Diabetes Mellitus

and Its Management

Sarwono Waspadji
Jakarta Diabetes & Lipid Center
Division of Endocrinology & Metabolism,
Department of Medicine, School of Medicine
University of Indonesia, Jakarta

Epidemiologi dan Patofisiologi DM

Diagnosis dan Klasifikasi DM
Patofisiologi Komplikasi DM
Prinsip Pengelolaan DM
Terapi Gizi Medis DM
Terapi Farmakologi
Pengelolaan Holistik Berbagai Faktor Risiko
Rekomendasi Diet ADA 2014

Diabetes Melitus
Suatu Sindrom kelainan metabolik
(karbohidrat, lemak dan protein),
ditandai adanya hiperglikemia,

akibat defek sekresi insulin,

defek kerja insulin, atau
kombinasi keduanya

2013 IDF Diabetes Atlas - Sixth edition

Diabetes Mellitus: A Huge and Growing Problem

2013 IDF Diabetes Atlas - Sixth edition

DM Prevalence in Indonesia
1980-1990 1.4 2.3 %
Manado
Toraja

1980-s
6.1%
0.9 % (Rural)

Prevalence of T2DM increase in line with

lifestyle changes
Koja Utara Tanjungpriok 1982
1.7 %
Kayuputih Jak-Tim
1992
5.7 %
Abadijaya, Depok
2001
12.8%
Jakarta (5 wilayah)
2005
11.8%
Ujung Pandang
2004/5
11 %
National Health Survey 2008
5.8 %
Nangapanda Ende
2010 (Rural)
DM (with OGTT)
1.55 %
IGT
2.22 %

SesudahMakan
Glukoneogenesis
Usus, Makanan

I
Glukosa Darah

Setelah makan,
Kadar glukosa akan
segera menjadi normal

I
Energi Otot

Lemak

Puasa
Glukoneogenesis
Usus, Makanan

Glukosa Darah

Walaupun masukan kalori

tidak ada,
kadar glukosa tetap normal,
mendapat pasokan dari
glukoneogenesis

Otot
Lemak

GLYCOGENOLYSIS
GLUCONEO
GENESIS

Insulin supply
& action

Pancreas
MUSCLE
INSULI
N

HGP

GLUCOSE

G l y c o ge n

+
GLUCOSE

LIVER
C O2

intestine
-

Lipolysis

FAT

Peripheral
Glucose
Uptake

DM TYPE 2

DM TYPE 1
Insulin supply

supply and action

Pancreas
MUSCLE
INSULIN

Glycogen

HGP

GLUCOSE

GLUCOSE

LIVER
GLUCONEOGENIC
PRECURSORS

GLUCOSE

USUS

FFA
CO2

GLYCEROL
FFA

LACTATE
Periph
Periph Glucose
Glucose Uptake
Uptake
FAT

SS/98

Massive gluconeogenesis
Intestine, Food

Amino acids

Keto-acids
kidney

Blood glucose
fat

Water
electrolyte
glucose
Ketone

Urine

Muscle wasting
Fat wasting

Epidemiologi dan Patofisiologi DM

Diagnosis dan Klasifikasi DM
Patofisiologi Komplikasi DM
Prinsip Pengelolaan DM
Terapi Gizi Medis DM
Terapi Farmakologi
Pengelolaan Holistik Berbagai Faktor Risiko
Rekomendasi Diet ADA 2014

Gejala Spesifik Diabetes

Melitus
Poliuria
Polidipsia
Polifagia
Berat Badan menurun cepat
Lemas
Gatal, Keputihan
Mata Kabur
Gangguan ereksi
Kesemutan
Luka lama sembuh

Major Risk Factors for Diabetes Mellitus

Family history of Diabetes Mellitus
Obesity
Age > 45 yrs
Previously identified IGT or FGT
Hypertension
Dyslipidemia
History of GDM or delivery of baby(ies) over 4 kg

Setiap ada kesempatan pemeriksaan,

periksalah juga kadar glukosa darah
sewaktu, atau puasa

Criteria for the Diagnosis of Diabetes Mellitus

(ADA 1997, WHO 1998)
Normoglycemia
FPG
< 100
2-h PG < 140

IFG or IGT

DM

FPG
> 100 - < 126 FPG
> 126
2-h PG > 140 - < 200 2-h PG > 200
Symptoms +
random BG
> 200

