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MEDICAL NUTRITION THERAPY

FOR MORBIDLY OBESE


PATIENTS
WITH INCREASED NEEDS
SECONDARY TO DIABETIC
WOUNDS

S a m antha
Ko ter w as
Th e U nive rsity
of M ar yland ,
C olle g e Pa rk
D iete tic Int ern

OUTLINE
Overview of Condition
Meet the Patient
Nutritional Considerations
Nutritional Assessment and Therapy
Conclusions and Summary

OVERVIEW OF THE
CONDITION

DIABETIC WOUNDS
Uncontrolled diabetes can lead to serious
complications, commonly including neuropathy
High blood sugar interferes with the ability of nerves to
transmit signals, and also weakens the walls of capillaries
that supply nerves with oxygen and nutrients

Diabetic neuropathy causes:


Poor circulation, making it harder to fi ght infection and heal
Lessened ability to feel pain, allowing ulcers to become out
of control

Diabetic wounds most often occur in patients


extremities
Over half of foot and leg amputations in the U.S. are due to
diabetes

DIABETIC WOUND CARE

E duc a t ion
Emphasizing patient responsibility for their own health
Blo od su ga r c on trol
Keeping blood glucose values <220 mg/dL
Wo und de br idem e n t
Frequent debridement to improve wound healing time
Adv a nc ed dressin gs
Using dressings that promote moisture balance, protease
sequestration, growth factor stimulation, antimicrobial activity and
oxygen permeability
Surger y
Utilizing vascular foot surgery to improve blood fl ow before
amputation is necessary

2015 NIH
Strategies

MEET THE PATIENT:


MP

GENERAL INFORMATION
MP is a 62 year old Caucasian male
BMI: 42.31
Seen outpatient at the wound clinic PTA
Patient was already scheduled to have a transmetatarsal
foot amputation 9/23 at Meritus

Dx hypoglycemia, right ischemic foot and sepsis


Pt c/o weakness, shakiness, and lethargy

MP was admitted on 9/22, and was discharged on


10/15 after 24 days of hospitalization

PATIENT HISTORY AND PHYSICAL

Social/Family History

Patient lives at home with


his wife
Patient is very limited in
motility; mostly bed
ridden
Both Father (77) and
Mother (48) died from
heart attacks

Physical Examination:

Medical History

Morbid obesity
Poorly controlled type 2
diabetes
Atrial fibrillation
Diabetic polyneuropathy
Peripheral vascular
disease
Dyslipidemia
HTN
End-stage renal disease
Peritoneal dialysis
Gangrene

Surgical History

Left BKA in 2005


Finger surgery
PD catheter
Drainage of scrotal
abscess due to gangrene

No change in weight or appetite, generalized fatigue


Last HgbA1C in August 2015: 6.3
Right forefoot gangrene with surrounding edema, erythema, foul smell

NUTRITIONAL HISTORY
Diet History
Patient denies change in appetite or weight change PTA
MP is completely cared for by his wife, who states she does
not follow a diabetic or renal diet at home
Have been educated multiple times at outpatient visits,
patient is followed by a dietitian at the Dialysis center at
least on a monthly basis

Physical Activity
Patient is very limited in motility
During hospitalization, patient was no ambulatory

Past Nutrition Therapy


Last admission was November 2011
Renal diet, average PO intake 100%

NUTRITIONAL HISTORY
Weight History
Weight fl uctuations r/t to multiple amputation
procedures, fl uid accumulation, and fl uid removal
procedures.

