NUTRISI PADA DIABETES

MELLITUS
OLEH
Prof.Dr.Fadil Oenzil, PhD, SpGK

Flow diagram of the development

of type II diabetes

1
2

c) Diabetic

Venous plasma glucose level

(mmol/L)

1
0

b) Person
with
impaired
glucose
tolerance

6
(a) Normal

individual

1 hour
Time after ingestion of 75 g
glucose

2 hour

Ball M (1997) Diabetes in Food and Nutrition

Diabetes : Metabolism out of control

-cytotrophic virus
Chemical toxin

Genetic predispositionin
-cell injury

Islet cell antibody (ICA)

Juvenile Ketpsis
Prone Insulin dependent
(type I) IDDM
Excessive food intake

Inadequate exercise

Obesity
Insulin resistence

Compensatory
Hyperinsulinism

genetic predisposition

B-cell decompensation

Maturity onset
Ketosis resistent
Insulin 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
individuals wishes and willingness to change

Heimburger D.C., et al (2006) Diabetes, Handbook of clinical nutrition

Nutritional recommendation for

persons with diabetes
Nutrient

PDGMI

ADA

Calori

ideal Body

ideal body

Carbohydrate % of
kcal

60-70% (up to 75%)

About 50%

Protein %

10 15%

10-20%

Fat total %

20 25%

<30%

SAFA %

< 10%

< 10%

MUFA %

Up to 15%

10-20%

PUFA %

<10%

<10%

Cholesterol mg/day

< 300 mg/day

< 300 mg/day

Fiber g/day

+ 25 gr/day

20-35 g/day

Sodium mg/day

Normotensi 3000

< 2400 mg *

Rekomendasi untuk pasien dengan

diabetes
Zat gizi

PDGMI

kalori

Berat badan ideal

karbohidrat

60-70% (sampai
75%)

(% kcal)

ADA

berat badan
Ideal
About 50%

Protein %

10 15%

10-20%

Total lemak %

20 25%

<30%

SAFA %

< 10%

< 10%

MUFA %

Up to 15%

10-20%

PUFA %

<10%

<10%

kolesterol mg/hari

< 300 mg/day

< 300 mg/day

serat g/hari

+ 25 gr/day

20-35 g/day

Normotensi 3000
< 2400 mg *
mg/d
Sukmaniah S (2007) Nutrisi pada Diabetes
Melitus, dalam buku pegangan penatalaksanaan

Na mg/hari

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 shouldn 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

Luas daerah dibawah kurva respon glukosa

darah tubuh setelah 2 jam terhadap makanan
Indek Glikemik =
X 100%
Luas daerah dibawah kurva respon glukosa
darah tubuh setelah 2 jam terhadap glukosa
murni

Glycemic index value by Jenny Miller :

1. Low if glycemic index < 55
2. Moderate if glycemic index 55 70
3. Hight if glycemic index > 70
Glycemic index value by Wolever et al :
1. Low if glycemic index < 70
2. Moderate if glycemic index 70 90
3. 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

Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 9 th ed

Upper
epidermis

Palisade
parenchy
ma

Bundle sheath

Spongy
parenchy
ma

xyle
m
phloe
msheath
Bundle

Vein

Stoma

Lower
epidermis
Stoma

Tabel : Indeks Glikemik Monosakarida, Disakarida dan Polisakarida

Murni dan Bahan Makanan Sumber Karbohidrat pada Orang
Normal

NO

Beban yang
diberikan

Luas area dibawah kurva

Indeks Glikemik (%)

(cm)
100

Glukosa murni

210,9

Fruktosa murni

45,3

22

Madu Sumbawa

162,3

77

Laktosa murni

20,95

10

Susu Laktogen

28,65

14

Kanji

87,73

42

Kentang

84,3

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

2.The distribution of carbohydrate

among meals and snacks
Meals

In Gram

Portion

Breakfast

60

Lunch

60

Afternoon snach

30

Dinner

75

Evening snack

30

255 g

17

Total

Rolfes S.R et all (2006) Nutrition and Diabetes Mellitus in Understanding Normal and Clinical Nutrition

