Manajemen Nutrisi Pada Pasien Stroke Dan Gangguan Makan

NUTRISI PADA PASIEN
NEUROPSIKIATRI
dr. Agussalim Bukhari, M.Med, Ph.D, Sp.GK(K)

Nutrition Department
School of Medicine
Hasanuddin University
@2013
Free Powerpoint Templates
Page 1
ISI
DUKUNGAN NUTRISI ENTERAL PADA
PASIEN KRITIS STROKE
Pendahuluan
Malnutrisi pada pasien stroke hemoragik
(prevalensi, patogenesis)
Faktor resiko penyakit stroke
Nutrisi pada pasien stroke
EATING DISORDER (GANGGUAN MAKAN)
Page 2
DUKUNGAN NUTRISI
ENTERAL PADA
PENDERITA KRITIS
STROKE
Page 3
TUJUAN
Memahami patomekanisme
terjadinya malnutrisi pada pasien
stroke
Memahami faktor resiko yang
berkaitan dengan nutrisi pada pasien
stroke
Menentukan pemberian terapi nutrisi
pada pasien stroke
Page 4
PENDAHULUAN
Page 5
PENDAHULUAN
stroke
penyebab utama kematian dan
kecacatan di dunia.
urutanketiga
ketigapenyakit
penyakitmematikan
mematikansetelah
setelah
urutan
penyakitjantung
jantungdan
dankanker
kanker(Yastroki
(Yastroki))
penyakit
urutan 1 penyebab kematian di
RS Indonesia
Prediksi2020
2020
2x
2xlipat
lipat
Prediksi
penanggulanganstroke
strokeyg
yglebih
lebihbaik.
baik.
penanggulangan
tantangan
strategi
strategipenanggulangan
penanggulangansecara
secara
tantangan
paripurna
paripurna
Intervensi medis +
Pengelolaan nutrisi
merup. tindakan
professional yang
rasional
Page 6
STROKE
Page 7
Prevalensi stroke
Page 8
T
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STROKE
M
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A
F
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A
P
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N
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R
I
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I
KEMAMPUAN MAKAN
?
MASALAH :
- PENDERITA
- KELUARGA
Page 10
Page 11
Page 12
PERUBAHAN STATUS GIZI PADA

PENDERITA STROKE
penurunan tingkat
kesadaran,
kesulitan untuk
menelan,
kelemahan lengan atau
wajah,
mobilitas yang rendah,
sakit saat mengunyah.
asupan zat gizi

kebutuhan metab.
status gizi
MALNUTRISI
defisiensi protein
Pe kadar serum albumin
angka ketahanan hidup &
kemampuan fungsional postKeputusan mengenai pengaturanstroke
pemberian terapi gizi merupakan salah
satu masalah tersulit dalam Free Powerpoint Templates
penatalaksanaan penderita stroke.
Page 13
MALNUTRISI PADA PASIEN

STROKE HEMORAGIK
Page 14
PREVALENSI
Page 15
Page 16
Tabel 1. Insidens malnutrisi pada kejadian stroke
Page 17
Page 18
Page 19
Page 20
Page 21
PATOGENESIS
Page 22
Page 23
ADA 3 HAL PENTING PADA KASUS

CRITICAL ILL
Hipermetabolisme
Hiperkatabolisme
Immunosupresi
Page 24
Page 25
STRESS METABOLIK
Hipoksia,
Inflamasi,
Nekrosis,
Trauma
Infeksi
Respons:
Lokal
Sistemik
Page 26
Hipermetabolisme
Peningkatan kecepatan metabolik

diatas normal : 140-200% dari nilai
normal
Kebutuhan E tidak dipengaruhi oleh
tipe stroke dan perubahan
kebutuhan E istirahat dari waktu ke
waktu
Page 27
NORMAL RANGE

