Pressure ulcers represent a major burden of sickness and significantly reduce the quality of life for people with pressure ulcers and their carers. They can be debilitating, cause pain and discomfort, and can have serious clinical consequences.
Pressure ulcers are wounds caused when an area of skin and/or the tissues below are damaged as a result of being placed under sufficient pressure to impair its blood supply. Typically they occur in a person that is immobilised, confined to a bed or a chair most of the time. As a result, they are commonly referred to as ‘bedsores’ or ‘pressure sores.’
Pressure ulcers are more likely to occur in those aged over 75 years, those who are seriously ill, have a neurological condition, impaired mobility, compromised skin and who are malnourished.
Poor nutritional status including eating problems, weight loss, low body weight, undernutrition and dehydration are associated with an increased risk for pressure ulcers. It has been reported that individuals with malnutrition/weight loss are almost 4 times more likely to develop pressure ulcers. Moreover, inadequate nutrient intake and low body weight are associated with slow and non-healing wounds. It is therefore of much interest to know whether diet or nutritional supplements can prevent the development of pressure ulcers, or help heal pressure ulcers that have already occurred.
What particular nutrients may be of importance in the prevention and treatment of pressure ulcers?
Of all the macronutrients, protein is often focused upon in the area of wound management because it is required for tissue synthesis and repair. Additionally, loss of protein through exudate (the fluid leaking from a wound) can contribute to increased protein needs. There has been a particular interest more recently in the amino acid, arginine, one of the building blocks of protein because it is suggested to have an important role in wound repair. Some studies have reported an increased rate of wound healing with arginine-rich supplementation, but currently there is inadequate evidence to endorse such supplementation in the management of pressure ulcers.
Certain micronutrients have also had specific attention for their postulated roles in wound healing, notably vitamin C and zinc.
Vitamin C has a well-known role in collagen structure formation, a key component of a healing wound. Vitamin C deficiency may cause the skin to become more fragile, and may slow down the healing process. You may recall from history lessons that one of the symptoms of scurvy, the vitamin C deficiency disease historically known as the ‘scourge of the sea’ was poor healing wounds.
There is though only poor quality evidence on the role of vitamin C supplementation in pressure sore healing. Most studies have looked at provision of multiple nutrients, and so the specific role of vitamin C is unclear. Routine administration of vitamin C is not currently recommended for prevention or treatment of pressure sores, although any deficiencies should be corrected. However, inclusion of fruit and vegetables in the diet, including good sources of vitamin C like citrus fruits and berries, green vegetables, peppers and tomatoes, is not only important for skin health, but has other health benefits.
Adequate zinc intake is necessary for healthy skin, and for critical functions within the immune system. A zinc deficiency can lead to depressed immunity and increased susceptibility to infection.
Foods that are high in zinc include red meat and poultry, shellfish, wholegrains (like brown rice, wholegrain bread, wholegrain breakfast cereals), nuts and seeds. Studies on zinc supplementation provide little robust evidence to support routine zinc supplementation for people with pressure sores. However, food sources of zinc can all be readily included in a healthy balanced menu.
Systematic review for nutrition supplementation
A 2014 Cochrane review investigated the effect of nutritional supplementation on the healing of pressure ulcers. Fourteen studies were evaluated: 7 examined mixed nutritional supplements, 3 protein supplementation, 2 zinc, and 2 vitamin C supplementation on the incidence of new ulcers, ulcer healing or changes in severity. The studies were conducted in hospitals and nursing homes, comparing nutritional supplements with a ‘standard’ diet.
The authors concluded there is currently no clear evidence of a benefit associated with nutritional interventions for either the prevention or treatment of pressure ulcers. It was however noted that this conclusion should not be interpreted as nutritional interventions having no effect on pressure ulcer healing, but more that this cannot currently be determined because the existing evidence base is limited and of low quality. Further trials of high methodological quality are necessary.
The National Institute for Health and Care Excellence (NICE) guideline on the prevention and management of pressure ulcers states that in adults whose nutritional status is adequate, nutritional supplements should not be offered specifically to prevent or treat a pressure ulcer. It recommends offering supplements to those who are found to have a nutritional deficiency, after assessment by a dietitian or other competent professional.
Hydration is also important
It should also be remembered that dehydration, as well as undernutrition, is associated with increased risk of developing pressure ulcers. Fluid is essential in promoting wound healing. Encouraging fluid intake is an important part of nutritional care management, and this does not just have to be water, but may include for example tea, coffee, juice or milk. Additionally, people with pressure ulcers may have additional requirements because of the fluid losses in the wound exudate.
Weight loss, undernutrition and dehydration are all risk factors for the development of pressure ulcers. Therefore, nutrition screening and assessment are essential to identify risk of malnutrition, including poor food/fluid intake and unintended weight loss. Do make sure that all your service users are screened to identify the risk of malnutrition and individualised nutrition care plans developed for them. Keep up the pressure on your staff to make sure this is done regularly!