New Guidelines For Addressing Nutrition Deficits In People With DFUs

28. January 2022
Jeff Hall, Senior Contributing Editor

Current estimates show that 37.3 million people, or 11.3 percent of the United States population, have diabetes.1 More than one-third of these patients will develop a diabetic foot ulcer (DFU) and recently published guidelines suggest that more than half of these patients have moderate or severe malnutrition.2

Recognizing the dearth of randomized controlled trials that specifically look at nutrition in people with DFUs as well as the challenges with nutrition adherence in this patient population, the authors of the new guidelines have emphasized practical screening and assessment tools, including key tips for physical exams, patient history and lab testing workups. The guidelines also provide an overview of dietary factors and nutrients, ranging from hydration and calorie intake to recommended protein requirements and glycemic targets, that impact one’s ability to heal a wound.

David G. Armstrong, DPM, MD, PhD, says many, if not most, of his patients with DFUs have some form of nutritional deficit. He adds this is particularly the case for patients with tissue loss as they are likely to have a protein deficit. Dr. Armstrong, a coauthor of the guidelines, says registered dietitians play an important role in the multidisciplinary care of this patient population.

“Nutrition isn’t the first thing you think about when visiting a limb preservation program or a wound healing unit, but it really is crucial,” maintains Dr. Armstrong, the President of the American Limb Preservation Society (ALPS) and a Professor of Surgery at the Keck School of Medicine at the University of Southern California (USC).

“We have had a number of patients who came in initially with hyperinflammatory states and really painful wounds. We found that just by getting them, over several months, optimized nutritionally, this played, by itself, a significant role in mitigating profound inflammation and helping some of these wounds move on to healing.”

Maritza Molina, RDN, a coauthor of the guidelines, notes that it is common for patients with DFUs and peripheral arterial disease (PAD) to fall short of meeting their calorie and protein needs. These patients also tend to have micronutrient deficiencies including vitamin D, vitamin B12, iron and zinc deficiencies, according to Molina, an Outpatient Clinical Dietitian at the Keck Medical Center of USC. She notes that some patients may not have safe access to food and many of these patients need a specialized or modified diet.

There is a section in the guidelines that notes the importance of empowering, positive language in discussing diabetes. In her experience, Molina says there are keys to getting patients to open up about their disease. First, it is important to assess the patient’s knowledge of diabetes. Molina notes this helps determine the level of diabetes education you can provide.

Molina emphasizes being mindful of the patient’s cultural differences, language, and level of education that may affect his or her dietary decisions. When speaking to a patient about diabetes and the importance of nutrition, Molina encourages clinicians to ask patients to repeat what has been covered with them to ensure their understanding. Molina adds that creating a comfortable atmosphere for the patient conversation can elicit more details to the point where the patient is sharing his or her challenges.

“In this way, the nutrition intervention can be a lot more catered towards patient needs,” maintains Molina.

She notes there is no one size fits all tool for assessing nutritional deficits and encourages the use of multiple tools, including food frequency questionnaires, 24-hour recalls and weight history. Molina adds there is a lack of use of the nutrition focused physical exam (NFPE).

“The NFPE has been around for a long time, however many clinicians do not use it, possibly due to the allotted time they may have with every patient,” suggests Molina. “However, it is definitely an essential tool to determine the level of nutrition intervention a patient may need.”

Molina recalls one case involving a malnourished patient with a chronic DFU who was unable to heal due to uncontrolled blood sugar. He lacked knowledge of the diabetes diet and the importance of glycemic control. Molina notes the patient was underweight, had poor food intake and needed a modified diet due to dysphagia. In addition to patient education on the importance of proper diet and glycemic control, the patient was placed on a dysphagia diabetes diet, according to Molina. With the establishment of nutrition goals and follow-up visits, the patient “was able to slowly gain weight, improve his blood sugar and improve wound healing at a faster rate than before,” notes Molina.


1. Centers for Disease Control and Prevention. Estimates of diabetes and its burden in the United States. National Diabetes Statistics Report. Available at: . Accessed on January 28, 2022.

2. Armstrong DG, Mills JL, Molina M, Molnar JA. Nutrition interventions in adults with diabetic foot ulcers. Guideline Central. Available at: . Published October 21, 2021. Accessed January 28, 2022.

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