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. Malnutrition can be divided into primary and secondary forms. Both primary and secondary malnutrition can result in the delay of wound healing. Primary malnutrition is related to poor food choices and insufficient intake. Clinicians can play a major role in disrupting primary malnutrition by evaluating the eating habits and social status of the patient, and providing or referring for nutritional intervention. Secondary malnutrition due to modifications in the metabolism can change the body’s daily requirements. One may consider diabetes a form of secondary malnutrition due to the fasting-like state that exists due to low levels of insulin. When metabolic stress is induced in the patient with diabetes, he or she has increased energy requirements. The body must then convert amino acids from the protein stores and fatty acids from adipose tissue into energy to compensate the metabolic need. Higher energy needs are required during the inflammatory and remodeling phase of wound healing. In addition, a loss of protein mass during the catabolic process of injury or infection can increase the severity of complications and delay wound healing.5 Assessing Nutritional Status: A Guide To Tests, Methods And Physical Exam Findings Multiple methods and tests have been proposed for analyzing one’s nutritional status. These methods can include anthropometrical measurements, laboratory profiles, subjective examinations and multivariable tests. Anthropometrical measurements and calculations, such as the body weight, body mass index (BMI), triceps skin fold thickness, and hip or waist circumference, are used as sole indicators or part of the battery of tests. However, many of these methods compare measurements to standardized tables that do not correlate well with different population groups, especially the elderly.4,6 Those tests that measure mass can be inaccurate in cases of edema, excessive fat accumulation, dehydration or muscle atrophy. Also be aware that the results of the anthropometrical studies and multivariable tests can be highly dependent upon the qualifications and experience of the examiner. This point was demonstrated in a study by the Pattison group that demonstrated an 85 percent correct diagnosis of malnutrition by the dietician and a 58 percent correct diagnosis in testing completed by a nurse.7 When it comes to anthropometric measurement, one should, at the very least, perform serial weight measurements in an outpatient wound care clinic. One can then correlate these measurements with the physical examination results and laboratory studies. Keep in mind that the findings from a physical exam can give you clues of malnutrition. It is first necessary to expose the feet and hands of the patient in order to perform an adequate evaluation. Upon examination, does the patient look his or her stated age? Note the fat distribution as abdominal fat accumulation is associated with type 2 diabetes. Evaluate skin turgor, texture, oral mucosal, conjunctiva and the presence of muscle wasting in the hands and feet.4,8 Changes in the skin and its appendages can indicate a nutrient deficit. Nutritional components for wound healing can be divided into macronutrients (carbohydrates, proteins and lipids) and micronutrients (water, oxygen, vitamins and minerals). While some of the individual components can be evaluated through clinical laboratory analysis, one should first assess the patient’s renal and liver function prior to interpreting other laboratory results. Order blood urea nitrogen, creatinine and, if indicated, a 24-hour urine creatinine clearance. The examinations for the liver status include aspartate transaminase (AST), alanine aminotransferase (ALT) and lactate dehydrogenase (LDH).9 Clinical laboratory studies for macronutrients, hydration and oxygenation are available in most laboratories. However, many of the laboratory studies for micronutrients are not readily available and the results may not be indicative of the body’s micronutrient storage levels. Many vitamin and mineral levels are directly related to the levels of acute phase reactants so assay values are of little use in inflammatory phases of wound healing. Key Considerations For Recommending Nutritional Supplements In clinical practice, when treating patients with wounds, it would be advisable to supplement at least the minimum daily recommended allowance of vitamins. However, if the patient is diabetic, a calcium supplement is recommended as these patients are at a higher risk for foot fractures than non-diabetic patients due to osteoporosis.21 Multiple factors will inhibit the absorption of vitamins and minerals so one should discuss the following points with patients. • Calcium reduces zinc absorption so they should be given at different times of the day.10 • Vitamin B6 will increase the absorption of zinc, so they should be given together.10 • Black dark tea will inhibit the absorption of iron. Green tea and peppermint tea will also inhibit absorption but dark tea is twice as inhibiting.11 • Coffee and calcium are also inhibiting factors for iron.11 • Tea drinkers have lower levels of vitamin C and iron than non-tea drinkers.11 • Wait one hour after taking vitamins and minerals before drinking tea.11 Nutritional Intervention In Wound Healing: What One Case Study Reveals To illustrate the difficulty and importance in evaluating the malnutrition and psychosocial stress of the wound patient, let us consider a short clinical case. The patient is a 56-year-old male with diabetes who presented to the general surgery department for a severe forefoot infection. After the patient underwent initial incision and drainage procedures, he was transferred to the plastic surgery inpatient ward in order to evaluate the possibility of grafting the surgical site. The plastic surgeon in charge of his case determined that grafting was not an option until part of the tissue void was re-established. The plastic surgery team then consulted our Diabetic Foot and Wound Clinic to begin wound care. 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. Dr. Menzies is a podiatrist in the Diabetic Foot and Wound Clinic at the Hamad Medical Center in Doha, Qatar. He is also the podiatrist for the Qatar National Olympic Committee as he specializes in biomechanics and sports medicine. He is state-registered in the United Kingdom and is a member of the Society of Chiropodists and Podiatrists in the United Kingdom.
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