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CURICULUM VITAE.

Nama Lengkap
: Dr.dr Dharma Lindarto. SpPD, KEMD
Tempat & Tanggal Lahir : D. Merangir, 22 Desember 1955.
Jabatan
: Kepala Divisi Endokrin-Metabolik Deprt IPD FKUSU/RSUP H Adam Malik
Medan
Alamat rumah
: Jln Gaperta No. 188 Medan 20124. Tel: 061- 8468380 HP: 0811631514
Alamat Kantor
: Div. Endok- Metab Dep I Peny Dalam FK USU/RSUP. H Adam Malik, Medan

)
Pendidikan

Dokter Umum

Ahli Penyakit Dalam

Konsultan Endokrin

S3 /Doktor

: FK USU Medan (1982)


: FK USU Medan (1993)
: PAPDI
(2005)
: FK USU Medan (2012)

Pendidikan Tambahan
1.The Course on the Management of Diabetes Mellitus in the Primary Health Services. Jakarta
August, 2000
2. Involved in Department of Endorinology & Metabolism. Royal Adelaide Hospital Internal Medicine
Services.
2001. Adelaide. Australia.
3. Course In Advances Endocrinology. Endocrine & Metabolic Society Of Singapore. 2005
4. Training Course in The Pathophisiology of Osteoporosis And Bone Disease. At Shangrila Las Rasa
Sentosa
Resort, Singapore. 2005.
5. Practical Diabetology Course, Skodsborg Health Centre, Denmark, 2006
Organisasi Profesi
1. Pengurus IDI Cabang Kota Medan
2. Pengurus PAPDI Cabang Medan.
3. Sekretaris Perkeni Cabang Medan.
4. Ketua Persadia Cabang Medan.
5. Anggota Perosi Wil Sumut

The Role of Lifestyle Modification


in T2DM Management

Dharma Lindarto
Div. Endokrin-Metabolik Departemen Ilmu Penyakit
Dalam FK USU / RSUP H Adam Malik Medan

Questions

Can type 2 diabetes be prevented?

Lifestyle

modification is effective in
preventing/delaying type 2 diabetes and should be
offered to all individuals at high risk of developing
type 2 diabetes (Grade A)

Evidence Statements
Lifestyle modification including increasing physical
activity, improving diet, and weight loss are effective in
preventing/delaying the onset of type 2 diabetes in high
risk individuals
Weight loss, physical activity and dietary modification
contribute to reducing the risk of developing type 2
diabetes

Evidence Statements
Lifestyle interventions in people with IGT reduce
progression to type 2 diabetes beyond the intervention
period
Pharmacological interventions (including metformin,
acarbose, rosiglitazone and orlistat) are effective in
preventing/delaying the onset of type 2 diabetes in high
risk individuals

Exercise & Type 2 Diabetes

Improves CV function & CHD risk profile.


Increases self confidence.
Improves glucose control:

Improving insulin sensitivity.


Increasing Glu T4 (glucose transporters).

KSU

Improves physical fitness & reduces fat %.

Prevention Diabetes
Primer
Secunder
Tertier

Stages in the natural history


of Type 2 diabetes
Normal

IGT

Genetic
Preclinical
predisposition state

Primary
prevention

NIDDM

Complications

Disability
Death

Clinical
disease

Complications

Disability
Death

Secondary
prevention

Tertiary
prevention

Stages in the natural history


of Type 2 diabetes
Normal

IGT

Genetic
Preclinical
predisposition state

Primary
prevention

NIDDM

Complications

Disability
Death

Clinical
disease

Complications

Disability
Death

Secondary
prevention

Tertiary
prevention

Stages in the natural history


of Type 2 diabetes

Normal

IGT

Genetic
Preclinical
predisposition state

NIDDM

Complications

Disability
Death

Clinical
disease

Complications

Disability
Death

Exercise Prescription for Diabetic 1/4


KSU

Aerobic activity for 30 min. extended (gradually)


to 60 min. every day or most days/week.
HR during activity should be gradually
increased to reach 60 70% of HR max.
Exercise session should include 5-10 min. of
warm-up and a 5 min of cool-down.
Exercise must involve most major muscles in
both lower and upper parts of the body.

Exercise Prescription for Diabetic

KSU

Exercise must be regular. Benefits are


diminished after 1 -2 weeks of stopping .

2/4

Moderate intensity weight training program is


recommended to maintain muscle strength
( 8-12 repetitions 2 times /week).
For those with feet problems, avoid running.
Alternate between walking, swimming, and cycling.

Exercise Prescription for Diabetic

When using insulin, avoid exercise if glucose


levels below 100 mg/dl or above 250 mg/dl.
Do not inject insulin into a body part that is
expected to be used during exercise.
Avoid dehydration by keeping your body
always hydrated.

