GIZI PADA KELAINAN ENDOKRIN ( OBESITAS, DM, DISLIPIDEMIA, GOUT )

Nurpudji A Taslim

Bagian Ilmu Gizi FK-UNHAS@2004.

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

OvereatingInactivitySmokingDiabetogenic drugs

PregnancyEndocrine diseasesDiabetogenic drugsMalnutritaion in utero

UnknownUnknownB- cell defectsInsulin resistanceGenetic factorsGenetic factorsGlucose toxicityHyperglycaemiaWorsening B-cell functions ? Amyloid depositionMalnutrition in utero

Impaired glucose toleranceNIDDMEnvironmental factorsEnvironmental factors

DIAGNOSIS CRITERIA OF DIABETES MELLITUSOral Glucose Tolerance Test (WHO Criteria 1985)Diabetes mellitus Basal >140 mg / dl After 2 hrs >200 mg / dl IGT Basal

DIABETES MELLITUSPENDAHULUANMenyerang segala lapisan umur dan sosial ekonomiPrevalensi 1,5% - 2,3% pada penduduk usia > 15 tahun Tahun 2020 > penduduk 178 juta, diperkirakan DM 3,56 jutaAntisipasi untuk mencegah dan menanggulangi timbulnya ledakan pasien DM harus dimulai dari sekarang

II. PEMERIKSAAN PENYARINGMass-screning> mahalPerlu 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 gestationalIV. DIAGNOSISGejala klasik

PolidipsiPoliuri + GDS > 200mg/dlPolifagiGejala penyerta lain

V. PENGELOLAAN DMTujuan- 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 makan2. Latihan jasmani3. Penyuluhan4. Obat berkhasiat hipoglikemik (Interna)

PERENCANAAN MAKANDAN OLAH RAGA* MAKANAN KOMPOSISI SEIMBANG :KH ( bervariasi 55-60%)P10 15 %L20 25 % Kalori sesuai kebutuhan Kolesterol < 300 g / hrSerat + 25 gr / hrOLAH RAGA 3 4 DALAM SEMINGGU

PENYULUHAN DM* PRIMER- Pasien yang disuluh :1. Kelompok RESTI2. 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.TERSIERMengenal dan mencegah komplikasiKesabaran dan ketekunan dapat menerima dan memanfatkan keadaan hidup dengan komplikasi kronis

KebutuhanAsupan(Asupan zat gizi = Kebutuhan zat gizi)Gizi Baik = Gizi seimbangGaris normalOBESITAS

KebutuhanAsupan(Asupan zat gizi < Kebutuhan zat gizi)Kurang Gizi = Gizi tidak seimbangGarisnormal

KebutuhanAsupan(Asupan zat gizi > Kebutuhan zat gizi)Gizi Lebih = Gizi tidak seimbangGarisnormal

Ibu hamilanemia 60%HAP/HPPMMR 390/100000BayiBBLR 16%KEP/ISPA/diare/IMRBalitaKEP 30%GAKIDiare/ISPA* brain development* loss generationAnak sekolah* KEP/Anemia* drug use* kinerja akademikMahasiswa:* gizi/enmiaTenaga kerja* Anemia* tbc, malaria,* CVD* Produktivitas

Penilaian KegemukanBBITLKIMT: - < 18.5 underweight

- 18.5 22.9 normal - 23 24.9 overweight - 25 29.9 obese I - > 30 obese II

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

pasien mendapat obat untuk penyakit lain hasilnya tetap kurang memuaskan.

PrevalenceWorld (BMI 30):

7% adult populationChina, 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 IndonesiaIndependent 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

Produksi Energi dan Keseimbangan Energi

Klasifikasi BB kurangNormalBB lebihObes IObes IIObes IIIRisiko ko-morbiditasIMT(Kg/m2)< 18.518.5 22.9> 2323 24.925 29.9> 30< 18.518.5 - 24.925.0 - 29.930.0 - 34.935.0 - 39.9> 40WHO (1998)Rendah Normal MeningkatModerat Berat Sangat beratReport of the WHO Consultation of Obesity, 1997The Practical Guide, NIH, NHLBI, 1998The Asia Pacific Perspective: Redefining obesity & its treatment, 2000Rendah Normal

