In this issue of Advances, three articles explore important nutrition topics and their relationships to wound healing. Their findings emphasize that all of our patients-and even ourselves, as providers-can use good nutrition to support skin health and prevent injury.

The first article is a secondary analysis of a randomized controlled trial examining the influence of nutrition on pressure injury outcomes among Asian nursing home residents. Dr Yap and her coinvestigators noted that Asian residents were more likely to develop pressure injuries; 6 of 97 Asian participants (6.19%) developed pressure injuries, but only 4 in the 408 (0.98%) non-Asian residents did. The risk factors for the increased incidence among Asian residents included a marginally lower body mass index, smaller meals, and a higher incidence of tub baths that may have compromised skin integrity. As part of their nutrition documentation, the authors examined five factors: the percentage of the meals consumed, number of servings, types of protein, liquid protein supplements, and snacks. A very interesting observation was that Asian participants had a higher protein intake from meat sources and less from liquid protein supplements. The authors note that this may be because most liquid protein supplements have a lactose base. They quoted a 99% incidence of lactose deficiency in Asians with only a 32% rate in non-Asians.

These findings remind us that the detailed evaluation of nutrition is complex. If meat is not fully digested, it may offer less protein to the body. Lactose-deficient individuals ingesting a lactose protein combination supplement will experience cramps, bloating, and loose stools. There is obviously a need to develop alternative liquid protein delivery carriers. Future research should examine other populations or additional high-risk variables with a more detailed dietary assessment.

Also included in this issue, an excellent systematic review by Kara Schneider and Najat Yahia, Effectiveness of Arginine Supplementation on Wound Healing in Older Adults in Acute and Chronic Settings, identified 39 RCTs and ultimately examined six articles that met the inclusion criteria. Arginine is an amino acid that is an essential building block of proteins. In addition, arginine has several other important functions as outlined in the article. The authors recommend arginine supplementation (as low as 4.5 g) in conjunction with oral nutrition supplementation because it may promote wound healing in older adult patients in acute and long-term care settings. However, the reviewed literature did not support the use of arginine supplementation alone to promote wound healing. Check the evidence in this article: will you routinely recommend or use arginine supplements?

As we all know, obesity is a major nutrition-related concern for wound care patients. Obesity is often associated with the three key risk factors of the metabolic syndrome:

* A_1c elevation, which is accompanied by an increased risk of type 2 diabetes mellitus;

* blood pressure elevation, which leads to an increased risk of stroke;

* cholesterol elevation, which is associated with heart disease.

Patients with a body mass index greater than 40 kg/m² may be candidates for bariatric surgery. In this month's CE/CME article, Andy Chu and colleagues examine the nutrition and dermatologic complications that are possible after bariatric surgery, especially when patients are nonadherent to long-term vitamin and mineral supplementation regimens. These surgeries either restrict the size of the stomach or remove portions of the stomach/intestine, often leading to malabsorption. Some surgeries combine both procedures. These operations often are associated with skin changes that may be clues to nutrition deficiencies. Malabsorption of necessary vitamins and nutrients can also simultaneously lead to delays in wound healing. Wound healers should be familiar with these nutrition deficiencies and their potential associated skin changes. Although the takeaways from this article are numerous, be sure to ask your patients about previous surgeries, including bariatric procedures.

For many in North America, the autumn season is associated with eating; in particular, these traditions include the Halloween and Thanksgiving holidays. Further, many religious traditions have holidays around this time that involve shared meals and feasting. We providers can all be ambassadors with our personal health choices and be an example for our own families as well as our patients. Be sure to review and share Canada's new 2019 food guide (https://food-guide.canada.ca) and the US Department of Agriculture's MyPlate initiative (http://www.choosemyplate.gov). These simple visual depictions can help everyone make better nutrition decisions, leading to improved skin health for all. Happy Thanksgiving, and happy healing!

Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM

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Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN

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