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OBESITAS;

TERAPI NUTRISI
&
TERAPI OBAT
Erwin Christianto


CURRICULUM VITAE



Nama : dr Erwin Christianto, M.Gizi SpGK
Tempat/Tanggal lahir : Malang, 26 Desember 1970
Pendidikan
- Dokter - 1998
Fakultas Kedokteran Universitas Brawijaya
- Magister Ilmu Gizi Kekhususan Gizi Klinik - 2006
Fakultas Kedokteran Universitas Indonesia
- Spesialis Gizi Klinik - 2007
Kolegium Ilmu Gizi Klinik
- Fellowship- Asia Pacific Hospice Network/
National Cancer Center Singapore - 2009
- Post Graduate Certificate of Health/Palliative Medicine,
Flinders University, Australia - 2010
Pengalaman Kerja
- Dokter Spesialis Gizi Klinik Eka Hospital Pekanbaru 2012-
- Konsultan Gizi Tim Nasional Sepakbola Indonesia 2010-1011
- Dokter Gizi Satuan Pelaksana Program Indonesia Emas
(Satlak Prima) SEA GAMES XVI 2011
- Ketua Kekhususan Gizi Klinik, Program Studi
Magister Ilmu Gizi Klinik FKUI, 2008-2010


Organisasi
- Anggota ex-officio BP2KB Pengurus Besar Ikatan Dokter
Indonesia (PB IDI) 2009-2012, 2012-2015
- Ketua Bidang Pengembangan Organisasi dan Pembinaan
Anggota Pengurus Pusat Perhimpunan Dokter Gizi Klinik
Indonesia (PDGKI) 2011-2014
- Anggota Perhimpunan Dokter Gizi Medik Indonesia (PDGMI)
- Anggota Working Group on Metabolism and Clinical Nutrition
- Anggota Masyarakat Paliatif Indonesia
- Anggota Asia Pacific Hospice Palliative Care Network
- Anggota Perhimpunan Onkologi Indonesia
Pembicara
-Pertemuan Ilmiah Tahunan-Perhimpunan Dokter Spesialis Gizi Klinik Indonesia
( PIT PDGKI), Jakarta 12-15 April 2012
- 1st Makassar Annual Meeting on Clinical Nutrition Symposium of Comprehensive
Management on Nutritional Care in Hospital Setting, Makassar, 2-3 Maret 2012
-The 2nd National Nutrition & Wellnes, Bandung, 4-8 Mei 2011
-Seminar Peran Dokter Layanan Primer (Dokter Umum) Dalam Penanggulangan Penyakit
Terkini, Bukittinggi 26 Februari 2011
- IOC Course on Sport Medicine, Jakarta 19-24 Mei 2010
-3rd National Symposium of Emergency in Daily Clinical Practice & 5th Symposium on
Emergency, Jakarta, 14-16 Mei 2010
-8th International Course on Metabolism & Clinical Nutrition 2010, Jakarta,
18-19 Februari 2010
-Kursus Penyegar dan Penambah Ilmu Kedokteran (KPPIK), Jakarta 18-19 April 2009
-Simposium Integrated Approach to Healthy Pregnancy and Newborn,
Jakarta 18-19 April 2009
-7th Basic Molecular Biology Course on Cancer Disease From Basic to Clinical Practice.
Malang 7 Februari 2009
-Lokakarya Pengembangan Kurikulum Berbasis Kompetensi, Magister Gizi dan Pangan
Terintegrasi dengan Pendidikan Profesi Gizi. Bogor, 22-24 Desember 2008
-Collegium Internationale GerontoPharmacologicum Congress 2006.
Jakarta, 11-13 Agustus 2006
Instruktur

