How to Best Supplement Vitamin
and Mineral Deficiencies Present
with Chronic Wounds
Supported by an educational grant from Abbott Nutrition.
Faculty Presenters
Maritza Molina, RDN
Lee C. Ruotsi, MD, CWS-P, ABWMS, UHM
Outpatient Clinical Registered Dietitian –
Department of Surgery at the
Keck School of Medicine of USC
Los Angeles, California
Medical Director – Saratoga Hospital Center
for Wound Healing and Hyperbaric Medicine
Saratoga Springs, New York
Board of Directors – National Pressure Injury Advisory
Panel (NPIAP)
Disclosures
Maritza Molina, RDN
Nothing to disclose in relation to this activity.
Lee Ruotsi, MD
Nothing to disclose in relation to this activity.
Disclosures and
Disclaimers
The faculty have been informed of their responsibility to disclose to the audience
if they will be discussing off-label or investigational use(s) of drugs, products,
and/or devices (any use not approved by the US Food and Drug Administration).
Applicable CME staff have no relationships to disclose relating to the subject matter of this
activity.
This activity has been independently reviewed for balance.
This continuing medical education activity includes device or medicine brand names for
participant clarity purposes only. No product promotions or recommendations should be inferred.
Learning Objectives
1
• Identify nutrition as a critical component of wound healing,
particularly as it relates to malnutrition, glycemic control, and
weight loss and weight maintenance
2
• Explain the importance of adequate protein intake to maximize
wound healing
3
• Recognize vitamin and mineral deficiencies present with ulcer
formation and how to best supplement them
4
• Examine the role of targeted nutrition therapy to support acute
and chronic wound healing
Q&A
Submit your questions anytime
via the question box
Nutrition:
A Critical
Component of
Wound Healing
Lee C. Ruotsi, MD, CWS-P, ABWMS, UHM
Medical Director – Saratoga Hospital Center for Wound Healing and Hyperbaric Medicine
Saratoga Springs, New York
Board of Directors – National Pressure Injury Advisory Panel (NPIAP)
Malnutrition – Definition
• A consensus statement by the Academy of Nutrition and Dietetics (AND) and the
American Society of Parenteral and Enteral Nutrition (ASPEN) published in May 2012
defines malnutrition as the presence of 2 or more of the following characteristics (this
definition also supported by EPUAP, NPIAP, and PPPIA)
– Insufficient energy intake
– Weight loss
– Loss of muscle mass
– Loss of subcutaneous fat
– Localized or generalized fluid accumulation that may sometimes mask weight loss
– Diminished functional status as measured by hand grip strength
AND = Academy of Nutrition and Dietetics; ASPEN = American Society of Parenteral and Enteral Nutrition; EPUAP = European Pressure
Ulcer Advisory Panel; NPIAP = National Pressure Injury Advisory Panel; PPPIA = Pan Pacific Pressure Injury Alliance.
Diagnostic Challenges
• Absence of objective laboratory data
• Unfamiliarity of provider/examiner with patient
• Subjectivity of today’s exam with some past point in time (eg, 1 month)
– How much did you weigh?
– What was your muscle mass and distribution?
– How hard could you squeeze my hand or instrument?
– Did you have any noticeable fluid accumulation?
At-Risk Factors
• Adults should be considered at-risk if they have any of the following
– Involuntary loss of 10% or more of usual body weight (UBW)
within 6 months or greater than 5% in 1 month
– BMI less than 18.5 or greater than 25kg/m2
– Chronic disease state(s)
– Increased metabolic requirements
– Altered diet or diet schedules
– Inadequate nutrition intake, including not receiving food or nutrition
products for more than 7 days
White JV, et al. JPEN J Parenter Enteral Nutr. 2012;36(3):275-283.
Ideal Body Weight (IBW)
• A weight believed to be maximally healthful for a person based chiefly on height, but
modified by factors such as gender, age, build, and degree of muscular development
• Male: 106 lbs. for first 5 ft. plus 6 lbs. for each additional inch
• Female: 100 lbs. for first 5 ft. plus 5 lbs. for each additional inch
• Not useful for determination of nutritional status at a given point in time
IBW = ideal body weight.
Usual Body Weight (UBW)
• Body weight value used to compare a person’s current weight with their own baseline
weight
– UBW may be a more realistic goal than IBW for most individuals
• Percentage deviation (loss) from UBW is the most sensitive tool for nutrition assessment
based on weight
UBW = usual body weight.
