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Recent Progress in Nutrition

(ISSN 2771-9871)

Recent Progress in Nutrition (ISSN 2771-9871) is an international peer-reviewed Open Access journal published quarterly online by LIDSEN Publishing Inc. This periodical is devoted to publishing high-quality papers that describe the most significant and cutting-edge research in all areas of nutritional sciences. Its aim is to provide timely, authoritative introductions to current thinking, developments and research in carefully selected topics. Also, it aims to enhance the international exchange of scientific activities in nutritional science and human health.

Recent Progress in Nutrition publishes high quality intervention and observational studies in nutrition. High quality systematic reviews and meta-analyses are also welcome as are pilot studies with preliminary data and hypotheses generating studies. Emphasis is placed on understanding the relationship between nutrition and health and of the role of dietary patterns in health and disease.

Topics contain but are not limited to:

  • Macronutrients
  • Micronutrients
  • Essential nutrients
  • Bioactive nutrients
  • Nutrient requirements
  • Nutrient sources
  • Human nutrition aspects
  • Functional foods
  • Nutraceuticals
  • Health claims
  • Public health
  • Diet-related disorders
  • Metabolic syndrome
  • Malnutrition
  • Nutritional supplements
  • Sport nutrition

It publishes a variety of article types: Original Research, Review, Communication, Opinion, Comment, Conference Report, Technical Note, Book Review, etc.

There is no restriction on paper length, provided that the text is concise and comprehensive. Authors should present their results in as much detail as possible, as reviewers are encouraged to emphasize scientific rigor and reproducibility.

Publication Speed (median values for papers published in 2023): Submission to First Decision: 6.7 weeks; Submission to Acceptance: 16.1 weeks; Acceptance to Publication: 6 days (1-2 days of FREE language polishing included)

Current Issue: 2024  Archive: 2023 2022 2021
Open Access Perspective

Nutrition for Healing Acute and Chronic Wounds: Current Practice, Recent Research Findings, and Insights for Improving Care

Mary Beth Arensberg 1, Bethan E. Phillips 2, Kirk W. Kerr 1,*

  1. Abbott Nutrition Division of Abbott, Columbus, Ohio, USA

  2. Centre of Metabolism, Ageing and Physiology (COMAP), MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research (CMAR), NIHR Nottingham Biomedical Research Centre (BRC), School of Medicine, University of Nottingham, Derby, UK

* Correspondence: Kirk W. Kerr

Academic Editor: Arrigo F. G. Cicero

Special Issue: Clinical Nutrition: Recent Advances and Remaining Challenges in Aiding Acute Surgical or Traumatic Wound Healing

Received: March 20, 2024 | Accepted: September 02, 2024 | Published: September 10, 2024

Recent Progress in Nutrition 2024, Volume 4, Issue 3, doi:10.21926/rpn.2403014

Recommended citation: Arensberg MB, Phillips BE, Kerr KW. Nutrition for Healing Acute and Chronic Wounds: Current Practice, Recent Research Findings, and Insights for Improving Care. Recent Progress in Nutrition 2024; 4(3): 014; doi:10.21926/rpn.2403014.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

Abstract

Wound prevalence is increasing as the global population ages. Older adults are at risk of wounds from falling and from other medical conditions that contribute to wound development and slowed healing (e.g., diabetes, cancer, chronic infections); they often experience health conditions that necessitate surgery and therefore post-surgical healing. Poor nutrition status, which includes deficiencies in macro- and micronutrients, is recognized as a key contributor to impaired wound healing in older adults. As such, the need for nutrition-focused wound care is also increasing. This Perspective review provides a framework for considering the links between nutrition, wounds, and healing. We start with a review of factors related to high incidence and prevalence of wounds in older adults, including inadequate nutrition. Nutrition interventions enhancing wound healing are also described as well as insights into strategies and tools for including nutrition as part of overall quality wound care, particularly for older adults. To meet the growing challenge of wound healing, professionals across care settings need to implement comprehensive and holistic wound-care strategies to benefit patient and healthcare-system outcomes. Nutrition is a critical intervention for these strategies.

