Is There Any Significant of Carbohydrate Intake in Diabetic Patient With Liver Diseases

7/30/2019 Is There Any Significant of Carbohydrate Intake in Diabetic Patient With Liver Diseases

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a ang u r on p a e 2010

Susetyowati

Prodi Gizi Kesehatan FK UGM


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KARBOHIDRAT - Overview Karbohidrat sederhanaKarbohidrat sederhana

MonosaMonosakaridakarida

DisaDisakaridakarida

ar o rat omp ear o rat omp e

PoPolisakaridalisakarida (glycogen and starches)(glycogen and starches)

seratserat (not digestible)(not digestible)


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KARBOHIDRATKARBOHIDRAT

Karbohidrat sederhana

(sugars)

Karbohidrat Komplek

(starches)

Blood

Glucose


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Timed Effect on Blood Sugar Levels

Meal 1 Hr 2 Hrs 3 Hrs 4 Hrs 5 Hr s 6 Hr s 7 Hr s 8 Hr s

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** (


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KARBOHIDRAT PADA DIABETES

Apakah karbohidrat menyebabkan

resistensi insulin?Apakah diet tinggi karbohidrat

memperbaiki kontrol glikemik?


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Insulin sensitivity improves with carbohydrateintakewhy?

Carbohydrate

Fat (terutama lemak jenuh)

Does Carbohydrate Cause Insulin Resistance?Does Carbohydrate Cause Insulin Resistance?

11 studies, non-diabetic: 7 studies comparing highCHO with low reported insulin sensitivity; 4 nodifferences

7 studies, diabetes: 5 studies comparing high CHOwith low reported insulin sensitivity; 2 nodifferences Bessesen. J Nutr. 2001;131:2782S; McClenaghan.

Nutrition Research Reviews. 2005;18:222


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One-Year Comparison of a HighMonounsaturated Fat

Diet With a High-Carbohydrate Diet in Type 2 Diabetes

High-MUFA diets are an alternative toconventional lower-fat, high-CHO diets

weight, body composition, cardiovascularrisk factors, and glycemic control.

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


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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

4

6

8

10

12

14

16

18

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

Mean

Plasma

Glucose*

(mmol/L)


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REKOMENDASI KARBOHIDRAT

Meta-analysis of the evidence

Diet tinggi KH (>60%) dan tinggi seratdibandingkan KH sedang (30-59%) dan rendahKH (


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REKOMENDASI KARBOHIDRATAmerican 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


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Carbohydrate Counting

Perencanaan makanan yang dapat menjagakadar gula darah sesuai dengan target,terutama jika karbohidrat yang dikonsumsidikombinasi dengan insulin yang

Penentuan jumlah sajian yang diperlukandalam Carbohydrate Counting inidisesuaikan dengan kalori yang dibutuhkan


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MANFAATMANFAAT

Carbohydrate CountingCarbohydrate Counting Lebih fleksibelLebih fleksibel

Gula tidak dilarangGula tidak dilarang

Setiap 15 gram karbohidrat (60 kal = dibutuhkan 1unit insulin).

Lebih perhatian pada bahan makanan yangLebih perhatian pada bahan makanan yangmeningkatkan kadar gula darahmeningkatkan kadar gula darah


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The Exchange System

Pengelompokkan bahan makanan yang dianggap

mempunyai nilai gizi yang kurang lebih sama

1 F a t

1 M e a t

1 V e g e ta b l e

1 Mi l k

1 Fruit

1 Starch

0 5 10 15


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Starch GroupStarch Group

(1 penukar = 15 g KH)(1 penukar = 15 g KH)

1 slice bread ( 30g)

cup mashedpotatoes

1/2 cup pasta (60g)

1/2 cup corn (60g)

1/3 cup rice (70g)


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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


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KELOMPOK BUAH

(15 g KH)1 small fresh fruit (4

oz)

canned fruit innatural juice)2 Tbsp raisins17 grapes C fruit juice1 Tbsp jelly, jam


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KELOMPOK SUSU DAN YOGURT

(12 g KH)

8 fl oz of skim, 1%, 2%,or whole milk

1 C p ain yogurt1 C plain or vanilla soy

milk


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KELOMPOK SAYURAN

(1 penukar = 5 g KH)

