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Division of Endocrinology and Metabolism

Department of Internal Medicine
Faculty of Medicine
University of Sebelas Maret Surakarta

Merupakan lambang
kemakmuran & kesuburan

Mengganggu Penampilan dan Estetika
+
Berkaitan dengan kesakitan dan kematian

Risiko : DM Tipe 2, Gangguan Lemak Darah,
Hipertensi, Stroke, Penyakit Jantung Koroner,
Gangguan sendi, Batu Empedu, Kanker

(A) (B)

OBESITAS SENTRAL : (A)
Lemak terkumpul terutama pd daerah perut
dan mempunyai kecenderungan untuk menderita
Penyakit Kardiovaskuler / Hipertensi / DM /
Gangguan Lemak Darah

OBESITAS PERIFER : (B)
Lemak terkumpul terutama pd daerah glutea
dan paha, belum terbukti sbg faktor risiko

Makan dengan kalori berlebihan

ATEROSKLEROSIS
Penyempitan, Gangguan Aliran, Gangguan Komponen,
Penyumbatan, Perdarahan
Phase 1 Phase 2 Phase 3
Awal Progresi Komplikasi
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1.1.1. Abnormal Regulation of Body Weight or Body Fat . Stress 2.1. Programming of Genetic Expression 2. Endocrine and Metabolic Diseases 4. Genetic Factors 1.2.6. Etiologies of Obesity 1. Diet Composition and Eating Patterns 2.5.1 Intrauterine Factors 2. Infection 3.6. Environmental Factors 2. Trauma 2. Drugs 2.6.3. Single-Gene Defects 1.2.4. Surgery 2.4. Polygenic Obesity 2. Emotional Factors 2.2 Early Developmental Factors 2.6.6. Amount of Physical Activity 2.3. Familial and Ethnic Factors 2.1.2.

Worldwide epidemic of obesity-producing virus . reduced outside playing time 2. Change in character of food (high fat. Larger portion sizes 3. Expansion of fast food sources and availability d. increased channels c. food more affordable b.Potential Explanations Advanced for the Epidemic of Obesity 1. refined carbohydrates) e. Organized sports for children. Reduced activity a. less attention to meal preparation 4. Increasing affluence among population. handheld and desktop e. Changes in food intake a. Two-income families. more cars. Fears of violence or kidnapping of children f. Easier access to food in environment c. Computer games. Greater affluence. Computers in workplace and home d. Cable TV. less heavy labor b.

Lower degree of satiety from high-fat foods 2. Greater efficiency of storage with excess intake 3. Greater palatability of high-fat foods c. Differences among individuals in oxidation of dietary fatty acids . Increased food intake a. Mechanisms of Obesity on High-Fat Diets 1. Generally lower chewing and swallowing time for high-fat foods d. Increased energy content of fat for same volume or weight b.

3. Osteoarthritis 2. Malignancy 2.1. Metabolic Syndrome (Syndrome X) 2. Medical Consequences of Obesity and Benefits of Weight Loss 1. Sleep Apnea 2.5.2.4. Gout 2. Gallbladder Disease 3. Other Medical Complications 2. Regional Fat Distribution 4. Benefits of Weight Loss Effects of Weight Loss on Type 2 Diabetes Effects of Weight Loss on Blood Pressure Effects of Weight Loss on Plasma Lipids Effects of Weight Loss on Cardiovascular Disease .

Metabolic Syndrome Proposed by the WHO Diabetes or impaired glucose tolerance or insulin resistance with two of the criteria below: • Hypertension (antihypertensive treatment and/or blood pressure >160/90 mmHg) • Dyslipidemia (triglyceride 1.9 in men and 0. high-density lipoprotein cholesterol. <1.0 mmol/L in women) • Obesity/abdominal obesity (BMI 30 kg/m2 and/or waist-hip ratio > 0. BMI.7 mmol/L and/ or HDL < 0. body mass index .9 mmol/L in men.85 in women) • Microalbuminuria (overnight urinary excretion rate 20 μg/min) HDL-C.

