kp 12.12 nutrisi pada dm
TRANSCRIPT
NUTRISI PADA DIABETES MELLITUS
OLEHProf.Dr.Fadil Oenzil, PhD, SpGK
Flow diagram of the development
of type II diabetes
12
10
8
6
4
0 1 hour 2 hour
Time after ingestion of 75 g glucose
(a)Normal
individual
b) Person with impaired glucose tolerance
c) Diabetic
Venous
pla
sma g
luco
se level
(mm
ol/L)
Ball M (1997) Diabetes in Food and Nutrition
Diabetes : Metabolism out of control
ß-cytotrophic virus Genetic predispositionin
Chemical toxin ß-cell injury Islet cell antibody (ICA)
Juvenile Ketpsis Prone Insulin dependent (type I) IDDM
Excessive food intake Inadequate exercise
Obesity
Insulin resistence genetic predisposition
Compensatory B-cell decompensation Hyperinsulinism
Maturity onsetKetosis resistentInsulin independent (type 2)NIDDM
Gropper S.S et al (2005) Diabetes : metabolism out in control , in anvanced Nutrition , 4 th ed
+
Goals of Medical Nutrition Therapy for Persons with Diabetes Mellitus
• Attain and maintain optimal metabolic outcomes, includes :– Blood glucose levels in the normal range or as close to
normal as is safely possible.– A lipid and lipoprotein profile that reduce the risk for
macrovascular diseases– Blood pressure level that reduce the risk for vascular
diseases– Prevent and treat the chronic complication of diabetes
Heimburger D.C., et al (2006) Diabetes, Handbook of clinical nutrition
– Modify nutrient intake and lifestyle as appropriate for prevention and treatment of obesity, dyslipidemia, CVD, hypertension and nephropathy
– Improve health through healthy food choices and physical activity
– Address individual nutritional need, taking into consideration personal and cultural preferences and lifestyle while respecting the individual’s wishes and willingness to change
Heimburger D.C., et al (2006) Diabetes, Handbook of clinical nutrition
Nutritional recommendation for persons with diabetes
Nutrient PDGMI ADACaloriCarbohydrate % of kcalProtein %Fat total %SAFA %MUFA %PUFA %Cholesterol mg/dayFiber g/daySodium mg/day
ideal Body60-70% (up to 75%)
10 – 15%20 – 25%< 10%Up to 15%<10%< 300 mg/day+ 25 gr/dayNormotensi 3000 mg/dHipertensi < 2400 mg/day
ideal bodyAbout 50%
10-20%<30%< 10%10-20%<10%< 300 mg/day20-35 g/day< 2400 mg *
Rekomendasi untuk pasien dengan diabetesZat gizi PDGMI ADA
kalorikarbohidrat (% kcal)
Protein %Total lemak %SAFA %MUFA %PUFA %kolesterol mg/hariserat g/hariNa mg/hari
Berat badan ideal 60-70% (sampai 75%)
10 – 15%20 – 25%< 10%Up to 15%<10%< 300 mg/day+ 25 gr/dayNormotensi 3000 mg/dHipertensi < 2400 mg/day
berat badan IdealAbout 50%
10-20%<30%< 10%10-20%<10%< 300 mg/day20-35 g/day< 2400 mg *
Sukmaniah S (2007) Nutrisi pada Diabetes Melitus, dalam buku pegangan penatalaksanaan nutrisi pasien ; Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 9 th ed
Tabel World Health Organization Dietary recommendations For Prevention of Chronic Disease
Nutrient Recommendation
Total fat 15 – 30% of total energy
Saturated fat < 10% of total energy
Polyunsaturated fat 3 – 7 % of total energy
Protein 10 – 15 % of total energy
Carbohydrate
Complex 55 – 75 % of total energy
Simple < 10 % of total energy
Fibre (nonstarch polysacharides) 16-24 g/d
Fruit and vegetables > 400 g/d
Salt 6 g/d
Cholesterol < 300 mg/d
Sumber : WHO, 1991
Carbohydrate
• Recommended 50%-60% (up to 70%) • Simple carbohydrat (sugar) raise blood glucose more
than Complex carbohydrat (starches) • Simple Carbohydrat should’n exced 5% • Maltosa, laktosa dan sukrosa produce large increases
in the blood glucose,fructose does not