Bagan Langkah-langkah diagnostik DM dan Gangguan Toleransi

Glukosa
Keluhan Klinis Diabetes
Keluhan klasik (-)

Keluhan klasik diabetes (+)

GDP

> 126

<126

GDP

GDS

> 200

<200

GDS

atau

> 126
>200

atau

100-125
140-199

<100
<140

Ulang GDS atau GDP

GDP
atau

GDS

>126
> 200

<126
<200

TTGO
GD 2 jam
>200

DIABETES MELITUS
Evaluasi status gizi
Evaluasi penyulit DM
Evaluasi perencanaan makan
sesuai kebutuhan
GDP = Glukosa Darah Puasa
GDS =
Glukosa Darah Sewaktu
GDPT = Glukosa Darah Puasa Terganggu
TGT = Toleransi Glukosa Terganggu

140-199
TGT

<140
GDPT

Normal

Nasihat umum
Perencanaan makan
Latihan jasmani
Berat idaman
Belum perlu obat penurun glukosa

Etiologic Classification of
Diabetes Mellitus (ADA 1997)
slide 1
I. Type 1 Diabetes (-cell destruction, usually leading to

absolute insulin deficiency)

A. Immune mediated
B. Idiopathic
II. Type 2 Diabetes (may range from predominantly insulin
resistance with relative insulin deficiency to a predominantly
secretory defect with insulin resistance)

III. Other Specific Types

A. Genetic defects of -cell function
- Maturity-Onset Diabetes of the Young (MODY) 1,2,3
- DNA mitochondria
B. Genetic defects in insulin action
C. Diseases of the exocrine pancreas
- Pancreatitis
- Trauma/pancreatectomy

Etiologic Classification of Diabetes

Mellitus (ADA 1997) slide 2
D. Endocrinopathies
- Acromegaly
- Cushings syndrome
E. Drug-or chemical-induced
- Vacor, pentamidine, nicotinic acid
- Glucocorticoids, thyroid hormone
F. Infections
- Congenital rubella, Cytomegalovirus
G. Uncommon forms of immune-mediated diabetes
- Anti-insulin receptor antibodies
H. Other genetic syndromes sometimes associated with
diabetes
- Downs syndrome, Klinefelters syndrome

IV. Gestational Diabetes Mellitus (GDM)

Epidemiologi dan Patofisiologi DM

Diagnosis dan Klasifikasi DM
Patofisiologi Komplikasi DM
Prinsip Pengelolaan DM
Terapi Gizi Medis DM
Terapi Farmakologi
Pengelolaan Holistik Berbagai Faktor Risiko
Rekomendasi Diet ADA 2014

Type 2 DM is NOT a Mild Disease

Microvascular
Diabetic
retinopath
y
Leading
cause
of blindness
in working-age
adults1

Macrovascular
Stroke
1.2- to 1.8-fold
increase in stroke3

Cardiovascular
disease
75% diabetic
patients
die from CV events4

Diabetic
nephropathy
Leading cause of
end-stage renal
disease2

Diabetic
neuropathy
Leading cause of
non-traumatic lower
extremity
5
amputations
Diabetic
Foot

Fong DS, et al. Diabetes Care. 2003; 26 (Suppl. 1):S99S102. 2Molitch ME, et al. Diabetes Care . 2003;
26 (Suppl. 1):S94S98.
3
4
Kannel WB, et al. Am Heart J. 1990; 120:672676. Gray RP & Yudkin JS. In Textbook of Diabetes 1997.
5
Mayfield JA, et al. Diabetes Care. 2003; 26 (Suppl. 1):S78S79.
1

Type 2 Diabetes Increases the

Risk of CVD
Any CVD event

Stroke
Intermittent claudication

Cardiac failure

CHD

MI

Males with DM
Females with DM

Angina pectoris
Sudden death

N/A

Coronary mortality
1

3
4
2
Age-adjusted risk ratio

(1 = risk for individuals without diabetes)

< 0.1;

p < 0.05;

p < 0.01;

Adapted from Kannel WB et al. Am Heart J. 1990; 120: 6726.