C cooked C cooked

ve etablesve etables 1 C raw vegetables1 C raw vegetables


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Exchange ListsExchange ListsExchange ListsExchange ListsCalories g CHO g Pro g Fat

Starch 80 15 3 0 -1

Fruit 60 15 0 0

Skim Milk 90 12 8 0 - 3

Low-fat Milk 120 12 8 5

Whole Milk 150 12 8 8

Vegetable 25 5 2 0

Very Lean Meat 35 0 7 0 - 1

Lean Meat 55 0 7 3

Medium Fat Meat 75 0 7 5

High Fat Meat 100 0 7 8

Fat 45 0 0 5


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SERAT DAN CARBOHYDRATESERAT DAN CARBOHYDRATE

COUNTINGCOUNTING

Tidak diruTidak dirubbah menjadiah menjadi

glukosaglukosa

Mengurangi total KHMengurangi total KH

ContohContoh ::13 g Total Carb13 g Total Carb

-- 3 g dietary fiber3 g dietary fiber

Count as 10 gramsCount as 10 gramscarbohydratecarbohydrate


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PENGARUHPENGARUH CARBOHYDRATE COUNTINGCARBOHYDRATE COUNTING

TERHADAPTERHADAP KADAR GLUKOSA DARAHKADAR GLUKOSA DARAH

PENDERITA DIABETES MELITUSPENDERITA DIABETES MELITUS

Penelitian Agus Prastowo (disampaikanPenelitian Agus Prastowo (disampaikan

pada IDU, Yogyakarta 2009)pada IDU, Yogyakarta 2009)

Carbohydrate CountingCarbohydrate Countingdengan penurunandengan penurunan

kadar glukosa darah penderita diabeteskadar glukosa darah penderita diabetes

melitus.melitus.


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ADAADA

NUTRITIONAL GUIDELINENUTRITIONAL GUIDELINE

TheThe AmountAmount of Carbohydrate is Moreof Carbohydrate is More

Important Than theImportant Than the TypeType


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EVIDENCE UPDATE ON DIABETESEVIDENCE UPDATE ON DIABETES(Diabetes management and education group(Diabetes management and education group --

British Diatetic association)British Diatetic association)LLower GI diets can improve HbA1cower GI diets can improve HbA1c

by 0.5%by 0.5%** andand 0.37%.0.37%.****

** Thomas D,Thomas D,etal.etal. Cochrane Database of Systematic Reviews 2009(1).Cochrane Database of Systematic Reviews 2009(1).****Opperman AM,Opperman AM, et al.et al.. British Journal of Nutrition 2004; 92(3):367. British Journal of Nutrition 2004; 92(3):367--81.81.


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Standards of Medical Care inStandards of Medical Care in

DiabetesDiabetes --20102010

Level B EvidenceLevel B Evidence

For individuals with diabetes, use ofFor individuals with diabetes, use of

t e g ycem c n ex an g ycem c oat e g ycem c n ex an g ycem c oamay provide a modest additionalmay provide a modest additional

benefit for glycemic control over thatbenefit for glycemic control over that

observed when total carbohydrate inobserved when total carbohydrate inconsidered alone.considered alone.


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Glycemic Index and Glycemic LoadGlycemic Index and Glycemic Load

Glycemic Index (GI)Glycemic Index (GI)

How rapidly a particular carbohydrate foodHow rapidly a particular carbohydrate foodmay rise blood glukosamay rise blood glukosa

How much impact a carbohydrate foodHow much impact a carbohydrate foodmay have on blood glucose levels,may have on blood glucose levels,depending on the number of grams ofdepending on the number of grams of

carbohydrate in a servingcarbohydrate in a serving


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INDEKS GLIKEMIKINDEKS GLIKEMIK

SpaghettiSpaghetti

IIGG = 37= 37

HanyaHanya 37%37% KHKH

dalam 2 jam pertamadalam 2 jam pertama

Sisanya dirubah menjadiSisanya dirubah menjadi

gula darah bebera jamgula darah bebera jam

kemudiankemudian..


