Effects of Nutrition Supplementation and Education on Wound Healing in Patients with Diabetic Foot Ulcer

Background and Significance: Diabetic foot ulcer (DFU) is one of the most devastating side effects of diabetes. It occurs in a diabetic patient as a result of neuropathy and or peripheral arterial disease of the lower limb. DFU has been categorized as a chronic wound and is a common cause of lower limb amputation in diabetic patients. Faster wound healing in DFU patients will have a significant impact on patients' quality of life and will reduce the associated economic burden. There are several factors that can affect wound healing including patients’ dietary intake, blood flow to the wound area, blood glucose, inflammation/infection, and body composition. Evidence has shown that the majority of DFU patients are suffering from undernutrition or malnutrition. Lack of dietary intake of essential nutrients have negative effects on wound healing including increasing healing time and enhancing susceptibility to infection which both can lead to amputation and/or death. Although current studies have reported a high prevalence of malnutrition which negatively affect the healing of patients with DFU, only limited studies have evaluated the effects of comprehensive nutrition intervention including nutrition supplementation and nutrition education on wound healing in this population. To our knowledge, studies in this field have only examined the effects of supplementing similar patients with certain amino acids and a limited number of vitamins and minerals and therefore cannot be compared or contrasted with our findings in the present study. Nutrition education is a key factor in increasing patients’ knowledge and awareness about their dietary needs, though hardly has been incorporated in similar studies with supplementation. Well educated patients normally will apply their knowledge in selecting better food choices and are more successful in meeting their dietary needs in comparison with non-educated patients. Providing DFU patients with complete nutritional supplements can facilitate improving nutritional intake, and along with nutrition education can aid patients to meet their dietary needs. Therefore, the purpose of this clinical randomized trial was to evaluate the effects of complete nutrition supplementation and education on the healing of DFU. Methods: A total of 29 patients with at least one foot ulcer of grade 1 A based on the University of Texas Diabetic Wound Classification who were willing to participate in the study, and met the inclusion criteria were randomly assigned to the treatment or control group. Participants in the treatment group were provided with an energy dense, protein rich supplement that contained essential vitamins and minerals as well. They were also simultaneously educated about consuming better food sources of essential nutrients. Participants in the control group only received standard of care for wound healing from the clinic. Change in wound area was evaluated at baseline and every four weeks thereafter until complete wound closure or up to 12 weeks using PictZar® Digital Planimetry Software. Dietary intake of participants, Ankle Brachial Index (ABI), body composition, and inflammatory biomarkers were evaluated at baseline and every four weeks until complete wound closure or up to 12 weeks. Hemoglobin A1C was measured at baseline and at the end of the study using A1c Now+ test. Results: Our findings indicated that nutritional intervention had a strong positive effect on the healing rate of the DFU patients. Mean reduction of wound area in the treatment group was 6.43 mm2/week more than the control group (p= 0.01). The greatest effects of the intervention were observed in the first four weeks, which show that the treatment group healed 12.8 times faster than the control group (p= 0.01). In part, the positive effects of the intervention could be due to an increase in dietary intake of energy, protein, and essential nutrients and an improvement in inflammation status and body composition of these patients. In the present study, a reason for not being able to see a significant change in blood flow could be as a result of normal ABI of the participants at baseline (mean ABI> 0.9). We also were not able to see a significant difference on the concentrations of hemoglobin A1C between the two groups. It is important to note that in addition to our intervention the participants in both groups also received a standard of care for wound healing from the clinic. Conclusion: The findings of this study suggest that supplementation with an energy dense, protein rich formula which also include essential vitamins and minerals, along with nutrition education is beneficial in wound healing of DFU patients. This dietary intervention also was able to improve inflammation status and body composition. Faster wound healing can have positive effects on quality of life in patients with similar conditions; however, additional studies are needed to confirm our findings.