This document discusses nutritional support in the prevention and treatment of pressure ulcers. It notes that pressure ulcers pose a significant burden through increased healthcare costs and prolonged hospital stays. Nutrition plays an important role both in preventing pressure ulcers in at-risk patients and in aiding the healing of existing ulcers. Several studies are summarized that have found protein and mineral supplements like zinc and vitamin C to help reduce pressure ulcer size and improve healing rates compared to standard care or placebo, though the evidence for zinc supplements alone is mixed.

2. DR. SAFAA HUSSEIN ALI
L E C T U R E R O F G E R I A T R I C M E D I C I N E
A I N S H A M S U N I V E R S I T Y
C A I R O – E G Y P T
S E N I O R R E G I S T R A R O F G E R I A T R I C M E D I C I N E
P R I N C E M A N S O U R M I L I T A R Y H O S P I T A L
T A I F - K S A
Nutritional support in
prevention and treatment of
pressure ulcers

3. Burden
 Pressure ulcer, while gaining increased attention from
health-care decision makers, remains a large problem.
 Reported prevalence in the acute setting ranges between 10
and 20%, and incidence rates between 4 and 10%. The
annual cost of treating pressure ulcer in the United
Kingdom was estimated to be £1.4–2.1 billion in 2004,
equivalent to approximately 4% of the total NHS
budget, and in the United States for the same time period it
was estimated to be US$2.2–3.6 billion.

4.  A large part of the cost attributable to pressure ulcer
is the prolonged length of stay in the hospital to treat
them. The economic opportunity cost of prolonged
hospital stay is that beds are not available for use to
other patients.
 This amount included reimbursement for
professional and support staff, wound care
supplies, electrical stimulation, rental of
equipment, and loss of potential income.

5. BURDEN OF ILLNESS
 The impact of pressure ulcers can be seen in human and economic
terms.
 In human terms, the geriatric patient who develops a pressure ulcer
has a four-fold increased risk of death. Pressure ulcers also affect
quality of life and lead to more frequent hospitalization.
 In economic terms, the cost of healing a pressure ulcer is likely high
because it often involves a multitude of prolonged complex
treatments and hospitalization. Once a pressure ulcer reaches stage
III or IV, it may take as long as 6 months to heal. Experts advise
that some ulcers may not be healable because of existing
comorbidities and may require ongoing treatment and care.

6. Factors Influencing Healing
 Many variables that can affect ulcer
healing, including patient demographics, pressure
ulcer size and severity, and pressure ulcer
management practices.

7. NUTRITION AND SORES
TWO PARTS:
 DOES NUTRITION AFFECT BED SORE HEALING?
 DOES NUTRITION HAVE A ROLE IN
PREVENTION OF BED SORES?

8. NUTRITION AND SORES
 Previous findings indicate malnutrition is significantly
associated with having pressure ulcer and the mean economic
cost of pressure ulcer attributable to malnutrition .
 Nutrition interventions have been found to reduce
the incidence of pressure ulcer in patients at risk of
developing pressure ulcer.
 Meta-analysis of intensive nutrition support in the prevention
of pressure ulcers (5 randomized controlled trials
(RCTs), n=1325 patients) revealed a significantly lower
incidence of pressure ulcer development in at-risk patients
compared with standard care .

9. NUTRITION AND SORES
 The economic modeling undertaken for this study predicts
that a substantial number of cases of pressure ulcer could
have been avoided, had an intensive nutrition support
intervention been provided to all at-risk patients.
 This corresponds to a substantial number of patient bed days
that could have been used for purposes other than patients
staying in hospital for an extended period of time with
pressure ulcers. Importantly, there were no predicted
additional cases of pressure ulcer or bed days lost to pressure
ulcer from this model, with the minimum number of cases
and bed days saved being 1082 and 3807, respectively .


10. NUTRITION AND SORES
 Importantly, the model chosen predicted a
95.1% chance of being economically cost saving,
while reducing the incidence of pressure ulcers and
releasing valuable bed days for use by other patients.
Of course, evaluation of the implementation of such
an intervention is required to test whether the
economic outcomes predicted are accurate.

