A Cross-sectional Pilot Study to Examine Food Sufficiency and Assess Nutrition Among Low-income Patients with Injection-related Venous Ulcers

Adequate nutrition has long been considered a critical component for wound healing, but literature regarding the relationship between nutrition and venous ulcer (VU) healing is limited.   A person’s nutrition is affected by the availability of food as well as his/her overall health. Food sufficiency and nutrition are important concerns in the care of persons of low income with injection-related VUs, which tend to be large and slow to heal. A cross-sectional pilot study was conducted to explore the relationship between food sufficiency/security and nutrition with regard to demographic, wound, quality-of-life, physical activity, falls, and fall risk variables. Nutrition was examined using 2 well-developed instruments that measure food sufficiency/security and assess nutrition — the United States Department of Agriculture’s Adult Food Sufficiency Questionnaire (FSQ) and the Nestle Mini Nutritional Assessment (MNA). All participants (N = 31, 54% men, mean age 56.1 ± 3.6 years, all African American) were recruited from an outpatient clinic. All had injection-related VUs from a history of injecting illicit substances. In terms of food sufficiency/security, most participants (26, 84%) reported having enough food in the house, but 10 (32%) worried about running out of food. From 16% to 22.6% of participants expressed concern with food sufficiency/security in terms of cutting meal size, eating less, hunger, and weight loss. Food sufficiency/security was high for 19 (61.3%), but 12 (39%) had marginal or lower food sufficiency/security. MNA scores showed 16 participants (52%) were at risk of malnutrition or malnourished. Low food sufficiency/security was significantly (P < 0.05) associated with less motivation for activity (r = -0.40) and less walking (r = -0.36). Better nutrition assessment scores were significantly associated (P <0.01) with fewer comorbidities (r = -0.57) and falls (r = -0.46) and with higher quality of life (r = 0.50), motivation for physical activity (r = 0.59), and balance confidence (r = 0.60). Both food security and nutrition assessment are important to assess in low-income persons with injection-related VUs. A number of significant relationships of the FSQ and MNA to other variables was found but needs further investigation with a larger sample.

______________________________________________________________________________________
RELATED CONTENT
Comparison of Nutritional Risk Between Urban and Rural Elderly
Vulnerable Populations: Considerations for Wound Care
______________________________________________________________________________________

Introduction

  The need for adequate nutrition for optimal wound healing has been recognized for centuries, and inadequate nutrition has been associated with delayed wound healing.^1,2 Wound healing requires carbohydrates, fat, amino acids, trace minerals, and vitamins.^1,3 Therefore, a person’s nutrition assessment should take into consideration 1) food sufficiency/security or the availability of appropriate and adequate food sources and 2) health assessment of the pathological consequences of the disease, present physical state, and current dietary intake.^4,5 Food insufficiency and nutritional deficiencies are best recognized and corrected expediently because even brief periods of malnutrition can have substantial negative effects on wound healing.⁶ For example, in the United States in 2013, 17.5 million households (14.3%) were food insecure (ie, they had limited or uncertain ability to acquire food).⁷ In a cross-sectional study of food security conducted in an emergency department (N = 520), Sullivan et al⁵ reported food insufficiency was significantly greater for persons with the lowest income, and food insecure patients had significantly more reports of chronic pain, substance abuse, and cigarette smoking. Thus, food sufficiency and nutrition assessment are 2 important concepts when examining nutrition for patients with injection-related venous ulcers (VUs), which tend to be large and slow to heal.^8-10

Wound healing (which involves cell proliferation, protein synthesis, and enzyme activity) is a complex, energy-demanding event that requires nutrition availability.^6,11 Chronic wounds may remain in a state of inflammation that leads to destruction of the extracellular matrix and protein loss.¹² Undernutrition delays wound healing; delays neovascularization; prolongs inflammation; decreases phagocytosis by leukocytes; is associated with dysfunction of B and T cells, decreasing fibroblast proliferation and altering collagen synthesis; and results in decreased mechanical strength of the skin.^6,12,13 With aging, underlying contributing factors such as aging skin and multiple comorbidities (ie, atherosclerosis, diabetes mellitus, and leg ischemia) negatively affect healing.¹³ Nutrition deficiencies impede the normal processes that allow progression through specific stages of wound healing.¹² The etiology of malnutrition is usually multifactorial, including availability of food, poor nutritional intake, comorbidities, functional state, social support, quality of life, and catabolism from a wound.^12,13