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
Rolfes S.R et all (2006) Nutrition and Diabetes Mellitus in Understanding Normal and Clinical Nutrition

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

Anderson J.W (2006) Nutritional management of DM in Modern Nutrition, 10 th ed

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

Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 9 th ed

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
Franz M.J (1996) Nutritional care in DM in Food, Nutrition and Diet Therapy 9 th ed :
Anderson J.W (2006) Nutritional management of DM in Modern Nutrition, 10 th ed

 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

Franz M.J (1996) Nutritional care in DM in Food, Nutrition and Diet Therapy 9 th ed :
Anderson J.W (2006) Nutritional management of DM in Modern Nutrition, 10 th ed

HFD contributes :
Decreasing glucosa transport into
muscle and adipose tissue
Decreasing activities of insulinstimulated process
Glycogen syntesis rates, glycogen
accumulation and glucose oxidation
are lower

Franz M.J (1996) Nutritional care in DM in Food, Nutrition and Diet Therapy 9 th ed :
Anderson J.W (2006) Nutritional management of DM in Modern Nutrition, 10 th ed

Fiber
Divided in to two general categories
Water soluble
Water insoluble

Soluble fibers
can lower blood suger level
decrease bodys need for insulin
lowers cholesterol level

Anderson J.W (2006) Nutritional management of DM in Modern Nutrition, 10 th ed

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

DIMETABOLISASI
OLEH BAKTERI
UNTUK
PERTUMBUHAN
BAKTERI
PROSES
AKHIR
HASIL
AKHIR

Selulosa

Hemiselulosa
Pentosa

Heksosa
Glikolisis

Lintasan
Pentosa
Piruvat

Asetat
propionat
butirat

Hidrogen
metana
karbondioksid
a
Keluar melalui
udara pernapasan
setelah absorpsi

Diabsorpsi oleh Keluar ke

usus halus dan feses
dimetabolisasik
an
Gambar : Pemecahan Serat Makanan di Dalam Usus Besar

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)

Anderson J.W (1999) Nutritional management of DM in Modern Nutrition, 9 th ed

 Lower serum cholesterol

Lower fasting and postprandial
serum triglycerides
May attenuate hepatic cholesterol
syntesis
May increase satiety between meals

Micronutrient
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

Glutathione
(Glutamate Cystein Glycine)
Selenium : Glutathione peroxidace enzyme co factor
Regeneration of antioxidants reguires Glutathione
R*

R
H

Vit E

Vit
E*

Vit C

Vit
C*

GS
H

NAD
P

GSS
G

NADP
H

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

Zinc
Improve insulin secretion
Enhances binding of insulin
Co 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 g
Adult women
70 g
Se content of some food (g / 100 g of food)
Seafood
100
Organ meat 20
Cereals
20
Dairy 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 mg
Adult women
270 mg
Milligram (mg) per 100 g food
Cocoa Powder
520
Bran Wheat
520
Soya
240
Peanut Raw 130

Chromium
Increase insulin binding to cells,
Increase insulin sensitive
Increase receptor number
Activates 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 g/day)
Content of some foods (g/100 g of food)
Egg yolk 183
Brewers yeast 112
Beef
57
Cheese
56
Apple
27

Zinc
Improve insulin secretion
Enhances binding of insulin
Co 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 seimbang
2. Asupan kalori dengan mengontrol berat badan
3. Pemberian makanan dengan indek glikemik yang rendah
4. Serat makanan yang cukup (25 gr/hari)
5. Kegiatan fisik teratur, terukur
6. Batasi asupan kolesterol
7. Bila perlu Suplemen makanan vitamin, mineral dan anti oksidan

References
Nutritional Care in Diabetes Mellitus,in
Food and Diet Therapy,by Krauses
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