11. An Evidence-Based Analysis
 Supplementation with 15 grams of hydrolyzed protein 3 times daily did not
affect complete healing but resulted in a 2-fold improvement in Pressure Ulcer
Scale for Healing (PUSH) score compared with placebo.
 Supplementation with 200 mg of zinc three times per day did not have any
significant impact on the healing of pressure ulcers compared with a placebo.
 Supplementation of 500 mg ascorbic acid twice daily was associated with a
significantly greater decrease in the size of the ulcer compared with a placebo
but did not have any significant impact on healing when compared with
supplementation of 10 mg ascorbic acid three times daily.
 A very high protein tube feeding (25% of energy as protein) resulted in a
greater reduction in ulcer area in institutionalized tube-fed patients compared
with a high protein tube feeding (16% of energy as protein).
 Multinutrient supplements that contain zinc, arginine, and vitamin C were
associated with a greater reduction in the area of the ulcers compared with
standard hospital diet or to a standard supplement without zinc, arginine, or
vitamin C.

Ont Health Technol Assess Ser. 2009; 9(3): 1–203.

12. Comparison of Protein Supplements and
Placebo*
 In an RCT, Lee et al. 2006 explored the effect of protein
supplement on the healing of stage II, III, and IV pressure
ulcers in long-term care residents. The trial compared 56
residents of long-term care facilities that received standard
care plus a concentrated fortified collagen protein hydrolysate
supplement for 8 weeks with 33 counterparts who received
standard care and a placebo. Seventy-one of the subjects
completed the study: 44 in the treatment group with 75
pressure ulcers and 27 in the placebo group with 33 pressure
ulcers. At 8 weeks, the protein hydrolysate group showed
twice the rate of pressure ulcer healing compared with the
placebo group (mean improvement in PUSH score 5.56 for
treatment vs. 2.85 for placebo). There were no significant
differences among the groups in the rate of adverse events.

13. PROTEINS
 Ek et al. 1991 studied the effect of a high
protein, high calorie, vitamin and mineral-enriched
liquid supplement on the development and healing
of pressure ulcers. At the end of 26 weeks, 28 of the
67 (41.8%) pressure ulcers in the supplement group
had healed compared with 25 of 83 (30.3%) pressure
ulcers in the group that only received a standard diet.
Although the nutritional supplement group
had a higher incidence of healed ulcers
compared with the control group (RR
1.39), this difference did not reach statistical
significance (95% CI, 0.90–2.14, P = .14)

14. PROTEINS
 Chernoff et al. 1999 reported in an RCT that 4 out of 6
institutionalized tube-fed patients that received a very
high protein (25% of energy) enteral tube feeding had
healed ulcers whereas none of the patients receiving a
standard high protein (16% of energy) formula had
healing of their pressure ulcers.
 The group receiving a very high protein formula also had
a 73% reduction in the surface area of the pressure ulcers
compared with a 42% reduction in the control group. The
differences in the rate of healing and surface reduction of
the pressure ulcers did not reach statistical significance.


15. An Evidence-Based Analysis
Health Quality Ontario
 Supplementation with 15 grams of hydrolyzed protein 3
times daily did not affect complete healing but resulted in a
2-fold improvement in Pressure Ulcer Scale for Healing
(PUSH) score compared with placebo.
 Supplementation with 200 mg of zinc three times per day did not have any
significant impact on the healing of pressure ulcers compared with a placebo.
 Supplementation of 500 mg ascorbic acid twice daily was associated with a
significantly greater decrease in the size of the ulcer compared with a placebo
but did not have any significant impact on healing when compared with
supplementation of 10 mg ascorbic acid three times daily.
 A very high protein tube feeding (25% of energy as protein) resulted in a
greater reduction in ulcer area in institutionalized tube-fed patients compared
with a high protein tube feeding (16% of energy as protein).
 Multinutrient supplements that contain zinc, arginine, and vitamin C were
associated with a greater reduction in the area of the ulcers compared with
standard hospital diet or to a standard supplement without zinc, arginine, or
vitamin C.