Morbid Obesity and Wound Healing
• High carbohydrate/sugar diets are common among obese patients
• Protein-sparing diet is common
• Correlation between obesity and wound healing complications
– Prolonged/increased inflammatory phase
– Alterations in immune function
– Wound infections
– Dehiscence
– Seromas
• Increase in fat cells (adipocytes) without adequate increase
in vascular supply resulting in hypoxic adipose tissue
Pierpont YN, et al. ISRN Obes. 2014;2014:638936.
What About Laboratory Studies?
Albumin
Prealbumin (Transthyretin)
• Nutrition marker of the distant past
• Short half-life – 48-72 hours
• Long half-life – 20 days
• Not affected by hydration status
• Largely impacted by inflammation as
negative acute phase reactant
• Relatively small body pool
• Sensitive to hydration status
• Affected by hepatic and renal disease
• Better indicator of overall morbidity than
nutritional status
Bharadwaj S, et al. Gastroenterol Rep (Oxf). 2016;4(4):272-280.
• Impacted by renal status
• Impacted by inflammation as negative
acute phase reactant; any inflammatory
state will drive levels artifactually low
Conditions Leading to Malnutrition
• Catabolic illness (eg, trauma, surgery, sepsis, etc.)
• Involuntary weight loss for any reason
• Chronic illness (eg, diabetes mellitus, cancer, renal failure, autoimmune)
• Eating disorders (eg, bulimia, anorexia)
• Chronic wounds
• Increased nutritional losses: enteral fistula
• Intestinal disease impairing absorption
• Absent or impaired dentition
• Impaired access to adequate food
Clinical Importance of Vitamins and Minerals
Who to Supplement
• Patients who are obviously malnourished
• Patients who have been unable to eat orally for one week
and have not been given other forms of nutrition
• Documented vitamin or trace mineral deficiency
• Supplement by PO meds, liquid replacement (if using
feeding tube), or TPN
Barchitta M, et al. Int J Mol Sci. 2019;20(5):1119.
How Much to Supplement
General Guidelines
• U.S. Department of Agriculture (USDA) recommended doses
• Avoid supraphysiologic doses or “mega-doses”
• Especially watch out for toxicity with high doses of fat soluble
vitamins (A, E)
• Remember that minerals can lead to toxicity, as well
Vitamin A
• Originally discovered in early 1900s by McCollum and Davis
• The effect of vitamin A on wound healing was described as early as 1940s
• Benefits of supplementation on non-deficient patients were described in 1960s
• Retinoids in common use in acne and other wound-related problems
Brandaleone H, et al. Ann Surg. 1941;114(4):791-798. Ehrlich HP, et al. Ann Surg. 1968;167(3):324-328. Barchitta M, et al. Int J Mol Sci.
2019;20(5):1119.
Vitamin A Deficiencies
• True vitamin A deficiencies will almost always adversely affect wound healing
at all stages
– Impairs B cell and T cell function during inflammatory phase
– Decreases epithelialization, collagen synthesis, and granulation tissue
development during proliferative and remodeling phases
– Hormonal modulation of several
important cell lines
Vitamin A
Barchitta M, et al. Int J Mol Sci. 2019;20(5):1119.
Vitamin A Supplementation
• Short-term supplementation with 10,000–25,000 IU/day recommended to
avoid toxicity
– Vitamin A levels easily monitored by lab test
• IM, IV, and topical applications also available
– Topical applications typically used for dermatologic purposes
• Can counteract the delay in wound healing caused by systemic corticosteroids for
treatment of inflammatory diseases by downregulating transforming growth factor-beta
(TGF-ß) and insulin-like growth factor-1 (IGF-1)
TGF-ß = transforming growth factor-beta; IGF-1 = insulin-like growth factor-1.
Barchitta M, et al. Int J Mol Sci. 2019;20(5):1119.
B Vitamins
• Essential cofactors in enzyme reactions involved in leukocyte formation and in
anabolic processes of wound healing
• Thiamine, riboflavin, pyridoxine, and cobalamin are also essential for the
synthesis of collagen
• Net effect: Vitamin B deficiencies indirectly affect the wound healing process by
impairing antibody production and WBC function, thereby increasing the risk of
infectious complications
• B complex vitamins commonly available and toxicity typically not a concern due
to water solubility
Barchitta M, et al. Int J Mol Sci. 2019;20(5):1119.
