Nutrition Pearls: Gem Quality Information on the Latest ... · PDF file26 Healthy Skin I I...

26 Healthy Skin I www.medline.com I October 2013

FEATURE NUTRITION PEARLS

Nutrition pearls are small nuggets of information that convey some of the most important and newest information related to wound healing. The pneumonic PEARLS is easily remembered because it represents six important concepts where nutrition and wound healing intersect. PEARLS stands for:

P: ProteinE: EnergyA: Amino acidsR: RDAs/RDIsL: Laboratory dataS: Sarcopenia

ProteinProtein is important because it is the only nutrient containing nitrogen. It is responsible for the synthesis of enzymes involved in wound healing as well as collagen synthesis. Protein is needed at every step of the wound healing process. When a patient does not consume an adequate supply of protein and calories over time, the result is protein-energy malnutrition (PEM). Often this manifests itself as unintended weight loss (UWL), which is one of the reasons it is so important to monitor each patient’s body weight on a regular basis.

The question of how much protein is required each day is one that permeates the literature with both pro-protein and anti-protein camps. The Recommended Dietary Allowance (RDA) of protein according to U.S. government standards is 0.8 grams per kilogram (2.2 pounds) of ideal body weight for the adult. Those who believe the RDA is suffi cient point out that too much protein may lead to various ailments such as osteoporosis, cancer, kidney disease, and cardiovascular issues from the high saturated fat content of certain high protein meats. Those who feel the RDA is woefully

by Nancy Collins, PhD, RD, LD/N, FAPWCA

eineineineininininn

Gem Quality Information on the Latest Hot Topics in Nutrition

Nutrition Pearls:

PUB_Healthy Skin_V11 I03.indd 26PUB_Healthy Skin_V11 I03.indd 26 10/16/13 1:01 PM10/16/13 1:0

October 2013 I www.medline.com I Healthy Skin 27

most patients require supplementation. A modular protein supplement is an easy solution. Table 1 lists factors to consider when selecting a protein supplement.

EnergyEnergy is another word for calories. If a patient consumes an inadequate amount of energy over a period of time, the result is UWL. The problem with UWL is that often, the lost weight is not fat but metabolically active lean body mass.

UWL in the wound population is frequently driven by a stress response

inadequate believe that while the RDA may be suffi cient for the average sedentary adult, it is certainly not enough for optimal health and well-being in many populations. They point to athletes, elderly persons and those with sickness and infi rmities as just three groups who may require much greater amounts. Patients with chronic and nonhealing wounds are routinely given additional protein in order to promote a positive nitrogen balance. Most clinicians recommend between 1.2 and 1.5 grams per kg. For a 140- pound patient, this means consuming between 11 and 14 ounces of protein each day. In order to reach this level,

to the wound. When the body is under stress, whether physical or psychological, its fi ght-or-fl ight mechanism is amplifi ed. The initial insult leads to local and generalized infl ammation and an increase in the level of stress hormones, particularly catecholamines and cortisol. At the same time, the body experiences a decrease in the level of anabolic hormones (human growth hormone and testosterone). This hormonal imbalance leads to a catabolic state, in which the body breaks down lean body mass to release



energy to meet increased demands. Working harder and faster than usual to fi ght off the stressor and regain homeostasis causes both body temperature and metabolic rate to increase, or the hypermetabolic state. This leads to an increased demand for glucose, which may be met by gluconeogenesis or rapidly breaking down lean body mass as a means of obtaining more energy.

For these reasons it is important for a patient to meet his or her energy needs each day. There are a multitude of interventions that may be used, including provision of favorite and culturally appropriate foods, recipe modifi cation to provide more nutrient- dense foods, socialization at mealtime, proper positioning and assistance, use of oral nutrition supplements (ONS), use of appetite stimulants, and patient education emphasizing the importance of proper nutrition in wound healing.

Amino AcidsA polypeptide chain is comprised of three categories of amino acids. Indispensable amino acids (IAA), also known as essential amino acids, are not synthesized by humans and must come from the diet. Dispensable amino acids (DAA), also known as nonessential amino acids, are produced by the body in suffi cient amounts under normal, healthy conditions. Conditionally indispensable amino acids (CIAA) are


produced in suffi cient amounts by healthy individuals. However, in the presence of certain disease states or underlying physiological stress such as nonhealing wounds, supplementation often is required to achieve an adequate supply of CIAAs. Two CIAAs that are often supplemented are arginine and glutamine. Some of the latest information about amino acids explores the relationship between arginine, glutamine and leucine and a cellular protein called target of rapamycin (TOR), which is involved in the cell signaling for protein synthesis and wound healing.

