Time may not be able to heal wounds, as the saying goes, but the body can—with proper medical and nutritional support, according to recent data for targeted nutrition therapy.

During the Symposium on Advanced Wound Care Spring 2021 virtual meeting, Maritza Molina, RDN, and David G. Armstrong, PhD, DPM, of the Keck School of Medicine of USC, in Los Angeles, discussed how incorporating nutrition as part of the overall treatment plan can promote healing, decrease treatment duration and improve patients’ overall quality of life.

Nutrition Assessment and Treatment

As a registered dietitian at USC, Ms. Molina’s primary role is nutrition optimization, which means improving wound healing through a nutrition-focused approach. With tools such as nutrition-focused physical assessment, 24-hour recalls and lab work, Ms. Molina assesses the overall nutritional status of patients before and after surgery and manages nutrition-related diseases like diabetes and renal disease through intervention and education.

These macronutrient and micronutrient plans are individualized based on disease state and/or malnutrition risk. Ms. Molina noted the following key ingredients to support wound healing:

• Arginine: A conditionally essential amino acid and precursor of nitric oxide, arginine is involved in vasodilation and blood flow support and plays a role in collagen synthesis. In combination with vitamin C, oral nutritional supplements containing arginine have led to greater improvement in pressure injury healing.
• Glutamine: Another conditionally essential amino acid, glutamine plays a role in collagen production, supports nitrogen metabolism and supports the immune system. A study of 40 patients with burns showed that supplemental glutamine led to improved healing and fewer wound infections (J Parenter Enteral Nutr 2003;27[4]:241-245).
• HMB (beta-hydroxy-beta-methylbutyrate): A metabolite of leucine, HMB slows protein breakdown, enhances protein synthesis and stabilizes the muscle cell membrane. A systematic review of seven randomized controlled trials of patients 65 years of age and older demonstrated greater muscle mass in the groups that received HMB (Arch Gerontol Geriatr 2015;61[2]:168-175).
• Collagen protein: Hydrolyzed collagen protein stimulates internal collagen production, which has been shown to increase the rate of wound healing.

In addition to these ingredients, Ms. Molina noted the following micronutrients that support the wound healing process:

• Zinc: important for skin integrity, mucosal membranes and immune response;
• Vitamin C: promotes collagen synthesis for tensile strength, modulates immune function and acts as an antioxidant;

• Vitamin E: plays a role in immune response and inflammation; and
• Vitamin B₁₂: important in the maintenance of red blood cells and supports wound strength.

Although there are clinical data to support each individual micronutrient, said Ms. Molina, when taken together, there is likely a better balance in tissue repair, wound healing and remission.

These macronutrients and micronutrients also have been shown to support wound healing at every stage of the healing process, including the hemostasis/inflammatory, proliferative and maturation phases. However, vitamin therapy should only be provided when deficiencies are present or there is poor oral intake, Ms. Molina said. Providers should consider conducting a 24-hour nutrition recall to determine whether more than 75% of estimated oral intake needs are being met.

“It’s important not to overwhelm patients with nutritional information,” Ms. Molina added. “Remember to use your clinical judgment and take it one step at a time.”

The Diabetic Foot: Common, Complex and Costly

Dr. Armstrong, a professor of surgery and the director of the Southwestern Academic Limb Salvage Alliance at USC, reported that lower extremity complications in diabetes have become more expensive than the five most expensive cancers in the United States. Diabetic foot ulcers also are associated with similar rates of five-year mortality (approximately 30%).

According to Dr. Armstrong, the best available data have shown that after one year of follow-up, approximately 40% of patients will experience another foot ulcer, and at five years, nearly 75% of patients will develop another one.

“We’re speaking at a wound healing meeting, but can we really heal anyone in this patient population in the big scheme of things?” Dr. Armstrong said. “Even when these patients are supposedly healed, recurrence is likely.”

One strategy proven to be effective in diabetic foot ulcers, however, is oral nutritional supplementation. A randomized study of Juven (Abbott), a unique blend of HMB, arginine, glutamine, hydrolyzed collagen protein and other macronutrients, demonstrated significantly improved wound healing of stage 1A diabetic foot ulcers in patients at risk for poor limb perfusion and/or low albumin levels (Diabet Med 2014;31[9]:1069-1077). No differences in healing were identified with supplementation in nonischemic patients or those with normal albumin levels.

“When we looked at the addition of this supplement as an adjunct to standard of care, it appears that the more [the patient] needs, the better it starts to work, which is usually the opposite of what we see in many clinical trials,” Dr. Armstrong said.

“It’s time to start paying attention to nutrition and measuring what we manage,” he added. “We’ve ignored this issue for far too long.”