Sukmaniah S (2007) Nutrisi pada Diabetes Melitus, dalam buku pegangan penatalaksanaan nutrisi pasien ; Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 9 th ed
Indek Glikemik =
Luas daerah dibawah kurva respon glukosa darah tubuh setelah 2 jam terhadap makanan
Luas daerah dibawah kurva respon glukosa darah tubuh setelah 2 jam terhadap glukosa murni
X 100%
Glycemic index value by Jenny Miller :1. Low if glycemic index < 552. Moderate if glycemic index 55 – 703. Hight if glycemic index > 70
Glycemic index value by Wolever et al :1. Low if glycemic index < 702. Moderate if glycemic index 70 – 903. Hight if glycemic index > 90
Factors affecting the glycemic response to food
• Rate of ingestion• Food form• Food components
– Fat content– Fiber content– Protein content– Starch characteristics
• Methods of cooking and prosessing
Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 9 th ed
• Physiologic effects– Pregastric hydrolysis– Gastric hydrolysis– Gastric emptying rate– Intestinal response– Intestinal hydrolysis and absorption– Pancreatic and gut hormone response– Colonic effects
Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 9 th ed
Upper epidermis
Bundle sheath
xylemphloe
mBundle sheath
Vein
Lower epidermis
Stoma
Stoma
Spongy parenchyma
Palisade parenchyma
Tabel : Indeks Glikemik Monosakarida, Disakarida dan Polisakarida Murni dan Bahan Makanan Sumber Karbohidrat pada Orang
Normal
Indeks Glikemik (%)NO Beban yang diberikan
Luas area dibawah kurva
(cm)
1 Glukosa murni
Fruktosa murni2
3 Madu Sumbawa
4 Laktosa murni
5 Susu Laktogen
6 Kanji
7 Kentang
210,9
45,3
162,3
20,95
28,65
87,73
84,3
100
22
77
10
14
42
40
Tabel : Indeks Glikemik n=30 orang (10 laki-laki, 20 wanita, Pasien Diabetes terkontrol, tes Fungsi Hati & Ginjal normal)
Glukosa 100 ± 0 %
Singkong 94,46± 24,245
Kentang 67,71± 24,35 %
Roti 67,25± 23,604 %
Nangka 63,97 ± 30,290 %
Nenas 61,61 ± 21,655 %
Pisang Raja 57,10 ± 18,074 %
Nasi Cianjur 50,07 ± 22,444 %
Sawo 43,86 ± 15,525 %
Jeruk Pontianak 40,82 ± 18,717 %
Pepaya Lokal 37,00 ± 21,37 %
Kacang Merah 9,46 ± 8,516 %
Kacang Tanah -7,93 ± 10,660 %
Counting Carbohydrate in clinical practice
1.Determine an appropriate carbohydrate intake and suitable distribution pattern– Example : A person consuming 2000 kcal daily
with carbohydrate allowance of 50% of calories• 50% x 2000 kcal = 1000 g kcal of carbohydrate• 1000 kcal carbohydrate = 250 g 4 kcal/g carbohydrate
Rolfes S.R et all (2006) Nutrition and Diabetes Mellitus in Understanding Normal and Clinical Nutrition
Meals In Gram Portion
BreakfastLunchAfternoon snachDinnerEvening snackTotal
6060307530
255 g
44252
17
2.The distribution of carbohydrate among meals and snacks
Rolfes S.R et all (2006) Nutrition and Diabetes Mellitus in Understanding Normal and Clinical Nutrition
3. CARBOHYDRAT COUNTING
• Carbohydrate counting can be done of two way :– Count the gram of carbohydrate provide by food– Count carbohydrate portion, expresed in term of
serving that contain aproximately 15 grams each• Requires knowledge about the food sources of
carbohydrate and understanding portion control
Rolfes S.R et all (2006) Nutrition and Diabetes Mellitus in Understanding Normal and Clinical Nutrition
Protein• Recommended 0,8 mg/kgbodyweight/day (10%-
20%)• In present nephropathy : <0,8 mg/kgbody
weight/day (<10%)• Protein with high biologic value, from both animal
and vegetables sources• Current study :
– Soy protein diets reduce hyperfiltration in diabetic