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Glycemic

Index of

Selected

Peanuts

Soybeans

Cashews, cherries

Milk, kidney beans, garbanzo beans

Butter beansYogurt

Tomato juice, navy beans, apples, pears

Apple juice

Chocolate, pudding

Grapes

Macaroni, carrots, green peas, baked beans

Rye bread, orange juice

LOW

Foods Wheat bread, corn, pound cakeBrown riceCola, pineapple

Ice cream

Raisins, white rice

Watermelon, popcorn, bagel

Pumpkin, doughnut

Sports drinks, jelly beansCornflakes

Baked potato

White bread

HIGH


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INDEKS GLIKEMIK

> 70% 55-70% < 55%

nasi

Mie

Bolu

Bihun

Oatmeal

Macaroni

Lemper

Perkedel

Bakwan

Kentanggoreng

Nanas

Mangga

Jeruk

Apel


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GLICEMIC LOAD

GL = GI x CHOg per serving/100

Tergantung dari porsi makanan

ow = 20


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GLICEMIC LOAD

CONTOH

IG roti putih = 70

GL of 1sl = 70 X 15g/100= 10.5

GL of 2sl = 70 X 30 /100

IG yang rendah

tinggi GL bila porsi

yang dimakan

= 21

GL of 3sl = 70 X 45g/100= 31.5

IG yang tinggi

rendah GL bila

porsinya terkontrol


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Hepatic complications of

diabetes mellitus

NAFLD 30-50% of patients havediabetes or are intolerant of

-,have hypertriglyceridemia.


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Fatty LiverFatty Liver

Common in individuals who areCommon in individuals who are

Overweight/obeseOverweight/obese

Type 2 diabeticType 2 diabetic

ys p aem cys p aem c Regular alcohol consumersRegular alcohol consumers


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NAFLDNAFLD

NAFLD is a spectrum of disease whichNAFLD is a spectrum of disease which includes Fatty liverincludes Fatty liver

disease and NASH, but only NASH is known to progress todisease and NASH, but only NASH is known to progress to

cirrhosis.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

DyslipidaemiaDM

HBP

Cirrhosis

Bright/ small liver on USS

+ splenomegaly

Abnormal ALT

Thrombocytopenia

Obesity

Poorly controlled DM

Poorly controlled lipids

Hypertension


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DIET RENDAH KALORIDIET RENDAH KALORI

RENDAH KARBOHIDRATRENDAH KARBOHIDRAT (


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UNRESTRICTED CALORIE LOWUNRESTRICTED CALORIE LOW--

CARBOHYDRATE DIETS, WEIGHT LOSS,CARBOHYDRATE DIETS, WEIGHT LOSS,

AND NAND NAFLDAFLD

lowlow--carbohydrate diets without restriction oncarbohydrate diets without restriction on

total calorie intake have equally proven to betotal calorie intake have equally proven to be

an effective tool to shortan effective tool to short--term weight lossterm weight loss

Annual Review of NutritionAnnual Review of NutritionVol. 29: 365Vol. 29: 365--379 (Volume publication date379 (Volume publication dateAugust 2009)August 2009)


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DIET RENDAH KARBOHIDRAT DANDIET RENDAH KARBOHIDRAT DAN

PENGARUHNYA PADA METABOLIKPENGARUHNYA PADA METABOLIK

SINDROMSINDROMEE DDiets that are lower in carbohydrate and relativelyiets that are lower in carbohydrate and relatively

higher in fat have greater benefits on insulinhigher in fat have greater benefits on insulin

sensitivity, triacylglycerol, and HDL cholesterolsensitivity, triacylglycerol, and HDL cholesterol

,, --dietsdiets

lowlow--carbohydrate diets mentioned above have showncarbohydrate diets mentioned above have shown

improvement in biochemical parameters of metabolicimprovement in biochemical parameters of metabolic

syndrome, central obesity, and insulin sensitivity insyndrome, central obesity, and insulin sensitivity inthe short termthe short term


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PENGARUH DIET KARBOHIDRATPENGARUH DIET KARBOHIDRAT

SEDANGSEDANG (40%(40%50%)50%) PADAPADA NNAFLDAFLD

moderate restriction of carbohydrate is amoderate restriction of carbohydrate is a

reasonable option for patients with NAFLDreasonable option for patients with NAFLD

because of the similar benefits in weight lossbecause of the similar benefits in weight loss

an mprovemen n parame ers o me a o can mprovemen n parame ers o me a o csyndrome seen with lowsyndrome seen with low--carbohydrate diets.carbohydrate diets.

longlong--term adherence with moderateterm adherence with moderate

carbohydrate restriction is presumably better.carbohydrate restriction is presumably better.


