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Si l Eff i TSimple, Effective TreatmentOf Wounds

The Role of Nutrition in Wound CareSue Stillman Linja, RD, LD - S&S Nutrition Network, Inc.

The adult learner will:

OBJECTIVES

The adult learner will:

Recognize the basic principles of nutrition and wound care

Identify methods to optimize healing through simple, yet

effective nutrition measures

Identify low cost products that can be used to improveIdentify low cost products that can be used to improve

nutrition and promote wound healing

Discuss cost effectiveness of standardizing nutrition

formulary

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Remember, We Must Treat the Whole Person, Not Just the HOLE

Dr. Margaret (Peggy) Doucette - 2005

Nutrition Considerations in Wound Prevention & Treatment

Energy (Calories)Energy (Calories)

Protein

Amino Acids

Arginine

Glutamine

Fluids

Micronutrients (Vitamins/Minerals)

Ascorbic Acid -Vitamin C

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Calories/Energy

Energy is provided through

carbohydrates, protein and

fats

Adequacy is essential for

pressure ulcer healing

Promotes anabolism,

nitrogen & collagen

synthesis

Calories/Energy

Kg Weight 30 35 caloriesKg Weight x 30-35 calories

175#= 79.5 kg x 30-35 =

2,385-2,785 calories qd

Mifflin-St. Jeor vs. Harris

Benedict Equation

Needs are adjusted up or

down individually based on

assessment, wound status

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Calorie Boosting Ideas

SEE HANDOUTSSEE HANDOUTS

Fortification/Enhancemen

ts

Fat - More than double

the calories

Nutrient-Rich vs. Empty

Calories

Don’t forget: Liberalize!

Cheap Tricks - CaloriesCheese - 1 oz (slice) = 100-125 calories

Add it t d i h t t t blAdd it to sandwiches, eggs, potatoes, vegetables

Avocado and Guacamole - 180 calories in 4 oz

EGGNOG - 1 cup = 350 calories

Nuts and Nut Butters - Nearly 100 calories per tablespoon

Add Nuts, PB or Nutella into cookies, muffins, shakes

Olive Oil and Maybe Even Butter - 1 Tablespoon = 135 calories

Salad Dressings, Mayos, Spreads - 2 oz = 175 calories

Chocolate - Peanut Butter Fudge- ok for PUREE diets - 100 calories in 1 inch

square

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Protein

Necessary for tissue

maintenance & repair

Depletion of protein

stores/intake impairs healing

Inhibits fibroblasts

Inhibits collagen synthesis

Consider overall nutritional

status, wound size, stage and

characteristics

Protein20-25% of calories daily

f t ifrom protein

Monitor renal function

1.2-1.5 grams of protein per

kilogram of body weight (may

go as high as 2.0 for severe wounds if renal

function allows per some studies)function allows per some studies)

175#=79.5 kg x 1.2-1.5 = 95-120

grams per day

Standard meat portion is 3 oz

(deck of cards) w/ 21 gr protein

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Protein Boosting Ideas

SEE HANDOUTS

Fortification/Enhancements

Best sources of protein

Use of Amino Acids

(Arginine & Glutamine)

Cheap Tricks - Protein

Beans, beans, beans - Make them into spreads, dips, add p p

them into soups, stews, cakes and cookies - 1/2 c = 10

grams protein

Eggs and liquid eggs - 2 eggs or 1/2 c = 12 grams protein

Whey protein isolates - 1/8 c = 12 grams

Non-fat dry milk powder - 1/2 c = 12 grams protein

Nuts and Nut Butter - 1 c = 20-25 grams

Greek yogurt - Mix it in or eat it plain - Up to 20 grams/6 oz

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Fluids

Necessary for Normal Cell

Function

Dehydration is a risk factor

for PU development and

poor healing

Optimal: Intake=Output

Fluids

30-35 ml per kilogram of

body weight

1 ml per calorie consumed

>1500 ml per dayp y

Adjust for drainage, air

beds, N/V/D, other losses

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Cheap Tricks - Fluids

Lattes, mochas, hot or cold cocoa and British teas - use

whole milk or cream if additional calories are needed

Soups, stews, sauces, hot cereals

Fruit or flavored smoothies, icees, shakes, malts

Fresh fruit or fruit in juice

Yogurt, gelato, pudding, custard, flan, ice cream, sherbet

Ascorbic Acid

It’s unlikely that moderate y

supplementation with Vitamin C

is harmful

Stabilizes the triple helix

structure of collagen & provides

strength to new collageng g

Antioxidant & improves iron

absorption

Consider 500-1000 mg Vit C qd

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Ascorbic Acid

Kakadu plum and camu

camu have 1000x more

Vitamin C then an orange (3000-5000 mg/100g)

