Chronic wounds, such as diabetic foot ulcers and venous leg ulcers, pose a significant challenge in healthcare, particularly in the field of internal medicine. While local wound care is essential, a crucial yet often overlooked aspect is the patient’s nutritional status. Malnutrition can severely impede wound healing, leading to prolonged suffering and increased healthcare costs. This blog post explores the intricate relationship between malnutrition and wound healing, highlighting key findings and offering practical insights.

The Vicious Cycle: Malnutrition and Chronic Wounds

Wound healing is a complex process involving various stages, including inflammation, proliferation, and remodeling. Adequate nutrition is paramount for each of these phases [1]. Poor nutritional status disrupts these phases, leading to a prolonged inflammatory response, limited collagen synthesis, and an increased risk of new wound formation [1].

Malnutrition, as defined by the European Society for Clinical Nutrition and Metabolism (ESPEN), is a condition resulting from inadequate nutrient intake or absorption, leading to alterations in body composition, particularly a reduction in fat-free mass and body cell mass [2]. This, in turn, impairs both physical and mental functions, adversely affecting the treatment outcomes for underlying diseases [2].

This condition creates a vicious cycle, as chronic wounds can also exacerbate malnutrition. The presence of a wound can increase the body’s metabolic demands, leading to nutrient depletion. Additionally, chronic wounds are often associated with pain, reduced mobility, and social isolation, further contributing to poor nutritional intake [1, 3].

Key Biochemical Markers and Their Significance

Several biochemical markers are used to assess nutritional status in patients with chronic wounds. In a study conducted at the Podkarpackie Oncology Center in Brzozów, Poland, researchers examined the role of albumin, hemoglobin, C-reactive protein (CRP), and the nutritional risk index (NRI) in patients with chronic wounds [1].

Albumin: This protein is crucial for maintaining osmotic pressure in the blood and transporting various substances. Low albumin levels (hypoalbuminemia) are commonly cited as an indicator of malnutrition [1, 4]. A study found a strong correlation between lower albumin levels and larger wound areas, indicating the role of malnutrition in impeding the healing process [1].
Hemoglobin: Essential for oxygen transport, low hemoglobin levels (anemia) can impair wound healing by reducing oxygen delivery to the tissues [1, 5]. Anemia was shown to be linked to impaired wound healing, highlighting the importance of monitoring and correcting this parameter in chronic wound management [1, 5, 6].
C-Reactive Protein (CRP): Synthesized in the liver in response to inflammation, CRP is a sensitive marker of infection. Elevated CRP levels may indicate an inflammatory response that could hinder wound healing [1, 7]. In the study, CRP levels were elevated in a majority of patients, reflecting the presence of inflammation [1].
Nutritional Risk Index (NRI): The NRI is a recommended tool for assessing nutritional status and risk of malnutrition [1]. It combines data on albumin levels and current body weight. Lower NRI values indicate an increased risk of malnutrition [1].

Key Findings: Impact of Malnutrition on Chronic Wounds

The study revealed several important associations:

Wound Area and Malnutrition: Larger wound areas were significantly correlated with lower levels of albumin, hemoglobin, and NRI in both venous insufficiency and diabetic foot disease patients [1]. This finding underscores the significant impact of malnutrition on wound size and severity [1].
Exudate and Malnutrition: Higher exudate levels were associated with lower hemoglobin and albumin levels [1]. Exudate is primarily water, but contains proteins, glucose, growth factors, and other nutrients. The increased exudate loss may contribute to nutritional imbalances [1, 8].
Tissue Damage and Malnutrition: Increased tissue destruction, as assessed by scales such as NPIAP/EPUAP and Wagner, was linked to lower albumin, lower NRI, and increased CRP levels [1]. This indicates that more severe tissue damage is often accompanied by a greater risk of malnutrition and inflammation [1].

Practical Implications for Internal Medicine

These findings have several practical implications for internal medicine and wound management:

Nutritional Assessment: Routine nutritional assessment should be an integral part of the care plan for patients with chronic wounds. This assessment should include evaluating biochemical markers, body weight, dietary intake, and functional status [1, 9].
Early Intervention: Early identification and intervention for malnutrition is essential to promote wound healing. This may involve dietary counseling, oral nutritional supplements, or even enteral or parenteral nutrition in severe cases [10].
Monitoring Biochemical Markers: Regular monitoring of biochemical parameters like albumin, hemoglobin, CRP, and NRI is essential for tracking a patient’s nutritional status and adjusting treatment plans as needed [1, 7].
Multidisciplinary Approach: Collaboration between internal medicine specialists, wound care specialists, dietitians, and nurses is critical to address the complex needs of patients with chronic wounds and malnutrition [11].
Individualized Care: Treatment plans should be tailored to each patient’s unique needs, considering their overall health status, wound characteristics, and nutritional status [1].