TOR is protein kinase that functions as a central element in signaling pathways involved in cell growth and proliferation, as well as in pathways of protein breakdown. mTOR stands for mammalian target of rapamycin. mTOR was discovered when rapamycin was tested as a cell growth inhibitor and a potential anti-cancer agent. Amino acids are involved because arginine, glutamine and leucine all activate mTOR signaling. This is consistent with what is known about the roles of these amino acids in promoting anabolic


Medline and TheraHoney are registered trademarks of Medline Industries, Inc.

a gift from nature

Your Go-To First Step forAutolytic Wound Debridement.

No prescription needed

Compatible with silvers and surfactants*

Low pH can “jump start” stalled wounds*

100% natural, medical-grade Manuka honey

*citations available upon reque

TheraHoney® Gel and Sheet #Therahoney

medline.com/pages/therahoney



processes, such as in wound healing. Evidence is accumulating to show that when the mTOR pathway is somehow disrupted, wound healing is altered. An unplanned medical experiment fi rst demonstrated a link between the mTOR pathway and wound healing. A study by Buhaescu and associates1 showed that when transplant patients were given an anti-rejection medication, it had an unexpected adverse side effect—impaired wound healing. The drug was found to inhibit mTOR. Normal mTOR function is vital for normal wound healing. Excessive mTOR activity leads to excessive scarring, such as keloids. Inhibition or underexpression of mTOR is associated with poor wound healing. The amino acids arginine, glutamine and leucine each can activate mTOR.

RDA/RDIThe topic of vitamin and mineral supplements for patients with wounds elicits many opinions and questions because there are only vague guidelines and little grade A evidence. The recommendation offered


by most clinical practice guidelines is to provide vitamin and mineral supplements when dietary intake is poor or defi ciencies are confi rmed or suspected. The issue is further complicated when one considers that defi ciencies run the gamut from subclinical to severe. A nutrition- focused clinical exam can be utilized by a trained professional to identify symptoms of many defi ciencies. This type of thorough physical assessment combined with clinical judgment and a complete diet history can shed light on the supplementation issue. Vitamin C and zinc are perhaps the two most common individual micronutrients associated with wound healing. Vitamin C is water soluble, meaning the body does not store it so it must be supplied each day. Vitamin C is needed for the hydroxylation of proline and lysine during collagen synthesis. It is also needed for carnitine production for fatty acid metabolism and to give tensile strength to newly built collagen. Symptoms of vitamin C defi ciency may develop rapidly but reverse quickly with treatment. Some of the consequences of a vitamin C defi ciency include lack of secretion of procollagen chains, wrong amino acid sequences and increased blood cell fragility.

Zinc is needed for all enzymatic reactions and in a defi ciency state, there may be a low rate of epithelialization as well as decreased

wound healing and collagen strength. Urinary losses of zinc increase with stress and weight loss. Body stores may be depleted in patients with malnutrition, chronic diarrhea and chronic corticosteroid use. Before supplementing, consider that (above 40 mg day, excess zinc may interfere with wound healing via affecting lysyl oxidase, an enzyme involved in collagen synthesis. Excessive zinc also interferes with copper and iron absorption and metabolism. It is important to remember that there is no magic combination of supplements that will make up for generalized poor nutrition and inadequate oral intake.

Laboratory DataWhen evaluating laboratory or biochemical data, it is important to note the date on which the labs were drawn. If the labs are several months old, they may not refl ect the patient’s current situation. However, the reverse is also true. Daily labs may be too frequent to detect any true changes in nutritional status; small daily changes are often the result of hemoconcentration fl uctuations. It is also important to note if the patient had a recent blood transfusion in which case some labs may be more refl ective of the donor rather than the patient.


Versatel contact layer wound dressing is a

conformable, fl exible, translucent silicone

wound contact layer. Channels in the dressing

allow fl uid to easily transfer to an absorbent

secondary dressing.

Gentle

The silicone coating allows for gentle

adhesion and eliminates potential trauma

when removed.

©2013 Medline Industries, Inc. Versatel is a trademark and Medline is a registered trademark of Medline Industries, Inc.