- Kursus Total Nutrition Therapy-Kolegium Ilmu
Bedah, Bali 4-5 Desember 2011
- Kursus Total Nutrition Therapy, Jakarta 27-28
Januari 2011
- The 7th International Course on Metabolism &
Clinical Nutrition 2010, Jakarta, 12-13 Februari 2009
- Kursus Total Nutrition Therapy, Jakarta, 20-21
Mei 2006
- Kursus Total Nutrition Therapy, Malang 23-25
Februari 2007
DEFINITION of OBESITY
Obesity is a medical condition in which excess body fat has
accumulated to the extent that it may have a negative effect on
health, leading to reduced life expectancy and/or increased
health problems (WHO,2000)



cardiovascular diseases, diabetes mellitus type 2, obstructive
sleep apnea, certain types of cancer, osteoarthritis and asthma.As
a result, obesity has been found to reduce life expectancy
(Haslam DW, James WP, 2005. Poulain M, Doucet M, Major GC et al. 2006)
OBESITY in INDONESIA
Berdasarkan data Riskesdas tahun 2010
prevalensi berat badan berlebih dan
obesitas pada orang dewasa di Indonesia
mencapai 21,7%

Obesitas penyakit degeneratif


PRINCIPLES IN OBESITY
MANAGEMENT
Obesity Treatment Pyramid
Diet
Physical Activity
Lifestyle Modification
Pharmacotherapy
Surgery
PRINSIP TERAPI NUTRISI
Energi Masuk
Energi Keluar
MEMILIH TERAPI NUTRISI
LCD
VLCD

NOT :
OCD
Blood type diet
Food combining diet
South beach diet

WHY NOT OCD ???
Adaptive reduction in basal metabolic rate in response to
food deprivation in humans: a role for feedback signals
from fat stores. Dulloo, Jaquet 1998. American journal of
clinical nutrition

Quote:
It is well established from longitudinal studies of human
starvation and semistarvation that weight loss is accompanied by
a decrease in basal metabolicrate (BMR) greater than can be
accounted for by the change in body weight or body composition
NHLBI, 1998, Clinical guidelines on the Identification,
Evaluation, and Treatment of Overweight and Obesity in Adults:
The Evidence Report

EVIDENCE CATEGORIES
Evidence
Category
Sources of
Evidence
Definition

A
Randomized
controlled trials (rich
body of data)
Evidence is from endpoints of well-designed RCTs (or trials that: depart only minimally from
randomization) that provide a consistent pattern of findings in the population for which
the recommendation is made. Category A therefore requires substantial numbers of studies
involving substantial numbers of participants.
B
Randomized
controlled trials
(limited body of
data)
Evidence is from endpoint of intervention studies that include only a limited number of RCTs,
post hoc or subgroup analysis of RCTs, or meta-analysis of RCTs. In general,
Category B pertains when few randomized trials exist, they are small in size, and the trial results
are some what inconsistent, or the trials were undertaken in a population that differs from the
target population of the recommendation.
C
Nonrandomized
trials
Observational studies
Evidence is from outcomes of uncontrolled or non randomized
trials or from observational studies.
D
Panel
Consensus
Judgment
Expert judgment is based on the panels synthesis of evidence from experimental research
described in the literature and/or derived from the consensus of panel members based on
clinical experience or knowledge that does not meet the above-listed criteria. This category is
used only in cases where the provision of some guidance was deemed valuable but an adequately
compelling clinical literature addressing the subject of the recommendation was deemed
insufficient to justify placement in one of the other categories (A Through C).
The combination of an LCD (1000-1500
kcal/d) and increased physical activity is
recommended because it produces weight
loss that also may result in decreases in
abdominal fat and increases in
cardiorespiratory fitness.
(Evidence category A)
Steady and long term weight loss
NHLBI, 1998, Clinical guidelines on the Identification, Evaluation, and
Treatment of Overweight and Obesity in Adults: The Evidence Report
Suggested Energy Intake Based on Initial
Body Weight
Body Weight
(kg)
Suggested Energy
Intake (kcal/d)
Approximate Initial
Energy Deficit
(kcal/d)
67.5-89.5 1000 500
90.0-112.0 1200 750
112.5-134.5 1500 1000
135.0-157.0 1800 1250
>157.5 2000 >1500
Klein et al. Gastroenterology. 2002 Sep;123(3):882-932.
National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on
the Identification, Evaluation, and Treatment of Overweight and Obesity in AdultsThe
Evidence Report. Obes Res 1998;6(suppl 2):51S-209S.
LCD atau
VLCD
????
Dietary therapy-energy content
Starvation

