Written by Gillian Gavaghan, OT
Virtual Hand to Shoulder Fellow'20/'21
We’ve all heard the many sayings relating to food and well-being – ‘an apple a day keeps the doctor away’, and ‘you are what you eat’. But, how true really is this?
Wound healing is essential for the maintenance of life and is a complex integration of tissue degradation and creation through a series of progressive and overlapping stages. Most wounds will heal with limited therapeutic intervention once given adequate time and nutrition.
Nutrition plays an integral role in the production of collagen, and thus wound repair. Without adequate protein supplies, zinc and vitamins A and C, collagen synthesis cannot proceed (Smith & Dean, 1998).
Ancient civilisations applied poultices to wounds as a means of promoting the repair process. Poultices were often made of starchy substances such as bran, oats or potatoes and combined with a hot liquid such as water, oils or vinegar – these combinations were believed to draw out infection, reduce inflammation and cool the skin.
Chinese Herbal Medicine dates back over 3,000 years. In the practice of Traditional Chinese Medicine, one or a dynamic integration of thousands of medicinal plants or dried animal parts are used to develop formulas to treat a person’s complaint. Some of these formulas have been evidenced to promote healing in the diabetic foot through intervening with the inflammatory phase by reducing levels of activin/follistatin and thereby accelerating the re-epithelialisation (Kuai et al., 2018). Research has found that one herbal remedy increases the level of collagen type I and type III in granulation tissue on the seventh day of wound healing in the test subjects (rats) (Li et al., 2005).
Studies have shown that both inadequate dietary intake and poor nutritional status correlates with protracted healing (Iizaka, 2010). Nutrition in wound healing must provide adequate support for an increased energy demand during the wound healing process. Caloric needs are estimated at 30-35kcal/kg (HSE, 2018).
Wound healing proceeds in three recognisable phases – inflammation, fibroplasia and maturation. We are able to affect alterations in collagen structure, otherwise known as wound healing, by both physical and chemical means (Smith, 1992). Amino acids are the chemical compounds which bond to form different types of collagen. Amino acids are the structural units which make up protein.
Adequate protein intake is essential for collagen synthesis, angiogenesis, fibroblast proliferation, immune function, tissue remodelling, wound contraction and skin structural proteins. The recommended range of protein associated with healing is between 1.25 and 1.5g/kg/day, though if the patient is severely catabolic, or has more than one wound, they may require greater levels of protein (Stechmiller, 2010).
Several vitamins and minerals are known to have an important role in wound healing. The literature supports a positive effect of supplementation of vitamin A in acute wounds and healing of fractures (Molnar et al., 2014).
The vitamin C deficiency disease scurvy is characterised by musculoskeletal pain. Reduced vitamin C also results in an impaired immune response and risk of wound dehiscence (HSE National Wound Management Guidelines, 2018). Epidemiologic evidence indicates an association between suboptimal vitamin C status and spinal pain. The prevalence of hypovitaminosis C and vitamin C deficiency is high in various patient groups, such as surgical/trauma (Carr & McCall, 2017). Supplementation in the deficient individual is beneficial; though, some researchers would suggest that the evidence for the use of vitamin C alone in the non-deficient patient is inconclusive (Quain and Khadori, 2015). However, some recent clinical studies have shown that vitamin C administration to patients with chronic regional pain syndrome decreases their symptoms (Carr & McCall, 2017) and a daily dose of 500 mg for fifty days is recommended to reduce the prevalence of CRPS after wrist fractures (Zollinger et al., 2007).
Zinc-containing enzymes are directly involved in wound healing. In a Cochrane review Wilkinson (2014) concluded that there is no evidence that oral zinc accelerates healing. Therefore, zinc supplementation is recommended only in the presence of zinc deficiency (Stechmiller, 2010). Arginine and glutamine are considered essential amino acids-needed in the diet under circumstances of metabolic stress. It is suggested that arginine is beneficial to wound healing but there is inconsistent evidence supporting a direct benefit of glutamine (HSE, 2018).
Conclusion: Promote Wound Healing with Good Nutrition
We are indeed a physical make up of what we eat. Amino acids form a variety of different bonds to construct collagen which is the basis for our soft tissue and bony anatomy. The medicinal properties of plant and animal-based products dates back millennia. For the majority of our service users, we can safely provide advice around healthful food choices which may help with recovery by providing the energy, vitamin, mineral and protein requirements necessary to promote healing.
