Nutrition 411: Nutrition Q & A: Real Answers to Your Questions

  When I started working in wound care, email was in its infancy. If a colleague had a question about nutrition, he or she would use the telephone to speak with me directly. Nowadays, email is the way most people communicate. Each week, I receive inquiries from patients, caregivers, colleagues, strangers, and the media. This month’s column features some of the most common questions from my mailbox — real questions from real healthcare practitioners seeking nutrition advice. Q: My hospital wants to use the nutrition score within the Braden Scale as a screening tool. Can the nutrition score be used this way?
  I do not recommend this practice. The Braden Scale is a risk assessment tool used as part of a pressure ulcer prevention program to predict pressure ulcer risk. It has been tested for reliability and validity as a whole. The nutrition subscore has not been tested individually and was not designed as a screening tool. Many tested nutrition screening tools are available. I have spoken to several registered dietitians (RDs) who work in facilities that have tried what you are proposing, and they found this practice results in an excessive number of nutrition consultations for patients.

Q: I have been following your advice for pressure ulcers. Do the same interventions work for venous and arterial ulcers?
  There is little to no research on the effect of nutrition interventions on arterial and venous wounds. Without any evidence to rely on, I can only offer my best guess and experience. Lower extremity ulcers are often the result of poor circulation related to arteriosclerosis, venous insufficiency, and similar problems. The obvious treatment is to find the underlying cause and try to correct it with surgery, medications, compression, and other management options. Any nutritionally compromised patient will have a more difficult time recuperating and responding to treatment in general; the advice to provide adequate calories, protein, and fluids each day holds true for everyone. For pressure ulcers, we often increase the protein component of the diet to combat loss of muscle mass and compensate for any catabolism due to a change in the hormonal milieu. If a patient with another type of wound has any sort of muscle wasting, providing additional protein seems to be a reasonable approach. As far as vitamins and minerals, a complete multivitamin is most likely adequate.

Q: How can I measure my patient’s height if he/she is bedbound? I usually leave that item blank in the health record or ask the patient how tall he is. Is that okay?
  Let’s begin with the second half of this question. No, it is not okay to leave height (or weight) blank on an assessment form. I have reviewed hundreds of malpractice cases, and incomplete assessments are always a trouble spot. If your data collection forms or electronic health records are asking for extraneous information you do not need, the solution is to review your process and redesign the form. In some cases, it is acceptable to ask the patient to tell you his/her height, but in my experience, the patient usually provides misinformation. So it is important to clearly indicate in the medical record that this was a “stated height” rather than a measured height. Eventually, the patient will be transferred to a facility where height actually will be measured, and then the record will show inconsistent data. It is not unusual for me to see charts where the patient was 5 feet, 7 inches in the hospital and 5 feet, 4 inches in the nursing home. Elderly patients never realize how much their height has changed over time (usually, their verbal height is taller than they currently measure). Although a 3-inch height difference seems very inconsequential and does not affect the care a patient ultimately receives, inaccuracies make it seem like the medical providers are inefficient. A patient’s wife once told me, “If they can’t even get my husband’s height correct, how can they manage his wound?”

  Bedbound patient height can be measured using the following approaches: The first is simply by measuring the arm span. Have the patient hold his arms straight out and measure fingertip to fingertip. This will approximate height. Make certain to note in the record that this is an arm span measurement. The second way is by using knee height calipers. These calipers are available for purchase from medical supply companies and provide an easy way to measure height.

Q: The surveyors seem to expect us to order vitamin C and zinc for every patient with a wound. My facility stopped routinely ordering these supplements based on the lack of evidence, and now we are being questioned. Should we start ordering these products again?
  You should not change your facility polices unless you believe they are flawed. Vitamin C and zinc supplements have long been connected to wound healing, but there is not an abundance of evidence to show efficacy or lack of efficacy. I doubt rigorous studies will ever be conducted on these products, so we have to work with the information we have.

  We know a great deal about the physiologic functions of vitamin C and zinc and the important roles they play in the wound-healing cascade. It seems logical to supplement to correct known deficiency; however, we often do not know if the patient is deficient or not. Clinical judgment in combination with a nutrition-focused physical exam may be our best indicator of any nutritional deficiencies. Thus, a policy that allows for supplementation when deemed necessary by the practitioner seems to work best. Most surveyors are not experts in wound healing, so it may be beneficial to share some of the latest nutrition articles and reviews that examine this topic.