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PENGARUH DIET TINGGIPENGARUH DIET TINGGI

KARBOHIDRATKARBOHIDRAT (50%(50%65%)65%) PADAPADA

NNAFLDAFLD

Belum banyak studi yang menunjukkanBelum banyak studi yang menunjukkanpemburukanpemburukan fatty liverfatty liver NASHNASH ketikaketikapasien diberikan diet tinggi karbohidratpasien diberikan diet tinggi karbohidrat

associated with higher odds of inflammation inassociated with higher odds of inflammation incontrast to higher fat intake, which wascontrast to higher fat intake, which wasassociated with lower odds of inflammation.associated with lower odds of inflammation.

Annual Review of NutritionAnnual Review of NutritionVol. 29: 365Vol. 29: 365--379 (Volume publication date August379 (Volume publication date August2009)2009)


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Physical ActivityPhysical Activity

Aerobic exercise with dietary restriction canAerobic exercise with dietary restriction canimprove insulin resistance and liver disease inimprove insulin resistance and liver disease inNAFLD in humanNAFLD in human

.,.,Nobili et al., Hepatology 2006Nobili et al., Hepatology 2006

Kugelmas et al., Hepatol 2003Kugelmas et al., Hepatol 2003

Ueno et al., J Hepatol 1997Ueno et al., J Hepatol 1997

Suzuki et al, J Hepatol 1005Suzuki et al, J Hepatol 1005

Hicknam et al, Gut 2004Hicknam et al, Gut 2004Screenivasa et al, JGH 2006Screenivasa et al, JGH 2006

Randomized controlled studies lackingRandomized controlled studies lacking


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Managemant of NASHManagemant of NASH

The patient should lose weight andThe patient should lose weight and

exerciseexercise

--resistanceresistance

Treatment of HyperlipidaemiaTreatment of Hyperlipidaemia


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Scientific evidence of interventions usingScientific evidence of interventions using

the Mediterranean diet: a systematic reviewthe Mediterranean diet: a systematic review

35 different experimental studies.35 different experimental studies.

Diabetes (25 studies): most studies reportedDiabetes (25 studies): most studies reportedreductions in total cholesterol, lowreductions in total cholesterol, low--densitydensitylipoproteins, triglycerides, apoprotein B andlipoproteins, triglycerides, apoprotein B and

very owvery ow-- ens y popro e n c o es ero , anens y popro e n c o es ero , anincrease in highincrease in high--density lipoproteindensity lipoproteincholesterolcholesterol

Insulin resistance and metabolic syndromeInsulin resistance and metabolic syndrome

were reduced with the Mediterranean diet inwere reduced with the Mediterranean diet insome studies.some studies.

Nutr Rev. 2006 Feb;64(2 Pt 2):S27Nutr Rev. 2006 Feb;64(2 Pt 2):S27--47.47.\\


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MEDITERRANEAN DIETMEDITERRANEAN DIET

Karbohidrat sedangKarbohidrat sedang (45%)(45%) karbohidratkarbohidratkomplekkomplek

Lemak sedangLemak sedang--tinggitinggi (35(3540%),40%), dengan lemakdengan lemakjenuh


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Hepatic encephalopathyHepatic encephalopathy

Hepatic encephalopathy requires highHepatic encephalopathy requires high

carbohydratecarbohydrate dietsdiets causing postprandialcausing postprandial

hyperglycemia, rapidhyperglycemia, rapid--acting insulinacting insulin

(lispro,(lispro, aspart, or glulisine) areaspart, or glulisine) areparticularly usefulparticularly useful


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Is There Any Significant of Carbohydrate Intake in Diabetic Patient With Liver Diseases

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