Nutrisi - Prof. Dr. Dr. Askandar, Sp.pd-fINASIM - Dr. Sri Murtiwi, Sp

APLIKASI 21 MACAM DIET DIABETES HASIL PENELITIAN DAN PENGALAMAN KLINIK SEJAK 1978

Askandarr Tjokro Askanda Tjokroprawir prawiro, o, Sri Sri Murtiwi Murtiwi Pusa Pu satt Di Diab abet etes es dan dan Nu Nutr tris isii Su Sura raba baya ya RSUD Dr Dr.. Soeto Soetomo-Fa mo-Fakult kultas as Kedokt Kedokteran eran Univer Universitas sitas Airla Airlangga ngga Jember Jem ber 23 April April 2017 2017

Goal of Medical Nutrition Therapy ADA-2014 1. To promote promote and support healthful eating patterns. To attain o

A1c 40 for men > 50 mg/dl women

2. Achieve and maintain body weight goals 3. Delay and preve prevent nt complications 4. Address individual nutrition need based on personal and cultural preferences

5. Maintain the pleasure of eating by providing positive message 6. Provide the person with diabetes with practical tools for day to day meal planning MNT has reported decreases o

A1c 1% (type1 DM)

o

A1c 1-2% (type2 DM)

o

LDL by 15-25 mg/dl

History of the B-Diet

•

Before 1978, Dr. Soetomo Hospital used to apply the diet that was basically Western in type for diabetic patients (A-Diet), but it did not suit the eating habits of Indonesian people.

•  Askandar Tjokroprawiro conducted a research on diabetic diet adapted to the eating habits of Indonesian people (B-diet) •  A comparative study using a crossover design was carried out on 200 OAD-treated and 60 insulin-treated outpatients. The  A-diet and the Bdiet were maintained isocalorically during the study

Askandar Tjokroprawiro Doctoral Program 1978

Basic compositions of the A-diet and the B –diet Askandar Tjokroprawiro, 1978

the A-diet

the B-diet *)

•

Calories

•

Isocaloric

isocaloric

•

Carbohydrate

•

50%

68%

•

Protein

•

20%

12 %

•

Fat

•

30%

20%

•

P:S ratio

•

±0.6

±1.0

•

500 mg

300 mg

•

6% vegetable

9 % vegetable

•  Average cholesterol daily intake •

Fiber 

(25-35 g/day) •

Meal frequency

•

3 meals equidistance

6 meals

•

Distribution of meal

•

30%,40%,30%

20%,10%,25%, 10%, 25%, 10%

*) Disertation-1978 (the B-Diet as The Mother-Diet

The result of the study showed

• The fasting blood sugar (FBS) value remained the same in both diets. • The two -hour post breakfast blood sugar (PBBS) level was of  anything a little bit lower in the B-diet. • The serum cholesterol level fell in the B-diet, while the serum TG levels were the same either in the A-diet or in B-diet. • The socio-economic analysis was in favour of the B-diet

Conclusions : Although the B-diet was high in CHO, there was no increase of glucose and TG levels

The Diet-B 1978 (Revised-2002) : The Mother - Diet Prospective Study (1978) and Clinical Experiences (Tjokroprawiro 1978-2016)

1

Diet-B*) : The Mother-Diet (1978)

2 Diet-B Fasting (Ramadhan) (1978) 3 Diet-B1 (60% Cbh, 20% P, 20% L) (1980) 4 Diet-B1 Fasting (Ramadhan) (1980) 5 Diet-B2** ) : DN(CKD)-Stage 2 (1982) 6 Diet-B3** ) : DN(CKD)-St 3 & 4 (1983) 7 Diet-Be** ) : REGULAR HD (1983) 8 Diet-M (Malnutrisi)

(1989)

9 Diet-M Fasting (Ramadhan) (1989) (1999) 10 Diet-G*** ) : for Gangrene

11 Diet-KV

: for CVD (1999)

12 Diet-GL 13 Diet-H (Hepar) 14 15 16 17 18 19 20 21

(2000) (2001)

Diet KV-T1 (2004) Diet KV-T2 For  (2004) Diet KV-T3 Pre GDM (2004) Diet KV-L (2004) Diet B1-T1 (2004) For  (2004) Diet B1-T2 Diet B1-T3 GDM (2004) Diet B1-L (2004)

From the End of the First Trimester with 2 g Myo-inositol plus 200 g Folic Acid Twice a day: Myo-Inositol Supplementation in Pregnant Women with a Family History of T2DM may Reduce GDM Incidence and the Delivery of Macrosomia Fetuses. (D’Anna, et al – Diabetes Care 36:854, 2013)

*) Diet-B : 68% CHO 12% Protein 20% FATs Prospective-Cross Over Design (1978) SAFA 5% PUFA 5% PS = 1.0 MUFA 10% Chol. 140 % Morbid > 200 %

< 80 % < 90 % 90 – 100 % > 110% 120 - 130 % 130 - 140 %

Under weight

BW x 40 – 60 Kcal

Normal

BW x

Over weight

BW x

Obesity

BW x 10 – 15 Kcal

BMI = Body Mass Index BMI =

BW in kg (H)2

Underweight

< 18.5

Normal

18.5 – 22.9

Overweight

> 23

at Risk

23 – 24.9

Obese I

25 – 29.9

Obese II

> 30

Pregnant

TM I

30 Kcal

TM II

=

(H-100)x30

+200

20 Kcal

TM III

=

(H-100)x30

+300

Lactation

= (H-100)x30

= (H-100)x30

+100

+400

Distribution Energy Intake & Schedule Askandar Tjokroprawiro, 1978-2016

At. 06.30 Breakfast 20% Kcal.