Q: In your earlier articles, you recommended prealbumin. Now it seems you don’t. Can you explain to me what I am misunderstanding?
  In the nearly 20 years I have been writing about wound care, new evidence has come to light that has affected standard of care. When I started out, albumin often was used as an indicator of nutritional status. Prealbumin became popular in the mid 1990s as an improvement over albumin due to its shorter half-life and smaller serum pool. As the new millennium arrived, more was learned about the entire class of hepatic proteins (albumin and prealbumin among them) and their relationship to inflammation. According to some authors, hepatic protein levels do not accurately measure malnutrition or nutritional repletion. Rather, hepatic proteins are better as indicators of morbidity and mortality and can help the practitioner identify patients who are at increased nutritional risk because of trauma or illness. Many variables, including inflammation, are known to affect serum protein levels. Currently, the feeling is that rather than rely on a single lab value, the practitioner should conduct a nutrition-focused physical exam and look at the patient as a whole.

Q: If someone is taking amino acids such as arginine and glutamine, does that count as protein?
  Arginine and glutamine are amino acids. Although amino acids are the building blocks of protein, they do not count as whole protein. Consider a patient who is assessed to require 65 g of protein/day. A common supplement provides 7 g each of arginine and glutamine. This does not count toward the goal of 65 g of protein/day because 14 g of amino acids is not the same thing as whole protein such as is found in an egg or chicken breast. It is possible to calculate the amount of nitrogen contributed by the amino acids, but most practitioners do not do this.

Q: My patient has renal disease and a Stage IV pressure ulcer. What should I do about the protein needs?
  This is a difficult question because renal disease has many meanings and runs the gamut from slightly compromised patients to persons on the verge of needing dialysis to those who are already receiving dialysis. In my opinion, the most difficult situation is the patient with stage 3 or 4 renal failure who is trying to heal a wound and stave off dialysis concurrently. For the wound, we typically recommend extra protein; for the renal failure we typically recommend decreased protein. In these cases, I prefer to speak to the patient and his/her family and get a sense of their goals and wishes. Some patients are adamant that they do not want dialysis, while others are more resigned and know it is likely coming soon. Based on the conversation, we can prioritize goals and plan the appropriate interventions.

Q: My patient is iron-deficient but complains that iron supplements make her stomach turn. She is refusing to take the iron pills. What foods can she eat instead?
    The top ten iron-containing foods are:
    Red meat
    Egg yolks
    Dark, leafy greens (spinach, collards)
    Dried fruit (prunes, raisins)
    Iron-enriched cereals and grains (check the labels)
    Mollusks (oysters, clams, scallops)
    Turkey or chicken giblets
    Beans, lentils, chickpeas, and soybeans
    Liver
    Artichokes.

  The problem with iron from food is limited absorption. Consuming foods rich in vitamin C at the same time as high iron foods can improve absorption rate. Tell your patient to have a glass of orange juice with his steak. As far as iron supplements, patients often have to try several brands until they find one they can tolerate. I have had success with Bifera (Meda Consumer Health Care, Inc); you might want to give supplements another chance. As a side note, I have no financial interest in this product.

Q: My patients don’t know what to cook and can’t afford a dietitian. Can you recommend a book?
  My favorite healthy cookbook is Eat What You Love by Marlene Koch, RD. This book has more than 300 recipes suitable for patients with diabetes, weight issues, and heart disease. My favorite recipe in the book is a makeover of the Orange Chicken recipe from a famous Asian fast food restaurant. Marlene’s version is low-calorie, low-fat, and tastes incredible. I like this book because it is real food in real portion sizes. It is the best-selling cookbook on the QVC shopping network, so many people agree!

Q: I work in an outpatient wound center in a poor area. My patients can hardly afford their medications. How can they get enough protein?
  One of the simplest and least expensive sources of protein is eggs. I often recommend cooking hard-boiled eggs and using them as a snack to provide a high-quality protein supplement. Each egg provides 7 g of protein. Less expensive cuts of meat, such as chuck and brisket provide, protein just as more expensive cuts do but need a longer time to cook and are best stewed or potted. Financial concerns are a reality of today’s world. Many supplement manufacturers have responded with coupons, product samples, and patient assistance programs for qualified patients. If you wish to use a certain product, it never hurts to ask the product representative or call the customer service number.

Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of RD411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation.

This article was not subject to the Ostomy Wound Management peer-review process.