it was found now that a composition which is effective against pressure ulcers should contain a combination of nutrients which does not only improve wound healing , but also has an effect in the preceding stages of improving blood circulation and controlling inflammation . such an effective composition , when in liquid form , should contain arginine ( 3 - 15 g / l , preferably 5 - 10 g / l ), vitamin c ( 3 - 14 times the recommended daily level , rda ), vitamin e ( 5 - 40 times the rda ) and preferably also zinc at a rate of at least 8 mg per l or per day , with an adequate zinc / copper ratio . a further improved composition also contains increased levels of carotenoids , minerals ( na , k , cl ) and / or flavonoids ( 8 - 40 mg / l ). the arginine to be used in the composition according to the invention may be in form of the free amino acid , or in the form of arginine - rich peptides or proteins such as pea proteins , or as metabolic equivalents of arginine such as ornithine or citrulline . the amount of arginine to be used is 3 - 15 g / day , preferably 5 - 10 g / day . the level of vitamin c is expressed herein as ascorbic acid equivalents , which comprise vitamin c ( ascorbic acid ) and compounds that can be transformed to ascorbic acid in the body , such as dehydroascorbic acid , ascorbyl palmitate and other ascorbyl esters . the amount of ascorbic acid equivalents is from 180 mg or 200 up to 840 mg or more per day . the preferred range is 300 - 780 , especially 350 - 700 mg / day . the level of vitamin e is expressed herein as tocopherol equivalents , which comprise α - tocopherol and equivalents . thus , 1 mg of α - tocopherol equivalent ( te ) (= 1 . 5 iu of vitamin e ) corresponds to 1 mg of d - α - tocopherol , 2 . 0 mg of d - β - tocopherol , 10 mg of d - γ - tocopherol , 30 mg of d - δ - tocopherol , 2 mg of d - α - tocotrienol or 18 . 6 mg of d - β - tocotrienol . the amount of tocopherol equivalent to be used is 50 - 400 mg / day . preferably , the minimum level is 100 , more preferably 120 , especially 180 mg / day , and the preferred upper limit is 320 , more preferably 250 mg / day . the efficacy of the combination described above is further increased by the presence of flavonoids , e . g . at a level of 8 - 40 , in particular 10 - 30 mg / day . according to the invention , flavonoids are understood to comprise hydroxy - substituted compounds having the flavone skeleton ( 2 - phenyl - chromone = 2 - phenyl - benzopyrone ) and isomers thereof such as the isoflavones ( 3 - phenyl - chromones ), chalcones ( 2 - cinnamoyl - phenols ) and aurones ( 2 - benzylidene - benzofuranones ). also the anthocyanidins ( which differ from the flavones by the presence of a pyrylium moiety instead of the pyrone moiety ) are considered to be included in the flavonoids . the hydroxy functions of the flavonoid compounds may be , and preferably are , partly alkylated or glycosylated , as is the case in natural compounds , such as anthocyans (= glycosylated anthocyanidins ) and glycosylated flavonols . among the flavones , the flavonols , especially the flavonotetraols and higher hydroxylated analogues , such as kaempferol , quercitin and myrecitin , and the methylated analogues such as sinensetin , tangeretin and nobiletin , as well as the glycosides such as rutin and myricitrin , are preferred . among the isoflavones , daidzein and genistein are examples of preferred compounds , and among the anthocyanidins , peonidin , cyanidin , pelargonidin , delphinidin , petunidin and valvidin are preferred . flavanones (= 2 , 3 - dihydroflavones ) such as hesperetin and naringin are other preferred flavonoids . the use of a mixture of flavonoids , such as in natural plant extracts or mixtures of plant ( e . g . citrus , tea , grape ) extracts , is advantageous . preferably , the flavonoids according to the invention comprise at least 40 % of flavonols and at least 10 % of anthocyans , more preferably at least 60 % and at least 15 %, respectively . analogues such as catechins , proanthocyanidins and other tannins , are preferably not present , i . e . account for less than 3 % of the flavonoids . the composition of the invention is aimed at improving blood circulation , accelerated curing and improving the immune status , and at compensating for loss of nutritional components that occurs during disease . also , it stabilises cell membranes against radical attack . in addition to the tocopherols and ascorbate , this function is enhanced by glutathione and nadph , which are made available through administration of methionine , cofactors and energy ( carbohydrates ). further preferred components are vitamins b6 ( pyridoxal ), b12 ( cyanocobalamine ) and folic acid , each being present at about 3 times the recommended average daily administration level ( such as the rda ). vitamins b1 ( thiamin ) and b2 ( riboflavin ), copper , zinc and manganese , are each preferably present at twice the rda . the zinc to copper ratio should preferably be in the range of 7 - 14 , especially 8 - 11 . iron , cobalt , iodide , chromium , selenium , fluoride , molybdenum and pantothenic acid , vitamin a ( in retinol equivalents , re ), vitamin d , vitamin k , niacin ( in niacin equivalents , ne ), biotin and inositol , are preferably present at 0 . 