WOUND DOCUMENTATION
Arterial ulcers of the toes of the right foot with dry
gangrene of the right forefoot. These have now
coalesced into one large mummifi es wound extending
to involve 4 or 5 of the toes
Open wound, right lower extremity, venous ulcer
Stage 3 pressure ulcer, left BKA amputation stump
Traumatic wound, right index and middle fi nger
Non-healing surgical wound in the abdomen
History of multiple traumatic wounds, stage 4
pressure ulcers, Fourniers gangrene

HIGHLIGHTS FROM HOSPITAL STAY


9 / 2 3 Pa t i e n t i s t r a n s f e rre d t o t h e O R f o r r i g h t t r a n s m e t a t a r s a l
amputation to try and salvage the leg. Initial Nutrition Assessment
completed
9 / 2 5 Pa t i e n t t r a n s i t i o n e d f ro m Pe r i t o n e a l D i a l y s i s t o H e m o d i a l y s i s ,
Pe rm a C a t h w a s p l a c e d . Pa t i e n t w a s s e e n b y R D f o r f o l l o w - u p
9 / 2 9 Pa t i e n t i s s t a b l e f o r d i s c h a rg e , o u t p a t i e n t H D p l a c e m e n t n e e d e d
p r i o r t o d i s c h a rg e . H P i s s e e n b y R D f o r f o l l o w u p .
1 0 / 1 Wo u n d M D c o n s u l t e d f o r r i g h t h e e l u l c e r a n d r i g h t h a n d n e c ro t i c
digits.
1 0 / 5 Wo u n d s u g g e s t s a m p u t a t i o n o f r i g h t l o w e r ex t re m i t y , n o c h a n g e s
to be done clinically with right hand digits. MP is seen by RD.
1 0 / 7 Pa t i e n t t r a n s f e rre d t o O R f o r R i g h t B KA
1 0 / 1 2 Pa t i e n t s e e n b y R D f o r f o l l o w u p

NUTRITIONAL
CONSIDERATIONS

NUTRITION AND DIABETIC WOUNDS


90% of people living with type 2 diabetes are
overweight or obese
According to protocol, a patient with diabetes and
obesity alone calls for a carbohydrate and calorie
restricted diet
However, it is important for the RD to always pay
close attention to wound documentation that may
alter diet recommendations
Wounds depending on stage and type can
substantially increase calorie and protein needs, even
in a morbidly obese patient

PROTEIN & DIABETIC WOUNDS


Protein is essential to promote positive nitrogen
balance
Importance of arginine, cysteine, and glutamine,
which are conditionally essential amino acids, has
emerged over the past decade
When determining protein needs in a wound patient

Signs of catabolism
Dietary History to determine typical protein intake
Weight history to determine unintended weight loss
Laboratory values to identify catabolism and infl ammation
Losses through Dialysis

CARBOHYDRATES & DIABETIC


WOUNDS
It is important to manage blood sugar control with
diet to optimize wound healing
Specifi c recommendations include
distributing carbohydrates evenly throughout the day
emphasizing complex carbohydrates as the preferred source
discussing appropriate snacking throughout the day

Emerging research: FOX01


A transcription factor which modulates expression of genes
involved in wound healing
A recent article in the Journal of Cell Biology reported that
in mice that the FOXO1 protein enhances wound healing,
but FOXO1 protein decreases wound healing in obese
diabetic mice with elevated blood sugars

NUTRITION
ASSESSMENT AND
THERAPY

NUTRITION DIAGNOSIS

Increased nutrient needs r/t altered skin


integrity and to promote anabolism e/b
pressure ulcers, gangrene to right foot,
infectious process, and dialysis

NUTRITION PRESCRIPTION
Using ABW of 247#
Energy: 2600-3120 kcals (25-30 kcal/kg)
Protein: 156-177 grams (1.5-1.7 gm/kg)
Fluid: Per MD

