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New Guidance Focused on Diabetic Foot Ulcers Highlights Importance of Team Care and Nutrition
Taking care of someone’s feet is an exemplary expression of humility. I grew up working with my father in his podiatry office. From an early age, I learned the difference you can make by helping people move through the world. Today, I am a professor of surgery at Keck School of Medicine at the University of Southern California. I recently co-founded the American Limb Preservation Society (ALPS), dedicated to eliminating preventable amputations and bringing together the next generation of interdisciplinary clinicians in the field.
At the start of my surgical residency, I assisted a patient with a diabetic foot ulcer (DFU) who, despite the extremity of the wound, did not experience any pain. This lack of pain was secondary to diabetic peripheral neuropathy. Recognizing the significance of this for people who live with diabetes and its impact on limb preservation, I decided to focus the rest of my career on looking beyond the point of pain and figuring out how to prevent it altogether. Current estimates show that 37.3 million people in the United States live with diabetes and that more than one-third of these patients will develop a DFU, which can lead to amputation if not treated properly.1,2
Most patients who experience diabetic-related medical issues affecting their lower extremities are treated by a single specialist. At ALPS, we have found that successful wound care and prevention require an approach that integrates multiple specialties. In traditional treatment settings, practitioners often treat only the pain or only the wound, which excludes some of the ways other functional areas of health care, such as registered dietitians and nutritionists, can support the healing process. This multidisciplinary treatment approach led me to work with a cross-functional group of medical experts to co-author medical guidance focused on the importance of nutrition to support wound healing.
NUTRITION AND NEW GUIDANCE
Together with Joseph L. Mills, MD, FACS; Maritza Molina, RDN; and Joseph A. Molnar, MD, PhD, FACS, we published Nutrition Interventions in Adults with Diabetic Foot Ulcers, an expert consensus and guide, highlighting the impact of nutrition-focused therapy to support wound healing in adults living with diabetes and DFUs. The guide suggests that more than half of these patients have moderate to severe malnutrition.3 Many of my patients who experience DFUs, when assessed for nutrition, have some form of nutritional deficit. For example, patients who show tissue loss associated with diabetes often show a protein deficit in their diet.
Nutrition can often be omitted from the treatment conversation with a specialist or when participating in a limb preservation program or wound healing unit. These guidelines help patients and clinicians better understand the critical role of nutrition in the DFU healing process and show that when patients who experience DFUs receive nutrition education and nutrition intervention, they can incorporate the right nutrients in their diets to support the wound healing process.
NUTRITION ROADMAP FOR CLINICIANS AND PATIENTS
The guide is designed to serve as a roadmap to help incorporate nutrition intervention in a way that can cater to individual patient needs. A nutritional assessment, which entails a thorough screening that includes patient history, existing diagnoses, patient preferences, age, lab test results, preexisting health and medical conditions, and risk tools and questionnaires, is essential to better understanding the patient’s needs. With that knowledge, the guide also recommends that clinicians consider the following:
Individual nutrition care plan: Specific nutrition plans should be individualized and based on existing diagnoses, patient preferences, age, laboratory test results, preexisting health and medical conditions, tolerance of vitamin/mineral sup-
plements, access to professional/caregiver/family support with grocery shopping and cooking, and other available resources.
Hydration and diet adjustments: Dietary changes are often the best starting point for nutrition intervention in patients with DFUs. Protein intake is essential to provide amino acids for optimized wound healing.
Oral nutritional supplements (ONS): Frequently, a proper diet alone is not sufficient for optimal wound healing. Starting ONS, such as therapeutic nutrition drinks, may be recommended to support wound healing. Therapeutic
nutrition drinks support wound healing by enhancing collagen production and can help replenish critical nutrients needed for wound healing, such as arginine, glutamine, HMB, and
other micronutrients.
Adherence and follow-up: Educating patients with DFUs about their increased dietary needs and the best dietary sources of essential nutrients involved in wound healing can lead to improved outcomes.
While the guide was developed primarily as a tool for clinicians, it can also serve as a resource for people living with diabetes and recommends the following:
Regular doctor’s visits: Patients should see their health care team regularly, at least 1 to 2 times per year.
Healthy habits: For those living with diabetes, one of the most important habits to develop is for patients to check their feet regularly for signs of ulcers, especially if they experience neuropathy.
Healthy diet: If a patient develops a foot ulcer, their body will need extra calories, protein, and vitamins and minerals to optimize healing. Make sure there is a healthy variety of fruits/vegetables, whole grains, dairy, and protein foods while limiting fats, oils, and sugars. Sometimes a standard diet alone is insufficient for the wound healing process to progress, and the health care team can develop an individualized care plan that may include nutritional powder drinks or targeted nutrition for wounds.
NUTRITION STUDY
Before developing this guide, I was the principal investigator on a study examining the effects of oral nutrition supplementation on wound healing in persons with DFUs. Study results showed that the addition of Juven (Abbott Laboratories), a therapeutic nutrition powder with arginine, glutamine and HMB, in conjunction with the standard of care, appeared to significantly improve the wound healing process.3
The randomized, double-blinded, multi-center, controlled study examined subjects with a DFU after 16 weeks of taking the therapeutic nutrition powder or a control drink. The study found that 60% of subjects who took the therapeutic nutrition powder showed wound closure at 16 weeks, compared with 34.4% of the control group (among subjects with albumin < 4.0 and ankle-brachial index [ABI] < 1.0).
Albumin is a protein made by the liver that helps carry various substances throughout the body, including hormones, vitamins, and enzymes. Albumin levels lower than 3.5 can increase the risk of infection.4The ABI is a simple test that compares blood pressure in the upper and lower limbs. A normal resting ABI is between 1.0 and 1.4.5
Treating patients with DFUs is a team effort. When implemented, improvements in wound care therapy can reduce the financial burden of treating DFUs, which can increase life expectancy and quality of life for people living with diabetes.
AUTHOR’S NOTE
These new guidelines are a strong educational tool, but they are not meant to be a stand-alone resource. Health care professionals should provide treatment based on a patient’s specific needs and situation. The guideline was produced and published with support from Guideline Central, with printing and distribution support by Abbott. For more information about this educational resource, please visit Guideline Central.
REFERENCES
1. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States. Accessed March 22, 2022. https://www.cdc.gov/diabetes/data/statistics-report/index.html.
2. Armstrong DG, Mills JL, Molina M, Molnar JA. Nutrition Interventions in Adults With Diabetic Foot Ulcers. Guideline Central. October 21, 2021. Accessed January 28, 2022. https://www.guidelinecentral.com/guideline/502765/.
3. Armstrong DG, Hanft JR, Driver VR, et al. Effect of oral nutritional supplementation on wound healing in diabetic foot ulcers: a prospective randomized controlled trial. Diabet Med. 2014;31(9):1069-1077. doi:10.1111/dme.12509
4. Moman RN, Gupta N, Varacallo M. Physiology, Albumin. StatPearls; 2022. https://www.ncbi.nlm.nih.gov/books/NBK459198/
5. Rac-Albu M, Iliuta L, Guberna SM, Sinescu, C. The role of ankle-brachial index for predicting peripheral arterial disease. Maedica (Bucur). 2014;9(3):295-302.
Dr Armstrong is a professor of surgery at the University of Southern California. He is the founder and co-chair of the International Diabetic Foot Conference, the largest annual international symposium on the diabetic foot in the world. He is also the founding president of the American Limb Preservation Society, an interdisciplinary medical and surgical society dedicated to eliminating preventable amputation in the United States and worldwide.
The opinions and statements expressed herein are specific to the respective author and not necessarily those of Wound Management & Prevention or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.