KSU

Use proper shoes, with silica gel or air-filled


soles, and always keep feet dry.

3/4

What happens when we begin exercise?

Increase in heart rate, cardiac output, respiratory


ventilation and oxygen consumption
Use of muscle fuel store (glycogen and fat) plus blood
glucose and fatty acids
Availability of muscle fuel store controlled by local
factors
Provision of fuel in the blood depends on hormonal
(insulin, glucagon, adrenaline) and sympathetic nervous
system effects on the liver and adipose tissue

What does insulin do?

Increase in GLUT -4 transporters, increases uptake of


glucose in muscle and fat cells

Aerobic Exercise
glucose

Rise in blood glucose


to meet fuel needs

Glut 4
Muscle
contracts

Increase in
insulin and
exercise
mediated
receptors
increase
muscle uptake
of glucose

ATP
Glycogen stores

Anaerobic exercise

Muscle cell
fatigue
Blood glucose rises
due to neuroendocrine
responses

Muscle
contracts

Creatine
phosphate

Lactic
acid

Creatine
kinase

ATP

ATP

Glycogen

glycolysis

Energy Cost of Physical Activity


(kilocalorie/kg. min)

Activity
Brisk walking
Running (7.5 min per km)
Running (5 min per km)
Swimming
Rope skipping (70/min)
Rope skipping (80/min)
Badminton
Tennis
Squash
Basketball
McArdle, et., 1991

Calorei
0.07
0.13
0.208
0.162
0.162
0.165
0.097
0.109
0.212
0.138

What is the Amount of Physical Activity


that Promotes Health?

Moderate Intensity Physical Activity.


Energy Expenditure = 3 - 6 MET
That is: 30 min/day, 5 days/week.
150 min. per week.
ACSM, 2000; CDC, 1996

1000 k. calories/week.
Drygas, et al., 2000; Fletcher, et al., 1996; Lee, et al., 2000

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Energy regulation during exercise

Fuel Contribution to
Total 02 Uptake (%)

100

Free fatty
acid uptake

Muscle glycogen
50

Blood glucose uptake

0
Glycogen

2
Glucose +
FFA Uptake

3
FFA

4 hrs
Glucose
Uptake

Graded Exercise Testing for


Diabetic

4/4

ADA Position Statement, Diabetes Care, 2002

KSU

It is recommended before any moderate to


high intensity exercise, especially if:
Age is > 35 yrs.
Type 2 diabetes for > 10 yrs duration.
Type 1 diabetes for > 15 yrs duration.
Presence of any CHD risk factors.
Presence of microvascular disease
(retinopathy, nephropathy).
Presence of peripheral vascular disease.

Using METS to estimate energy


expenditure

A MET is a metabolic equivalent and is a way of estimating


energy expenditure
Ratio of work metabolic rate to standard resting metabolic
rate of 1(quiet sitting)
They provide information about EE during activity and can
be used to calculate energy expenditure per minute of
activity for individuals
Activity

METs

BMX biking

8.5

Ballet

4.8

Washing dishes

2.3

Sleeping

0.9
Ainsworth et al 2000 Med Sci
Sport & Exerci

How much energy is used in activity?

A 43kg 13year old male will use..


Activity

20 minutes

60 minutes

Football

120kcal

360kcal

Swimming
(leisure)

90kcal

270kcal

Cycling (leisure) 60kcal

180 kcal

Running (5mph) 105kcal

315kcal

Walking
(2.5mph)

135kcal

45kcal

Energy expenditure during exercise can be calculated from


detailed activity diaries. Harrell et al (2005) adapted the
calculation used in adults for children

Energy content of snacks


30g carbohydrate snack Energy content
500ml isotonic sports drink 120kcal
40g jelly babies

150kcal

1.5 breakfast cereal bars

155kcal

Jaffa cakes x 4

138kcal

Chocolate bar ( 3x fun


size)

243kcal

3 digestive biscuits

210kcal

Depending on the individual and their overall energy intakes,


additional carbohydrate may contribute excess energy intake.

