Fuadiyah Nila K., S.Gz, MPH Leny Budhi Harti, S.Gz Jurusan Gizi FKUB Basic Carbohydrate Counting Fuadiyah Nila K., S.Gz, MPH Leny Budhi Harti, S.Gz Jurusan Gizi FKUB

Diet Diabetes Mellitus

Nutrition Care Process (ADA,2003) Practice Settings Dietetics Knowledge Skills & competencies Code of Ethics Nutrition assessment obtain/collect timely and appropriate data analyze/interpret with evidence-based standards document Nutrition diagnosis identify & label problem determine cause/ contributing risk factors cluster signs & symptoms/ defining characteristics document Relationship between Patients/client/group and Dietetics Professional Economics Health Care Systems Nutriton monitoring & Evaluation monitor progress measure outcome indicators Evaluate outcomes document Evidence-based Practice Nutrition interventions plan nutrition Intervention Formulate goals & determine a plan of action implement nutrition intervention Care is delivered & actions are carried out document Critical Thinking Communication Collaboration Social Systems

Asuhan Gizi Individual Nutritional Care Process X Asuhan Gizi Standard Asuhan Gizi Individual Sosio Kulture Ekonomi Keluarga Kebiasaan X Pantang Makanan Pengaturan Diet

Lena has been overweight for a few years Lena has been overweight for a few years. She is 52 years old, and she found out that she has type 2 diabetes 1 year ago. She has been seeing a doctor at her physician’s office for nutrition information, and the doctor has referred her to a registered dietitian (RD) in the outpatient clinic at the nearby hospital. Kulkarni, KD.Clin. Diabetes 23: 120 - 122

Lena brings her food records to her initial visit with the RD Lena brings her food records to her initial visit with the RD. The RD reviews the records, which consist only of Lena’s food choices with no portion sizes or amounts consumed listed. The RD recommends that Lena consider weighing and measuring her portion sizes and writing them down along with her food choices. The RD provides Lena with a copy of the American Diabetes Association (ADA) basic carbohydrate counting pamphlet1 and uses food models to demonstrate appropriate portions of the foods Lena might select. Kulkarni, KD.Clin. Diabetes 23: 120 - 122

Content : Definition of carbohydrate counting Level of carbohydrate counting Indication of using carbohydrate counting Why should people with diabetes use carbohydrate counting???? Steps to count carbohydrate counting

Definition of carbohydrate counting Carbohydrate counting is a meal-planning approach and not a specific diet It places emphasis on the total amount of carbohydrate consumed, rather than on the source or type of carbohydrate consumed Kulkarni, KD.Clin. Diabetes 23: 120 - 122

Level of carbohydrate counting Basic Advance understanding the relationship among food, physical activity, and blood glucose levels includes understanding pattern management and how to use insulin-to-carbohydrate ratios Kulkarni, KD.Clin. Diabetes 23: 120 - 122

Level of carbohydrate counting introduces patient to the concept of carbohydrate counting and for carbohydrate consistency Chiesa, G, et al. Acta Biomed 2005; 76; suppl. 3 : 44-48

Level of carbohydrate counting Focuses on the relationships among food, diabetes medication, physical activity and blood glucose level and Chiesa, G, et al. Acta Biomed 2005; 76; suppl. 3 : 44-48

Level of carbohydrate counting how to match short-acting insulin to carbohydrate using carbohydrate-to- insulin ratios. Chiesa, G, et al. Acta Biomed 2005; 76; suppl. 3 : 44-48

Level 1 / Basic Carbing Goals Regulate blood glucose by balancing carbohydrate intake with the diabetes medication and physical activity Achieve and maintain consistency of carbohydrate intake at meals and snacks at similar times each day Eating similar amounts of carb foods at each meal or snack helps “even out” the ups-and-downs in your blood glucose level. 1. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995. 2. Practical Carbohydrate Counting, American Diabetes Association, 2001. 3. Using Carbohydrate Counting in Clinical Practice, JADA, 1988, v98, n8 6

Who Can Use Carbing Carbohydrate counting can be used by anyone with diabetes, not just people taking insulin

Why Should People with Diabetes Use Carbohydarte Counting???? Food contains many nutrients such as Macronutrients : carbohydrate, protein, and fat Micronutrients : vitamins and minerals

Why Should People with Diabetes Use Carbohydarte Counting????