SOURCE:HANDBOOK OF CLINICAL NUTRITION, 1997
Page 28
Tabel 2. Studi pengukuran kebutuhan energi

istirahat setelah stroke
Page 29
Page 30
Hiperkatabolisme
Peningkatan kecepatan metabolik

dan katabolisme setelah terjadi
perlukaan
Dimediasi oleh sitokin dan hormon
(anti-regulator)
Peningkatan profil dalam jangka
waktu lama -> deplesi massa tubuh
(lean -> otot dan lemak)
Karakteristik ini -> fase flow respon
metabolik dominan katabolik
Page 31
CHARACTERISTIC OF METABOLIC PHASE OCCURRING

AFTER SEVERE INJURY
EBB PHASE
RESPONSE
Hypovolemic
Shock
Tissue perfussion
metabolic rate
Oxygen Consump.
Blood pressure
Body temperature
FLOW PHASE
Acute response
Adaptive response
Catabolism
predominates
Anabolism
predominates
Glucocorticoid
Glucagon
Cathecolamine,
Release of cytokines,
lipid mediators,
Production of acute
phase protein
Excretion of nitrogen
Metabolic rate
Oxygen consumption
Impaired utilization of fuel
Hormone response
gradually diminish
Hypermetabolic rate
Associated with recovery
Potential for restoration of
body protein
Wound healing depends
in part on nutrient intake

Source: Krauses FOOD,NUTRITION & DIET THERAPY, 2004
Page 32
Flow
Flow Phase
Phase
Energy
Energy
expenditu
expenditu
re
re
Ebb
Ebb
Phase
Phase
12242244-48
Adaptati
Adaptati
on
on
Time
Time
Hari ke-7
Gambar 2. Respon metabolik pada stroke
Page 33
NORMAL RANGE

SOURCE:HANDBOOK OF CLINICAL NUTRITION, 1997
Page 34
Tabel 3. Studi yang melaporkan terjadi peningkatan

fase akut reaktan segera setelah stroke
Page 35
Gangguan fungsi saluran

cerna
gangguan fungsi oral, faring dan
esofagus -> disfagia
terjadi secara spontan (beberapa
hari -> beberapa bulan -> beberapa
tahun)
tipe disfagia : orofaringeal dan
esofageal
Subtipe disfagia : mekanik atau
motorik
meningkatkan resiko malnutrisi
Page 36
Disfagia:
45%-55% pada pasien rawat inap dengan stroke akut.

lebih 48% pasien dg disfagia menunjukkan kekurangan gizi satu
minggu setelah stroke
Gejala :
keluar air liur, seperti tercekik, batuk saat diberikan makanan dalam
mulut, ketidakmampuan untuk mengisap dari sedotan,makanan
tersimpan dalam kantung pipi ( mungkin pasien tidak
menyadarinya), gag reflek negatif, infeksi saluran pernafasan atas
yang kronis.
komplikasi disfagia: aspirasi me risiko pneumonia.
disfagia + pneumonia prognosis buruk
Page 37
Tabel 4. Hubungan antara disfagia dan terjadinya

malnutrisi
Page 38
Defisit kognitif
Gangguan visual
Parese ekstremitas atas
Penurunan
asupan
makanan
secara volunter yang berhubungan
dengan depresi
Efek apraksia -> menurunkan
kemampuan untuk makan secara
mandiri
Page 39
FAKTOR RESIKO PENYAKIT

STROKE
Page 40
FAKTOR RESIKO
Page 41
STROKE
Page 42
Tabel 5. Faktor-faktor stroke yang berhubungan

dengan nutrisi
Faktor-faktor resiko
Faktor-faktor proteksi
BMI > 27 kg/m2
Asupan total
lemak terutama
omega-3
Penambahan BB > 11 kg selama Konsumsi buah-buahan sehari-hari
16 tahun (wanita)
Rasio
lingkar
pinggang-lingkar Konsumsi flavonoid > 4.7 cangkir
pinggul > 0.92 (laki-laki)
teh hijau/hari
Diabetes
Konsumsi ikan pada wanita kulit

putih dan hitam dan pria kulit
hitam
Hipertensi
Kolesterol tinggi
Page 43
Page 44
Penatalaksanaan Stroke
Umum: 5 B (breathing, blood, brain, bladder,
bowel), obat proteksi sel otak, terapi terhadap
faktor risiko dan penyulit, rehabilitasi medis.
Spesifik:
stroke non hemoragik: asetosal, neuroprotektor, trombolisis,
antikoagulan.
stroke hemoragik: mengobati penyebabnya, neuroprotektor,
tindakan pembedahan, menurunkan tekanan intrakranial
yang tinggi.
Page 45
NUTRISI PADA PASIEN