Very low-calorie
Diets (VLCD)
Intake < 800 kcal

Wadden et al. J Consult Clin Psychol 1994;62:165.
W
e
i
g
h
t

L
o
s
s

(
k
g
)

-25
-20
-15
-10
-5
0
Time (wk)
0 26 52 78
Biweekly
behavior therapy
Weekly
behavior therapy
Very-low-calorie diet (420 kcal/d)
Low-calorie diet (1200 kcal/d)
Low-calorie Diets
Intake 800-1200 kcal

Moderate energy
deficit Diets
Intake 1200 kcal
LCDs are recommended for weight loss in overweight and obese
persons (Evidence category A)
VLCDs produce greater initial weight loss than LCDs. However
longterm (>1 year) weight loss is not different with the LCDs.
(Evidence category A)
NHLBI, 1998, Clinical guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults: The Evidence Report
Steady and long term weight loss
Weinsier et al. Am J Med 1995;98:115.
0
0.5
1
1.5
2
2.5
3
3.5
I
n
c
i
d
e
n
c
e

o
f

G
a
l
l
s
t
o
n
e

F
o
r
m
a
t
i
o
n

(
%

s
u
b
j
e
c
t
s
/
w
k
)

Rate of Weight Loss (kg/wk)
0 0.5 1 1.5 2 2.5
1
2
3 4
5
6
7
8
9
Increasing rate of weight loss will increase risk of gallstone
formation
The risk of gallstone formation increased markedly when the
rate of weight loss exceeded 1.5 kg per week

DIETARY TRICKS & TIPS
Jaga porsi makan


Piring kecil
Seimbangkan ukuran/size;nasi,sayur,lauk
Buat rencana makan harian/mingguan
Awas false hunger
Menu Diet 1000 kalori,
150 g KH (60%), P 37,5 g (15 %), L 22 g (25%)
Pagi
Sandwich Tuna
Siang
Ikan bakar , sup tahu , Brokoli cah & buah
Malam
Ikan bakar , sup tahu , Brokoli cah & buah



Menu Diet 1000 kalori,
150 g KH (60%), P 37,5 g (15 %), L 22 g (25%)
Pagi
Sandwich Tuna
Roti gandum 35 gr 1,5 iris
Ikan tuna 20 gr ptg
Wortel 50 gr gls
Selada + Tomat 50 gr gls
Minyak olive 5 gr 1/2sdm
Jeruk 100 gr 2 bh


Kal KH P L
90 20 2 -
25 - 3,5 1
12,5 2,5 0,5 -
- - - -
50 - - 5
50 12
---------------------------
227,5 34,5 6 6
Siang

Nasi ( beras merah ) 100 gr 6-8sdm
Ikan bakar 40 gr 1 ptg
Sup tahu sutera 50 gr 1 bj sdg
+Putih telur 30 gr 1 btr
Brokoli cah jamur 100 gr 1 gls
Minyak olive 5 gr 1/2sdm
Apel 85 gr 1 bh
Pir 115 gr 1 bh

Kal KH P L
175 40 4 -
50 - 7 2
40 3,5 2,5 1,5
30 - 7 -
25 5 1 -
50 - - 5
50 12 - -
50 12 - -
--------------------------
470 72,5 21,5 8,5
Malam

Nasi ( beras merah ) 50 gr 3-4 sdm
Ikan bakar 40 gr 1 ptg
Sup tahu sutera 50 gr 1 bj sdg
Brokoli cah jamur 100 gr 1 gls
Minyak olive 5 gr 1/2 sdm
Apel 85 gr 1 bh
Jeruk 50 gr 1 bh