p < 0.001

Effect of Hyperglycemia
Sorbitol
pathway

DAG-PKC
pathway

Hexosamine
pathway

AGE
pathway

Oxidative stress
Increase
Increase of procoagulant proteins
proteins
Extracellular
Extracellular coagulant
Increase
Increase of
of ::

matrix
matrix
Collagen
Collagen
Fibronectin
Fibronectin

von
von Willebrandt
Willebrandt
factor
factor
tissue
tissue factor
factor

Decrease
Decrease of
of
proliferation,
proliferation,
migration,
migration,
and
and
fibrinolytic
fibrinolytic
potential
potential

Vascular complications

Increase
Increase of
apoptosis
apoptosis

Stehouwer CDA et al. 200

Biochemical Pathways of Hyperglycemic Damage

Nonenzymatic
glycation
Pentose
shunt
HK/GK

Glucose

R-5P

GlcN-6P

Hexosamine
pathway

GFAT

G-6P

F-6P

GAPDH

GA-3P

AR

Sorbitol
SD

DHAP

Polyol
pathway

DAG

Fructose

Oxidative
stress

PKC

Glycolysis

Pyruvate
DAG de novo
synthesis

The Progression from CV Risk Factors to

Endothelial Injury and Clinical Events
LDL-C

Smoking
Diabetes
Heart failure

Risk Factors

BP

Oxidative stress
Endothelial
Dysfunction
NO

PAI-1

Local mediators

VCAM

Tissue ACE-Ang II

Endothelium

ICAM, cytokines
Thrombosis

Inflammation Vasoconstriction

Growth
factors matrix
Vascular Lesion
and Remodelling

Proteolysis

Plaque Rupture

Vascular Complications
NO = nitric oxide

Adapted
Adapted from
from Gibbons
Gibbons GH,
GH, Dzau
Dzau VJ.
VJ. N
N Engl
Engl JJ Med
Med .. 1994;330;14318.
1994;330;14318.

Epidemiologi dan Patofisiologi DM

Diagnosis dan Klasifikasi DM
Patofisiologi Komplikasi DM
Prinsip Pengelolaan DM
Terapi Gizi Medis DM
Terapi Farmakologi
Pengelolaan Holistik Berbagai Faktor Risiko
Rekomendasi Diet ADA 2014

Natural History of Disease

Progression

Aggressive treatment of established cardiovascular risk factors

Macrovascular
complications
Microvascular
complications

Aggressive glycemic control

-cell function

Insulin
resistance
Blood
glucose

10

Prevention
IGT/IF
G of IGT
Prevention

0
Diagnosis

Treatment

10

Years

Type 2
diabetes

Prevention of progression of IGT to Type 2 DM

Adapted from Bergenstal RM, et al. Diabetes mellitus, carbohydrate metabolism and lipid disorders. In

Strategies for Reduction of Diabetic

Cardiovascular Complications
Prevention of impaired glucose tolerance
Prevention of progression of IGT to type 2

diabetes
Lifestyle Modification
Patients should be encouraged to
lose weight if necessary, exercise
and eat healthily
Prescription of appropriate
medications

Strategies for Reduction of Diabetic

Complications
Prevention of impaired glucose tolerance
Prevention of progression of IGT to type 2
diabetes
Aggressive glycemic control
Aggressive treatment of established
cardiovascular risk factors

The Cornerstones of
DM Management Medical Nutrition
Therapy

1. Education

Medications

Lifestyle
Modification

2. Medical Nutrition
Therapy
An essential component of any
comprehensive
diabetes mellitus management program
3. Physical Activity
4. Pharmacological Intervention

Epidemiologi dan Patofisiologi DM

Diagnosis dan Klasifikasi DM
Patofisiologi Komplikasi DM
Prinsip Pengelolaan DM
Terapi Gizi Medis DM
Terapi Farmakologi
Pengelolaan Holistik Berbagai Faktor Risiko
Rekomendasi Diet ADA 2014

Medical Nutrition Therapy

in Diabetes
As integral part of:
Prevention and management of
diabetes
Component of diabetes education
Prevention of diabetes
complication
Source: Diabetes Care, Vol. 31, Suppl. 1, 2008

Slide 31

Targets of Medical Nutrition Therapy in

Prevention and Management of Type 2 Diabetes
Individual with Diabetes
Risk-factors or with Prediabetes
1) To reduce the risk of diabetes
and cardiovascular disease by
promoting healthy food choices
and physical activity
leading to moderate weight loss
that is
maintained.