STROKE
Page 46
TUJUAN PENGELOLAAN NUTRISI

Mencegah dan menangani malnutrisi
Mempertahankan fungsi neurologi
Fasilitasi pengembalian fungsi-fungsi
tubuh secara optimal
Page 47
JALUR PEMBERIAN NUTRISI

Nutrisi enteral
Nutrisi parenteral (perifer atau sentral)
Kombinasi enteral + parenteral
Page 48
INDIKASI NUTRISI
ENTERAL DAN
PARENTERAL
Penilaian Nutrisi
Keputusan untuk memulai Dukungan Nutrisi Khusus
Fungsi Saluran Pencernaan

Ya
Tidak
Nutrisi Parenteral
Nutrisi Enteral
Jangka pendek
Nasogastrik
Nasoduodenall
Nasojejunal
Jangka panjang
Gastrostomi
Jejunostomi
Fungsi Sal Cerna

Normal
Nutrisi
Parenteral Perifer
Jangka panjang atau

Pembatasan cairan
Nutrisi
Parenteral Total
Compromised
Nutrisi Lengkap
Mencukupi
Berlanjut ke
Makanan
Oral
Jangka pendek
Formula Khusus
Nutrients
Tolerance
Tidak mencukupi
Nutrisi parenteral
Sebagai suplemen
Dilanjutkan ke nutrisi
Enteral total
Fungsi saluran
cerna membaik
Mencukupi
Diet yg lebih
Kompleks dan
Makanan oral
Sesuai dengan
penerimaan
Free Powerpoint
Ya
Tidak
Sumber: ASPEN Board of Directors

Guidelines for the use of Parenteral and
Enteral Nutrition in adult and pediatric
Patients. JPEN 1993: 17.
Templates
Page
49
KEUNTUNGAN NUTRISI ENTERAL

Ekonomis
Memacu sekresi hormon pencernaan
Mencegah atrofi villi
Menghambat pertumbuhan bakteri dan
translokasi bakteri
Tanpa resiko sepsis kateter dan flebitis.
Heimburger, Douglas C. Handbook of Clinical Nutrition. Mosby, 1997. P 209 211.

Page 50
KAPAN NUTRISI ENTERAL DIBERIKAN

Pemberian nutrisi enteral
direkomendasikan setelah kondisi
hemodinamik stabil
Memasuki fase flow
Page 51
PEMBERIAN NUTRISI ENTERAL
Diberikan secara oral

perhatikan cita rasa
Bisa juga menggunakan cara :
Nasogastric feeding
Page 52
INDIKASI NUTRISI PARENTERAL

1.
2.
3.
4.
5.
6.
7.
8.
post op 3-4 hari

peradangan usus
fistula enterokutaneus
short bowel sindrom
pankreatitis akuta, tambahan oral kebutuhan meningkat
hiperkatabolik akut renal failure
terapi tambahan kanker
luka bakar hebat, malformasi traktus gastrointestinal (TGI)
pada neonatus
9. koma hepatik
Page 53
Page 54
Tabel 6. Studi efikasi asupan enteral setelah

terjadinya stroke
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Page 56
Tabel 7. Modifikasi tekstur-cairan dan makanan

Texture
Description of fluid texture
Fluid
Thin fluid
Still water
Naturally thick fluid
Product leaves a coating on a empty glass
Thickened fluid
Fluid to which commercial thickener has been added to thicken

consistency
Can be drunk through a straw
Can be drunk from a cup if advised or preferred
Leaves a thin coat on the back of a spoon
Stage 1
Stage 2
Cannot be drunk through a straw

Can be drunk from a cup
Leaves a thick coat on the back of a spoon
Stage 3
Cannot be drunk through a straw

