Nutrition 411
The Diabetic Foot Ulcer — Can Diet Make
a Difference?
Liz Friedrich, MPH, RD, CSG, LDN; and Nancy Collins, PhD, RD, LD/N, FAPWCA
T he statistics are shocking: 25.8 million Americans, or
8.3% of the population of the US, has been diagnosed
with diabetes.1 Among the complications of the disease are
diabetic foot ulcers (DFUs), which affect as many as 20% of
patients with diabetes during their lifetime.2 DFUs can sig-
nificantly impair a patient’s quality of life, require prolonged
hospitalization, involve infection and gangrene, and may ul-
timately result in amputation.
The National Pressure Ulcer Advisory Panel (NPUAP)
has established evidence-based nutrition recommendations
for the prevention and treatment of pressure ulcers. These
guidelines focus on increasing micro- and macronutrients to
promote wound healing.3 Unfortunately, no such guidelines
exist for treating DFUs, and it is unclear if recommendations
for pressure ulcers can be extrapolated to DFUs. However, it
appears that nutrition does play an important role. A poor
diet can result in altered immune function, malnutrition, and
poor glycemic control, all of which are risk factors for poor
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healing.4,5 Achieving and maintaining a healthy body weight
can help maximize wound healing because glycemic control
can be negatively affected by obesity.6 Healthcare profession-
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als (HCPs) should encourage patients with DFUs to consume
a healthy diet that contains nutrient-dense foods. A regis-
tered dietitian (RD) skilled in medical nutrition therapy for
diabetes can assess, treat, and monitor patients with DFUs to
help them meet their complex nutritional needs.
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Immune Function and Malnutrition
Compromised immune function is one factor associated
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with nonhealing wounds; it affects wound healing in a num-
ber of ways.4 Protein-energy malnutrition is associated with
impaired immunocompetence, including depressed cell-me-
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diated immunity and phagocyte dysfunction.7 Malnutrition
also makes a person more susceptible to infection.8 Infection,
whether systemic or localized in a DFU, can have an impact
on wound healing because of the stress it places on the body.
A diet that provides adequate protein, calories, vitamins, and
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minerals can help maximize immune function.
Nutrient deficiencies can affect the complex process of
wound healing in a multitude of ways.9 Malnutrition and/or
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nutrient deficiencies can impair collagen synthesis, prolong
inflammation, decrease phagocytosis (causing dysfunction
of B and T cells), and decrease the mechanical strength of
the skin.4 Many patients with chronic skin ulcers have altered
Ms. Friedrich is President, Friedrich Nutrition Consulting, and Associate Director, Nutrition411.com. Dr. Collins is a registered dietitian based in Las Vegas, NV,
and founder and executive director of Nutrition411.com. For the past 23 years, she has served as a consultant to healthcare institutions and as a medico-legal
expert to law firms involved in healthcare litigation. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com or Ms. Friedrich at ekf@carolina.rr.com.
10 ostomy wound management® november 2013
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nutritional status; in one study, malnutrition was identified
in 62% of persons with a DFU and was a predictor of poor
outcome.10 To maximize pressure ulcer healing and meet nu-
tritional needs, the NPUAP recommends 30 to 35 calories
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per kilogram of body weight per day, 1.25 to 1.5 g of pro-
tein per kilogram body weight per day, and enough vitamins
and minerals in the daily diet to meet the Dietary Reference
Intakes for vitamins and minerals.3 Micronutrients involved
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in wound healing include vitamin A, vitamin C, magnesium,
copper, and zinc.9 Supplements of these or other nutrients
may be recommended if a deficiency is confirmed or suspect-
ed.3 The NPUAP guidelines may be a useful starting point for
treatment of the DFU but may need to be adjusted, especially
in the presence of impaired kidney function or poor glycemic
control.
Glycemic Control
High blood glucose can lead to defective white blood cell
function and render a DFU susceptible to infection.2,11 High
blood glucose also can affect the production of inflamma-
tory molecules, interfere with collagen synthesis, and change
cellular morphology.5 In a recent study at Johns Hopkins, el-
evated A1c was significantly associated with a poor wound
healing rate.12 Food choices, including the timing and car-
bohydrate content of meals and snacks, can impact glyce-
mic control. Any form of carbohydrate when eaten in excess
(including whole grains and not just simple sugars) can af-
fect blood sugars, so portion control of all carbohydrates is
important. Choosing whole grain breads and cereals instead
of refined grains will provide added fiber, vitamins, and min-
erals. HCPs can encourage patients to use portions that are
outlined by ChooseMyPlate, the US Department of Agricul-
ture (USDA) food guide available at www.choosemyplate.
gov/food-groups/. Medical nutrition therapy should include
helping patients choose appropriate carbohydrate portions
and balance food with oral medication and insulin to help
optimize glycemic control.
Weight Loss
All overweight or obese individuals who have or are at risk
for diabetes should consider weight loss as part of their treat-
ment plan.6 Studies show that moderate weight loss (5% of
body weight) is associated with decreased insulin resistance,
improved measures of glycemic and blood lipid control, and
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 Nutrition 411

