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Laporan Siang
Kamis, 2 Maret 2023
 1. Definitions of Diabetes Mellitus Type 1 and Type 2
• DM Type 1: autoimune destruction of the pancreatic beta cells, leading to absolute insulin deficiency
• DM Type 2: charcterized by hyperglycaemia and insulin resistance → in the long term: can impair
pancreatic beta cell function and lead to insulin deficiency
• Stricly associated with: obesity

Incread risk of macro- and micro-vascular complication:

Cardiovascular disease, cerebrovascular disease, peripheral vascular
disease, retinopathy, nephopathy and gastrointerstinal problem

• Impair function and quality of life

• Reducing life expectancy
2. Nutrition Therapy for Diabetes
● Nutrition therapy + counselling = fundamental aspects of diabetes care

● The goals :
○ Optimization of metabolic control
○ The management of CVD risk factors
○ The achievement/maintenance of ideal body weight
○ The prevention of acute and chronic complications

● Key points → considering energy balance to achieve and maintain the desired
body weight, types and distribution of macronutrients and dietary patterns
2.1 Energy Balance
● Lowering calorie intake and inducing weight loss -> very important for
overweight and obese patients with DMT2
● Weight loss ≥5% -> reduction in clinical risk factors for cardiovascular disease
● Weight loss 5 - 10% -> delay the progression from prediabetes to DMT2,
improve HbA1c and lipid levels, inducing diabetes remission
● To obtain weight loss -> low calorie diets with supervision
● Important nutritional issues to be considered in DMT1 and DMT2:
○ Consistency of daily carbohydrate intake and meal timing
○ Macronutrient content of meals
○ Dietary compliance
○ Avoidance of hypoglycemia
2.2 Carbohydrate Consistency
● Variations in daily carbohydrate intake can result in unstable glucose control and
hypoglycemia
● Although patient with DMT2 are less prone to hypoglycemia than DMT1, meal planning for
carbohydrate consistency may be beneficial when insulin therapy is prescribed
● For patient receiving fixed doses of short and intermediate acting insulin, regularity in the
amount and source of carbohydrate at meals and snack is important 🡪 associated with
lower HbA1c, while variations of protein, lipid had no effect
● Several approach are available to plan meals including basic and advanced carbohydrate
counting (calculated in grams in carbohydrate per food portion) and sample menus (specify
the time and amounts of food to be eaten at each meal and snack)
● Best approach depending on patient’s lifestyle and learning capabilities
2.3 Meal / Insulin Timing
• Meal timing at regular interval  glycemic control
• Flexibility of the amount of short/rapid acting insulin to cover an establish amount of
carbohydrate  less blood glucose fluctuation
• Carbohydrate counting for insulin therapy adjustment
2.4 Physical Activity / Exercise
• Physical activity is an important thing that we need to consider when we want to regulate
glycaemic control in addition to the dietary and pharmacological intervention.

• The benefits of physical activity in addition to glucose control are also to regulate weight, reduce
the risk of cardiovascular disease (hypertension, dyslipidemia, cardiovascular disease), improve
mood and quality of life.

• Exercise should perform 30-60 minutes of moderate in aerobic moderate intensity (minimum
150 minutes per week). Patient with cardiovascular disease before, should be careful with high
intensity training.
2.5 Macronutrient Content

• The composition of macronutrients to manage glycaemic control in diabetic patients are still
controversial and various. It depends on patient’s eating pattern, preference, and target for
metabolic control.

• The macronutrients composition recommendation in diabetic patients : 44-46% carbohydrates,

36-40% fats, 16-18% protein.

• It is accepted in particularly diabetic patients to have different eating pattern like low fat, low
carbohydrate, and mediterranean
2.5.1. Carbohydrates

• monitoring carbohydrate intake by carbohydrate counting, is a very important to improve and

maintain glycaemic control for patients on insulin therapy.

• Lowering carbohydrate content is a recognized strategy to induce weight loss in

overweight/obese patients with or without diabetes, particularly type 2 may be challenging
especially in the long term

