February 11, 2015
Annals of Internal Medicine
TAKE-HOME MESSAGE
- The authors of this randomized, controlled trial involved 200 malnourished patients in long-term care who had pressure ulcers. Participants in the intervention arm were given nutritional supplements, which were energy-dense, protein-rich, and enriched with arginine, zinc, and antioxidants for 8 weeks. The control group received an equal volume of an isocaloric, isonitrogenous formula. Results showed a greater reduction in pressure ulcer area in the intervention group and a more frequent reduction in area of ≥40% at 8 weeks. No difference was seen in rates of complete healing, incidence of wound infections, or total number of dressings at 8 weeks.
- Pressure ulcer healing in malnourished patients is better after supplementation with a formula enriched with arginine, zinc, and antioxidants.
Primary Care
Written by David Rakel MD, FAAFP
Nutrients to speed pressure ulcer healing
In malnourished patients with grade 2–4 pressure ulcers, a nutritional supplement that contained higher amounts of the nutrients (listed below) with more fat resulted in an 18.7% improvement in wound healing at 8 weeks compared with the healing in the study patients taking the control formula. The authors speculate that there is likely a beneficial synergistic effect among nutrients since prior research with isolated nutrients (vitamin C, zinc) has not shown benefit. No prior studies have been performed with isolated arginine.
Nutrient differences in study formula vs control formula
- Arginine: 6 g
- Zinc: 18 mg
- Selenium: 128 µg
- Vitamin C: 500 mg
- Vitamin E (alpha tocopherol): 76 µg
- More fat
- Arginine and vitamin C both enhance collagen and fibroblast formation. Arginine also stimulates nitric oxide (the supplement equivalent of Viagra), which enhances blood circulation. Zinc supports DNA synthesis, immune function, and cellular proliferation. The antioxidant effect of these nutrients also helps to reduce free radical–induced inflammation.
Surprisingly, this was not an industry-sponsored study. Grant support came from a university in Italy and used a product called Cubitan, which came in 200-mL bottles containing 20 g of protein and 250 kcal. The participants drank a 200-mL bottle twice daily for 8 weeks or until wounds were healed.
Since there was likely a synergistic effect of nutrients, eating whole food is the best way to provide an environment for ideal synergistic nutrient absorption. Therefore, I have included a list of “wound-healing super foods” that include the nutrients that this study found to be most helpful.
Super foods for wound healing
- Spinach (arginine, zinc, vitamin C, and vitamin E)
- Sunflower seeds and nuts (arginine, zinc, selenium, vitamin E)
- Broccoli (vitamins C and E)
- Shrimp (arginine, selenium, vitamin E)
- Fats (olive oil, fish oil)
Abstract
BACKGROUND
Trials on specific nutritional supplements for the treatment of pressure ulcers (PUs) have been small, inconsistent in their formulations, or unsuccessful in controlling for total supplement calorie or protein content.
OBJECTIVE
To evaluate whether supplementation with arginine, zinc, and antioxidants within a high-calorie, high-protein formula improves PU healing.
DESIGN
Multicenter, randomized, controlled, blinded trial. (ClinicalTrials.gov: NCT01107197).
SETTING
Long-term care and home care services.
PATIENTS
200 adult malnourished patients with stage II, III, and IV PUs.
INTERVENTIONS
An energy-dense, protein-rich oral formula enriched with arginine, zinc, and antioxidants (400 mL/d) or an equal volume of an isocaloric, isonitrogenous formula for 8 weeks.
MEASUREMENTS
The primary end point was the percentage of change in PU area at 8 weeks. Secondary end points included complete healing, reduction in the PU area of 40% or greater, incidence of wound infections, the total number of dressings at 8 weeks, and the percentage of change in area at 4 weeks.
RESULTS
Supplementation with the enriched formula (n = 101) resulted in a greater reduction in PU area (mean reduction, 60.9% [95% CI, 54.3% to 67.5%]) than with the control formula (n = 99) (45.2% [CI, 38.4% to 52.0%]) (adjusted mean difference, 18.7% [CI, 5.7% to 31.8%]; P = 0.017). A more frequent reduction in area of 40% or greater at 8 weeks was also seen (odds ratio, 1.98 [CI, 1.12 to 3.48]; P = 0.018). No difference was found in terms of the other secondary end points.
LIMITATION
Participation was restricted to patients who were malnourished, were able to drink oral supplements, and were living in long-term care institutions or receiving home care services.
CONCLUSION
Among malnourished patients with PU, 8 weeks of supplementation with an oral nutritional formula enriched with arginine, zinc, and antioxidants improved PU healing.