Nutrition For Wound Healing

By:
Fakharuddin Bin Abu Zahar
Pegawai Dietetik
Hospital Sultanah Aminah Johor Bahru
 Introduction
Optimal wound healing requires adequate nutrition.
Nutrition deficiencies impede the normal processes
that allow progression through stages of wound
healing.
Malnutrition has also been related to decreased
wound tensile strength and increased infection rates.
Malnourished patients can develop pressure ulcers,
infections, and delayed wound healing that result in
chronic nonhealing wounds.
Chronic wounds are a significant cause of morbidity
and mortality for many patients and therefore
constitute a serious clinical concern
Factors Affecting Wound Healing
Process
Local Factor
Oxygenation
Infection
Systemic Factor
Age
Diabetes
Medication
Obesity
Alcohol consumption
Smoking
Nutrition
 Nutrition

nutrition has been recognized as a very important factor that

affects wound healing. Most obvious is that malnutrition or
specific nutrient deficiencies can have a profound impact on
wound healing after trauma and surgery. Patients with
chronic or non-healing wounds and experiencing nutrition
deficiency often require special nutrients. Energy,
carbohydrate, protein, fat, vitamin, and mineral metabolism
all can affect the healing process
Arnold and Babul 2006
 Malnutrition

Research shows that malnutrition negatively effects

the wound healing process.
Malnutrition prolongs the inflamatory phase by
decreasing the proliferation of fibroblast and
formation of collagen as well as reducing tensile
strength and angiogenesis.
It can also place patient at risk of infection by
decreasing T-cell function, phagocytic activity
 Nutrition Assessment

Anthropometric measurement eg actual/ideal

bodyweight, height, BMI
Biochemial data eg. Albumin level
Clinical data physical examination
Dietary recall 24hr dietary recall
Nutrition Screening Tools MST, NRS 2000, SGA
 Macronutrients

Energy
Carbohydrate
Protein
Fats
 Energy

Necessary for anabolism, nitrogen synthesis, collagen

formation, and wound healing.
Recommended guideline for calories for optimal
wound healing 30-35 kcal/kg /day (ASPEN)
For obese or geriatric patients with chronic wound an
individualized approach evaluating their metabolic
state should be considered.
Individual who are underweight or losing weight
increase their energy goals to 35-40 kcal/kg/day to
optimise wound healing (NPUAP)
 Carbohydrate

Glucose is the major source of fuel used to create the cellular

ATP that provides energy for angiogenesis and deposition of
the new tissues (shepperd 2003)

The use of glucose as a source of ATP synthesis is essential in

preventing the depletion of other amino acids and protein
substrates (arnold and barbul 2006)
Source of Carbohydrate

- Cereal eg. Rice, mee, meehoon, bread,

biscuits
- Root eg tapioca, potatoes, sweet
potatoes
- Strachy vege eg corn, pumpkin
- starch based products
 Protein
Necessary for the synthesis of enzymes involved in
wound healing, proliferation of cells and collagen and
formation of connective tissue.
A deficiency of protein also affects the immune
system, with resultant decreased leukocyte
phagocytosis and increased susceptibility to infection
(Gogia 1995).
Source of Protein

- Fish
- chicken, eggs, pultry products
- Milk and dairy products
- Legumes and nuts
- Meat
 Protein

Recommended range of protein associated with

healing is 1.25-1.5gm/kg/day
Severely catabolic, with more than 1 wound or stage 3
or 4 pressure ulcer may require 1.5-2gm/kg/day.
 Amino acids

Arginine semi essential amino acids, associated with

promoting protein synthesis and nitric oxide production as well
as enhance immune function.

It is shown also arginine supplementation can enhance wound

strength and collagen deposition in acute wounds.
 Arginine
Arginine improves immune function, and stimulates
wound healing in healthy and ill individuals (Tong and
Barbul, 2004).

Under psychological stress situations, the metabolic

demand of arginine increases, and its supplementation
has been shown to be an effective adjuvant therapy in
wound healing (Campos et al., 2008)

Studies on arginine are remain inconsistent . Some

reported concern on increased nitric oxide in septic
patient leading to hypotension.
 Amino Acids

Glutamine has shown to play important role in wound healing.

Necessary for fuel source for fibroblast, epithelial cells and
macrophages.
Improved nitrogen balance and enhance immune function after
major surgery, trauma and burn injury. However studies were
not focusing on effects on wound healing
Recommendation is 0.57gm/kg/day.
 Fat

Fish oil has been widely touted for the health benefits of omega-3 fatty acids
such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).

The effects of omega-3 fatty acids on wound healing are not conclusive. They
have been reported to affect pro-inflammatory cytokine production, cell
metabolism, gene expression, and angiogenesis in wound sites (McDaniel et
al., 2008; Shingel et al., 2008).