Vitamin C (Ascorbic Acid)
• Involved in wound healing with several roles
– Cell migration and transformation
– Collagen synthesis
– Antioxidant response
– Angiogenesis
– Recruits leukocytes to wound bed
during inflammatory phase and
participates in their transformation
into macrophages
– Strengthens bonds between collagen fibers to
increase strength of extracellular matrix (ECM)
ECM = extracellular matrix.
Barchitta M, et al. Int J Mol Sci. 2019;20(5):1119.
Vitamin C Supplementation
• 500 mg/day in non-complicated wounds to 2 gm/day in severe wounds
• Vitamin C supplementation appears to have beneficial effect only in
combination with zinc
• Particularly helpful in pressure injury
Barchitta M, et al. Int J Mol Sci. 2019;20(5):1119.
Vitamin D and Vitamin E
Vitamin D
• Recent evidence in pressure injury and
venous ulcer patients suggests the
involvement of Vitamin D in the wound
healing process
• Role is not well understood; more research
is needed to understand uses for Vitamin D
in wound healing
• Broader importance of Vitamin D in other
aspects of health are well understood
Barchitta M, et al. Int J Mol Sci. 2019;20(5):1119.
Vitamin E
• May negatively impact collagen
synthesis, antioxidant response, and
the inflammatory phase
• Appears to counteract the benefits of
Vitamin A supplementation in wound
management
Zinc
• Essential for DNA replication in inflammatory and
epithelial cells and fibroblasts
• Inflammatory phase
– Promotes immune response and counteracts
susceptibility to infectious complications through
activation of lymphocytes and production of antibodies
• Proliferative and remodeling phases
– Essential for collagen production, fibroblast proliferation,
and epithelialization
Barchitta M, et al. Int J Mol Sci. 2019;20(5):1119.
30
Zn
65.409
Zinc
Zinc Supplementation
• 40-220 mg/day in zinc-deficient patients may be useful
• Benefit in non-deficient patients is under debate
• Zinc levels measurable with lab test
• Topical administration of zinc to surgical wounds has been shown to significantly
impact the wound healing process
• Common etiologies of zinc deficiency
– Chronic alcoholism
– Psoriasis
– Severe surgical trauma
– Gastrointestinal fistulas
– Large body surface area burns
Barchitta M, et al. Int J Mol Sci. 2019;20(5):1119.
Case Study: JT – Pressure Injury
JT is a 57 y/o male with
spina bifida-related
paraplegia
– Ht: 160 cm (63 in)
– Wt: 57 kg (125 lbs)
– BMI: 22
– 12 months ago:
Wt: 60 kg (142 lbs)
BMI: 25.2
• JT is single and works
full time in a retail
hardware store
• PMH: Iron deficiency anemia (IDA), Type 2 diabetes, hypertension,
hyperlipidemia, and deep vein thrombosis (DVT); incontinent of
urine (self-caths); colostomy; smoker 30+ years
• Wounds: Stage 4 pressure injury right ischium present for greater
than 6 months; secondary healing stage 3 to right trochanter
• Medications: furosemide (diuretic), metformin (antihyperglycemic),
atorvastatin (lipid-lowering), potassium chloride, over-the-counter
antacids
• Action Plan:
– Wound evaluation done, imaging and labs completed, imaging
normal
– Began negative pressure wound therapy (NPWT) with assistance of
home care
IDA = iron deficiency anemia; DVT = deep vein thrombosis; NPWT = negative pressure wound therapy
Case Study: JT – Pressure Injury
• 24-hour recall:
Breakfast – 3 cups of coffee with sugar or honey
Midday – fried meat sandwich, fries, soft drink, “whatever I can get delivered”
Evening – frozen meal or canned soup, such as bone broth
Snacks – beer, whiskey, pretzels, chips
• Nutrition history:
JT admits his diet isn’t too good. Describes appetite as “ok.” He eats what he
wants when he is hungry. Some days, he skips meals. His alcohol intake is 1-2
beers or drinks daily. His sister told him to use “stick-on vitamins” (patch type
dietary supplements) and drink bone broth to stay healthy.
• He believes his HbA1c is “pretty good – so his diet must be ok, too”
Malnutrition Screening Tool (MST)
Risk Indicator
Response
Points
Recent weight loss?
No
Unsure
2-13 pounds
14-23 pounds
24-33 pounds
34 or more pounds
0
2
1
2
3
4
Weight loss score
Eating poorly because of
decreased appetite?
0-4
No
Yes
Appetite score
MST score
0
1
0-1
Weight loss + Appetite
0-5
MST = malnutrition screening tool.
