You are what you eat - so, when the body is recovering from an injury, what nutrients does it need to be healthy again? National Nutrition Month® is a campaign created by the Academy of Nutrition and Dietetics, focusing on the importance of making informed food choices and developing sound eating and physical activity habits. To celebrate this month of education and insight, we’re focusing on the proper nutritional decisions that enable the body to fight trauma and recover from injury properly. Whether it be wound care, post-injury healing or everyday soreness from exercise, here are some evidence-based perspectives to help you guide your athletes, your patients or yourself through the landscape of nutritional choices throughout the healing process.

While you might not view wound care as an energy-draining process, the body actually demands an increased amount of energy so the wound can heal correctly. While the nutritional needs of patients will vary based on age, comorbidities, body weight, activity level, stage of the healing process and the severity, size and number of wounds, experts recommend caloric intake start at 30-35 kcal per kg of body weight.1

These experts also recommend focusing on the correct micro and macronutrients that are critical to maintain appropriate levels of energy to support the entire healing process.

Carbohydrates: In the proliferative phase of wound healing, carbohydrates stimulate insulin production, which is helpful in the anabolic processes.1

Fats: Substantial fat consumption supplies additional energy to the wound healing process, as well as structural functions during tissue growth. “Dietary fats can produce ATP via beta-oxidation, thereby addressing other energy-requiring processes to spare protein for wound healing.”1

Protein: Because protein plays a fundamental part in each stage of wound healing, wounds increase the body’s demand for protein by up to 250%. “Protein supplies are essential to collagen synthesis, angiogenesis, fibroblast proliferation, immune function, tissue remodeling, wound contraction, and skin structural proteins. One key role of protein is the maintenance of oncotic pressure, particularly in venous insufficiency wounds, where excess extraluminal pressure due to peripheral edema will exacerbate wound formation and slow wound healing.”1

Fluids: Fluid maintains skin turgor and promotes tissue perfusion and oxygenation during the wound healing process. The goal for fluid intake in patients with wounds is approximately 1 ml per kcal each day.1

Arginine: The amino acid arginine plays a diverse role in wound healing. “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 supplementation was observed to increase collagen deposition in wounds.”1

Glutamine: Glutamine, another amino acid, decreases infectious complications and protects against inflammatory injury by inducing the expression of heat shock proteins. “It increases insulin sensitivity and serves as an energy source by production of nicotinamide adenine dinucleotide phosphate or by breakdown to glutamate and alpha-ketoglutarate to be used in the Krebs cycle. Additionally, glutamine appears to have a role in leukocyte apoptosis, superoxide production, antigen processing, and phagocytosis, all with implications on the inflammatory phase of wound healing.”1

Vitamine A: Vitamin A assists in wound closure. Topically-applied vitamin A has been used to stimulate epithelial growth, fibroblasts, and ground substance. “It has also been shown to have an anti-inflammatory effect in open wounds, increasing the number of monocytes and macrophages at the wound site early in the inflammatory phase and facilitating epithelial cell differentiation.”1

Vitamin C: Vitamin C is believed to influence collagen formation, immunomodulation and antioxidant functions during wound healing.1

Vitamin D: Vitamin D induces the antimicrobial peptide cathelicidin to promote healing. “Researchers concluded that vitamin D and its receptor signaling regulates structural integrity and transport functions of epithelial barriers with implications for wound healing.”1

Zinc: More than 200 zinc-containing enzymes, including superoxide dismutase, are involved in wound healing. “They function as antioxidants and modulate cell replication, nucleic acid metabolism, tissue repair, and growth. However, excess zinc supplementation can interfere with the absorption of other cations, specifically iron and copper. Therefore, supplementation should be avoided unless deficiency is present.”1

After suffering a musculoskeletal injury, the proper nutritional support can help the body regain optimal fuel for rehabilitation. Barb Hoogenboom, EdD, PT, SCS, ATC, suggests, “Rehab professionals should value the knowledge and contributions of registered dietitian nutritionists (RDN's). Networking and collaboration with a RDN can be used to optimize the post-injury/post-operative healing environment, physiologically prepare the athlete for rehab sessions, and maximize rehabilitation efforts.” Recently, Katie Knappenberger, MS, RD, CSSD, ATC published a complete guide through the National Athletic Trainers Association (NATA) to help clinicians navigate the unique nutritional needs of an athlete on the mend. Here are some of her top tips:2

• Trauma or surgery may require up to 20 percent more calories, and crutching requires two to three times more energy than walking. Make sure you’re consistently fueling the body to ensure a strong foundation for recovery.
• If your athlete or patient is dealing with post-op nausea, recommend bland foods like bananas, rice, applesauce and toast, as well as smaller and more frequent meals with nutrient-dense liquids like smoothies. Constipation can also occur after surgery, in which case you can recommend increasing fluid and fiber intake.
• If antibiotics are prescribed, include prebiotic and probiotic-rich foods to restore the beneficial bacteria involved in digestive and immune health that antibiotics can remove. Prebiotic options include jicama, onion, garlic, asparagus, oats, wheat, barley and mushrooms. Probiotic options include yogurt, kombucha, sauerkraut, miso soup and kimchi.
• Increase protein intake alongside the amino acid leucine to maintain anabolic function during the immobilization phase. Leucine rich foods include cheese, meat, fish, nuts and seeds and tempeh. For best results, consume 20 to 35 grams of leucine-rich protein every three hours during the day and before bed.
• Control inflammation by swapping pro-inflammatory fats like fried and greasy foods, processed meats and vegetable oils with anti-inflammatory fats found in olive oil, avocado, fish, flax, nuts and seeds. Antioxidant-rich fruits like goji berries, blueberries, tart cherries, elderberries and pineapple can also help control inflammation, and speed up healing.
• While the athlete or patient may want to reduce carbohydrate intake to control body weight, whole grains provide many nutrients that fuel and support rehabilitation and healing. A board-certified specialist in sports dietetics (CSSD) can give individualized nutrition recommendations so the patient feels confident in his or her recovery plan.
• Excessive alcohol intake can exacerbate muscle loss during immobilization, impair muscle building and contribute to inflammation. Make sure the athlete or patient is responsibly monitoring his or her alcohol intake.
• Consider injury specific nutrition interventions that come with concussions, bone injuries, tendon and ligament injuries and orofacial injuries. Read the full article for these specific nutritional recommendations.2