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).
 Micronutrients

Vitamin A
- Act as immune stimulant, maintain mucosal and epithelial integrity,
increases collagen formation and enhance epithelial synthesis.
- RDA 900Ug RE (3000 IU) male ; 700Ug RE (2333 IU) female

Vitamin C
- Plays an essential role in fibroblast maturation and collagen formation.
- Vitamin C deficiencies result in impaired healing, and have been linked to
decreased collagen synthesis and fibroblast proliferation, decreased
angiogenesis, and increased capillary fragility. Also, vitamin C deficiency
leads to an impaired immune response and increased susceptibility to
wound infection (Arnold and Barbul, 2006; Campos et al., 2008)
- RDA 75mg/day (female); 90mg/day (male)
 Micronutrients

Vitamin E
No clear role in wound healing. clinical studies have not yet
proved a role for topical vitamin E treatment in improving
healing outcomes (Khoosal and Goldman, 2006).
Vitamin E, an anti-oxidant, maintains and stabilizes cellular
membrane integrity by providing protection against destruction
by oxidation. Vitamin E also has anti-inflammatory properties
and has been suggested to have a role in decreasing excess scar
formation in chronic wounds.
RDA 15mg/day
 Micronutrients

Zinc
Necessary for the synthesis of granulation tissue and
reepithelialization and also exerts an anti inflamatory
and anti microbial effect.
In present of deficiencies, zinc should be
supplemented 40mg/day and discontinued when
deficiency corrected.
RDA recommended of 11mg/day (male); 8mg/day
(female)
 Micronutrients

Iron
Iron is required for the hydroxylation of proline and lysine, and, as
a result, severe iron deficiency can result in impaired collagen
production

(Shepherd, 2003; Arnold and Barbul, 2006; Campos et al., 2008).

 Fluid

Necessary for perfusion and oxygenation of healthy and

healing tissues.
Increase in fluid demand exist in patient receiving high protein
intake or major fluid loss from wound with high exudate,
treatment with suction or negative pressure wound therapy
devices or other causes.
Recommendation of 30-35ml/kg bwt or 1.0-1.5ml/kcal as daily
intake.
 What can we give?

High Protein and High Calorie Diet - where appetite is not a major issue

Enteral Formula
- Food intake is suboptimal
- Achieving 50% of requirement from food intake
- Patient is on tube feeding

Parenteral Nutrition
- Where the gut is not functioning
 Type of Enteral Formula

Standard Polymeric
Disease specific
Modular product
Semi elemental
Elemental
 Enteral Formula

Standard Polymeric Formula

- eg. Ensure, Enercal Plus, Nutren Optimum, Jevity (with Fibre)
- Complete balance nutrition formula
- Apropriate for age 4yrs above
- Percentage of macronutrients: CHO 55%, Protein 15%, Fat 30% in
average.
- Powdered form and ready to drink (RTU)
- 1.0kcal/ml
Enteral Formula Disease Specific

GlucernaSR / Nutren Diabetic / Glucerna RTD

- Useful to control glucose blood glucose level.
- 1.0 kcal/ml
- Low glycaemic index
- Suitable for oral supplement or tube feeding
- CHO 50%, protein 20%, fat 30%
- Contain dietary fiber
 Enteral Formula - Nepro

Useful for patient on dialysis

2.0kcal/ml
Patient with fluid restriction
Low electrolyte content
High amount of protein
475kcal/serving
Enteral Formula Semi Elemental

Peptamen
- Partially digested
- Easily absorb by body
- High in protein and calories
- Use for problem with malabsorption and promote
wound healing as well
 Enteral Formula Modular

Myotein
100% whey
Provide 5gm protein per scoop
Additional protein to meet individual requirement.
 Enteral Formula - MCT

Medium chain tryglyceride

1ml provide 8kcal
Quickly absorb and use as fast energy compare to
long chain fatty acids
Useful in problem with malabsorption or to provide
instant energy for the body to use.
Can be added in enteral formula and also in food.
 References

Nutr Clin Pract. 2010 Feb;25(1):61-8. Understanding the role of

nutrition and wound healing. Stechmiller JK.
J Dent Res. 2010 March; 89(3): 219229. Factors Affecting Wound
Healing S. Guo and L.A. DiPietro
American Dietetic Association. Nutrition Support For Wound
Healing. Joyce K. Stechmiller, Linda Cowan, Katherine M. Logan
Cleveland Clinic Journal of Medicine Vol 68 August 2001 Prevention
and Treatment of Pressure Ulcers: What works? What Doesnt?
David R. Thomas
Nutrition in Clinical Practice Vol 25 February 2010. Understanding
The Role of Nutrition and Wound Healing. Joyce K. Stechmiller
Nutrition In Clinical Practice Vol 25 February 2010. Nutrition
Management of Pressure Ulcer . Jennifer Doley