16. Zinc Supplementation
 Zinc is a trace mineral that is an integral part of many
body tissues and enzymes. It plays an important part in
the synthesis of deoxyribonucleic acid and ribonucleic
acid that foster tissue growth and healing, as well as
collagen synthesis.
 Zinc deficiency is associated with hair
loss, diarrhea, poor appetite, decrease in sense of taste
and smell, and lesions in the skin and eye.
 A study had shown that up to 88% of eating-dependent
nursing home residents had dietary zinc intake below
50% of the recommended daily allowance. Hence dietary
supplementation of zinc had been investigated as a
treatment for pressure ulcers. (Posthauer 2005, Advances in Skin and Wound Care)

17. Randomized Controlled Trial Comparing
Zinc Supplement With Placebo*
 In a randomized, double-blind crossover study,
Norris et al. randomized 14 patients with pressure
ulcers to receive either 200 mg zinc sulphate or
placebo 3 times daily placebo for 24 weeks. Volume
of the ulcers was measured every 4 weeks and after
12 weeks the groups switched therapy. Only 3
patients completed the study. The mean net change
in the volume of pressure ulcers was 10 mL (SD 9
mL) in the zinc sulphate treated group compared
with a net change of 6.0 mL (SD 17.5 mL). The
difference between the groups was not statistically
significant .

18. Randomized Controlled Trial Comparing
Zinc Supplement With Placebo*
 Brewer et al. (1967) reported no significant
difference in the rate of pressure ulcer healing in
spinal cord injury patients treated with 220 mg of
zinc sulphate 3 times daily for 2 to 3 months (1/6
with healed pressure ulcer) compared with patients
receiving a placebo (2/7 patients healed).

19. zinc
 Houston et al. 2001 compared the adverse effects of 26
older institutionalized patients that received 440 mg zinc
sulphate daily for the treatment of pressure ulcers with 44
patients with pressure ulcers that received similar care
without zinc sulphate supplementation. After 30 days of
treatment, the beneficial effects of zinc sulphate on
healing were not obvious.
 The only significant difference in healing between the
groups over the 30 days was greater improvement in ulcer
volume in patients with stage III or IV ulcer (P < .05), but
not in stage II.

20. ZINC
 However, zinc sulphate supplementation was
associated with a higher incidence of adverse
events. The odds of an infection requiring
antibiotic therapy were 7.8 times greater in
patients receiving zinc sulphate (P < .009). In
addition, subjects with zinc sulphate were 12.5
times more likely to experience nausea/vomiting
than were comparison subjects receiving similar
care without zinc sulphate (P < .02). Adverse
effects could not be explained by the presence of
diabetes mellitus or differences in energy intake.
(Houston, Haggard et al., 2001, Journal of American Geriatric Society 49 : 1130)

21. An Evidence-Based Analysis
Health Quality Ontario
 Supplementation with 15 grams of hydrolyzed protein 3 times daily did not affect
complete healing but resulted in a 2-fold improvement in Pressure Ulcer Scale for
Healing (PUSH) score compared with placebo.
 Supplementation with 200 mg of zinc three times per day
did not have any significant impact on the healing of
pressure ulcers compared with a placebo.
 Supplementation of 500 mg ascorbic acid twice daily was associated with a significantly
greater decrease in the size of the ulcer compared with a placebo but did not have any
significant impact on healing when compared with supplementation of 10 mg ascorbic
acid three times daily.
 A very high protein tube feeding (25% of energy as protein) resulted in a greater
reduction in ulcer area in institutionalized tube-fed patients compared with a high
protein tube feeding (16% of energy as protein).
 Multinutrient supplements that contain zinc, arginine, and vitamin C were associated
with a greater reduction in the area of the ulcers compared with standard hospital diet or
to a standard supplement without zinc, arginine, or vitamin C.

Ont Health Technol Assess Ser. 2009; 9(3): 1–203.