MeningkatModeratBeratBB kurangNormalBB lebihBerisiko Obes IObes IIIMT (Kg/m2)Risiko ko-morbiditasAsia Pacific (2000)

Lingkar Perut

WHO 2000

94 cm () 80 cm ()

Eropa

102 cm () 88 cm ()

Asia Pasifik

90 cm ()80 cm ()

1.psd

Risk-Benefit Assessment Relative Risk & BMI

Clinical Classification of overweight Number of fat cells Fat distribution

Anatomic classificationEtiologic classificationFunctional calssificationAnatomic Characteristics of Adipose Tissue and Fat Distribution

The distribution of adipose tissue or body fat can be divided into three componentsThe first is the percentage of body fatThe 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 hipsThe third is visceral fat, as intra-abdominal depot increases with age and carries the highest risk for developing cardiovascular and other disease consequences

Etiologic classificationNeuroendocrine obesityDrug induced weight gainCessation of SmokingSedentary lifestyleDiet

Neuroendocrine Obesity Hypothalamic Cushings syndrome Hypothyroidism Polycystic ovary syndrome Growth hormone

DietOvereatingRestrained eatingDietary fat intakeNight-eating syndromeBinge-eatingInfant feeding practicesProgressive hyperphagic obesity

Classification of obesityAnatomic classificationA. Microscopic1. Fat cell size2. Fat cell numberB. Macroscopic1. Total body fat2. Subcutaneous fat distribution3. Visceral fat4. Abnormal or unusual fat deposits

Obesity and Cardiovascular Risk

The metabolic aspects of abdominal obesity represent only one of the contributors towards cardiovascular disease in visceral obesity.Other factors include:hypertensionrenal hyperfiltration and albuminuriaincreased inflammatory responsesincreased prothrombotic factorsendothelial dysfunctionand a whole array of lipid abnormalities

Together, these contribute to the development of cardiovascular disease and end organ damage in obese patients.

Expectations

Patient-Doctor Expectations

EXPECTATIONSPENDAHULUAN 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 KegemukanJenis kelaminUmurKelas sosialKebiasaan makanAktifitas fisikFaktor psikologisFaktor hormonal

RISIKO OBESITASRisiko obesitas dibagi atas 2 golongan :Risiko psikososialRisiko medis

Penanganan Kegemukan Prinsip : Mengusahakan keseimbangan

energi yang negatif dalam tubuh,yaitu dengan mengurangi intake dan memperbesar output.Terapi dietAktifitas fisik / olah ragaPerubahan sikapTerapi farmakologis

( obat-obatan dan operasi )

Diet TerapiPengurangan kalori 500 1000 cal / hariLemak total < 30 % total kaloriSFA 8 10 % total kaloriMUFA sampai 15 % total kaloriPUFA sampai 10 % total kaloriKolesterol < 300 mg / hariSerat 20 30 gr / hari

Aktifitas FisikOlah raga yang dilakukan F frekuentI IntensitasT TimeT Type

Perubahan Sikap

Self MonitoringStimulus controlTechnique for self reward

Terapi Obat & OperasiTerapi lain 6 bulan gagalIMT > 30, IMT > 27 risiko kegemukan Operasi bila IMT > 40, IMT > 35

dengan risiko kegemukanTujuan Diet Rendah Kalori

Menurunkan BB Retriksi diet

Syarat Diet Rendah KaloriPengurangan kalori 500 1000

kalori / hariAsupan protein normal atau

sedikit diatas normalCukup vitamin dan mineralTinggi serat

Jenis Diet Rendah KaloriDiet 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 / hariObesitas beratDokter dan ahli giziKombinasi perubahan gaya hidupEfek samping

KESIMPULAN1. Program yang terirtegrasi 2. Keberhasilan tergantung individu 3Jenis diet tergantung tingkat obesitas4. Komunikasi dan pangawasan sangat dianjurkan5Pemakaian obat dan operasi dilakukan pada keadaan tertentu

Diagnosis :Anamnesis & pemeriksaan klinikObservasi visualPemeriksaan KimiaNUTRITION in DYSLIPIDEMIAPengaturan Diit Tujuan : 1. Menurunkan kadar kolesterol darah2. Menurunkan BB bila terlalu gemuk

Diet Rendah Cholesterol & Lemak TerbatasPenggunaan lemak sedikit di batasiSebagian besar lemak yang digunakan berjenis lemak tak jenuhPenggunaan bahan makanan yang mengandung banyak cholesterol dibatasiBila terlalu gemuk, jumlah kalori dibatasi.

