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MANAJEMEN GIZI PADA

KELAINAN ENDOKRIN
( OBESITAS, DM, DISLIPIDEMIA)

Nurpudji A Taslim
Bagian Ilmu Gizi
FK-UNHAS
@2005.

DIABETES MELLITUS

DIAGNOSIS CRITERIA
of DIABETES MELLITUS

WHO 1999
Symptoms of Diabetes plus casual
plasma glucose concententration > 200
mg/dl or
FPG > 126 mg /dl or
Or 2 h-plasma glucose > 200 mg/dl

Environmental factors

Environmental factors
Overeating
Inactivity
Smoking
Diabetogenic drugs

Genetic factors
Unknown

Genetic factors
Unknown

Insulin resistance

Pregnancy
Endocrine diseases
Diabetogenic drugs
Malnutrition in utero

B- cell defects
Glucose toxicity
Hyperglycaemia
Impaired glucose
tolerance

Worsening B-cell functions


? Amyloid deposition
Malnutrition in utero

NIDDM

DIAGNOSIS CRITERIA OF
DIABETES MELLITUS
Oral Glucose Tolerance Test
(WHO Criteria 1985)
Diabetes mellitus

IGT

Basal

>140 mg / dl

After 2 hrs

>200 mg / dl

Basal

<140 mg /dl

After 2 hrs
Normal

140 -199 mg / dl

Basal

<140 mg /dl

After 2 hrs

<140 mg / dl

DIABETES MELLITUS

PENDAHULUAN
Menyerang segala lapisan umur dan sosial
ekonomi
Prevalensi 1,5% - 2,3% pada penduduk usia
> 15 tahun
Tahun 2020
> penduduk 178 juta,
diperkirakan DM 3,56 juta
Antisipasi untuk mencegah dan
menanggulangi timbulnya ledakan pasien DM
harus dimulai dari sekarang

II. PEMERIKSAAN PENYARING


Mass-screning> mahal
Perlu dilakukan pada kelompok resti
* > 40 tahun,
* Obesitas,
* Hipertensi,
* Riwayat DM pada kehamilan
* Dislipidemia
* Riwayat dengan kelahiran BBLR

III. KLASIFIKASI
* DM
- IDDM
- NIDDM
- MRDM
- DM tipe lain
* Toleransi glukosa terganggu
* DM gestational

IV. DIAGNOSIS
Gejala klasik
Polidipsi
Poliuri
+ GDS > 200 mg/dl
Polifagi
Gejala penyerta lain

V. PENGELOLAAN DM
1. Tujuan
- Jangka pendek : menghilangkan keluhan
/ gejala.
- Jangka panjang : mencegah komplikasi
- Cara
: menormalkan kadar
glukosa dan lipid
- Kegiatan
: - mengelola pasien
secara holistik
- menganjurkan
perawatan mandiri.

PILAR UTAMA
PENGELOLAAN DM
1. Perencanaan

makan
2. Latihan jasmani
3. Penyuluhan
4. Obat berkhasiat hipoglikemik
(Interna)

PERENCANAAN MAKAN
DAN OLAH RAGA
* MAKANAN KOMPOSISI SEIMBANG :
- KH
- P
- L

( bervariasi 55-60%)
10 15 %
20 25 %

Kalori sesuai kebutuhan


Kolesterol < 300 g / hr
Serat + 25-35 gr / hr
OLAH RAGA 3 4 DALAM SEMINGGU

PENYULUHAN DM
* PRIMER

- Pasien yang disuluh :


1. Kelompok RESTI
2. Perencana kebijaksanaan kesehatan
- Materi :
Faktor faktor yang berpengaruh
pada timbulnya DM dan usaha untuk
mengurangi faktor resiko

* SEKUNDER
- Pasien yang disuluh :
Kelompok pasien DM (baru)
- Materi :
= Definisi DM
= Penatalaksanaan secara umum
= Obat
= Perencanaan makan dengan
bahan penukar.

