Nutrition Interventions in Adults with Diabetic Foot Ulcers GUIDELINES Pocketcard

• Updated on: 2022-06-15
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Patient-Centered Subjective Global Assessment (PG-SGA)
Malnutrition Universal Screening Tool (MUST)
Nutrition Focused Physical Assessment (NFPA)
Mini Nutritional Assessment (MNA)
Assessment
If an initial screening suggests an increased risk for malnutrition, the next step should be a thorough nutrition assessment.
In addition to the initial assessment, return visits should be scheduled regularly. These visits should include sufficient time for the care team to assess adherence and make appropriate adjustments to patient's individualized care plan.
Physical Exams
In addition to examination of the patients feet and ulcer, a physical exam should also concentrate on skin quality, muscle tone, obesity, or low body weight, as well as hair quality and cheilosis.
At each visit, anthropometric questionnaires/measurements should be administered and/or measured, and should include the following:
Current vs. normal body weight
% Weight loss or % weight gain over time
Under/overweight amount and %
Patient History
Obtain information of social issues that predispose to malnutrition.
Depression, living on a fixed income, living alone, and geriatric age group are all risks factors for malnutrition
More detailed history of eating habits is likely to divulge a diet low in protein and high in carbohydrates — e.g., high caloric snack foods such as chips, cookies and crackers require no preparation and may dominate the diet.
Specific questions should be asked regarding fruit, vegetable, and protein intake to determine adequacy of nutritional components.
Ensure a patient’s dietary intake exceeds 75% of the estimated energy, protein, and water needed for wound healing.
Some important tools than can be used to determine appropriate daily nutrition intake are:
Conducting 24-hour dietary recalls
Determining safe access to food and need for specialized or modified diet
Evaluating socioeconomic status and home dynamics
Comorbidities
Medical problems that interfere with eating such as bowel disorders should be identified.
Other disease states such as recurrent infections or cancer increase nutritional requirements and may lead to malnutrition.
Table 3. Risk Factors for Ulcer Development
Medical History
Pharmaceuticals (e.g., corticosteroids, diuretics)
Calories
Caloric needs are high when a diabetic foot ulcer is present. Calories provide energy to aid in wound healing and energy demand increases with the patient’s nutrition risk factors and the severity of wound(s).
Adequate energy aids in collagen formation, anabolism, cell metabolism, and development of new tissue such as blood vessels.
Generally, the recommended daily calorie intake is 2,000 for women and 2,500 for men.
Overweight patients with a BMI >30 are at risk of malnutrition, yet patients with significant unintentional weight loss over a specific amount of time are also at risk.
Conducting 24-hour recalls and food frequency questionnaires should be practiced at every visit when treating a patient to ensure the patient is meeting estimated caloric needs.
Utilize indirect calorimetry as the gold standard for identifying energy needs. If indirect calorimetry is not available, there are other formulas that can provide a standard starting point.
Table 5. Kcal Recommendations
22–25 kcal per kg of IBW
ABW, actual body weight; BMI, body mass index; IBW, ideal body weight
Macronutrients
Carbohydrates, protein, and fats are the three essential food groups known as macronutrients.
Specific macronutrient needs are high when a patient has a DFU, especially if the patient is malnourished or is at risk of malnutrition, because the body may be at or close to a catabolic state.
When in a catabolic state, the body will utilize its own skeletal muscle as its energy source. This results in a loss of lean body mass and worsening of the patient’s wound healing process.
Protein
Protein intake is essential to provide amino acids for optimized wound healing
These amino acids build and repair muscle, skin tissues, hormones, and enzymes, and help to regulate fluid balance and promotes positive nitrogen balance.
Protein is important in all stages of the healing process from hemostasis to remodeling.
Increased protein levels have been linked to improved wound healing rates.
Many guidelines recommend 1.25–1.5 g/kg body weight per day of protein for malnourished patients with pressure injuries.
Quality of protein consumed is also important to provide adequate essential amino acids which cannot be synthesized in the human body.
Protein intake is particularly important for collagen production. Collagen is the major protein of scar tissues that:
Provides tensile strength in the healing wound.
Modifies cellular activities to optimize mitogenesis, differentiation and migration
Is involved in interactions between enzymes which remodel the extracellular matrix, including matrix metalloproteinases and their tissue inhibitors.
Table 6. Protein Requirements
Up to 2 g/kg/d of ABW or use IBW if patient is obese
Critically ill with BMI 30–40
Up to 2 g/kg/d of IBW
Critically ill with BMI >40
Up to 2.5 g/kg/d of IBW
* In adults with chronic kidney disease who are not critically ill, it is reasonable to prescribe, under close clinical supervision, a dietary protein intake of 0.6–0.8 g/kg/d of ABW per day to maintain a stable nutritional status and optimize glycemic control.
Carbohydrate and Fats
Carbohydrates and fats provide a patient’s energy needs
Both fats and carbohydrates help support inflammatory response, cellular activity, angiogenesis, and collagen deposition in the proliferative phase of healing process.
For patients who have poor glycemic control and/or diabetes their carbohydrate requirements will require focused attention throughout treatment.
