This is the first in a series of guest posts by Dr. Nancy Collins, a wound care-certified, registered dietitian nutritionist with expertise in wound care. Dr. Collins has a B.S. from University of Nevada, Las Vegas as well as an M.S. in dietetics and nutrition and a Ph.D. in human nutrition from Florida International University.
November is National Diabetes Month, a time when communities across the country team up to bring attention to diabetes and its impact on more than 30 million Americans. With holiday meals and parties just around the corner, wound care clinicians could not find a better month than November to educate their patients with diabetic foot ulcers about proper nutrition.
The Important Role of Nutrition in Wound Healing
Nutrition is a critical component of healing, particularly as it relates to immune function, glycemic control, malnutrition, and weight loss, as well as weight maintenance. Every visit to the wound clinic gives clinicians the opportunity to discuss nutrition with patients while providing treatment.
Nutrition intervention does not require anything fancy or complicated. Sometimes, all it takes is inquiring about what the patient ate that day or providing a list of healthy food suggestions. A more formal way to begin nutrition education is to ask patients to complete a nutritional screening questionnaire, such as the MNA® Mini Nutrition Assessment (https://www.mna-elderly.com). This validated, six-question tool takes just a few minutes to complete and can identify those at risk for malnutrition, as well as those who are possibly already malnourished. Wound Care Advantage clinicians can find additional nutrition information in the company’s Luvo operating system.
Malnutrition and/or nutrient deficiencies can impair collagen synthesis, prolong inflammation, decrease phagocytosis (causing dysfunction of B and T cells), and decrease the mechanical strength of the skin. For these reasons, it is important to ask patients about their food intake and help them understand the importance of eating a variety of nutrient-dense foods each day.
Providing Chairside Advice
Patients often ask about diet, and many struggle with weight issues. Clinicians often advise patients to eat “better” or “healthy foods,” but this vague advice needs a bit of refinement in order to truly help patients make changes in their intake.
Here are some easy answers to three of the most common questions asked by patients with diabetic foot ulcers.
“What should I eat?”
Patients should eat plenty of protein-rich foods, including lean meats and seafood, skinless poultry, eggs, and tofu. They should consume whole-grain and high-fiber carbohydrates, such as whole-grain breads, cereals and pasta, brown rice, beans, fruits with the skin, and berries. They should choose low-fat dairy products and non-starchy vegetables, such as cauliflower, tomatoes, peppers, carrots, broccoli, cabbage, kale, and spinach.
For patients with diabetes, glucose monitoring is critical. Patients with elevated A1C levels may have delayed wound healing or complications because high glucose levels cause the cell walls to become rigid. This, in turn, impairs blood flow through the critical small vessels at the wound surface. It also impedes red blood cell permeability and flow, and it impairs the release of oxygen. In addition, persistently elevated blood glucose levels affect the body’s ability to eliminate bacteria, which can lead to an increase in infections, something not wanted in patients with open wounds.
Remind patients to read all food labels and check the sugar content. For example, some brands of yogurt have very high amounts of hidden sugar, so it is important to stress that patients make a habit of reading labels before buying.
“What can I snack on?”
The variety of snacks is endless depending on a patient’s preferences, but the key is to limit snacks to about 15 grams or less of total carbohydrates. This is because the body breaks carbohydrates down into glucose. Patients should spread carbohydrate intake throughout the day. A few snack examples include a hard-cooked egg with one slice of whole-grain toast or ½ cup of low-fat cottage cheese topped with ½ cup of lite peaches.
“Should I take vitamins to heal my wound?”
Yes, a multivitamin and mineral supplement is probably a good idea. An optimal diet usually is adequate to meet all the vitamin and mineral requirements of healthy individuals. Unfortunately, not many of us consume an optimal diet every day, and most patients have medical conditions that may increase their needs for specific vitamins and/or minerals. A supplement can fill any gaps and acts as a good insurance policy.
Unfortunately, few studies address optimal intake levels for wound healing, or whether supplementation is beneficial. The big unanswered question is whether patients would benefit from supplements above the reference level and, if so, by how much? Many clinicians recommend additional vitamin C and zinc. Vitamin C is water soluble and may help in other areas such as immunity, so it is not very concerning if a patient wants to take additional vitamin C. Zinc, however, is different because it is not water soluble, and long-term zinc supplementation may, in turn, cause a copper deficiency, so additional zinc is only recommended when a deficiency is suspected.
The Missing Piece of the Puzzle
Healing begins from the inside out. Building new tissue requires calories, protein, and many vitamin and mineral cofactors. Poor nutrition can hinder patients’ success at healing diabetic foot wounds, so make sure to ask about their meals and snacks. If you discover a complex nutritional problem that is beyond a simple discussion, refer the patient to a registered dietitian nutritionist. Medical nutrition therapy for patients with diabetes is often a covered benefit on insurance plans, as well as Medicare Part B.
Together, we can make sure we have fewer diabetic foot ulcers to treat next November when National Diabetes Month comes around again.
About the Author: Nancy Collins, PhD, RDN, LD, NWCC, FAND, is a teacher, frequent lecturer, and published author who is passionate about educating health care professionals. She is a featured speaker at wound care conferences throughout the year. To contact her, visit her website, www.drnancycollins.com.