  Limited research has explored nutrition for persons with VUs. These studies generally involved older adults and did not mention injection drug use. Using the Nestle Mini Nutritional Assessment¹⁴ (MNA), Szewczyk et al¹⁵ compared the nutritional status of hospitalized older adults with vascular disease who never had VUs (n = 40) with randomly selected outpatients with VUs (n = 37). Almost half (48%) of all participants were at risk for malnutrition or were malnourished; differences were not influenced by gender or age (mean age of both groups was ~70 years). A significantly higher proportion of patients (P <0.05) at risk for malnutrition or currently malnourished was found in the VU group. The authors recommended complete patient assessment must include evaluation of nutritional status.

  In a 12-week prospective study, Legendre et al⁸ examined the prevalence of protein deficiency in outpatients presenting with venous leg ulcers and its prognostic value for wound outcomes. The authors compared 41 patients with VUs to 43 patients with other skin lesions; mean age of the total group was 73 years. Individuals with VUs had significantly more weight loss or low body mass index (BMI), lower serum albumin, and higher inflammatory syndrome and anemia. Persons with VUs had a high prevalence (27%) of protein deficiency. Although at 12 weeks 66% of patients had favorable healing changes, unfavorable outcomes were found with protein deficiency. Protein deficiency was associated with a significant increase in wound area at 12 weeks. The authors concluded the prevalence of protein deficiency in outpatients with venous leg ulcers is high and significantly associated with poor healing (P = 0.0034). In contrast, Milic et al¹⁶ examined risk factors among 189 patients (mean age 61 years) related to failure of VUs to heal with compression therapy; within 52 weeks of compression therapy, 12.7% of VUs failed to heal. A high BMI (>33 kg/m²), along with short walking distance (<200 m), history of wound debridement, and deep ulcers (>2 cm), were indicators of slow healing. Independent parameters associated with nonhealing were calf-ankle circumference ratio <1.3, fixed ankle joint, and reduced ankle range of motion.

  Variables associated with nutrition assessment are included in varied studies. For example, Miller et al¹⁷ performed a secondary analysis of data collected (N = 156) during an e-learning educational program developed about factors that shape the effectiveness of multicomponent education programs. In the leg ulcer prevention program, 1 of the 6 sessions included healthy eating and hydration (6 items). The study identified few significant associations and those found were considered minor, such as between supplements and multivitamin use (r = 0.45), adequate fluid consumption with more than 8 glasses consumed daily, and eating well and elevating legs (r = 0.32). The authors concluded that although persons with venous disease are encouraged to make multiple behavior changes, association between health behaviors subsequently pursued was limited.

  Nutrition assessment remains an important component of care for persons with VUs, although little research has examined it. Studies could not be found about nutrition assessment and persons with injection-related VUs that generally occur before age 60 years⁹ and are in persons with low income. The purpose of this cross-sectional pilot study was to examine food sufficiency/security and assess nutrition in persons with injection-related VUs and to evaluate the relationship of these variables to demographic, quality-of-life, wound, physical activity, falls, and fall risk variables. The US Department of Agriculture Adult Food Sufficiency Questionnaire18 (FSQ) and the MNA¹⁴ were the primary nutrition instruments.

Design. This cross-sectional pilot study included nutrition variables for future research studies. The sample size was determined by the number of available persons with injection-related VUs; interest in participation was gauged when persons receiving treatment at the authors’ facility came for clinic visits. In addition to the presence of an injection-related VU, inclusion criteria stipulated: age 40–65 years; able to respond in English; and a registered patient in the urban, low-income, wound care clinic. The exclusion criterion was physically or mentally too ill to participate in the research process. The questions about nutrition were part of a broad pilot study that included variables about pain, mobility, falls and fall risk, and sleep.

  The participants were previously described in detail in the study’s report on pain,¹⁹ falls and balance confidence,²⁰ and Five-Times-Sit-to-Stand (FTSTS) and Timed-Up-and-Go (TUG) Tests²¹; only a summary of the participants will be presented here.

