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Nutritional Support for Wound Healing

Nutritional Support for Wound Healing



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Published by Tracy
Describes the proper nutrition required for wound healing. Details the four phases and nutritional requirements to ensure each phase is completed successfully.
Describes the proper nutrition required for wound healing. Details the four phases and nutritional requirements to ensure each phase is completed successfully.

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Published by: Tracy on Feb 19, 2009
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Alternative Medicine Review
Volume 8, Number 4
Page 359
Wound Healing
AbstractHealing of wounds, whether from accidentalinjury or surgical intervention, involves theactivity of an intricate network of blood cells,tissue types, cytokines, and growth factors.This results in increased cellular activity, whichcauses an intensified metabolic demand fornutrients. Nutritional deficiencies can impedewound healing, and several nutritional factorsrequired for wound repair may improve healingtime and wound outcome. Vitamin A is requiredfor epithelial and bone formation, cellulardifferentiation, and immune function. VitaminC is necessary for collagen formation, properimmune function, and as a tissue antioxidant.Vitamin E is the major lipid-soluble antioxidantin the skin; however, the effect of vitamin E onsurgical wounds is inconclusive. Bromelainreduces edema, bruising, pain, and healingtime following trauma and surgical procedures.Glucosamine appears to be the rate-limitingsubstrate for hyaluronic acid production in thewound. Adequate dietary protein is absolutelyessential for proper wound healing, and tissuelevels of the amino acids arginine andglutamine may influence wound repair andimmune function. The botanical medicines
Centella asiatica 
Aloe vera 
have been usedfor decades, both topically and internally, toenhance wound repair, and scientific studiesare now beginning to validate efficacy andexplore mechanisms of action for thesebotanicals. To promote wound healing in theshortest time possible, with minimal pain,discomfort, and scarring to the patient, it isimportant to explore nutritional and botanicalinfluences on wound outcome.(
Altern Med Rev 
Nutritional Supportfor Wound Healing
Douglas MacKay, ND,and Alan L. Miller, NDIntroduction
Wound healing involves a complex seriesof interactions between different cell types,cytokine mediators, and the extracellular matrix.The phases of normal wound healing include he-mostasis, inflammation, proliferation, and remod-eling. Each phase of wound healing is distinct,although the wound healing process is continu-ous, with each phase overlapping the next. Be-cause successful wound healing requires adequateblood and nutrients to be supplied to the site of damage, the overall health and nutritional statusof the patient influences the outcome of the dam-aged tissue. Some wound care experts advocate aholistic approach for wound patients that consid-ers coexisting physical and psychological factors,including nutritional status and disease states suchas diabetes, cancer, and arthritis. Keast and Orsted
wittily state, “Best practice requires the assess-ment of the whole patient, not just the hole in thepatient. All possible contributing factors must beexplored.”Wound repair must occur in a physiologicenvironment conducive to tissue repair and regen-eration. However, several clinically significantfactors are known to impede wound healing, in-cluding hypoxia, infection, tumors, metabolic dis-orders such as diabetes mellitus, the presence of debris and necrotic tissue, certain medications, and
Douglas J. MacKay, ND – Technical Advisor, ThorneResearch, Inc; Senior Editor,
Alternative Medicine Review 
;private practice, Sandpoint, ID.Correspondence address: Thorne Research, PO Box 25,Dover, ID 83825 E-mail: duffy@thorne.comAlan L. Miller, ND – Technical Advisor, Thorne Research,Inc; Senior Editor,
Alternative Medicine Review 
.Correspondence address: Thorne Research, PO Box 25,Dover, ID 83825 E-mail: alanm@thorne.com
Page 360
Alternative Medicine Review
Volume 8, Number 4
Wound Healing
a diet deficient in protein, vitamins, or minerals.In addition, increased metabolic demands aremade by the inflammation and cellular activity inthe healing wound, which may require increasedprotein or amino acids, vitamins, and minerals.
The objective in wound management isto heal the wound in the shortest time possible,with minimal pain, discomfort, and scarring to thepatient. At the site of wound closure a flexible andfine scar with high tensile strength is desired.Understanding the healing process and nutritionalinfluences on wound outcome is critical to suc-cessful management of wound patients. Research-ers who have explored the complex dynamics of tissue repair have identified several nutritionalcofactors involved in tissue regeneration, includ-ing vitamins A, C, and E, zinc, arginine, glutamine,and glucosamine. Botanical extracts from
