What You Should Know About Nutrition And Wound Healing

Author(s): 
By Patricia Abu-Rumman, DPM, and Robert A. Menzies, BSc(Hons), MChS, SRCh

The clinical examination revealed a wound on the dorsum of his foot that measured 11 cm by 4 cm with a depth of 2 cm. The physical examination was positive for a loss of protective threshold, intact vascular status, and no significant changes in the skin and its appendages. Laboratory studies revealed a hemoglobin A1c of 7.7%, albumin of 3.9 g/dl, a normocytic, normochromic red blood cell picture, as well as normal liver and renal function.
We noted that this patient has secondary malnutrition due to diabetes. However, the hemoglobin A1c indicates fairly good control of the carbohydrates. Since pre-albumin testing in not available in Qatar at this time, we must rely on albumin, total protein assays and physical examination techniques to determine the patient’s protein status. These techniques revealed a protein deficient state for the patient. In addition, the wound is very large so there will be an increased protein demand in order to facilitate healing.
We initially covered the wound with a dry, sterile dressing as ordered by the various surgical services. The wound bed was 80 percent fibrotic with no signs of infection. We performed bedside debridement and applied a collagen particle paste. We continued this daily protocol and discharged the patient three days after the initial consultation.

It’s also important to keep in mind that the patient is an Indian national working in Qatar and is the sole source of financial support for his wife and youngest son. His salary is in the lower economic level and he has limited sick time available. As an expatriate working in Qatar, he could risk losing his position if excessive sick time were necessary.
This case involved working closely with the family to find an affordable protein for daily consumption and increasing the patient’s overall protein intake. In coordination with diabetes educators, dieticians and a diabetologist, the patient’s diet was modified to include a high protein source and we prescribed a daily multi-vitamin plus minerals and additional zinc. Through written and verbal communication with the patient’s employer, we obtained the company’s cooperation in extending the patient’s leave time without penalty. The patient’s oldest son also arrived in Qatar to assist with some of the daily responsibilities of the family.
Following up with the patient in the clinic, we performed sharp debridements on a weekly basis and debrided the devitalized extensor tendons when necessary. We also continued with the dressing protocol of collagen particles. The wound progressed without complications. At week 13, we changed the dressing to Promogran (Johnson and Johnson) and a tielle dressing. Final closure occurred within weeks. The total healing time from initial consult to closure was five months.

Final Notes
Early screening and treatment for nutritional status can have a profound effect on wound healing. Select screening methods that are available in your facility and feasible to perform. One may implement simplified recommendations using the plate model for nutrition until you can obtain or refer for professional dietary help. Instruct your patient to consider his or her serving plate as a pie: 1/5 of the plate for the meats, fish, eggs or cheese, 2/5 for staple foods like rice, pasta, bread and 2/5 for fruit and vegetables.17
In order to maintain hydration, talk to patients about calculating the amount of fluid intake they must consume, using 30-40 ml/kg/ day as a guideline for patients with wounds.19 Investigate multivitamins available in your area and then recommend brands with the aforementioned adequate amounts. The key is early aggressive intervention.

Dr. Abu-Rumman is the Head of Podiatric Services for the Diabetic Foot and Wound Clinic at the Hamad Medical Center in Doha, Qatar. She is a Diplomate of the American Board of Medical Specialities in Podiatry, and is board-certified in the prevention and treatment of diabetic foot wounds. Dr. Abu-Rumman is currently the Qatar reprentative for the International Working Group for the Diabetic Foot and is a member of the Qatar National Planning Committee for Diabetes.

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