JUMLAH




Kal KH P L
90 20 2 -
50 - 7 2
40 3,5 2,5 1,5
25 5 1 -
50 - - 5
50 12 - -
25 6 - -
--------------------------
330 46,5 12,5 8,5
------------------------------
1027,5 153,5 40 23
% 61 16 21
KAPAN MINUM OBAT ???
Obesitas morbid
Obesitas dengan penyakit penyerta, yang gagal
dengan terapi nutrisi dan olahraga


TERAPI OBAT OBESITAS
Menghambat absorpsi lemak orlistat


Menurunkan absorpsi lemak + 30%
Aman untuk jangka lama
Tidak meningkatkan tekanan darah
Efek samping tidak nyaman

TERAPI OBAT OBESITAS
Serotonin agonists


Mengurangi rasa lapar
Berikatan dengan reseptor serotonin
Lorcaserin


TERAPI OBAT OBESITAS
Sympathomimetics diethylpropion, phentermine


Menyebabkan rasa kenyang
Hanya untuk jangka pendek (s.d 12 minggu)
Stimulasi sekresi norepinefrin
Menghalangi re-uptake NE
Meningkatkan tekanan darah
TERAPI OBAT OBESITAS
Suplemen diet
chitosan, guargum tidak efektif
Ginseng, green tea, L-carnitine, psyllium,
conjugated linoleic acid kurang data
Hoodia gordoni belum ada penelitian ilmiah
Indah Sari
Makan terlalu malam atau ngemil membuat perut buncit,
bagaimana mekanisme dan solusi?
Tubuh kita sudah didesain untuk bekerja 24 jam dan
mempertahankan kondisi tubuh / homeostasis. Dan
memperbaiki sel sel dalam satu hari. Peran enzim juga ada,
salah satunya adalah hormon pertumbuhan (berkembang pada
malam hari). Yang membuat hormon ini turun karena sering
begadang. Makan malam tidak membuat perut buncit. Kebiasaan
makan baik pagi, siang, malam yang memicunya. Yang biasa
buncit adalah laki laki karena predesposisi adalah perut.
Sedangkan perempuan pada paha pinggul bokong. Saran : makan
pada waktunya.
Rahma
Pola makan yang baik pada penderita diabetes? Kalau makan malam harus
minum air hangat? Perbedaan beras merah atau putih?
Makan pada waktunya terutama yang diabetes. Ada enzim pada lambung
bersifat priodik yang keluar 24 jam yang mencerna makanan dan harus ada
makanan di lambung jika tidak enzim akan merusak lambung. Adanya bakteri
yang mencerna makanan juga membuat gangguan pada tubuh. Pada penderita
diabetes harus ada cemilan karena ada peningkatan gula darah minimal 2 jam
sesudah makan nasi.
Absorbsi air pada dasarnya TIDAK BERBEDA pada suhu panas maupun
dingin. Yang membedakan : tidak mungkin minum air panas banyak daripada
dingin. Penelitian mengatakan bahwa minum air dingin 500ml bisa
menurunkan suhu tubuh. Menyebabkan kompensasi sehingga metabolisme
meningkat.
Kandungannya pada dasarnya tidak berbeda. Beras merah memiliki selaput
yang tinggi vitamin B6 dan B12. selaputnya memiliki serat. Bukan berarti sehat
namun tinggi serat dan vitamin B. Bagi yang fobia sayur bagus mengkonsumsi
beras merah. Beras merah sebaiknya tidak dimasak dengan rice cooker.

Simon Petrus
Bagaimana cara diet bagi penderita maag?
90% maag disebabkan karena jam makan yang tidak
teratur. Perhatikan makanan yang dimakan juga
mempengaruhi kondisi lambung. Makanan yang
dominan diserap oleh tubuh adalah karbohidrat karena
banyaknya enzim yang memfasilitasi dalam
pencernaannya. Intinya makanlah makanan yang
seimbang. Makanan yang harus dihindari penderita sakit
maag : makanan yang mengandung asam (daging,
makanan berlemak & berminyak), kurangi STRESS