Safe advice to our patients could include:
Plan healthy, balanced meals and snacks that include the right amount of foods from all the food groups — protein, fruits, vegetables, dairy and grains.
Choose vegetables and fruits rich in vitamin C, such as strawberries or spinach. For adequate zinc, choose whole grains and consume protein, such as eggs, meat, dairy, seafood or tofu, lentils and chickpeas for those who follow plant based diets. Some wounds may require a higher intake of certain vitamins and minerals to support healing. Speak with your relevant healthcare provider before starting any new supplements.
Include adequate protein throughout the day. Include a source of protein at each meal or snack. A sample menu may include scrambled eggs for breakfast, chilli & bean tacos for lunch, yogurt or cheese for a snack and chicken with sweet potato and greens at dinner. For vegan or plant based nutrition a sample diet may include tofu scramble with spinach and mushrooms, lentil soup with salad sandwich on wholemeal bread for lunch, hummus and oatmeal crackers or mixed nuts for snacking and chilli ‘sin’ carne or chickpea curry with wholemeal rice and a leafy green salad for dinner.
Stay well-hydrated with water or other unsweetened beverages.
For people with diabetes, control blood sugar levels to help prevent chronic wounds from developing and to support healing and recovery.
If experiencing high pain levels a daily dose of Vitamin C 500 mg for fifty days can reduce complaints (Zollingeret al., 2007). Unmetabolized vitamin C will be excreted in the urine (HSE, 2018).
Supplementation of other minerals (zinc, glutamine, arginine, antioxidants) in ones’ diet has only been shown to be effective in patients who are malnourished (HSE, 2018).
Carr, A.C. & McCall, C. (2017) The role of Vitamin C in the Treatment of Pain: New Insights. Journal of Translational Medicine 15(1):77
HSE (2018). National Wound Management Guidelines retrieved from https://www.hse.ie/eng/about/who/qid/nationalsafetyprogrammes/pressureulcerszero/hse-national-wound-management-guidelines-2018-201119.pdf in June 2020
Iizaka, S., Okuma, M., Sugama, J. and Sanada, H. (2010). The impact of malnutrition and nutrition related factors on the development and severity of pressure ulcers in older patients receiving home care. Clinical Nutrition, 29 (1):47-53
Kuai, L., Zhang, J., Deng, Y., Xu, S., Xu, X., Wu, M., Guo, D., Chen, Y., Wu, R., Zhao, X., Nian, H., Li, B., & Li, F.(2018). Sheng-ji Hua-yu formula promotes diabetic wound healing of re-epithelization via Activin/Follistatin regulation. BMC Complementary Alternative Medicine, 18, 32 (2018).
Li, B., Wang, Z., Xiao, X., Li, F., & Fan, B. (2005). Effects of Shengji Huayu Recipe and its decomposed formulas on synthesis of collagen types Ⅰ and Ⅲ in granulation tissue of rats in early wound healing. Journal of Chinese Integrative Medicine, 3(3):216-219.
Molnar, J. A., Underdown, M. J. and Clark, W. A. (2014). Nutrition and Chronic Wounds. Adv Wound Care (New Rochelle), 3, 663-681.
Quain, A. M. and Khardori, N. M. (2015). Nutrition in Wound Care Management: A Comprehensive Overview. Wounds, 27, 327-35.
Smith, K. (1992). ‘Wound Healing’. In Concepts in Rehabilitation of the Hand. (Stanley, B.G. & Tribuzi, S.M), Philadelphia, F.A. Davis Company, pp 35-54
Smith, K.L. & Dean.S.J. (1988) Tissue Repair of the Epidermis and Dermis. Journal of Hand Therapy, 11(2): 95-104
Stechmiller, J.K. (2010). Understanding the role of nutrition and wound healing. Nutrition in Clinical Practice; Feb, 25(1): 61-68.
Wilkinson, E. A. (2014). Oral zinc for arterial and venous leg ulcers. Cochrane Database Systematic Rev
Zollinger, P.E., Tuinebreijer, W.E., Breederveld, R.S. & Kreis, R.W. (2007). Can Vitamin C Prevent Complex Regional Pain Syndrome in Patients With Wrist Fractures? Journal of Bone & Joint Surgery, 89(7): 1424-1431