POLICY, GOVERNANCE AND CONSENSUS MANAGEMENT OF

DIABETES MELLITUS AND OBESITY DISEASE.

Compiled to fulfill the assignment of the Global Disease Nursing Course group
(KPA 1632)

By
Group 8 / Class B
MakhrufiM. AS Ardianto NIM 182310101054
Siska Safirah NIM 182310101067
Elyza Andari Fauzan NIM 192310101058
Dwi Nanda Pratiwi NIM 192310101077
Kingkin Nindi Oktasari NIM 192310101139

Supervisor:
Ns. Kushariyadi, S.Kep., M. Kep
NIP. 760015697

BACHELOR NURSING STUDY PROGRAM

NURSING FACULTY
UNIVERSITY OF JEMBER
2021
INTRODUCTION

Diabetes Mellitus (DM) is a type of metabolic disorder that can be seen

from the presence of symptoms of high blood glucose levels or hyperglycemia,
due to trigger factors in the form of abnormalities in insulina activity or lack of
insulin secretion or both (American Diabetes Association (ADA) 2004 in
Smeltzer, et al. 2008). Diabetes mellitus will arise if the insulin produced is
deficient in maintaining blood sugar within normal limits, accompanied by the
inability of body cells to respond so that it will experience impacts such as,
polyphagia, polyuria, polydipsia, decreased body weight, eye disorders, tingling,
weakness, pruritus vulvae by women, and erectile dysfunction by men (Soegondo
and Subekti, 2009). There are so many causes that can lead to obesity, as well as
non-compliance in taking medication regularly so that blood glucose cannot be
controlled optimally. Then there are also other causes, including socioeconomic
conditions, stages of knowledge and education, the state of depression that is
being experienced.

Obesity is a non-menstrual disease (PTM) in the presence of an excessive

triacial accumulation of glycerol in fat tissue with a trigger factor for excessive
energy intake or exceeding the limit of body needs (Indra, 2006) The trigger
factors for obesity can be the influence of the surrounding social environment,
lifestyle habits, psychology / stress, active smoking, disruption of the nervous
system and endoctrines, always consuming alcoholic drinks and high-fat foods,
and age (Mukherjee, et al. (2013)) . Obesity is a chronic disease that can adversely
affect an individual, both polygenic and monogenic, causing dysfunction or
pathology.

BACKGROUND

Diabetes mellitus is a chronic disease that arises due to the body's inability
to utilize the insulin that has been produced or due to trigger factors in the
pancreas that are not able to produce insulin. Diabetes mellitus is one of the non-
communicable diseases that has been the target of follow-up by world leaders and

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experts, considering the number of cases of diabetes prevalence has increased
significantly in recent times.(WHO Global Report, 2016).

On a global scale record, it has been recorded that 422 million adults have
diabetes in 2104. This is an extra record if we look at the data in 1980 when there
were 108 million who had diabetes. In the world analysis (age standardized) has
increased markedly by almost 2 times starting from 1980, with the percentage
gain of 4.7% changing to 8.5% in adult cases. These events indicate that there is
an increase in the cause of the associated risk, such as obesity. Recently, data
related to diabetes has been increasing and occurs in regions with low and middle
income levels of the economy.

This type of disease has killed 1.5 million people in 2012. Cases that occur
with high blood sugar conditions have resulted in an increasing number of victims
by 2.2 million people. Summary of data results obtained as much as 43% of the
3.7 million cases occurred under 70 years of age. Data on diabetes cases,
especially those under 70 years of age, often occur in countries with low
economies when compared to countries with high income status (WHO
Global Report, 2016).

Table 1. Percentage of Case Death Results at the Age of 20-69 Years Based
on Classification of State Income and Gender. (Source: WHO,
2016)

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Note: The Total Total Includes Countries outside WHO

Table 2. Distribution of Estimated Prevalence and Total Cases of Diabetes

(Age> 18 Years) (Source: WHO, 2016)

WHO already has a view and predicts globally that in 2014 diabetes will
attack adults aged over 18 years, with an incidence rate of 422 million cases. In all
parts of the world cases of diabetes have become a threat to the population. The
results of the data obtained have increased in relation to diabetes cases with a
number of 422 million or a fourfold range. In Indonesia, based on a doctor's
diagnosis related to diabetes mellitus data, when compared to 2013, especially
those aged ≥ 15 to 2% (Riskesdas, 2018). The lowest province was in NTT (0.9%)
and the highest was DKI Jakarta (3.4%). According to age classification, DM is
very vulnerable at the age of 55-64 years and 65-74 years and female (1.8%)
while male (1.2%). Urban areas (1,

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Figure 3.The prevalence of diabetes mellitus in communities aged ≥ 15 years
in each province based on doctor's diagnosis in 2013 and 2018
(Source: Riskesdas, National Research and Development Agency
2018).

