enhanced with vitamin C
Iron• The dietary reference intake: Premenopausal women: 18 mg/d Postmenopausal women: 8mg/d Men: 8 mg/d• There is no recommended intake for wound healing.• Routine supplementation not recommended for wound healing.• The upper tolerable for iron is 45mg/d(Thompson, C.W., Nutrition and wound healing. 2003)
FLUID• Dehydrated skin is less elastic, more fragile and more susceptible to breakdown• Dehydration will also reduce efficiency of blood circulation, this will impair the supply of oxygen and nutrients to the wound• Tissue oxygenation important for wound heal• Encourage consume 30 mL of fluid/kg of actual body weight, meaning a 70-kg person should consume 2.5 L of fluid per day (McGee M et al., 2001)• Individuals with draining wounds, emesis, diarrhea, elevated temperature, or increased perspiration need additional fluids to replace fluid lost.
Haruan Fish & Gamat• Channa Striatus Essential Omega 6 fatty acid, arachidonic acid (AA) is found abundance in the haruan’s meat• AA is known to be essential for the repair and growth of skeletal muscle tissue, and plays an important role in the inflammatory process• (Jais AM et al., 1994)Haruan is found to contain unusually high arachidonic acid (AA) but almost no eicosapentaenoic acid (EPA). AA which is a precursor of prostaglandin may initiate blood clotting and be responsible for growth• The haruan also contains high levels of amino acids important in the wound healing process. These include glutamic glycine which is the most important component of human skin collagen.• Gamat : Omega 3 + Omega 6
Malnutrition Screening Tool (MST)• Has the resident lost weight recently without trying ? No 0 Yes, how much (kg)? 1-5 1 6-10 2 11-15 3 >15 4 Unsure 2• Has the resident been eating poorly (for example less than ¾ of usual intake) because of a decreased appetite? No 0 Yes 1
Malnutrition Screening Tool (MST) MST If the total score is ≥ 2, the individual is likely to be underweight and /or at risk of malnutrition and should be assessed by a dietitian. It is important to note that overweight or obese individuals can still have protein and nutrient deficiencies that can often be missed. Unintentional weight loss in there individuals may be equally detrimental as they will lose protein stores instead of fat.References:1. Ferguson M, et al. Nutrition 1999.2. Banks M, et al. Malnutrition and Pressure Ulcers in Queensland Hospitals. Proceedings of 22nd NationalDAA Conference, Melbourne 2004. Abbott Australasia Pty Ltd.
Route of Nutrient Delivery• Oral intake with high-protein, high-calorie foods or supplements is usually sufficient to promote wound healing.• Patients who are unable to meet their energy and protein requirements orally, and who have a functioning gastrointestinal tract, require enteral supplementation.• Enteral nutrition, not parenteral nutrition, is the preferred route of nutrient delivery to prevent villus atrophy and reduce infectious complications. (Mayes T et al.,2001)
Route of Nutrient Delivery• Active nutritional support (oral nutritional supplements or enteral feeding ) should be routinely considered in malnourish patients BMI <18.5 kg/m2 unintentional weight loss of >10% within the last 3–6 months. BMI <20 kg/m2 and unintentional weight loss >5% within the last 3–6 months (NICE. Clinical Guideline,2006)
CONCLUSION• Nutrition is a key component in the treatment plan for individuals with Pressure ulcer, diabetic ulcers, or chronic wounds.• Early identification of undernutrition and the correction of nutritional deficits promote healing and improve the patients quality of life.• The use of a nutritional screening tool highlights those at risk of nutritional deficiency.• Age-appropriate protein and energy needs should be the minimum provided, and nutritional supplements or enteral feeding should be considered if minimum goal is not achieved.
CONCLUSION• A high-energy, protein-enriched supplement containing arginine, vitamin C, vitamin E, improved the overall healing of the pressure ulcer (Heyman et al., 2008).• Proteins, carbohydrates, arginine, glutamine, polyunsaturated fatty acids, vitamin A, vitamin C, vitamin E, magnesium, copper, zinc, and iron play a significant role in wound healing, and their deficiencies affect wound healing.• A complete, balanced diet with a mix of nutrients is the best. Excessive vitamin and mineral supplements do not increase rate of healing but may detrimental. (Sylivia Escott- Stump, 2006)
REFRENCES• Health benefits of the Haruan Fish: Aids wound healing after surgery, UPM• Malaysian Dietary Guidelines, MOH Malaysia 2010• e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e308-e312• Arnold M, Barbul A (2006). Nutrition and wound healing. Plast Reconstruct Surg (177 Suppl):42S–58S.• Shepherd AA (2003). Nutrition for optimum wound healing. Nurs Stand 18 :55–58• Clark M, Schols JM, Benati G, et al, European Pressure Ulcer Advisory Panel. Pressure ulcers and nutrition: a new European guideline. J Wound Care 2004;13:267-272.• Stechmiller JK, Childress B, Cowan L. Arginine supplementation and wound healing. Nutr Clin Pract 2005;20:52-61.)• ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr 2002;26:1SA-138SA.
REFRENCES• Levine M, Rumsey SC, Daruwala R, Park JB, Wang Y. Criteria and recommendations for vitamin C intake. JAMA 1999;281:1415-1423.• The Canadian Journal of CME / April 2002• Mayes T, Gottschlich MM: Burns and Wound Healing. In: The Science and Practice of Nutrition Support: A Case- Based Core Curriculum. Kendall/Hunt Publishing Co., Iowa, 2001, pp. 391-420.• McGee M, Binkley J, Jensen GL: Geriatric Nutrition. In: The Science and Practice of Nutrition Support: A Case-Based Core Curriculum. Kendall/Hunt Publishing Co., Iowa, 2001, pp. 373-90.• Cohen IK, Diegelmann RF, Lindblad WJ: Wound Healing: Biochemical and Clinical Aspects. W.B. Saunders Co., Toronto, 1992, pp. 248-73.• Malone M: Supplemental zinc in wound healing: Is it beneficial? Nutr Clin Pract 2000; 15:253-6.• Monsen E: Dietary reference intakes for the antioxidant nutrients: Vitamin C, selenium and carotenoids. J Am Diet Assoc 2000; 100:637-40.• National Institute for Health and Clinical Excellence (NICE). Quick reference Guide on the prevention and treatment of pressure ulcer. 2005• Sylvia Escott-Stump, Nutrition and Diagnosis-Related Care 2006