Ferguson M, et al. Nutrition. 1999;15(6):458-464. Position of the Academy, J Acad Nutr Diet. 2020.
MST Score
0-1 – Not at risk,
re-screen if stay
exceeds 7 days
≥2 – At risk
Full assessment
and nutrition
intervention
Mini Nutritional
Assessment
MNA®
Note: JT is 57 years old,
MNA validated for adults
65+ yrs. Numerous
studies using MNA in
younger adults.
MNA = mini nutritional assessment.
Kaiser MJ, et al. J Nutr Health Aging. 2009;13:782-788. www.mna-elderly.com
Case Study: JT – Pressure Injury
• The Malnutrition Screening Tool
(MST) score = 1
• Mini Nutrition Assessment Screening
Tool (MNA) score = 9
• How would you interpret these
scores?
JT is probably at risk for malnutrition due to weight
loss, pressure injury, and diet
Case Study: JT – Pressure Injury Progression
• JT does not return to wound clinic for followup appointments. He worked until COVID
lockdowns began, but then he was laid off.
JT is depressed and starts drinking alcohol
daily. Appetite is poor.
• Wounds progressively worsened
• JT’s depression worsens
• NPWT was discontinued by home care
• JT returned to wound clinic 5 months later
• Wt 48 kg (105 lbs), BMI 18.7
Wt 5 mos ago: 57 kg (125 lbs), BMI 22
Case Study: JT – Pressure Injury Progression
• 2 months later, pressure injuries continue
to worsen
• JT is more depressed, confused, and
reports having trouble making decisions
and remembering to take his meds
• His diet is high in low-quality carbs
and low in high-quality protein
• Alcoholic beverages 1-3 x/day
• Consulted plastic surgeon at local trauma
center for reconstructive surgery; was
told his nutrition needed to improve
Case Study: JT – Pressure Injury Progression
Nutrition Goals
þ Meet energy and protein needs using 2019 International Pressure Injuries CPG
þ Maintain or gain weight
þ Meet hydration needs
þ Limit alcohol intake
þ Meet micronutrient needs
þ Better management of blood glucose
þ Make every bite of food count towards wound healing
CPG = clinical practice guidelines.
Case Study: JT – Pressure Injury Progression
• Nutrition support following 2019 International Guideline
implemented
• Nutritional intervention initiated with evidence of some
wound improvement
Case Study: JT – Pressure Injury Progression
• Elective surgeries opened up
again
• Local plastic surgeon performed
reconstructive surgery with large
rotational flap
• Now 10 months post-op with
durable results
Nutrition Screening, Goals, and
Treating Nutrition Challenges to Help
Optimize the Wound Healing Process
Maritza Molina, RDN
Outpatient Clinical Registered Dietitian –
Department of Surgery at the
Keck School of Medicine of USC
Los Angeles, California
Email: maritzamolina.RDN@gmail.com
Macronutrients
• Energy: Caloric needs are high when a wound is present as calories provide energy to
the body to aid in wound healing
– Energy demand will increase with patient’s nutrition risk factors and severity of wound(s)
– Adequate energy aids in collagen formation, anabolism, cell metabolism, and development of
new blood vessels
• The 3 main sources of energy come from macronutrients:
– Fats: Cell structure; important role in the inflammatory process
– Carbohydrates: Glucose = energy = primary source of energy; energy for angiogenesis and
the deposition of new tissue
– Protein: Repair and build tissues
• They all play an essential role in the wound healing process.
Langley G, et al. The ASPEN Adult Nutrition Support Core Curriculum. 3rd ed. American Society for Parenteral and Enteral Nutrition; 2017.
Importance of Adequate Protein Intake
to Maximize Wound Healing
Protein: Exergonic protein intake is essential for optimized
wound healing as it promotes a positive nitrogen balance
• Protein serves as a building block to help build and
repair muscle, skin tissues, hormone and enzyme
production, and fluid balance
• Protein deficits can affect immune processes causing increased
risk of malnutrition and delayed wound healing
– 20 amino acids
– 9 essentials (body does not make)
– 11 non-essential (body can synthesize them)
• Some non-essential amino acids are “conditionally essential” when the body is in dire
need or the body cannot synthesize it
Langley G, et al. The ASPEN Adult Nutrition Support Core Curriculum. 3rd ed. American Society for Parenteral and Enteral Nutrition; 2017.
