Nutrition 411: Vitamin Supplementation: The Lingering Questions in Wound Healing
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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
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 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.
Malnutrition and Nutrient Repletion
Most patients with chronic skin ulcers also have some degree of malnutrition, which gives healthcare providers a reasonable justification to recommend multivitamin supplements for the sake of normalizing micronutrient 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 substantially to the wound healing process are vitamin A, vitamin C, zinc, and copper.2,5,7 Vitamin A stimulates the immune system, maintains mucosal and epithelial integrity, and increases collagen formation. Vitamin C is critical to fibroblast proliferation and collagen formation. Zinc is important for the synthesis of granulation tissue, re-epithelialization, and has anti-inflammatory and antimicrobial effects. Copper is important for the production of enzymes involved in the cross-linking of connective tissue.2 Table 1 summarizes the risk factors for deficiency of these key nutrients.