Figure 4.The prevalence of diabetes mellitus originates from gender, age,

area of domicile in 2018 (Source: Riskesdas, National Research
and Development Agency 2018).

Determination of the commemoration of World Diabetes Day which is

always commemorated on November 14 (PBB, 2006). However, a determination
of that day still did not have a meaningful effect. In fact, every time diabetes cases
are increasing, especially in Indonesia, considering that it is still in a transitional
period, epidemiology, culture, economy, behavior, demographics, technology, and
so on. This non-communicable disease case can be said to be a disease that
aggravates the country on the quality of human resources, and death so that
Indonesia will be affected, such as the lack of bilateral cooperation interaction in
obtaining demographic inset for the next 14 years.

Obesity is one of the non-communicable diseases that has an impact on the

health status of the population so that there are many cases of high mortality rates
globally. The data obtained is that around 44% of adult cases and 20% occur in
children over five years of age using BMI measurements. Obesity has become a
disease that often occurs with significant cases tripling since 1980, resulting in an
impact of 4 million cases of deaths every year worldwide, with a factor of 2/3 due

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to cardiovascular disease which has an effect on reducing the quality of life as
evidenced by 120 million cases in disabilities. (DALYs) (GBD 2015 Obesity
Collaborators 2017).

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Figure 4. Overweight / Obesity Prevalence by Age Group and Region, 1980–
2016 (Source: UNICEF, WHO, and World Bank 2016)

The results of Basic Health Research in 2013 and 2018 show that
Indonesia is in a state of emergency. Obesity There is a case of a child with a
percentage of 7% predicted to face an obesity in 2018 (Ministry of Health, 2018).

Obesity case rate (BMI ≥25 to <27) and obesity (BMI ≥ 27) in the adult
group are very significant so that they become a threat to nutritional disorders that
occur in Indonesia. Obesity shows that adult women are more at risk (41.6%).

Figure 5. Prevalence of Overweight / Obesity of Various Ages ((Source:

RISKESDAS 2007, 2010, 2013, 2018; SIRKERNAS 2016)

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 The problem of obesity that occurs in society can also have an impact on
adolescents. Adolescents are very at risk of obesity to adulthood. The weight of
adolescents on average is closely related to plasma insulin levels, blood pressure,
blood lipids, increased lipoprotein levels. In helping to minimize the obesity rate
that occurs in society, the government is forced to implement several decisions
that may be a little forceful on society in pursuing a healthy lifestyle.

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DATA ANALYSIS

The author conducted a data search on the topic of Diabetes Mellitus Type 2 and Obesity by using some literature in online journals
or articles using databases such as Google Scholar and Science Direct. The data obtained from the database is in the form of journals in the
last 5 years. Literature search using the keywords "Obesity, Diabetes mellitus type 2, diet formula, physical exercise, diabetes mellitus
treatment". After the search, the authors selected 5 journals used in the literature study.

No
Author Year Title Result Recommendation
.
1. Nova 2019 The Relationship Based on the distribution of This study suggests:
Nurwinda Sari between Central Diabetes Mellitus incidence, 32 1. Increase insight and
Obesity and the respondents had type II diabetes knowledge about obesity and
Incidence of Type and 30 respondents had other diabetes melitus type 2 in
II Diabetes types. From the results of order to avoid it.
Mellitus statistical tests, the results show 2. Set a healthy lifestyle and
that there is a relationship avoid high-fat consumption
between central obesity and the patterns which are a factor in
incidence of Type II Diabetes obesity.
Mellitus with a p-value = 0.000. 3. Creating a habit of physical
Furthermore, it was found that activity as an effort to avoid

