Nutrients and social determinants of health in wound care management
Practitioners should consider an integrated strategy of wound healing, said James Carter, Jr., MD, FACC, RPVI, IFMCP, at the 2021 Institute for Functional Medicine Annual International Conference held virtually June 3-5.
A wound is a cutaneous lesion related to a traumatic or surgical event. An ulcer is a cutaneous lesion related to an underlying chronic disease or comorbidity. A non-healing wound or ulcer shows no improvement in four weeks or has not healed in eight weeks.
This matters for patients because non-healing wounds are common, debilitating, and expensive, Carter said. They cause significant negative impact on function and wellbeing, as well as an increase in morbidity and mortality.
Wound healing occurs in four stages, Carter said, which include hemostasis within minutes, inflammation within three days, proliferation within three to 12 days, and remodeling within three days to six months. Progression through the phases is dependent upon intact immune and inflammatory pathway that respond to tissue injury, supplanting homeostasis.
Supporting patients successfully through these stages must consider the gut microbiome, social determinants of health, and nutrients, Carter said.
Immune cells are important to a healthy sequence of events leading to healing wounds, Carter said. Gut-associated lymphoid tissue (GALT) is a major site of immune initiation. He said this is not thought about enough when discussing proper wound healing support.
Resolution of the inflammatory is also required for optimal wound healing, Carter said. Anti-inflammatory molecules include those found in foods with essential fatty acids arachidonic acid—which includes anti-inflammatory molecules lipoxins—as well as eicosatetraenoic acid (EPA) and docosahexaenoic acid (DHA)—which include anti-inflammatory molecules e-series and d-series resolvins, protectins, and maresins. Practitioners must assess the balance between pro-inflammatory and anti-inflammatory factors to tip the scales towards metabolic homeostasis versus metabolic stress, he said.
A basic approach to wound care includes local assessment of the wound and periwound skin, followed by a systems-thinking, comprehensive evaluation. Carter said he incorporates the SPIN-IT approach to comprehensive wound care:
This approach also incorporates breath, movement, self-love, connection, forgiveness, and giving.
Carter said practitioners need to look beyond the wound and focus on the patient’s story. The functional medicine molecule includes listing antecedents, triggering events, and mediators and perpetuators in retelling the patient’s story. In organizing the patient’s clinical imbalances, practitioners should consider mental, emotional, and spiritual factors within assimilation, structural integrity, communication, transport, biotransformation and elimination, energy, and defense and repair. Modifiable personal lifestyle factors should include sleep and relaxation, exercise and movement, nutrition, stress, and relationships.
Nutrition can play a critical role in wound healing, he said, as food is central to function, protection, repair, and recovery. Foods should support cellular mechanisms, including endothelial, mitochondrial function, endoplasmic reticulum physiology, epigenetics, and enzymatic support, as well as immunomodulation and inflammatory balance, gut permeability and microbiome health, detoxification, structural integrity of bone and muscle, adrenal and thyroid support, sleep and mood, and neural pathways and pain thresholds.
Additionally, Carter said practitioners may be able to nutritionally manipulate cellular systems to enhance wound healing, with prebiotics and probiotics, phytonutrients, vitamins and minerals, omega-3 and omega-6 fatty acids, amino acids, and protein.
An individual’s microbiota is unique, Carter said. The gut microbiome essential functions are xenobiotic metabolism or detoxification, production and metabolism of food components, and regulation of physiologic mechanisms. Dramatic short-term changes can occur, as gut microbes can regulate their gene expression in response to diet changes.
Beyond nutrition, Carter said practitioners must consider social determinants of health when working with patients, including socioeconomic position, culture, language, safety and security, access and allocation of resources, biases, inequities, and racism, navigation, mental health, living environment, shelter, social support, and toxic or stressful exposures.
With specific healing and recovery-focused dietary interventions, practitioners can use food to support inflammatory resolution, healing, repair, and recovery of function.”
“Eat the rainbow, and help patients understand it’s enjoyable and that food tastes good,” Carter said. “It’s about restoring the joy of living.”
Editor's note: This article is part of our live coverage of the 2021 Institute for Functional Medicine Annual International Conference. Click here for a list of full coverage.