Cannot be drunk from a cup
Needs to be taken with a spoon
A smooth, pouring, uniform consistency

A food that has beeb pureed and sieved to remove particles
A thickener may be added to maintain stability
Cannot be eaten with a fork
A smooth, pouring, uniform consistency

A food that has beeb pureed and sieved to remove particles
Cannot be eaten with a fork
Drops rather than pours from a spoon but cannot be pipped or
layered
Thicker than A
Food
A
Page 57
Tabel 7. Modifikasi tekstur-cairan dan makanan

C
A thick, smooth, uniform consistency

A food that has beeb pureed or sieved to remove particles
Can be eaten with a fork or a spoon
Will holds its own shape on a plate, and can be moulded,
layered and piped
No chewing required
Food that is moist, with some variation in texture

Has not been pured or sieved
These foods may be served or coated with a thick gravy or
sauce
Foods easily mashed with fork
Meat should be prepared as C
Requires very little chewing
Dishes consisting of soft, moist food

Foods can be broken into pieces with a fork
Dishes can be made up of solids and thick sauces or gravies
Avoid foods which cause a choking hazard
Normal
Any foods
Page 58
Page 59
PENGELOLAAN NUTRISI
Stroke akut hipermetabolik
Pasca stroke
Penilaian status nutrisi
Pemeriksaan dan penghitungan kebutuhan
nutrien
Penentuan jenis,
pemberian nutrien
bentuk,
cara
dan
jalur
Pemantauan dan evaluasi penyesuaian

Page 60
Energi cukup. fase akut: 1100-1500 kkal/hari atau 25

kkal/kgBB per hari
Protein 15-20% dari total energi atau 1,2-1,5 g/kgBB

per hari. GGK: protein diberikan rendah, yaitu 0,6
g/kgBB.
KH minimal 150 g atau 50-65% dari kebutuhan energi

total.
Lemak 2 g/kg/BB/hari atau 20-30% dari kebutuhan

energi total. t.u lemak tidak jenuh ganda, batasi
sumber lemak jenuh, yaitu < 10% dari kebutuhan
energi total. Kolesterol < 300 mg.
National Cholesterol Education Program (NCEP)

merekomendasikan asupan lemak < 30% total energi,
SFA <7%, MUFA<15%. PUFA) <10% dengan
cholesterol < 200 mg.13,15
Page 61
Cairan: minimal 1500 ml per hari pd

pasien dg berat 50-80 kg.
Supplementasi vitamin dan mineral
sesuai dengan Recomended Dietary
Allowances (RDAs)
Serat cukup me kadar kolesterol
darah dan mencegah konstipasi.
Bentuk makanan disesuaikan dengan
keadaan pasien
Diberikan dalam porsi kecil dan sering.
Bila ada demam, maka kebutuhan
kalori ditambahkan sebesar 13%
Page 62
Tahapan
Page 63
Page 64
PENILAIAN KEBUTUHAN KALORI

Sangat sulit
Basal Expenditure Energy (BEE) bisa
meningkat
Estimasi BEE:
A. Indirect Calorimetri
B. Harris Benedict Equation
C. Resting Expenditure Energy (REE)
Page 65
KEBUTUHAN ENERGI BASAL (KEB) =

HARRIS BENEDICT EQUATION
LAKI-LAKI
BEE = 66 + 13,7 W + 5 H 6.8 A
PEREMPUAN
BEE = 655 + 9.6 W + 1.7 H 4.7 A
Page 66
KEBUTUHAN ENERGI KOREKSI =

KEB x faktor aktivitas x faktor stres
ACTIVITY FACTORS
1,2 for pt confined in bed
1,3 for ambulatory pt
1.5 1,75
most normally active person
2,0 extremely active person
STRESS FACTORS
1,2 minor surgery
1,35 skeletal trauma
1,44 elective surgery
1,6 1,9
mayor sepsis
1,88 trauma plus steroid
2,1 2,5
severe thermal burn
Page 67
PEMBERIAN KALORI BERDASARKAN