Individual with Diagnosed

Diabetes
1) To achieve and maintain:

Blood Glucose levels in

the normal range

A lipid profile that reduces

the risk for vascular
diseases

Blood Pressure levels in

the normal range

2) To prevent / delay progressivity

of chronic complications
3) To address individual nutrition
needs, taking into account
personal and cultural
preferences and willingness to
change
Diabetes Care. 2008; 31 (Suppl. 1) :

Historical
Historical Perspectives
Perspectives of
of
Nutritional
Nutritional Recommendation-Energy
Recommendation-EnergyIntake
Intakefor
forDiabetics
Diabetics
Year
Year

Carbohydrate
Protein
Fat
Carbohydrate
Protein
Fat
((%
%of
oftotal
totalcalories)
calories)

pre-1921
starvation
pre-1921
starvation diet
diet
1921
20
10
70
1921
20
10
70
1950
40
20
40
1950
40
20
40
1970
45
20
35
1970
45
20
35
1986
up
12<35
1986
upto
to60
60
12-20
20
<35
1994
**
15****
1994
15-20
20
2004
**
15***
2004
15-20
20
***
(up
(upto
to80-90%-ADA
80-90%-ADAand
and85-90%-EASD
85-90%-EASDfor
forfat
fatand
andCHO)
CHO)
more
morefat
fatfrom
fromMUFA
MUFA
**based
basedon
on nutrition
nutritionassessment
assessmentand
andtreatment
treatmentgoal
goal
****less
lessthan
than10%
10%calories
caloriesfrom
fromsaturated
saturatedfats;
fats;
less
than
10%
from
polyunsaturated
fatty
less than 10% from polyunsaturated fattyacid
acid
***
less
than
7
%
calories
from
saturated
fats
for
*** less than 7 % calories from saturated fats fordyslipidemia
dyslipidemia
less
trans
fatty
acid
less trans fatty acid

History
History of
of Dietary
Dietary Composition
Composition for
for
Diabetics
Diabetics in
in Indonesia
Indonesia
Year
Year

1950
1950
1960
1960
1975
1975(old)
(old)
(new)
(new)
2006
2006

Carbohydrate
Fat
Carbohydrate Protein
Protein
Fat
(%
(%of
oftotal
totalcalories)
calories)
15
15
15
15

35
35
20
20

40
40
65
65

45-55
45-55
60-70
60-70

20-25
20-25
15-20
15-20

30-35
30-35
20-25
20-25

10-20
10-20

20-25
20-25

45-(60-65)
45-(60-65)

Indonesian Society of Endocrinology

Nutrition Recommendation for DM

Nutrient

ADA 2003

Perkeni
2002
2006

Protein (%)

15-20

10-15

10-20

Fat (%)

25-35

20-25

20-25

SFA

< 10

MUFA

~ 10

PUFA

~ 10

~ 10

CHO (%)

46-60

60-70

CHO fract.

Cholesterol

300 mg/dL

Sodium (mg)
Sucrose (%)
Fiber (g)

< 10

<7
~ 10

< 300

60-70 for
CHO + Mufa
~10

45-65
(Low GI)

< 200

< 3000
< 10
20-35

< 2400
<5
25

<5
25

Diet & Exercise in Diabetes

Important in type 1 and type 2 diabetes
In type 2 diabetes:
Obesity and physical inactivity are
major risk factors
Diet and exercise may provide good
long-term glycaemic control in some
patients
Improved cardiovascular status
Cost-effective

Additive Effects of Behavior and Diet

Therapy with Pharmacotherapy for
Obesity

Weight Change (%)

0
Medication alone
-5

Medication and behavior

modification

-10

-15
-20
-25

Medication, behavior
modification and calorie
management
0

*P< .05 vs medication

alone.

Wadden et al. Arch Intern Med

2001;161:218.