Keywords

Nutrition; nutrition interventions; quality wound care; wound healing

1. Introduction

Wound healing is a significant health-related challenge in the 21st century [1]. From a global perspective, chronic wounds of mixed etiologies have a pooled prevalence of 2.21 per 1000 population [2]. With ever-improving public health programs and medical treatments, human longevity has markedly extended over the last century, and as such, the global population of older adults (>60 years) is growing at a remarkable rate (i.e., from 1 billion in 2019, expected to double to 2.1 billion by 2050) [3]. Accordingly, wound prevalence is increasing, as older adults are at greater risk of wound injuries from both falling [4], and from medical conditions that contribute to wound development and slowed healing (e.g., diabetes) [5,6], as well as from health conditions that necessitate surgery and therefore post-surgical healing [7,8]. For example, a United States (US) study of older adults found that 15% of individuals required care for wounds or wound-related infections in a year [9]. The financial costs of wound care are high, raising the focus on lowering risk and improving care as strategies to achieve cost savings [6]. In the US, total public spending for all wound types in older adults was estimated to be at least $28 billion annually [9]. Importantly, disparities in both wound prevalence and in wound healing outcomes have been associated with age, race/ethnicity, and care setting [10,11,12].

Some factors related to wound healing, such as nutrition, are potentially modifiable factors that can be improved to lead to better wound outcomes, particularly for older adults [13,14,15]. To highlight links between nutrition, wounds, and healing, this Perspective review paper describes factors related to high wound incidence, prevalence, and poor healing in older adults, including inadequate nutrition. We specifically outline nutrition interventions shown to enhance wound healing and those supported with recent research findings and implemented in current practice. We also provide insights into effective use of nutrition care to improve overall quality of care and wound healing in older adults.

2. Wound Healing and Older Adults

Poorly healing wounds are responsible for pain, increased hospitalization rates, social isolation, longer lengths of hospital stay, limb amputation, and death; risks are often specified by wound type [16]. A newly recognized aspect of wound care is the importance of maintaining or restoring health-related quality of life [17,18,19,20]. Conditions such as nutrition, financial burden, socioeconomic and educational status, and acute and chronic stress are variables known to impact both wound healing and patients' quality of life [21]. Similarly, ethnic-based social disparities have been reported to contribute to poor wound healing and lower quality of life [20,22].

Successful wound healing is a complex process that can be influenced by many factors, including a patient’s age, underlying health or disease, nutrition status, and socio-demographic status, along with the wound’s size, severity, presence or absence of infection, and location and the blood flow to the wounded area (Figure 1). In older people, poor wound healing is a particular challenge because wounds heal less efficiently with age-related skin changes and with physiological changes related to metabolic diseases and cardiovascular conditions [23,24]. Complete wound healing is especially challenging in individuals with comorbidities such as obesity or cardiovascular disease [25,26]. Poor nutrition status, which includes deficiencies in macro- and micronutrients, is a common contributor to impaired wound healing in older adults [27]. The disproportionately high prevalence of poor nutrition in older people may be due to social strains and economic difficulties, in addition to early satiety and other medical problems [28]. As well, some medications commonly used in treating older adults’ health conditions can affect skin integrity and impair wound healing, e.g., antibiotics, angiogenesis inhibitors, steroids, and nonsteroidal anti-inflammatory drugs [29,30]. Irrespective of a patient’s age, other wound factors influence the time needed for healing, specifically, the type, size, and severity of a wound, and inflammation, infection, or ischemia [25,31,32]. With all these factors interacting, the duration of the wound-healing process varies widely; healing may follow a normal and timely path to resolution, may be interrupted or delayed resulting in a hard-to-heal wound, or may be so impaired that the wound is non-healing unless specialized treatment strategies and interventions are used.

Click to view original image

Figure 1 Wound healing factors and outcomes.

