What You Should Know About Nutrition And Wound Healing
Wound healing is a complex process that depends upon the delicate balance of physical and spiritual well-being of the individual. In order to maintain this required balance for wound healing, clinicians must be aware of and evaluate five major conditions including: adequate perfusion, decreased bacterial load, protection from mechanical stress, sufficient nutrition and the patient’s psychosocial status. While one can evaluate the first three conditions through clinical examination techniques, laboratory assays and special studies, the nutritional status and psychosocial status of the patient often remain neglected as the busy clinician may disassociate the wound from the patient as a whole. The nutritional status and the psychosocial status are interrelated yet independent factors. One can visualize perfusion, bacterial load and protection from mechanical stress as a balancing bar over a base composed of nutritional status and psychosocial status. Negative outcomes in any of the five areas will upset the balance and wound healing cannot progress. During the initial visit, one should assess the nutritional and psychosocial status of the patient, and continually reevaluate the status during the course of wound healing. Implementing appropriate screening methods for patients can facilitate early intervention. How Psychosocial Issues Can Affect Nutrition Psychosocial issues play a central role in wound treatment compliance, especially in patients with diabetes. When it comes to foot complications among people with diabetes, associated factors may include increased depression, a divorced or widowed status, substance abuse, a decreased support system, withdrawal from social situations and any alteration in the patient’s daily living activities.1 The International Consensus on the Diabetic Foot document also listed solitary habitation and lack of family or others’ support as risk factors for lower extremity complications among diabetic patients. This document also cited poor education and low economic status as additional risk factors.2 A study conducted by Wissing, et. al., identified that individuals who lived and ate alone had fewer meals per day, consumed meals that were not reflective of a properly balanced diet and ate snacks that were of lower nutritional value.3 It is critical that clinicians identify social isolation and the patient’s ability to obtain appropriate food through subjective questionnaires. An example of one of the screening tests for determining the psychosocial role in nutrition is the Nutritional Screening Initiative Checklist (NSI), which was developed as a self assessment for elderly patients.4 It consists of 10 questions with weighted responses to positive answers. The following questions are asked in the NSI checklist: 1. I have an illness or condition that made me change the kind and/or amount of food I eat. (2 pts.) 2. I eat fewer than two meals per day. (3 pts.) 3. I eat few fruits or vegetables or milk products. (2 pts.) 4. I have three or more drinks of beer, liquor, or wine almost every day. (2 pts.) 5. I have tooth or mouth problems that make it hard for me to eat. (2 pts.) 6. I do not always have enough money to buy the food I need. (4 pts.) 7. I eat alone most of the time. (1 pt.) 8. I take three or more prescribed or over-the-counter drugs a day. (1 pt.) 9. Without wanting to, I have lost or gained 10 lb. in the last six months. (2 pts.) 10. I am not always physically able to shop, cook or feed myself. (2 pts.) If the total score is between 0 and 2, then the patient has minimal nutrition risk and can be reassessed in six months. A total score between 3 and 5 indicates a moderate nutritional risk and a total score of 6 or higher indicates a high nutritional risk. Patients who are deemed to have a moderate nutrition risk should be reassessed every three months and encouraged to take an active role in reducing their risk status. Individuals who are classified at a high nutrition risk warrant clinical intervention either on the practitioner level or through referral to dietitians, health departments, social services, a primary care physician or a diabetologist. Defining Primary And Secondary Malnutrition Now that we have identified the psychosocial factors that can increase the risk of malnutrition, it is important to define the types of malnutrition and what nutrients are necessary in wound healing.