Pressure ulcers are a significant and costly healthcare problem for patients and healthcare providers. An understanding of the role of nutrition in their prevention and management can help ameliorate the condition to a large extent.
Pressure ulcers are also referred to as decubitus ulcers, pressure sores, and bedsores. The National Pressure Ulcer Advisory Panel defines them as ‘localized areas of tissue necrosis (cell death) that develops when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time’. Therefore, pressure ulcers are most likely to occur on the sacrum, hipbone and the heels.
Pressure ulcers vary in severity and can be staged. A Stage 1 ulcer is a non-blanchable, reddened area of intact skin. In darker skin tones, the ulcer may appear with red, blue or purple hues. A stage 2 ulcer is partial thickness skin loss involving the epidermis, dermis, or both. A stage 3 ulcer is full thickness skin loss involving damage to or necrosis of subcutaneous tissue. A stage 4 ulcer is full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle or bone.
A proper assessment of the risk of developing a pressure ulcer, or the stage of an existing ulcer, can help determine the correct dietary intervention. Other factors including other medical conditions, age and the weight of the patient should also be taken into account. The following recommendations are a general guide to diet in pressure sores. A dietician should be consulted to amend them to a particular case.
Calories are needed to spare the protein. Pressure sores often get infected, due to the decreased blood supply, further increasing the calorie requirement. The recommended calorie intake for treating pressure ulcers is usually 30 to 35 calories per kilogram. Adjusted body weight must be used when determining the needs for an obese patient.
There is no known benefit of excessive calories on wound healing. However, the spectrum of macronutrients does make a difference. Appropriate macronutrients can often accelerate healing and prevent infection.
An inadequate protein intake delays wound healing and prolongs the inflammatory (destructive) phase of pressure ulcers. Therefore, protein recommendations for treating pressure ulcers are usually 1.2 to 1.5 grams per kilogram. Expressed as a percentage, at least 24% of the calorie intake should come from calories. The advantage of a high-protein diet is further supplemented with the correct choice of protein supplements.
Whey proteins are an excellent choice for any case of pressure ulcers. From a nutritional perspective, whey proteins are an ideal candidate for healing. Essential amino acids that need to be provided by the diet comprise 60% of whey protein. Protein quality scoring methods rank whey protein at or near the top because of the excellent amino acid profile, easy digestibility and high utility quotient. Exciting new research indicates certain whey protein components also help promote the growth of new body tissues. Regeneration and repair is augmented on a diet rich in whey proteins.
Casein constitutes 80% of the total nitrogen in milk. Glutamic acid is the predominant amino acid in casein. Proline, Aspartic Acid, Leucine, Lysine and Valine are also present. Casein is a good source of essential amino acids. Casein is also a good source of non-essential amino acids like arginine and glutamine that repair the damaged muscle fibers and maintain a healthy immune system. Arginine supplementation appears to benefit wound healing even if the patient is not deficient. Oral supplementation of 17 to 24.8 grams of free arginine per day has been shown to affect wound healing. The safe maximum intake of glutamine is 0.57 grams per kilogram.
A high fluid intake is also needed to maintain good skin turgor and blood flow to wounded tissues. This also helps prevent dehydration, a risk factor for skin breakdown and pressure ulcers. The fluid intake should match the person’s weight (30 to 35 milliliters per kilogram) and the calorie intake, as well (1 ml/cal). Correct calorie consumption from a fluid-based protein diet can achieve the best result. More fluids may be needed if there is a fever, or if there is fluid loss from an open wound.
Micronutrients also play a role in healing pressure ulcers. Vitamin C aids in collagen synthesis and expedites wound healing. Vitamin A also enhances collagen formation, and a deficiency results in delayed wound healing and increased vulnerability to infection. Zinc is required for both collagen formation and protein synthesis. Low serum zinc levels have been associated with impaired healing. Recommendations for treating pressure ulcers are usually 15 to 25 mg of elemental zinc per day, which is present in 66 to 110 mg zinc sulphate. However, long-term excessive use of zinc supplementation can induce a copper deficiency, so zinc should be taken for 10 days and then the wound should be reassessed.