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 respondents who were obese had obesity which is then
an 8.333 chance of experiencing associated with an increase in
Type II Diabetes Mellitus or Diabetes Mellitus.
obtained OR = 8.333 (95% CI; 4. Measuring obesity to monitor
2.516 - 27.60). nutritional status by measuring
body mass index (BMI), waist
circumference, and waist-to-
hip ratio.
2. Tika Ayu 2018 The Effect of Diabetes mellitus is a disorder This study suggests:
Pratiwi, Obesity on the metabolisme chronic due to 1. Health workers are expected to
Rahayu Lubis, Incidence of insulin retention. Opeople with provide counseling about
Erna Mutiara Diabetes Mellitus obesity can increase the risk of increasing knowledge about
in Women of type 2 diabetes mellitus. Wanita diabetes mellitus, causal
Fertile Age in Dr. of childbearing age with an age factors, symptoms,
Djoelham Binjai in range of 20-29 years have a fairly complications, and ways to
2017 large risk of type 2 diabetes prevent diabetes mellitus.
mellitus, this is due to a greater 2. Diabetics are expected to keep
increase in body mass index. blood sugar in a normal state,
Based on the results of research, reduce weight in obese people,

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 the effect of obesity in women of regulate eating habits, and do
childbearing age on the incidence physical activity.
of diabetes mellitus shows a value
of p = 0.009 (p<0.05) and OR =
2,931, meaning that women of
childbearing age with obesity
have risk ie 2,9 times the potential
for diabetes mellitus compared to
those who are not obese. This can
be reduced by improving people's
lifestyles and diets.
3. Lena j. Stork, 2021 Efficiency of a 15- From this study, it was found that This study suggests carrying out
Peter J. Week Weight-Loss a structured weight loss program weight loss for 15 weeks for people
Meffert, Janine Program, Including that includes the LCD formula with diabetes mellitus type 2 who
Rausch, a Low-Calorie and physical activity is very are obese as an effort to avoid
Simone Formula Diet, on effective in preventing the health complications that can arise
Gartner, Ali A. Glycemic Control reduction of HbA1c, body weight such as hypertension. In this
Aghdassi, in Patients with and anti-diabetes treatment program, the patient consumes a
Jens-Peter Type 2 Diabetes including insulin and also liver low calorie diet with a balanced

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 Kuhn, Mellitus and function tests in patients with formula with 5 sachets of food for
Matthias Kraft, Overweight or Type 2 Diabetes Mellitus who one day which has an energy
Maik Pietzner, Obesity experience diabetes mellitus. content of 800 kcal. Patients are
Markus M. obesity. When monitoring blood also advised to drink> 2.5 L of
Lech, and sugar levels and anti-diabetes water per day. During the last 5
Antje drugs, hypoglycemia can be weeks of this program, energy
Steveling avoided. BP, HDL-C and LDL-C intake will gradually be increased
did not change. between 1,200 to 1,500 kcal to
stabilize the health and weight of
the body.
4. Abdelkrim 2018 Physical Execise From the study, it was found that Studies suggest that people with
Khadir, Sina Enhanced Heat in obese diabetic subjects there diabetes accompanied by obesity
Kavalakatt, Shock Protein 60 was a decrease in HSP60 levels can do physical exercise. This
Preethi Expression and along with physical exercise and physical exercise involves
Cherian, Samia Attenuated and there was a decrease in the moderate intensity aerobic exercise
Warsame, inflammation in the expression of inflammatory as well as resistance training which
Jehad Ahmed Adipose tissue of markers in SAT although there can be done with the help of a
Abubaker, Human Diabetic was a marginal change in BMI. treadmill or stationary bike. The
Mmohammed Obese Physical exercise also increases session in this physical exercise is

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 Dehbi and Ali cellular stress defenses by divided into 10 minutes of warm-
Tiss increasing HSR in diabetic up, 40 minutes of exercise program
subjects. at a maximum HR of 65-80% and
10 minutes of cooling at a
maximum HR of 50-60%. physical
exercise is done 3 times a week for
3 months.
5. Amrita 2020 Treatment of From the research results, it was This study suggests that people
Banerjee, Insulin Resistance found that Nanomedicine pADN- with Diabetes Mellitus Type 2
Divya Sharma, in Obesity- chitosan-oleate-AHP functions to accompanied by obesity can treat
Riddhi Trivedi, Associated Type 2 mitigate insulin resistance in the adiponectin gene therapy using
and Jagdish Diabetes Mellitus long term. Nanomycels consisting chitosan nanomycels targeting
signh through of chitosan conjugated to oleic adipocytes which function to treat
Adiponectin Gene acid and adipose homing peptide insulin resistance. This study
Therapy or AHP were developed to deliver suggests paying attention to dosage
pADN to adipocytes. use when using the adiponectin
Subcutaneous administration of gene therapy treatment. This can
pADN-chitosan-oleate-AHP in a optimize the nursing plan for the
single dose given to obese mice therapy. In addition, the rigorous

