KP 12.12 Nutrisi Pada DM

NUTRISI PADA DIABETES MELLITUS

OLEHProf.Dr.Fadil Oenzil, PhD, SpGK

Flow diagram of the development

of type II diabetes

12

10

8

6

4

0 1 hour 2 hour

Time after ingestion of 75 g glucose

(a)Normal

individual

b) Person with impaired glucose tolerance

c) Diabetic

Venous

pla

sma g

luco

se level

(mm

ol/L)

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 onsetKetosis resistentInsulin 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 ADACaloriCarbohydrate % of kcalProtein %Fat total %SAFA %MUFA %PUFA %Cholesterol mg/dayFiber g/daySodium mg/day

ideal Body60-70% (up to 75%)

10 – 15%20 – 25%< 10%Up to 15%<10%< 300 mg/day+ 25 gr/dayNormotensi 3000 mg/dHipertensi < 2400 mg/day

ideal bodyAbout 50%

10-20%<30%< 10%10-20%<10%< 300 mg/day20-35 g/day< 2400 mg *

Rekomendasi untuk pasien dengan diabetesZat gizi PDGMI ADA

kalorikarbohidrat (% kcal)

Protein %Total lemak %SAFA %MUFA %PUFA %kolesterol mg/hariserat g/hariNa mg/hari

Berat badan ideal 60-70% (sampai 75%)

10 – 15%20 – 25%< 10%Up to 15%<10%< 300 mg/day+ 25 gr/dayNormotensi 3000 mg/dHipertensi < 2400 mg/day

berat badan IdealAbout 50%

10-20%<30%< 10%10-20%<10%< 300 mg/day20-35 g/day< 2400 mg *

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

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

Indek Glikemik =

Luas daerah dibawah kurva respon glukosa darah tubuh setelah 2 jam terhadap makanan

Luas daerah dibawah kurva respon glukosa darah tubuh setelah 2 jam terhadap glukosa murni

X 100%

Glycemic index value by Jenny Miller :1. Low if glycemic index < 552. Moderate if glycemic index 55 – 703. Hight if glycemic index > 70

Glycemic index value by Wolever et al :1. Low if glycemic index < 702. Moderate if glycemic index 70 – 903. 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


Upper epidermis

Bundle sheath

xylemphloe

mBundle sheath

Vein

Lower epidermis

Stoma

Stoma

Spongy parenchyma

Palisade parenchyma

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

Normal

Indeks Glikemik (%)NO Beban yang diberikan

Luas area dibawah kurva

(cm)

1 Glukosa murni

Fruktosa murni2

3 Madu Sumbawa

4 Laktosa murni

5 Susu Laktogen

6 Kanji

7 Kentang

210,9

45,3

162,3

20,95

28,65

87,73

84,3

100

22

77

10

14

42

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

Meals In Gram Portion

BreakfastLunchAfternoon snachDinnerEvening snackTotal

6060307530

255 g

44252

17

2.The distribution of carbohydrate among meals and snacks


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


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 : Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 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


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


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


• 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


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


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


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 USUS BESAR

Pati

Heksosa

Selulosa Hemiselulosa

Pentosa

Lintasan Pentosa

Piruvat

Glikolisis

Hidrogen metana karbondioksida

Keluar melalui udara pernapasan setelah absorpsi

Asetat propionat butirat

Keluar ke feses

Diabsorpsi oleh usus halus dan dimetabolisasikan

DIMETABOLISASI OLEH BAKTERI UNTUK PERTUMBUHAN BAKTERI

PROSES AKHIR

HASIL AKHIR

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)


• Lower serum cholesterol• Lower fasting and postprandial serum

triglycerides• May attenuate hepatic cholesterol syntesis• May increase satiety between meals

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

Micronutrient

Glutathione (Glutamate – Cystein – Glycine)

Selenium : Glutathione peroxidace enzyme co factor

Regeneration of antioxidants reguires Glutathione

R*

RH

Vit E

Vit E*

Vit C

Vit C*

GSH

GSSG

NADP

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

ZincImprove insulin secretion Enhances binding of insulinCo 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 μgAdult women 70 μgSe content of some food (μg / 100 g of food)

Seafood 100Organ meat 20Cereals 20Dairy 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 mgAdult women 270 mg

Milligram (mg) per 100 g foodCocoa Powder 520Bran Wheat 520Soya 240Peanut Raw 130

ChromiumIncrease insulin binding to cells,Increase insulin sensitiveIncrease receptor numberActivates 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 183Brewers yeast 112Beef 57Cheese 56Apple 27

Zinc

Improve insulin secretion Enhances binding of insulinCo 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

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 seimbang2. Asupan kalori dengan mengontrol berat badan3. Pemberian makanan dengan indek glikemik yang rendah4. Serat makanan yang cukup (25 gr/hari)5. Kegiatan fisik teratur, terukur6. Batasi asupan kolesterol7. 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

• Penatalaksanaan Diabetes Melitus Terpadu

KP 12.12 Nutrisi Pada DM

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