Nutrition Interventions in Adults with Diabetic Foot Ulcers

• Diabetic foot ulcers (DFU) are chronic wounds in the foot or feet associated with neuropathy and/or peripheral artery disease (PAD) of the lower limb in patients with diabetes mellitus.
• Reports from the Centers for Disease Control and Prevention show that in the United States there are nearly one in four adults living with diabetes, which indicates that a large number of Americans are at risk of DFU.
• DFUs will develop in up to 34% of patients with diabetes at some time in in their lives, and of those, approximately 15%–25% will require an amputation.
• Moderate or severe malnutrition has been identified in over half of patients with DFU, and malnutrition in DFU is correlated with increased lower-extremity amputation.
• Improvements in wound care therapy, including nutrition interventions, can reduce the financial burden of DFUs and increase life expectancy and quality of life.

• There is no internationally agreed upon standardized definition of malnutrition, neither for protein energy malnutrition nor for micronutrient deficiency, in the context of chronic wounds or in DFU.
• There is a lack of high-quality randomized controlled trials to evaluate the benefits of nutritional supplementation in DFU, and existing studies use a wide range of outcome variables.
• Ensuring patient compliance when it comes to nutrition can be notoriously challenging.
• However, there is a clear correlation between nutritional status and healing, and as such, a balanced diet with adequate fluids, calories, proteins, and nutrients is fundamental to the healing process.
• The following guidelines are designed to assist the clinician to accomplish the difficult goal of improved outpatient nutrition to support the healing DFU wound.
• We recommend that you use your clinical judgement as every patient case is unique. The nutrition plan should be individualized based on disease state and/or risk of malnutrition.

• Proper management of patients with DFUs should include a multidisciplinary care team.
• The care team may consist of one or more podiatrists, dietitians/nutritionists, surgeons, primary care, endocrinologists, wound care specialists, dermatologists, experts in psychosocial care, etc.

• How clinicians talk to and about people with diabetes plays an important role in engagement, conceptualization of diabetes and its management, treatment outcomes, and psychosocial well-being. For people with diabetes, language has an impact on motivation, behaviors, and outcomes.
• Every member of the healthcare team can serve people with diabetes more effectively through a respectful, inclusive, and person-centered approach.
• Stigma that has historically been attached to a diagnosis of diabetes can contribute to stress and feelings of shame and judgment.
• Person-first, strengths-based, empowering language can improve communication and enhance the motivation, health, and well-being of people with diabetes.
• Avoid using the word "diabetic" as a noun, as well as labeling someone “a diabetic person”. This gives the impression that a person is being labeled as their disease.
• This guide uses the term “diabetic foot ulcer” for simplicity, however the phrase should be avoided when speaking with patients. Instead, use “foot ulcer”, “ulcer of the foot as a result of diabetes” or similar.

• Patients with diabetic foot ulcers seen in ambulatory settings may be considered to be of adequate nutritional status when in reality, that is not the case and further screening and assessment would indicate this
• Healthcare providers should develop and implement a formalized nutrition screening and assessment protocol to help identify patients with or at risk of malnutrition.
• The goal of nutrition screening is early identification of patients at risk for malnutrition.
• There are numerous validated nutrition screening tools (See Table 2).
• Selecting the appropriate tool depends upon the population and the available resources.

• If an initial screening suggests an increased risk for malnutrition, the next step should be a thorough nutrition assessment.
• In addition to the initial assessment, return visits should be scheduled regularly. These visits should include sufficient time for the care team to assess adherence and make appropriate adjustments to patient's individualized care plan.