All wounds start out as acute wounds. An acute wound can result from any traumatic incident that damages the skin, e.g., an abrasion or laceration, a burn, a penetrating or blunt trauma, or a surgical incision [14]. Ideally, an acute wound heals in a timely and orderly manner. A small-sized cut will normally heal within a week by progressing through stages that begin with hemostasis, followed by a precise choreography of cell proliferation, inflammation, innervation, and angiogenesis [14]. By contrast, a larger or hard-to-heal wound follows this same course but can take many months to achieve full wound healing or may develop into a chronic wound [33,34]. Hard-to-heal and chronic wounds require specialty wound care, which includes multi-disciplinary care for wound management, ongoing wound screening and assessment, and tailored interventions ideally involving nutrition care. Diabetic foot ulcers, venous leg ulcers, and pressure ulcers are examples of chronic lower extremity wounds that are common in older people [35]. In the most severe cases, wounds may fail to heal and therefore become a non-healing wound. Wound healing involves a complex interplay between different types of cells, cytokines, mediators, and the vascular system.

In normal healing, the cascade through three healing phases is systematic and efficient. The three phases of wound healing are (i) inflammation, which includes vasoconstriction of blood vessels and platelet aggregation to help stop bleeding, (ii) proliferation of cells to repair tissue and skin damage and prepare for the next phase, and (iii) remodeling, which completes tissue restoration and re-establishes skin integrity [33,34,35,36,37]. These wound-healing processes typically drive the body into a metabolic state that increases energy and protein demand and utilization [14].

3. Nutrition Interventions for Healing Acute and Chronic Wounds

3.1 Macronutrients

To meet increased nutrition demands for healing wounds, sufficient supplies of macronutrients—carbohydrates, proteins, and fats—are critical to restoration of tissue and skin integrity [38]. An appropriate supply of nutrients is also essential to support skin remodeling and reduce scar formation, an important aesthetic outcome [38]. Dietary carbohydrates and proteins can break down into glucose, which is the main metabolic fuel for anabolic processes, including collagen synthesis, fibroblast growth and function, and thus supporting wound healing [39]. Dietary protein is critical for collagen synthesis, tissue remodeling, skin structure, angiogenesis, and fibroblast proliferation [14,28]. The formation and function of key components of the immune system—leukocytes, monocytes, lymphocytes, and macrophages depend on adequate supplies of protein as well [28]. Without adequate protein supplies, the inflammatory phase of healing may be prolonged with resultant poor healing and even wound dehiscence [14]. In addition, macronutrient fats provide energy for cellular proliferation and are an essential structural component of cell membranes as phospholipids [14]. Fats also play a necessary role in the inflammatory responses important to wound healing; omega-3 and omega-6 fatty acids are precursors to inflammatory-phase mediators, i.e., prostaglandins, leukotrienes, and thromboxane [40].

Along with carbohydrates, protein, and fat, fluid is a fundamental component of wound healing. Fluid helps maintain skin turgor, perfusion, and oxygenation and acts as a dilutant for glucose, micronutrients, and waste removal [28,41]. Evidence-based recommendations for carbohydrate, protein, fat, and fluid requirements for optimal wound healing are listed in Table 1.

Table 1 Macronutrient and Fluid Requirements for Adults with Wounds.

3.1.1 Amino Acids, Branched Chain Amino Acids, and the Leucine Metabolite ß-Hydroxy-ß-Methylbutyrate (HMB)

Wounds are complex and may benefit not just from adequate protein but also from protein components, i.e., specialized amino acids recognized to promote optimal healing. Conditionally essential amino acids are those that cannot be synthesized in sufficient quantities during certain physiological periods, such as during growth or recovery from trauma [43]. For example, the amino acids arginine and histidine, are conditionally essential and may be needed by patients with wounds due to these amino acids’ roles in growth and healing processes [28,44,45]. Glutamine can be considered conditionally essential too, especially for immune function in stress conditions [46].

Arginine supports cellular proliferation, collagen deposition, and lymphocyte function and serves as a precursor for nitric oxide [13,40]. Nitric oxide metabolites have been shown to positively affect wound repair [40]. In addition, arginine is an essential component of collagen synthesis and stimulates growth hormone and T cells and positive nitrogen balance [13,40,47]. The recommendation for supplementing arginine in patients with pressure or stasis wounds is 4.5 g/day in addition to optimal protein intake [28].

