IMPORTANCE OF GOOD NUTRITION IN HEALING WOUNDS

MRS.SHEELAPAUl (DIETITIANS)

MRS.MALINI




The importance of good nutrition in the healing of wounds and the promotion of health is widely accepted, but remains of low priority in health care and insufficient numbers of patients receive nutritional assessment. Practitioners need to become more knowledgeable about the role of nutrition in the promotion of wound healing.



Whereas good nutrition facilitates healing, malnutrition delays, inhibits and complicates the process . Nutritional support is fundamental to patient care and needs vary on an individual patient basis. Before we examine the importance of nutritional assessment, we need to look at the nutrients which have key roles in the healing process:


Protein
Protein depletion can affect the rate and quality of wound healing. There is an increase in demand for protein in the presence of a wound, a requirement further increased in the event of sepsis or stress. Protein is required as part of the inflammatory process, in the immune response and in the development of granulation tissue. The main protein synthesised during the healing process is collagen, and the strength of the collagen determines wound strength.











Even short periods of low protein intake can result in significantly delayed wound healing. Protein inadequacy has also been shown to affect remodelling of the wound. In extreme cases of hypoalbuminaemia (i.e. low levels of the serum protein albumin) from long periods of insufficient protein intake, oedema may develop.

The amino acid arginine becomes essential during severe stress. It is abundant in the structure of collagen, and increases its tensile strength. Arginine metabolism is also related to the production of nitric oxide, which is bactericidal, and also aids wound healing through microvascular and haemodynamic changes.


Carbohydrate
As part of the healing process the body enters a hypermetabolic phase, where there is an increase in demand for carbohydrate. Cellular activity is fuelled by adenosine triphosphate (ATP) which is derived from glucose, providing the energy for the inflammatory response to occur. In the case of insufficient carbohydrate, the body breaks down protein to provide glucose for cellular activity . Therefore, in order to correct hypoalbuminaemia, carbohydrate is required as well as protein.

Fats


Fats have a key role in cell membrane structure and function.Certain fatty acids are essential, as they cannot be synthesised in sufficient amounts, so must be provided by diet. The role of essential fatty acids in wound healing is unclear, but as they are involved in the synthesis of new cells, depletion would certainly delay wound healing. Omega-3fatty acids are anti-inflammatory, which aids wound healing.

Vitamins
B-Complex vitamins are co-factors or co-enzymes in a number of metabolic functions involved in wound healing, particularly in the energy release from carbohydrates.


Vitamin C has an important role in collagen synthesis, in the formation of bonds between strands of collagen fibre, helping to provide extra strength and stability. There is loads of evidence showing increased requirements for vitamin C during injury, stress and sepsis, but there is no evidence that mega dosing improves clinical outcomes

Vitamin K is involved in the formation of thrombin, and deficiency in the presence of wounds could lead to a haematoma. Vitamin A is also involved in the cross-linking of collagen and the proliferation of epithelial cells.

Minerals
Zinc is required for protein synthesis and is also a co-factor in enzymatic reactions. There is an increased demand for zinc during cell proliferation and protein secretion. Zinc also has an inhibitory effect on bacterial growth, and is involved in the immune response. Early studies suggest zinc supplementation, over and above that of the hospital diet, speed wound healing. Iron is a co-factor in collagen synthesis, and deficiency in iron delays wound healing. Copper is also involved in collagen synthesis.

Supplementation
The issue of supplementation in aiding wound healing is debatable. It is doubtless that a sufficient intake of all nutrients is needed, and that requirements may be raised during the healing process. This is often also the time when the patient, feeling unwell, has a poor appetite and dietary intake. There is some argument for supplementation with vitamin C and zinc in wound healing, but the evidence seems to point to being only when the patient is deficient in intake or has a low serum status. It is therefore necessary to check status of these two micronutrients along with other biochemical parameters in appropriate patients.


The ideal way to meet requirements of the above nutrients is by consuming adequate intake of normal foods (Perkins 2000). A normal hospital diet provides foods from all four food groups, but is often insufficient in quantity for patients with increased requirements. These patients may require supplementation with sip feeds, which are also fortified with an array of micronutrients. If a patient is consuming adequate amounts of food and sip feed supplements, it is doubtful that he/she will require specific vitamin or mineral supplements. In patients who have particularly stubborn wounds, a multi-vitamin and multi-mineral supplement may be administered.

Due to increased requirements, and the fact that many patients have a poor appetite and dietary intake, where oral sip feeds cannot help, artificial nutritional support may be initiated in the form of naso-gastric or gastrostomy feeding. Often patients are fed overnight by tube and encouraged to eat during the day, with the aim to wean them off tube feeding as nutritional status improves.

