Bedsores, also known as pressure ulcers, represent a significant health challenge, particularly for individuals with limited mobility. These injuries arise from sustained pressure on the skin, which impairs blood flow and leads to tissue damage. While medical treatment and pressure relief strategies are paramount, nutrition, especially a high-protein diet, plays a crucial role in wound healing and overall recovery.
Understanding Bedsores
Bedsores, or pressure injuries, are damages to your skin caused by staying in the same position for a long time. Bedsores occur when pressure reduces or cuts off blood flow to your skin. This lack of blood flow can cause a pressure wound injury to develop in as little as two hours. Skin cells on your epidermis (your skin’s outer layer) start to die. As the dead cells break down, a pressure ulcer injury forms.
Risk factors
People who have thinner skin and people who have limited (or no) ability to move are more likely to develop bedsores. These include people who:
- Are in a coma or a vegetative state.
- Experience paralysis.
- Use wheelchairs.
- Wear casts and splints or prosthetic devices.
Stages of Bedsores
Healthcare providers use a staging system to determine the severity of a pressure ulcer.
- Stage 1: Your skin looks red or pink, but there isn’t an open wound. It may be hard for people with darker skin to see a color change. Your provider may refer to this stage as a pressure injury. Your skin may feel tender to the touch. Or your skin might feel warmer, cooler, softer or firmer.
- Stage 2: A shallow wound with a pink or red base develops. You may see skin loss, abrasions and blisters.
- Stage 3: A noticeable wound may go into your skin’s fatty layer (the hypodermis).
- Stage 4: The wound penetrates all three layers of skin, exposing muscles, tendons and bones in your musculoskeletal system.
Complications
Bedsores increase your risk of potentially life-threatening bacterial infections like cellulitis and septicemia. You may develop sepsis or require an amputation. Worldwide, bedsores lead to the deaths of more than 24,000 people each year.
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Some people develop sinus tracts, which are passages that connect the pressure sore injury to structures deeper in your body. Depending on the sinus tract connection, you may develop:
- Bacteria in your bloodstream (bacteremia), which can lead to bacterial meningitis or endocarditis.
- Bone infections (osteomyelitis) or joint infections (septic arthritis).
- Group A streptococcus infections, ranging from cellulitis to necrotizing fasciitis (flesh-eating disease).
Fever and chills are often the first signs of an infected bedsore.
Why Protein Matters for Bedsore Healing
Your body uses protein to build and repair skin and other body tissues. Protein is an essential nutrient that plays a pivotal role in various bodily functions, including tissue repair and immune response. When bedsores develop, the body requires an increased supply of protein to rebuild damaged skin and tissues. A high-protein diet provides the necessary building blocks for this process, facilitating faster and more effective wound healing.
What Constitutes a High-Protein Diet for Wound Care?
This diet involves eating healthy protein foods throughout the day. A high-protein diet for wound care involves consuming a greater amount of protein than is typically recommended. The exact amount depends on your health condition, age, sex, and level of physical activity. It's crucial to talk with your healthcare provider or a registered dietitian nutritionist about what’s right for you.
Studies have shown that increased protein intake is associated with better healing of pressure ulcers, with a recommended daily intake of 1.25 to 1.5 g/kg of body weight. But it's important to monitor both healing rates and renal function in a person getting supplements and to adjust intake as needed, Ms. Posthauer said.
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Recommended Protein Intake
The current NPUAP/EPUAP guidelines for pressure ulcer treatment recommend offering 30-35 calories/kg of body weight/day and 1.2-1.5 grams of protein/kg of body weight/day for individuals with pressure ulcers. Based on the guidelines, an elderly individual with a stage IV pressure ulcer weighing 130 lbs. requires 1,772-2,068 calories and 74-88 grams of protein for healing.
Food Choices for a High-Protein Diet
To eat a high-protein diet for wound care, include protein at every meal and snack. Choose varied sources of protein. That helps you get a wider range of all the nutrients that protein foods provide. Some of these nutrients, such as zinc, also help promote wound healing. Following are some healthy choices for getting the protein you need.
