Dr.Risky Ika Riani,Sp.GK

Semarang, 2015

Medical nutrition therapy for METABOLIC DISEASE

DIABETES MELITUS

4 Pilar Penatalaksanaan DM

obat oral insulinDiit Aktifitas fisik

1. Edukasi2. Terapi gizi medis / Medical nutrition therapy (MNT )3. Aktifitas fisik4. Intervensi Farmakologi

Prinsip Penyusunan Diit DM

• Perhitungan kalori sehari sesuai dengan kebutuhan penderita• Mengarah ke berat badan normal• Menunjang pertumbuhan• Mempertahankan kadar glukosa darah dalam batas normal• Mencegah atau memperlambat berkembangnya komplikasi

vascular• Sesuai dengan kemampuan daya beli tiap penderita• Komposisi sesuai kebiasaan / pola makan sehari-hari

Bagaimana penghitungan Kalori?

• Rule of thumb 30-40 kkal/kgBB/hari• Harris Benedict formula- wanita: 655+ (9,6xBB)+(1,8xTB)-(4,7xu)x

Aktiv.fisik x stress factor- pria: 655+ (13,7xBB)+(5xTB)-(6,8 xu)x

Aktiv.fisik x stress factor

Bahan makanan yang dianjurkan

Sumber karbohidrat : nasi, roti, mie, kentang, singkong

Sumber protein rendah lemak : ikan, ayam tanpa kulit, susu skim, tempe, tahu, kacang-kacangan

Sumber lemak dalam jumlah terbatas yaitu makanan yang mudah dicerna.

Makanan yang diolah dengan cara mengkukus, panggang, rebus.

Makanan yang tidak dianjurkan

Gula pasir, gula jawa, sirop, jam, jelly, buah-buahan yang diawetkan dengan gula, susu kental manis, minuman, ice cream

Makanan mengandung lemak : cake, makanan siap saji, goreng-gorengan

Makanan banyak natrium : ikan asin, telur asin, makanan yang diawetkan

Program Pencegahan Diabetes

(American Diabetes Association)

• Menurunkan berat badan 5%• Mengatur diet- asupan lemak < 30% kalori

- asupan lemak jenuh < 10% kalori

- serat 25 g/1000 kkal

• Olahraga (< 150 menit/minggu)

Protein

• Menghasilkan 4 kcal/g• Pasien DM dengan fungsi

ginjal ang baik diberikan 10% - 20% total kcal

• Bila GFR turun 0.6 -0,8 g/kgbb

Lemak• Menghasilkan 9 kcal/gr• Rekomendasi umum <30% total kcal &

lemak jenuh <10% total kalori dapat diberikan pada pasien DM yang mempunyai profil lipid dan berat badan yang normal

• Bila pasien obesitas dan profil lipid tinggi, pengurangan asupan lemak disertai peningkatan aktifitas fisik harus dilakukan

• Bila LDL pasien tinggi lemak jenuh harus dibatasi <7% of total kalori.

Karbohidrat

• Menghasilkan 4 kcal/g• Asupan total KH lebih

penting dari sumber KH itu sendiri.

• Kebutuhan total sehari dapat diberikan secara individual, tergantung dari kebiasaan makan pasien, kadar gula darah, dan target kadar profil lipid yang kita inginkan.

Serat• Rekomendasi : 20 to 35 g/hari• Jangan lupa asupan cairan !• Penting untuk menjaga fungsi GI dan mencegah terjadinya

keganasan GI• Asupan serat yang cukup efektif terhadap perbaikan profil

lipid • Menimbulkan rasa kenyang

Sodium

• Rekomendasi <3000 mg/day• Untuk pasien dengan hipertensi ringan <

2400 mg/day• Sedangkan untuk pasien dengan hipertensi

berat atau dengan edema serta nefropati < 2000 mg/day or less

• Mengatur asupan kalori sesuai kebutuhan pasien tersebut dan mengatur asupan karbohidrat, yakni mengurangi konsumsi

karbohidrat sederhana (makanan yang mengandung tepung2an contoh: jajan pasar, gorengan, roti yang terbuat dari tepung

terigu)• Mengurangi minum minuman manis, mengandung gula, sirup,

minuman berkarbonasi• Mengurangi cemilan terutama yang mengandung tepung, dan

anjuran kepada pasien untuk mengkonsumsi karbohidrat yang tidak mudah diserap (karbohidrat kompleks) seperti beras merah ataupun makanan yang terbuat dari gandum utuh.