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

3. Gunakan susu skim pengganti susu penuh4. Batasi penggunaan kuning telur hingga 3 butir seminggu5. Gunakan tahu, tempe dan hasil olahan kacang-kacangan6. Batasi penggunaan gula dan sejenisnya7. Makanlah banyak sayuran buah.

Pencegahan :Sedini mungkin- Balita- Anak & remajaEnergi cukupMakanan bervariasiSaturated fat < 10 %Total fat < 30 %Cholesterol < 300 mg/ hari2. Periksa darah secara teratur

3. Bagi risiko tinggi beri petunjuk intensif pengaturan diet

4. Olah raga teratur

5. Perhatikan penyakit yang menyertai

Risiko tinggi :Upayakan BB normalAsupan kalori sesuai kebutuhanAsupan lemak jenuh < 20 % total kaloriLTJG : LJ = 2 : 1Cholesterol < 250 mg / hariProtein H/N = 1 : 1Konsumsi serat / fiber.

National Cholesterol Education Program Adult Treatment Panel III 2001 (ATP III)Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (ATP III)

NHLBI

ATP IIIFocus on Multiple Risk FactorsDiabetes: CHD risk equivalentFramingham projections of 10-year CHD riskIdentify certain patients with multiple risk factors for more intensive treatmentMultiple metabolic risk factors (metabolic syndrome)Intensified therapeutic lifestyle changes

ATP IIIModification of Lipid and Lipoprotein ClassificationLDL cholesterol

ATP III Lipid & Lipoprotein ClassificationLDL Cholesterol (mg/dL)

ATP III Lipid & Lipoprotein ClassificationHDL Cholesterol (mg/dL)

Nabel EG, Cardiovascular Disease, N Engl J Med 2003;349:60-72

ATP III Lipid & Lipoprotein ClassificationClassification of Serum TriglyceridesNormal

A Model of Steps in Therapeutic Lifestyle Changes (TLC)

Reinforce reductionin saturated fat andcholesterolConsider addingplant stanols/sterolsIncrease fiber intakeConsider referral for MNT

Initiate Tx forMetabolicSyndromeIntensify weightmanagement &physical activityConsider referral for MNT

6 wks6 wksQ 4-6 mo Emphasizereduction insaturated fat &cholesterolEncouragemoderate physicalactivityConsider referral for medical nutrition therapy (MNT)

MonitorAdherenceto TLCVisit N

Rationale for Medical Nutritional Therapy (MNT)Animal models: consumption of SFA & Cholesterol elevates LDL-CHuman study in 1965 (Hegsted et al & Keys et al) predictive equations absolute LDL changeEpidemiologic evidence: The Seven Countries Study, Ni-Hon-San StudyDietary 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 FeaturesTLC DietReduced intake of cholesterol-raising nutrients (same as previous Step II Diet)Saturated fats

TLC DietNutrientRecommended IntakeSaturated fatLess than 7% of total caloriesPolyunsaturated fatUp to 10% of total caloriesMonounsaturated fat Up to 20% of total caloriesTotal fat2535% of total caloriesCarbohydrate5060% of total caloriesFiber2030 grams per dayProteinApproximately 15% of total caloriesCholesterolLess than 200 mg/dayTotal calories (energy)Balance energy intake and expenditure to maintain desirable body weight/prevent weight gain

Saturated Fatty Acids (SFA)1% reduction SFA = 2% reduction of cholesterol SFAs 12:0 16:0 hypercholesterolemicMost potent 14:0 (myristic acid)