Time (months)

10

12

The Relationship Between Healthy

Nutrition and Blood Glucose

Source: Long-term Effects of a Lifestyle Intervention on Weight and

Cardiovascular Risk Factors in Individuals with Type 2 Diabetes; Four Years
Results of the Look AHEAD Trial. The Look AHEAD Reseach Group

Algoritma Pencegahan DM tipe 2

Dari Sindrom Metabolik dan Prediabetes
Deteksi
Dini

Perubahan Gaya
Hidup

Terapi
Farmakologis

Pemantauan
Berkala

wayat keluarga KV, DM TGM

Glukosa drh
elainan kardiovaskular Aktivitas Belum Dianjurkan
Tekanan drh
erbagai Faktor risiko
Dislipidemia
jasmani Secara Umum
aktor risiko KV
Kebugaran fisi
BB turun
BB lebih
BB
Gaya hidup santai
Hipertensi
Peran Petugas Kesehatan di
Merokok
Tingkat Pelayanan Primer
Dislipidemia
wayat DMG, bayi >4000 g Sangat Dominan
TGO

DM Developing a Diet

developing
a dietinto consideration :
Factors
to take
Food intake / preferences
Lifestyle (such as physical activity)
Medication regimen
Metabolic control
Glycemic control
Anthropometric measurements
AACE 2007, ADA 2008

The Fundamentals of Food

Management for Diabetes Patients
Similar with healthy people:
Balance food intake according to calories and nutrition needs for each
individual
Weight loss, increased physical activity, and weight management
Consistency in day-to-day carbohydrate intake at meals and snacks
Nutritional content
Timing of meals and snacks
Carbohydrates are the principal determinant for blood glucose

Emphasis (triple Js):

Jadwal (Schedule)
Jenis (Type)
Jumlah (Amount)

Slide 41

Weight Management - Diabetes Management

Weight Loss- Diabetes Program Components
Relearn Portion Control Bahan makanan Penukar
Avoid Sweets and High Fat Desserts
Plan Your Exercise
Visit Your Doctor to Monitor Your Medication Needs

Additional Weight Loss-Diabetes Program Aspects

Eat at Regular Intervals
Good Sources of Protein
Vitamins and Minerals (Micro-nutrients)
Sodium, Potassium and Magnesium
Water and Fluid Balance
Glycemic Index

Nutrition Care Process Steps

Step 1: Nutrition Assessment
Step 2: Nutrition Dagnosis
Step 3: Nutrition Intervention
Food and/or Nutrient Delivery
Nutrition Education
Nutrition Counseling
Coordination of Care

Step 4: Nutrition Monitoring and Evaluation

International Dietetics and Nutrition Terminology (IDNT) Reference Manual.
Standardized Language for the Nutrition Care Process.
American Dietetic Association. First Edition 2008.

Dietisien dalam Terapi Gizi Medis

Sebagai anggota tim pengelola pasien
dietisien berperan aktif,
menjemput bola,
mengemukakan saran dan pendapat,
untuk keberhasilan pengelolaan pasien,
BEKERJA SAMA DENGAN
Dokter
Perawat
dll.
Dalam mengelola berbagai penyakit terkait

Epidemiologi dan Patofisiologi DM

Diagnosis dan Klasifikasi DM
Patofisiologi Komplikasi DM
Prinsip Pengelolaan DM
Terapi Gizi Medis DM
Terapi Farmakologi
Pengelolaan Holistik Berbagai Faktor Risiko
Rekomendasi Diet ADA 2014

Algoritme Pengelolaan DM tipe-2 Tanpa

Dekompensasi
Diagnosis
DM

Tahap-I

Tahap-II

Tahap-III

GHS

GHS
+
monoterapi
Catatan:
1. GHS = gaya hidup
sehat
2. Dinayatakan gagal
bila terapi selama
2-3 bulan pada
tiap tahap tidak
mencapai target
terapi HbA1c <7%
3. Bila tidak ada
pemeriksaan
HbA1c dapat
dipergunakan
pemeriksaan
glukosa darah
Rata-2 hasil
pemeriksaan
beberapa kali
gukosa darah
sehari yang

GHS
+
Kombinasi 2
OHO
Jalur pilihan
alternatif, bila:
-tidak terdapat insulin
-penyandang betulbetul menolak insulin
-kendali glukosa belum
optimal