  Procedure. Participants were recruited consecutively when they came for their scheduled wound care clinic appointment. A registered nurse assessed potential participants on inclusion and exclusion criteria. Participants signed a consent form. Nurses read questionnaires to participants and recorded their responses onto paper questionnaires and performed the functional performance measures. Participants were compensated $10 for their 1-hour participation time. The study was Institutional Review Board-approved; thus, all rules about confidentiality were followed.

  Instruments.
  Demographic and Health Questionnaires. These instruments together obtained general information about each participant such as gender, race, age, and medical diagnoses. Participants responded to a list of 21 possible medical diagnoses. In calculating comorbidities, conditions causally related to VU status (deep vein thrombosis, liver disease including hepatitis B and C, and lower-extremity neuropathy) were omitted. BMI was calculated from the person’s weight in kg and height in m (BMI = kg/m²). The test-retest reliability values for the Demographic and Health History Questionnaires are 0.99 and 0.86, respectively.²²

  PROMIS Global Health scale. Quality of life was measured with the PROMIS Global Health scale.²³ The Global Health instrument consists of 10 items tabulated for a total score. Scores range from 55 (excellent/completely/never) to 9 (poor/not at all/always/very severe). Higher scores indicate higher quality of life. Relative to the general US population, persons with chronic illnesses had poorer quality of life, and this was more pronounced when 2 or more chronic conditions were present.²⁴ The PROMIS Global Health total score has a reliability of 0.87.²⁴

  Daily Walking Scale, Active Living Scale, and the Motivation for Physical Activity Scale. Physical activity was examined with 1) the 2 subscales from the Legs in Daily Use questionnaire — namely, the Daily Walking Scale and Active Living Scale²⁵ — and 2) the Motivation for Physical Activity Scale.^26,27 The Daily Walking Scale asks participants how far they walked on a daily basis. The Active Living Scale asks if standing or walking had increased, decreased, or stayed the same over the past 5 years. For analyses, responses of increased and stayed the same were combined because of the sample size. Internal consistency reliabilities for the Daily Walking and Active Living questionnaires are 0.58 and 0.67, respectively.²⁵ The Motivation for Physical Activity Scale consisted of 7 items. They were scored strongly disagree (1) to strongly agree (5). The instrument includes items such as “Even if walking is difficult, I do not let the way I feel stop me from doing activities,” and “I feel better when I do a certain amount of physical exercise.” The Motivation for Physical Activity Scale has an internal consistency alpha of 0.67.²⁵

  Activities-specific Balance Confidence score (ABC-16), FTSTS test, and TUG test.^20,21 Falls and fall risk were examined by number of falls. A fall was defined as unintentionally coming to rest on the ground, the floor, or other lower surface.²⁰ Participants were asked if they had fallen during the past year and the number of times they had fallen.

  The ABC-16 assesses the confidence to maintain balance while performing selected activities.²⁸ Participants were asked how confident they are in not losing balance or becoming unsteady when performing 16 items of daily living (scored from 0% [not confident] to 100% [completely confident]). ABC scores >80% are indicative of being highly functioning; scores >50% and <80% indicate moderate level of functioning.²⁹ Reliability of the test is high, often 0.90 or above.^30-32

  As a functional performance test, the FTSTS test begins with the person sitting in a chair, arms crossed over the chest. The participant is instructed to stand up and sit down as quickly and safely as possible 5 times.²¹ The test ends when the person sits for the last time with his/her back against the back of the chair. The time to complete the test is recorded in seconds with a standard stop watch.²¹ Good reliability was reported for the FTSTS test in different studies: test-retest 0.89,³³ 0.96 intraclass correlation coefficient,³⁴ and 0.89 intraclass correlation coefficient.³⁵

  The TUG test, another functional performance measure, involves the participant sitting in a standard chair with armrests with his/her back against the chair and arms on the arm rests.²¹ Each participant is told to rise from the chair, walk 3 meters, turn, walk back to the chair, and sit down with his/her back against the chair. Time to complete the test is recorded in seconds. Reliability of the TUG test has been examined in many populations and is high (ie, ICC = 0.87 to 0.99).^36-38

  United States Department of Agriculture’s Adult Food Sufficiency Questionnaire (FSQ). The validated FSQ was used to measure food security¹¹; it can be used with households with and without children. Food security means access by all people at all times to enough food for an active, healthy life; food is acquired in socially acceptable ways.^5,7 Questions include topics such as running out of food, food did not last and did not have money to get more, cannot afford to eat balanced meals (see Table 1). Two additional questions addressed how often the event happened for “cut size of meals or skip meals because there wasn’t enough money for food” and “not eat for a whole day because there wasn’t enough money for food.” The sum of the affirmative responses to the 10 items provides the raw score on the scale. Score 0 is high food security among adults; score 1–2, marginal food security among adults; score 3–5, low food security among adults; and score 6–10, very low food security among adults.

