The development of wounds, foot ulcers in particular, is a serious complication for patients with diabetes. Numerous factors related to diabetes can impair wound healing, including wound hypoxia (inadequate oxygen delivered to the wound), infection, nutrition deficiencies, and the disease itself.2 Fluctuating blood sugar and hypoxia from poor circulation may impair the ability of white blood cells to destroy pathogenic bacteria and fungi, increasing infection risk. The diabetic foot ulcer does not follow the normal progression of wound healing and develops chronic inflammation rather than improving.
Progression of wound healing:
| Normal patient | Patient with diabetes |
| Acute response: Activation of hemostatic cascade, release of growth factors and cytokines |
Acute response:Activation of hemostatic cascade, release of growth factors and cytokines |
| Recruitment of neutrophils and macrophages as part of inflammatory Response; attraction of fibroblasts and endothelial cells to injury site |
Recruitment of neutrophils and macrophages as part of inflammatory Response; attraction of fibroblasts and endothelial cells to injury site |
| Phase 3: Cell proliferation, deposition of extracellular matrix |
Cell proliferation, deposition of extracellular matrix |
| Phase 4: Remodeling | Phase 4: Chronic inflammation |
Blood sugar control becomes a vicious cycle. High blood sugar can increase infection rate3 and impair wound healing, and wound inflammation and infections can elevate blood sugar. While nutrition is neither the cause of nor the sole solution for resolving diabetic foot ulcers, blood sugar management is a priority. Poorly controlled diabetes adversely affects the ability of leukocytes to destroy invading bacteria and to prevent the harmful proliferation of usually benign bacteria present in the healthy body.
The importance of nutrition
Malnutrition further impairs wound healing in the diabetic patient. In a study on nutrition assessment and amputation in diabetic patients, surgical wounds healed in only two of 11 patients who had total lymphocyte counts less than 1500 mm3 and serum albumin less than 3.5 g/dL,4 two indicators of malnutrition. It is well understood that adequate nutrition status benefits recovery from surgical and other wounds.
Standard enteral formulas may not be appropriate for the patient with diabetes.5 Coulston notes that this type of formula can impair blood glucose control and recommends a disease-specific formula instead. While a high carbohydrate, low fat diet generally is recommended for diabetics, better control of blood sugar may be achieved with formulas that supply only moderate amounts of carbohydrate, along with moderate amounts of fat. High proportions of omega-6 fatty acids from sources like corn, safflower or soybean oil are not recommended because they are precursors for the pro-inflammatory prostanoids, like prostaglandin E2(PGE2), and leukotrienes that may further impair wound healing.
Omega-3 fatty acids from fish and linolenic acid and medium-chain triglycerides do not exacerbate inflammation. Longer chain carbohydrates and fiber can aid glucose control. Feeding should progress gradually to minimize the effects of excess calories on blood glucose. A study comparing a high carbohydrate enteral formula with a reduced carbohydrate, modified fat formula found that patients on the modified fat formula had 10 percent fewer infections.6
Hyperglycemia may result from several factors: inflammation and infections, the use of steroid medications, and the feeding process. Feeding schedule and medications may need to be adjusted for optimal blood sugar control. Blood sugar should be monitored approximately every six hours, less often for stable patients.
It has been postulated that diabetic wound healing may benefit from higher intakes of antioxidant nutrients because of the oxidative stress associated with the disease.7 In one study of diabetic patients, levels of vitamins E and C were below normal in skin wounds that were healing.8 Another area of study is prevention of lipid peroxidation, thought to impair wound healing. A study on diabetic mice found that inhibition of lipid peroxidation at the wound site restored nearly normal wound healing.9 Additional research is necessary to determine the effects of antioxidant nutrients in diabetes.
Tags: Additional research, Development of wounds, diabetes, Diabetes and Wound Care, diabetic foot, disease, further, infection, infections, malnutrition, medications, nutrition deficiencies, patients, surgical, The development, The development of wounds, Wound Care, wounds
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