GSH
+
Kombinasi 3
OHO

GHS
+
Kombinasi 2
OHO
+
Basal insulin
Insulin intensif
(Basal-plus
atau
Basal-bolus)

AACE Comprehensive Diabetes Management Algorithm. Endocrine Practice. 2013;10(2):331

Individualized Treatment based on several criteria to control

blood glucose

Slide 48

Inzucci SE, et al. Diabetologia. 2012

Diabetes Care. 2012;35(6):1364-79

Type of Insulin

Onset
of Action

Peak
of Action

Duration
of Action

Presentation

30-60 min

30-90 min

3-5 hours

Vial, pen/cartridge

Insulin lispro (Humalog)

5-15 min

30-90 min

3-5 hours

Pen/cartridge

Insulin glulisine (Apidra)

5-15 min

30-90 min

3-5 hours

Pen

Insulin aspart (NovoRapid)

5-15 min

30-90 min

3-5 hours

Pen, vial

2-4 hours

4-10 hours

10-16 hours

Vial, pen/cartridge

Insulin glargine (Lantus)

2-4 hours

No peak

22-24 hours

Pen

Insulin detemir (Levemir)

2-4 hours

No peak

16-24 hours

Pen

70% NPH; 30% regular

(Mixtard, Humulin 30/70)

30-60 min

Dual

10-16 hours

Pen/cartridge

70% insulin aspart protamine

30% insulin aspart (NovoMix 30)

10-20 min

Dual

15-18 hours

Pen

75% insulin lispro protamine

30% insulin lispro (Humalog Mix 25)

5-15 min

Dual

16-18 hours

Pen/cartridge

Insulin in Indonesia

Insulin prandial (meal-related)

Insulin short-acting
Regular (Actrapid, Humulin R)
Insulin analog rapid-acting

Insulin intermediate-acting
NPH (Insulatard, Humulin N)

Insulin long-acting

Insulin Campuran

PERKENI Consensus Guidelines 2011.

Insulin Action Profiles

Insulin Level

Rapid (lispro, aspart, glulisine)

Short (regular)
Intermediate (NPH)
Long (detemir)
Long (glargine)
0
22

2
24

10

12

14

16

Hours After Injection

18

20

Benefits and Limitations of T2DM Treatment

Options
DPP-4
GLP-1
inhibit Sulfon
Glinid
or
ilureas Biguanide
e

FPG
PPG

TZD

++

++

++

++

++

++

agonis
AGI
t
Neutr
+
al
++

Insulin

+++

+++

+++

Level of Risk
Hypoglycae
mia

Neutral

Modera
te

Neutral

Mild

Neutral

Weight
gain

Neutral

Mild

Benefit

Mild

Moderate

Neutral Neutral

Neutr
Moderate
Neutral
al
to severe
Neutr
Benefit
al

Mild to
Moderate

Contraindic Neutra Contraindic Neutr

Neutral
ated in CHF
l
ated in CHF
al

Neutral

CV event
Drug-drug
interaction

Neutral

Modera
te

Neutral

Moder
ate

Neutral

Neutr
Neutral
al

Adapted from: Rodbard HW, et al. Endocr Pract. 2009;15:540-559.

Neutral

Epidemiologi dan Patofisiologi DM

Diagnosis dan Klasifikasi DM
Patofisiologi Komplikasi DM
Prinsip Pengelolaan DM
Terapi Gizi Medis DM
Terapi Farmakologi
Pengelolaan Holistik Berbagai Faktor Risiko
Rekomendasi Diet ADA 2014

Natural History of Disease

Progression

Aggressive treatment of established cardiovascular risk factors

Macrovascular
complications
Microvascular
complications

Aggressive glycemic control

-cell function

Insulin
resistance
Blood
glucose

10

Prevention
IGT/IF
G of IGT
Prevention

0
Diagnosis

Treatment

10

Years

Type 2
diabetes

Prevention of progression of IGT to Type 2 DM

Adapted from Bergenstal RM, et al. Diabetes mellitus, carbohydrate metabolism and lipid disorders. In

Strategies for Reduction of Diabetic

Complications
Prevention of impaired glucose tolerance
Prevention of progression of IGT to type 2
diabetes
Aggressive glycemic control
Aggressive treatment of established
cardiovascular risk factors