• In addition to examination of the patients feet and ulcer, a physical exam should also concentrate on skin quality, muscle tone, obesity, or low body weight, as well as hair quality and cheilosis.
• At each visit, anthropometric questionnaires/measurements should be administered and/or measured, and should include the following:
  • Current vs. normal body weight
  • % Weight loss or % weight gain over time
  • Under/overweight amount and %
  • BMI
  • Edema
  • Skin integrity

• Obtain information of social issues that predispose to malnutrition.
  • Depression, living on a fixed income, living alone, and geriatric age group are all risks factors for malnutrition
• More detailed history of eating habits is likely to divulge a diet low in protein and high in carbohydrates — e.g., high caloric snack foods such as chips, cookies and crackers require no preparation and may dominate the diet.
  • Specific questions should be asked regarding fruit, vegetable, and protein intake to determine adequacy of nutritional components.
• Ensure a patient’s dietary intake exceeds 75% of the estimated energy, protein, and water needed for wound healing.
  • Some important tools than can be used to determine appropriate daily nutrition intake are:
    • Conducting 24-hour dietary recalls
    • Meal frequency questionnaire
    • Determining safe access to food and need for specialized or modified diet
    • Evaluating socioeconomic status and home dynamics

• Medical problems that interfere with eating such as bowel disorders should be identified.
• Other disease states such as recurrent infections or cancer increase nutritional requirements and may lead to malnutrition.

1. Medical History
2. Age
3. Weight
4. Risk assessment tool results (e.g., Braden Scale)
5. Current medications and comorbidities
6. Ability to meet nutritional needs independently
7. Oral problems (e.g., trouble chewing or swallowing)

Among the standard laboratory studies, several should be considered:

• HbA1c should be obtained to determine diabetes control and carbohydrate intake.
• A complete blood count (CBC) may identify a nutritional anemia.
  • Microcytic hypochromic anemia may indicate iron deficiency. Macrocytic anemia may indicate folate or B12 deficiency.
• Total lymphocyte count may be a useful index of overall nutritional health.
• Albumin and prealbumin are often ignored as nutritional indicators because they are susceptible to change by metabolic stress such as infection or trauma and may therefore give confusing information about nutrition.
  • Whatever the source of a low albumin and prealbumin, one should determine the cause and address it to optimize healing.
• If the history and physical exam indicate micronutrient deficiencies, specific tests may be ordered

• Developing and implementing a personalized nutrition care plan and catering to patients caloric, protein, hydration, micronutrient needs, and need for diet modifications will ensure that patient nutrition is optimized and meeting all essential needs for wound healing.
• When poor nutrition or malnutrition is present, wound healing can be delayed, worsen, or even come to a halt
• Hyperglycemia is a huge contributing factor for wound development and poor wound healing.
• Optimal glycemic control is essential along with ensuring the patient’s HbA1c is at or near 7.0%. The exact target HbA1c should be based on age and insulin production.

• Proper nutrition is fundamental to healing.
• Multiple local, systemic, environmental, and even social factors must be optimized to assure healing.
• Wounds require protein, calories, and micronutrients to provide the substrate to support neovascularization, collagen formation and epithelialization.
• Deficiency of a single nutrient such as Vitamin C are well known to cause poor wound healing.
• Care providers managing patients with traumatic wounds should be aware of the importance of metabolic support to provide nutrient substrate to heal the wound.

• Hydration is essential since it helps regulate body temperature, maintains kidney function, helps deliver nutrients to cells, contributes to good skin turgor, and helps better blood flow, which are all important factors when preventing and/or treating diabetic wounds.
• Hydration requirements can be 1 mL/kcal or standard maintenance fluid requirements are 25–35 mL/kg of body weight/day for healthy adults.
• Before calculating estimated hydration needs consider the following:
  • Heart failure
  • Renal function
  • Serum sodium values
  • Dehydration
  • Altered GI function (e.g., vomiting and/or diarrhea)
  • Skin turgor
  • Edema
  • Hepatic cirrhosis
  • Pharmaceuticals (e.g., corticosteroids, diuretics)

• Caloric needs are high when a diabetic foot ulcer is present. Calories provide energy to aid in wound healing and energy demand increases with the patient’s nutrition risk factors and the severity of wound(s).
  • Adequate energy aids in collagen formation, anabolism, cell metabolism, and development of new tissue such as blood vessels.
• Generally, the recommended daily calorie intake is 2,000 for women and 2,500 for men.
• Overweight patients with a BMI >30 are at risk of malnutrition, yet patients with significant unintentional weight loss over a specific amount of time are also at risk.
• Conducting 24-hour recalls and food frequency questionnaires should be practiced at every visit when treating a patient to ensure the patient is meeting estimated caloric needs.
• Utilize indirect calorimetry as the gold standard for identifying energy needs. If indirect calorimetry is not available, there are other formulas that can provide a standard starting point.