9 men and 0. . World Health Organization National Cholesterol International Diabetes ( WHO ) Education Program Federation ( IDF ) ( NCEP ) Insulin resistance &/or impaired 3 of 5 are present Central Obesity (waist circumference fasting glucose plus at least two of the > 90 cm men and > 80 cm Women) following : plus at least two : of the following Obesity Obesity BMI > 30 &/or Waist > 102 cm (40 inches) men and Waist-to-hip-ratio > 0.85 88 cm (35 inches) women women Dyslipidemia HDL-C HDL-C HDL-C < 35 mg/dL men and < 40 < 40 mg/dL men and < 40 mg/dL men and mg/dL women &/or triglycerides > 10 < 50 mg/dL women < 50 mg/dL women or mg/dL specific treatment Triglycerides Triglycerides > 150 mg/dL > 150 mg/dL or Specific treatment Hypertension Hypertension Hypertension >140/90 mm Hg &/or >130/85mm Hg &/or >130/85mm Hg &/or Antihypertensive meds Antihypertensive meds Treatment for hypertension Fasting plasma glucose Fasting plasma glucose > 100 mg/dL > 100 mg/dL Microalbuminuria Sandhofer et al Albumin/creatinine ratio 25 -250 Eu J Clin Inves 37 : 109 2007 Source: American College of Nurse Practitioners 2008 Elsevier Inc.

Proinflammatory state (elevated of CRP) 6.Components of Metabolic Syndrome ATP III that related to CVD (2004) 1. Abdominal obesity ( Waist circumference : ♂ ≥ 90 Cm / ♀ ≥ 80 Cm ) ♂ ≥ 102 Cm / ♀ ≥ 88 Cm ) 2. Prothrombotic state (elevated of PAI-1) . Raised blood pressure ≥ 130 / ≥ 85 mmHg 4. Insulin Resistence ± glucose intolerance Fasting blood sugar ≥ 110 mg/dl 5.( ♂ < 40 / ♀ < 50 mg/dl ) TRIGLYCERIDE ( > 150 mg/dl) 3. Atherogenic dyslipidemia HDL-Chol.

. high-density lipoprotein cholesterol. < 50 mg/dL in women) • High blood pressure (130/85 mmHg) • High fasting glucose (110 mg/dL) HDL-C. Clinical Identification of the Metabolic Syndrome • Abdominal obesity (waist circumference >102 cm [40 in] in men. >88 cm [35 in] in women) • Hypertriglyceridemia (150 mg/dL) • Low HDL-C (<40 mg/dL in men.

triglycerides. PAI-1. Risk Factors for Coronary Heart Disease Associated With Obesity • Hypertension • Diabetes mellitus (type 2) • Dyslipidemia (high TG. HDL-C. high-density lipoprotein cholesterol. plasminogen activator inhibitor . LDL-C Lowdensity lipoprotein cholesterol. small dense LDL-C) • Hyperinsulinemia • High levels of PAI-1 • Hyperviscosity • Obstructive sleep apnea TG. low HDL-C.

• Researchers and health care providers need to help patients become more aware of the positive outcomes associated with healthful lifestyles. incurable condition. increasing activity. • Obesity requires long-term management similar to diabetes and hypertension. and surgery. • Existing treatment includes counseling. New treatments are under investigation. regardless of the impact on weight. economic. and personal costs.Key Points : The Future of Obesity Treatment • Obesity is a chronic. modification of diet. • Prevention of obesity and an emphasis on environmental change requires greater attention. pharmacotherapy. with significant health. .

Obesity Treatment 1.2.3. Very Low-Calorie Diets 4. Orlistat 2. Psychosocial and Lifestyle Interventions 2. Pharmacotherapy 2. Surgery . Potential New Drugs 3. Sibutramine 2.1.

portion controlled. Low-calorie diets may include but are not limited to low-fat/high-carbohydrate. A multivitamin and mineral supplement is warranted to meet the nutritional needs of the patient and to provide replacements for the micronutrients lacking in the low- calorie diet. . The Low-Calorie Diet Low-calorie diets provide approx 800–1200 cal/d . specific patterns. whereas others may incorporate fortified meal replacements. high-protein/low carbohydrate. These diets may include regular foods. and restriction of one type of food or food groups.

Lanjutan ……………… The Low-Calorie Diet Combined intervention of a low-calorie diet. . group support. nutrition and exercise education. Behavioral counseling. and medical management should be part of the treatment protocol for patients on a low-calorie Diet program for long-term weight-maintenance success. Low-calorie diets can decrease one’s weight by an average of 8% over 3 to 12 mo of treatment . and behavior therapy provides the most successful therapy for weight loss and weight maintenance. increased physical activity.

essential minerals and vitamins. . by convention are diets that provide between 300 and 800 kcal per day. and varying amounts of carbohydrates and fats. also referred to as supplemented fasting. Although some early VLCDs provided as little as 35 g of protein and 300 kcal.Calorie Diets (VLCDs) VLCDs.DEFINITION Very Low . in the last 20 yr most commercial formulations have provided at least 50 g of protein and ranged in daily energy intake between 400 and 600 kcal. All VLCDs provide enough protein to meaningfully reduce lean tissue wasting.