reduced blood pressure.6 Unfortunately, many patients attempt to lose weight

by restricting calories and/or protein. This practice could result in impaired
wound healing because nutrient needs, particularly calories and protein, are
elevated in the presence of a wound.13
Experts don’t know the optimal mix of protein, carbohydrate, and fat in the
diet needed for successful weight loss, but low-carbohydrate diets could have a

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negative effect on health. The body needs at least 130 g of carbohydrate per day
to provide enough glucose for normal bodily functioning.6 Low-carb diets can
limit other nutrients, including dietary fiber, vitamins, and minerals. For safe
and effective weight loss for persons with a DFU, a moderate calorie restriction
combined with regular physical activity (if feasible) will usually have a posi-
tive effect. Patients can be advised to use the Dietary Guidelines for Americans

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(www.health.gov/dietaryguidelines ) (see Table 1) and ChooseMyPlate.gov for
guidance on appropriate food choices and portion sizes to help facilitate weight
loss.

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Specialized Nutrition Interventions
Oral nutrition supplements. High-protein, high-calorie, nutrient-enriched
supplements (referred to as oral nutrition supplements, or ONS) may be recom-
mended between meals if food intake doesn’t meet a patient’s needs for wound

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healing.3 ONS can help meet basic needs for weight maintenance in patients
with chronic disease and/or those who are experiencing unintended weight
loss. They provide additional calories and are a source of carbohydrate and
should be recommended in the overall context of a patient’s eating pattern and
medications. The effect of high-protein ONS on blood sugars and renal func-
tion should be evaluated frequently.
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Amino acids. Arginine and glutamine are two amino acids that have been
studied extensively for their role in wound healing. In addition, beta-hydroxy-
methylbuterate, which is a metabolite of the amino acid leucine, has been
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linked with improved wound healing and tissue regrowth. Results of studies
of ONS containing these nutrients are mixed, some showing promising bene-
fit11,14,15 and others showing little benefit.16 Currently, no evidence-based guide-
lines are available for addressing the safe use and appropriate dosage of these
supplements.3,9 However, ONS containing these ingredients are available as an
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option to promote wound healing and often are used successfully with patients
with chronic wounds.
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Practice Points
Nutrition is a critical component of the healing of DFUs, particularly as it
relates to immune function, malnutrition, glycemic control, and weight loss
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and weight maintenance. Recommendations for a healthful eating pattern

(following the Dietary Guidelines for Americans and ChooseMyPlate) should
be individualized based on protein, calorie and carbohydrate needs, blood sug-
ars, and weight. Nutrition assessment and intervention by a RD can help pa-
tients with a DFU maximize their nutritional status to promote wound healing.
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Long-term randomized trials of individual nutrients and clinically relevant

endpoints are needed to show the benefits of nutritional supplementation and
dietary interventions. Until they are available, the best evidence suggests the
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importance of screening every patient for malnutrition, estimating caloric

needs, and monitoring dietary intake of essential nutrients to ensure those
needs are met.17 n

References
1. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and
general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S.
Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.
Available at: www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed June 21, 2013.