NutritionalAssessment
If a patients nutritional status is compromised, and they are unlikely to meet their requirements recovery will be delayed. Therefore nutritional assessment is vital to provide a baseline to work from. A good nutritional assessment involves the multidisciplinary approach including medical, nursing and dietetic staff. A number of assessment techniques may be employed including biochemical tests, weight, body mass index, anthropometry and dietary assessments. Nutritional Screening is an invaluable method of basic assessment done at nursing level. This is where a number of questions are asked concerning the patient's nutritional status to come up with a risk score, in order to identify possible risk of undernutrition. From this appropriate action can be initiated, which may include more detailed nutritional assessment.

Summary
It is obvious that nutrition plays a crucial role in wound healing, but there is little evidence that supplementing a patient's diet with specific nutrients in isolation improves clinical outcome. Further research is needed to identify the levels of supplements that will be of benefit to malnourished patients . Recommendations to patients with wounds should be to consume a healthy balanced diet, with sufficient quantities of energy and protein foods. All patients with wounds should have appropriate nutritional assessment through the multidisciplinary team.

IS ALCOHOL A CHOICE FOR ME

(Alcohol and Diabetes)

You may have heard that alcohol has certain health benefits. However, any pattern of drinking can be harmful. Proven ways of improving your health include: healthy eating, being active, and being a non-smoker.

The Association’s Clinical Practice Guidelines recommend that:

* People using insulin should be aware of delayed hypoglycemia (low blood glucose) that can occur up to 24 hours after drinking alcohol.
* People with type 1 diabetes should be aware of the risk of morning hypoglycemia if alcohol is consumed 2 to 3 hours after the previous evening’s meal.
* Alcohol should be limited to 1-2 drinks per day (less than 14 standard drinks / week for men and less than 9 standard drinks/ week for women).
* People with diabetes should discuss alcohol use with their diabetes healthcare team.

Health risks of alcohol use for people with diabetes

Alcohol can:

* affect judgement
* provide extra calories that can make weight loss or weight management a challenge
* increase blood pressure
* contribute to sexual difficulties
* damage the brain and nerves
* increase your triglycerides
* contribute to inflammation of the pancreas
* dehydrate the body which is very dangerous in someone with high blood glucose
* increase the risk of various cancers over time
* increase the risk of personality change such as depression or aggression
* worsen eye disease
* damage your liver over time



For young people in particular, alcohol use:

* can lead to addiction
* is associated with a dramatic increase in injuries and death

For those on insulin or some diabetes medications

* Drinking alcohol can increase your risk of having low blood glucose. To reduce this risk, take the following steps:

BEFORE Drinking Alcohol

* Eat regular meals, take your medication(s), and check your blood glucose levels frequently,
* Wherever you are, make sure someone with you knows your signs and symptoms of low blood glucose and how to treat it so they can help you.
* Be aware that glucagon, a treatment for low blood glucose, will not work while alcohol is in the body,
* Wear diabetes identification such as a Medic Alert

WHILE Drinking Alcohol

* Eat carbohydrate-rich foods when drinking alcohol.
* Eat extra carbohydrate-rich foods if you are dancing, playing sports or doing other physical activity.
* Drink slowly.

AFTER Drinking Alcohol

* Tell a responsible person that you have been drinking. They should look for low blood glucose symptoms.
* Check your blood glucose before going to bed. Eat a carbohydrate snack if your blood glucose is lower than usual.
* Set an alarm or have a responsible person wake you up through the night and early morning – a delayed low blood glucose can occur anytime up to 24 hours after drinking alcohol.
* You need to get up on time the next day for any food, medication or insulin you normally take. Missed medication or insulin can lead to high blood glucose, ketones and diabetic ketoacidosis (DKA).

You should not drink alcohol if you:

* are pregnant or trying to get pregnant,
* are breastfeeding,
* have a personal or family history of drinking problems,
* are planning to drive or engage in other activities that require attention,
* are taking certain medications.

In nutshell

If you do not drink alcohol, don’t start.
* If you choose to drink alcohol, intake should be moderate (daily intake should be limited to two drinks for adult men and one drink for adult women).
* When drinking alcohol, make sure you know how to prevent and treat low blood glucose.
* Heavy alcohol use can make blood glucose control more difficult and increases other health risks.
* Talk to your Psychologist or healthcare professional if you have questions.

B.Elayaraja M.Sc.,M.Phil.,PGDGC

Psycho social counselor.