In the management of diabetic wounds, we must evaluate and address all of the various components necessary for appropriate wound healing in order to avoid derangements which will ultimately lead to wound chronicity. Inadequate vascular supply, the presence of infection in the wound bed, and the patient's nutritional status all factor into preventing a wound from healing.

What is your algorithm for evaluation of a patient's nutritional status?

Generally, I look at albumin, pre-albumin, and TLC. Good job on this
Ryan, as it is an important topic especially since inadequate nutrition
may occur in those we least suspect it, obese individuals. One reason
for this might be diabetic gastropathy (and other visceral motor
impairments) which can reduce absorption of nutrients.

Dr. Fitzgerald brings up a crucial point: nutrition is a critical component not only of treatment of wounds in people with diabetes, but also in preventing wounds from developing and progressing. The American Diabetes Association Standards of Care recommend that "people with pre-diabetes or diabetes should receive individualized MNT as needed to achieve treatment goals, preferably provided by a registered dietitian familiar with the components of diabetes MNT. Including an RD as an integral member of the medical treatment team is imperative to achieve optimum health for people with diabetes."

Standards of Medical Care in Diabetes 2008
Diabetes Care 31:S12-S54, 2008

Yet in my experience, nutrition assessment and intervention is often lacking, especially as a preventative tool. Developing a referral network of RDs with extensive training and background in diabetes education, and then utilizing their specific skill set on a routine basis, will improve the health and well-being of all people with diabetes. Making sure that your patients follow-up with an RD, and working together with the RD to develop a comprehensive care plan, is a win-win situation for everyone.

Lynn Grieger, RD, CDE, cPT
Health, food and fitness coach
freelance writing and public speaking
http://www.LynnGrieger.com
802-362-2810

It is very gratifying to see that an up and coming podiatric physician is recognizing the importance of nutritional status on the outcome of surgery and wound healing. As stated prealbumin is a more time sensitive indicator and is therefore a better predictor of current nutritional status than albumin levels. We may see false highs however, in patients with renal failure or with those on steroids. It was my understanding that prealbumin is a more costly test to run than serum albumin and that is one of the obstacles to practice. In addition to this lab test, an assessment by an RD would provide additional insight including changes in weight, current energy and protein intakes, appetite and other indicators of nutritional status that would be necessary to assess in order to implement treatment.

Carol Sherman, MPH, RD, LD/N, CDE
Registered Dietitian/Nutrition Therapist
Nutrition Information Resources
Boca Raton, FL

Dr.Fitzgerald raises several good points, not just about establishingand monitoring pre-albumin levels but alsothat there aremultiple factors that must be addressed to promote and advance woundhealing. Some just look at the "hole" but as Cynthia Fleck, teaches inher lectures:
TheNutrition and Wound Healing Connection and ThePressure is On: The Pressure Ulcer Dilemma,
we need tolook at the whole-the whole person. And, to promote wound healing inthese most difficult wounds, it does take a multidisciplinaryteam.
EnJOY!


Joy Pape,
RN BSN CDE WOCN CFCN
PRESENT Diabetes Contributing NursingEditor

Very good article to keep a heads up for something as important as the nutrtional status of the patient. We see the obvious, but we need to think past that and keep in mind the less than obvious. It is also good to get the additonal resource that a Nutritionist can bring to case management.

I second the comment from Dr. Rogers...Good job on this one. Andrew I. Levy, DPM