Diabetes and Obesity: Twin Challenges for Wound Healing
- Janet S. Mackenzie, MD, ABPS, CWSP, AAGP
- November 30, 2020
Wound healing is a highly-controlled, normal biological process that occurs when skin integrity is broken. Healing can be disrupted or delayed depending on factors such as age, weight, chronic illness, immunosuppression and nutrition. These factors can ultimately cause wounds to worsen or become chronic, which impacts a patient’s quality of life and increases their risk of hospital readmission.
An important way to improve wound healing is by identifying at-risk patients and taking preventative action. Two notable and prevalent diseases to consider when assessing wound patients are obesity and diabetes. These chronic conditions increase the risk of wound development and disruptions in the healing process.
Continue reading to learn more about the challenges that diabetes and obesity present in wound healing and how healthcare providers can address them to improve their patient outcomes.
Vohra Wound Physicians is the nation’s most trusted wound care solution and is at the forefront of wound care advancement. Vohra’s methodologies facilitate superior patient outcomes, generally resulting in a 21-day improvement in healing times and an over 80% reduction in wound-related hospitalizations and complications.
Incidence of Diabetes and Obesity
Diabetes and obesity are prevalent and often devastating chronic diseases that frequently go hand in hand. Both conditions present daily challenges to patients and are risk factors for several comorbidities, including chronic wounds.
Obesity is a serious and increasingly common disease characterized by an excess of body fat. In 2018, the Centers for Disease Control and Prevention (CDC) reported that the prevalence of diabetes had reached 42.4%, a significant increase from 30% in 1999-2000. According to the World Health Organization (WHO), the worldwide obesity rate has nearly tripled since 1975. At the current rate, over 1 billion adults will be obese by 2025.
The rising number of people who are obese has caused the condition to become recognized as a public health problem. Obese patients are at increased risk for numerous health conditions, including heart disease, some cancers, arthritis, stroke and Type 2 diabetes. All of these conditions can impact wound healing, and many are preventable.
Diabetes is another critical risk factor in wound healing. The CDC estimates more than 34 million people in the U.S., or about 10% of the population, have diabetes. This includes 23.1 million who have been diagnosed and an estimated 7.2 million who are undiagnosed. In addition, an estimated 84.1 million people have prediabetes, which can also cause delayed wound healing. Type 2 diabetes patients, in particular, are at increased risk for obesity, heart disease and stroke.
How Obesity Impacts Wound Healing
In order to understand the impact of obesity on wound healing, it’s helpful to recognize the properties of adipose tissue, or fat. Adipose tissue is divided into lobules, or small lobes, that receive their blood supply from capillary beds. In obesity, there is an excess of adipose tissue. This raises the risk of vascular/venous insufficiency, which is when blood is not properly flowing to the heart. In areas with high adipocyte density, venous insufficiency increases the stiffness of the fat tissue, which restricts capillary proliferation and angiogenesis. In other words, fat tissue restricts the blood supply and limits the development and growth of small blood vessels that provide the surrounding tissue with oxygen and nutrients.
Venous insufficiency leads to symptoms such as leg or ankle swelling, pain while walking, varicose veins, and even venous ulcers, which are chronic, slow-healing wounds. In obese patients with venous ulcers or other wounds, improper blood flow can prevent the wounds from being properly oxygenated, which in turn impacts healing.
People with obesity, especially in the abdominal area, have a higher level of oxidative stress, which is an imbalance between free radicals and antioxidants. This raises levels of reactive oxygen species, which ultimately damages DNA, RNA and proteins and causes cell death, thereby impacting wound healing.
Obese people also have lower levels of the protein hormone adiponectin. In addition to impacting glucose regulation, adiponectin helps regulate wound healing through keratinocyte proliferation and migration, so decreased levels can impair perfusion and re-epithelialization of the wound. Simply put, adiponectin helps control the growth of skin cells that is vital to wound healing. Lower levels of the hormone means the body cannot appropriately adjust skin cell growth and wounds heal slowly or not at all.
Nutrition is another key component of wound healing that can be disrupted in obesity. Although many assume that obese patients consume sufficient micro and macro nutrients, they often eat a high-calorie, high-carbohydrate diet full of empty calories and suffer from nutritional deficiencies.