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 with diabetes resulted in an safety of this study is critical to the
increase in insulin up to 6 weeks. successful development and clinical
This is equivalent to the removal potential of this therapy.
of glucose in healthy mice. In
addition, between mice given
pADN-chitosan-oleate-AHP and
healthy mice had comparable
serum adiponectin levels up to 3
weeks of treatment.

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RESULTS

From several studies according to the journal analysis above, it was found
that there was a relationship between central obesity and the incidence of Type II
Diabetes Mellitus. People who are obese will be more at risk of developing type II
diabetes mellitus. This is because people who are overweight will cause the levels
of leptin in the body to increase. Thus, increasing blood sugar levels. This incident
is also triggered by a lack of physical activity and high consumption of
carbohydrates, protein and fat. Diabetes mellitus type II can occur in children and
adults. People aged 45 years and over have a higher risk of developing type II
diabetes mellitus due to increased insulin production, experiencing insulin
resistance, and impaired insulin secretion due to aging.

There are several things that can be done for diabetes treatment, such as a
structured weight loss program that includes an LCD formula, physical activity,
the presence of insulin treatment, and also liver function tests in patients with
Type 2 Diabetes Mellitus who are obese. From one of these journals, it was found
that in obese diabetic subjects there was a decrease in HSP60 levels along with
physical exercise and a decrease in the expression of inflammatory markers in
SAT although there was a marginal change in BMI. Physical exercise also
increases cellular stress defenses by increasing HSR in diabetic subjects. There is
also the treatment of type II diabetes mellitus with Nanomedicine pADN-
chitosan-oleic-AHP gene therapy. This gene therapy serves to mitigate insulin
resistance over a long period of time.

DISCUSSION AND RECOMMENDATIONS

An unhealthy lifestyle can cause various problems in the body, such as

diabetes mellitus. In a supporting journal entitledThe Effect of Obesity on the
Incidence of Diabetes Mellitus in Women of Fertile Age in Dr. Djoelham Binjai
in 2017, obesity in women of childbearing age can increase the risk of diabetes
mellitus by 2,9 times greater than women of childbearing age without obesity. Hal
this is because women of childbearing age have a greater chance of increasing
body mass index. (Pratiwi et al., 2019)

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 Nurses who act as educators can improve in providing information to
patients about enhancement knowledge about diabetes mellitus, causal factors,
symptoms, complications, and ways to prevent diabetes mellitus. In a research
article, explained that patients with type 2 diabetes mellitus who are overweight or
obese can run a weight loss program, a low calorie diet, and physical activity. It is
effective in lowering HbA1c, weight loss, antidiabetic treatment including insulin,
and improving liver function.(Storck et al., 2021).

Control and prevention of diabetes mellitus can be done individually or

involve the community. Individuals can adopt a healthy lifestyle and physical
activity especially if they have a history of impaired glucose tolerance.
Community-based health efforts with Posbindu can be an early detection of risk
factors for diabetes mellitus, because in Posbindu, blood sugar checks are carried
out so that when problems are found, education and intervention can be carried
out at health service facilities.(Indonesian Ministry of Health, 2020).

There are several things that can be done to control diabetes mellitus,
namely by adjusting the diet by adjusting the calories needed by people with
diabetes mellitus, doing physical activity with a minimum duration of 30 minutes,
carrying out pharmacological therapy as recommended by a doctor, for people
with diabetes mellitus with obesity can do monitoring nutritional status such as
measuring BMI, as well as involving families to encourage people with diabetes
mellitus to adhere to treatment, behave in a healthy life, or help change a healthier
lifestyle. In a study, it was explained that a person with diabetes mellitus
accompanied by obesity can perform adiponectin gene treatment therapy to treat
insulin resistance by using chitosan nanomycell.. Pthe use of doses when using the
adiponectin gene therapy treatment must be considered. (Banerjee, 2020).