Antropometri
Timbang berat badan (BB)
Kasus BB normal dan cenderung malnutrisi
BB actual ( Brocca)
Orang dewasa dengan obesitas
menggunakan perhitungan BB Ideal (BBI)
Page 68
PENILAIAN STATUS NUTRISI

Penilaian perubahan body composition akibat
berkurangnya pergerakan badan
Pemeriksaan biokimia
laboratorium
Pasca perawatan malnutrisi dukungan nutrisi

yang adekuat
Page 69
MODEL DIET
Diet langkah I
Total lemak 30%
Lemak jenuh < 10%
PUFA
: sampai 10%
MUFA
: sampai 15%
KH
: 55%
Protein
: 15%
Kolesterol : < 300 mg/hari
Diet langkah II
Total lemak 30%
Lemak jenuh < 7%
PUFA
: sampai 10%
MUFA
: sampai 15%
KH
: 55%
Protein
: 15%
Kolesterol : < 200 mg/hari
Page 70
PENILAIAN KEBUTUHAN LEMAK

Menurunkan lemak total
Menurunkan lemak jenuh dan
kolesterol
Menurunkan kalori apabila
penderita overweight /obese
Page 71
PENILAIAN KEBUTUHAN PROTEIN

Ekskresi nitrogen
Anjuran
bertahap
: 1.5 2.2 g/kgBB/hari secara
Pemantauan
: UUN dan kreatinin urin
Monitor
: fungsi ginjal (ureum &
kreatinin) dan fungsi hepar
Brain Chaned Amino Acid (BCAA) dapat
dipertimbangan (pada pasien dengan hepatic
encephalophaty)
Serum albumin dipertahankan diatas 2.2 g/dL.
Page 72
CARA MENGHITUNG KEBUTUHAN NITROGEN

1. Berdasarkan sekresi urea pada urine [urinary urea nitrogen
= UUN]. Untuk ini dibutuhkan urine tampung 24 jam.
Langkah-langkah yang harus dilakukan:
Ukur UUN 24 jam
Hitung total UUN dengan menggunakan rumus:
totalUUN
[UUN ][Vol .Urine]

100
Hitung asupan protein penderita/hari

Hitung nitrogen balans dengan menggunakan rumus:
N [ g / hari ]
A sup an Pr otein
[UUN 4]
6.25
Keterangan : asupan protein yang dikonversi ke nitrogen = 6.25

UUN = 4 gr [rata-rata nitrogen yang dikeluarkan selain melalui
urine]
Page 73
Contoh:
Seorang penderita yang mempunyai asupan protein
62.5 g/hari sekresi urin 500 mg/dl UUN dalam 2000
ml urine
Maka:
UUN = 500 x 2000/100
= 10.000 mg atau 10 gr
N [g/hari] = [62.5/6.25] [10 + 4]
= 10 14
= - 4 (negatif nitrogen balance)
Page 74
2. Berdasarkan kebutuhan energi penderita:

tentukan kebutuhan energi penderita dalam sehari
Perkirakan ratio energi dan nitrogen, hal ini bervariasi
tergantung kondisi penderita. Dapat digunakan 1:150 untuk
proses anabolisme dan atau 1:200 untuk maintenance
Hitung kebutuhan nitrogen dengan menggunakan rumus:
Kcal
Contoh:
KebutuhanN [ g ]
: Nratio
Diasumsikan kebutuhan energiKcal
penderita
sehari=2250 kcal,
dan ratio kcal nitrogen 1:150, maka kebutuhan nitrogen
penderita tersebut adalah:
2250
N[ g ]
15 gNitrogen
Dengan menggunakan hasil
tersebut
di atas dapat
150
ditentukan kebutuhan protein:
Pro[g] = Nitrogen [g] x 6.25
= 15 x 6.25
= 95.75 protein
Page 75
PENILAIAN KEBUTUHAN ELEKTROLIT
Monitor kadar elektrolit dalam darah : Na, K,

