Malang Nutrition Update 2010 Susetyowati Prodi Gizi Kesehatan FK UGM

KARBOHIDRAT - Overview
Karbohidrat sederhana Monosa Monosakarida karida Disa Disakarida karida Karbohidrat komplek Po Polisakarida lisakarida (glycogen and starches) serat (not digestible)

KARBOHIDRAT
Karbohidrat sederhana (sugars)

Blood Glucose

Karbohidrat Komplek (starches)

Timed Effect on Blood Sugar Levels

Meal

1 Hr

2 Hrs

3 Hrs

4 Hrs

5 Hrs

6 Hrs

7 Hrs

8 Hrs

Carbohydrate. rapid digestion, total absorption/conversion to glucose (100%) Sugar Alcohols.. moderate digestion, partial absorption as glucose (50%) Protein slow digestion, partial conversion to glucose* (~40%) Fat slow digestion, little conversion to glucose** (<20%) * In absence of dietary carbs ** may cause insulin resistance in large qty

KARBOHIDRAT PADA DIABETES

Apakah karbohidrat menyebabkan

resistensi insulin? Apakah diet tinggi karbohidrat memperbaiki kontrol glikemik?

Does Carbohydrate Cause Insulin Resistance?

Insulin sensitivity improves with carbohydrate intakewhy?
Carbohydrate Fat (terutama lemak jenuh)

McClenaghan review:
11 studies, non-diabetic: 7 studies comparing high

CHO with low reported insulin sensitivity; 4 no differences 7 studies, diabetes: 5 studies comparing high CHO with low reported insulin sensitivity; 2 no differences Bessesen. J Nutr. 2001;131:2782S; McClenaghan.
Nutrition Research Reviews. 2005;18:222

One-Year Comparison of a HighMonounsaturated Fat Diet With a High-Carbohydrate Diet in Type 2 Diabetes
High-MUFA diets are an alternative to

conventional lower-fat, high-CHO diets with comparable beneficial effects on body weight, body composition, cardiovascular risk factors, and glycemic control.

Diabetes Care. 2009;32(2):215-220.

Sucrose In The Diet Of Persons With Diabetes

12 type 1; 11 type 2; 6 weeks CHO similar in both diets; all starch or 45 g starch

replaced with 45 g of sucrose (18% of calories) No differences: day-long glucose levels, HbA1c, insulin profiles in type 2
18 16 14
Mean Plasma Glucose* (mmol/L)

12 10 8 6 4
7:30 8:30 9:30 10:30 11:30 12:30 13:30 14:30 15:30 16:30 17:30 18:30 19:30 20:30

Peterson DB et al. Diabetologia 1986;29:216

REKOMENDASI KARBOHIDRAT Meta-analysis of the evidence

Diet tinggi KH (>60%) dan tinggi serat dibandingkan KH sedang (30-59%) dan rendah KH (<30%) secara significant penurunan kontrol glikemik (HbA1C, GD) dan penurunan parameter lemak Diet tinggi Kh 55-65% ; serat 25-35 g

Journal of the american college of nutrition, vol. 23 no. 1, (2004)

REKOMENDASI KARBOHIDRAT
American Diabetes Association Statement Dietary Carbohydrate (Amount and Type) in the Prevention and Management of Diabetes Diabetes Care, Volume 24 (9), 2004 ADA Clinical Practice Recommendations -2010 Nutrition Recommendations for the Management. of Diabetes Diabetes Care, 31(S), 2008

Standards of Medical Care in Diabetes -2010

Level A Evidence Monitoring carbohydrate intake, whether by carbohydrate counting, exchanges, or experienced-based estimation, remains a key strategy in achieving glycemic control.

Am Diab Assoc. Diabetes Care 2008;31(suppl 1):S61;

Carbohydrate Counting
Perencanaan makanan yang dapat menjaga

kadar gula darah sesuai dengan target, terutama jika karbohidrat yang dikonsumsi dikombinasi dengan insulin yang digunakan. Penentuan jumlah sajian yang diperlukan dalam Carbohydrate Counting ini disesuaikan dengan kalori yang dibutuhkan

MANFAAT Carbohydrate Counting

Lebih fleksibel Gula tidak dilarang Setiap 15 gram karbohidrat (60 kal = dibutuhkan 1 unit insulin). Lebih perhatian pada bahan makanan yang meningkatkan kadar gula darah

The Exchange System

Pengelompokkan bahan makanan yang dianggap mempunyai nilai gizi yang kurang lebih sama
1 S ta rch 1 Fruit 1 M ilk 1 V e ge ta ble 1 Meat 1 Fa t 0 5 10 15

Starch Group (1 penukar = 15 g KH)