Adheres Gently, Minimizes Pain

Versatel™ Wound DressingContact your Medline representative or call 1-800-MEDLINE

(1-800-633-5463) for the opportunity to try Versatel for yourself.

Conformable

Flexible, pliable design conforms to body

contours, improving patient comfort.

Fluid transfer

Designed to allow wound fl uid to easily

transfer into a secondary dressing.

Translucent

Allows easy viewing of the wound upon

application and between dressing changes.

dy

n

nges.

http://goo.gl/imosd



Historically, serum proteins— albumin, prealbumin, transferrin and retinol-binding protein—were used to measure malnutrition. C-reactive protein (CRP), total lymphocyte count and serum total cholesterol are not serum proteins but sometimes are used as indicators of malnutrition. Normal ranges for these lab tests are listed in Table 2. Despite the standard use of lab tests to help diagnose malnutrition, experts have no consensus about which, if any, biochemical markers identify malnutrition, especially in the frail, elderly population. Current thinking suggests that hepatic proteins are not indicators of nutritional status but rather indicators of morbidity and mortality and recovery from acute and chronic disease. Changes in albumin, prealbumin or transferrin should not be used to suggest changes in protein status in individuals with acute or chronic infl ammatory states.2

NUTR IT ION PEARLS

Although laboratory values taken singly or together may provide some clues to nutritional status, they probably do not provide suffi cient information to identify malnutrition or evaluate the success of nutrition interventions. The good news is that there is an effort underway to identify and document malnutrition. In 2012 the Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (ASPEN) released a joint consensus statement titled “Characteristics Recommended for the Identifi cation and Documentation of Adult Malnutrition (Undernutrition).”3

This groundbreaking article will likely change the world of adult malnutrition as we know it. The authors propose the three-pronged etiology-based defi nition of malnutrition that was adopted by the international consensus committee: starvation-

Nearly 3.6 million people in the United States have

sarcopenia, putting them at increased risk for physical

disability and frailty.4


October 2013 I www.medline.com I Healthy Skin 33

related, chronic disease-related, and acute disease or injury- related. Table 3 outlines and defi nes the proposed categories.

SarcopeniaSarcopenia often is defi ned as an age-related shift in body composition, specifi cally the loss of muscle mass. The word sarcopenia has Greek origins and literally means “poverty of fl esh.” As we age, we naturally lose muscle mass and replace it with fat—anyone over the age of 45 can tell you how the body changes. Nearly 3.6 million people in the United States have sarcopenia, putting them at increased risk for physical disability and frailty.4 People who are obese also can suffer this loss of muscle loss. In this case, we term it sarcopenic obesity. Although sarcopenia

Table 2 Normal laboratory values of selected nutrition indicatorsLab test Normal rangeAlbumin 3.5–5.0 g/dLPrealbumin 16–36 mg/dLRetinol-binding protein 2.6–7.6 mg/dLC-reactive protein <0.8 mg/dLCholesterol <200 mg/dLTransferrin 212–360 mg/dLTotal lymphocyte count ≥1,800 cubic millimeter (mm3)

Sources:Litchford ML. The Advanced Practitioner’s Guide to Nutrition and Wounds.Greensboro, NC: Case Software and Books; 2006.Pronsky ZM. Food Medication Interactions, 15th ed. Birchrunville, PA; 2008.

Table 3 Proposed Etiology-Based Defi nitions of Malnutrition1. Malnutrition in the Context of Social or Environmental Circumstances

(starvation-related malnutrition). This may be pure starvation due to fi nancial or social reasons, or could be caused by anorexia nervosa.

2. Malnutrition in the Context of Acute Illness or Injury. Examples include organ failure, pancreatic cancer, rheumatoid arthritis or sarcopenic obesity.

3. Malnutrition in the Context of Chronic Illness. Examples include major infections, burns, trauma or closed head injury.

References:1. Buhaescu I, Izzedine H, Covic A. Sirolimus—challenging current perspectives. Ther. Drug Monit.

2006;28:577-584.2. Fuhrman MP, Charney P, Mueller CM. Hepatic proteins and nutrition assessment. J Am Diet Assoc,

2004;104:1258-1264.3. White JV, Guenter P, Jensen G, Malone A, Schofi eld M. Consensus Statement of the Academy of

Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recom-mended for the Identifi cation and Documentation of Adult Malnutrition (Undernutrition). J Acad Nutr Diet. 2012;112:730-738.

