This is a presentation I done with 3 days in a rush for a presentation in a workshop. I hope it brings certain information to my blog users. From www.littlediet.info.

1. DIET AND TISSUE HEALING

2. 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.

3. 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.

4. 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.

5. 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

6. 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

7. 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

8. PROTEIN : 14 g/ serving
1 piece 2 piece chicken 2 match box 2 pieces
drumstick breast lean meat tempe
1 fish 2 match box 2 medium 1 ½ piece
( 6inches) fish eggs (hen) tauhu

9. Milk & Dairy products: 7 g
PROTEIN
1 glass milk 4 rounded tablespoon
(250ml) powdered milk
¾ cup yogurt 2 thin slices cheese

10. NUTRITIONAL SUPPLEMENTS
Standard
1 scoop : 36-38kcal
: 1.4-1.7 g protein
Fibre
supplemented Glucose
Gluc
Intolerance

11. Protein Powder : Myotein
1 scoop : 5 gram protein

12. QUESTIONS ?????
Patient A, weight 50kg, protein requirement
1.2-1.3 g /kg body weight.
How much the protein that patient needs?

13. ANSWER……
60 gram-65 gram protein / day
How to get 60-65gram protein??

14. 60-65g protein???
14 14
7 g g g
7 g 7 g 7 g

15. 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

16. 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.

17. Sources of Arginine
Source Amount of Arginine (g)
Endogenous Arginine production ~ 15-20g/d
Dietary protein 1g 54mg arginine
Oral diet, dependent upon intake ~3-6g/d
Oral liquid supplements ~4.5g/240ml
Enteral tube feeding formulas: ~12.5-18.7g/L
arginine enriched
Enteral tube feeding formulas: ~1-2g/L
standard
Parenteral amino acid solutions ~10-12g/L
(10%)

18. 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)

19. Glutamine
Recommendation Dosage:
• Enterally:
0.35-0.57 g/kg/d
(20 – 30 g/day depending on patient’s weight)
• Parenterally:
>0.2 g/kg/day
(Thompson, C.W., Nutrition and wound healing. 2003)

20. 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

21. 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).

22. 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

23. 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.

24. 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)

25. 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)

26. 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)

27. 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

28. 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)

29. 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

30. 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)

31. 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

32. 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)

33. 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.

34. 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

35. NUTRITION SCREENING

36. 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

37. 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 National
DAA Conference, Melbourne 2004. Abbott Australasia Pty Ltd.

38. 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)

39. 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)

40. 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
patient's 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.

41. 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)

43. 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.

44. 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