  MNA. The MNA is a screening and assessment tool to identify older adults (65 years of age and older) who are malnourished or at risk for malnutrition.¹⁴ Guigoz³⁹ reviewed the literature about the MNA: the reported prevalence of malnutrition in community-dwelling elderly was 2% and risk of malnutrition was 24%. In outpatients and elderly receiving home care, the prevalence of undernutrition was 9% and 45% were at risk of malnutrition. The wide variability is due to level of dependence and health status of the elderly studied. Although the participants in the current study were generally <65 years of age, this instrument was used because of the items, speed of use, and history of accuracy. The screening portion has 6 items about food intake, weight loss, mobility, stress, neuropsychological problems, and BMI. Points are totaled for a maximum of 14 points. The assessment portion has 12 items about nutrition, living arrangements, health, and measurements of midarm circumference and calf circumference. The maximum total assessment score is 16. The 2 scores are summed (total = 30); scores of 17 to 23.5 points indicate at risk for malnutrition and <17 points, malnourished. The instrument has a long history of validity,¹⁴ and Guigoz concluded the MNA screening and assessment tool is reliable and has defined thresholds.³⁹

  In addition to instrument use, the number of lower extremity wounds were counted and the greatest length and width of each wound was measured. Length and width were multiplied for wound area.

  Data analyses. Data were coded and analyzed using SPSS (Chicago, IL). Descriptive statistics were used to examine the frequency, percentages, and distribution of demographic characteristics along with means and standard deviations of quantitative measures. Pearson product-moment correlations facilitated examination of the relationships among the variables. The authors were especially interested in nutrition specific to persons with VUs because it is a clinical group with distinct lower extremity changes in need of nutrition for healing. Alpha was set to 0.05 2-tail for all statistical tests.

Participants. Of the 35 persons invited, 31 participated (response rate 88.6%). Their mean age was 56.1 ± 3.6 years; 54% were men; all were African American. They had a mean of 5.1 ± 2.4 comorbidities, a mean BMI of 27.6± 4.9 kg/m² (overweight range), and a mean quality-of-life score 0.85 ± 0.82.

  Four persons had VUs on the right leg only, 13 had VUs on the left leg only, and 14 had VUs on both.¹⁹ The mean total wound surface area was 95.6 ± 119.06 cm2; the mean total number of ulcers was 2.39 ± 1.36.

  In terms of falls and balance confidence, 61.3% (n = 19) were repeat fallers. They had a mean ABC-16 score of 67.04 ± 27.82, mean FTSTS test 21.10 ±11.37 seconds, and mean TUG score 14.35 ± 7.1 seconds.^20,21 Twenty (65%) walked less than a half mile per day, and 20 (65%) had both decreased walking and standing over 5 years. Motivation for physical activity had a mean score of 3.3 ± 68.

  FSQ and MNA Scores. Table 1 shows items in the FSQ. Approximately 26 participants (84%) stated having enough food in their house, but 10 (32%) worried about running out of food. The proportion of participants who reported cutting meal size, eating less, hunger, and weight loss ranged from 16% to 22.6%. When total scores were examined (see Table 2), 61.3% had high food security, 12.9% had marginal food security, and 25.9% had low to very low food security.

  For the MNA, 15 (48.4%) of the participants were at risk of malnutrition and 15 (48%) were not at risk (see Table 3). Only one person was rated as malnourished.