Cl , HCO3, Ca
Monitor Blood Gas
Jika terjadi hipertensi maka diet -> diet

rendah garam sesuai dengan keadaan
klinisnya (derajat hipertensi)
Page 76
PENGELOLAAN NUTRISI PADA PASCA STROKE
Pantau sesering mungkin

Modifikasi diet
Modifikasi diet bila ada kesulitan menelan
Page 77
KEBUTUHAN KALORI PASCA STROKE
23 28 kcal/kgBB/hari (parese)
Pantau BB : hindari BB yang berlebihan
Dekubitus tingkatkan kebutuhan protein
Page 78
KESIMPULAN
Page 79
1. Stroke merupakan penyakit vaskuler bersifat kedaruratan medis

dengan morbiditas dan mortalitas yang tinggi di dunia dan di
Indonesia.
2. Malnutrisi dapat terjadi pada pasien stroke akut yang disebabkan
oleh faktor hipermetabolisme, hiperkatabolisme, gangguan saluran
cerna dan defisit kognitif.
3. Faktor resiko terjadinya stroke yang berkaitan dengan nutrisi dan
dapat dimodifikasi adalah hipertensi, diabetes melitus, konsumsi
alkohol, peningkatan kadar lipid dalam darah dan merokok .
4. Manajemen nutrisi pada pasien stroke adalah pemberian nutrisi
enteral dini pada fase flow (< 72 jam) dengan kebutuhan energi
terkoreksi , diet dislipidemia, kebutuhan protein sesuai kebutuhan
serta diet rendah garam
Page 80
GANGGUAN MAKAN
(EATING DISORDER)
Page 81
EATING DISORDER
Anorexia Nervosa
Bulimia Nervosa
Other Conditions
Page 82
CHAPTER OBJECTIVES
1. Contrast healthy attitudes toward uses of food with
behavior pattern that could lead to unhealthy uses of
food
2. Outline the causes of, effects of, typical persons
affected by and treatment for anorexia nervosa.
3. Outline the causes of, effects of, typical persons
affected by and treatment for anorexia bulimia
4. Describe still other forms of eating disorder; bingeeating disorder, night eating syndrome and the athlete triad
5. Relate the presence of eating disorders to current
social trends
6. Describe methods to reduce the development of eating
disorders, including the use of warning signs to identify early
cases
Page 83
OBJECTIVES
To understand the differences between
various eating disorders e.g. anorexia and
bulimia nervosa
To consider causative factor presenting
features,
at
risk
groups,
medical
complications, prevention and treatment
Page 84
CHAPTER OUTLINE
1.
2.
3.
4.
5.
Refresh your memory

From ordered to disordered eating habits
Anorexia Nervosa
Anorexia Bulimia
Prevention of eating disorders
Page 85
REFRESH YOUR MIND

YOU MAY REVIEW:
The effects of neurotransmitters on food
intake
The role of genetic risk in disease
susceptibility
Calculation of BMI
The effects and treatment of osteoporosis
The effects and treatment of iron deficiency
anemia
Page 86
EATING BEHAVIORS
Why do we eat?
Internal hunger
Energy external pleasure, social,
personality, environment
What is abnormal eating behavior?
Abnormal eating behavior = eating disorder?
Page 87
EATING BEHAVIORS
Why do we stop eating ?
We stop eating when we are satisfied?
Eating is a behavior, not necessarily related to
hunger or fullness
Page 88
MANY OF US, OCCASIONALLY EAT UNTIL WERE

STUFFED AND UNCOMFORTABLE
Problems controlling our food intake and body weight
Progressive weight gain lead to medical problems
Associated with simple overeating and too little physical
activity
Obesity chronic diseases most common eating
disorder in our society
Some people are more susceptible to these eating
disorders than other people are for genetic,
physiological and physical reasons
Successful treatment must go beyond nutritional
therapy
Eating disorders any age in both female and male, not
restricted to any socio-economic class or ethnicity
Page 89
FROM ORDERED TO DISORDERED EATING

