Penanganan Gizi Obesitas Putu Amrytha Sanjiwani, S.Gz Disampaikan Pada Kuliah Terapi Dietetik Obesitas

Obesitas di Indonesia (Depkes RI)

Bagaimana mengetahui Obesitas ? Ukur Tebal Lemak Bawah Kulit Ukur TB & BB Ukur Tebal Lemak Bawah Kulit Indeks Broca : BB normal = TB-100 , BB ideal = BB normal – 10%, Obesitas > 20% BB normal. Indeks Massa Tubuh (BMI ). - kurus < 18.5 - normal 18-23 - overweight 23-27 - obese > 27 Tebal Lipatan Kulit (Mayer) daerah tricep - pria > 16 mm - wanita > 28 mm

Klasifikasi BMI pada Populasi Dewasa Asia Classification BMI (kg/m2) Risk of Co-morbidities Underweight < 18.5 kg/m2 Low (but ↑risk of clinical problem) Normal range 18.5 - 22.9 kg/m2 Average Overweight: > 23 At Risk 23.0 – 24.9 kg/m2 Increased Obese I 25.0 - 29.9kg/m2 Moderate Obese II > 30.0 kg/m2 Severe

 Ukur Lingkar Pinggang Obesitas sentral (gemuk perut) Lingkar pinggang & lingkar panggul: resiko  CVD, DM, Ht, dyslipidemia (Depress, 1994; Young & Gelskey; Oshough, 1995). Obesitas sentral : >0.95 M; >0.85 F Lingkar Umbilikus: pria > 100 cm wanita > 90cm

Distribusi lemak tubuh Gynoid (pear-shape) Android (apple-shape) Ovid-shape

Siapa yang bisa kegemukan ? Semua lapisan umur bisa, tetapi ternyata pria lebih banyak (survey epidemiologi di USA tahun 1990 didapat overweight dan obesitas 25-40% adalah pria), namun lebih banyak wanita yang mengeluh. Pada status sosial ekonomi rendah ternyata (di Amerika) obesitas lebih banyak (30% pada wanita miskin, 16% pada kelas menengah & 5% pada wanita tingkat atas dan kaya.

Dimana & kapan bisa terjadi ? Dimana saja dan kapan saja (baik di negara berkembang maupun negara yang sudah maju, disemua lapisan umur).

Mengapa bisa terjadi ? Masukan kalori melebihi pemakaian berlangsung lama -------> kelebihannya disimpan jari lemak----> obesitas Makanan faktor terpenting penyebab tunggal/ bersama penyakit lain. Bouchard (1991): a. penyebab utama (95%) karena gangguan pola makan (makan dalam jumlah yang banyak; sering ngemil terutama terjadi di sore & malam hari sekitar jam 18 – 24 saat nonton TV; rakus makanan tertentu: kacang, coklat, es krim, bakso yang ternyata kaya karbohidrat dan lemak; b. tak seimbangnya bahan makanan (bergeser ke arah lemak hampir 50% dan dari tepung ke bahan yang mudah diserap yaitu gula) C. 5% faktor genetik.

Penyebab Obesitas: Faktor genetik Faktor lingkungan & perilaku: Pola & kesenangan makan dini dipelajari dari ortu Kadar lemak makanan yang dikonsumsi Asupan Alkohol Energy expenditure  aktifitas fisik Pengaruh Sosio-ekonomi, pendidikan, budaya Mood & cooping strategies Proses menua Kehamilan pada wanita

Mengapa kita bertambah gemuk? Energy OUT Energy IN Energy IN = Energy OUT

PENYAKIT AKIBAT OBESITAS

5 Prinsip Utama Menejemen Obesitas Modifikasi Perilaku: 1st line strategi Terapi Gizi Medis & Modifikasi Diit: 2 macam diit yg efektif turunkan BB LCD & VLCD Gaya Hidup Sehat: Aktifitas Fisik Reguler Strategi obat2an: penekan nafsu makan & penghambat penyerapan lemak Operasi

Untuk mencegah bagaimanakah langkahnya ? Kendalikan diri terhadap: a. makan yang tidak mendesak (makan sebelum lapar berhenti sebelum kenyang), b. isi waktu luang tidak dengan ngemil & mengurangi suka iseng (nyobain berbagai macam makanan dan warung makan) , c. berolah raga yang terukur dan teratur (jenis & porsi yang sesuai) d. mengatasi stres yang menjadi latar belakang ngemil (diantaranya dengan selalu rajin berdo’a, serahkan diri kepada TYME

PENGATURAN MAKAN RENDAH KALORI SEIMBANG ZAT GIZI KURANGI KALORI 500 KCAL/ HARI  BB ↓ 0.5 KG / MINGGU Makan 5-6x sehari, Porsi kecil, Harus sarapan Banyak minum, cairan tingkatkan rasa kenyang Banyak serat makanan  lama mengunyah, rendah kalori, cepat kenyang Waktu/ lamanya makan minimal 20 menit Makan perlahan2, kunyah dengan baik