CONCLUSION

Diabetes mellitus is a chronic disease that arises due to the body's inability
to utilize the insulin that has been produced or due to trigger factors in the
pancreas that are not able to produce insulin. The incidence of diabetes mellitus is
related to excess body weight which is triggered by a lack of physical activity and

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an unbalanced diet, which causes leptin levels in the body to increase. To
overcome this, nurses can provide counseling by emphasizing the application of a
healthy lifestyle both physical activity and diet and providing education to
patients regarding the importance of routine check-ups, especially regular blood
sugar levels.

REFERENCES

Banerjee, A., Sharma, D., Trivedi, R., & Singh, J. (2020). Treatment of insulin
resistance in obesity-associated type 2 diabetes mellitus through adiponectin
gene therapy. International Journal of Pharmaceutics, 583 (April), 119357.
https://doi.org/10.1016/j.ijpharm.2020.119357

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Bulu A., TD Wahyuni, and A. Sutriningsih. 2019. The Relationship Between
Compliance Level Of Taking Medication With Blood Sugar Levels In
Patients With Type II Diabetes Mellitus. Nursing News. 4 (1): 181-189.

Dyah, P. N, et al. (2020). Relationship between HbA1C and CRP in Patients with
Type 2 Diabetes Mellitus with Obesity and Non-Obesity. Journal of
Nutrition College, 9 (4) .2020, 267-272.

J. Storck. Lena, et al (2021). Efficiency of a 15-Week Weight-Loss Program,

Including a Low-Calorie Formula Diet, on Glycemic Control in Patients
with Type 2 Diabetes Mellitus and Overweight or Obesity. Obesity Facts,
14,45-55.

The Indonesian Ministry of Health (2020) Remain Productive, Prevent, and

Overcome Diabetes Mellitus. Jakarta: Center for Data and Information.

Ministry of Health of the Republic of Indonesia. 2018. World Diabetes Day 2018.
Center for Data and Information, Ministry of Health, Republic of Indonesia.
Accessed on the embankment, May 5,
2018.https://pusdatin.kemkes.go.id/download.php?file=download/pusdatin/
infodatin/infodatin-Diabetes-2018.pdf

Khadir, A., Kavalakatt, S., Cherian, P., Warsame, S., Abubaker, JA, Dehbi, M., &
Tiss, A. (2018). Physical exercise enhanced heat shock protein 60
expression and attenuated inflammation in the adipose tissue of human
diabetic obese. Frontiers in Endocrinology, Vol. 9, pp. 1–
13.https://doi.org/10.3389/fendo.2018.00016.

Nugroho, PS 2020. Gender and age are at risk for obesity in adolescents in
Indonesia. Journal of Public Health. 7 (2): 110-114

Nurwinda Sari, Nova. (2018). The Relationship between Central Obesity and the
Incidence of Type II Diabetes Mellitus. Sai Betik Scientific Journal of
Nursing, 14 (2).

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Pratiwi, TA, Lubis, R., Mutiara, E. 2018. The Effect of Obesity on the Incidence
of Diabetes Mellitus in Women of Fertile Age in Dr. Djoelham Binjai 2017.
Journal of Healthcare Technology and Medicine. 4(1): 1-10

Sari, NN (2019). Correlation between Central Obesity and Incidence of Diabetes

Mellitus Type Ii. Sai Betik Journal of Nursing, 14 (2),
157.https://doi.org/10.26630/jkep.v14i2.1299.

Shekar, M., and B. Popkin. 2020. Obesity Health and Economic Consequences of
an Impending Global Challenge. Washington: World Bank Group.

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 PRESENTATION SESSION AND GROUP DISCUSSION 8
Presentator: 1. Makhrufi MAS Ardianto (18-054)
2. Kingkin Nindi O. (19-139)

1. Questions from Erma Yunita Sari (19-038)

Answered by: Siska Sarifah (18-067)
The first question is what strategies are recommended so that obese patients can
carry out a physical activity program safely and comfortably? The strategy carried
out to increase mobility and activities of daily life in DM patients who experience
physical mobility problems is to do physical exercise racistance training or weight
training 2-3 times per week according to the doctor's instructions, besides that
nurses are also advised to teach patients with ROM extremity below as indicated
to increase muscle strength as well as maintain joint flexibility.