  Relationship of FSQ and MNA with demographic, wound, quality-of-life, physical activity, and falls and fall risk variables. The FSQ was significantly related to 2 physical activity variables (see Table 4). The lower the FSQ score, meaning higher food security, the higher the Motivation for Physical Activity score (r = -0.40); walking increased or stayed the same (r = -0.36). Although not statistically significant but worth noting in a pilot study were correlations among higher food security and lower number of ulcers (r = 0.25), higher ABC-16 (r = -0.30), standing increase or stay the same (r = -0.34), and higher BMI (r = -0.35).

  Higher MNA scores (ie, better nutrition) (see Table 4) were significantly related to fewer comorbidities (r = -0.57), higher quality-of-life scores (r = 0.50), higher Motivation for Physical Activity (r = 0.59), lower repeated falls (r = -0.46), and higher/better ABC-16 scores (r = 0.60). Not statistically significant but worth noting in a pilot study were better MNA scores’ relationships to fewer number of ulcers (r = -0.27), increased walking and standing (r = 0.33), and less time to complete FTSTS (r = -0.30) and TUG (r = -0.32).

Discussion

  Food sufficiency and nutrition were examined for low-income persons with injection-related VUs including the relationship of nutrition to demographic, wound, quality of life, physical activity, and fall risk. About 39% of patients had marginal or lower food security and 52% were at risk of malnutrition or malnourished. The 2 instruments measure different concepts, both of which are crucial in nutrition assessment. The FSQ was significantly related to 2 physical activity variables, whereas the MNA related significantly to 5 other variables.

  A high prevalence of chronic venous insufficiency (CVI) and VUs is present in persons who have injected illicit drugs.⁹ For 713 persons enrolled in methadone maintenance treatment, 17.8% had healed or open VUs. About 92% of the sample had some clinical evidence of venous disease.9 Persons born between the late 1940s and early 1960s (the baby boomer population) have the highest prevalence of ever injecting drugs,⁴⁰ underscoring the potential to develop CVI changes. In addition, injection-related VUs often begin before age 65 years. The mean age of participants in the authors’ methadone treatment study of CVI was 46 years.⁹ As these individuals age, they have many other long-term comorbidities such as hypertension, diabetes mellitus, heart disease, and hepatitis C virus that can affect their health and nutritional status. Thus, understanding the role of nutrition and wound healing is critical.^{2,4,6,11,12,41-43}

  Nutritional deficiencies affect wound healing by impeding fibroblast proliferation, collagen synthesis, and epithelialization.³ High exudate loss can result in as much as 100 g of protein lost in a day.⁴⁴ Any delay in healing increases cost of care. Augustin et al⁴⁵ recruited 502 patients from 147 institutions in Hamburg, Germany; they used questionnaires, structured interviews, and clinical examination to study leg ulcer costs (78.5% were VUs). The annual total cost for a leg ulcer in Euros was a mean of 9060 ($11,325 using a conversion factor of $1.25) per patient per year.⁴⁵ Additional costs include pain, lack of mobility, and social isolation, all affecting quality of life. Thus, leg ulcers are associated with high cost for health insurance, patients, and society.⁴⁵ Addressing the role of nutrition in healing may influence costs. Unfortunately, no standard regimen exits for testing or monitoring nutritional deficiencies in patients with wounds.¹¹ Jaul¹³ noted patients with wounds need a comprehensive, multidisciplinary approach to healing, and this approach should include comorbidities, functional status, nutritional status, social support, ethical beliefs, and quality of life.

  Food insecurity and hunger result from financial issues and are undesirable.⁵ They are potential precursors to nutrition, health, and development problems.⁵ In Sullivan et al’s⁵ cross-sectional study, 13% of patients screened positive for food insecurity.⁵ This is low compared to current findings of 39%. The food-insecure patients compared to the food-secure patients were more likely to be younger, female, less likely to be white, had lower household incomes, and less likely to have a high school education or health insurance.⁵ They were more likely to report chronic pain, drug or alcohol abuse, and to have smoked within the past year.⁵ Food-insecure patients had higher BMIs because of trying to stretch the dollar by purchasing calorie dense, inexpensive foods.⁵ The current study did not find a relationship between food insecurity and gender. The current authors also found low food security was associated with higher BMI, but this was not statistically significant. They reported food-insecure patients were less likely than food-secure patients to be moderately active.⁵ Food-insecure patients had lower motivation for activity and decreased walking. The presence of food insecurity is a concern for persons with wounds because of the need of nutrition for healing.