Fasting Month/ Ramadhan Formula 4.3.1

At. 09.30 Snack

10% Kcal.

At. 12.30 Lunch

25% Kcal.

At. 18.00 (30% Kcal)

: Main Course I

At. 15.30 Snack

10% Kcal.

At. 20.00 (25%Kcal)

: Main Course II

At. 18.30 Dinner

25% Kcal.

At. 21.00 (10%Kcal)

: Snack

At. 21.30 Snack

10% Kcal.

At. 03.00 am (25%Kcal) : Main Course III

3J J1 = Jumlah (Amount of Energy Intake) J2 = Jenis (Kind of Food) J3 = Jadual (Schedule )

The Indonesian Moslems Fast During Ramadhan Month Askandar Tjokroprawiro Guidelines, 2016

•

Diabetisi on diet and or OAD with the glucose level 1 hour post prandial < 200 mg/dL safe on fasting

•

In clinical practice on insulin injection (basal-bolus) with blood glucose level < 300mg/dL , basal insulin 2/3 dose at fast-break, rapid acting insulin before Tarawih and Sahur (2/3 dose) (Fomula 4.3.1)

•

Combination therapy OAD + insulin : basal insulin on fast-break (2/3 dose), OAD at fast-break and Tarawih exception gliptin group can be given at Sahur  (Formula 4.3.1)

•

Don’t give strong hypoglycemia agent on Sahur, exercise can be done after Tarawih

RAMADHAN−DIET (DIET−4.3.1) Plus FORMULA 2/3 RAMADHAN−DIET (DIET−4.3.1) : DIETETIC REGIMEN DURING RAMADHAN Insulin and OAD Doses : 2/3 of Its Previous Ones (Clinical Experiences, as Observed in Daily Practice, Surabaya 2010-2016)

A During Fasting Month/Ramadhan: There are 4 Meals  A

which consist of 3 Main Meals and 1 Snack B The 3 Main Meals : FAST-BREAKING, TARAWIH, SAHUR B

1. The First Main Meals

: FAST-BREAKING (Buka Puasa)

2. The Second Main Meals : TARAWIH 3. The Third Main Meal C The Only 1 Snack C

: SAHUR : BEFORE SLEEP

Insulin Dose During Fasting : 2/3 from Usual, and Injected at Fast-Breaking

COMPOSITION AND INDICATIONS (Summarized : Tjokroprawiro 1978-2016) 1

B-Diet ,1978 • • • • • •

2

3

68% CHO, 12% Protein, 20% Fat Low-moderate economic status Hunger to their diet Cardiovascular complication DM > 5 yrs  Cholesterol level B-Fasting Diet,1978 Formula 4.3.1

4

Formula 4.3.1

Diabetic Nephropathy Diet,1982,1983 5

B2-Diet : Pra-HD High calorie, low protein 0,6 gr/kg BW

6

B3-Diet : Pra-HD • High calorie, low protein 0,8 gr/kg BW • Indication : -  Protein Loss -   Catabolism

B1-Diet,1980 • • • • • • •

60% CHO, 20% Protein, 20% Fat Used to high protein diet Youth with diabetes Under weight Fracture, TBC, Surgery Grave’s disease Malignancy

B1-Fasting Diet,1980

7

Be-Diet : HD • High calorie, low protein 1 gr/kg BW • Indication : end stage renal failure on hemodialysis (HD) • High calorie : 2100-2300 kcal

COMPOSITION AND INDICATIONS (Summarized : Tjokroprawiro 1978-2016) 8

M-Diet (Malnutrition),1989

12 GL-Diet (Sugar Diet), 2000

• CHO 55%, Protein 25%, Fat 20% • Cholesterol < 300mg/dl • Indication : MRDM 9

M-Fasting Diet, 1989

• 30 gr sugar: GL1, GL3, GL5 • 15 gr sugar: GL2, GL4, GL6 • Indication : Severe Renal Failure + SRMD 13 H-Diet (Hepar), 2001

•G-Diet

Formula 4.3.1

Pregnant & Lactation Diet, 2004 Vascular Complications,1999 10 G-Diet (Gangren)

 B1-diet rich in arginin Folic acid, B6, B12 vitamins 11 KV-Diet (Kardiovaskuler)