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Nutrition 411

Table 1. Dietary guidelines for Americans: 2010 key recommendations18

• Maintain calorie balance over time to achieve and sustain a healthy weight

o Prevent and/or reduce overweight and obesity through improved eating and physical activity behaviors

o Control total calorie intake to manage body weight

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o Increase physical activity and reduce time spent in sedentary behaviors

o Maintain appropriate calorie balance during each stage of life

• Focus on consuming nutrient-rich foods and beverages

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o Increase fruit and vegetable intake

o Eat a variety of vegetables, especially dark-green, red, and orange vegetables and beans and peas

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o Consume at least half of all grains as whole grains

o Increase intake of low-fat and fat-free milk products

o
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Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans and peas, soy
products, and unsalted nuts and seeds

Increase the amount and variety of seafood consumed by choosing seafood in place of some meat and poultry

Replace protein foods that are higher in solid fats with choices that are lower in solid fats and calories and/or are
sources of oils
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o Use oils to replace solid fats where possible

o Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D, which are nutrients of concern
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in American diets. These foods include vegetables, fruits, whole grains, and milk and milk products

2. Pham HI, Rich J, Veves A. Wound healing in diabetic foot ulceration: a 12. Christman AL, Selvin E, Margolis DJ, Lazarus GS, Garza LA. Hemoglobin
review and commentary. WOUNDS. 2000;12(4):79–81. A1c is a predictor of healing rate in diabetic wounds. J Invest Dermatol.
3. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Ad- 2011:131(10):2121–2127.
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visory Panel. Prevention and treatment of pressure ulcers: clinical practice
guideline. Washington, DC: National Pressure Ulcer Advisory Panel;2009.
4. Academy of Nutrition and Dietetics Nutrition Care Manual. Available at:
www.nutritioncaremanual.org. Accessed June 21, 2013.
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13. Demling RH Nutrition, anabolism, and the wound healing process: an
overview. Eplasty. Available at: www.ncbi.nlm.nih.gov/pmc/articles/
PMC2642618/. Accessed June 21, 2013.
14. Sipahi S, Gungor O, Gunduz M, Cici M, Demirci MC, Tamer A. The ef-

5. Tsourdi E, Barthel A, Rietzsch H, Reichel A, Bornstein SR. Current as-
pects in the pathophysiology and treatment of chronic wounds in diabetes
mellitus. Available at: www.hindawi.com/journals/bmri/2013/385641/. Ac-
cessed June 10, 2013.
6. Standards of Medical Care in Diabetes 2012. Diabetes Care. 2013:36(1
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fect of oral supplementation with a combination of beta-hydrozy-beta-
methylbutyrate, arginine and glutamine on wound healing; a retrospective
analysis of diabetic haemodialysis patients. BMC Nephrol. Available at:
www.ncbi.nlm.nih.gov/pmc/articles/PMC3598478/pdf/1471-2369-14-8.
pdf. Accessed June 12, 2013.

supp1):S11–S66.
7. Litchford MD. Clinical: biochemical assessment. In: Mahan LK, Escott-
Stump S, Raymond JL (ed). Krause’s Food and the Nutrition Care Process,
13th ed. St. Louis, MO: Elsevier Saunders;2012:198.
8. Katona P, Katona-Apte J. The interaction between nutrition and infection.
Clin Infect Dis. 2008:46(10).0:1582–1588.
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15. van Anholt RD, Sobotka L, Meijer EP, Heyman H, Groen HW, Topinko-
va E, et al. Specific nutrition support accelerates pressure ulcer healing
and reduces wound care intensity in malnourished patients. Nutrition.
2010;29(9):867–872.
16. Bauer JD, Isenring E, Waterhouse M. The effectiveness of a specialized
oral nutrition supplement on outcomes in patients with chronic wounds: a

9. Stechmiller JK. Understanding the role of nutrition and wound healing.
Nutr Clin Pract. 2010;25(1):61–68.
10. Zhang S, Tang Z, Fang P, Qian HJ.0, Xu L, Ning G. Nutritional status dete-
riorates as the severity of diabetic foot ulcers increases and independently
associates with prognosis. Exp Ther Med. 2013;5(10):215–222.
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pragmatic randomized study. J Hum Nutr Diet. 2013;26(5):452–458.
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2013:16(1):39-49.
18. Dietary Guidelines for Americans 2010. Available at: www.health.gov/di-
etaryguidelines. Accessed June 24, 2013.

11. Tatti P, Barber A. The use of a specialized nutritional supplement for

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