Franz M.J (1996) Nutritional care in DM in Food, Nutrition and Diet Therapy 9 th ed : Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 9 th ed
Fat• Recommended 20- 25% of total energy• SAFA < 10% ,atherogenik potential (as.laurat, palmitat,
miristat) : lemak mentega dan lemak hewani• PUFA < 10%, have tendency to lower HDL and and increased
free radical (omega 3 : fish oil and omega 6 oil , corn oil, oil sunflower )
• MUFA up to 15% : olive oil, peanut oil– In NIDDM, it does increase LDL– Improve glycemic control, triglyseride dan HDL levels– Enhance insulin resistence
Anderson J.W (2006) Nutritional management of DM in Modern Nutrition, 10 th ed
Omega-3 fatty acid• Effects omega 3 in diabetic are :
– Decrese cholesterol, triglyseride and blood pressure– Decrease platelet aggregation– Improve insulin sensitivity (NIDDM)
twice weekly intake of fish (fish oil)
lower cardiovasculer deseases
– Intake 3 g fish oil daily significanly lower serum triglyceride without affecting glucosa metabolism
– Intake 4 g/day EPA or DHA : serum glucosa increase and serum triglyceride decrease
Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 9 th ed
Dislipidemia
• If LDL cholesterol level are elevated– SAFA < 7% of total calories– Dietary cholesterol < 200 mg/day
• If triglycerides and VLDL are the primary concern– Moderate increased of MUFA– SAFA < 10%– Moderate of carbohydrate intake
Franz M.J (1996) Nutritional care in DM in Food, Nutrition and Diet Therapy 9 th ed : Anderson J.W (2006) Nutritional management of DM in Modern Nutrition, 10 th ed
• Hight Fat Diet (HFD) contributes :– Obesity– Insulin resistance– Hypertension– Atherosclerotic cardiovascular disease– Impaired celluler glucose metabolism– Decrease the number of insulin receptors in
several tissues
Franz M.J (1996) Nutritional care in DM in Food, Nutrition and Diet Therapy 9 th ed : Anderson J.W (2006) Nutritional management of DM in Modern Nutrition, 10 th ed
HFD contributes :
• Decreasing glucosa transport into muscle and adipose tissue
• Decreasing activities of insulin-stimulated process
• Glycogen syntesis rates, glycogen accumulation and glucose oxidation are lower
Franz M.J (1996) Nutritional care in DM in Food, Nutrition and Diet Therapy 9 th ed : Anderson J.W (2006) Nutritional management of DM in Modern Nutrition, 10 th ed
Fiber
• Divided in to two general categories– Water soluble– Water insoluble
• Soluble fibers – can lower blood suger level – decrease body’s need for insulin– lowers cholesterol level
Anderson J.W (2006) Nutritional management of DM in Modern Nutrition, 10 th ed
Fiber
• Fiber fermentation products such as short chain fatty acid (SCFA) are absorbed from the colon into the portal vein; in the liver they may directly affect glucose metabolism
• SCFA decrease HMG-CoA reductase activities, so cholesterol syntesis is inhibited
Mikroorganisme di Dalam Usus Besar
MEMASUKI USUS BESAR
Pati
Heksosa
Selulosa Hemiselulosa
Pentosa
Lintasan Pentosa
Piruvat
Glikolisis
Hidrogen metana karbondioksida
Keluar melalui udara pernapasan setelah absorpsi
Asetat propionat butirat
Keluar ke feses
Diabsorpsi oleh usus halus dan dimetabolisasikan
DIMETABOLISASI OLEH BAKTERI UNTUK PERTUMBUHAN BAKTERI
PROSES AKHIR
HASIL AKHIR
Gambar : Pemecahan Serat Makanan di Dalam Usus Besar Manusia
Advantages of High Fiber Intakes
• Slow nutrient digestion and absorption• Decrease postprandial plasma glucose• Increase tissue insulin sensitivity• Increase insulin receptor number• Stimulate glucose use• Attenuate hepatic glucosa output• Decrease counterregulatory hormone release (e.g.
