New Diabetic Foot Ulcer Guidelines Highlight Importance Of Nutrition

David G. Armstrong, DPM, MD, PhD

New guidelines endorsed by the American Limb Preservation Society highlighted the importance of nutrition in wound healing for adults with diabetes, who also experience diabetic foot ulcers (DFU).

The guidelines stated that nutritional interventions were “recommended for all patients who could benefit now or in the future from nutritional care.” As such, healthcare providers should develop and implement an individualized nutrition care plan for individuals with or at risk of a DFU, who are additionally malnourished or at risk of malnutrition.

DFUS are shown to develop in up to 34% of patients with diabetes at some point in their lives, with approximately 15% - 25% then requiring amputation. Previously, no internationally agreed upon standardized definition for malnutrition existed in the context of chronic wounds or in DFU.

Study author David G. Armstrong, DPM, MD, PhD, American Limb Preservation Society noted the new guidelines are designed to assist the clinician to "accomplish the difficult goal of improved outpatient nutrition to support the healing DFU wound.”

Particularly, the guidelines stressed the importance of a multidisciplinary care team and how clinicians communicate with patients on the conceptualization of diabetes and its management, which may play a crucial role in treatment outcomes.

Screening Recommendations

Screening and assessment help indicate when patients may be considered to be of adequate nutritional status, although it may not be the actual case. The guidelines urged healthcare providers develop and implement a formalized nutrition screening and assessment protocol to help identify patients with or at risk of malnutrition.

Validated screening tools recommended included the Nutritional Risk Index (NRI), Malnutrition Universal Screening Tool (MUST), and Mini Nutritional Assessment (MNA). Assessment tools included the Patient-Centered Subjective Global Assessment (PG-SGA) and Nutrition Focused Physical Assessment (NFPA).

Further, they recommended that in addition to an examination of the feet and ulcer, a physical exam can concentrate on skin quality, muscle tone, obesity, or low-body weight. A patient's history may lead to information that makes patients predisposed to malnutrition, including social issues such as depression, income status, living alone, and geriatric age.

Additionally, a patient’s dietary intake should be measured to determine adequacy of nutrition and intake exceeding 75% of the estimated energy, protein, and water necessary for wound healing.

Comorbidities should additionally be identified, as well as risk factors for ulcer development including medical history, age, and weight. Other laboratory evaluations recommended included HbA1c, a complete blood count (CBC), and total lymphocyte count.

Dietary Factors

In order to optimize and meet essential needs for wound healing, the guidelines recommended implementing a personalized nutrition care plan, with specific catering to caloric, protein, hydration, micronutrient needs, and need for diet modification. Further, optimal glycemic control is considered essential, as is ensuring the patient’s HbA1c is at or near 7.0%.

The guidelines highlighted important factors involved in healing, including:

Local Factors

• Wound infection
• Bacterial colonization
• Ischemia
• Venous insufficiency
• Debris or foreign bodies
• Oxygen saturation
• Mechanical trauma/pressure
• Neuropathy

Systemic Factors

• Nutrient deficiencies
• Diabetes melitus
• Renal disease
• Cardiovascular disease
• Advanced age
• Lack of mobility
• Smoking
• Certain medications

Other important factors included hydration, due to regulations in body temperature, maintaining kidney function, delivering nutrients in cells, contributing to good skin turgor, and aiding in better blood flow.

Additionally, if a DFU is present, caloric needs are high and the guidelines recommended conducting 24-hour recalls and food frequency questionnaires at every visit. Other needs included specific macronutrient needs and protein, which work to optimize wound healing.

Patients with poor glycemic control and/or diabetes may require focused attention throughout treatment. In addition, mono and poly-unsaturated fatty acids, including eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and arachidonic acid should be considered. Amino acids highlighted included hydroxymethylbutyrate, arginine, and glutamine.

The guidelines noted that carbohydrate daily recommendations varied from individual to individual based on numerous factors, such as maturity of T2D, daily glycemic control, and if the patient is on insulin therapy or oral hypoglycemics

They highlighted glycemic targets for inpatient glycemic control as such:

Critically Ill

• Glucose 140 - 180 mg/dL
• Glucose <140 mg/dL may be appropriate for some patients
• Glucose <110 mg/dL

Non Critically Ill

• Premeal glucose <140 mg/dL
• Random glucose <180 mg/dL
• Reassess therapy for pre meal glucose <100 mg/dL
• Change therapy for pre meal glucose <70 mg/dL

Importance of Interventions

The guidelines concluded that specific nutrition plans should be individualized and based on existing diagnoses, patient preferences, age, lab test results, and pre-existing health and medical conditions.

Thus, it stressed the importance of setting goals that promote improvement in or maintenance of nutritional status, prevention of infection, and optimization of nutritional intake to prevent impaired or delayed wound healing.

They continued that proper diet may be insufficient for optimal wound healing, so early oral nutrition supplements (ONS) may be important for those at greater risk of malnutrition.

In terms of patient adherence, educating patients with DFUs about increased dietary needs and the best dietary sources of essential nutrients involved in wound healing could lead to improved outcomes.

Moreover, patients should be counseled directly by their clinician, which often results in improved HbA1c, quality of life, and adherence.

The guidelines, “Nutrition Interventions in Adults with Diabetic Foot Ulcers,” was published online by the American Limb Preservation Society.