Many obese patients also suffer from diabetes, which can cause further challenges.
How Diabetes Impacts Wound Healing
Diabetes mellitus is a chronic disease in which insulin problems prevent glucose from being properly metabolized, leading to dangerously high blood sugar. In Type 1 diabetes, patients do not produce insulin, and in Type 2 diabetes, insulin is not properly utilized.
Research has indicated that 15% of individuals with diabetes will have a non-healing diabetic foot ulcer during their lifetime. This is a serious complication that precedes 84% of all diabetic-related lower leg amputations. In addition to diabetic foot ulcers, Type 1 and Type 2 diabetics may experience impaired wound healing due to several factors, including:
Immune System Function – High glucose levels trigger an inflammatory response that can slow healing. Diabetic inflammation also influences the concentrations of MicroRNA present in body fluids. This plays a pivotal role in skin development.
Hypoxia – Oxygen is vital to the wound healing process. Diabetics often experience vascular disruption or insufficiency leading to hypoxia, or improper oxygenation. This may weaken skin integrity and delay wound healing.
Neuropathy – Diabetics have decreased neuropeptides, which are immunoregulatory signaling molecules that play a part in the process of cell division necessary for wound healing. Neuropeptides are also part of the bidirectional connection between the immune system and nervous system, so they can impact immune response.
Impaired angiogenesis – Vascular endothelial growth factor (VEGF) is a critical mediator in the production of new blood vessels in wound healing. In diabetes there is an increased expression of VEGF leading to improper angiogenic response.
Fibroblast and epidermal cell dysfunction – Those who are obese and/or diabetic may experience micro- and macronutrient deficiencies. Wound healing requires adequate protein, glutamine, vitamin C, vitamin A and oxygen, all of which impact fibroblast activity. They are crucial to breaking down fibrin clots, creating structures to support cell growth and contracting the wound.
High levels of matrix metalloproteases (MMP) – MMP can degrade the extracellular matrix. Levels of MMP in chronic wound fluid of people with diabetes is nearly 60 times higher than in acute wounds. This can lead to degradation of growth factors necessary for wound healing.
Reactive oxygen species (ROS) – In normal healing, ROS levels are balanced. In hypoxic states, such as diabetes, ROS levels rise far beyond any beneficial effect, triggering added damage.
Advanced glycation end products – In a hyperglycemic environment, the formation of advanced glycation end products triggers the formation of disorganized collagen fibrils. This reduces the elasticity of the skin and scar thickness.
Promoting Wound Healing in Patients with Both Conditions
People suffering from diabetes and those suffering from obesity both face challenges in wound healing, but this can be further aggravated when the conditions are co-morbid. According to Harvard Medical School, approximately one-third of overweight people have Type 2 diabetes and 85% of diabetics are overweight. As a result, healthcare providers administering wound treatment must take preventative measures in these at-risk patients.
Wound assessment and tracking are vital to supporting health and reducing the potential for infection, gangrene or limb amputation, particularly in those with diabetes or obesity. Here are some ways to promote wound healing in obese and diabetic patients:
Monitor and control blood sugar to improve cellular response
Encourage physical activity where reasonable. Physical activity has demonstrated the ability to help speed healing in chronic wounds in an animal model
Take precautions against physical injuries
Reduce local pressure on bony areas to avoid pressure ulcers. This can be done through mobilization and repositioning.
Ensure that patients maintain a balanced diet and adequate nutrition. If needed, consult a dietician or nutritionist and provide supplements.
Ensure adequate hydration and fluid intake until urine is a light straw color
Advise between seven to eight hours of quality sleep
Early recognition of breaks in skin integrity and prompt corrective action are important first steps in preventing the development of chronic wounds, especially in those with diabetes or obesity.
Vohra Wound Physicians, the nation’s most trusted wound care solution, is dedicated to reducing rehospitalization rates at scale. Founded in 2000, the physician-led company works with nearly 3,000 skilled nursing facilities, educates thousands of clinicians each year, and uses proven, proprietary technologies to provide superior wound healing to patients at healthcare facilities and their homes.