  Almost half of the patients with injection-related VUs had an MNA total score showing they were at risk for malnutrition and significantly related to aspects of physical activity and fall risk. Feldblum et al⁴⁶ screened 259 elderly patients 65 years and older within 72 hours of being hospitalized. They reported high numbers (81.5%) of these patients were at risk for malnutrition, and malnutrition was associated with lower physical function; low food consumption, poor appetite, and chewing problems were associated with the development of malnutrition. Szewczyk et al¹⁵ used the MNA with 40 hospitalized older adults with vascular disease (mean age 77 years) and with 37 outpatients with VUs (mean age 70 years).¹⁵ Of the total sample, 48% were at risk for malnutrition or were malnourished. Age and gender were not significantly related to nutritional status. The proportion of patients at risk for malnutrition or currently malnourished was significantly higher for patients with VUs (24 out of 37) versus vascular disease (13 out of 40), P <0.05.¹⁶ The authors concluded the nutrition assessment of all patients with VUs seemed warranted. Considering current findings about low food security and risk for malnutrition MNA scores, additional studies are needed.

 Laboratory tests that assess nutrition were not available; hence, it is not known how these assessments correlate with laboratory values for protein deficiency. In a study of 41 patients with leg ulcers and 43 without leg ulcers, Legendre et al⁸ reported protein deficiency was higher in outpatients presenting with leg ulcers compared to the general population. Protein deficiency has been independently associated with increased wound area and other wound complications such as wound infection and hospitalization.⁸ Examining the literature about the MNA across multiple settings, Guigoz³⁹ noted large variability in the risk for malnutrition depending upon the setting. The risk of malnutrition for community-dwelling elderly was 24%. Guigoz³⁹ noted the MNA detected risk for malnutrition before severe changes in serum proteins or weight. The MNA was developed for persons >60 years of age and validated in outpatient and institutionalized living home settings.⁴⁷ The mean age of participants in the current study was 56.1 years (SD = 3.6), younger than 60 and in an outpatient setting.

  This study was a pilot study; the sample size was small and restricted to obtaining participants from 1 clinic. The study needs to be expanded to multiple sites to increase the sample size. An oral examination was not performed, yet the number and condition of natural teeth are important for eating. Nowjack-Raymer and Sheiham⁴⁸ examined a large data set (N = 6,985) in terms of demographics, dental status, diet, and nutritional status and reported dental status significantly affected diet and nutrition. The intake of nutrient-rich foods was associated with decreased number of teeth present — namely, people with <28 teeth had significantly lower intakes of carrots, tossed salad, and dietary fiber and lower serum levels of beta carotene, folate, and vitamin C compared to fully dentate people.

  The current study did not collect a detailed illicit drug history. Hence, the effect of types of drug use, years of drug use, or years of not using drugs on the variables for this study is not known.

Nutrition is a critical part of wound care for outpatients with VUs. These wounds can be slow to heal and be negatively affected by insufficient food and inadequate nutrition. Because persons with injection-related VUs may be <65 years of age, providers may not consider nutrition assessment. Yet, this pilot study showed concerns about food security and risk for malnutrition. Wounds place a marked negative burden on the person and the health care system. The patient needs to be in a good physical state for healing. Nutrition is a cornerstone in the healing process, and nutrition instruments should be easy to complete and comprehensive. For patients living in poverty, the security of food also must be part of nutrition assessment. This may mean health professionals using social service referrals for food programs and food availability. Dietitians should be available to assist outpatient wound care providers with assessment and nutrition teaching and planning. Persons with VUs will need to learn healthy food decisions that increase nutrition within the boundaries of their economic status. Future research to increase understanding about VUs and nutrition is needed, including longitudinal studies examining nutrition across the trajectory of VU healing, initial food security and nutritional assessments on early manifestations of healing, and frequency of need to evaluate food security and complete nutritional assessments.

Dr. Pieper is a Professor/Nurse Practitioner, College of Nursing; and Dr. Templin is a Professor, Center for Health Research, Wayne State University, Detroit, MI. Please address correspondence to: Barbara Pieper, PhD, RN, CWOCN, ACNS-BC, FAAN, 1356 Yorkshire, Grosse Pointe, MI 48230; email: bapieper@comcast.net.