• Carbohydrates, protein, and fats are the three essential food groups known as macronutrients.
• Specific macronutrient needs are high when a patient has a DFU, especially if the patient is malnourished or is at risk of malnutrition, because the body may be at or close to a catabolic state.
• When in a catabolic state, the body will utilize its own skeletal muscle as its energy source. This results in a loss of lean body mass and worsening of the patient’s wound healing process.

• Nutrition interventions are recommended for all patients who could benefit, now or in the future, from nutritional care.
• Nutrition intervention involves many strategies, including hydration, diet, oral nutritional supplements, tube feeding, and parenteral nutrition.
• Healthcare providers should develop and implement an individualized nutrition care plan for individuals with, or at risk of, a DFU who are malnourished or who are at risk of malnutrition.
• Specific nutrition plans should be individualized and based on existing diagnoses, patient preferences, age, lab test results, pre-existing health and medical conditions, tolerance of vitamin/mineral supplements, access to professional/caregiver/family support with grocery shopping and cooking, and other available resources.
• It’s important to set 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.
• Offer most individuals with nutritional and DFU risks a minimum of 30–35 calories per kg body weight per day, 1.25–1.5 g of protein per kg body weight per day, and 1ml/kcal/day of fluid intake.
  • For individuals with a high BMI, lower calorie intake while still meeting protein goals may be appropriate.
• Conducting 24-hour recall, food frequency questionnaires, and reviewing food diaries (if available) will play an essential role in helping you determine a patient’s energy and protein needs.
• The goal of intervention is to help the patient consume food and fluid in amounts that meet estimated nutritional requirements, maintain, reduce, or increase body weight, depending on BMI, and prevent unintentional weight loss.

• Hydration status affects blood volume, blood circulation, and skin turgor, all of which are important in the wound-healing process.
• Standard maintenance fluid requirements are 25–35 mL/kg/day for healthy adults.

• Dietary changes are often the best starting point when it comes to nutrition intervention in patients with DFUs.
• Patients should start by eating less unhealthy fat, such as trans-fat, saturated fat, and cholesterol, and eating more unsaturated fats.
• Priority should be given to nutrient dense foods.
• Sodium intake should be reduced to 3,400 mg or less per day to help with control of blood pressure.
• Oral nutrition supplements (ONS) can be taken between meals as needed to help provide additional protein and micronutrients.
• Patients should consider varying the types of foods and supplements taken to avoid taste fatigue
• High-calorie, high-protein fortified foods and supplements should be offered, in addition to dietary changes, when dietary changes alone are not sufficient to meet nutritional requirements.

• Oftentimes a proper diet alone will not be sufficient for optimal wound healing.
• Starting ONS early is especially important for patients who are at greater risk for malnutrition and for those who are already showing signs of malnutrition.
• ONS are liquids, semi-solids or powders that provide macro- and micronutrients needed for wound healing.
• For many patients with DFUs, ONS will be more effective than dietary changes alone.
• The addition of specific supplements such as arginine, glutamine and HMB as an adjunct to standard of care may improve healing of diabetic foot ulcers, especially in patients with poor limb perfusion and/or low albumin levels.
  • In a study of healthy elderly subjects, supplementation with arginine, glutamine, and HMB increased collagen deposition (as reflected by hydroxyproline content) at the wound site, suggesting that supplementation may provide a safe, non-invasive, nutritional means for improving wound repair.
• Therapeutic Nutrition Powders (e.g., Juven®) are among the most commonly used supplements.
  • These have been shown to support wound healing by enhancing collagen production and can help replenish critical nutrients needed for wound healing such as arginine, glutamine, HMB and also other micronutrients.
• When offering nutritional supplements discuss oral supplements available and flavor options.
• Encourage oral supplement intakes in-between meals.
• All ONS should always be administered along with proper hydration and a balanced diet.

