PENATALAKSANAAN GIZI

PADA DIABETES MELLITUS

by Juhairina
MEDICAL NUTRITION THERAPY
(MNT) based on :
EFFECTIVENESS OF NUTRITION THERAPY
 MNT IN TYPE 1 DIABETES
• Insulin therapy should be integrated into an
individual’s dietary and physical activity
pattern (E)
• Individuals using rapid-acting insulin by
injection or an insulin pump should adjust the
meal and snack insulin doses based on the
CHO content of the meals and snacks (A)
• For individuals using fixed daily insulin doses,
CHO intake on a day-to-day basis should be
kept consistent with respect to time and
amount (C)
 MNT IN TYPE 2 DIABETES
• Implement lifestyle changes that reduce
intakes of energy, saturated and trans
fatty acids, cholesterol, and sodium and
increase physical activity in order to
improve glycemia, dyslipidemia, blood
pressure (E)
• Plasma glucose monitoring can be used
to determine whether adjustments to
foods and meals will be sufficient to
achieve blood glucose goals or if
medication(s) needs to be combined with
MNT
Energy Balance, Overwt and Obesity
• In overweight and obese insulin-resistant
individuals, modest weight loss has been
shown to improve insulin resistance. Thus,
weight loss is recommended for all such
individuals who have or are at risk for
diabetes. (A)
• For weight loss, either low-carbohydrate or
low-fat calorie-restricted diets may be
effective in the short term (up to 1 year). (A)
• For patients on low-carbohydrate diets,
monitor lipid profiles, renal function, and
protein intake (in those with nephropathy),
and adjust hypoglycemic therapy as
needed. (E)
Energy Balance, Overwt and Obesity

• Physical activity and behavior modification are

important components of weight loss programs
and are most helpful in maintenance of weight
loss. (B)
• Weight loss medications may be considered in
the treatment of overweight and obese
individuals with type 2 diabetes and can help
achieve a 5–10% weight loss when combined
with lifestyle modification. (B)
Energy Balance, Overwt and Obesity

Bariatric surgery may be considered for

individuals with type 2 diabetes and BMI>35
kg/m2 and can result in marked
improvements in glycemia
Long term benefits and risks of bariatric
surgery in individuals with pre-diabetes or
diabetes continue to be studied (B)
 Carbohydrates in Diabetes

Dietary pattern that includes CHO from

fruits, vegetables, whole grains, legumes,
and low fat milk is encouraged for good
health (B)
Monitoring CHO, whether by CHO
counting, exchange, or estimation
remains a key strategy in achieving
glycemic control (A)
 Carbohydrates in Diabetes
Sucrose-containing foods can be substituted for
other carbohydrates in the meal plan or, if
added to the meal plan, covered with insulin or
other glucose-lowering medications. Care
should be taken to avoid excess energy intake.
(A)
The use of glycemic index may provide a
modest additional benefit over that observed
when total CHO is considered alone (B)
 Glycemic Index
The blood glucose response of a given food
compared to an equal amount of a CHO standard
(typically glucose or white bread)

Influenced by various factors

Starch structure
Fiber content
Cooking methods
Degree of processing
Whether it is eaten in the context of a meal
Presence or absence of fat
 Fiber and Diabetes

As for the general population, people with

diabetes are encouraged to consume a
variety of fiber-containing foods. However,
evidence is lacking to recommend a higher
fiber intake for people with diabetes than
for the population as a whole. (B)

It requires very large amount of fiber (~50

grams) to have a beneficial effect on
glycemia, insulinemia, lipemia
 Sweeteners and Diabetes
Sugar alcohols and nonnutritive sweeteners are
safe when consumed within the daily intake levels
established by the Food and Drug Administration
(FDA) (A)
Nonnutritive sweeteners Include aspartame,
acesulfame K, sucralose, and saccharin
FDA has established an acceptable daily intake
(ADI) for food additives
Average intake of aspartame is 2 to 4 mg/kg/day,
whereas the ADI is 50 mg/kg/day
ADI of acesulfame K is 15 mg/kg, which is the
equivalent of a 60 kg person eating 36 teaspoons of
sugar daily
 Nutritive Sweeteners: Fructose