Glutamine is a primary energy source for rapidly multiplying epithelial cells and fibroblasts [40]. Glutamine also plays a role in leukocyte apoptosis, superoxide production, antigen processing, and phagocytosis, which impacts the inflammatory phase of wound healing [28]. Glutamine is critical for tissue repair, cell proliferation, and collagen synthesis [47]. Glutamine supplementation is considered safe for malnourished patients as part of the nutrition management of underlying protein calorie deficits [28]. However, due to conflicting clinical trial results with combination supplements, there is no conclusive evidence to support glutamine supplementation specifically for wound healing [14,40].

Branched-chain amino acids—valine, leucine, and isoleucine—are essential amino acids that promote protein anabolism and reduce the severity of cachexia, prevent (or treat) hepatic encephalopathy, promote wound healing, and stimulate insulin production [48]. In addition, leucine also functions as a signaling molecule to stimulate protein synthesis [49].

HMB is a metabolite of leucine and has been shown to both stimulate protein synthesis and decrease protein degradation [49,50]. Based on the anti-catabolic effects of HMB on muscle mass in healthy adults, including older adults, HMB supplementation has also been studied in other muscle-wasting conditions (e.g., chronic pulmonary disease, hip fracture, and in AIDS-related and cancer-related cachexia) [49]. A review of relevant clinical studies documents that HMB can attenuate the development of sarcopenia in older adults and the effect of HMB was optimal when combined with exercise [49]. A meta-analysis determined that HMB supplementation could mitigate losses of lean body mass in older adults without a significant increase in fat mass [51].

Based on studies demonstrating the efficacy of HMB for maintaining lean body mass, including through stimulating protein synthesis pathways and decreasing protein degradation, more recent research has focused on identifying the efficacy of HMB, arginine, and glutamine to improve wound healing [49]. One study in individuals with diabetes and foot ulcers demonstrated that the use of HMB, arginine, and glutamine improved wound healing but only in patients with poor limb perfusion and/or low serum albumin levels [47]. A more recent retrospective study used electronic health records to compare outcomes of patients with existing wounds in a rehabilitation institution who were given a daily nutrition supplement containing HMB, arginine and glutamine (in addition to usual care) with outcomes of patients receiving usual care only [50]. Patients receiving the nutrition supplement had significant wound healing within 2 weeks of initiation and at twice the rate of healing compared to patients who did not receive the nutrition supplement [50]. Indeed, the use of this wound-specific supplement combined with a hospital diet resulted in a nearly two-fold better wound area reduction compared to the control group [50]. Based on such results, the use of a wound-specific supplement has been included in the European Society for Clinical Nutrition and Metabolism (ESPEN) Guidelines as a promising area of exploration [52].

3.2 Vitamins and Minerals

While the data supporting vitamin and mineral supplementation to enhance wound healing are limited, it is important to ensure that patients are adequately assessed and treated for underlying vitamin and mineral deficiencies that could impact wound healing and lead to poor- or non-healing conditions [40]. Antioxidant vitamins A, C, and E may counteract adverse effects of reactive oxygen species in wounded tissues, and they also contribute to other wound healing processes such as epithelialization (vitamin A), and collagen synthesis and angiogenesis (vitamin C), [53]. A recent study of orthopedic trauma patients documented a high prevalence of vitamin A, C, D, and zinc deficiencies in over half of the study group [54]. Furthermore, low pre-albumin levels and vitamin C deficiency were associated with wound complications in this study [54]. A summary of important vitamins and minerals for optimal wound healing is provided in Table 2.

Table 2 Vitamins and Minerals Important for Wound Healing.