 B-diet rich in arginin Folic acid, B6, B12 vitamins

14 15 16 17 18 19 20

• Pregestational (KV-Diet) - KV-T1 = TM I - KV-T2 = TM II - KV-T3 = TM III - KV-L = Lactation • Gestational DM (B1-Diet) - B1  – T1 = TM I - B1  – T2 = TM II - B1  – T3 = TM III

Medical Nutritional Therapy for DM in Pregnancy SDNC (Surabaya Diabetes and Nutrition Centre)-Clinical Experiences (Summarized : Tjokroprawiro, Indrawati, Frieda et al 1999-2016)

TRIMESTER Additional LACTATION Diet-KV for PGDM Diet-B1 for GDM Calories (AC) 1st TRIMESTER

KV-T1

B1 -T1

100 Kcal

2nd TRIMESTER

KV-T2

B1 -T2

200 Kcal

3rd TRIMESTER

KV-T3

B1 -T3

300 Kcal

LACTATION

KV-L

B1 -L

400 Kcal

PDGM : PreGestational Diabetes Mellitus KV-T1: Prescribed KV-Diet plus 100 Kcal B1-T1: Prescribed B1-Diet plus 100 Kcal

From the End of the First Trimester with 2 g Myo-inositol plus 200 g Folic Acid Twice a Day: MyoInositol Supplementation in Pregnant Women with a Family History of T2DM may Reduce GDM Incidence and the Delivery of Macrosomia Fetuses. (D’Anna, et al Diabetes Care 36:854, 2013)

Myo-inositol is a member of the B Vitamins (Vit.B8) and a component of the cell membrane Founded in : fruit (oranges), Beans, Grains, Nuts Function in Insulin Signal Tranduction D’Anna

R et al Diabetes Care 2013, 36 (4) :854-857

Pregnant Outpatients with the Family History T2DM The end of the 1 st trimester

Myo-inositol 200 mg + 200 ug folic acid n=110

Placebo :Folic acid 200 ug  N=110

GDM 6%

GDM 15.3% P=0.04

Conclusions :Myo-inositol supplementation in pregnant women with a family history of T2DM may reduced GDM incidence and delivery of macrosomia fetuses D’Anna

R et al., Diabetes Care 2013, 36 (4) :854-857

RELATION OF THE INSULIN PATHWAY TO PHOSPHATIDYLINOSITOL Coustan DR. Diabetes Care 2013, 36:777-778

COCOA FLAVONOIDS Martin MA et al., Molecular Nutrition and Diabetes http://dx.doi.org/10.1016/B978-0-12.801585.8.00015-4

Cocoa powder is rich source of  Fiber (26-40%) Protein (15-20%) CHO (about 15%) Lipid (10-24%), Vitamins and minerals

Cocoa mainly contains high amounts of flavanols: Epicatechin (EP) Catechin Procyanidins B2and B1

In a randomized crossover trial, healthy volunteers were given either flavanol rich dark chocolate (100 g/day) White chocolate (100 g/day) for 15 days Ingestion dark chocolate significantly : lower insulin resistance (HOMA -IR) Increase insulin sensitivity (ISI)

Similar result on hypertensive subject with or without glucose intolerance Dark chocolate : decreased HOMA-IR, increased insulin sensitivity and increased β -cells function compared to white chocolate

In a longer study , overweight and obese adults that consumed a high-flavanol cocoa (902 mg flavanols/day) for 12 weaks significantly improved insulin sensitivity compared with low flavanol cocoa

Davidson K et al., Int J Obes (Lond) 2008;32:1289-1296

MOLECULAR MECHANISM OF ACTION OF COCOA AND ITS FLAVANOLS Main Source: Martin et al 2016, Other Journals : Vazquez-Prieto et al 2012, Yamashita et al 2012, Cordero-Herrera et al 2013, Fernandez-Millan et al 2014, Provided : Tjokroprawiro 2016

IR, IRS-2, AKT, AMPK, IRS-1, GLUT-2 PEPCK, GLUCOSE PRODUCTION PKC, IKK, JNK, PTP1B PPAR-

IR, IRS-1, IRS-2, AKT, AMPK, GLUT-4 PKC, IKK, JNK, PTP1B, PPAR- , ERK, IL-6 ADIPONECTIN

COCOA FLAVANOLS: LIVER

Catechin, Epicatechin, Procyanidins

WHITE ADIPOSE TISSUE (WAT) Insulin Secretion -Cell Survival

GLUT-4 and TRANSLOCATION

SKELETAL MUSCLE

PANCREAS

SUMMARY • There are 20 variation of the B-diet, thus up to now 21 diabetic diets totally available at Dr. Soetomo Hospital Surabaya

• Indications of each type of diet are based on metabolic findings and clinical complications and or situations (kidney, liver, cardiovascular risks, diabetic ulcers, pregnancy, etc)

• Supplementation of myo-inositol (grain, bean, nuts, etc), onion, tomato, grapes, and cocoa flavonoids are recommended

Surabaya Diabetes and Nutrition Center Staffs, 2016