Download Vitamin supplementation: the Lingering Questions in wound Healing

Nutrition 411
Vitamin Supplementation: The Lingering
Questions in Wound Healing
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sure ulcers as yet exists for these other types of wounds.3
In the quest to achieve optimal wound care for their patients, many healthcare providers feel compelled to be as
proactive as possible, turning to vitamin and mineral supplements as the answer to a faster, more complete recovery.
Many health professionals themselves report taking vitamin
supplements and often recommend them to their patients.6
Surveyors, plaintiff attorneys, family members, and others
may inadvertently influence care because lack of interventions may be misconstrued as lack of care.
Although this notion of looking to multivitamins for
added healing support is not misguided, it is important for
health providers to be aware not only of the benefits provided, but also the possible harm these supplements may cause
and to understand the importance of obtaining an accurate
nutritional assessment of their patients. Such an assessment should include a list of comorbidities, patient history,
medications, usual food intake, and prior nutritional status.
In addition, a detailed wound history is necessary, including evaluation of any wound drainage, use of air-fluidized
mattresses, and other factors that may affect nutrition. Together, this information serves as a kind of map to help the
practitioner determine possible nutrient gaps and deficiencies and to design a nutrition care plan that will promote
effective wound healing.7
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he decision to recommend vitamin supplements to patients with wounds continues to be an open question
for wound care and nutrition experts. Studies to date have
not conclusively shown that routine multi- or individual vitamin supplementation in the absence of specific nutrient
deficiencies hastens wound healing. The issue of vitamin
supplementation is important and often discussed in the
wound care world but is not extensively researched. This
leaves many healthcare professionals to make treatment decisions based on the limited evidence they see in the available literature. In clinical situations, more often than not
practitioners must rely on expert opinion and professional
judgment as their guideline.1
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Nancy Collins, PhD, RD, LD/N, FAPWCA; and Elizabeth Eilender, MS, RD, CDN
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Evaluating Studies
Data in the available studies are difficult to evaluate for
many reasons. Some research does not include enough anthropometric information, such as patient height, weight,
and body mass index (BMI); some studies lack detailed descriptions of the type of wounds involved; and many studies
tend to categorize enteral or parenteral nutrition therapy as
single entities without detailing their specialized nutrient
profiles, making it difficult to know which nutrient combinations are responsible for any particular outcome.1
In addition, many older studies use outdated biochemical assessments, such as serum albumin and serum prealbumin. These blood values often are low because of the inflammation associated with the wound and not necessarily
because of protein depletion. In studies of pressure ulcers
specifically, it is difficult to separate the outcomes related to
nutrition status from other variables, such as topical treatments, repositioning schedule, and mobility.1
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Turning to Supplements
One thing experts know for sure is that under-nutrition is a large contributor to poor or delayed wound
healing2,3 and that adequate nutrition has been shown
to promote healing.4 To date, research evidence has been
strong enough to establish nutrition guidelines in the case
of pressure ulcers,5 but these are just one type of wound
among many, including diabetic ulcers, arterial ulcers, venous ulcers, burns, traumatic injuries, and surgical incisions. No guideline similar to what is available for pres-
Enriched and Fortified Foods
In recent years, a thorough dietary assessment has become all-the-more critical because of the trend among food
companies to add nutrients to a wide variety of foods that
do not naturally contain these compounds. This change
in food manufacturing practice has created a substantial
health issue, both for the general public and for specific
patient populations with respect to nutrient-nutrient interactions, drug-nutrient interactions, and problems with
excess intake.8
For example, many breakfast cereals are fortified with
multiple nutrients, and the public often does not take into
account the cumulative effects these foods can have on daily
nutrient intake or in combination with a multivitamin supplement.8 Therefore, any patient assessment of oral intake
must include questions about fortified food consumption,
knowledge of the nutrient information on the package, and
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
consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Elizabeth Eilender, MS, RD, CDN, is an adjunct
professor in the department of nursing at Saint Peter’s College, Jersey City, NJ, and a nutrition consultant for Senecare™, Holbrook, NY.
