Wound management is a significant and growing health burden on the community. Delayed wound healing and wound infection place a substantial financial burden on health care systems, as a result of increasing dependency and increased hospital admissions. Chronic wounds also have a very large social and quality of life impact on individuals and carers.

Nutrition plays an essential role in wound healing and wound care practices, and nutritional support needs to be considered a fundamental part of wound management. Attending to nutrition in wound care is also cost-effective.
Poor nutrition before or during the healing process may delay healing and impair wound strength, making the wound more prone to breakdown. Neglecting the nutritional health of an individual with a wound can compromise the entire wound management process.

Chronic wounds are a large social, economic and healthcare burden in Australia, and around the world. Chronic wounds can be defined as wounds that take more than 4-6 weeks to heal. Examples of wounds that may become chronic:
• Pressure ulcers
• Post-operative wounds
• Wounds in people with diabetes
• Ulcers on legs and feet
• Venous leg ulcers
• Extended burns
• Stomas
• Amputation wounds

Risk factors
Chronic wounds may occur in any individual but are more frequent in the elderly and chronically ill. With an ageing population and a dramatically increasing prevalence of chronic disease, wound care will inevitably become an even more significant issue for health systems.

Diabetes is a predisposing factor for wounds (ulcers on legs and feet), which is a major issue considering the increasing number of people with diabetes.

It is estimated that over one million people in Australia have diabetes. It is reported that the number of people with diabetes in Australia had more than doubled between 1981 and 2001 and the trend is for ever increasing rates of diabetes. Diabetes is under-diagnosed and under-treated.

Risk factors that can impact wound healing:
• Arthritis
• Chronic liver disease
• Diabetes
• Excess alcohol intake
• Impaired self-caring
• Inadequate nutrition
• Inflammatory disease
• Older age (over 65 years)
• Polypharmacy
• Poor circulation
• Poor cognition/cognitive dysfunction
• Renal failure
• Smoking
• Vascular disease
• Weakened immune system

Nutrition in wound healing
There is a large body of evidence demonstrating the essential role of nutrition in wound healing. Without adequate nutrition healing may be impaired and prolonged. Improved nutritional status enables the body to heal wounds such as the accelerated wound healing seen with nutritional supplementation.

Wound healing is a complex process – in simple terms, it is the process of replacing injured tissue with new tissue produced by the body which demands an increased consumption of energy and particular nutrients, particularly protein and calories.

A wound causes a number of changes in the body that can affect the healing process, including changes in energy, protein, carbohydrate, fat, vitamin and mineral metabolism. When the body sustains a wound, stress hormones are released in a fight-or-flight reaction and the metabolism alters in order to supply the injured area with the nutrients it needs to heal – known as the catabolic phase. The body experiences an increased metabolic rate, loss of total body water, and increased collagen and cellular turnover. These effects can be pronounced even with a small wound.

Even in today’s society where we are fortunate to have access to a variety of nutritional foods, older people often suffer from malnutrition. In fact it has been estimated that up to 60% of older patients in hospitals are malnourished, or at risk of malnutrition. Of those in nursing homes, between 40 and 85% have malnutrition, and 20 to 60% of home care patients are malnourished. Reference for these figures?

This is an important consideration as elderly people are more likely to have slow to heal wounds and are more likely to be malnourished.

Nutrition for chronic wounds needs to be assessed on an individual basis (refer to following sections), however pressure ulcers – especially larger or multiple ulcers – and ulcers on legs in people with diabetes place high demand for nutrients on the body.

Nutritional evidence
There are a number of nutrients that play an important role in wound healing:

Protein is essential for the maintenance and repair of body tissue. Depleted protein levels will cause a decrease in collagen development, slowing the wound healing process. Adequate protein levels will help achieve optimal wound healing rates.2,26,27 Protein requirements should be calculated on an individual basis, and they should be monitored closely. This needs to happen along with the provision of calories, because if energy needs aren’t met the body will use protein for energy rather than for wound healing.26

L-Arginine is an amino acid that has several properties that enhances a number of the pathways involved in wound healing, such as its role in structural protein synthesis. As the body needs more protein during wound healing the demand for normally nonessential amino acids, such as l-arginine, becomes essential. Dietary supplementation with arginine has been shown to enhance protein metabolism, helping to decrease muscle loss, and collagen synthesis, which helps to increase the strength of the wound.1,3,16,20 In addition, l-arginine is essential for the stimulation of the nitric oxide pathway, which is in turn important for collagen deposition in wound healing.16,28,29

L-Arginine supplementation has also been shown to enhance the immune system and improve the secretion of growth hormone and insulin that are also involved in wound healing.3 People with pressure ulcers who have been treated with supplements containing arginine show a significantly improved rate of ulcer healing. L-Arginine is also effective in healing chronic ulcers in people with diabetes (ultimately helping to reduce leg amputations).