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EDUKASI

• Mengurangi makanan yang mengandung kolesterol dan lemak

jenuh serta lemak trans tinggi dengan cara mengurangi

makanan yang digoreng terutama dengan minyak yang

digoreng berkali kali (minyak jlantah).

• Mengkonsumsi makanan dan buah yang mengandung rendah

gula, rendah fruktosa, idak mengandung alkohol (conth: durian,

nangka, nanas) dan kaya antioksidan, bila memungkinkan kulit

pada buah sebaiknya dikonsumsi juga jangan dibuang.

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• Makan makanan yang mengandung tinggi serat larut, yakni

sayuran dan agar agar tanpa gula. Bila perlu menanak nasi

dianjurkan untuk ditambah agar2 tanpa rasa untuk

menambah kandungan serat.

• Makan secara teratur, jenis makanan, jadwal makanan dan

jumlah makanan harus disesuaikan dengan pasien.

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• Kontrol rutin ke puskesmas / pelayanan kesehatan secara teratur 1 bulan sekali, periksa laboratorium secara rutin (monitoring

kadar gula dalam darah) 1 bulan sekali, dan bila memungkinkan pengecekan HbA1C tiap 3 bulan sekali.

• Minum obat secara teratur.

• Memberikan informasi tentang latihan fisik yaitu setidaknya dilakukan 3 kali seminggu secara teratur dengan intensitas ringan

sampai sedang dan lamanya 30-60 menit berupa olahraga aerobik seperti berjalan, berenang, bersepeda (bila keadaan

memungkinkan dan kaki diabetik sudah sembuh) atau dengan menggerakkan otot2 tangan dan kaki secara pasif. Mengajarkan

senam kaki diabetik.

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HIPERTENSI

Heli J. Roy, PhD, MBA, RDPennington Biomedical Research Center

LSU AgCenter

The DASH Diet Plan

PBRC 2011 21

Hypertension Prevalence

• 72 million people in the US age 20 and older have high blood pressure, or 1 in 4.

• One-third of people are unaware they have hypertension.

• Less than half of American adults have optimal blood pressure.

• Increases in prevalence and severity in African Americans.

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PBRC 2011 22

Why is High Blood Pressure Important?

• Makes the Heart work too hard.• Increases the pressure on the walls of arteries

and can cause hardening of arteries.• If left untreated, can cause heart failure,

kidney disease, and blindness.• Increases risk for heart disease and stroke.

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PBRC 2011 23

Untreated Hypertension

Target Organs that are Damaged:• The heart – heart disease• The brain - cerebrovascular disease• The kidneys - renal disease• Arteries - large vessel disease

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What causes High Blood Pressure?• Genetic factors• Being overweight or obese• High salt intake• Narrowing or stiffening of the

arteries• Aging• Loss of elasticity of arterial wall• Stress • Too much alcohol• Organ system disorders

Image: http://www.nhlbi.nih.gov7/29/2011

PBRC 2011 25

Who can develop High Blood Pressure?

Anyone, but it is more common in:• African Americans. They tend to get it earlier

and more often then Caucasians.• Older individuals. 60% of Americans over 60

have hypertension.• The overweight and obese.• Those with family history.

High normal bp:135-139/85-89 mm Hg.

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PBRC 2011 27

• Less than 140/90• Less than 130/80 if have diabetes• Ideally 120/80 or less • Lifestyle Changes when over 135/85

Blood Pressure Goals

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Risk Factors

Non-Modifiable Modifiable• Age• Race/ethnicity• Gender• Family history

• Overweight• Abnormal lipid metabolism• Smoking• Physical inactivity• Unhealthy diet• Excessive alcohol intake

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Lose Weight if Overweight

• If follow DASH diet and increase activity, weight loss should occur gradually

• Even 10 pounds can make a big difference!