glucagon)
Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 9 th ed
• Lower serum cholesterol• Lower fasting and postprandial serum
triglycerides• May attenuate hepatic cholesterol syntesis• May increase satiety between meals
Potential causes of nutritional deficiences in diabetic patients :- Dietary restriction- Increase requirement- Ignorance
Who will need supplementation :- Diabetes in the elderly- Early complication of diabetes- Uncontrolled diabetics with high dose therapy
Micronutrient
Glutathione (Glutamate – Cystein – Glycine)
Selenium : Glutathione peroxidace enzyme co factor
Regeneration of antioxidants reguires Glutathione
R*
RH
Vit E
Vit E*
Vit C
Vit C*
GSH
GSSG
NADP
NADPH
Recent evidence reviewed indicating :- Increase oxidative damage in diabetes mellitus- Deficits in anti oxidant enzymes
Hyperglycemic increase oxidative stress
change the redox potential
of glutathione
Reactive oxygen species
(West IC. Diabet Med 2000, 17, 171 - 180)
Propose Metabolic Interaction Glucose, Oxygen, Gluthabione and Nitric Oxide
ZincImprove insulin secretion Enhances binding of insulinCo factor anti oxidant enzyme : S O D, catalase, peroxidase
Zn-metallo thionien complex in the islet cell provides protection against free radicals
Necessary for adeguate function of T-cell lymphocyte – foot ulcer(Chausmer J Am Coll Nutr 1998, 17, 105 – 115, Mooradian & Morley, Am J Clin Nutr, 1987, 45, 806 – 895)
- Recommended daily dietary intake of Zn (Australia) Adult 12 – 16 mg - Zinc milligrams per 100 g food
Oysters raw 45 bran (Wheat) 16 cocoa powder 7 Yeast dry 8 Crab 6
Selenium
Recommended Daily Dietary intake of Se (Australia).Adult men 85 μgAdult women 70 μgSe content of some food (μg / 100 g of food)
Seafood 100Organ meat 20Cereals 20Dairy Product 6
Magnesium (Mg)
- Co – factor in the glucose transport system plasma membranes- Important role in activity of various enzymes in glucose oxidation- Play a role in release of insulin(Mooradian & Morley, Am J Clin Nut, 1987, 45, 866 – 895)
Recommended daily dietary intake of Mg (Australia)Adult men 320 mgAdult women 270 mg
Milligram (mg) per 100 g foodCocoa Powder 520Bran Wheat 520Soya 240Peanut Raw 130
ChromiumIncrease insulin binding to cells,Increase insulin sensitiveIncrease receptor numberActivates receptor insulin kinase
Supplemental chromium :Severe neuropathy & glucose intolerance ware reversed(Anderson R.A Diabetes & Metabolism 2000, 26, 22 – 27)
Estimated Safe & Adequate Daily Dietary Intake(ESADDI) USA adult 0.05 – 0.2 mg (200 μg/day)Content of some foods (μg/100 g of food)
Egg yolk 183Brewers yeast 112Beef 57Cheese 56Apple 27
Zinc
Improve insulin secretion Enhances binding of insulinCo factor anti oxidant enzyme : S O D, catalase, peroxidase
Zn-metallo thionien complex in the islet cell provides protection against free radicals
Necessary for adeguate function of T-cell lymphocyte – foot ulcer(Chausmer J Am Coll Nutr 1998, 17, 105 – 115, Mooradian & Morley, Am J Clin Nutr, 1987, 45, 806 – 895)
- Recommended daily dietary intake of Zn (Australia) Adult 12 – 16 mg - Zinc milligrams per 100 g food
Oysters raw 45 bran (Wheat) 16 cocoa powder 7 Yeast dry 8 Crab 6
Sweeteners
• Two categories of sweeteners– Nutritive (calori containing) (fructosa, common sugar alcohols, the polyols)
– Nonnutritive (noncaloric) (saccharin, aspartam, acesulfame-K and sucralose
recommende by FDA)
Sweetener
• Sacharin : potential association of bladder cancer when ingested in excessive quantities
• Aspartam : is contraindicated only for person with phenylketouria
Alcohol
• Moderate intake alcohol is associated with a decrease in the incidence of diabetes and CVD in person with diabetes
• Man : no more two drinks/day• Women : one drink/day• One drink consist of 1,5 oz shot of distilled spirit, 4 oz
glass of wine or 12 oz beer
PENATA LAKSANAAN OBESITAS
SERING MENIMBANG BERAT BADAN 75%
MENGURANGI JAJAN 60%
MENGURANGI PORSI MAKANAN 60%
SELEKSI MAKANAN 57%
MEMPERBANYAK GERAK BADAN 55%
GENUINE DESIRE
DISIPLIN
DUKUNGAN LINGKUNGAN
IKAT PINGGANG SEBELUM MAKAN
OBAT PENEKAN NAFSU MAKAN
CEGAH YOYO FENOMENA
PENUTUP
DIETARY MANAGEMENT OF DIABETES (PERENCANAAN MAKAN PADA DIABETES MELITUS)1. Makro nutrient : Karbohidrat, lemak dan protein seimbang2. Asupan kalori dengan mengontrol berat badan3. Pemberian makanan dengan indek glikemik yang rendah4. Serat makanan yang cukup (25 gr/hari)5. Kegiatan fisik teratur, terukur6. Batasi asupan kolesterol7. Bila perlu Suplemen makanan vitamin, mineral dan anti oksidan
References
• Nutritional Care in Diabetes Mellitus,in Food and Diet Therapy,by Krause’s
• Diabetes in Handbook of Clinical Nutrition by Heimburger D.C and Weinsier R.L
• Nutritional management of Diabetes Mellitus in Modern Nutrition in Health and Diseases by Williams and Wilkins
• Penatalaksanaan Diabetes Melitus Terpadu