- Fish and Shellfish: These provide not only protein, but also a heart-healthy kind of fat called omega-3 fatty acids. Aim to eat fish and shellfish at least twice a week. Choices that are higher in omega-3s include salmon, anchovies, sardines, Pacific oysters, and trout.
- Poultry: Options like chicken, turkey, and Cornish hen are good sources of protein. Remove the skin to reduce the saturated fat.
- Lean Meats: Meats such as beef, pork, veal, and lamb are often high in saturated fat, so look for the leanest options. For beef, choose Select or Choice grades, and trim off visible fat from the edges. Leaner cuts include flank, top round, sirloin, and tenderloin. Buy extra lean ground beef, if possible. For pork, leaner cuts include center loin chop or tenderloin.
- Dairy and Eggs: Dairy products and eggs provide protein, too. Pick cheeses with less saturated fat, such as reduced-fat cheeses and cottage cheese. Choose low-fat or fat-free milk and yogurt.
- Plant-Based Proteins: These provide fiber and healthy fats in addition to quality protein. Examples are beans, hummus, black-eyed peas, nuts, peanut butter, and tofu.
Zinc-Rich Foods
Zinc-rich protein foods may have additional benefits for wound healing. Oysters have particularly high zinc levels. Other sources of zinc include beef, poultry, crab, lobster, beans, nuts, and dairy products. (Zinc is also found in whole grains and fortified breakfast cereals.)
Foods to Limit or Avoid
Limit protein and dairy foods that are high in saturated fat. That includes fatty cuts of meat, whole milk, full-fat cheese, cream, and butter. Also limit processed meats, such as bacon, ham, sausage, hot dogs, and lunch meats. They are often high in both saturated fat and sodium. Don’t have fried fish or chicken. Healthier cooking methods include baking, broiling, grilling, roasting, and stir-frying.
Additional Dietary Considerations
While you are focusing on sources of protein, don’t lose sight of the other parts of your diet. It’s still important to eat vegetables, fruits, and whole grains. A varied, healthy diet provides the vitamins, minerals, and other substances you need for better overall health and healing. Round out your meals with fruits and vegetables high in vitamin C. Your body uses vitamin C to make collagen, a substance needed to help wounds heal. Sources of the vitamin include grapefruit, kiwifruit, oranges, strawberries, broccoli, green and red peppers, and tomatoes.
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Hydration: Fluids are important for all individuals especially when we are increasing the protein in the diet. Older adults' decreased sense of thirst presents an additional challenge. Offer four ounces of water or juice with each medication given and keep fresh water handy. Remember most elderly individuals cannot lift heavy mugs. An alternative to these large pitchers is an insulated 8-10 oz. covered cup. The nursing facility where I consult has a juice station on every unit that offers three types of juice. Both residents and staff have access to the juice station. In addition to the traditional beverages served, the facility also offers a variety of regular or low calorie soft drinks at mealtimes and during the hydration pass between meals. Enhancing water by adding a low calorie flavor packet can boost fluid intake. Gelatin, ice cream, fruit juice bars, sherbet and soup are favorite foods that increase the daily fluid content of the diet.
Smaller, Frequent Meals: Rather than three large meals offer several small meals during the day and be certain that each one has a good source of high quality protein. An ounce of meat, fish, or poultry is equivalent to 1/4 cup of cooked dried beans, 1/2 oz. of nuts, 1(1/4) Tbsp. of peanut or almond butter, one egg (2 egg whites), 1 oz. of cheese or 1/4 cup of cottage cheese. Aim for at least two or more ounces of protein at each meal.
Vitamin C: Round out your meals with fruits and vegetables high in vitamin C. Your body uses vitamin C to make collagen, a substance needed to help wounds heal. Sources of the vitamin include grapefruit, kiwifruit, oranges, strawberries, broccoli, green and red peppers, and tomatoes.