4. Morley JE. Abbott Nutrition Health Institute. The 110th Abbott Nutrition Research Conference: Selected Summaries. Columbus, OH. June 23– 25, 2009.

5. Vella C, Kravitz L. Sarcopenia: The Mystery of Muscle Loss. Available at: www.unm.edu/~lkravitz/Article%20folder/sarcopenia.html. Accessed March 28, 2010.

• Form – Liquid or powder• Final volume• Nutrient density• Palatability• Ease of administration• Use in tube feedings

• Digestibility and tolerance• Source of protein – Whey – Casein – Soy – Collagen • Cost

Table 1 Considerations when selecting a modular protein supplement


Support Tissue Building Take a Powerful Step with Nutrition shown to support building tissue1

Healing from an injury is complex; many factors include nutritional status, can affect

outcomes. A balanced diet is essential for building tissue, but sometimes more is

needed. This is when Juven® can help.

REVIGOR® ARGININE GLUTAMINE

Revigor helps produce

new tissue by slowing

muscle breakdown

and enhancing protein

synthesis2

Amino Acid that

supports blood fl ow

and is a building block

for proteins3

Helps stimulate

fi broblastic collagen

production and

protein synthesis4,5

Clinically shown to

help support tissue

building1

Use under medical supervision as part of a complete, balanced diet.

References: 1. Williams JZ, et al: Ann Surg 2002;236:369-375. 2. Wilson GJ, Wilson JM, Nutr Metab (Lond) 2008;5:1. 3. Stechmiller JK et al. Nut Clin Pract 2005;20:5261. 4. Bellon G, et al: Biochem Biophys Acta 1995; 1268:311-323. 5. Karma E, et al: Comp Biochem Phisiol B Biochem Mol Biol 2001; 130:23-32.

©2013 Abbott Laboratories 88931/July 2013

+(a source of HMB)

+ =

is seen mostly in physically inactive individuals, it is also evident in individuals who remain physically active throughout their lives. This fi nding suggests that physical inactivity is not the only contributing factor to sarcopenia. Current research is fi nding that the development of sarcopenia is a multifactorial process generally attributed to three factors: motor unit restructuring, protein defi ciency, and changes in hormone concentrations.5

Stemming sarcopenia is important because patients with wounds are often also affected by a cytokine-driven stress response, which causes additional losses of lean

body mass. In combination, there may be a critical loss of lean body mass and in turn, delayed healing or chronic wounds. Interventions focus on progressive resistance exercise to turn on the body’s own anabolic drive, provision of adequate protein at each meal, and amino acid supplements. Several other therapies are currently being explored.

Putting It All TogetherYou are now in possession of six nutrition pearls. Make sure your patients consume adequate protein, energy and amino acids each day. Meet the RDAs/RDIs and monitor labs, but remember,

there is no magic vitamin supplement or laboratory test. Sarcopenia doesn’t have to be inevitable. Keep patients moving!

This article is adapted and updated from Dr. Collins’ lecture presented at the Symposium on Advanced Wound Care and printed in Ostomy Wound Management, April 2010.

NUTR IT ION PEARLS


Now Available on Medline University

Continuing Education Courses

for Dietitians

Visit www.medlineuniversity.com, follow the directions for

free registration, and choose from these courses approved

for continuing education contact hours for Registered

Dietitians (RD) and Dietetic Technician, Registered (DTR)

by the Commission on Dietetic Registration (CDR).

Dietitian Courses

• Nutrition for Wound Management

• Basics of Enteral Nutrition Support

• Combating Malnutrition in Long Term Care

• Nutrition and the MDS 3.0 for Positive Outcomes

• Person-Centered Dining

• Nutrition’s Role in Urinary Tract Infections and Hydration

• Nutritional Considerations for the Prevention and

Treatment of Clostridium diffi cile

©2013 Medline Industries, Inc. Medline and Medline University

are registered trademarks of Medline Industries, Inc./ MedlineU

Enroll for FREE at

medlineuniversity.com


Nutrition Pearls: Gem Quality Information on the Latest ... · PDF file26 Healthy Skin I I...

Documents

Transcript of Nutrition Pearls: Gem Quality Information on the Latest ... · PDF file26 Healthy Skin I I...