Fat content of snacks


One of the benefits of increased exercise is the
potential lipid lowering effects.
It may be important to consider saturated fat
content of snacks

30g carbohydrate snack Fat content


500ml isotonic sports drink 0g
40g jelly babies

0g

1.5 breakfast cereal bars

6g

Jaffa cakes x 4

4g

Chocolate bar ( 3x fun


size)

9g

3 digestive biscuits

9.6g

Carbohydrate requirements
Will vary with
duration and intensity
of exercise, as well as
age of child
Minimum of 15g per
hour
Avoid consuming
excess calories

Exercise in the Prevention of Diabetes


Participants are either normal or have
Malmo
Study
Da Qing, China

Sweden

The Nurses
Health Study

USA

Finnish

Finland

Diabetes
Prevention Study

USA

Experimental Study

China

males 260
(6 yrs)
males & 577
Females (6 yrs)
70,000

GTT

Eriksson & Lindgarde,


Diabetologia, 19991
Pan, et al,
Diabetes Care, 1997
.,Hu, et al

Nurses (8 yrs)
&males 523
Females (4 yrs)

JAMA, 1999

males & 3234


Females (3 yrs)

Diabetes Prev. Program


Research Group,

Tuomilehto, et al., N
Engl J Med, 2001

N Engl J Med, 2002


KSU

Trials to Prevent / Delay Progression


From IGT to Type 2 Diabetes
Medications

Diabetes Prevention Program:


metformin, (troglitazone)

TRIPOD: troglitazone

STOP-NIDDM: acarbose

NAVIGATOR: nateglinide and


valsartan

DREAM: rosiglitazone and ramipril

XENDOS: orlistat

ORIGIN: glargine insulin

ACT NOW: pioglitazone

TRIPOD = Troglitazone in Prevention of Diabetes Study; STOP-NIDDM = Study to Prevent NonInsulin-Dependent Diabetes Mellitus; NAVIGATOR = Nateglinide and Valsartan in
Impaired Glucose Tolerance Outcomes Research; DREAM = Diabetes Reduction Approaches with Ramipril and Rosiglitazone; XENDOS = Xenical in the Prevention of Diabetes in
Obese Subjects; ORIGIN = Outcomes Reduction with Initial Glargine Introduction.

2005. American College of Physicians. All Rights Reserved.

Cumulative Incidence of Diabetes in the


Finnish Study
The Cumulative Incidence of Diabetes

(after 4 years of intervention)


P < 0.001

58% Risk Reduction

Tuomilehto et al. N Eng J Med 2001, 344(18):13

2005. American College of Physicians. All Rights Reserved.

Prevention of post exercise


hypoglycaemia

Insulin reduction
If

exercise 1 or 2 times per week, can see a marked


change in insulin sensitivity overnight try exercise
day doses
Reduce insulin with food post exercise may need
between 30 and 100% reductions depending on type
and duration of exercise

Increase carbohydrate intake


Eat

immediately after exercise to maximise


replacement of muscle and liver glycogen
Spread carbohydrate appropriately across the day
supper may need to contain 1g carbohydrate/kg body
weight

Summary 1

Exercise may lower or raise blood glucose during


exercise depending on
Type

and intensity and duration


Insulin levels
Pre exercise blood glucose levels

Post exercise blood glucose may fall for up to 20


hours due to effects of increased insulin
sensitivity and muscle and liver glycogen
replenishment
Hypoglycaemia

post exercise will require more


treatment > 15g glucose found to be needed.
If liver glycogen stores are deplete glucagon may be
in effective

Summary 2
Young people need to be encouraged to do
regular activity
This may not improve diabetes control
Where weight is a concern care should be taken
to match additional food consumption with
energy requirements
Where possible adjust insulin to prevent
hypoglycaemia during exercise if weight is
concern
Effective exercise management requires regular
blood glucose monitoring before, during and
after activity

Summary 3
When young people are deciding to take up
structured training for a sport, it is important
for the diabetes team to consider;
The physiological requirements of training and
competition
The lifestyle of the athlete
The culture of the sport
Anti Doping ????? Therapeutic Use Exemption
(TUE) may be needed (www.100percentme.co.uk)

Terapi Gizi Medis pada Diabetes

Perencanaan Makan pada DM

Adalah sebuah bagian yang essensial dlm pengelolaan diabetes


yang menyeluruh

Tujuan

Mengendalikan glukosa darah


Mengendalikan lipid darah
Menunda atau mencegah komplikasi
Mencapai-mempertahankan BB normal

Berkontribusi dalam A1C sebanyak 1-2% dalam 6-12 minggu


pertama dimulainya terapi gizi medis

Perencanaan Kebutuhan Gizi Pasien


Diabetes
Untuk kepentingan klinik praktis dalam menghitung jumlah kalori, penentuan status gizi
memanfaatkan rumus Broca, yaitu:
Berat badan (BB) idaman = (TB 100) 10 % (TB 100)
NB: Untuk wanita < 150 cm dan pria < 160 cm, tidak dikurangi 10% lagi
BB kurang
BB normal
BB lebih
Gemuk