In a patient with elevated BMI and poor diabetes management, one should minimize energy intake while optimizing protein intake.
Only in patients of low BMI will it likely be necessary to set specific minimal caloric goals.
Important fats to consider are mono and poly-unsaturated fatty acids that play a major role in cell membranes.
Eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and arachidonic acid, are fatty acids that contribute to membrane fluidity, membrane and intracellular signals, and the modulation of apoptotic pathways.
Carbohydrate daily recommendations will vary from patient to patient based on maturity of T2DM, daily glycemic control and if patient is on insulin therapy or oral hypoglycemics.
The average woman needs about 3–4 choices (45–60 g), while men may need 4–5 choices (60–75 g) at each meal.
This number could vary more or less depending on the individual calorie needs (i.e., pregnant/nursing, ill, etc.), medication, and level of physical activity.
Carbohydrates are measured in grams: 4 kcal/g of carbohydrate.
Every carbohydrate food type has a specific serving size.
1 carbohydrate serving = 15 g of carbohydrates
Table 7. Glycemic Targets for Inpatient Glycemic Control
Critically Ill
Reassess therapy for premeal glucose <100 mg/dL
Change therapy for premeal glucose <70 mg/dL
Hydroxymethylbutyrate (HMB)
HMB is a metabolite of leucine, an essential amino acid, and can be acquired through both plant and animal foods such as grapefruit and catfish
HMB has been shown to:
Decrease the proteolysis, increase the protein synthesis, decrease the apoptosis, and increase the cell proliferation
Stabilize the muscle cell membrane and modulate protein degradation.
When supplementing with HMB, current evidence suggests that either 1 g of HMB should be consumed 3 times per day or 1.5 g of HMB should be consumed 2 times per day, for a total of 3 g of HMB daily (or 38 mg/kg of bodyweight).
One study has shown that a combination of these three nutrients arginine, glutamine and HMB improves wound healing of DFUs in patients who have poor limb perfusion and/or low albumin levels.
Arginine
Arginine is a conditional essential amino acid that can be synthesized by the body from glutamine and is a precursor of nitric oxide and proline. It plays an essential role in the inflammatory process and collagen synthesis, regulates pathways required for tissue cell growth, replication and repair and may be beneficial to enhance wound healing.
Arginine can become essential in malnourished patients with DFUs or those at risk of DFUs.
Arginine is beneficial in larger dosages when a diabetic wound is present since it has been shown to enhance wound strength and collagen deposition.
Supplemental arginine improve markers of wound healing such as greater protein and hydroxyproline in the wound bed, enhanced T-lymphocyte function, and promotion of positive nitrogen balance.
For patients who have existing diabetic wounds with adequate protein intake, the recommended dose of arginine supplementation is 4.5 g/day.
Glutamine
Glutamine is also a conditional essential amino acid. It becomes essential when wounds are present since it helps support the immune system and helps stimulate collagen synthesis.
Glutamine is also essential for wound repair. It is used by intestinal cells within wounds for cell proliferation, and inflammatory cells including lymphocytes and macrophages
When the body’s immune system is affected due to illness and or infection, the demand for glutamine is high since inflammatory cells use glutamine as a leading source of fuel.
Recommended glutamine doses range from 20–40 g daily depending on the condition being treated.
Micronutrients
Vitamins and minerals are essential to the health of the body and should be included in all nutritional assessments.
Other Vitamins and Micronutrients
Vitamin C:
Vitamin C is known to be an essential vitamin in the role of tissue repair
Vitamin C aids in tissue regeneration and collagen formation and is required for collagen tensile strength.
Vitamin C plays a major role in the absorption of iron, activation of copper, protein metabolism, and plays an important role in immune function.
Excess Vitamin C will be excreted in the urine, and long-term excess vitamin C may cause oxalate deposits in bone or soft tissues.
Large doses are sometimes provided for antioxidant activity.
Zinc:
Zinc is a trace mineral that is necessary for cell replication and growth.
Zinc plays a major role in immune function, protein synthesis, DNA synthesis and proliferation of inflammatory cells and epithelial cells.
Zinc is influenced by infection and the inflammatory process.
Inflammation and/or infection may falsely lower zinc serum levels. In this case serum zinc levels should not be used to determine need for supplementation.
Zinc levels need to be monitored by a health care professional to ensure they stay within normal range.
Vitamin E:
Vitamin E is a fat-soluble vitamin that is known to act as an antioxidant. It is responsible for normal fat metabolism and collagen synthesis.
Research has demonstrated a positive effect on pressure injury healing when combined with arginine and zinc in energy-dense oral supplements.
Recommended daily allowance for healthy adults is 15mg/day.
Vitamin D:
Vitamin D, referred to as calciferol is a fat-soluble vitamin that is naturally present in foods, especially fortified/enriched foods, and can be generated by sun exposure.
Vitamin D promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable normal bone mineralization.
Vitamin D also aids in reduction of inflammation as well as modulation cell growth, neuromuscular and immune function, and glucose metabolism.
Table 8. Micronutrient Table