3.3 Specialized Nutrition Supplements

Key nutrient supplementation is critical to achieve optimal wound healing in both acute and chronic wounds. Daher et al conducted a systematic review of 28 studies on nutrient supplementation for wound healing in healthy patients and in those with diabetic foot ulcers, pressure injuries, and other wound types [63]. Nutrient supplementation differed across the included studies, and included protein and amino acids, HMB, vitamins and minerals, probiotics, and mixed nutrients [63]. Altogether, findings indicated that arginine and omega-3 supplementation improved wound healing in surgical head and neck cancer, which was demonstrated by a decrease in postoperative complications and reduced length of hospital stay [63]. Vitamin- and mineral-enriched supplements were more effective than non-fortified protein supplements for pressure injuries and diabetic foot ulcers [63]. Formulas containing arginine, omega-3, zinc, vitamins C, D, and E, and magnesium appeared to be the most effective in healing a variety of wounds [63]. Based on the data, wound-specific nutrition supplementation (glutamine, arginine, and omega-3 fatty acids) should be considered for patients with moderate-to-severe injuries, and hard-to-heal wounds to meet their individual nutrient requirements [14]. These key nutrients should be provided at injury onset and during recovery to achieve optimal wound healing. In the case of surgical wounds, these often represent a special case; because surgery is often pre-scheduled, nutrition care can be provided both before (prehabilitation) and after surgery to effectively improve outcomes [64,65]. A convenient way to provide needed macro- and micronutrients is daily consumption of complete oral nutrition supplements (ONS).

Use of complete ONS or use of complete ONS with enriched protein levels is an effective approach to providing adequate nutrients to support wound healing. Such ONS is best given along with counseling for use and with additional guidance on healthy food intake [14]. For individuals with high risk for nutrition inadequacy, wound-specific nutrition supplements can be added to the treatment regimen, e.g., to provide conditionally essential amino acids such as glutamine, arginine, and HMB, a natural metabolite of leucine. For optimal wound healing, nutrition support should be initiated as soon as possible after injury and tailored to meet the specific needs of the patient and wound type [14].

4. Strategies and Tools for Incorporation of Nutrition Care into Real-World Practice

Professional guidelines specific to nutrition and wound care can provide a basis for developing strategies to improve real-world practice. In addition, given the abundance of evidence for the importance of nutrition to achieve optimal wound healing, updated wound care protocols should specify implementation of nutrition screening, assessment, diagnosis, and intervention [66]. Further, it is important for healthcare systems to implement quality improvement programs to benefit wound care outcomes related to medical and human outcomes as well as healthcare costs and savings.

4.1 Professional Guidelines and Guidance on Nutrition Care and Wound Healing

Nutrition is integral to healing wounds of all types and across clinical settings; as such, good nutrition status is key to achieving optimal wound resolution [13]. Despite this understanding, Donnelly et al warned that most individuals with diabetic foot ulcers do not meet current consensus recommended levels on optimal dietary intake for wound healing, with many having inadequacies for fiber, zinc, protein, vitamin E, and vitamin A [67]. General guidance on nutrition for wound healing can be sourced from reviews and overviews including:

  • Perioperative and enhanced recovery after surgery (ERAS) guideline protocols [64,68,69].
  • American College of Surgeons preoperative guidelines for older adults [7].
  • National Pressure Injury Advisory Panel (NPIAP) guidelines [70] Updated version [71] Development of a fourth edition of the Guidelines (2025) is currently underway.
  • Management of diabetic foot ulcers [47,72].
  • Pressure ulcer prevention and healing [73].

Optimizing nutrition as part of quality wound care involves a team of healthcare professionals—ideally at the local level—trained to address associated physiologic and immunologic processes, as well as manage underlying social and societal factors [28]. Members of the team may include clinicians for wound assessment and management, wound care nurses, patient educators, home health caregivers, rehabilitation professionals, mental health specialists, social workers, as well as registered dietitian nutritionists. These team members support the important components of nutrition care and quality improvement.

4.2 Nutrition Screening and Assessment for Diagnosis and Intervention

Determining a wound’s cause and characterizing its exact location, size, and severity are essential to providing appropriate care [74]. So too is determining nutrition risk factors and then referral to a nutrition specialist to guide nutrition care. Any screening tool must be quick and easy to administer, reliable, and economical for clinical use. Multiple nutrition screening tools are available, so healthcare professionals can select a tool suitable for the population being screened and the wound care setting [66]. Assessment tools help healthcare professionals make a diagnosis. Once a wound patient is diagnosed as malnourished or at-risk, the next step is referral to a registered dietitian/nutrition professional who develops a nutrition care plan for intervention, and continues with regular follow-up monitoring [75,76].