Importance of Adequate Protein Intake
to Maximize Wound Healing
• In wound healing, especially in chronic wounds, the body is under metabolic stress
• When metabolic stress is present, there is an increased demand of both essential and
non-essential amino acids: Some non-essential amino acids that become conditionally
essential will be glutamine and arginine, both of which aid in wound healing
– Arginine is beneficial in larger dosages when a wound is present as it is proven to enhance
wound strength and collagen
– Arginine supplementation in conjunction with oral nutrition supplementation may promote
wound healing in older adult patients in acute care and LTC settings as evidenced by
significant reductions in wound size and improvements in wound healing when compared
with oral nutrition supplementation alone
– Glutamine amino acid is essential for wound repair as it is used by inflammatory cells, such
as lymphocytes, macrophages, and intestinal cells within wounds for cell proliferation
Posthauer ME, et al. ASPEN/Adult Nutrition Support Core Curriculum. 3rd ed. American Society for Parenteral and Enteral Nutrition; 2017.
Importance of Adequate Protein Intake
to Maximize Wound Healing
Adequate protein intake promotes collagen production
and is important in all stages of the healing process
1. Hemostasis/Inflammatory Phase: Begins immediately at
onset of injury. Emergency repair system>blood clotting,
redness, pain. Release of inflammatory mediators, such as
macrophages, cytokine signaling, and neutrophils.
2. Proliferative Phase (Constructive Phase) Days 4-14:
Epithelialization/granulation at wound area, growth factors.
3. Maturation Phase (Remodeling Phase) Days 8-365:
Collagen synthesis, tissue regeneration, wound contraction.
Illustration by Yichen Wang https://sqonline.ucsd.edu/2020/04/skinregeneration-in-wound-healing-the-art-of-self-preservation/
Posthauer ME, et al. ASPEN/Adult Nutrition Support Core Curriculum. 3rd ed. American Society for Parenteral and Enteral Nutrition; 2017.
Energy and Protein Recommendations
Energy
Malnourished, chronic wound,
underweight:
• 30-35 kcal/kg body weight/day
Protein
Standard recommendations for
malnourished/chronic wound:
• 1.25-1.5g/kg body weight/day
• Stable diabetic wounds not at risk of
malnutrition or malnourished:
– Kcal recommendations for diabetic patients:
o BMI less than 30 or under 130% of IBW:
25-30 kcal of adjusted body weight
(ABW)
ABW = adjusted body weight.
American Limb Preservation Society. Accessed June 19, 2022. (Last updated March 15, 2022)
https://www.guidelinecentral.com/guideline/502765/pocket-guide/502768/
Langley G, et al. The ASPEN Adult Nutrition Support Core Curriculum. 3rd ed. American Society for Parenteral and Enteral Nutrition; 2017.
Targeted Nutrition is Essential
for Optimal Wound Healing
Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. EPUAP/NPIAP/PPPIA; 2019.
Role of Targeted Nutrition Therapy to
Support Acute and Chronic Wound Healing
Status and Skin Health
• Nutrition plays a major role in the wound healing process, and wound healing is such a
complex process that it is pertinent for nutritional support to be considered part of wound
management
• Patients who start off with poor nutrition and/or at risk of malnutrition may face
complications in wound healing
• When poor nutrition or malnutrition are present, wound healing can be delayed, worsen,
or even come to a halt
• Focusing on nutrition optimization in all patients with wounds will essentially provide a
good foundation for wound healing
Nutrition Optimization: Improve Wound Healing
Through a Nutrition-focused Approach
• Nutritionally prepping patients for upcoming surgery
• Utilizing a nutrition-focused approach to improve wound healing by determining nutrition
challenges and nutrition-related risk factors that a patient may have
• Management of nutrition-related disease, such as
– Diabetes
– Renal disease
– Hypertension (HTN)
– Peripheral vascular disease
HTN = hypertension.
Risk Factors of Poor Nutrition: Malnutrition
Malnutrition means “poor nutrition” ― either a person is getting more nutrients than they
need (over nutrition), or they are not getting enough nutrients (under nutrition)
Etiology: There are generally three etiologies that drive malnutrition
1. Acute illness or injury: Trauma, burns, infections
2. Starvation: Chronic starvation, anorexia
3. Chronic disease: Organ failure, obesity, cancer
When malnutrition is present, it may accelerate to production of a diabetic foot ulcer (DFU)
or worsen/delay the healing process of an already developed DFU.
Malnutrition will cause:
• Impaired absorption > delayed immune function > delayed healing
• Increased nutrient requirements
• Altered nutrition transport utilization
DFU = diabetic foot ulcer.
