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A new set of guidelines highlights the role of nutrition in wound healing in adults with diabetic foot ulcers (DPUs).

The guidelines, which have been endorsed by the American Limb Preservation Society, said nutritional interventions were “recommended for all patients who may benefit now or in the future from nutritional care”. Recommendations calling on healthcare providers to develop and implement individualized nutrition care plans for people with or at risk of PDU who are additionally malnourished or at risk of malnutrition.

DFUS has been shown to develop in up to 34% of patients with diabetes at some point in their lives, with approximately 15% to 25% then requiring amputation. Previously, there was no internationally recognized standardized definition of malnutrition in the context of chronic wounds or DFU.

Study author David G. Armstrong, DPM, MD, PhD, of the American Limb Preservation Society, noted that the new guidelines are designed to help the clinician “achieve the challenging goal of improving outpatient nutrition to support DFU wound healing”.

In particular, the guidelines highlighted the importance of a multidisciplinary care team and how clinicians communicate with patients about the conceptualization of diabetes and its management, which can play a crucial role in treatment outcomes.

Screening recommendations

Screening and assessment help indicate when patients may be considered to be in adequate nutritional status, even though this may not be the actual case. The guidelines urged healthcare providers to develop and implement a formalized nutrition screening and assessment protocol to help identify patients with or at risk of malnutrition.

Recommended validated screening tools included the Nutritional Risk Index (NRI), Malnutrition Universal Screening Tool (MUST), and Mini Nutrition Assessment (MNA). Assessment tools included Patient-Centered Subjective Global Assessment (PG-SGA) and Nutrition-Focused Physical Assessment (NFPA).

Additionally, they recommended that in addition to a foot and ulcer examination, a physical examination could focus on skin quality, muscle tone, obesity, or low body weight. A patient’s history can lead to information that makes patients predisposed to malnutrition, including social issues such as depression, income status, living alone, and geriatric age.

In addition, a patient’s food intake should be measured to determine nutritional adequacy and intake exceeding 75% of estimated energy, protein, and water required for wound healing.

Comorbidities should additionally be identified, as well as risk factors for developing ulcers, including medical history, age, and weight. Other recommended laboratory assessments included HbA1c, a complete blood count (CBC), and a total lymphocyte count.

Dietary factors

In order to optimize and meet essential needs for wound healing, the guidelines recommended the implementation of a personalized nutritional care plan, with specific management of calorie, protein, hydration, in micronutrients and the need to modify the diet. Additionally, optimal glycemic control is considered essential, as is ensuring that the patient’s HbA1c is at or near 7.0%.

The guidelines highlighted important factors involved in healing, including:

Local factors

  • wound infection
  • Bacterial colonization
  • Ischemia
  • Venous insufficiency
  • Debris or foreign bodies
  • oxygen saturation
  • Mechanical trauma/pressure
  • Neuropathy

Systemic factors

  • Nutritional deficiencies
  • Diabetic sugar
  • kidney disease
  • Heart disease
  • Advanced age
  • Lack of mobility
  • Smoking
  • Certain medications

Other important factors included hydration, due to the regulation of body temperature, maintenance of kidney function, supply of nutrients to the cells, contribution to good skin turgidity and aid in better blood circulation.

Additionally, if a DFU is present, caloric needs are high and guidelines recommend performing 24-hour recalls and food frequency questionnaires at each visit. Other needs included specific macronutrient and protein requirements, which help optimize wound healing.

Patients with poorly controlled blood sugar and/or diabetes may require special attention throughout treatment. Additionally, mono and polyunsaturated fatty acids including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and arachidonic acid should be considered. Highlighted amino acids included hydroxymethylbutyrate, arginine and glutamine.

The guidelines noted that daily carbohydrate recommendations varied from individual to individual depending on many factors, such as T2D maturity, daily glycemic control, and whether the patient was on insulin therapy or oral hypoglycemias.

They highlighted glycemic targets for inpatient glycemic control as such:

Seriously ill

  • Glucose 140 – 180 mg/dL
  • Blood glucose
  • Blood glucose

Not seriously ill

  • Preprandial blood glucose
  • Random blood glucose
  • Reassess treatment for premeal blood glucose
  • Change treatment for preprandial blood glucose

Significance of interventions

The guidelines concluded that specific nutritional plans should be individualized and based on existing diagnoses, patient preferences, age, lab test results, and pre-existing health and medical conditions.

Thus, he emphasized the importance of setting goals that promote the improvement or maintenance of nutritional status, the prevention of infections, and the optimization of nutritional intake to prevent impaired or delayed wound healing.

They continued that an appropriate diet may be insufficient for optimal wound healing, so early oral nutritional supplements (ONS) may be important for those most at risk of malnutrition.

In terms of patient adherence, educating patients with DFU on the increased dietary requirements and the best dietary sources of essential nutrients involved in wound healing could lead to better results.

Additionally, patients should be counseled directly by their clinician, often resulting in improved HbA1c, quality of life, and compliance.

Guiding lines, “Nutritional interventions in adults with diabetic foot ulcerswas published online by the American Member Preservation Society.


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