TERSIER

- Mengenal dan mencegah


komplikasi
- Kesabaran dan ketekunan dapat
menerima dan memanfatkan
keadaan hidup dengan komplikasi
kronis

OBESITAS

Gizi Baik = Gizi seimbang


(Asupan zat gizi = Kebutuhan zat gizi)

Garis
normal

Asupan

Kebutuhan

Kurang Gizi = Gizi tidak seimba


(Asupan zat gizi < Kebutuhan zat gizi)

Garis
normal
Asupan

Kebutuhan

Gizi Lebih = Gizi tidak seimban


(Asupan zat gizi > Kebutuhan zat gizi)

Garis
normal
Kebutuhan

Asupan

Ibu hamil

Bayi
BBLR 16%
KEP/ISPA/
diare/IMR

Balita
KEP 30%
GAKI
Diare/ISPA

anemia 60%
HAP/HPP
MMR 390/100000

* brain development
* loss generation

* Drop out

Anak sekolah
* KEP/Anemia
* drug use
* kinerja akademik

Mahasiswa:
* gizi/enmia

Tenaga kerja
* Anemia
* tbc, malaria,
* CVD
* Produktivitas <<

GIZI-KESEHATAN
DAN
ECONOMIC LOST

Economic
lost

Usila:
* tbc, malaria
* CVD, Ca
* Gizi

Penilaian Kegemukan
BBI
TLK
IMT

: - < 18.5
- 18.5 22.9
- 23 24.9
- 25 29.9
- > 30

underweight
normal
overweight
obese I
obese II

Pendahuluan
Dokter saat ini mengatasi akibat dari obesitas
daripada obesitas itu sendiri.

pasien mendapat obat untuk penyakit lain


hasilnya tetap kurang memuaskan.

Prevalence
World (BMI 30):
7% adult population
China, Japan, and Africa (BMI 30):
< 5%
England (BMI > 30):
17.3% & 16%
Urban Samoa (BMI 30):
75% & 60%
Indonesia
(BMI >25):
7.1 % & 4.2% (1982)
24.1% & 10.9% (1992)
51.4% & 43.6% (2001)

Researches in
Indonesia
Independent institution research in community (Insight)

Lack of obesity knowledge

Lack of BMI knowledge

84 % : want to loose weight

50 % : do not understand the problem

65 % : obesity = not a disease


HISOBI (ISSO), ongoing epidemiology research 2003

FFA

Adipose
Tissue

Lipid
FFA
Leptin
Adiponectin
Visfatin
Resistin
Adipsin (ASP)
Angiotensinogen/AT-II
Cytokines
(TNF, IL-6)

Prostaglandin NO PAI-1

Adipokines Secreted by Adipose Tissue

Produksi Energi dan Keseimbangan Energi


Energy Production and Energy Balance
Basal
metabolism

Carbohydrate
Protein

Fat

Thermic effect
of food

Physical
activity
Adaptive
thermogenesis

Klasifikasi
WHO (1998)

Asia Pacific (2000)

IMT
Risiko
(Kg/m2) ko-morbiditas

IMT
Risiko
(Kg/m2) ko-morbiditas

BB kurang < 18.5


Rendah
Normal
18.5 - 24.9 Normal
BB lebih 25.0 - 29.9 Meningkat
Obes I
30.0 - 34.9 Moderat
Obes II
35.0 - 39.9 Berat
Obes III
> 40 Sangat berat

BB kurang < 18.5


Rendah
18.5 22.9 Normal
Normal
> 23
BB lebih
23 24.9 Meningkat
Berisiko
25 29.9 Moderat
Obes I
> 30
Obes II
Berat
Report of the WHO Consultation of Obesity, 1997
The Practical Guide, NIH, NHLBI, 1998
The Asia Pacific Perspective: Redefining obesity & its treatment, 2000

Lingkar Perut
WHO 2000
94 cm ()
80 cm ()
Eropa
102 cm ()
88 cm ()
Asia Pasifik
90 cm ()
80 cm ()

Risk-Benefit Assessment
Relative Risk & BMI

Clinical Classification of
overweight
Anatomic classification
Etiologic classification
Functional calssification

Anatomic Characteristics of
Adipose Tissue and Fat
Distribution
Number of fat cells
Fat distribution

The distribution of adipose


tissue or body fat can be
divided into three components
The first is the percentage of body fat
The second is the distribution of fat into :
1.

