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What Do We Truly Know About Nutritional Intervention for DFU?
How important is nutritional intervention for patients with a diabetic foot ulcer (DFU)? Two experts at Great Debates and Updates in Diabetic Foot, one podiatric and one in nutrition, share their thoughts and insights from the literature, emphasizing the highs and lows of what the evidence reveals. Andrew Crisologo, DPM, FFPM RCPS (Glasg) began by pointing out a multitude of factors that influence DFU healing, including vascular status, immobilization, diabetes, malnutrition, smoking, infection, aging, and immunosuppression. He acknowledged that nutritional status does make a difference in a general sense. However, the patient population is very heterogeneous, and the literature touches on areas such as geriatrics, pressure injury, and surgical wounds. However, he contended that the literature on nutrition in DFU specifically is lacking.
He then shared several studies that are potentially relevant, but that may have flaws that clinicians should keep in mind. One 2005 study did examine the role of nutritional supplements on wound healing in a geriatric population, but this included several wound types, no true control, and did not show any difference between 2 differently dosed cohorts.1 In 2006, researchers looked at various stages of pressure injury in geriatric nursing home patients and nutritional supplements.2 These authors used the (Pressure Ulcer Scale for Healing) PUSH score as a primary outcome, said Dr. Crisologo, but did not evaluate wound severity, complete healing, or other wound care treatments used.2
Focusing on the literature that does directly address DFU and nutrition, he noted that the 2023 International Working Group on the Diabetic Foot (IWGDF) guidelines advise to not use pharmacological agents that supplement vitamins and trace elements to improve wound healing over the standard of care.3 Dr. Crisologo additionally shared that he found 12 randomized controlled trials related to DFU in this area, and discussed several of them in his session.4-8 Overall, he noted flaws in many, including small sample sizes, lack of differences in time to healing, or lack of comment on time to full healing, among others.
Key takeaways, per Dr. Crisologo, include that:
· Nutrition plays a role in wound healing in the greater body of literature;
· The literature in DFU is lacking for convincing evidence; and
· Current literature shows changes in surrogate markers, but healed wounds were either not evaluated or not significant.
Then, from the nutrition expert perspective, Alicia Gilmore, MS, RD, CSO, LD, an Assistant Professor at the University of Texas Southwestern Medical Center in the School of Health Professions, countered that nutrition indeed does have an impact on wound healing. She presented multiple studies that support the importance of nutrition, and shared how her team applies these concepts to DFUs. Pena and team in 2020 found that nutritional status does impact wound healing.8 And guidelines published in 2020 give specific direction on metrics for energy requirements, protein, and amino acids.9 Specifically, Ms. Gilmore shared that arginine and glutamine can play a role in wound healing, to help immune function, nitrogen balance, and gluconeogenesis.9 She also pointed out that vitamins, A, C, and D all have critical characteristics relevant to wound healing. Zinc, magnesium, and copper are also mentioned in the literature, she said.
Ms. Gilmore then encouraged to think about what malnutrition truly is. It can be related to one’s intake, but can also include issues with nutrient absorption, transportation, or utilization. In 2013, Zhang and team concluded that with increasing severity of diabetic foot ulcer severity, nutritional status deteriorates, and has an independent association with prognosis.10 This study looked at 192 patients, who had a mean HbA1c of 8.8, outside of ideal glycemic control. She shared that those with Wagner grades 1-5 DFUs had a 62% rate of malnourishment, compared to 11.7% of those with a Wagner grade 0 lesion. Those patients with malnourishment had higher infection rates, and less rates of healing.10 Accordingly, Ms. Gilmore contended that nutrition could predict clinical outcomes.
Another study she shared, from 2016, looked at 478 patients with limb-threatening DFUs.11 Each patient underwent screening by a registered dietician within 48 hours. Their nutrition scores decreased (a negative finding) as severity of lower extremity amputation increased. Each decrease in nutrition score increased their risk of major lower extremity amputation by 23% and minor by 11%.11
Additionally, Ms. Gilmore said that it isn’t just nutrition itself that matters, but the quality as well. She cites examples of patients not meeting ideal guidelines for many nutrients, or exceeding the appropriate intake for things like sodium or simple carbohydrates. She reviewed more examples of studies that looked at nutritional aspects and their correlation with metrics relevant to wound healing. She stressed that the literature as a whole supports the role of nutrition and nourishment in wound healing, and that this could benefit patients with DFU.
References
1. Collins CE, Kershaw J, Brockington S. Effect of nutritional supplements on wound healing in home-nursed elderly: a randomized trial. Nutrition. 2005;21(2):147-155.
2. Lee SK, Posthauer ME, Dorner B, Redovian V, Maloney MJ. Pressure ulcer healing with a concentrated, fortified, collagen protein hydrolysate supplement: a randomized controlled trial. Adv Skin Wound Care. 2006;19(2):92-96.
3. Chen P, Vilorio NC, Dhatariya K, et al. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2023:e3644.
4. Eneroth M, Larsson J, Oscarsson C, Apelqvist J. Nutritional supplementation for diabetic foot ulcers: the first RCT. J Wound Care. 2004;13(6):230-234.
5. Armstrong DG, Hanft JR, Driver VR, et al. Diabetic Foot Nutrition Study Group. Effect of oral nutritional supplementation on wound healing in diabetic foot ulcers: a prospective randomized controlled trial. Diabet Med. 2014;31(9):1069-1077.
6. Jones MS, Rivera M, Puccinelli CL, Wang MY, Williams SJ, Barber AE. Targeted amino acid supplementation in diabetic foot wounds: pilot data and a review of the literature. Surg Infect (Larchmt). 2014 Dec;15(6):708-712.
7. Razzaghi R, Pourbagheri H, Momen-Heravi M, et al. The effects of vitamin D supplementation on wound healing and metabolic status in patients with diabetic foot ulcer: A randomized, double-blind, placebo-controlled trial. J Diabetes Complications. 2017;31(4):766-772.
8. Pena G, Kuang B, Cowled P, et al. Micronutrient status in diabetic patients with foot ulcers. Adv Wound Care (New Rochelle). 2020;9(1):9-15.
9. Munoz N, Posthauer ME, Cereda E, Schols JMGA, Haesler E. The role of nutrition for pressure injury prevention and healing: the 2019 international clinical practice guideline recommendations. Adv Skin Wound Care. 2020;33(3):123-136.
10. Zhang SS, Tang ZY, Fang P, Qian HJ, Xu L, Ning G. Nutritional status deteriorates as the severity of diabetic foot ulcers increases and independently associates with prognosis. Exp Ther Med. 2013;5(1):215-222.
11. Gau BR, Chen HY, Hung SY, Yang HM, Yeh JT, Huang CH, Sun JH, Huang YY. The impact of nutritional status on treatment outcomes of patients with limb-threatening diabetic foot ulcers. J Diabetes Complications. 2016;30(1):138-142.