Kris-Etherton PM & Yu S, Individual fatty acids effects on plasma lipids and lipoproteins: human studies, Am J Clin Nutr 1997;65 (suppl):1628S44S

Monounsaturated (MUFA)Oleic acids (18:1) : hypocholesterolemic , lowers LDL-CEffects are less than linoleic acidsHDL raises

Polyunsaturates (PUFA)18:2n-6 (linolenic acid) decreases TC & LDL-CHDL effect: not significant

Trans Fatty AcidsFormed in the hydrogenation processMostly elaidic acid(trans 18:1n-9)Elevates LDL-C and reduces HDL-C

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

CholesterolLess potent regulator of plasma lipoprotein than fatty acidsWider variation in response to dietary cholesterolSynergy of cholesterol and fatty acids ?

Schaefer EJ, lipoproteins, nutrition, and heart disease, am J Clin nutr2002;75:191-212

LDL-Lowering Therapeutic Options: Plant StanolsPlant stanols

Kerckhoffs et al, Effects on the HumanSerum Lipoprotein ProfileOf -glucan, Soy ProteinAnd Isoflavones, PlantSterols and Stanols, Garlic,And Tocotrienols, J. Nutr 132: 2494-2505,2002

LDL-Lowering Therapeutic Options: Plant StanolsPlant stanols> affinity for micelles than cholesterolOptimum dose: 2 g/day, reduces LDL-C 0.54 mmol/L 25% reduction in CHDAvailability: margarines

Law M, Plant sterol and stanol margarines and health, BMJ Vol 320 25 March 2000, 861-64

LDL-Lowering Therapeutic Options: Soluble FiberSoluble fiber: non-starch polysaccharides and lignins, resistant to digestionExample: -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 FiberMechanisms of Hypocholesterolemic effect of soluble fiber: Bile acids binding enterohepatic circulation Food mass viscosity< Rate of glucose absorption lower insulin conc.

In BriefATP III incorporates TLC in every step of treatmentMedical Nutrition Therapy focused on reduced intake of SFA and cholesterolPlant stanol and dietary soluble fiber are recommended

GOUTPenyakit radang sendi akut, yang biasanya melibatkan satu sendi saja terutama ibu jari kaki Kadar asam urat

KlasifikasiGout primer akibat gangguan metabolismeGout sekunder akibat dari penyakit lainSering terjadi pada laki-laki, perempuan menopouse, obesitas, konsumsi makanan yang berprotein tinggiTerapi

MedikamentosaPengaturan makanan ( diet )

Diet Rendah Purin* Tujuan :1. Mengurangi pembentukan asam urat2. Menurunkan berat badan bila penderita terlalu gemuk dan mempertahankannya dalam batas normal.

Syarat syarat :Rendah purin,mengandung 120-150 mg purin.Cukup kalori, protein, mineral dan vitaminHidrat arang tinggiLemak sedangBanyak cairan

Makanan yang boleh dan tdk boleh diberikan

Gol.Bhn.Mkn.Mkn.yg.bolehMkn.yg.tdk.bolehSumber H.ASemua-Sumber P. HewaniDaging,ayam,ikan tongkol,tenggiri,telur,susu,keju 50gr/hrSardin, kerang, jantung, hati, limpa, paru, otak, ekstrak daging/kaldu,bebek, angsa, burungSumber P. NabatiKacang-kacangan atau tahu/tempe 50gr/hr-

Gol.Bhn.Mkn.Mkn.yang.bolehMkn.yg.tdk.bolehSumber LemakMinyak dalam jumlah terbatas-SayuranSemua sayuran sekehendak kecuali asparagus,kacang polong,buncis,kembang kol,bayam jamur maksimum.50 gr/hr-BuahSemua macam buah-MinumanTeh,kopi,sodaalkoholBumbu dll.Semua bumburagi

The metabolic aspects of abdominal obesity represent only one of the contributors towards cardiovascular disease in visceral obesity.Other factors include:hypertensionrenal hyperfiltration and albuminuriaincreased inflammatory responsesincreased prothrombotic factorsendothelial dysfunctionand a whole array of lipid abnormalities

Together, these contribute to the development of cardiovascular disease and end organ damage in obese patients.