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Nutrition 411
status. Approximately 40% to 60% of hospitalized older
adults are either malnourished or at risk for malnutrition,
40% to 85% of nursing home residents are malnourished,
and 20% to 60% of home care patients are malnourished.3
Because deficiencies of trace elements and minerals are
common in the presence of general malnutrition — ie,
protein-energy malnutrition — clinical studies suggest
patients take a dietary supplement at doses five to 10 times
higher than the Recommended Daily Allowance (RDA)
until the nutritional imbalances resolve.3
The main micronutrients known to contribute subMalnutrition and Nutrient Repletion
stantially to the wound healing process are vitamin A,
Most patients with chronic skin ulcers also have some vitamin C, zinc, and copper.2,5,7 Vitamin A stimulates the
degree of malnutrition, which gives healthcare providers immune system, maintains mucosal and epithelial ina reasonable justification to recommend multivitamin tegrity, and increases collagen formation. Vitamin C is
supplements for the sake of normalizing micronutrient critical to fibroblast proliferation and collagen formation.
Zinc is important for the synthesis of
granulation tissue, re-epithelializaTable 1. Risk factors of select micronutrient deficiencies in adults
tion, and has anti-inflammatory and
Nutrient
Risk factors for deficiency
antimicrobial effects. Copper is imVitamin A
Fat malabsorption, as seen in short bowel
portant for the production of enzymes
syndrome, chronic diarrhea, pancreatic
involved in the cross-linking of coninsufficiency, cystic fibrosis, and celiac disease
nective tissue.2 Table 1 summarizes the
risk factors for deficiency of these key
Vitamin C
Low serum levels reported in critically ill patients,
dialysis patients, and bariatic surgery patients
nutrients. Table 2 summarizes dosage
recommendations for repletion of key
Copper
Deficiency is uncommon, but reported in
micronutrients known to be involved
patients with burns, celiac disease, gastric
surgery, and long-term enteral and parin wound healing.
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a tally of total intake of specific vitamins and minerals that
have the potential to limit the metabolism of one because
of the other, interact with medications, or reach excessive
levels in the patient. It is not uncommon for a patient in
long-term care to receive oral nutrition supplements such
as Ensure® (Abbott Nutrition, Columbus, OH) three times
daily, along with a multivitamin supplement, a zinc supplement, a vitamin C supplement, and a fortified oral diet.
When taken together, the cumulative amounts of certain
elements such as zinc may be more than expected.
Increased gastrointestinal (GI) losses and decreased GI
absorption: celiac disease, Crohn’s disease,
chronic diarrhea, short bowel syndrome, and
high-output GI fistulas. Copper supplementation
may cause zinc deficiency. Also seen in trauma,
burns, HIV, and pancreatic insufficiency
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Zinc
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enteral nutrition administration. Prolonged zinc
supplementation may cause copper deficiency
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Adapted from Doley J. Nutrition management of pressure ulcers. Nutr in Clin Prac.
2010;25(1):50–59.
Table 2: Dosage recommendations for vitamin repletion
Dietary reference
intake (DRI)
Suggested dosage for
repletion
Vitamin A
3,000 IU (males)
2,333 IU (females)
100,000 IU/day x 3 days; then
50,000 x 2 weeks IM; then
10,000–20,000 IU/day orally
for 2 months2
Vitamin C
90 mg (males)
75 mg (females)
500–1,000 mg/day in divided
doses of 250 mg each7
Copper
900 μg
2 mg/day orally x 6 months
have been used in various
deficiency etiologies2
Zinc
11 mg (males)
8 mg (females)
40 mg/day elemental zinc
x 10 days4
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Supplement Quality
Most vitamin and mineral supplements sold in the US are synthetically
produced, although some brands are
manufactured from natural ingredients
that include vegetable, animal, or mineral sources and are more expensive.
