If you have a client with a Grade 3 or Grade 4 pressure injury and/or other wound which is slow to heal, have they ever been reviewed by a dietitian?

This may sound like an unusual or surprising suggestion, but there is a massive link between someone’s nutritional status and their body’s ability to heal wounds.  This connection is frequently overlooked, in spite of the 2019 International Guidelines on the Prevention and Treatment of Pressure Ulcers/Injuries specifying that a comprehensive nutrition assessment should be completed for ALL clients with a pressure injury.1

You can’t build skin out of thin air.  The food you eat provides the “building blocks” necessary to form new, healthy skin.  In fact, malnutrition is a massive contributing factor to wounds developing in the first place.2

So while clients may have amazing district nursing and tissue viability teams in place offering the most advanced dressings, a wound simply cannot heal without the appropriate amounts of protein and other nutritional “building blocks.” Even clients who have struggled with slow wound healing for YEARS, can often start to heal beautifully once they get the nutrition right.

How can a dietitian help with wound healing?

Dietitians can help clients with wound healing in five main ways.

1. Blood tests

There are three main blood tests which need to be done any time a wound is slow to heal:

• HbA1C (to check for diabetes/pre-diabetes);
• full blood count (to check for iron deficiency anaemia);
• ferritin (a secondary marker for iron deficiency anaemia).

Elevated blood glucose levels can make a wound much slower to heal and much more prone to infection.  Insufficient iron in the body can lead to reduced ferritin levels and ultimately, low haemoglobin levels.  Low haemoglobin levels will reduce the amount of oxygen that the red blood cells can deliver to the wound and this can slow wound healing.

2.  Protein intake

Wound healing requires extra protein — and while some clients are aware they need to eat “more” protein, many are unclear as to exactly how much protein they need to eat.  Protein requirements are based on body weight and someone with a pressure injury or wound typically needs about 1.2 – 1.5 grams protein per kg body weight(1) (subtract 25% if the client is obese).  High-calorie, high-protein nutrition supplements are one option for increasing the protein intake in underweight clients.  However, the situation is much more tricky in overweight or obese clients, where they often have extremely high protein requirements but extremely low calorie needs.  Some clients hear the “more protein” message and are happy to load up on more meat/chicken/fish, only to realise that they have gained significant amounts of weight because they didn’t reduce their intake of other foods to offset this. Weight monitoring is critical during the wound healing period, to prevent unwanted weight gain (or weight loss).

3.  Micronutrients (vitamins & minerals)

Certain vitamins and minerals are absolutely critical for wound healing and skin repair, such as vitamin A, vitamin C, vitamin E, zinc, copper, selenium and magnesium.2, 3  Wound healing increases the body’s need for certain nutrients and additional supplements are often required to ensure that these higher needs are being met.  To achieve this, dietitians may start clients on either a nutritionally complete multivitamin and mineral supplement or if they are underweight, an oral nutrition supplement.

Over-the-counter multivitamin and mineral supplements are not all the same, and some have excessive amounts of some nutrients while missing out on others.  Examples of nutritionally balanced multivitamin and mineral supplements include Sainsbury’s A-Z, Tesco A-Z or Asda A-Z.  Most wounds will require an additional vitamin C supplement on top of this as well.

4. Arginine

While consuming enough protein is important for wound healing (as outlined above), higher levels of the amino acid arginine (in particular) can speed up and support wound healing even more.4, 5, 6  The 2019 International Guidelines on the Prevention and Treatment of Pressure Ulcers/Injuries specify that adults with a Stage II or greater pressure injury consume a high-calorie, high-protein oral nutrition supplement containing arginine, zinc and antioxidants.  Other research suggests that combining the arginine with glutamine, omega-3 fatty acids and/or nucleotides, may provide an additive or synergistic effect for even better wound healing.4, 7

5.  Hydration and other lifestyle factors

Dehydration causes the skin to lose elasticity and makes it more fragile.2  It also slows the transport of oxygen and nutrients to the wound.8  A dietitian can work with clients to increase their fluid intake if required.

Being overweight, smoking and/or consuming high amounts of alcohol are other lifestyle factors which can contribute to slow wound healing.3  A dietitian can certainly help clients with managing their weight and can also direct clients to resources that support them to stop smoking or reduce their alcohol intake, if required.

For a more detailed explanation of how nutrition impacts wound healing, check out: Nutrition….healing wounds from the inside out.

To refer a client with a pressure injury or slow healing wound, contact Specialist Nutrition Rehab at info@specialistnutritionrehab.co.uk or 0121 384 7087.

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