1 slice bread ( 30g) cup mashed

potatoes 1/2 cup pasta (60g) 1/2 cup corn (60g) 1/3 cup rice (70g)

SUMBER KARBOHIDRAT 1 penukar 175 kkal ; 4 g protein ; 40 g kh

Nasi 100 g ( gls) Nasi tim 200 g (1gls) Kentang 200 g (2 bj sdg) Singkong100 g (1 ptg sdg) Roti Tawar 80 g (4 iris) Ubi1 50 g (1 bj sdg) Kraker 50 (5 bh bsr) Mie basah 100 g

KELOMPOK BUAH (15 g KH)

1 small fresh fruit (4 oz) C canned fruit (in natural juice) 2 Tbsp raisins 17 grapes C fruit juice 1 Tbsp jelly, jam

KELOMPOK SUSU DAN YOGURT (12 g KH)

8 fl oz of skim, 1%, 2%, or whole milk 1 C plain yogurt 1 C plain or vanilla soy milk

KELOMPOK SAYURAN (1 penukar = 5 g KH)

C cooked

vegetables 1 C raw vegetables

Exchange Lists
Calories Starch Fruit Skim Milk Low-fat Milk Whole Milk Vegetable Very Lean Meat Lean Meat Medium Fat Meat High Fat Meat Fat 80 60 90 120 150 25 35 55 75 100 45 g CHO 15 15 12 12 12 5 0 0 0 0 0 g Pro 3 0 8 8 8 2 7 7 7 7 0 g Fat 0 -1 0 0-3 5 8 0 0-1 3 5 8 5

SERAT DAN CARBOHYDRATE COUNTING

Tidak dirub dirubah menjadi glukosa Mengurangi total KH Contoh : 13 g Total Carb - 3 g dietary fiber

Count as 10 grams carbohydrate

PENGARUH CARBOHYDRATE COUNTING TERHADAP KADAR GLUKOSA DARAH PENDERITA DIABETES MELITUS

Penelitian Agus Prastowo (disampaikan pada IDU, Yogyakarta 2009) Adanya hubungan antara pemberian diet Carbohydrate Counting dengan penurunan kadar glukosa darah penderita diabetes melitus.

ADA NUTRITIONAL GUIDELINE

The Amount of Carbohydrate is More Important Than the Type

EVIDENCE UPDATE ON DIABETES

(Diabetes management and education group British Diatetic association)
Lower

GI diets can improve HbA1c by 0.5%* 0.5%* and 0.37%. 0.37%.** **

* Thomas D,etal. D,etal.

Cochrane Database of Systematic Reviews 2009(1).

**Opperman ** Opperman AM, et al.. al.. British Journal of Nutrition 2004; 92(3):36792(3):367-81.

Standards of Medical Care in Diabetes -2010

Level B Evidence For individuals with diabetes, use of the glycemic index and glycemic load may provide a modest additional benefit for glycemic control over that observed when total carbohydrate in considered alone.

Glycemic Index and Glycemic Load

Glycemic Index (GI) How rapidly a particular carbohydrate food may rise blood glukosa Glycemic Load (GL) How much impact a carbohydrate food may have on blood glucose levels, depending on the number of grams of carbohydrate in a serving

INDEKS GLIKEMIK
Spaghetti
IG = 37 Hanya 37% KH spaghettis gula darah dalam 2 jam pertama Sisanya dirubah menjadi gula darah bebera jam kemudian. kemudian .

LOW

Glycemic Index of Selected Foods

HIGH

Peanuts Soybeans Cashews, cherries Milk, kidney beans, garbanzo beans Butter beans Yogurt Tomato juice, navy beans, apples, pears Apple juice Chocolate, pudding Grapes Macaroni, carrots, green peas, baked beans Rye bread, orange juice Banana Wheat bread, corn, pound cake Brown rice Cola, pineapple Ice cream Raisins, white rice Watermelon, popcorn, bagel Pumpkin, doughnut Sports drinks, jelly beans Cornflakes Baked potato White bread

INDEKS GLIKEMIK
> 70% nasi Mie Lemper Perkedel Bakwan Kentang goreng 55-70% Bolu Bihun Nanas Mangga < 55% Oatmeal Macaroni Jeruk Apel

GLICEMIC LOAD

GL = GI x CHOg per serving/100 Tergantung dari porsi makanan Low GL = < 10 Medium GL = 11-19 High GL = > 20

GLICEMIC LOAD
CONTOH IG roti putih = 70 GL of 1sl = 70 X 15g/100 = 10.5 GL of 2sl = 70 X 30g/100 = 21 GL of 3sl = 70 X 45g/100 = 31.5

IG yang rendah tinggi GL bila porsi yang dimakan besar IG yang tinggi rendah GL bila porsinya terkontrol

Hepatic complications of diabetes mellitus

NAFLD

30-50% of patients have diabetes or are intolerant of carbohydrates, and 20-80% of them have hypertriglyceridemia.

