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Wound Care Q&A

Optimizing Nutrition For Wound Healing

These expert panelists discuss how to help wound care patients who are underweight as well as what diet modifications can facilitate optimal wound healing.

Q:

What do you do for underweight patients with wounds?

A:

Kazu Suzuki, DPM, CWS, finds intervening for underweight patients easier than for those who need weight loss. As he says, one would want patients to be in an anabolic state, in which they have abundance of calories and protein.

The easiest way to do this, Dr. Suzuki notes, is to add nutritional shakes and drink mixes to a patient’s regular diet. He recommends and prescribes his patients drink a nutritional shake once or (ideally) twice a day in order to increase the total calorie and protein consumed in a day to well above their daily maintenance calories of 2,000 calories (which varies depending on the patients’ height and gender). In his institution, he uses the Abbott Laboratories brands of nutritional shakes: Ensure Enlive shakes for most wound care patients and Glucerna shakes for those with diabetes. Dr. Suzuki says the shakes “taste great, especially when served cold” and patients find the lactose-free shakes taste like milkshakes. He also cites the use of Juven Therapeutic Nutrition Drink Mix (Abbott Laboratories), which supplies branched chain amino acids (BCAA) and patented B-hydroxy B-methylbutyric acid (HMB), which is specific to promote lean body mass and wound healing. Dr. Suzuki tells patients they can purchase these products in grocery stores, pharmacies or online, but he also says it may be cheaper to purchase them in bulk in warehouse stores.

“When in doubt of nutritional impairment of your patients, it is prudent to consult a registered dietitian to review their diet and daily intake,” adds Dr. Suzuki.

Christopher Winters, DPM, will discuss diet with underweight patients and question them as to their eating habits. He will check patients’ protein, prealbumin, albumin, zinc, complete blood cell count (CBC) and their comprehensive metabolic panel. Dr. Winters also asks patients who is cooking their meals and who does the shopping and where. If there is cause for concern, he will refer a patient to a nutritionist.  

Laura Shin, DPM, PhD, immediately gets nutritionists on board. She acknowledges some controversy regarding diets for patients with diabetes and finds there is often a need to tailor things specifically to the individual. She generally follows the National Pressure Ulcer Advisory Panel (NPUAP) guidelines including: eating 30 to 35 calories per kilogram of body weight per day, eating 1.25 to 1.5 g of protein per kilogram of body weight per day and taking enough vitamins and minerals daily to meet the Dietary Reference Intakes for vitamins and minerals.1Dr. Shin also may recommend adding oral nutritional supplements such as Ensure to a patient’s meals.

Dr. Shin also evaluates patients’ eating habits at home. “We find that education is key for patients with nutritional deficits,” says Dr. Shin.  

“Some patients may complain that they don’t want to get fat but I would tell them they can hit the gym and lose weight once the wounds are completely healed,” says Dr. Suzuki.

Q:

What is a good diet to follow for better wound healing?

A:

In addition to adequate calorie intake, Dr. Shin ensures patients are also getting the micronutrients involved in wound healing, including vitamin A, vitamin C, magnesium, copper, and zinc. She often has patients supplement their diets with Juven, zinc and vitamin C for optimal healing.

Dr. Winters discusses with patients the importance of a well-rounded diet, especially vegetables and specifically those vegetables with a variety of colors as these have powerful antioxidants and nutrients. He encourages maintaining a balance among carbohydrates, protein and fat. Dr. Suzuki generally recommends patients follow a whole-food, plant-based diet. He says this diet should include a lot of vegetables and fruits, minimal oil and minimal processed foods.

If his patients are underweight, Dr. Suzuki would not restrict their oils and fats, especially if these are from healthy fat sources like olives, nuts and seeds. He notes that the American Heart Association does not recommend coconut oils, due to a lack of data to state that they are helpful or detrimental in our health. Dr. Winters tells patients not to be afraid of fats in moderation, especially polyunsaturated fats.   
Dr. Suzuki recommends his patients watch the documentaries Forks Over Knives and What the Health from Netflix. He notes each film makes an argument for a whole food, plant-based diet versus a standard American diet rich in calorie-dense processed food and animal products. Dr. Suzuki adds that recent Harvard Medical School research involving 131,342 participants has shown that a plant-based protein diet is tied to an improved mortality rate while high animal protein intake, especially that from processed red meat, was positively associated with mortality, suggesting the source of protein is important.2

Q: 

What kind of diet do you follow personally?

A:

Dr. Suzuki follows the diet developed by Dean Ornish, MD, noting it is basically a “whole food, plant-based” diet (i.e. vegan diet). After much skepticism about veganism, Dr. Suzuki became a vegan and lost 60 pounds of unwanted weight, saying he is “in the best shape of my life. Kyrie Irving, Serena Williams and Venus Williams follow plant-based diets and are on top of their respective games. Now I know why.”  

Dr. Winters says a diet including fish, in particular cold water wild caught fish, is healthy. He will eat meat sparingly and when he does, Dr. Winters prefers turkey over chicken and chicken over beef. Dr. Winters always eats a serving of vegetables and tries to have fruit for dessert. Although pasta is a favorite, he recommends eating it in moderation as one does not want too many carbohydrates.  
Similarly, Dr. Shin tries to stay balanced with a mix of vegetables, protein and starches. With two little boys, she says it can be difficult to find flavorful food that is not fried or full of sodium. She notes her family will eat a whole grain pasta with sautéed garlic, fresh vegetables and chicken.  

Dr. Suzuki also follows the studies from Valter Longo, PhD, the Director of the University of Southern California Longevity Institute, who recommends eating just two meals a day (time-restricted eating), with mostly a whole food, plant-based diet. After age 65 to 70, he notes one should add some animal-based protein in a small amount as this will prevent the loss of lean body mass and muscle strength (sarcopenia).3Longo also advocates a periodic five-day fast, which is clinically proven to decrease abdominal fat, cholesterol and blood pressure while increasing the circulating stem cells and promoting “autophagy,” which was the cell biology concept awarded the 2016 Nobel Prize in Medicine.

“This is a cutting edge in nutritional science that has implication in our medical treatment. Autophagy (‘self-eating’) is a process in which the human body selectively digests injured or inflamed tissues for recycling. I can tell you personally that my plantar fasciitis from marathon training has disappeared after three cycles of Dr. Longo’s fasting program,” says Dr. Suzuki.

Dr. Shin is an Assistant Professor of Clinical Surgery in the Department of Vascular Surgery at the Keck School of Medicine at USC.

Dr. Winters is affiliated with the American Health Network in the Indianapolis area and many hospitals in Indiana. He is board-certified in wound care by the Council for Medical Education and Testing, and is board-certified in the prevention and treatment of diabetic foot wounds by the American Board of Multiple Specialties in Podiatry.

Dr. Suzuki is the Medical Director of the Tower Wound Care Centers at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. He can be reached at Kazu.Suzuki@cshs.org.

Wound Care Q&A
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Clinical Editor: Kazu Suzuki, DPM, CWS
References
  1. National Pressure Ulcer Advisory Panel. New 2014 Prevention and treatment of pressure ulcers: clinical practice guideline. Available at http://www.npuap.org/resources/educational-and-clinical-resources/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guideline/  .
  2. Song M, Fung TT, Hu FB, et al. Association of animal and plant protein intake with all-cause and cause-specific mortality. JAMA Intern Med. 2016; 176(10):1453–63.
  3. Longo V. The Longevity Diet: Discover the New Science Behind Stem Cell Activation and Regeneration to Slow Aging, Fight Disease, and Optimize Weight.Avery Publishing, New York, 2018.
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