• Discuss with patient the benefits and harms of enteral or parenteral feeding to provide additional or an alternative source of nutrition support.

• Overweight and Obese Patients
  • Most diabetic patients are overweight or obese, which by definition, is malnutrition.
  • Many such patients are sarcopenic, with decreased lean body mass despite excess body weight.
  • It is possible for the overweight or obese patient to meet the metabolic needs of the healing wound while simultaneously losing weight.
  • Weight loss improves diabetes control which helps heal the wound but also decreases the pressure on the DFU in the ambulatory patient.
• Older Adults
  • A significant number of patients with diabetes are geriatric.
  • Geriatric patients also have a variety of social and physiologic issues that lead to decreased protein and micronutrient intake.
  • Many geriatric patients should be considered malnourished until proven otherwise.

• Educating patients with DFUs about their increased dietary needs as well as the best dietary sources of essential nutrients involved in wound healing can lead to improved outcomes.
• Patients should be counselled on nutrition in a group or individually. It has been demonstrated that when clinicians collaborate with the patient in a meaningful exchange of information, HbA1c, quality of life and adherence is improved.
• Patients should be educated on proper hydration, tracking daily glucose targets, and consistency, including the use of reminder alarms throughout the day.
• Patients may not be able to meet estimated needs with diet alone — do not hesitate recommending oral nutrition supplements to help meet these needs.

1. Patients should eat three meals a day and 1–2 snacks in-between meals based on blood sugar levels and goals.
2. No skipping meals!
3. Patient should try to consistently eat the same amount of carbohydrates at each meal.
4. If patient skips a meal, they should not try to make up for carbohydrates not eaten, instead they should stay around same carbohydrate recommendation for every meal.
5. Patients with T2DM should consume 20–35 g of fiber from raw vegetables and unprocessed grain per day. The FDA advocates consumption of 25 g dietary fiber per 2,000 calories consumed.
6. Diet should focus on whole grain foods, plenty of fiber, and choosing foods that are less processed to avoid rapid spikes and drops of blood sugar levels.

• How often should I be screened for nutritional deficiencies?
  • You should see your healthcare team regularly, at least 1–2 per year. In addition, if you are malnourished or at great risk for becoming malnourished, you should see your care team more frequently.
• How important is exercise?
  • Proper diet and exercise go hand in hand, so both are very important! Exercise is even more important when your BMI is higher than 30.
• Do supplements taste bad?
  • This is a common myth. There are a variety of supplements that come in many formats and flavors. If one type of flavor of supplement tastes bad to you, there are usually a handful of others that you can try until you find what tastes best for you.
• How do I know if I am getting enough vitamins/nutrients in my diet?
  • Your healthcare team will work with you to create an individualized care plan, and will conduct regular check-ins to ensure that your nutrition levels are where they should be. As long as you stick closely to this plan you will receive the appropriate levels. Talk to you doctor if you are having a hard time sticking to the individualized care plan.
• Does nutritious food and/or supplementation cost a lot?
  • No! In fact, it will cost you a lot more in the long run by not taking the right steps to keep your nutrition in check. There are many healthy and nutritious foods, as well as supplements, that are affordable.

1. www.cdc.gov/diabetes/managing/eat-well.html
2. http://www.nutrition.gov/topics/diet-and-health-conditions/diabetes
3. www.diabetes.org/healthy-living/recipes-nutrition/understanding-carbs/carb-counting-and-diabetes
4. http://www.diabetesfoodhub.org/
5. http://www.eatright.org/health/diseases-and-conditions/diabetes

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