CCD-high
NAS
4oz Nepro Supplements BID
Double portions of protein with trays

NUTRITION INTERVENTION
1 . C o l l a b o r a t i o n w i t h o t h e r c a re p ro v i d e r s ( RC - 1 . 3 )
D i s c u s s w i t h M D i n c re a s e d n u t r i e n t n e e d , c h a n g e d i e t o rd e r f ro m Re n a l t o
CCD-high, NAS
N u r s i n g i s a w a re t h a t P O i n t a ke a n d w e i g h t s h o u l d b e m o n i t o re d c l o s e l y
Goal: Diet is changed in 24 hours
2 . P ro t e i n - m o d i fi e d d i e t ( N D - 1 . 2 . 3 )
A d d d o u b l e p o r t i o n s o f p ro t e i n ( m e a t , fi s h , a n d e g g ) t o p a t i e n t s t r a y s t o
e n s u re a d e q u a t e p ro t e i n i n t a ke
G o a l : D i e t m o d i fi c a t i o n a d d e d i n 2 4 h o u r s
3. Supplements (ND-3.1)
S e n d 4 o z N e p ro s u p p l e m e n t B I D t o e n s u re a d e q u a t e p ro t e i n i n t a ke
G o a l : Pa t i e n t c o n s u m e s > 5 0 % o f s u p p l e m e n t s
4. Survival Information (E-1.3)
S p e a k w i t h p a t i e n t re g a r d i n g t h e n e e d f o r a h i g h c a l o r i e , h i g h p ro t e i n d i e t f o r
wound healing
G o a l : Pa t i e n t s P O i n t a ke i m p ro v e s t o > 7 5 %

MONITORING AND EVALUTATION

Indicator

Criteria

Adequate Nutrition Therapy

Calorie and protein provided


through the diet ordered meet
patients estimated needs

Food Intake

Intake of trays >75%

Supplement Intake

Intake of supplements >50%

DIET AND PO INTAKE

CONCLUSIONS

KEY POINTS
For obese patients, it is imperative to recognize
situations when a patient requires additional nutrition
support
May be provided through modifying meal trays, adding scheduled
snacks, or ordering supplements.

Nutrition is imperative in wound healing


Increased protein needs depending on stage, type, and size

For Wound healing, it is important to keep blood glucose


values <220 mg/dL
Carbohydrate-controlled diet and education

THANK YOU

REFERENCES
( 1 ) L i p s ky B A , B e re n d t A , D e e r y H G , e t a l . , f o r t h e I n f e c t i o u s D i s e a s e s S o c i e t y o f
A m e r i c a . D i a g n o s i s a n d t re a t m e n t o f d i a b e t i c f o o t i n f e c t i o n s . C l i n I n f e c t D i s . 2 0 0 4 ;
39(7):885-910.
( 2 ) Ta n g , Yu n a n , e t a l . " P ro re s o l u t i o n t h e r a p y f o r t h e t re a t m e n t o f d e l a y e d h e a l i n g
of diabetic wounds."Diabetes2013; 62.2: 618-627.

( 3 ) Po s t h a u e r , M a r y E l l e n . " T h e ro l e o f n u t r i t i o n i n w o u n d c a re . " A d v a n c e s i n S k i n
& Wound Care 2012;25.2: 62-63.

( 4 ) C o l l i n s , N a n c y , a n d A . S c h n i t z e r. " H o w d i e t a r y p ro t e i n i n t a ke p ro m o t e s w o u n d
healing."Wound Care Advisor 2013;2.6: 16-19.

( 5 ) Ya z d a n p a n a h , L e i l a , M o r t e z a N a s i r i , a n d S a r a A d a r v i s h i . " L i t e r a t u re re v i e w o n
t h e m a n a g e m e n t o f d i a b e t i c f o o t u l c e r. " W o r l d J o u r n a l o f D i a b e t e s 6 . 1 ( 2 0 1 5 ) : 3 7 .
( 6 ) Z h a n g , C h e n y i n g , e t a l . " F OXO 1 d i ff e re n t i a l l y re g u l a t e s b o t h n o r m a l a n d
diabetic wound healing."The Journal of Cell Biology209.2 (2015): 289-303.
( 7 ) C o l l i n s , N a n c y , a n d C . S l o a n . " D i a b e t i c Wo u n d H e a l i n g T h ro u g h N u t r i t i o n a n d
G l y c e m i c C o n t ro l . " To d a y s W o u n d C l i n i c 7 . 2 ( 2 0 1 3 ) .