5 - 4 , especially 1 - 2 times the rda values for each . minerals should preferably be present as follows ( amounts per day ): sodium 200 - 1200 mg , chloride 240 - 1400 mg , potassium 500 - 1800 mg , calcium 500 - 1000 mg , phosphorus 400 - 900 mg and magnesium 150 - 400 mg . carotenoids ( which , for the purpose of the invention , include xanthins and xanthophylls ) are preferably present at a level of 0 . 8 - 16 mg , preferably 1 - 6 mg per day . the carotenoids are advantageously in their natural form , as can be found in extracts from plants like tomato , pepper , marigold and fruit of oil palm . preferably , such extracts are mixed and the composition may e . g . contain lutein ( 20 - 60 %), lycopene ( 1 - 30 %), α - carotene ( 5 - 25 %), β - carotene ( 5 - 40 %), cryptoxanthine ( 1 - 15 %) and zeaxanthine ( 1 - 15 %). choline or a metabolic equivalent thereof such as betaine or phosphatidyl choline , is preferably present at a level of 20 - 3000 mg / day , which may comprise e . g . 1 g or more of phosphatidyl choline . carnitine , creatine and taurine may be present at levels of 10 - 100 mg , 100 - 1000 mg and 10 - 100 mg , respectively , per day . long - chain pufa &# 39 ; s of the ω - 3 series , especially epa and dha , can also advantageously be present . the total of epa and dha is advantageously between 0 . 1 an 1 . 0 g / day . the ω - 6 / ω - 3 ratio of the lc - pufa &# 39 ; s is between 1 and 6 , preferably between 2 and 5 . linoleic acid ω - 6 ) may also be present , preferably at a level of at least 0 . 1 g / day . another advantageous group of components of the composition of the invention are dietary fibres , which can include soluble non - starch polysaccharides such as gum arabic or pectin , insoluble non - starch polysaccharides such as cellulose , hemicellulose and lignin , oligosaccharides such as inulin or galacto - oligosaccharides and / or resistant starch . the preferred level of dietary fibre is 3 - 20 g / day or 3 - 20 g / liter . carbohydrates , flavourings and yeast extracts may further improve the nutritive and organoleptic quality of the composition . the product is preferably packed in a form which protects it from oxygen and light , especially uv , e . g . in 100 - 1000 ml units . the smaller amounts are useful as food supplements , whereas the larger amounts are suitable as complete foods , for enteral use . the amounts of the important components arginine , vitamin c and vitamin e can also be defined with reference to a unit energy content ( 1000 kcal ) or to a unit volume ( 1 liter ), as in the appending claims . a similar definition can be given for preferred components such as flavonoids ( 16 - 60 mg / 1000 kcal , 16 - 80 mg / l ), carotenoids ( 1 . 6 - 20 mg / 1000 kcal , 1 . 6 - 24 mg / l ), zinc ( 18 - 60 mg / 1000 kcal , 18 - 75 mg / l ) and copper ( 2 . 5 - 10 mg / 1000 kcal , 2 . 5 - 12 mg / l ). by way of summary , table 1 shows art - recommended and preferred ranges for compositions , as well as examples of formulations that can be used as a liquid composition which provides the total daily minimum nutritional supply , and may be supplemented with energy as required . the ingredients as listed in table 1 in 1000 times the amounts given in the last column of table 1 were mixed in a tank , homogenised using methods known in the art , and brought to a total volume of 1000 l . the mixture was packed in 500 mls flask for use as tube feeding . the ingredients as listed in table 1 in 1000 times the amounts given in the 6th column of table 1 were mixed in a tank , homogenised using methods known in the art , and brought to a total volume of 400 l . the mixture was packed in 200 ml cartons . the following ingredients : sodium 600 g , chloride 900 g , tocopherols 150 g , choline 800 g , no flavonoids and no carotenoids , and the further components at 1000 times the amount of column 6 of the table were mixed and packed as in example ii . the product is a whitish drink and is especially suitable for the treatment of decubitus after substantial mineral loss , as in cases of chronic open wounds .
the invention pertains to a method of treating or preventing pressure ulcers , comprising enterally administering to a subject in need thereof a composition comprising proteins , carbohydrates , fats , arginine or equivalents thereof , ascorbic acid equivalents and α - tocopherol equivalents , wherein arginine or equivalents thereof is administered in a daily amount of 3 - 15 g , ascorbic acid equivalents are administered in a daily amount of 180 - 840 mg and α - tocopherol equivalents are administered in a daily amount of 50 - 400 mg .