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Wound Healing & Nutrition
Wound care is a multidisciplinary specialty working in conjunction to achieve successful wound closure. Suboptimal nutrition can alter immune function, collagen synthesis, and wound tensile strength, all of which are essential in the wound healing process. The progression of normal wound healing consists of phases that can vary in length, (inflammatory phase;  the proliferative phase; the remodeling phase). Given the prolonged potential for the wound healing process, nutrition should be considered in wound prevention, and wound preparation,  as well as in the treatment of acute and chronic wounds. Nutrition must provide adequate support for an increased energy demand during the wound healing (30-35 kcal/kg, or up to 40 kcal/kg), but may be individualized based on patient status. 
In wound healing, inadequate protein stores result in increased skin fragility, decreased immune function with poor healing, and decreased reserve capacity with longer recuperation after illness. Carbohydrates stimulate insulin production, which is helpful in the anabolic processes of wound healing, particularly during the proliferative phase. However, hyperglycemia can reduce granulocyte function and increase infectious complications. Adequate fat intake in the patient with an acute or chronic wound can supply additional energy to the wound healing process, as well as structural functions including axonal myelination and lipid bilayers in cell and organelle membranes during tissue growth. 
The presence of a wound increases protein demand by up to 250% and caloric demand by up to 50% to maintain adequate LBM stores. Arginine is a conditionally essential amino acid, normally synthesized in the kidney and liver from citrulline. Supplementation of arginine may be required in patients with sepsis, trauma, and wounds. Arginine is a precursor for nitric oxide, which is essential in the inflammatory process of wound healing, but it is also used in the production of collagen. Arginine is also a precursor of proline, which is necessary for the synthesis of collagen. Additionally, arginine supplementation was observed to increase lymphocyte mitogenesis. Supplementation of arginine with pressure wounds or stasis wounds was 4.5 g/day, but this can only be followed in the setting of adequate protein intake. Glutamine decreases infectious complications and protects against inflammatory injury by inducing the expression of heat shock proteins. It is a precursor for glutathione, an antioxidant necessary for stabilization of cell membranes, transporting amino acids across membranes, and a cofactor for enzymatic reactions. The data supports evaluating the patients’ nutritional status and ensuring sufficient calories from a balanced diet of carbohydrates, fats, and protein, and supplementing protein, fluid, and vitamins A and C as needed.