Terapi Gizi Medis Pada Obesitas Rendah Kalori Seimbang BB  lama; tidak ada efek samping Tidak sesuai harapan pasien Program  BB komersial cepat tapi ada efek samping

Terapi Gizi Medis (TGM) Medical Nutrition Therapy (MNT) Pada Obesitas Jumlah energi (energy content) Komposisi Makronutrien (macronutrient composition) Keaneka-ragaman pangan (Food variety) Besar porsi (Portion size) Kombinasi diet & aktivitas fisik Kombinasi diet & obat-obatan

Jumlah Energi: Diit Rendah Kalori Low Calorie Diets/ LCDs The weight reducing dietary regiment tailored to an individual need initially should provide a 600-1000 kcal/d energy deficit, based on estimated initial maintenance energy This may be best achieved by a reduction in overall fat & CHO intake Gradual weight loss: 0.5-1kg/ week

Diet Sangat Rendah Kalori (Very Low Calorie Diet/ VLCD) The used of VLCD should be advised by specialist doctor and be monitored for adversed reaction The VLCD provide calorie 400-800 kcal/d, protein 30-40% of total calorie VLCD may occasionally be useful for rapid weight loss prior to a surgical procedure Very rapid weight loss

Komposisi Makronutrien Recommended Nutrient Content of a Weight-Reducing Diet 8%-10% Saturated fatty acids Polyunsaturated fatty acids Monounsaturated fatty acids Protein 15% <10% Fat <30% Carbohydrate >55% <15% Recommended nutrient content of a weight-reducing diet Dietary guidelines proposed by the National Institutes of Health [1] recommend a 500 kcal/d deficit for overweight persons (BMI 25.0-29.9 kg/m2) who have obesity-related complications, and for persons with class I obesity (BMI 30-34.9 kg/m2). This energy deficit will result in approximately a 1-lb (0.45 kg) weight loss per week and about a 10% weight reduction at 6 months. A 500-1000 kcal/d deficit is recommended for those with class II (BMI 35.0-39.9 kg/m2) or class III (BMI 40 kg/m2) obesity, which will produce about a 1- to 2-lb weight loss per week and a 10% weight loss at 6 months. The recommended macronutrient composition for a low-calorie weight loss diet is shown in this figure and includes 55% or more of daily calories from carbohydrates, 15% from protein, and 30% or less from fat. In addition, specific recommendations are made regarding the composition of fat ingestion: total energy intake should be comprised of 8%-10% calories from saturated fat, 10% or less calories from polyunsaturated fats, and 15% or less calories from monounsaturated fats. Daily cholesterol intake should not exceed 300 mg/d, and daily fiber intake should be between 20-30 g/d. National Institutes of Health, National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults – The Evidence Report. Obes Res. 1998;6(suppl 2):51S-209S. Calories: 500-1000 kcal/d reduction Cholesterol: <300 mg/d Fiber: 20-30 g/d Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults– The Evidence Report. Obes Res. 1998;6 (suppl 2).

Aneka-ragam Pangan-Meal Variety Increase meal variety with different taste will increase : Energy intake Positive energy balance Weight balance Stubbs et al, European J.of Clin. Nutr., 2001 * Same food at each course Different food at each course Energy Intake (kJ) 1 2 3 4 Total Meal Course *P<0.001 vs same food at each course. Rolls et al. Appetite 1984;5:337.

Besar Porsi - Portion Size There is a linear relationship between portion size served and energy intake: increasing the portion size increased the amount that was consumed. Amount Consumed (g) Effect of portion size on energy intake Food portion size affects energy intake. In this study, young adult men and women were served four different portions of macaroni and cheese for lunch on different days, and were allowed to consume as much food as they liked [1]. The data demonstrate a linear relationship between portion size served and intake: increasing the amount of macaroni and cheese served increased the amount that was consumed. Rolls BJ, Morris EL, Roe LS. Portion size of food affects energy intake in normal-weight and overweight men and women. Am J Clin Nutr 2002 Dec;76(6):1207-13. 500 625 750 1000 Amount of Macaroni and Cheese Served (g) Rolls et al. Am J Clin Nutr. 2000 Dec;76(6):1207-13.

Pedoman makan JANGAN LEWATKAN SARAPAN SNACK BUAH2AN: PAGI SIANG Diit Rendah Kalori 1500 JANGAN LEWATKAN SARAPAN SNACK BUAH2AN: PAGI SIANG SORE Makan, Timbang, Olah Raga Makan ½ dari biasanya Rendah MAL (Manis, Asin, & Lemak)

Beberapa Tips Buat rencana menu & daftar belanja.beli mak. Rendah kalori trt saat lapar Jangan lewatkan waktu makan. Makan & kunyah perlahan2. Bersihkan meja dari makanan. Minta tolong keluarga & teman Sisakan mak dalam piring, pilih piring yang relatif kecil Simpan mak. Hanya di dapur Cicipi mak. Hanya sekali saja Biarkan org lain bersihkan piringnya

Terima Kasih, Matur Nuwun, Thank You, Mbue Bujur