< 90%
90 110 %
110 120 %
> 120 %

BB idaman
BB idaman
BB idaman
BB idaman

Petunjuk Praktis Pengelolaan DM Tipe 2, Perkeni, 2002

Perencanaan Kebutuhan Gizi Pasien


Diabetes

** Stress metabolik berupa infeksi, operasi, dll

Petunjuk Praktis Pengelolaan DM Tipe 2, Perkeni, 2002

Perencanaan Kebutuhan Gizi Pasien


Diabetes
Kebutuhan Energi

Basal : 25-30 kkal/kg BB ideal perhari


Faktor penentu kebutuhan kalori
1.
Jenis kelamin
2.
Umur : 40-59 th dikurangi 5% basal,
60-69 th dikurangi 10%
3.
Aktifitas : istirahat +10%, aktif ringan +20%,
sedang +30%, berat 40+50%
4. BB
: 20 % basal
5. Stress : + 20 % basal

Kebutuhan Energi per kg BB berdasar aktivitas

Gemuk
Normal
Kurus

Contoh

Ringan
20-25 kal
30 kal
35 kal

Sedang
30 kal
35
40

Berat
35 kal
40
40-50

: BB 54 kg (BB normal), aktivitas ringan,


Jadi kebutuhan energi = 54kgx30 kkal =1620 kkal
dibulatkan = 1700 kalori sehari

Karbohidrat
Anjuran 45-65% total asupan energi
Total KH <130 g/hari tidak dianjurkan
Diutamakan tinggi serat.
Sukrosa 5 % total asupan energi
Distribusi 3X makan /hari
1 g KH = 4 kkal

R/ ORIBEST
Konsensus Pengelolaan & Pencegahan DM tipe 2, 2011

Protein
Anjuran

10-20% total asupan energi


Pada nefropati asupan protein 0.8g/kgBB/hari
atau 10% dari kebutuhan energi
1 g protein = 4 kkal

Konsensus Pengelolaan & Pencegahan DM tipe 2, 2011)

Protein

Guna protein: untuk pertumbuhan dan mengganti


jaringan yang rusak

Sumber protein : ikan, seafood, daging tanpa lemak,


ayam tanpa kulit, kacang-kacangan, tahu, tempe, susu
rendah lemak

Lemak
Anjuran

20-25% total asupan energi


Lemak jenuh (UFA) < 7% asupan energi
Lemak tak jenuh ganda (PUFA) < 10% total
asupan energi
Lemak sumber MUFA (minyak zaitun/olive, wijen,
bunga matahari, alpukat)
Asupan kolesterol < 200 mg perhari
1 g lemak = 9 kkal

Konsensus Pengelolaan & Pencegahan DM tipe 2, 2011

Serat
Anjuran 25 g/hari
Serat larut air (buah dan sayuran) dapat
menurunkan/memperlambat penyerapan glukosa dan lipid

Serat
Serat baik untuk kesehatan, karena:
- Membuat perut terasa lebih kenyang

- Membantu menurunkan gula darah


- Membantu menurunkan lemak darah
- Melancarkan buang air besar

Sumber Serat

Kacang-kacangan, buah, sayur segar, roti


gandum, tahu, tempe

Pemanis
Terdiri dari pemanis berkalori (gula alkohol dan
fruktosa) dan tidak berkalori (aspartam, sakarin,
sukralose)
Fruktosa tidak dianjurkan > 50 g perhari karena efek
samping pada lemak darah

Natrium
Na: 3000 mg = 6-7 g NaCl (1 sdt. Garam dapur)
Garam dapur dalam jumlah berlebihan berisiko
meningkatkan tekanan darah
Kurangi konsumsi makanan yang diasinkan seperti : ikan
asin, telur asin, corned beef, sarden, sosis, nugget dll

Pembagian Porsi Makan


Makan Pagi
Makan Siang
Makan Malam
Makanan Selingan

: 25 %
: 30 %
: 30 %
: 10-15 %

Gula & makanan yang mengandung gula murni


(Hindari/Batasi)

49

Tepung & makanan yang terbuat dari


tepung-tepungan (HINDARI / BATASI)

Pedoman Pemberian Makan


3 J (Jadwal, Jumlah, Jenis)
1.

Jadwal

: 3 x makan utama
2 3 x makanan selingan

2.

Jumlah

: Volume, bahan makanan sehari,


kandungan zat gizi sesuai anjuran

3.

Jenis

: bervariasi, memilih makanan

nutritious dan healthy

Bahan makanan penukar


Memudahkan

pengguna untuk menukar


bahan makanan dengan nilai gizi hampir
sama
Bahan makanan penukar digolongkan
menjadi : 8 golongan
Setiap satu satuan penukar bahan makanan
mempunyai nilai gizi yang hampir sama

Simpulan

Terapi

gizi medis dan upaya penurunan berat badan


(jika diperlukan) mambantu memperbaiki resistensi
insulin, profil metabolik dan kadar glukosa darah

Exercise American Style

Than You For Your Attention

KSU