Android obesity-upper segment or male type of obesity


where fat is primarily on the trunk and shoulders

2.

Gynoid obesity-lower segment of female obesity-in which


the primary fat deposits is located on the thighs or hips

The third is visceral fat, as intra-abdominal depot increases


with age and carries the highest risk for developing
cardiovascular and other disease consequences

Etiologic classification
1. Neuroendocrine obesity
2. Drug induced weight gain
3. Cessation of Smoking
4. Sedentary lifestyle
5. Diet

Neuroendocrine
Obesity
Hypothalamic
Cushings syndrome
Hypothyroidism
Polycystic ovary syndrome
Growth hormone

Diet

Overeating
Restrained eating
Dietary fat intake
Night-eating syndrome
Binge-eating
Infant feeding practices
Progressive hyperphagic
obesity

Classification of obesity
I.

Anatomic classification
A. Microscopic
1. Fat cell size
2. Fat cell number
B. Macroscopic
1. Total body fat
2. Subcutaneous fat distribution
3. Visceral fat
4. Abnormal or unusual fat deposits

Obesity and Cardiovascular


Risk
Dyslipidaemia
Total-C LDL-C
Triglycerides
Apo-B HDL-C

Endothelial
dysfunction

Hypertension
Left ventricular
hypertrophy
Congestive heart
failure

Visceral
Obesity

Prothrombosis
Fibrinogen
PAI-1

Insulin resistance
Glucose intolerance
Hyperglycaemia
Type 2 diabetes
Renal
Hyperfiltration
Albuminuria

Inflammatory
Response

Expectations

Patient-Doctor
Expectations
% subjects
achieving goal

Dream weight

Weight loss (kg)


to achieve goal
(%)
37.7 (38)

Happy weight

31.1 (31)

9%

Acceptable weight

24.9 (25)

24%

Disappointed weight

17.2 (17)

20%

Below disappointed
weight

____

47%

Imagined goal

Baseline weight= 99.1 kg

Dasar terapi obesitas


Kegemukan lemak tubuh
> 30 % BB wanita
> 25 % BB pria
Aktifitas fisik berkurang- intake tetap
Negara maju ------------ sosek rendah
Negara berkembang --- sosek
menengah keatas.

Faktor faktor Kegemukan

Jenis kelamin
Umur
Kelas sosial
Kebiasaan makan
Aktifitas fisik
Faktor psikologis
Faktor hormonal

RISIKO OBESITAS
Risiko obesitas dibagi atas 2 golongan :
Risiko psikososial
Risiko medis

Penanganan Kegemukan
Prinsip :
Mengusahakan keseimbangan
energi yang negatif dalam tubuh,yaitu dengan
mengurangi intake dan memperbesar output.
Terapi diet
Aktifitas fisik / olah raga
Perubahan sikap
Terapi farmakologis
( obat-obatan dan operasi )

Diet Terapi

Pengurangan kalori 500 1000 cal / hari


Lemak total < 30 % total kalori
SFA 8 10 % total kalori
MUFA sampai 15 % total kalori
PUFA sampai 10 % total kalori
Kolesterol < 300 mg / hari
Serat 20 30 gr / hari

Aktifitas Fisik
Olah raga yang dilakukan
F frekuent
I Intensitas
T Time
T Type

Perubahan Sikap
Self Monitoring
Stimulus control
Technique for self reward

Terapi Obat & Operasi


Terapi lain 6 bulan gagal
IMT > 30, IMT > 27 risiko
kegemukan
Operasi bila IMT > 40, IMT > 35
dengan risiko kegemukan