• Delivers 4 kcals/gram
• Has lower glycemic index than sucrose or
starch
• Large amounts may negatively affect lipids
• No advantage to substituting it for sucrose
• Found naturally in foods such as fruits and
vegetables
 Protein and Diabetes

Insufficient evidence to suggest that usual

protein intake (15-20% of energy) should
be modified (E)
In individuals with Type 2 diabetes,
ingested protein can increase insulin
response without increasing plasma
glucose concentrations. Therefore, protein
should not be used to treat acute or
prevent nighttime hypoglycemia (A)
 Protein and Diabetes

 High-protein diets are not recommended as a

method for weight loss at this time. The long-
term effects of protein intake >20% of calories
on diabetes management and its complications
are unknown.
 Although such diets may produce short-term
weight loss and improved glycemia, it has not
been established that these benefits are
maintained long term, and long-term effects on
kidney function for persons with diabetes are
unknown. (E)
 Dietary Fat

• Saturated Fat: <7% of total calories (A)

• Cholesterol: <200 mg/day in people with
diabetes
• Minimize intake of trans-fatty acids (E)
• Two or more servings of fish per week
providing n-3 polyunsaturated fatty acids are
recommended (B)
Optimal Mix of Macronutrients

The best mix of protein, CHO and fat

varies depending on individual
circumstances
The DRIs recommend that healthy adults
should consume 45-65% of energy from
CHO, 20-35% from fat, and 10-35% from
protein
Total caloric intake must be appropriate
for weight management
 Lipid Goals in Diabetes

LDL cholesterol <100 mg/dl

HDL cholesterol
Men >40 mg/dl
Women >50 mg/dl
Triglycerides <150 mg/dl
Blood Pressure Goals in Diabetes

Patients with diabetes should be

treated to a systolic blood pressure
<130 mmHg (C)
Patients with diabetes should be
treated to a diastolic blood pressure of
<80 mmHg (B)
 Fiber and Phytoesterols

Soluble fiber: 3 grams of soluble fiber (3

servings of oatmeal) or 3 apples can lower
total cholesterol by 5 mg (2%)
Plant stanols: 2-3 grams can lower total and
LDL-C by 9 to 20%
 Micronutrients
• There is no clear evidence of benefit from vitamin or
mineral supplementation in people with diabetes
(compared with the general population) who do not
have underlying deficiencies (A)
• Routine supplementation with antioxidants such as
vitamins E and C and carotene is not advised
because of lack of evidence of efficacy and concern
related to long term safety (A)
• Benefit from chromium supplementation in
individuals with diabetes or obesity has not been
clearly demonstrated and therefore can not be
recommended (E)
 Micronutrients
Vitamin/mineral needs of people with
diabetes who are healthy appear to be
adequately met by the RDAs.
Those who may need supplementation
include those on extreme weight-reducing
diets, strict vegetarians, the elderly, pregnant
or lactating women, clients with
malabsorption disorders, congestive heart
failure (CHF) or myocardial infarction (MI)
Chromium and magnesium are beneficial only
if the client is deficient.
 Sodium
• Association between hypertension (HTN) and both
types of diabetes mellitus (DM)
• Same intake as general population is recommended
for otherwise healthy people with DM—less than
3000 mg/day
• For people with mild HTN and diabetes—should
have less than 2300 mg/day
• For people with more serious HTN or edematous
clients with nephropathy recommend 1500 mg/day
or less
 GOALS OF MNT

