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NUTRISI PADA DIABETES

MELLITUS

OLEH
Prof.Dr.Fadil Oenzil, PhD, SpGK
Peripheral Insulin
Resistance

Decreased glucose
uptake

Hyperglycaemia

Increased insulin
secretion

Flow diagram of the development


Beta-cell exhaution
of type II diabetes

Impaired insulin
secretion

Increased hepatic
Increased FFA Glucose production

diabetese
12
c) Diabetic
Venous plasma glucose level (mmol/L)

10
b) Person with
impaired
8 glucose
tolerance

(a) Normal
4
individual

0 1 hour 2 hour

Time after ingestion of 75 g glucose


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 onset
Ketosis resistent
Insulin 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 ADA
Calori ideal Body ideal body
Carbohydrate % of 60-70% (up to 75%) About 50%
kcal
Protein % 10 – 15% 10-20%
Fat total % 20 – 25% <30%
SAFA % < 10% < 10%
MUFA % Up to 15% 10-20%
PUFA % <10% <10%
Cholesterol mg/day < 300 mg/day < 300 mg/day
Fiber g/day + 25 gr/day 20-35 g/day
Sodium mg/day Normotensi 3000 mg/d < 2400 mg *
Hipertensi < 2400
mg/day
Rekomendasi untuk pasien
dengan diabetes
Zat gizi PDGMI ADA
kalori Berat badan ideal berat badan
karbohidrat 60-70% (sampai Ideal
(% kcal) 75%) About 50%

Protein % 10 – 15% 10-20%


Total lemak % 20 – 25% <30%
SAFA % < 10% < 10%
MUFA % Up to 15% 10-20%
PUFA % <10% <10%
kolesterol mg/hari < 300 mg/day < 300 mg/day
serat g/hari + 25 gr/day 20-35 g/day
Na mg/hari Normotensi 3000 mg/d < 2400 mg *
Hipertensi < 2400
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
Luas daerah dibawah kurva respon glukosa darah
tubuh setelah 2 jam terhadap makanan
Indek Glikemik = X 100%
Luas daerah dibawah kurva respon glukosa darah
tubuh setelah 2 jam terhadap glukosa murni
Glycemic index value by Jenny Miller :
1. Low if glycemic index < 55
2. Moderate if glycemic index 55 – 70
3. Hight if glycemic index > 70

Glycemic index value by Wolever et al :


1. Low if glycemic index < 70
2. Moderate if glycemic index 70 – 90
3. 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
Palisade
parenchyma

Bundle sheath
Spongy
parenchyma

xylem
Vein
phloem Stoma
Bundle sheath

Lower epidermis

Stoma
Tabel : Indeks Glikemik Monosakarida, Disakarida dan Polisakarida Murni dan
Bahan Makanan Sumber Karbohidrat pada Orang Normal

Luas area dibawah kurva Indeks Glikemik (%)


NO Beban yang diberikan
(cm)

1 Glukosa murni 210,9 100

2 Fruktosa murni 45,3 22

162,3 77
3 Madu Sumbawa

4 20,95 10
Laktosa murni
5 Susu Laktogen 28,65 14

6 Kanji 87,73 42
7 Kentang 84,3 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
2.The distribution of carbohydrate
among meals and snacks

Meals In Gram Portion


Breakfast 60 4
Lunch 60 4
Afternoon snach 30 2
Dinner 75 5
Evening snack 30 2
Total 255 g 17

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 :
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 Pati Selulosa Hemiselulosa


USUS
BESAR Pentosa
Heksosa
DIMETABOLISASI
OLEH BAKTERI Glikolisis Lintasan
UNTUK Pentosa
PERTUMBUHAN
BAKTERI Piruvat

PROSES Hidrogen
AKHIR Asetat propionat metana
butirat karbondioksida

HASIL Keluar melalui udara


AKHIR Diabsorpsi oleh Keluar ke feses pernapasan setelah
usus halus dan absorpsi
dimetabolisasikan

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
Micronutrient
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
Glutathione
(Glutamate – Cystein – Glycine)

Selenium : Glutathione peroxidace enzyme co factor

Regeneration of antioxidants reguires Glutathione

R* Vit E
Vit C
GSH NADP

RH
Vit E*
Vit C*
GSSG 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
Zinc
Improve insulin secretion
Enhances binding of insulin
Co 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 μg
Adult women 70 μg
Se content of some food (μg / 100 g of food)
Seafood 100
Organ meat 20
Cereals 20
Dairy 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 mg
Adult women 270 mg
Milligram (mg) per 100 g food
Cocoa Powder 520
Bran Wheat 520
Soya 240
Peanut Raw 130
Chromium
Increase insulin binding to cells,
Increase insulin sensitive
Increase receptor number
Activates 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 183
Brewers yeast 112
Beef 57
Cheese 56
Apple 27
Zinc
Improve insulin secretion
Enhances binding of insulin
Co 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
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 seimbang
2. Asupan kalori dengan mengontrol berat badan
3. Pemberian makanan dengan indek glikemik yang rendah
4. Serat makanan yang cukup (25 gr/hari)
5. Kegiatan fisik teratur, terukur
6. Batasi asupan kolesterol
7. 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