Why Should People with Diabetes Use Carbohydarte Counting???? In fact, 90-100 % of the carb you eat appears in your bloodstream as blood glucose within a few hours after you have eaten. Protein and fat have much less effect on your blood glucose Bolderman, K.M, 2007. Educational Information From BD Medical Diabetes Care

Steps to Count Carbohydrate Counting Step 1 : Make healthy food choices Step 2 : Focus on carbohydrate Step 3 : Set carbohydrate goals Step 4 : Determine carbohydrate content Step 5 : Monitor effect on blood glucose level Canadian Diabetic Association, 2005

Step 1 Make healthy food choices Enjoy a variety of vegetables, fruits, whole grains, Use added fats in small amounts. Choose portion sizes Canadian Diabetic Association, 2005

Steps to Count Carbohydrate Counting Step 1 : Make healthy food choices Step 2 : Focus on carbohydrate Step 3 : Set carbohydrate goals Step 4 : Determine carbohydrate content Step 5 : Monitor effect on blood glucose level Canadian Diabetic Association, 2005

Step 2 Focus on Carbohydrate

Step 2 Focus on Carbohydrate

Steps to Count Carbohydrate Counting Step 1 : Make healthy food choices Step 2 : Focus on carbohydrate Step 3 : Set carbohydrate goals Step 4 : Determine carbohydrate content Step 5 : Monitor effect on blood glucose level Canadian Diabetic Association, 2005

Step 3 : Set Carbohydrate Goals dietitian will help to set a goal for grams of carbohydrate at each meal and snack This may be the same from day to day or may be flexible, depending on patient needs Canadian Diabetic Association, 2005

Step 3 : Set Carbohydrate Goals Perencanaan sesuai dengan kebiasaan dan budaya makan pasien Analisis zat gizi dari kebiasaan makan pasien Jumlah energi Distribusi energi selama 24 jam Analisis terhadap komposisi zat gizi Perhitungan KH setiap sajian Perhitungn zat gizi yang diperlukan pasien Energi Distribusikan dalam 24 jam Komposisi zat gizi sesuai dengan kebiasaan Perhitungan jumlah karbohidrat per sajian Pilih obat yang diperlukan sesuai jumlah karbohidrat

Analisis zat gizi dari kebiasaan makan pasien Step 3 : Set Carbohydrate Goals Analisis zat gizi dari kebiasaan makan pasien Food record Jumlah energi Distribusi energi selama 24 jam Analisis terhadap komposisi zat gizi Perhitungan KH setiap sajian

Food Record

Food Record

Food Record

Food Record Energi dari hasil record : ....... Kkal Distribusi energi : - pagi : .....% - snack : .....% - siang : .....% - malam : .....% Komposisi zat gizi : - protein : ....% - KH : ....% - Lemak : ....% Serving KH per sajian

Perhitungn zat gizi yang diperlukan pasien Energi Distribusikan dalam 24 jam Komposisi zat gizi sesuai dengan kebiasaan Perhitungan jumlah karbohidrat per sajian

Perhitungn zat gizi yang diperlukan pasien Status Gizi  IMT IMT = BB (kg)/ {TB (m)}² Berikut ini pembagian IMT berdasar standard Asia menurut IOTF, WHO (2000) : <18,5 = Underweight 18,5-22,9 = Normal 23-24,9 = At risk 25-29,9 = Obese I >=30 = Obese II

Perhitungan Kalori BMI Normal : 25 – 30 cal/kg BW Kurus : > 40 cal/kg BW Overweight : < 20 cal/kg BW (BMI requiring and /obese 130 g/day of CHO)

Perhitungn zat gizi yang diperlukan pasien Energi Distribusikan dalam 24 jam Komposisi zat gizi sesuai dengan kebiasaan Perhitungan jumlah karbohidrat per sajian Distriusi kalori dalam 24 jam  disesuaikan dengan kebiasaan makan pasien

Perhitungn zat gizi yang diperlukan pasien Energi Distribusikan dalam 24 jam Komposisi zat gizi sesuai dengan kebiasaan Perhitungan jumlah karbohidrat per sajian

Perhitungn zat gizi yang diperlukan pasien Karbohidrat sebesar 45-65% total asupan energi. Protein sebesar 10 – 20% total asupan energi. Asupan lemak sekitar 20-25% kebutuhan kalori. Perkeni, 2006

Perhitungn zat gizi yang diperlukan pasien Energi Distribusikan dalam 24 jam Komposisi zat gizi sesuai dengan kebiasaan Perhitungan jumlah karbohidrat per sajian