22. Ascorbic Acid Supplementation
 Ascorbic acid is the enolic form of vitamin C. In addition to its
antioxidative effects, vitamin C also plays an important role in
tissue repair and regeneration within the body. It acts as a
cofactor for enzymes involved in the synthesis of connective
tissues, in particular collagen, an important process in wound
healing.
 Vitamin C deficiency has been associated with risk of pressure
ulcer .
 Elderly subjects admitted for femoral bone fracture that
developed pressure ulcers were found to have leukocyte
vitamin C levels about 50% lower than those in similar
patients that remained ulcer free (Selvaag 2002).

23. Ascorbic…….
 Tayor et al. 1974 compared 10 surgical patients with
an existing pressure ulcer who received 500 mg of
ascorbic acid twice daily with 10 patients who
received a placebo twice daily. Both groups received
similar wound care. After 1 month, 6 of the patients
in the ascorbic acid group had complete ulcer
closure compared with 3 patients in the placebo
group.

24. Ascorbic…….
 This difference was not statistically significant;
however, patients in the ascorbic acid group showed
significantly greater reduction in the mean ulcer area
compared with the placebo group (84% vs.
42.7%,P < .005).

25. Ascorbic …….
 In a more recent RCT, ter Riet et al. 1995 compared
42 nursing home patients with a pressure ulcer
(grade 2 or worse) that received 500 mg ascorbic
acid twice daily with 45 residents that received 10
mg ascorbic acid twice daily. After 12 weeks, there
were no significant differences in the rate of absolute
or relative reduction in surface area or volume of the
ulcers between the groups.

26. An Evidence-Based Analysis
Health Quality Ontario
 Supplementation with 15 grams of hydrolyzed protein 3 times daily did not affect
complete healing but resulted in a 2-fold improvement in Pressure Ulcer Scale for Healing
(PUSH) score compared with placebo.
 Supplementation with 200 mg of zinc three times per day did not have any significant
impact on the healing of pressure ulcers compared with a placebo.
 Supplementation of 500 mg ascorbic acid twice daily was
associated with a significantly greater decrease in the size of
the ulcer compared with a placebo but did not have any
significant impact on healing when compared with
supplementation of 10 mg ascorbic acid three times daily.
 A very high protein tube feeding (25% of energy as protein) resulted in a greater reduction
in ulcer area in institutionalized tube-fed patients compared with a high protein tube
feeding (16% of energy as protein).
 Multinutrient supplements that contain zinc, arginine, and vitamin C were associated
with a greater reduction in the area of the ulcers compared with standard hospital diet or
to a standard supplement without zinc, arginine, or vitamin C.
Ont Health Technol Assess Ser. 2009; 9(3): 1–203.


27. Multinutrient Supplement
 The use of multinutrient (mixed nutrient) liquid
nutritional supplements is a common practice to
provide additional protein, energy, vitamins, and
minerals to people requiring additional nutrition
support.

28. Multinutrient
 Benati et al. 2001 reported on the results of 16 hospitalized
patients with severe cognitive impairment that were
randomized into 3 arms. The study compared the effect of a
high protein, high calorie supplement enriched with
arginine, zinc, and antioxidants (vitamins A, C, and E) with
a group receiving a similar supplement without the
enrichment and a control group receiving a standard
hospital diet.

29. Multinutrient
 Benati et al. reported that patients treated with the
supplement enriched with arginine, zinc, and
antioxidants seemed to have the lowest pressure
sore status tool score (best healing) and more rapid
improvement. No numerical data was provided,
however, and the statistical significance cannot be
assessed.

30. Multinutrient
 The decrease in PUSH scores (improvement in
pressure ulcer healing) was –6.8 for the arginine-
zinc-vitamin C enrichment group compared with –
2.0 for the standard supplement group and –1.7 for
the hospital diet group. However, there is insufficient
data to determine whether the differences in
improvements among the groups are statistically
significant.


31. Multinutrient
 Desneves et al. 2005 conducted a similar study to explore
the effect of a high protein, high energy supplement
enriched with arginine, zinc, and vitamin C. This treatment
was compared with treatment with the same high protein,
high energy supplement without enrichment and to the
standard hospital diet.