For the second question, does adiponectin gene therapy have any side effects on
the body? If there are any preventive measures that can be done to reduce the risk
of these side effects? In the journal used in our essay by Banerjee et al. In 2020,
there is no mention of the side effects of using the adiponectin gene therapy.
Because until now this experiment has not been applied to humans, because there
is no correct dosage
the use of adeponectin gene therapy and in the journal explained that the
administration of adeponectin gene therapy alone is temporary in the treatment of
insulin resistance in type 2 diabetes mellitus with obesity, namely for 6 weeks and
sugar levels will return to normal after 6 weeks. Researchers say there is a need
for further studies to optimize the treatment plan.

2. Questions from Umi Latifah (19-008)

Answered by: Elyza Andari Fauzan (19-058)

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The first question, what kind of rehabilitative efforts can be applied to diabetes
patients in the recovery phase or patients who have lost some parts of their body
due to amputation?
Medical rehabilitation therapy for diabetic complications such as myopathy,
neuropathy and arthropathy, can use various modalities such as laser,
electrostimulation, and diathermy. Rehabilitative efforts that can be carried out for
diabetic patients during recovery or for patients who have lost limbs due to
amputation include wound care and physiotherapy.
a. The wound treatment here includes: 1) Washing the wound which aims to get
rid of necrosis, excessive wound fluid, the remaining dressings used and the
body's metabolic remains on the wound surface; 2) Debridement is performed to
avoid infection or cellulitis, because tissue necrosis is always associated with an
increase in the number of bacteria; 3) Antibiotic therapy, to inhibit gram-positive
and gram-negative germs; 4) Selection of suitable wound dressings. In addition to
wound care, Hb and albumin checks are also needed because they greatly affect
wound healing. Try to keep the Hb over 12 g / dl and the blood albumin to be
maintained at more than 3.5 g / dl.
b. Physiotherapy is a form of health service aimed at individuals and / or groups,
including to develop, maintain, restore movement and body function by using
manual handling. Rehabilitating physiotherapy that can be performed on post-
amputation surgery patients, for example manual therapy such as massage, will
reduce pain and tension in overworked muscles in new situations.

The second question, what are the contraindications for using the adiponectin
gene to treat insulin resistance?
In the journal Banerjee et al (2020) there is no mention of the side effects of using
adiponectin gene therapy. Because until now these experiments have not been
applied to humans, and still need for further studies. To increase adiponectin
levels, the drug metformin can be used, which activates the enzyme adenosine
monophosphate protein kinase (AMPK). Metformin increases adiponectin levels
significantly in adipose tissue. Metformin is used to raise adiponectin levels
thereby reducing the risk of insulin retention. And adiponectin gene therapy can

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help with weight loss in obesity. Adiponectin greatly impacts kidney failure
because it can cause cardiovascular risk if blood plasma adiponectin levels are
low and cause death if blood plasma adiponectin levels are high.

3. Questions from Hanifah Rahmawati (19-064)

Answered by: Dwi Nanda P. (19-077)
The first question, there are several things that can be done in the treatment of
diabetes for obese clients, including a structured weight loss program which
includes an LCD formula, physical activity, the presence of insulin treatment, and
liver function tests of obese diabetics. Previously, permission to straighten out the
results of his research was due to Hanifa's misunderstanding. So, according to the
third journal on the paper
Our group mentioned that patients with Type 2 Diabetes Mellitus and also Obesity
can follow a structured weight loss program which includes 2 things namely LCD
and physical activity. The results of this program are proven to be effective in
reducing HbA1c, body weight, antidiabetic drugs including insulin because in this
program clients do not use insulin temporarily but some are still using levels
according to conditions, and improve liver function tests. So all patients who
suffer from Diabetes Mellitus Type 2 and Obesity if going to do this program
must do these 2 things, namely the LCD diet and recommended physical activity.

The second question, regarding the stages of this program. So this program is
carried out for 15 weeks. The first 6 weeks of doing a low calorie diet with a
balanced formula (LCD). A day 5 sachets is equivalent to 800 kcal which on
average contains 96 g of carbohydrates, 70 g of protein, 15 g of fat and the
recommended vitamins and minerals. Clients also drink water> 2.5L and other
calorie-free drinks. The following 4 weeks, the energy was increased to 1,200 kcal
with the same program. Then in the last 5 weeks the energy was increased
between 1,200-1,500 kcal according to the body's condition so that the body
weight remains stable. Then once a week the client is monitored for health status.
Weight loss program with physical exercises poured in gradually adjusted to the
condition of the body and other ailments if any.

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