Patients often ask whether “natural”
vitamins are better than “synthetic”
ones. Purified vitamins and minerals are refined, processed products, so
no vitamin or mineral supplement is
natural, whether extracted from foods
or manufactured in a laboratory. The
resulting product is the same. For example, the vitamin C made from rose
hips is chemically identical to the vitamin C chemically synthesized from
cornstarch. Both are ascorbic acid.9
In 2007, the US Food and Drug Administration (FDA) issued new regulations, known as Good Manufacturing
Practices (GMPs), for dietary supplements, whereby supplement manufacturers are required to guarantee their
product’s identity, purity, strength,
and composition.10 However, because
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Practice Points
The jury is still out on routine vitamin supplementation for
wound healing, and this issue is not likely to be solved by researchers any time soon. Meanwhile, most clinicians agree that
supplementation to correct known or suspected deficiencies is
the proper course of action. The problem lies in correctly identifying deficiencies. To aid in this, a thorough nutrition history,
intake analysis, and nutrition-focused clinical exam should be
performed and documented in the medical record. Vitamins
are essential to many steps in wound healing, but supplementation in the face of inadequate calories, protein, and fluids accomplishes nothing. Clinicians are advised to not lose sight of
the larger picture while searching for a magic pill. n
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the FDA does not have the resources to enforce those rules,
one way to determine if a brand is likely to be a good product
is to see if it carries a US Pharmacopeia (USP) or NSF International (NSF) designation. Brands with such verification marks
indicate the manufacturer has voluntarily asked these trusted
nonprofit authorities to verify the quality, purity, and potency
of the raw ingredients or complete product.10,11
Because many factors affect a dietary supplement’s digestibility, as well as the bioavailability of its nutrients, no evidence is conclusive that one supplement is superior to another
based on the source of the ingredients12 or its form (tablet,
chewable, capsule or liquid),10 although patients may prefer
one over the other.
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nutrition 411
References
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1. Skipper A. Challenges in nutrition, pressure ulcers, and wound healing. Nutr
in Clin Prac. 2010;25(1):13–15.
2. Doley J. Nutrition management of pressure ulcers. Nutr in Clin Prac.
2010;25(1):50–59.
3. Stechmiller JK. Understanding the role of nutrition and wound healing. Nutr
in Clin Prac. 2010;25(1):61–68.
4. Wild T, Rahbarnia A, Kellner M, Sobotka L, Eberlein T. Basics in nutrition and
wound healing. Nutrition. 2010;26:862–866.
5. Dorner B, Posthauer ME, Thomas D. The Role of Nutrition in Pressure Ulcer Advisory Panel White Paper. National Pressure Ulcer Advisory Panel,
2009. Available at: www.npuap.org/Nutrition%20White%20Paper%20Website%20Version.pdf. Accessed April 13, 2012.
6. Dietitians Use and Recommend Dietary Supplements: Report of a Survey.
Available at: http://7thspace.com/headlines/407968/dietitians_use_and_
recommend_dietary_supplements. Accessed April 3, 2012.
7. Sherman AR, Barkley M. Nutrition and wound healing. J Wound Care.
2011;20(8):357–367.
8. Lichtenstein AH, Russell RM. Essential nutrients: food or supplements?
Where should the emphasis be? JAMA. 2005;294:351–358.
9. Herbs and Supplements: Nutritional Support (General). NYU Langone Medical Center. Available at: www.med.nyu.edu/content?ChunkIID=21731. Accessed April 13, 2012.
10.Collins N, Friedrich L. Multivitamin supplements — magic bullet or waste of
money? Ostomy Wound Manage. 2010;(56)5:18–24.
11.www.consumerreports.org/cro/2012/03/the-scoop-on-vitamins-and
supplements/index.htm. Accessed April 13 2012.
12.Yetley EA. Multivitamin and multimineral dietary supplements; definitions,
characterizations, bioavailability, and drug interactions. Am J Clin Nutr.
2007;85(suppl 2):69S–76S.
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