HABITS
Eating : completely instinctive behavior for animal
extra ordinary number of physiological, social
and culture purposes for humans
Take a religion meanings
Signify bonds within family and ethnic groups
Provide a means to express hostility, affection,
prestige or class values
Within the family, supplying, preparing and
distributing food may be a means of expressing
love, hatred or even power
Page 90
IN FACT
MEDIA, AUDIOVISUAL INFLUENCES
Ultraslim body will bring :
happiness
Love
ultimately success
Contradictory
Much society becoming fatter/obese
Page 91
FOOD :
MORE THAN JUST A SOURCE OF
NUTRIENTS
From birth adult; food link with personal
and emotional experiences
Food can be symbol of comfort
Eating stimulate neurotransmitter
(serotonin)
and
natural
opiods
(endorphins)---produce a sense of calm
and euphoria in the human body
Stress some people turn to food for a
drug like, calming effect
Page 92
USING FOOD AS A BARGAINING

Contributing to abnormal eating behavior
Extreme lead to disordered eating
Mild or short term change effect of
stressful or illness or desire to modify the
diet for variety of health and personal
appearance reason
Problems bad habit, a style eating adapted
from friends or family members or an aspect of
preparing for athlete competition
Disordered eating:
lead to weight loss or weight gain
certain nutritional problems
requires in depth professional attention.
sustained, distressing professional
intervention
Page 93
ANOREXIA NERVOSA
An eating disorder involving a physiological
loss or denial of appetite
Followed by self starvation
Related in part to distorted body image and to
various social pressure commonly associated
with puberty
Page 94
BULIMIA NERVOSA
An eating disorder in which large quantities of
food are eaten at one time (binge eating) and
then purged from the body by vomiting or
misuse of laxative, diuretics or enemas
Alternate means to counteract the binge
behavior are fasting and excessive exercise
Page 95
BINGE EATING DISORDER

An eating disorder characterized by recurrent
binge eating and feelings of loss of control over
eating that have lasted at least 6 months
Can be triggered by frustration, anger,
depression, anxiety, permission to eat forbidden
food and excessive hunger
Page 96
PROGRESSION FROM ORDERED TO

DISORDERED EATING
Anxiety to hunger and satiety signal;
limitations of calorie intake to restore weight
to healthful level
Some disordered eating habits begins as
weight loss is attempted very restricted
eating
Clinically evident eating disorder recognized
Page 97
MEDICAL COMPLICATIONS OF ANOREXIA

NERVOSA AND BULIMIA NERVOSA
Cardiovascular : arrhythmia, bradycardia, oedema

cardiomyopathy, hypotension, peripheral cyanosis
Dermatologic
: callus formation on hands, carotene
pigmentation, dry skin/nails, lanugo hair, thinning scalp hair, irritation
at corners of mouth
Endocrine
: amenorrhoea, decreased triiodothyronine and
thyroxine levels, increased cortisol and growth hormone levels
Gastrointestinal : bloating, early satiety, constipation, dental caries,
diarrhoea, oesophageal rupture
Hematologic
: mild anaemia, low white blood cell count
Metabolic
: hypokalemia, hyponatremia, hypokalemia
Musculoskeletal : delayed bone maturation, reduced stature,
osteoporosis, seizures
Page 98
TYPICAL CHARACTERISTIC OF ANOREXIA

NERVOSA
Loss weight >85% : BMI <17,5

False body perception
Ritual involving food
Maintain of rigid control in lifestyle
Felling of panic after small weight gain
Felling of purity, power and superiority
Preoccupation of food
Helplessness in the presence of food
Lack of menstrual periods for at least 3
months
Possible presence of bingeing and purging
practices
Page 99
TYPICAL CHARACTERISTICS OF BULIMIA

NERVOSA
Secretive binge eating (not in front of others)
Eating when depressed or under stress
Bingeing on a large of food followed by
fasting, laxative or diuretic abuse, itself
induce vomiting or excessive exercise
Fluctuating weight
Shame,
embarrassment,
deceit
and
depression, low self esteem and guilt
Loss of control, fear of not being able to stop
eating
Perfectionism ; people pleaser
Erosion of teeth, swollen glands
Purchase of syrup of ipecac to induces
vomiting
Page 100
PHYSICAL EFFECTS OF ANOREXIA NERVOSA
Lower body temp