Patients should be informed of the risks associated with the VLCD and that even though most patients will experience significant weight losses. low- carbohydrate form. their chances for long-term maintenance of the weight loss is unlikely. The VLCD is often consumed in a liquid. high-protein. alcoholism. The Very Low-Calorie Diet Very low-calorie diets (VLCDs) provide approx 400 to 800 cal/d and are protein sparing modified fasts. and cholecystitis. hepatic disease. insulin-dependent diabetes. These diets promote rapid weight loss and should only be used with obese clients and are contraindicated for patients with renal. cardiac disease. psychological disturbances. .

nutrition and exercise education. and medical management along with long-term weight-maintenance support should be part of the treatment protocol for patients on a VLCD program. Treatment with this restrictive calorie level should not exceed 12 to16 wk and must include a period of 4 to 6 wk of gradual of refeeding and reintroduction of solid foods and carbohydrates . . group support. Psychological counseling.A skilled physician specializing in treatment of obesity should medically monitor patients frequently and review laboratory tests and medical changes weekly.

Low-Calorie Step I Diet Nutrient Recommended Intake Calories Approximately 500 to 1000 kcal/d reduction from usual intake Total fat 30% or less of total calories Saturated fatty acids 8–10% of total calories Monounsaturated fatty acids Up to 15% of total calories Polyunsaturated fatty acids Up to 10% of total calories Cholesterol <300 mg/d Protein Approximately15% of total calories Carbohydrate 55% or more of total calories Sodium chloride No more than 100 mmol/d (~2.4 g of sodium or ~6 g of sodium chloride Calcium 1000–1500 mg/d Fiber 20–30 g/d .

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INDICATIONS the use of a VLCD The decision of whether the use of a VLCD is warranted for a particular patient revolves around the balance of the small risks associated with this very restricted diet compared to that individual’s risks associated with excess body fat. . With the increased awareness of the interaction between obesity and co-morbidity conditions like type 2 diabetes and hypertension. employing a VLCD for individuals with BMIs as low as 25 plus at least one comorbidity is reasonable. and its use therefore needs not be unduly restricted. to be a candidate for VLCD. In the past. arbitrary convention dictated that. a patient needed to be more than 20% above reference body weight (which translates to a body mass index [BMI] >27). the risks inherent in a VLCD are low. With a well-formulated diet and appropriate medical monitoring.

.. and significantly impaired liver function (e. unstable angina. myocardial infarction within the prior 6 mo.g. patients who are unable to comprehend the need for close diet adherence and medical monitoring should be excluded. serum creatinine >20 mg/L). In addition. serum albumin <32 g/L) or renal function (e. active life-threatening malignancy. as should those with a history of poorly controlled eating disorders.g. Contraindicate use of a VLCDs Medical conditions that contraindicate use of a VLCD include type-1 diabetes or any history of diabetic ketoacidosis.. symptomatic cerebrovascular disease. such as anorexia nervosa or bulimia nervosa.

the loss of lean body mass ceases. By the end of wk 2 of a VLCD. Along with this major fluid egress in the first wk. given adequate protein and minerals. . The onset within a few days of the natriuresis of fasting and mobilization of liver and muscle glycogen with its associated intracellular water can result in up to 10 lb of total weight loss in the first wk. plus 1 or 2 lb of lean body mass as the body adapts to the developing nutritional ketosis. the patient’s fluid and electrolyte status stabilizes and. EFFECTS the use VLCD on weight With initiation of a VLCD. the actual adipose tissue loss may total 2 to 3 lb. prompt and frequently marked weight loss occurs.

the degree of support provided to the patient. The total weight loss achievable with a VLCD varies greatly depending on a number of factors such as initial weight. Interestingly. Lanjutan ……………… EFFECTS the use VLCD on weight From that time on. a majority of appropriately selected patients will adhere to a VLCD and achieve mean losses in the 50 to 60 lb range. and the duration of diet use. the average weekly weight loss ranges from 1. if the VLCD is interrupted even briefly during a major weight- loss effort.5 lb/wk for the shorter person with little activity to 3 lb/week for a taller and more active Person. . If used for sustained periods of 4 to 5 mo. resumption of the diet proves to be very difficult for unknown reasons.

