Why Protein is Important for Healing Wounds

By Bruce E. Ruben, M.D., Medical Director of Encompass HealthCare

and Wound Medicine, West Bloomfield, MI
Keywords: Bruce Ruben, Nutritional Assessment, Nutritional
Management, Pressure Ulcers, Protein, Wound Healing
A day doesn't go by that I'm not bombarded with information on the
newest diet, the latest exercise trend or the fastest way to get in
shape. My email inbox opens with message subjects like "click here to
drop 10 pounds fast" or "how to get a Kardashian body without
surgery." I overhear women at a local breakfast haunt order egg whites
instead of whole eggs, because they contain less fat and they are
worried about gaining weight. How about the latest craze of ordering
sandwiches wrapped in lettuce because everyone is afraid of the
dreaded carbohydrates? Our culture is so focused on losing weight,
getting in shape, and looking like the latest model on the cover of
Vogue or GQ that we have lost sight of what is healthy.
Yet on the other extreme, I see adults and children who are so
overweight that the word "obesity" now applies to children at an
alarming rate. In fact, the percentage of children aged 6-11 years in
the United States who were obese increased from 7% in 1980 to nearly
18% in 2012. Similarly, the percentage of adolescents aged 12-19
years who were obese increased from 5% to nearly 21% over the same
period.1 Children's clothing stores have adopted the newer label "plus
sizes," replacing its predecessor "husky." Sadly, these plus sizes
currently comprise 50% of store inventory.2 Medically speaking, it is a
well-known fact that childhood obesity is causing type 2 diabetes.3
So we have the two extremes: the population that strives to be thin
and buff and the population that overeats and overindulges.
But what if I told you that many of the patients that I see in my office
each day have non-healing wounds because they don't eat enough?
And what if I told you that these patients don't know that they aren't
11 http://www.cdc.gov/healthyschools/obesity/facts.htm
22 http://www.babble.com/mom/plus-sized-clothing-for-toddlers/
33 http://www.nytimes.com/2012/04/30/health/research/obesity-andtype-2-diabetes-cases-take-toll-on-children.html?_r=1

eating enough to heal their wounds? (And neither do their primary care
doctors!) And to complicate matters further, what if you knew that the
breakdown of protein, carbohydrates and fat must be in certain
proportions in order to get their non-healing wound to heal, despite
other medical treatments that they may needeven if they are
consuming upwards of 4,000 calories per day from foods like donuts,
cookies, and cake?
Why Protein is Important for Healing Wounds
page two, by Bruce E. Ruben, M.D., Medical Director of Encompass
HealthCare and Wound Medicine, West Bloomfield, MI

Supporting Wound Healing Through Nutrition

It is important to understand that proteins are the building blocks for
your body while carbohydrates and fats are primarily used for energy.
Think of it like this: the protein is the framing structure, just like wood
is the framing structure for a house. Your body is supported by the
underlying wood framing, (i.e. the protein.) A diet with too many carbs
and fats and not enough protein is like a house with really fancy bricks
overlaying a straw foundation. (Think about "The Three Little Pigs.")

Figure 1 Good Protein Sources

Carbohydrates and fats, however, are very important because they are
used for energy. They support the energy requirement for protein to do

its job in total, the work of living. In fact all three make up the
nutritional profile needed for healthy living. The recommended diet
ratio for an otherwise healthy person is 20% protein, 55%
carbohydrates, and 25% fat. The general rule of thumb here is to
consume approximately .5 grams of protein per 1 kg of weight. So
someone who weighs 45 kg (or 99 pounds) needs about 23 grams of
protein per day which equates to roughly 3-4 ounces, the size of a
small chicken breast.