• Maintain as near-normal blood glucose levels as

possible by balancing food, insulin and exercise
• Achieve recommended serum blood lipid levels
• Provide energy intake to maintain or attain healthy
weight
• Prevent and treat acute and long-term diabetes-
related complications
• Enhance over all health
 GOALS OF MNT
Type 1 *** *** Type 2
• Increase in energy intake • Reduction of energy
possible intake for obese
• Diet and Insulin nec. to • Diet alone may control
control BS blood glucose
• Equal distribution of CHO • Equal distribution of CHO
through meals for insulin desirable, not
activity essential;low fat desirable
• Consistency in daily • Consistency in daily
intake - control BS intake - control wt.
 GOALS OF MNT
Type I ** **Type 2
• Timing of meals - • Timing of meals not
crucial essential
• Snacks - frequently • Snacks - not
necessary recommended
• Additional food for • Additional food for
exercise - CHO 20 exercise if on
g/h for moderate sulfonylurea or
physical activity insulin
 Nutrition Assessment
• Type of diabetes, any • Dietary 24 hour recall
complications (meals, snacks, and
• Blood sugar control beverages)
• Past medical history • Favorite foods
• Anthropometrics- • Food allergies
height, weight, BMI, • Eating patterns and
body composition habits
• Physical activity
• Biochemical- labs
• Readiness to change
• Medications, including
• Attitude
supplements
 Meal Planning Strategies
• Timing of meals • Carbohydrate counting
• Healthy choices and – Prescribed meal plan
balanced meals – Exchange system
• Variety including – Carbohydrate servings
nutrient-rich foods and – Label reading
high-fiber foods – Glycemic index
– Insulin to carbohydrate
• Moderation using
ratio + correction factor
portion control (if applicable)
• Limit refined sugars
“So what do diabetic pts can
eat?”
How to be a “Nutritionist” when you
do not have an RD
 Doctor’s Advice
• “Nutrition is an important part of taking care of your
diabetes”
• Avoid telling patients to diet and lose weight without
resources
• Do not recommend fad diets, try to encourage
healthy lifestyle changes instead
• Be specific- “try to be active at least 30 minutes most
days of the week”
• Keep it positive
 Basic Nutrition Advice
• Timing of meals and snacks (no more than 4
hours without eating)
• Don’t skip meal
• Get a variety of healthy, high-fiber foods
• Limiting refined carbs and added sugars
• Watch portion sizes and read labels
• Keep a food journal
• Learn to make lifestyle changes and not diet
for a short period of time
 MEAL PLAN DIABETIC

1. Diabetes Pyramid/My
Pyramid
2. Plate Method
3. Exchange List
4. Carbohydrate Counting
 2. The Plate Method

Fruit

Vegetables
(non-starchy)

Meat & Grains, Beans,

Alternates Starchy Vegetables

37
 3. EXCHANGE LIST
menurut ukuran rumah tangga
 Hitung kebutuhan kalori
 Menetapkan menu harian
berdasarkan satuan ukuran rumah
tangga
 Dapat diganti dgn menu lain yg
kandungan zat gizinya sejenis

38
Menurut “Consensus Dietary Guidelines for Healthy Living and
Prevention of Obesity, Metabolic Syndrome, Diabetes, and Related
Disorders” Diabetes Technology & Therapeutics , 2011

REKOMENDASI KALORI:
– Cukup untuk mempertahankan berat badan ideal
– Sesuai dengan aktivitas sehari-hari (ringan,
sedang dan berat)
– Sesuai umur, jenis kelamindan status fisiologis
– Berat badan ideal bertujuan untuk
mempertahankan indeks massa tubuh antara
18,5-22,9 kg/m2
 CARA MENGHITUNG KALORI :
Tentukan Status Gizi berdasarkan IMT (Indeks Massa
Tubuh) : IMT = Berat Badan (kg) / Tinggi Badan (m)2

Status Gizi Underweight Normal Overweight Obese I Obese II

IMT(kg/m2) < 18,5 18,5-22,9 23-24,9 25-29,9 >30

Kebutuhan Kalori (Kcal/Kg IBW/day)

