Overview of Diabetes Mellitus Diabetes is an illness in which the individual’s blood glucose level is above the established range. Glucose is present in the foods we eat. Most foods contain a blend of carbohydrates, proteins, and fats. The amount of each of these nutrients in the foods we consume determines how quickly the body transforms food into glucose. For instance, consuming carbohydrates affects blood glucose levels one to two hours after the meal. Ingesting protein has very little influence on blood glucose levels, and the glucose from the fat in foods is slowly absorbed and does not contribute to increased glucose levels.¹ Insulin is a hormone that helps glucose enter the cells to release energy. In individuals with type 1 diabetes, the body does not produce insulin.

In type 2 diabetes the body either does not make or does not use the insulin produced by the body in an efficient manner. Type 2 diabetes is the most common type of diabetes. With reduced insulin production or use, the glucose released by food stays in the bloodstream (reflected as increased glucose levels). Prediabetes is a condition in which individuals have increased blood glucose levels, but not sufficiently high levels to meet diagnostic criteria for diabetes. The presence of prediabetes increases the risk of developing type 2 diabetes.¹ In 2015, 30.3 million Americans had diabetes. Of these, only 23.1 million had been formally diagnosed. The remainder were undiagnosed. Twenty-five percent of older Americans have diabetes. Of the 7.2 million hospital discharges related to diabetes, 1.5 million involved patients who also had cardiovascular disease, five of each 1,000 had a lower extremity amputation, and 7.7 of 1,000 individuals had diabetic ketoacidosis. It is also estimated that in 2011 to 2012, 36.5% of individuals with diabetes also had chronic kidney disease. Diabetes is the seventh leading cause of death in the United States.²

Pressure Injury Overview

According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure injury is defined as follows: “A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.”³

Pressure injuries normally develop over bony prominences. These include the elbows, heels ankles, buttocks, shoulder blades, spine, greater trochanters, among others. Individuals with decreased sensation, impaired blood flow, and limited mobility (bedridden or in wheelchairs) are at increased risk for developing pressure injuries. The neuropathy and poor circulation seen in patients with diabetes make the presence of this condition a risk factor for developing pressure injuries. As a rule, individuals with reduced sensation may not be aware of the constant pressure on their tissues, thus reducing their attentiveness to shifting positions. The constant pressure reduces blood flow (circulation) to the tissue and results in decreased tissue perfusion and atrophy. Impaired blood flow also contributes to decreased nutrient delivery to the site. This change increases the risk for tissue injury. Individuals unable to turn and position themselves independently are especially vulnerable to develop pressure injuries.³ For existing pressure injuries, diabetes can impact the rate of healing. As previously mentioned, narrowing of the blood vessels contributes to decreased flow of blood and oxygen to a wound. High glucose levels can impair the function of red blood cells that carry nutrients to the tissue. Without adequate nutrients and oxygen, a wound heals slowly.⁴

Nutrition Care for Patients with Diabetes and Pressure Injuries

Managing the nutritional status of individuals with diabetes and pressure injuries to promote adequate nutrient consumption and stable blood glucose levels is important in promoting wound healing. Encouraging individuals to consume a healthy diet and maintaining a balanced nutritional status can help to modulate blood glucose levels and provide sufficient vitamins and minerals to support the healing process.⁵

The consumption of adequate protein, carbohydrates, fluids, vitamins, and minerals is a vital aspect of promoting wound healing. The NPUAP pressure injury prevention and treatment guidelines encourage the provision of individualized energy intake based on underlying medical condition and level of activity for individuals at risk for or with actual pressure injures. The guidelines support providing sufficient calories (30–35 calories per kilogram of body weight), protein (1.25–1.5 g protein per kilogram of body weight), and fluids (30 mL per kilogram of body weight), as well as good sources of vitamins and minerals.⁶

Determining what to eat can be the most challenging part of daily self-management for people with diabetes. The American Diabetes Association (ADA) has long held that there is no “one size fits all” approach to nutrition therapy for individuals with diabetes. The ADA goals for providing nutrition therapy for individuals with diabetes include promoting adhering to healthful eating patterns and emphasizing a variety of nutrient-dense foods in appropriate portion sizes to improve overall health and specifically to⁵:

• Achieve and maintain body weight goals
• Attain individualized glycemic, blood pressure, and lipid goals
• Delay or prevent complications of diabetes

There is no single ideal dietary distribution of calories among carbohydrates, protein, and fats for individuals with diabetes. Therefore, macronutrient distribution should be individualized while maintaining total calorie and metabolic goals in mind. As appropriate, individuals with pressure injuries and diabetes should be referred to the registered dietitian or nutritionist to provide medical nutrition therapy.⁵

Implications for Practice

Providing nutrition therapy to individuals with pressure injuries in the presence of other comorbidities can be a challenge. Not only can the presence of diabetes be a risk factor for developing pressure injuries, but also uncontrolled blood glucose levels can interfere with wound healing. The good news is that the nutrition care guidelines for these medical conditions seem to complement each other, thus making the development of a patient-centered healthful eating pattern less complex. With appropriate nutritional interventions, it is possible to obtain metabolic homeostasis that promotes wound healing. A meal pattern high in protein with an adequate amount of calories can be a good starting point. A consistent meal pattern with similar nutritional composition can be healthful by controlling blood glucose levels and promoting wound healing. Meal patterns should be customized to meet the individual’s regular eating pattern.

References

1. National Institute of Diabetes and Digestive and Kidney Diseases. Managing Diabetes. 2016. https://www.niddk.nih.gov/health-information/diabetes/overview/managing…. Accessed June 27, 2018.

2. Centers for Disease Control and Prevention, US Department of Health and Human Services. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-sta…. Accessed June 27, 2018.

3. National Pressure Ulcer Advisory Panel. NPUAP Pressure Injury Stages. National Pressure Ulcer Advisory Panel website. 2014. http://www.npuap.org/resources/educational-and-clinical-resources/npuap…. Accessed June 27, 2018.

4. Chauhan VS GS, Kumar P, Srivastava S, Shukla VK. . The prevalence of pressure ulcers in hospitalised patients in a university hospital in India. J Wound Care. Wound Cre. 2005;14(1):36-37. https://www.magonlinelibrary.com/doi/abs/10.12968/jowc.2005.14.1.26724. Accessed June 27, 2018.

5. American Diabetes Association. Standards of Medical Care in Diabetes-2018 Abridged for Primary Care Providers. Clin Diabetes 2018. 2018;36(1):14-37. http://clinical.diabetesjournals.org/content/36/1/14. Accessed June27, 2019.

6. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Pressure Ulcer Treatment: Quick Reference Guide. 2014. https://www.npuap.org/wp-content/uploads/2014/08/Updated-10-16-14-Quick…. Accessed June 27, 2018.

About the Author

Dr. Nancy Munoz is the Assistant Chief for Nutrition and Food Service for the Southern Nevada VA Healthcare System. Teaching healthcare practitioners the role of nutrition as a modifiable risk in the development of pressure ulcers is at the core of her practice. Dr. Munoz has authored and served as expert reviewer for books and manuscripts for numerous professional publications, and the Academy of Nutrition Evidence Analysis Library. She currently serves as the Professional Development Chair for the Dietetics in Healthcare Communities DPG, is a member of the Academy’s Positions Committe and the WoundSource editorial advisory board, and is the current Vice President for the National Pressure Ulcer Advisory Panel.