Fatty Liver

Common in individuals who are

Overweight/obese Type 2 diabetic Dyslipidaemic Regular alcohol consumers

NAFLD

NAFLD is a spectrum of disease which includes Fatty liver disease and NASH, but only NASH is known to progress to cirrhosis. 2nd hit Fatty Liver
Obese BMI>28 Centipetal (apple) Bright liver on USS Insulin Resistance Normal ALT

NASH
Obese BMI>28 Bright liver on USS Abnormal ALT Features of metabolic syndrome
Dyslipidaemia DM HBP

Cirrhosis
Bright/ small liver on USS + splenomegaly Abnormal ALT Thrombocytopenia Obesity Poorly controlled DM Poorly controlled lipids Hypertension

DIET RENDAH KALORI RENDAH KARBOHIDRAT (<40%) THD PENURUNAN BB PADA NAFLD

subjects on hypocaloric lowlow-carbohydrate diets have statistically significant weight loss over the short term (six months) in comparison to those on the conventional diet. there was no significant difference at one year.
Annual Review of Nutrition Vol. 29: 365365-379 (Volume publication date August 2009)

UNRESTRICTED CALORIE LOWLOWCARBOHYDRATE DIETS, WEIGHT LOSS, AND NAFLD NAFLD

low-carbohydrate diets without restriction on lowtotal calorie intake have equally proven to be an effective tool to shortshort-term weight loss

Annual Review of Nutrition Vol. 29: 365365-379 (Volume publication date August 2009)

DIET RENDAH KARBOHIDRAT DAN PENGARUHNYA PADA METABOLIK SINDROME SINDROM E

Diets that are lower in carbohydrate and relatively higher in fat have greater benefits on insulin sensitivity, triacylglycerol, and HDL cholesterol concentrations than do similarly hypocaloric, lowlow-fat diets lowlow -carbohydrate diets mentioned above have shown improvement in biochemical parameters of metabolic syndrome, central obesity, and insulin sensitivity in the short term

PENGARUH DIET KARBOHIDRAT SEDANG (40% (40% 50%) PADA NAFLD

moderate restriction of carbohydrate is a reasonable option for patients with NAFLD because of the similar benefits in weight loss and improvement in parameters of metabolic syndrome seen with lowlow-carbohydrate diets. longlong -term adherence with moderate carbohydrate restriction is presumably better.

PENGARUH DIET TINGGI KARBOHIDRAT (50% (50% 65%) PADA NAFLD

Belum banyak studi yang menunjukkan pemburukan fatty liver NASH ketika pasien diberikan diet tinggi karbohidrat Higher carbohydrate intake was significantly associated with higher odds of inflammation in contrast to higher fat intake, which was associated with lower odds of inflammation.
Annual Review of Nutrition Vol. 29: 365365-379 (Volume publication date August 2009)

Physical Activity

Aerobic exercise with dietary restriction can improve insulin resistance and liver disease in NAFLD in human
Cinar et al., JGH 2006 Nobili et al., Hepatology 2006 Kugelmas et al., Hepatol 2003 Ueno et al., J Hepatol 1997 Suzuki et al, J Hepatol 1005 Hicknam et al, Gut 2004 Screenivasa et al, JGH 2006

Randomized controlled studies lacking

Managemant of NASH

The patient should lose weight and exercise Pharmacological treatment of InsulinInsulinresistance Treatment of Hyperlipidaemia

Scientific evidence of interventions using the Mediterranean diet: a systematic review

35 different experimental studies. Diabetes (25 studies): most studies reported reductions in total cholesterol, lowlow-density lipoproteins, triglycerides, apoprotein B and very lowlow-density lipoprotein cholesterol, an increase in highhigh-density lipoprotein cholesterol Insulin resistance and metabolic syndrome were reduced with the Mediterranean diet in some studies.

Nutr Rev. 2006 Feb;64(2 Pt 2):S272):S27-47. 47.\ \

MEDITERRANEAN DIET

Karbohidrat sedang (45%) karbohidrat komplek Lemak sedangsedang-tinggi (35 (35 40%), dengan lemak jenuh < 10% , tinggi monounsaturated fats Menghindari alkohol Diet Mediteranean The Mediterranean diet may be also useful to ameliorate liver function tests in obese patients with insulin resistance and diabetes Metabolic Syndrome and Related Disorders. June 2010, 8(3): 197197-200

Hepatic encephalopathy

Hepatic encephalopathy requires high carbohydrate diets causing postprandial hyperglycemia, rapidrapid-acting insulin (lispro, aspart, or glulisine) are particularly useful