This effect has been difficult to quantify using an objective metric. but that they are better able to resist it. Lanjutan ……………… EFFECTS the use VLCD on weight Most patients on a VLCD report a reduced perceived need to eat within the first week or two of the diet. whereas others note that hunger persists. This effect usually persists for a number of months as long as the diet induced nutritional ketosis is not interrupted by increased carbohydrate. Some report it as decreased hunger. . owing in part to the variable perceptions of patients.

these symptoms can be prevented by the routine addition of 2 to 3 g/d of sodium (taken as bouillon) in all patients not requiring continued diuretic medication. based on when they occur during the VLCD. fatigue. orthostatic symptoms occurring during normal daily activities are the result of the combination of diet-induced natriuresis and an inadequate sodium intake. Although there is a modest reduction in peak aerobic performance in the first week or two of a VLCD. Side effects the use of VLCD There are two groupings of VLCD side effects. and lightheadedness. The most common among these is the combination of weakness. . Thus. Those that occur initially during adaptation to carbohydrate restriction and nutritional ketosis are either transient or respond promptly to intervention. along with attention to adequate dietary potassium.

and this is associated with a 10% reduction in resting metabolic rate. This is the result of the severe energy restriction. Constipation can also occur during a VLCD. but it is usually exacerbated by dehydration. then a carbohydrate-free fiber supplement can be used. If increasing fluid intake to a minimum of 2 L/d does not resolve it. . and returns to normal when the VLCD is stopped. Lanjutan ……………… Side effects the use of VLCD Most patients starting on a VLCD also note greater sensitivity to cold. This is owing in part to the low fiber content of many formulations. This effect of the VLCD on resting metabolism is not reversed with exercise and cannot be safely overcome with the addition of exogenous thyroid hormone.

they respond promptly to supplementation with 200 mEq/d of slow-release magnesium chloride. They are more common in people with a history of diuretic medication use or prior heavy ethanol consumption. suggesting prior depletion of this essential mineral as the root cause. Lanjutan ……………… Side effects the use of VLCD Muscle cramps sometimes occur either early or late in treatment with a VLCD. . In almost all cases.

however. . The mechanism for this effect of ketogenic diets is the competition between β-hydroxybutyrate and uric acid for excretion in the renal tubule. Lanjutan ……………… Side effects the use of VLCD In patients with a history of gout. or by treatment of the acute event with a nonsteroidal anti-inflammatory drug (NSAID). This process induces a transient rise in serum uric acid in the first few weeks of a VLCD. an attack of this acute arthritis can be induced during initiation of the VLCD. during which time those patients prone to gout are at risk of an attack. the renal handling of uric acid returns to normal and the risk of an acute attack subsides. This can be managed by prophylaxis with allopurinol in selected patients with a history of gout. With the subsequent adaptation to nutritional ketosis.

patients deemed high risk because of prior history of or existing gallstones can be treated prophylactically with ursodeoxycholic acid . hair loss. This is best managed by maintaining enough daily fat intake (>20 g/d) to prevent cholestasis. this modest dietary fat intake does not significantly impact the rate of weight loss. . Late-onset side effects can include dry skin. the gallbladder experiences an increased flux of cholesterol during rapid weight loss. and loss of normal menstrual cycles in women. All of these are self-limited and can be treated symptomatically or by physician reassurance. Lanjutan ……………… Side effects the use of VLCD As noted previously. and they routinely resolve when the VLCD is stopped. Given the typical patient’s net oxidation of 150 to 200 g/d of body fat. In addition.

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5 6. Glukosa darah Puasa 80 – 100 > 100 – 125  126 2. Glukosa darah 2 jam 80 – 144 145 – 179  180 3.5–22. Kolesterol LDL (mg/dl) < 100 100 – 129  130 6. Kolesterol HDL (mg/dl) > 45 7. Tekanan darah (mmHg) < 130/80 130-140/80-90 >140/90 .5 – 8 >8 4. IMT (kg/m2) 18. Kriteria Pengendalian DM Baik Sedang Buruk 1. A1C (%) < 6. Kolesterol total (mg/dl) < 200 200 – 239  240 5. Trigliserida < 150 150 – 199  200 8.9 23 – 25  25 9.