Cardio Vascular Disease in patients

with T2DM
Primary composite
endpoint* (%)

Conclusion
The intensified intervention
aimed at multiple risk
factors reduces the risk of
cardiovascular and
microvascular events by
about 50 %

60
50
40
30

Conventional
treatment
P = 0.007
Intensive treatment

20
10
0

12

24

36

48

60

72

84

96

44
61

41
59

13
19

Follow-up (months)
Number at
risk

80
80

72
78

70
74

63
71

59
66

50
63

Conventional
Intensive
* Composite endpoint = CV death and amputation
(with either therapy), and relative risk for organ damage
Gaede P et al. N Engl J Med. 2003; 348: 3839
(with intensive therapy)

Impact of Gluco-metabolic Characteristics

on Risk of Major CV Events in TNT
Patients With
Major Cardiovascular Event (%)

(All Patients)
16

12

Characteristic absent Characteristic present

HR=1.33

HR=1.30

HR=1.24

HR=1.18

HR=1.48

Low
HDL-C

Fasting Body-mass
TriglyceridesHypertension
glucose
index 250 mg/dL
100 mg/dL 28 kg/m2

Deedwania for TNT. Lancet. 2006;368:919-928(A).

Strategies for Reduction of Diabetic

Cardiovascular Complications
Aggressive treatment of established

cardiovascular risk factors

Antihypertensive medications
Lipid modifying agents
Antiplatelet agents

Epidemiologi dan Patofisiologi DM

Diagnosis dan Klasifikasi DM
Patofisiologi Komplikasi DM
Prinsip Pengelolaan DM
Terapi Gizi Medis DM
Terapi Farmakologi
Pengelolaan Holistik Berbagai Faktor Risiko
Rekomendasi Diet ADA 2014

A. Clear evidence from well conducted,

generelizable RCTs that adequately powered:
Well conducted Multicenter trial , Metaanalysis.
B. Supporting evidence from well conducted cohort
studies
C. Supportive evidence from poorly controlled or
uncontrolled studies
E. Expert consensus or clinical experience

Standard of Medical Care in Diabetes. ADA 2014

Diabetes Care.2014;1(suppl 1): S 120-S143

Optimal Mix of Macronutrients

Evidence suggests that there is not an ideal percentage of
calories from carbohydrate, protein, and fat for all people with
diabetes B;
therefore, macronutrient distribution should be based on
individualized assessment of current eating patterns,
preferences, and metabolic goals. E

Eating Patterns
A variety of eating patterns (combinations of different foods or
food groups) are acceptable for the management of diabetes.
Personal preferences (e.g., tradition, culture, religion, health
beliefs and goals, economics) and metabolic goals should be
considered when recommending one eating pattern over another.
E

Carbohydrates
Evidence is inconclusive for an ideal amount of carbohydrate
intake for people with diabetes. Therefore, collaborative goals
should be developed with the individual with diabetes. C

The amount of carbohydrates and available insulin

may be the most important factor influencing
glycemic response after eating and should be
considered when developing the eating plan. A
Monitoring carbohydrate intake, whether by carbohydrate
counting or experience-based estimation, remains a key strategy
in achieving glycemic control. B
For good health, carbohydrate intake from vegetables, fruits,
whole grains, legumes, and dairy products should be advised
over intake from other carbohydrate sources, especially those
that contain added fats, sugars, or sodium. B

Quality of carbohydrates
Glycemic Index and Glycemic Load
Substituting lowglycemic load foods for
higherglycemic load foods may modestly
improve glycemic control. C

The ADA recognizes that education about glycemic index and

glycemic load occurs during the development of individualized
eating plans for people with diabetes.
Some organizations specifically recommend use of lowglycemic
index diets (124,125).
However the literature regarding glycemic index and glycemic load
in individuals with diabetes is complex, and it is often difficult to
discern the independent effect of fiber compared with that of
glycemic index on glycemic control or other outcomes.
Further, studies used varying definitions of low and high glycemic
index (11,88,126), and glycemic response to a particular food
varies among individuals and can also be affected by the overall
mixture of foods consumed (11,126).