32. Multinutrient
 At the end of 3 weeks, patients that received
supplementary arginine, zinc, and vitamin C had
significantly better PUSH scores (P < .05) and had
approximately 2.5-fold greater improvement in
PUSH score compared with the other 2
groups, even though there were no significant
differences in the patients’ intake of protein and
energy among the 3 groups.


33. An Evidence-Based Analysis
Health Quality Ontario
 Supplementation with 15 grams of hydrolyzed protein 3 times daily did not affect complete healing but
resulted in a 2-fold improvement in Pressure Ulcer Scale for Healing (PUSH) score compared with
placebo.
 Supplementation with 200 mg of zinc three times per day did not have any significant impact on the
healing of pressure ulcers compared with a placebo.
 Supplementation of 500 mg ascorbic acid twice daily was associated with a significantly greater
decrease in the size of the ulcer compared with a placebo but did not have any significant impact on
healing when compared with supplementation of 10 mg ascorbic acid three times daily.
 A very high protein tube feeding (25% of energy as protein) resulted in a greater reduction in ulcer area
in institutionalized tube-fed patients compared with a high protein tube feeding (16% of energy as
protein).
 Multinutrient supplements that contain zinc, arginine, and
vitamin C were associated with a greater reduction in the
area of the ulcers compared with standard hospital diet or
to a standard supplement without zinc, arginine, or vitamin
C.
Ont Health Technol Assess Ser. 2009; 9(3): 1–203.

34. Summary Statements – Nutrition Therapy
 Supplementation with 15 grams of hydrolyzed protein 3 times
daily did not affect complete healing but resulted in a 2-fold
improvement in PUSH score compared with a placebo.
 Supplementation with 200 mg of zinc 3 times daily
did not have any significant impact on the healing of
pressure ulcers compared with a placebo.
 Supplementation of 500 mg ascorbic acid twice daily was
associated with a significantly greater decrease in the size of
the ulcer compared with a placebo but did not have any
significant impact on healing when compared with
supplementation of 10 mg ascorbic acid 3 times daily.


35. Summary Statements – Nutrition Therapy
 A very high protein tube feeding (25% of energy as
protein) resulted in a greater reduction in ulcer area in
institutionalized tube-fed patients compared with a high
protein tube feeding (16% of energy as protein).
 Multinutrient supplements that contained zinc, arginine,
and vitamin C were associated with a greater reduction in
the area of the ulcers compared with standard hospital
diet or to a standard supplement without zinc, arginine,
or vitamin C.
 It should be noted, however, that firm conclusions
cannot be drawn because of methodological flaws and
the small sample size.

36. PRESSURE ULCER PREVENTION AND NUTRITION
 There are 5 relevant RCTs comparing the
effectiveness of nutritional supplementation in
addition to the standard hospital diet compared with
the standard hospital diet alone.

37. PRESSURE ULCER PREVENTION AND
NUTRITION
 Five studies compared the effect of nutritional
supplementation on the incidence of pressure ulcers
with that of a standard hospital diet.
 Nutritional supplementation ranged from 1070 to
6300 kJ/day (254 to 1,500 c/day). The follow-up
study period ranged from 2 weeks to 6 months.

38. PRESSURE ULCER PREVENTION AND
NUTRITION
 In one study by Hartgrink et al., the nutritional
supplementation was delivered via nasogastric tube.
 All studies used a different pressure ulcer
classification system for the outcome measure

39. RESULLTS
 reports the results of the meta-analysis of the studies
comparing nutritional supplementation and a
standard diet to a standard hospital diet alone.
 There is an overall statistically significant RRR of
15% in the incidence of pressure ulcers in favour of
nutritional supplementation to a standard hospital
diet.

40. TAKE HOME MESSAGE
 Supplementation of standard hospital diet with
protein, ascorbic acid (500 mg twice daily), or
multinutrient supplements was associated with a
significantly greater or faster reduction in the size of
pressure ulcers, but did not result in a significant
increase in the proportion of healed pressure ulcers.

41. Grade of Evidence
 There is very low quality evidence supporting an
RRR of 15% in the incidence of pressure ulcers when
nutritional supplementation is added to a standard
hospital diet.