Chili peppers & red and

green peppers

Guava, kiwi, parsley,

broccoli, brussel sprouts,

papaya, and strawberries

are all higher than oranges

Zinc

Cell proliferation & collagen

synthesis

Role in immune function

Antioxidant properties

Competes with copper and

increase in one can lead to

deficiency of the other

Use for wound healing

remains controversial

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ZincRDA/DRI- 15 mg

S l t ti 40 50Supplementation- 40-50 mg

Oysters - 6 medium =77 mg

Beef - 3 ounces = 9 mg

Fortified breakfast cereal -

3/4 43/4 c = 4 mg

Yogurt 1 cup = 2 mg

Chickpeas, pumpkin seeds,

dark chocolate

Cheap Tricks - Vitamin C and Zinc

F tifi d l ith t d f itFortified cereal with yogurt and fruit

Fruit and yogurt smoothies

Fruit/nut mix

Smoked oysters and cheese

Peppers - raw as a snack, cooked as a side or stuffed

Kiwi/strawberries - blended and added as topping to

desserts, ice cream, yogurt, fish

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1000 Calorie, 30 gram Protein, 240 ml Fluid, Rich in Vit C & Zinc - Cup of Soup & Half Sandwich

How would you do it?

Other Considerations -Lactose Intolerance

Often mis-diagnosed and over treated

Misconception - Lactose Intolerant = Dairy Free

Suggestions:

Chocolate milk vs white

Start small & increase

Don’t drink milk alone

Use lactose free milk or give Lactaid before

meals

Active culture yogurt & cheese are often

tolerated

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Other Considerations -Management of Diarrhea

Identify the cause as soon as possible

(usually not lactose)

Drink fluids often but should be broths,

non-caffeinated soda, tea w/honey, sport

drinks

Foods that are bulk-forming include

apples, bananas, rice, cheese, white

bread, applesauce

Active culture yogurt; probiotics

May purchase Pectin (ie-Sure Jell, Certa)

- Mix 30 ml w/fluid BID

Supplements vs Food

#1 Goal = Use

FOOD FIRST!

Some companies,

however pay veryhowever, pay very

little for

supplements

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Supplement vs Food

Cost for 4 oz Homemade Milkshake

Calories = ~180

Whole Milk - $.09

Ice Cream - $.06

Fruit - $ 12Fruit $.12

Labor - $.53 (4 min)

Total = $.80 or $.20/oz

Cost for 4 oz Ensure Plus w/ Great Corporate Pricing

Standardized FormulariesRD, MD and Wound Team

decides 2-3 choices for

supplements

High calorie, high protein,

lactose free

Juice based, less sweetJuice based, less sweet

Lower calorie, higher

protein (Protein isolate)

Price shop; order bulk

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Tips for Low Cost Purchases

Buy bulk when possible - Ex:

Nuts (Planters Pecans 6 oz =Nuts (Planters Pecans 6 oz =

$20 vs. $8/lb bulk)

Shop the bargains - Canned

Food Warehouse, Costco,

local sales, online options like

AmazonAmazon

Use leftovers - makes great

soup, stews, casseroles,

muffins

http://www.walgreens.com/pharmacy/http://www.walmart.com/cp/Pharmacy

http://www.abbottstore.com/ajax-only-do-not-edit/first-order-savings/page/save15percentoff/

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Questions & Thank You’s

Any questions?

Sue Stillman Linja, RD, LD - sue@sandsnutrition.com

Thank you to Abbott Lab for sponsoring this session and forThank you to Abbott Lab for sponsoring this session and for

the Idaho Dairy Council for some of the colorful handouts

1. American Dietetic Association. ADA Nutrition Care Manual. Chicago: American Dietetic Association, 2010.

2. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. (National Pressure Ulcer Advisory Panel). Prevention

References

and treatment of pressure ulcers: clinical practice guideline. 2009.

3. Dorner B, Posthauer ME, Thomas D, National Pressure Ulcer Advisory Panel. (National Pressure Ulcer Advisory Panel). The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper. 2009.

4. Posthauer ME, Droner B, Collins N. Nutrition: A Critical Component of Wound Healing. Adv in Skin and Wound Care. December 2010;23:560-571

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5. Litchford MD. Advanced Practitioner's Guide to Nutrition & Wounds Greensboro, NC: CASE Software & Books; 2010 www.casesoftware.com).

6. Molnar J, ed. Nutrition and wound healing. Boca Raton, Fl: CRC Press; 2007.