Aktivitas Obese Normal Underweight
Ringan 20-25 30 35
Sedang 30 35 40
Berat 35 40 45-50

Contoh : Laki-laki (aktivitas ringan), BB : 62 kg; TB : 165 cm

maka IMT : 22,7 kg/m2
Jadi Kebutuhan Kalori per hari = 62 x 30 = 1860 Kkal/hari
No Gol. Bahan Makanan Kalori Protein Lemak Karbohidrat
(g) (g) (g)
1 Sumber Karbohidrat 175 4 - 40
2 Sumber Protein Hewani
Rendah Lemak 50 7 2 -
Lemak Sedang 75 7 5 -
Tinggi Lemak 150 7 13 -
3 Sumber Protein Nabati 75 3 7 7
4 Sayuran
Golongan A - - - -
Golongan B 25 1 - 5
Golongan C 50 3 - 10
5 Buah-buahan 50 - - 12
6 Susu
Tanpa Lemak 75 7 - 10
Rendah Lemak 125 7 6 10
Tinggi Lemak 125 7 10 10
7 Minyak
Lemak tidak jenuh 50 - 5 -
Lmeak Jenuh 50 - 5 -
1 porsi bahan makanan sumber karbohidrat setara dengan
175 kal, 4 gr protein, 40 gr karbohidrat

¾ gelas 2 gelas 3 potong sedang

2 biji sedang 1 potong sedang

2 gelas
1 porsi bahan makanan sumber vitamin/mineral
setara dengan

1 buah sedang 1 potong besar 1 potong besar

1 gelas 1 gelas 1 gelas

1 porsi bahan makanan sumber protein hewani setara
dengan 50 kkal, 7 gr protein, 2 gr lemak; 75 kkal, 7 gr prot, 5 gr lemak

1 potong sedang 1 potong sedang 1 potong sedang

1 butir 5 ekor sedang 10 biji sedang

1 porsi bahan makanan sumber protein nabati setara
dengan 75 kkal, 5 gr protein, 3 gr lemak, 7 gr karbohidrat

1 biji besar 2 potong sedang 2 sendok makan

SEBANYAK APA 1 PORSI ITU?
ENERGI(kalori) 1100 1300 1500 1700TOTAL1900
KALORINYA
2100 2300 2500
Pagi :
Nasi ½ 1 1 1 1751 ½ 1½ 1½ 2
Ikan 1 1 1 1 50 1 1 1 1
Nabati
Sayur A
Minyak
-
S
1
-
S
1
½
S
1
½
S
1
37,5½
0 S2
1
S
2
1
312,5
S
2
20%
1
S
2
50
10.00 :
Buah
Susu
1
-
1
-
1
- 10%
1
-
1
-
1
-
1
1
1
1
Siang :
Nasi 1 1 2 2 2 2½ 3 3
Daging 1 1 1 1 1 1 1 1
Nabati
Sayur A
1
S
1
S
1
S 30-35%
1
S
1
S
1
S
1
S
2
S
Sayur B 1 1 1 1 1 1 1 1
Buah 1 1 1 1 1 1 1 1
Minyak 1 2 2 2 2 3 3 3
16.00 :
Buah 1 1 1 10%
1 1 1 1 1
Malam :
Nasi 1 1 1 2 2 2½ 2½ 2½
Ikan 1 1 1 1 1 1 1 1
Nabati 1 1 1 1 1 1 1 1
Sayur A
Sayur B
S
1
S
1
S
1
20-25%
S
1
S
1
S
1
S
1
S
1
Buah 1 1 1 1 1 1 1 1
Minyak 1 1 1 1 2 2 2 2
4. Carbohydrate (CHO) Counting Defined

