What The Experts Say About Nutrition, Diabetes And Wounds

These expert panelists discuss good diets for patients with diabetes and wounds, how to educate patients on nutrition, and how to advise patients who are underweight or overweight.

Q: What is a good diet for patients with diabetes and/or wounds?

A: Consuming adequate protein, carbohydrates, fluids, vitamins, and minerals is a vital aspect of promoting wound healing, emphasizes Nancy Munoz, DCN, MHA, RDN, FAND.^1,2 As she says, the American Diabetes Association (ADA) goals for providing nutrition therapy for individuals with diabetes include encouraging adherence to a healthy eating pattern and consuming an assortment of nutrient-dense foods in recommended portion sizes to promote health and to achieve and maintain a healthy body weight.³

Frank Aviles Jr., PT, CWS, FACCWS, CLT, agrees. “As a clinician who has seen wounds across the continuum of care, I used to harp on patients getting an adequate amount of protein, vitamin C, vitamin D, and adequate hydration while maintaining adequate glucose control if they have diabetes,” he says. He notes the importance of other nutrients, vitamins and minerals, such as zinc, vitamin A and vitamin B.

Kristen Smith, MS, RD, LD, says one should prescribe an individualized diet to promote wound healing in a patient based on the severity of the wound and the patient’s accompanying medical conditions. However, she says typically the diet should focus on protein, calories, fluid, and certain micronutrients. Smith says most patients will require a higher protein diet, which may warrant the need for additional high protein oral supplements. She says one should encourage patients to eat at least 3 meals and 2 to 3 snacks a day to help ensure adequate protein and calorie intake.    

“A healthy eating pattern with a consistent, individualized percentage of carbohydrates from calories will also help to achieve glycemic, blood pressure, and lipid goals as well as help to defer or prevent comorbidities associated with diabetes,” says Munoz.  

In an inpatient setting, Aviles says maintaining adequate nutrition is not an issue because patients will have a tailored and monitored balanced diet. In the outpatient setting, he says the answer to this question differs today from what it once was. Aviles emphasizes that the diet needs to be not only healthy, but one that the patient can accomplish in a measurable way that is affordable. Supplements must be used as needed when patients’ skin integrity is impaired and objective testing results are noted, says Aviles.

“Once home, if the patient has not embraced a new eating lifestyle, there is not likely to be any long-term change, increasing the opportunity for chronic wounds,” emphasizes Aviles.

Q: How can clinicians effectively educate patients with diabetes on nutrition?

A: Aviles suggests getting to know the patient as part of the education process. “It may seem routine to healthcare providers who constantly speak with patients in a busy clinic, but we also need to get to know our patients and learn why, specifically, they are struggling with proper nutrition,” he says. “In that sense, there is nothing routine about educating a patient on nutrition and the barriers that prevent a proper nutritional diet.”

Aviles and his colleagues have made a stronger commitment to empower their patients while recommending resources for support, as opposed to simply telling patients what to eat and what not to eat. Clinically, he can educate patients on how their glucose levels influence healing and how problems can develop throughout the body. Aviles typically hones in on how abnormal glucose levels lead to a greater risk of infections, slow to no healing potential of patients’ wounds, and the reality of undergoing an amputation.

When educating patients with diabetes on nutrition, Smith emphasizes understanding self-care challenges and potential barriers to compliance. She says one should discuss with patients potential barriers to compliance with a diabetic diet, such as financial, psychosocial support, or nutrition knowledge deficits. Motivational interviewing techniques may be helpful to facilitate patient’s own decision-making and improve adherence to a diabetic diet, according to Smith. As she notes, such a counseling technique is a patient-centered behavior change model that helps to improve a patient’s perception and promotes behavior changes. For some patients, Smith advises it may be helpful to discuss the complications of diabetes and how diet compliance can play a role in managing blood sugars and preventing the further complications of a progressive disease.

In promoting wound healing, Munoz notes the importance of managing the nutritional status of individuals with diabetes and pressure injuries to promote adequate nutrient consumption and stable blood glucose levels.⁴ She says having a diet with a consistent meal pattern with similar nutritional composition from one meal to the next aids in regulating blood glucose levels, which promotes wound healing. Meal patterns designed to meet the individual’s regular eating pattern, with a carbohydrate range of 40-60% of total calories from carbohydrate can be a good starting point, according to Munoz. She recommends a protein intake of 1.25-1.5 grams of protein per kilogram of body weight with an adequate number of total calories. 

Aviles says showing patients with diabetes the less desirable outcomes of the disease can be a strong motivator to diet compliance. He recalls talking to a patient with diabetes about how a lack of nutrition control can lead to amputation. Shortly thereafter, he says this same patient met another patient in the waiting room who told him, “take care of yourself now or you will end up with no legs and in a wheelchair.” Aviles says at the time, this patient just so happened to be kicking his residual limbs, following an above-knee amputation, in the air.
 