Centella asiatica,
and the enzyme brome-lain from pineapple have also been shown to im-prove healing time and wound outcome. Eclectictherapies, including topical application of honey,sugar, sugar paste, or Calendula succus to openwounds, and comfrey poultices and hydrotherapyto closed wounds are still in use today. Althoughanecdotal reports support the efficacy of theseeclectic therapies, scientific evidence is lacking.
The Four Phases of Wound Healing
Tissue injury initiates a response that firstclears the wound of devitalized tissue and foreignmaterial, setting the stage for subsequent tissuehealing and regeneration. The initial vascular re-sponse involves a brief and transient period of vasoconstriction and hemostasis. A 5-10 minuteperiod of intense vasoconstriction is followed byactive vasodilation accompanied by an increasein capillary permeability. Platelets aggregatedwithin a fibrin clot secrete a variety of growth fac-tors and cytokines that set the stage for an orderlyseries of events leading to tissue repair.The second phase of wound healing, theinflammatory phase, presents itself as erythema,swelling, and warmth, and is often associated withpain. The inflammatory response increasesvascular permeability, resulting in migration of neutrophils and monocytes into the surroundingtissue. The neutrophils engulf debris andmicroorganisms, providing the first line of defenseagainst infection. Neutrophil migration ceasesafter the first few days post-injury if the wound isnot contaminated. If this acute inflammatory phasepersists, due to wound hypoxia, infection,nutritional deficiencies, medication use, or otherfactors related to the patient’s immune response,it can interfere with the late inflammatory phase.
In the late inflammatory phase, monocytesconverted in the tissue to macrophages, which di-gest and kill bacterial pathogens, scavenge tissuedebris and destroy remaining neutrophils. Mac-rophages begin the transition from wound inflam-mation to wound repair by secreting a variety of chemotactic and growth factors that stimulate cellmigration, proliferation, and formation of the tis-sue matrix.The subsequent proliferative phase isdominated by the formation of granulation tissueand epithelialization. Its duration is dependent onthe size of the wound. Chemotactic and growthfactors released from platelets and macrophagesstimulate the migration and activation of woundfibroblasts that produce a variety of substancesessential to wound repair, including glycosami-noglycans (mainly hyaluronic acid, chondroitin-4-sulfate, dermatan sulfate, and heparan sulfate)and collagen.
These form an amorphous, gel-likeconnective tissue matrix necessary for cell migra-tion.New capillary growth must accompanythe advancing fibroblasts into the wound to pro-vide metabolic needs. Collagen synthesis andcross-linkage is responsible for vascular integrityand strength of new capillary beds. Impropercross-linkage of collagen fibers has been respon-sible for nonspecific post-operative bleeding inpatients with normal coagulation parameters.
Early in the proliferation phase fibroblast activityis limited to cellular replication and migration.Around the third day after wounding the growingmass of fibroblast cells begin to synthesize andsecrete measurable amounts of collagen. Collagenlevels rise continually for approximately threeweeks. The amount of collagen secreted duringthis period determines the tensile strength of thewound.
Alternative Medicine Review
Volume 8, Number 4
Page 361
Wound Healing
The final phase of wound healing iswound remodeling, including a reorganization of new collagen fibers, forming a more organized lat-tice structure that progressively continues to in-crease wound tensile strength. The remodelingprocess continues up to two years, achieving 40-70 percent of the strength of undamaged tissue atfour weeks.
Figure 1 summarizes the phases of woundhealing and nutrients that impact the variousphases.
 Figure 1.
 Nutrient Impacts on the Phases of Wound Healing
Calendula succus – topical antimicrobial
Drugs, herbs, vitamins, amino acids, or minerals that effect blood-clottingmechanisms should be avoided prior to surgery.
Inflammatory Phase
Vitamin A – enhances early inflammatory phaseBromelain and adequate protein intake – prevent prolonging inflammatory phaseVitamin C – enhances neutrophil migration and lymphocyte transformation
Proliferative Phase
Vitamin C – necessary for collagen synthesisCentella asiatica – promotes type-1 collagen synthesisGlucosamine – enhances hyaluronic acid productionVitamin A – promotes epithelial cell differentiationZinc – required for DNA synthesis, cell division, and protein synthesisCalendula succus and Aloe vera – support formation of granulation tissue
Protein deficiency – inhibits wound remodeling

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