•A meal-planning approach for all patients

with diabetes, based on the following
ideas:
–Carbohydrate is the main nutrient
affecting postprandial glycemic response
–Total amount of carbohydrates consumed
is more important than the source of
carbohydrates
Benefits of
Carbohydrate Counting
•More flexible than other meal-
planning methods
•Sugar is not forbidden
•Attention is focused on the foods
that are most likely to make blood
glucose levels go up
 Foods That Contain
Carbohydrates
• Breads, cereals, pasta, and grains
• Rice, beans, and starchy vegetables (potatoes, corn, and
peas)
• Fruit and fruit juices
• Milk and yogurt
• Regular soda, fruit drinks, jelly beans, and gumdrops
• Cakes, cookies, and candy
 Grams of Carbohydrate
(per food category)
•Starch and fruit: 1 serving equals about 15
grams (g) carbohydrate
•Milk: 1 serving equals about 12 g
carbohydrate
•Vegetables: 1 serving equals about 5 g
carbohydrate
Foods Without Carbohydrate

Protein and fat groups contain 0 g carbohydrate

Examples:
• Protein: Meat, fish, poultry, cheese, eggs, peanut butter,
cottage cheese, and tofu
• Fat: Butter, oils, margarine, mayonnaise, cream cheese, sour
cream, nuts, seeds, avocados, and salad dressings
 Decrease Maintain Increase
BW BW BW
WOMAN 2-3 3-4 4-5
(per serve
carbo)
Calorie total 1200-1500 1700-1900 2100-2300
per day
MAN (per 3-4 4-5 4-6
serve carbo)
Bahan Berat URT Energi P (g) L (g) KH Carbo Contoh Menu
(g) (kal) (g) Count
Menu I
Nasi 100 1 ½ gelas 4 0 40 Nasi
Ayam tanpa kulit 40 1 potong 7 2 0 Botok Ayam
Tahu 110 1 biji 3 7 7 Perkedel Tahu
Sayuran 100 1 gelas 1 0 5 Sayur kare
Buah 110 1 potong 0 0 12 Pepaya
Minyak 10 2 sdk teh 0 0 0
JUMLAH 487 15 19 64 4
Menu II
Coleslow 71,8 1 porsi 4,5 2 5 FASTFOOD
French fries 108 1 porsi 4 17,5 40
Fried 130 1 porsi 16 28,5 20
chicken/dada
Coca cola diet 200 1 botol 0 0 0
JUMLAH 790 24,5 48 65 4

Menu III Martabak manis

Martabak manis 150 2 potong 390 11 10 64 4 Teh panas
 Food Labels
Total carbohydrate—
includes grams of sugar, sugar
alcohol, starch, and dietary
fiber
Total grams of
carbohydrate—to determine
amount of carbohydrate
eaten, multiply grams of total
carbohydrates on the label by
the number of servings eaten
 LIHAT TAKARAN SAJINYA!

BERAPA KALORINYA?
KEBANYAKAN BIKIN GEMUK!
LIHAT JUMLAH LEMAK,
JANGAN KEBANYAKAN!
LIHAT SODIUM (GARAM)
LEBIH SEDIKIT LEBH BAIK!
LIHAT KARBOHIDRAT TOTAL!
JANGAN KEBANYAKAN
LIHAT SERATNYA, MAKIN
PERHATIKAN! INILAH ANGKA BANYAK MAKIN BAIK
KECUKUPAN GIZI, 5% ITU LIHAT GULA! MAKIN SEDIKIT
RENDAH, 20% ITU TINGGI. ZAT
MAKIN BAIK!!
GIZI BAIK=PILIH YANG TINGGI,
ZAT GIZI BURUK PILIH YANG
RENDAH!
 =

500 kcal : 450 gr = 1,1 kcal/gr 500 kcal : 144 gr = 3,5 kcal/gr
1360 Kcal
 Physical Activity Helps
• Regular physical activity lowers blood sugar
AND improves the way insulin works.
• For most people, this means finding ways to
move around for at least 30 minutes more
nearly every day.
• Should be CRIPE (continous, rhytmic, interval,
progressive, endurance)
• Reached Maximal HR (60-70% x 220 – age)

60