Komposisi makanan yang dianjurkan terdiri dari:

Karbohidrat
Karbohidrat yang dianjurkan sebesar 45-65%
total asupan energi.
Pembatasan karbohidrat total <130 g/hari tidak
dianjurkan
Makanan harus mengandung karbohidrat
terutama yang berserat tinggi.
Gula dalam bumbu diperbolehkan sehingga
penyandang diabetes dapat makan sama
dengan makanan keluarga yang lain
Sukrosa (gula pasir) tidak boleh > 5% total
asupan energi

Protein
Dibutuhkan sebesar 10 20% total asupan energi.
Sumber protein yang baik adalah seafood
(ikan, udang, cumi, dll), daging tanpa lemak,
ayam tanpa kulit, produk susu rendah lemak,
kacang-kacangan, tahu, dan tempe.
Pada pasien dengan nefropati perlu asupan
protein menjadi 0,8 g/Kg BB perhari atau
10% dari kebutuhan energi dan 65% hendaknya
bernilai biologik tinggi.

Lemak
Asupan lemak dianjurkan sekitar 20-25% kalori.
Tidak diperkenankan > 30% asupan energi.
Lemak jenuh < 7 % kebutuhan kalori
Lemak tidak jenuh ganda < 10 %,
selebihnya dari lemak tidak jenuh tunggal.
Bahan makanan yang perlu dibatasi adalah yang
banyak mengandung lemak jenuh dan
lemak trans antara lain:
daging berlemak dan susu penuh
(whole milk).
Anjuran konsumsi kolesterol < 200 mg/hari.

Serat
Seperti halnya masyarakat umum, penyandang DM
dianjurkan mengonsumsi cukup serat dari
kacang-kacangan, buah, dan sayuran serta sumber
karbohidrat yang tinggi serat, karena mengandung
vitamin, mineral, serat, dan bahan lain yang baik
untuk kesehatan.
Anjuran konsumsi serat adalah 25 g/hari.

Natrium
Anjuran asupan natrium untuk penyandang diabetes
sama dengan anjuran untuk masyarakat umum yaitu
tidak lebih dari 3000 mg atau sama dengan 6-7 gram
(1 sendok teh) garam dapur.
Mereka yang hipertensi, pembatasan natrium
sampai 2400 mg garam dapur.
Sumber natrium antara lain adalah garam dapur,
vetsin, soda, dan bahan pengawet seperti
natrium benzoat dan natrium nitrit.

Pemanis alternatif
Pemanis dikelompokkan menjadi :
pemanis berkalori
pemanis tak berkalori.
Termasuk pemanis berkalori adalah gula alkohol dan fruktosa.
Gula alkohol antara lain isomalt, lactitol, maltitol, mannitol,
sorbitol dan xylitol.
Dalam penggunaannya, pemanis berkalori perlu diperhitungkan kandungan kalorinya sebagai bagian dari kebutuhan
kalori sehari.
Fruktosa tidak dianjurkan digunakan pada penyandang DM
karena efek samping pada lemak darah.
Pemanis tak bergizi yang masih dapat digunakan antara lain
aspartam, sakarin, acesulfame potassium, sukralose,
dan neotame.
Pemanis aman digunakan sepanjang tidak melebihi
batas aman (Accepted Daily Intake / ADI)

Perhitungan berat badan Ideal (BBI) dengan

Rumus Brocca yang dimodifikasi adalah sbb:
Berat badan ideal = 90% x (TB dalam cm-100) x 1 kg.

Bagi pria dengan tinggi badan di bawah 160 cm dan

wanita di bawah 150 cm, rumus dimodifikasi menjadi:
Berat badan ideal (BBI) = (TB dalam cm-100) x 1 kg.
BB Normal : BB ideal 10 %
Kurus : < BBI - 10 %
Gemuk
: > BBI + 10 %

Makanan sejumlah kalori terhitung dng komposisi

tersebut di atas dibagi dalam 3 porsi besar untuk:
makan pagi (20%),
siang (30%) dan
sore (25%) serta
2-3 porsi makanan ringan (10-15%) di antaranya.
Untuk meningkatkan kepatuhan pasien,
sejauh mungkin perubahan dilakukan sesuai
dengan kebiasaan.
Untuk penyandang diabetes yang mengidap
penyakit lain, pola pengaturan makan disesuaikan
dengan penyakit penyertanya.

Thank You

Thank Yo