Practical Meal Planning Suggestions
- Breakfast: Have scrambled eggs with whole grain toast and a grapefruit half or orange.
- Lunch: Have a bowl of split-pea soup or three-bean chili (made with kidney, pinto, and black beans). Or have thin strips of lean broiled beef atop a mixed green salad.
- Snack: Spread peanut butter on apple slices, celery sticks, or whole grain crackers.
- Dinner: Have grilled chicken or fish with a medley of broccoli, carrots, red peppers, and whole grain pasta.
Tips for the Elderly
The typical older adult (over 65) doesn't consume the recommended calories or protein as defined by the Institute of Medicine which suggests adult males consume 2,080 calories and females 1,762 calories. The challenge is encouraging older adults to consume the meals. The frequent comment is "this is too much food" or "I am not hungry".
- Skim milk powder can be added to cooked cereals, scrambled eggs, cream soups, puddings, potatoes, casseroles, muffins or meat mixtures such as meat loaf or meat balls (begin with 1 Tbsp.
- Milk is a good source of protein and calcium and whole milk has 150 calories vs. 121 calories in 2%. Add whole milk and/or 1 Tbsp.
- Mix instant breakfast with whole milk vs. skim and add ice cream to boost calories and protein. Offer 4 oz.
- Make homemade milkshakes with whole milk and a variety of ice cream flavors to avoid taste fatigue.
- Peanut butter is a high quality protein that can be used in multiple ways- in sandwiches, spread on crackers, toast, or bananas, or added to pudding, muffins or shakes.
- Eggs are an excellent source of protein and are easy to digest. In addition to serving them at breakfast, make egg salad sandwiches, deviled eggs, sliced hard-boiled eggs or add them to casseroles. Many older adults like breakfast foods in the evening vs.
- Cheese is a simple food to add to salads, scrambled eggs, vegetables, casseroles, soups or serve on crackers and sandwiches. Cream of tomato soup and a grilled cheese sandwich are considered comfort foods.
- Lentils, split peas, kidney, navy and pinto beans are good sources of fiber and protein and are easy on the budget. They can be used in soups or casseroles. If you live in the mid-west or south, ham and beans, corn bread and buttermilk are considered staples.
- Yogurt is currently a popular product. Try Greek yogurt for increased protein. Substitute plain Greek yogurt for salad dressing when making sandwich spreads or add a dollop to a baked potato.
Supplementation
Enteral nutrition is an option for some individuals, but only if it is monitored carefully, Ms. Posthauer said. When considering enteral nutrition, ask the individual and family members whether they understand the risks and benefits associated with this more invasive form of feeding.
Research does not support the use of mega doses of vitamin C to enhance wound healing, but some evidence supports the use of zinc supplements if a deficiency exists in that mineral. Strive for a balanced diet and confirm a deficiency before adding any vitamin supplement, said Ms. Posthauer.
The Importance of a Multidisciplinary Approach
ARLINGTON, VA. “Please involve dietitians early on if you see people with pressure ulcers or those who are at high risk of developing pressure ulcers,” said Ms. People with pressure ulcers are in a hypermetabolic condition, she explained. More research is needed on the impact of nutrition on wound healing in obese patients, Ms. Posthauer said. Patients with stage III or IV pressure ulcers should not be on restricted diets. Patients with pressure ulcers need to eat 30-35 kilocalories per kilogram of body weight a day, she said. Ms.
- Consider the individual's favorite foods and cultural preferences.
- Offer variety.
- Offer high-calorie, high-protein supplements, using trial and error to determine which one the patient prefers.
“There needs to be a team effort in following up to see that the food is being consumed,” Ms. Posthauer emphasized.
Additional preventative measures
While nutrition alone cannot entirely prevent or heal bedsores, it plays a vital role in supporting the body's healing processes and reducing the risk of developing these painful ulcers. A well-balanced diet rich in protein, vitamins, minerals, omega-3 fatty acids, and fiber can promote wound healing, enhance immune function, and maintain overall skin health.
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