Posthauer ME, et al. ASPEN/Adult Nutrition Support Core Curriculum. 3rd ed. American Society for Parenteral and Enteral Nutrition; 2017.
Nutrition Screening Tools and Assessment
Utilizing nutrition-focused
assessment tools and
markers will help provide
essential information on a
patient’s overall nutrition
status, deficiencies, and
malnutrition risks that in
turn directly affect wound
healing
• Nutrition-Focused Physical Exam (NFPE): Primarily used in an
inpatient setting; can be used for any lifestyle: Inspect, Palpate,
Percussion, Auscultate, Labs
• Subject Global Assessment (SGA): Physical appearance, edema,
weight, gastrointestinal (GI), food percent intake, functional capacity
• Mini-Nutrition Assessment (MNA): Widely used in the US among
the elderly population >65 years; evaluate independence, meds, and
meals daily
• Weight history: Usual body weight (UBW), current body weight
(CBW), BMI, ideal body weight (IBW), percentage of weight loss over
time period (ie, weeks, months, years)
• Recent biochemical data: Preferably over the preceding 3 months
• Dietary 24-hour recall, food frequency questionnaire
CBW = current body weight.
JeVenn A, et al. ASPEN Adult Nutrition Support Core Curriculum. 3rd ed. American Society for Parenteral and Enteral Nutrition; 2017.
The Nutrition Care Process
The Nutrition Care Process (NCP) is a systematic method of providing high-quality
nutrition care, which will help determine the level of nutrition intervention a patient
may need.
STEP 1 ASSESS: Utilize nutrition screening tools to collect and document nutrition evidence
STEP 2 DIAGNOSE: Determine nutrition challenges ― Nutrition Diagnosis
STEP 3 INTERVENTION: The nutrition intervention will be based on the nutrition diagnosis.
Recommendations, education, and setting goals directed to the root cause “etiology”
of the nutrition challenges will help improve/treat the diagnosis
STEP 4 MONITOR/EVALUATION: Has client achieved goals and/or making progress to
achieve goal?
NCP = Nutrition Care Process.
EatRightPro, https://www.eatrightpro.org/practice/quality-management/nutrition-care-process
Addressing Nutrition Challenges
• Modified texturized diet: Does patient have dysphagia,
loose or no dentures?
• Poor appetite: Recommend appetite stimulants if/when
medically appropriate (megestrol, dronabinol, mirtazapine)
• Can’t meet kcal goals: Try to meet kcal goals by
recommending low-volume, high-calorie foods
• Safe access to food: How does patient get meals?
– Government/state programs, Meals on Wheels,
EBT, food pantry
• Use oral nutritional supplements to help meet kcal,
protein, and nutrient needs if patient is unable to meet
them through food
Loman BR, et al. JPEN J Parenter Enteral Nutr. 2019;43(6):794-802.
Oral Nutrition Supplement
• If patient is unable to meet caloric and protein needs with solid food, recommend
oral nutrition supplements
• If patient is unable to meet 65%-75% of nutrition through food, enteral nutrition is
suggested
Loman BR, et al. JPEN J Parenter Enteral Nutr. 2019;43(6):794-802.
51
Armstrong DG, et al. Diabet Med. 2014;31(9):1069-1077.
Elements of Oral Nutrition Supplementation
• Arginine – supports blood flow and is a building block for
proteins, which can contribute to wound healing
• Glutamine – involved in fibroblastic formation of collagen and
supports the immune system
• CaHMB (calcium ß-hydroxy-ß-methylbutyrate) – a metabolite
of leucine that helps produce new tissue by slowing down
muscle breakdown and stabilizing muscle cell membranes
• Collagen protein – shown to help stimulate internal collage
production
• Micronutrients (vitamins C, E, & B12 and zinc) – important
nutrients for the wound healing process
Clark RH, et al. JPEN J Parenter Enteral Nutr. 2000;24:133-139. Sugihara F, et al. Jpn Pharmacol Ther. 2015;43:1323-1328. Lee SK, et al. Adv
Skin Wound Care. 2006;19:94-96.
Use Your Clinical Judgement as
Each Patient Case is Unique
• The nutrition macronutrient and micronutrient
plan should be individualized based on
disease state and/or risks of malnutrition
• Conducting 24-hour recall, reviewing food
diaries if available, and conducting food
frequency questionnaires will play an essential
role in helping you determine a patient’s
energy and protein needs
Reason
Investigate
Review
Analyze
Thank you
Questions?