Why Protein is Important for Healing Wounds

page three, by Bruce E. Ruben, M.D., Medical Director of Encompass
HealthCare and Wound Medicine, West Bloomfield, MI

However, when someone has a non-healing wound like a pressure

ulcer, that person needs to eat three times the amount of protein in
order to keep up with the body's demands. In this example, the body is
in a constant state of effort in trying to heal the wound, even though
it's not visible from the outside. It's as if your body is
running a race, all day long, trying so hard to recruit all of the
necessary biochemical protein-based processes such as collagen
formation, oxygen delivery, etc., that are needed in order to heal the
wound.
Without enough protein, the body gets "confused" and chooses,
instead, to break down nutritional protein first, and then the body's
structural protein (i.e. muscle) to meet the energy demands to
preserve the most vital organs for life which are the heart and the
brain. Patients in these states are considered "protein energy
malnourished" and are in a catabolic state: their protein is used for
energy vs. the normal anabolic state where protein is used for
structure and function.
Protein Intake and the Nutritional Status of Patients with
Wounds
Without this knowledge, patients with serious wounds continue their
ordinary, every day eating habits, never stopping to think about their
diet because this critical information may be widely ignored by medical
doctors at large. In fact, most people who start down the wound
healing path first see their primary physician. Often, they are not

assessed properly for their nutritional status because, for example,

they may look overweight. Unless they are nutritionally assessed with
either an indirect calorimeter or through a carefully calculated process,
there is really no way of knowing if their nutrition is supporting the
wound healing process. So an obese patient with a non-healing wound
who isn't eating enough protein unknowingly starts using protein for
energy instead of carbs and fat. He might look well-nourished from the
outside, but that person's wound will never heal due to his ongoing
catabolic state.
Furthermore, additional nutrition is needed in patients with other
comorbidities such as bone infections, and/or increased activity level,
sometimes exceeding what most people can eat. In these instances, a
feeding tube might be necessary for nutritional support, usually
administered at bedtime.

Why Protein is Important for Healing Wounds

page four, by Bruce E. Ruben, M.D., Medical Director of Encompass
HealthCare and Wound Medicine, West Bloomfield, MI

One thing is clear: nutrition is an often-missed piece of the woundhealing puzzle and no number of wound healing techniques such as
hyperbaric oxygen therapy, IV antibiotics, vascular corrections for
venous insufficiency, or even offloading will help that patient heal his
wound until his body is working and functioning correctly. To go back to
the house metaphor, adequate wood has to be readily available to
frame a strongly grounded house.
So, it's important to know the role that protein plays in wound healing
for populations of patients who suffer from pressure ulcers and other
non-healing wounds and it's equally important to seek out a
professional wound medicine physician if all other efforts are failing.
Last, adequate hydration is as critical to life itself as it is to wound
healing. Your body contains 60-70% water by weight, more water than
any other component. Regulating body temperature, transporting
nutrients, and waste removal are just a few of water's critical functions.
The work of healing also consumes additional water beyond water loss
in breath, sweat, urination and defecation. No less than 2.5-3.5 liters

per day are recommended in healthy circumstances but that may need
to be doubled in a serious wound healing situation.
The lesson here is clear: once we all challenge the social pressure of
looking like Twiggy or bravely delve into our probable, underlying,
psychological reasons for overeating, what's left is basic nutrition:
nutrition that applies to healthy individuals and nutrition that is
specialized for patients with non-healing wounds.
About the Author
Dr. Bruce Ruben is the Founder and Medical Director of Encompass
HealthCare and Wound Medicine, located in West Bloomfield, Michigan.
Encompass Healthcare is an outpatient facility featuring advanced
wound care, IV antibiotic therapies, hyperbaric oxygen treatment,
nutritional assessment, and other treatment modalities. Dr. Ruben is
board certified in Internal Medicine, Infectious Disease, and in
Undersea and Hyperbaric Medicine. He is a member of the Medical and
Scientific Advisory Committee and National Spinal Cord Injury
Association (NSCIA) board, an advisory board member of
WoundSource, and serves on the board of The Emily Stillman
Foundation.