Perhitungn zat gizi yang diperlukan pasien Karbohidrat sebesar 45-65% total asupan energi Dibagi dalam beberapa kali makan KH per sajian snack snack Pagi .....% = ...g Malam .....% = ...g Siang .....% = ...g Sesuai dengan kebiasaan makan pasien

Perhitungn zat gizi yang diperlukan pasien Perhitungan jumlah karbohidrat per sajian Carbohydrate serving/ choice (carb serving/ choise) Carb grams

Carb Seving/ Carb Choise 1 carb serving/ choie = 15 g karbohidrat Kulkarni, KD.Clin. Diabetes 23: 120 - 122

Carb Seving/ Carb Choise Ex : untuk makan pagi, Tn. H membutuhkan 45 g karbohidrat g KH = 3 carb serving ↓ 2 slice of bread + ½ cup of fruit juice

How Can I Use Nutrition Facts on Food Labels?

Case Study Tn. Han, usia 37 tahun. Penderita DM type 2. TB 155 cm, BB 75 kg. Bekerja sebagai pegawai yang sebagaian besar aktifitasnya dilakukan dengan duduk. Pulang dan pergi kerja diantar oleh sopir. Pemeriksaan gula darah puasa/dl, DG 2 JPP 310 mg/dl

Food pattern (Hasil Food Frequency Questionnaire/FFQ) CHO yang paling sering: nasi, mie, roti Protein hewani ayam, daging, telur Protein nabati tempe dan tahu Sayur jarang hanya 1x/hari Buah frekuensi jarang, konsumsi dalam bentuk jus Snack dalam bentuk makanan tinggi kalori

Stage 1 Nutritional Assessment Antropometri : BB = 75 kg, TB= 155 cm BBI = (155-100) x 90% = 49.5 cm IMT = 75/1.5 2 = 31 (0bese)

Record Hari 1 Waktu Makan Menu Bahan Makanan Portion Size Jml karbohidrat URT Gram Serving Sarapan Nasi putih Ayam grg Tempe grg Pecel Teh manis Nasi Ayam Minyak Tempe Bayam Taoge Kcang tnh Gula pasir 1 gls 1 ptg sdg ½ sdm 2 ptg sdg ½ gls ¼ gls 2 sdm 130 50 5 25 20 60 - 8 6 ½ ½ 1 102 g (…..%) 6.5 serv. Makan siang Tot Carb Makan malam

Hasil Record Hari E P (gr) F (gr) CHO (gr) Hari 1 3310.6 76.2 148.8 417.9 Hari 2 3657.3 128.7 179.3 386 Hari 3 3071.2 106.1 138.8 343.8 Rata-rata intake 3346 103.6 155.6 387.2

Stage 3 Nutrition Intervention Perhitungan kebutuhan 20 Kal x 75 = 1500 Kalori KH 55% = 55/100 x 1500 = 825 Kalori= 206.3 gram Lemak 25% = 25/100 x 1500 = 375 Kalori = 41.6 gr Protein 20%= 20/100x1500= 300 Kalori= 75 gr

Stage 4 Meal planning (KH) sesuai dengan kebiasaan makan Energi = 3346 Kalori, CHO= 382.7 g yang terbagi dalam : Sarapan (%) = Snack (%) Makan siang (%) Makan malam (%)

Distribusi konsumsi KH dalam gr dan serving unit Kebiasaan mkn = 382.7 g CHO Kebutuhan = 206.3 g CHO gram CHO Unit serving CHO 54(26%) 3.5 35 (17%) 2 60 (29%) 4 8 (4%) 1 49 (24%) 3 206 13.5 Waktu makan gram CHO Unit serving CHO Sarapan 100.6 (26%) 6.5 Snack 65.5 (17%) 4 Siang 111.0 (29%) 7.5 15.4 (4%) 1 Malam 90.2 (24%) 6 Total 382.7 25

Steps to Count Carbohydrate Counting Step 1 : Make healthy food choices Step 2 : Focus on carbohydrate Step 3 : Set carbohydrate goals Step 4 : Determine carbohydrate content Step 5 : Monitor effect on blood glucose level

Step 4 : Determine carbohydrate content Write down what you eat and drink throughout the day Be sure to note the portion sizes Record the grams of carbohydrate in these foods and drinks.

Steps to Count Carbohydrate Counting Step 1 : Make healthy food choices Step 2 : Focus on carbohydrate Step 3 : Set carbohydrate goals Step 4 : Determine carbohydrate content Step 5 : Monitor effect on blood glucose level

Step 5 : Monitor effect on blood glucose level Work with your health care team to correct blood glucose levels that are too high or too low

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