4.3 Implementing a Nutrition-Focused Quality Improvement Program (QIP)

One of the ways to advance implementation of nutrition and wound care protocols and interventions is through a nutrition-focused QIP. As identified in a commentary on quality improvement for pressure injuries, “the success of any quality improvement project begins with acknowledging problems, defining and addressing each issue in detail, and setting goals” [77]. In healthcare, quality improvement seeks to standardize care processes for reduced variation, achieve predictable results, improve outcomes for patients and healthcare systems and help meet quality measures. QIP methods can be applied to nutrition and clinical practice [78,79,80,81]. Nutrition care models are available for QIP [81,82], as are exemplary studies related to nutrition in wound healing [79,80,83,84].

Nutrition-focused QIPs are also important for improving outcomes and reducing costs to benefit value-based healthcare. The US Centers for Medicare & Medicaid Services (CMS) has a number of wound care quality measures and related patient safety indicators across multiple US care settings (acute, post-acute, home care, clinic-based care, and private practiced-based care, Supplementary Table S1 and Supplementary Table S2) [24,85,86]. Most recently CMS adopted a new pressure injury electronic clinical quality measure for hospital reporting beginning in 2025 [86]. Leveraging quality nutrition care to improve wound outcomes can have meaningful impact on such quality measures. Nutrition-focused QIPs can also support improved public health, such as the measurable public health objectives for pressure injury readmissions set by the US Office of Disease Prevention and Health Promotion [87].

5. Summary and Conclusions: Nutrition Is Vital for Healing Wounds

Wound healing is a complex process that depends on many factors including a patient’s age and underlying health or disease, along with the wound size, severity, and location and the blood flow to the wounded area. A patient’s nutrition status plays a prominent role in healing because the catabolic process of inflammation and the anabolic process of wound repair increase nutrition needs. To support wound healing, patients require adequate macro- and micronutrients. In generally healthy and well-nourished individuals, an acute wound will likely follow an efficient and highly predictable pathway to healing. However, with nutrition deficiencies and increased nutrition needs, healing of wounds such as surgical incisions, traumatic injuries, burns, and pressure injuries or diabetic foot ulcers, may be delayed or stopped. Such wounds persist as hard-to-heal chronic wounds or non-healing wounds.

In these more complex cases, nutrition care becomes a critical aspect of overall treatment. For individuals with wounds and nutrition risk or malnutrition, ONS are often recommended to ensure complete and balanced dietary intake, especially adequate protein. In addition, wound-specific nutrition supplements can be added to the treatment regimen, (e.g., to provide amino acids such as glutamine, arginine, leucine and the metabolite of leucine, HMB).

To meet the growing challenge of healing wounds, healthcare professionals across care settings need to implement comprehensive and holistic wound-care strategies to benefit patient and healthcare system outcomes. In addition, today’s practitioners must meet wound-related quality measures specific to their site of care, while also aiming to reduce costs for care. Nutrition is a critical intervention for both goals.

Acknowledgements

The authors thank Cecilia Hofmann, Ph.D. (C Hofmann & Associates, Western Springs, IL, USA) for her skillful writing assistance.

Author Contributions

Mary Beth Arensberg: Conceptualization, writing – original draft, writing – review & editing. Bethan E. Phillips: Writing – review & editing. Kirk W. Kerr: Conceptualization, writing – review & editing.

Competing Interests

Kirk W. Kerr and Mary Beth Arensberg are employees and stockholders of Abbott.

Additional Materials

The following additional materials are available in the supplementary materials.

 

  1. Table S1: Examples of Institution-based Wound or Pressure Injury-Related Quality Measures, including those Leveraged by the Centers for Medicare and Medicaid Services (CMS) for Value-based Healthcare.
  2. Table S2: Examples of Clinician-based Wound or Pressure Injury-Related Quality Measures, including those Leveraged by the Centers for Medicare and Medicaid Services (CMS) for Value-based Healthcare.

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