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PBRC 2011 30

Reducing Overweight and Obesity

Lifestyle modification:• Reduce caloric intake by 500-1000 kcal/day

(depending on starting weight)• Target 1-2 pound/week weight loss• Increase physical activity• Healthy diet

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Diet and Hypertension

• Non-pharmacologic way of treating hypertension

• DASH diet– Dietary Approaches to Stop Hypertension– High in whole grains, fruits, vegetables, and low-

fat dairy– Adequate Calcium, Potassium, Magnesium– Low in red meat, sweets and sugar beverages– Low in saturated and trans fat, cholesterol

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Mineral Intake and Hypertension

Potassium• Clinical trials and meta-analyses indicate

potassium (K) supplementation lowers BP• Adequate K intake, preferably from food

sources, should be maintained• Evidence is strong enough to support a health

claim on high potassium foods• Best sources are fruits and vegetables

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Mineral Intake and Hypertension

Magnesium• Evidence suggests an association between

lower dietary magnesium intake and high blood pressure

• Food sources are nuts, beans, vegetables

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Mineral Intake and Hypertension

Calcium• American Heart Association Statement– Increasing calcium intake may preferentially lower

blood pressure in salt-sensitive people– Benefits more evident with low initial calcium

intakes (300-600 mg/day)

• Best food sources are dairy products.

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DASH Reduces Homocysteine Levels

• Effect a result of diet high in vitamin B-rich milk and milk products, fruits and vegetables

• Lowering homocysteine with DASH may reduce CVD risk an additional 7%-9%

Appel, et al. Circulation, 102:852, 2000

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PBRC 2011 36

DASH Diet Patternbased on a 2,000 calorie diet

Food Group Servings*Grains 6-8Vegetables 4-5Fruits 4-5Low-fat or fat free dairy 2-3Meats, poultry, fish less than 6Nuts, seeds, dry beans and peas 4-5/weekFats and oils 2-3Sweets 5/ weekSodium 2300 mg

* Per day unless indicated

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• Slowly increase intake of fruits and vegetables to 8 or more per day

• Three servings of low fat and non-fat dairy products a day

• Nuts, seeds and dried beans 4-5 times per week

Dash Diet

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DASH Diet continues...

• More whole grain cereals and breads

• 6 ounces or less of meat, fish or poultry per day

• Small amounts of liquid or soft margarine or oil

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Eat Less Sodium

• DASH is more effective if also reduce sodium

• Less than 2400 milligrams per day

• Reduce slowly in 2-3 weeks so that taste buds will get use to less salt

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PBRC 2011 40

Ways to Cut Sodium• Remove salt shaker• Add little if any salt to

cooking • Buy more fresh or plain

frozen “no added salt” veggies

• Use more herbs and spices • Make soups and stews

ahead without salt and let flavors blend

• Use fresh poultry, lean meat, and fish

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Using the Food Label to Cut Sodium

• Sodium is a chemical that makes up ½ of table salt

• Limit to 2400 milligrams per day

• Look for “low sodium” or “salt free” – watch “reduced sodium”

• Choose more foods with Daily Value less than 10%

• Balance higher sodium foods with lower sodium foods

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• Look for the amount of sodium in foods by finding it on the Nutrition Facts Label.

• Choose foods that have lower amount of sodium based on the label.

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Physical Activity

Guidelines• Fit into daily routine• Aim for at least 150 minutes/week of

moderate aerobic exercise• Start slowly and gradually build intensity• Wear a pedometer (10,000 steps)• Take stairs, park further away or walk to

another bus stop, etc.

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Be Physically Active

• brisk walking• house cleaning• lawn care• gardening

• swimming• cycling• walking a golf

course• racket sports• dancing

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Don’t Smoke!

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Quit Smoking• Injures blood

vessel walls• Speeds up

process of hardening of the arteries.

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Limit Alcohol Intake

Excessive alcohol raises blood pressure and can harm liver, brain, and heart. Alcohol is an oxidant.

What counts as a drink?• 12 oz beer• 5 oz of wine• 1.5 oz of 80 proof whiskey

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Try to -

• Follow a healthy eating pattern.

• Be Active • Not Smoke• Control Your Weight• Take Your Medicine

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PBRC 2011 49

In Summary

• Make a “Dash” for more –– fruits and vegetables– whole grains and breads– non-fat and low fat dairy foods– nuts, seeds and beans

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Conclusion

• Hypertension is a very controllable disease, with drastic consequences if left uncontrolled.

• Hypertension can be treated by diet and lifestyle measures that are as, or more effective than medication.

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Resources

• www.nhlbi.nih.gov• http://

www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

• http://emall.nhlbihin.net/hbpSubLink.asp?p=2&h=3&g=27&r=1

• http://dashdiet.org 7/29/2011