Tujuan
Diet Rendah Kalori
Menurunkan BB
Retriksi diet

Syarat Diet Rendah Kalori

Pengurangan kalori 500 1000


kalori / hari
Asupan protein normal atau
sedikit diatas normal
Cukup vitamin dan mineral
Tinggi serat

Jenis Diet Rendah Kalori


Diet rendah kalori I
( 1200 kalori / hari )
Diet rendah kalori II
( 1500 kalori / hari )
Diet rendah kalori III
( 1700 kalori / hari )

VLCD
( Very Low Calori Diet )

200 800 kalori / hari


Obesitas berat
Dokter dan ahli gizi
Kombinasi perubahan gaya hidup
Efek samping

KESIMPULAN
1. Program yang terirtegrasi
2. Keberhasilan tergantung individu
3 Jenis diet tergantung
tingkat
obesitas
4. Komunikasi dan pangawasan

sangat dianjurkan
5 Pemakaian obat dan operasi
dilakukan pada keadaan tertentu

NUTRITION
in
DYSLIPIDEMIA

Diagnosis :
1. Anamnesis & pemeriksaan klinik
2. Observasi visual
3. Pemeriksaan Kimia

Pengaturan Diet
Tujuan :
1. Menurunkan kadar kolesterol darah
2. Menurunkan BB bila terlalu gemuk

Diet Rendah Cholesterol &


Lemak Terbatas
- Penggunaan lemak sedikit di batasi
- Sebagian besar lemak yang digunakan
berjenis lemak tak jenuh
- Penggunaan bahan makanan yang
mengandung banyak cholesterol dibatasi
- Bila terlalu gemuk, jumlah kalori dibatasi.

Cara Pengaturan Diet :


1. Hindarkan penggunaan kelapa, minyak kelapa,
lemak hewan, margarine dan mentega,
sebagai pengganti gunakan minyak yang
berasal dari tumbuhan dalam jumlah yang
ditentukan.
2. Batasi penggunaan daging hingga 2 kali
seminggu ( paling banyak 100 gr ). Makanlah
ikan sebagai pengganti

3. Gunakan susu skim pengganti


susu penuh
4. Batasi penggunaan kuning telur
hingga 3 butir seminggu
5. Gunakan tahu, tempe dan hasil
olahan kacang-kacangan
6. Batasi penggunaan gula dan
sejenisnya
7. Makanlah banyak sayuran buah.

Pencegahan :
1. Sedini mungkin
- Balita
- Anak & remaja
Energi cukup
Makanan bervariasi
Saturated fat < 10 %
Total fat < 30 %
Cholesterol < 300 mg/ hari

2. Periksa darah secara teratur


3. Bagi risiko tinggi beri petunjuk
intensif pengaturan diet
4. Olah raga teratur
5. Perhatikan penyakit yang
menyertai

Risiko tinggi :
1. Upayakan BB normal
2. Asupan kalori sesuai kebutuhan
3. Asupan lemak jenuh < 20 % total
kalori
4. LTJG : LJ = 2 : 1
5. Cholesterol < 250 mg / hari
6. Protein H/N = 1 : 1
7. Konsumsi serat / fiber.

A Model of Steps in
Therapeutic Lifestyle Changes (TLC)
Visit 2
Evaluate LDL
response

Visit I
If LDL goal not
Begin Lifestyle 6 wks
achieved,
Therapies
intensify
LDL-Lowering Tx
Emphasize
reduction in
saturated fat &
cholesterol
Encourage
moderate physical
activity

Visit 3
Evaluate LDL
response
6 wks If LDL goal not
achieved,
consider
adding drug Tx

Reinforce reduction
in saturated fat and
cholesterol
Consider adding
plant stanols/sterols
Increase fiber intake

Consider referral for


Consider referral for
medical nutrition
MNT
therapy (MNT)

Initiate Tx for
Metabolic
Syndrome
Intensify
weight
management
&
physical
activity
Consider
referral
for MNT