Slowed metabolic rate from decreased synthesis of thyroid gland
Decreased heart rate
Iron deficiency anemia
Rough, dry, scaly, and cold skin
Low WBC
Abnormal feeling of fullness or bloating
Loss of hair
Appearance of lanugo
Constipation
Low blood potassiumheart rhythm disturbancedeath
Loss of menstrual periods
Loss of teethacid erosion
Muscle tears and stress fractures in athlete--- decreased bone and
muscle mass
Page 101
TREATMENT OF ANOREXIA NERVOSA

Nutrition therapy
Gain the persons cooperation and trust
Gain weight 2-3 pounds/weeks
Monitoring blood levels of mineral (K, PO4,
Mg)
Maintain adequate food intake
Psychological and related therapy
Emotional problems
Use cognitive behavior therapy
Family therapy
Food is a drug of choice for anorexic patient
Page 102
HEALTH PROBLEMS STEMMING

FROM BULIMIA NERVOSA
Demineralization of teeth as an impact
of the acid in vomit
Blood potassium drops significantly
Salivary gland swollen
Stomach ulcer and bleeding
Constipation
Ipecac syrup induced vomitingis toxic
to the heart, liver and kidneys
Page 103
Salivary gland swollen
Page 104
TREATMENT OF BULIMIA NERVOSA

Decreased the amount of food consumed in
binge session
Psychotherapy improved self acceptance
less concern about body weight
Cognitive behavior
Pharmacological therapy may be
beneficial in conjunction with other therapy
Nutrition counseling
Correcting misconceptions about food
Re-establishing regular eating habits
DEVELOPING REGULAR EATING HABITS
Page 105
KESIMPULAN
Page 106
1. Persepsi yang berbeda terhadap makanan yang mempengaruhi

penampilan akan menimbulkan gangguan makan (eating disorder)
2. Gangguan makan dapat berupa anoreksia nervosa dan bulimia
nervosa
3. Anoreksia nervosa akan berusaha menyangkal rasa lapar yang
dialaminya (self starvation). Hal ini berkaitan dengan persepsi yang
salah terhadap penampilan dirinya
4. Bulimia nervosa, pasien akan merasa bersalah makan dalam porsi
yang besar sehingga akan berusaha mengeluarkan kembali
makanan tersebut (rangsang muntah)
5. Anoreksia nervosa dan bulimia nervosa akan mengganggu sistem
dalam tubuh
6. Manajemen pada kedua gangguan makan tersebut adalah terapi
nutrisi dan psikologik
Page 107
TERIMA KASIH
Page 108

Manajemen Nutrisi Pada Pasien Stroke Dan Gangguan Makan

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NUTRISI PADA PASIEN

dr. Agussalim Bukhari, M.Med, Ph.D, Sp.GK(K)

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PERUBAHAN STATUS GIZI PADA

asupan zat gizi

MALNUTRISI PADA PASIEN

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Tabel 1. Insidens malnutrisi pada kejadian stroke

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Tabel 1. Insidens malnutrisi pada kejadian stroke

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Tabel 1. Insidens malnutrisi pada kejadian stroke

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Tabel 1. Insidens malnutrisi pada kejadian stroke

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Tabel 1. Insidens malnutrisi pada kejadian stroke

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ADA 3 HAL PENTING PADA KASUS

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Peningkatan kecepatan metabolik

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Tabel 2. Studi pengukuran kebutuhan energi

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Peningkatan kecepatan metabolik

CHARACTERISTIC OF METABOLIC PHASE OCCURRING

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Gambar 2. Respon metabolik pada stroke

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Tabel 3. Studi yang melaporkan terjadi peningkatan

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Gangguan fungsi saluran

45%-55% pada pasien rawat inap dengan stroke akut.

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Tabel 4. Hubungan antara disfagia dan terjadinya

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FAKTOR RESIKO PENYAKIT

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Tabel 5. Faktor-faktor stroke yang berhubungan

BMI > 27 kg/m2

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NUTRISI PADA PASIEN