Conclusion

Malnutrition significantly impacts wound healing in patients with chronic wounds, creating a vicious cycle that hinders recovery. Early nutritional assessment, proper monitoring of key parameters, and a multidisciplinary approach are paramount for ensuring optimal treatment outcomes. By recognizing the intricate link between malnutrition and wound healing, internal medicine specialists can play a crucial role in improving patient care and overall well-being.

To delve deeper into internal medicine and enhance your practical skills, consider exploring our below courses:

Clinical Fellowship in Internal Medicine

Certification Program in Family Medicine

International Certification Course for Primary Healthcare Physicians in Non-communicable Diseases

These programs will equip you with the knowledge and expertise that are essential for success in managing complex medical conditions.

References

[1] Skórka, M.; Bazaliński, D.; Więch, P.; Kłęk, S.; Kozieł, D.; Sierżantowicz, R. Nutritional Status in a Group of Patients with Wounds Due to Diabetic Foot Disease and Chronic Venous Insufficiency. J. Clin. Med. 2025, 14, 43.
[2] Cederholm, T.; Barazzoni, R.; Austin, P.; Ballmer, P.; Biolo, G.; Bischoff, S.C.; Compher, C.; Correia, I.; Higashiguchi, T.; Holst, M.; et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin. Nutr. 2017, 36, 49-64.
[3] Probst, S.; Gschwind, G.; Murphy, L.; Sezgin, D.; Carr, P.; McIntosh, C.; Gethin, G. Patients ‘acceptance’ of chronic wound-associated pain-A qualitative descriptive study. J. Tissue Viability 2023, 32, 455-459.
[4] Akirov, A.; Masri-Iraqi, H.; Atamna, A.; Shimon, I. Low Albumin Levels Are Associated with Mortality Risk in Hospitalized Patients. Am. J. Med. 2017, 130, 1465.e11-1465.e19.
[5] Gezawa, I.D.; Ugwu, E.T.; Ezeani, I.; Adeleye, O.; Okpe, I.; Enamino, M. Anemia in patients with diabetic foot ulcer and its impact on disease outcome among Nigerians: Results from the MEDFUN study. PLoS ONE 2019, 14, e0226226.
[6] Efteli, E. Effects of hemoglobin and albumin levels on the development of pressure injury in inpatients in intensive care clinics. MAKU J. Health Sci. Inst. 2022, 10, 71–78.
[7] Kaya, T.; Ulaş, S.B.; Nalbant, A.; Yıldırım, I.; İşsever, K.; Karacaer, C.; Bilgin, C.; Vatan, A.; Acar, T.; Acar, B.A.; et al. C-reactive protein/albumin ratio as a novel predictor for nutritional status of geriatric patients. Brain Behav. 2024, 14, e70017.
[8] Zieliński, M.; Markiewicz, S.; Gabriel, M.; Krasiński, Z. Exudate in the wound healing process. Leczenie Ran 2021, 18, 37–44.
[9] Jensen, G.L.; Cederholm, T.; Correia, M.I.T.; Gonzalez, M.C.; Fukushima, R.; Higashiguchi, T.; de Baptista, G.A.; Barazzoni, R.; Blaauw, R.; Coats, A.J.; et al. GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community. J. Parenter. Enter. Nutr. 2018, 43, 32-40.
[10] Volkert, D.; Beck, A.M.; Cederholm, T.; Cruz-Jentoft, A.; Hooper, L.; Kiesswetter, E.; Maggio, M.; Raynaud-Simon, A.; Sieber, C.; Sobotka, L.; et al. ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clin. Nutr. 2022, 41, 958–989.
[11] Pytlak, K.; Szymańska, P.; Skórka, M.; Bazaliński, D. Quality of life of patients covered by the Complex Treatment of Chronic Wounds. Pielęgniarstwo Chir. I Angiol./Surg. Vasc. Nurs. 2023, 17, 38–45.