Q: How do you advise underweight patients with wounds on nutrition?

A: Smith notes it is important for underweight patients to understand the importance of adequate nutrition for would healing, especially in regard to calorie and protein intake. She says an underlying disease may play a factor in patients’ current weight status, so liberalizing dietary restrictions and finding preferred nutrition-dense foods should be encouraged for this type of patient. She encourages patients to eat small, frequent meals that are nutrient-dense to promote adequate intake.

Munoz says underweight individuals and those with PI should allow 30-35 kcal/ kg of body weight as a starting point. For individuals who cannot meet their nutritional needs with a regular diet, she notes the addition of oral nutrition supplements can be an appropriate intervention. Individuals with a suspected or confirmed nutrient deficiency should consider adding a multi-vitamin to their dietary regimen.

Aviles refers underweight patients to a dietitian on his team. From the wound care perspective, Aviles says his role is to provide patients with clinical evidence as to why their wounds have failed to make progress or how nutrition impacts the wound-healing repair process. He would compare wound healing to growing a vegetable garden, which takes time, but says it will be important to provide the soil with necessary nutrients and food to yield a great crop.

“Try growing a crop in sandy or rocky soil,” says Aviles. “Sandy soil makes it difficult for retaining nutrients and water, as rocky soil does not drain well and not having enough organic material for plants to survive is a problem. Having the right soil, or in our case, appropriate nutrition, will definitively help our wound-repair process.”
 

Q: How do you advise overweight or obese patients with wounds on nutrition?

A: Smith suggests educating overweight or obese patients with wounds on the importance of adequate nutrition, including calories and protein. Aviles says adequate protein intake, vitamin C, hydration, and other considerations are important.

Munoz similarly notes it is important for consume a healthy diet that is higher in protein with a moderate amount of carbohydrates to support glycemic control. She says a healthy eating pattern should include the consumption of fruits, vegetables, whole grains, and fat-free or low-fat milk and milk products. Also, she says such patients should include lean meats, poultry, fish, beans, eggs, and nuts while staying within their daily caloric needs. 

Aviles refers obese or overweight patients to a dietitian. As he notes, more adults today are considered obese, which predisposes them to conditions such as heart disease and diabetes, conditions that will both affect the wound repair process. Clinically, Aviles will discuss how obesity impairs the wound-healing process and how lifestyle must change in order for the wound to make progress.

“The message becomes powerful when you discuss interventions such as amputations with associated mortality rates when wound healing has failed,” says Aviles. “Clinicians must empower themselves with knowledge and concentrate on patient-centered care. Don’t forget that if the patient is not part of the solution in this patient-centered model and you are working harder than the patient, then failure will be eminent.”

While weight loss may be a goal for overweight or obese patients, Smith says consuming adequate macronutrients (calories and protein) is crucial to promote wound healing. She cautions that significant weight loss is not often recommended when trying to promote wound healing. For patients with diabetes, Smith says consuming consistent carbohydrates throughout the day is important to prevent fluctuations in blood sugar, saying higher fiber sources such as whole grains, fruits, and vegetables are the preferred source. 

Frank Aviles Jr. is wound care service line director at Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapy (PT)/wound care consultant at Louisiana Extended Care Hospital, Natchitoches; and PT/wound care consultant at Cane River Therapy Services LLC, Natchitoches.

Nancy Munoz is a lecturer at University of Massachusetts Amherst, a freelance writer, and the assistant chief, nutrition and food services, at VA Southern Nevada Healthcare System, Las Vegas. She may be reached at dr.nmunozrd@outlook.com

Kristen Smith is a spokesperson for the Academy of Nutrition and Dietetics. She is the bariatric surgery coordinator for Piedmont Healthcare in Atlanta, GA and the founder of a blog that promotes healthy eating for the entire family. She is the nominating committee director for the Academy's Weight Management dietetic practice group. Smith is also a member of the Academy's Nutrition Entrepreneurs dietetic practice group, the American Society of Metabolic and Bariatric Society and the Obesity Action Coalition.

1. National Institute of Diabetes and Digestive and Kidney Diseases. Managing Diabetes. Available at https://www.niddk.nih.gov/health-information/diabetes/overview/managing-diabetes. Published 2018.

2. Centers for Disease Control and Prevention, US Department of Health and Human Services. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Available at https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf.  

3. American Diabetes Association. Standards of Medical Care in Diabetes-2018 Abridged for Primary Care Providers. Clin Diabetes. 2018. 2018;36(1):14-37. 

4. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Pressure Ulcer Treatment: Quick Reference Guide. https://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf . Published 2014.