Delayed onset muscle soreness, or DOMS, may not be as serious of an ailment or require a long recovery like wounds or musculoskeletal injuries. Still, this natural result of regular exercise can be both healed and prevented by proper nutrition.“Any nutritional strategies to minimize DOMS should be employed to assist athletes in post-exercise recovery,” says Hoogenboom, “interestingly, the strategies of inclusion of Omega-3 fatty acids, Taurine, and Polyphenols for minimizing DOMS are consistent with excellent nutrition in general!”

In one review of nutritional intervention for DOMS, researchers reviewed four nutrients that have been suggested to aide sore muscles:

1. Caffeine: Experts propose that caffeine’s mechanism of DOMS reduction is closely related to adenosine receptors. Caffeine can block adenosine receptors, which may reduce DOMS by deactivating the central nervous system. Main sources of caffeine include coffee, tea and chocolate3
2. Omega-3 Fatty Acids: Omega-3 fatty acids containing eicosanoids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). “Phillips et al. (2003) reported that nutritional intervention with DHA reduced exercise-induced inflammatory response. Therefore, it is assumed that intake of omega-3 fatty acid results in anti-inflammatory response to exercise which may reduce DOMS.” Main sources of omega-3 fatty acids include salmon, walnuts, chia seeds and oysters.3
3. Taurine: Taurine is an organic acid found in skeletal muscle and has many biological functions such as membrane stabilization, antioxidant capacity, osmoregulation and calcium homeostasis regulation. Several studies recently demonstrated the effect of taurine on DOMS, although the exact mechanism is not known. Main sources of taurine include animal foods, like meat, fish and dairy.3
4. Polyphenol: Polyphenol is a component of phytochemicals found in many plants, serving antioxidant capacity and anti-inflammation capabilities. “Specific components of polyphenol such as anthocyanins and flavonoids are known to serve antioxidant and anti-inflammatory activities. According to the previous studies, a potential mechanism for reducing DOMS by ingestion with polyphenol is its action on membrane stability and reduced lipid peroxidation by inhibiting peroxyl radical activation.” Main sources of polyphenol include dark chocolate, berries, beans and nuts.3

As you can tell from these recommendations, maintaining a healthy, balanced diet is not only conductive to maintaining weight and building muscle. The body’s ability to heal wounds, recover from injury and keep you in the gym or on the field requires the right amount of healthy micro and macronutrients so it may heal itself correctly. Hoogenboom says it’s important to note that "High quality food choices are important for adequate fueling for training, competition, rehabilitation and recovery. It is not as simple as just how many calories you are ingesting, rather quality, variety, and excellent macro- and micronutrient distribution is important. A RDN can assist in building a plan that includes high quality foods.”

If you want to learn more about how nutrition can enhance your or your patient’s abilities to heal and perform, visit the Academy of Nutrition and Dietetics. While you’re there, learn more about their National Nutrition Month Campaign and get involved!

Dr. Hoogenboom is a professor and an associate program chair at Grand Valley State University, in the Department of Physical Therapy. She began her education in physical therapy receiving a certificate from Cleveland State University, then a Master’s Degree in Health Sciences from Grand Valley State University, and a Doctorate in Educational Leadership from Eastern Michigan University. She was one of the first Board Certified Sports Clinical Specialists in West Michigan in 1993, and has since been recertified twice by the ABPTS, most recently in 2013. She has been a Certified Athletic Trainer since 1988. She maintains a clinical practice by volunteering at the GVSU Pro Bono clinic. Barb is a member of the American Physical Therapy Association and a member of the American Academy of Sports Physical Therapy, where she has been honored with the Academy's highest award, The Ron Peyton Award, and is also a member of the Turner A. Blackburn Sports Physical Therapy Hall of Fame. She also received the "Lifetime Excellence in Education" award from the AASPT. She is a member of the Female Athlete Triad Coalition, and The Orthopedic Society for Sports Medicine. Barb enjoys clinical research, and has authored many research and clinical commentary articles on the female athlete, nutrition, functional movement, and movement analysis. She has contributed to 10 textbooks and 5 Home Study Courses on various musculoskeletal topics. She is the editor of the therapeutic exercise textbook entitled "Therapeutic Exercise: Techniques for Intervention" the third edition of which was released in 2014. She is also the Senior Associate Editor for The International Journal of Sports Physical Therapy.

References:

1. https://www.woundsresearch.com/article/nutrition-wound-care-management-comprehensive-overview
2. https://www.nata.org/sites/default/files/nutrition-for-injury-recovery-and-rehabilitation.pdf
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4294436/