Q 4-6 mo

Visit N
Monitor
Adherence
to TLC

Rationale for Medical Nutritional


Therapy (MNT)
Animal models: consumption of SFA &
Cholesterol elevates LDL-C
Human study in 1965 (Hegsted et al & Keys et
al) predictive equations absolute LDL change
Epidemiologic evidence: The Seven Countries
Study, Ni-Hon-San Study
Dietary intervention trial evidence: DART, Lyon
Diet Heart, Lifestyle Heart Trial (Ornish) , etc
Schaefer EJ, Lipoproteins, nutrition, and heart disease, Am J Clin Nutr2002;75:191-212

Therapeutic Lifestyle
Changes (TLC)
Major Features
TLC Diet
Reduced intake of cholesterol-raising nutrients (same
as previous Step II Diet)
Saturated fats <7% of total calories
Dietary cholesterol <200 mg per day

LDL-lowering therapeutic options


Plant stanols/sterols (2 g per day)
Viscous (soluble) fiber (1025 g per day)

Weight reduction
Increased physical activity

What Oil Is Best for


Dyslipidemics?
Scaheffer: The ideal natural oil may be
canola oil because of its low saturated fat
content and its reasonable balance of n-6
to n-3 fatty acids (ratio of 2:1)

Schaefer EJ, lipoproteins, nutrition, and heart disease, am J Clin


nutr2002;75:191-212

LDL-Lowering Therapeutic
Options: Plant Stanols
Plant stanols
> affinity for micelles than cholesterol
Optimum dose: 2 g/day, reduces LDL-C
0.54 mmol/L 25% reduction in CHD
Availability: margarines
Law M, Plant sterol and stanol margarines and health, BMJ Vol 320 25 March
2000, 861-64

LDL-Lowering Therapeutic
Options: Soluble Fiber
Soluble fiber: non-starch polysaccharides
and lignins, resistant to digestion
Example: -glucans, pectin, resistance
starch (crystallized amylose)1
-glucans from oats
1. Cummings JH & Englyst HN,What is dietary fibre?, Trends in Food Science
& Technology, April 1991, pp.99-103

LDL-Lowering Therapeutic
Options: Soluble Fiber
Mechanisms of Hypocholesterolemic effect of
soluble fiber:
Bile acids binding
enterohepatic circulation

Food mass viscosity


< Rate of glucose absorption
lower insulin
conc.
<Cholesterol synthesis
SCFA fermentational products inhibit cholesterol
synthesis
Kerckhoffs et al, Effects on the Human Serum Lipoprotein Profile Of -glucan,
Soy Protein And Isoflavones, Plant Sterols and Stanols, Garlic, And
Tocotrienols, J. Nutr 132: 2494-2505, 2002

In Brief
ATP III incorporates TLC in every step of
treatment
Medical Nutrition Therapy focused on
reduced intake of SFA and cholesterol
Plant stanol and dietary soluble fiber are
recommended

Makanan yang boleh dan tdk boleh


diberikan
Gol.Bhn.Mkn.

Mkn.yg.boleh

Mkn.yg.tdk.boleh

Sumber H.A

Semua

Sumber P. Hewani

Daging,ayam,ikan
Sardin, kerang,
tongkol,tenggiri,telur jantung, hati, limpa,
,susu,keju 50gr/hr
paru, otak, ekstrak
daging/kaldu,bebek,
angsa, burung

Sumber P. Nabati

Kacang-kacangan
atau tahu/tempe
50gr/hr

Gol.Bhn.Mkn.

Mkn.yang.boleh

Mkn.yg.tdk.boleh

Sumber Lemak

Minyak dalam jumlah


terbatas

Sayuran

Semua sayuran
sekehendak kecuali
asparagus,kacang
polong,buncis,kemban
g kol,bayam jamur
maksimum.50 gr/hr

Buah

Semua macam buah

Minuman

Teh,kopi,soda

alkohol

Bumbu dll.

Semua bumbu

ragi