• Low carbohydrate diet are not recommended in pregnant or lactating women, in diabetic
patients with eating disorders and/or renal disease  potential risk of ketoacidosis
2.5.2. Glycaemic Index and Glycaemic Load
● Food containing the same amount of carbohydrate can differently
impact plasma glucose level → because of a different glycaemic index
(GI) and/or glycaemic load (GL).
● The glycaemic index is determined by the incremental rise in blood
glucose after ingestion of portion of the test food containing 50 g of
carbohydrate
● Example of low-glycaemic index food → non-starchy vegetables, nuts,
and legumes.
● Example of high-glycaemic index food → bread, and other refined
products made from grains
2.5.2. Glycaemic Index and Glycaemic Load (cont)
- Glycaemic index → The quality of carbohydrate ingested
- Glycaemic load → The quantity of carbohydrate also influences the blood
glucose response
- Glycaemic load → the product of the glycaemic index value of food and its total
carbohydrate content
- Recent metaanalysis → small benefits on glycaemic control and cardiovascular
risk factor from low glycaemic index/load diets in patien with moderately
controlled DMT1 an DMT2
- Increased risk for diabetes, low glycaemic index diets heve been associated with
improvement of cardiovascular risk factor→ need consuming low GI/GL diets→
diet with high GI/GL: associated with the incidence DMT2
2.5.3. Fibre
● Dietary fibre has been related to reduced all-cause mortality in patients
with diabetes
● Has positive effect on glycaemic control, blood lipids, and inflammation
● Requirement: 14 grams per 1000 calories per day
2.5.4. Non-Nutritive Sweeteners
● Non-nutritive sweeteners do not significantly affect metabolic control
and may reduce calorie intake if used to replace caloric sweeteners
● Recommendations: reduce the intake of sugar-sweetened beverages by
substituting non-nutritive sweetened beverages, with long term goal of
decreasing both types of beverages in favour of water
2.5.5. Protein
● DM patient without kidney disease → dietary protein → glucose control
and reduce cardiovascular risk (uncertain)
● Typically 1-1,5 g/kg/day
● Moderate-to-advanced diabetic kidney disease (with or w/o
albuminuria) → protein intake 0,8 g/kg/day
● KDIGO 2020 guidelines:
○ Diabetic patient with CKD non dialysis: 0,8 g/kg/day
○ Diabetic patient with CKD on dialysis: 1,0-1,2 g/kg/day
● Source of protein: substitute lean meat, fish, eggs, nuts, soy product,
beans, seeds for red meat
● Dietary protein stimulate insulin secretion (caution in hypoglycaemia)
2.5.6. Fat
● Ideal quantity for diabetic patients is uncertain
● Type of fat more important than quantity for metabolic and
cardiovascular management
● Saturated and trans fat → increase cardiovascular disease
● MUFA and PUFA have protective effect and lower risk of DM type 2
● Mediterranian diets → lower risk DM, improve glycaemic control, and
improve plasma lipid pattern in DM
● Increase consumption of food with omega 3 is recommended
● Routine omega 3 supplement is not recommended
● Trans fatty acid consumption strictly limited
2.5.7. Micronutrients
● There is no evidence that supplementation has an impact on diabetes onset, progression,
or complication → some supplements can cause side effects

● Supplementation recommended when there is deficiency or for special population:

Vegetarian, very low calorie diet, older adults, patient with coeliac disease

● Vitamin D:
○ Low level of vit D & Calcium → inflammation & beta cell destruction → predispose to DMT1 &
DMT2
○ Supplementation: only for patient with reduced plasma concentration or have higher requirement
(pregnancy & breastfeeding)

● Metformin: associated iwith vit B12 deficiency → periodic annual testing of vit B12 level is
recommended for patients on metformin therapy, anaemia, or peripheral neuropathy
2.5.8 Alcohol
• Alcohol intake limited :
• 10 g per day for women
• 2 drinks per day for men
• Should be consumed with food
• Monitor blood glucose  because increase risk of delayed
hypoglycemia by patients on insulin therapy and/or secretagogue
• Increase risk of weight gain  extra calories
2.6 Dietary Pattern
• To achieve glycemic control and target body weight
• Mediterranean, low fat and low carbohydrate diets
• The Mediterranean  improved lipid profile, reduced rate of
cardiovascular events, weight loss in long term
3. Specific Situation
3.1 Acute complication (Hypoglycemia)
• Hypoglycaemia  if the patient is not trained properly to match
hypoglycaemic therapy with diet and physical activity.
• Overtreating hypoglycaemia hyperglycaemia and increased calorie
intake, resulting in weight gain
• hypoglycaemia (blood glucose <70 mg/dL)
• Blood glucose 51 and 70 mg/dL  the 15-15 rule  15 g of fast- acting
carbohydrate, retest blood glucose after 15 minutes.
• blood glucose levels fall ≤50 mg/dL  30 g of fast-acting carbohydrate
• Once the blood glucose is >70 mg/dL  insulin dose to cover
carbohydrate intake at the following meal
3.2 Chronic complication: Diabetic
gastroparesis
• Glucose control strongly related with microvascular complications including
neuropathy
• Gastrointestinal autonomic neuropathy may affect nutritional status
• Clinical manifestation known as gastroparesis ( dyspepsia dan/ delayed
gastric emptying)
• Pathogenesis:
1. Acute and chronic hyperglycaemia
2. Enteric neuromuscular inflammation
• Symptomatic or asymtopmatic
• Symptomatic: nausea, vomiting, early satiety, abdominal pain and, in
severe cases, weight loss
• Gold standard for gastric emptying measurement: scintigraphy after
ingestion of a test meal with measure of gastric retention after 2 hours

• Pillars for management gastroparesis

1. Optimization blood glucose control
2. Dietary modificatons aiming the prevention of
1. Dehydration
2. Micronutrient deficiency and calori protein malnutrition
3. Pharmacological treatment
• Acute hyperglycaemia  delays gastric emptying
• optimization of blood glucose levels  use of insulin pumps and adequate hydration
management of gastroparesis
• fractionation of meals into small
• frequent snacks of liquid/semiliquid consistency
• selection of small- particle-size foods
• Dietary modification failure  oral nutritional supplement, enteral and parenteral
nutrition
• Nasojejunal tube feeding  safe and effective
• First-line pharmacological therapy  prokinetics (metoclopramide, domperidone
and macrolides)  increase the rate of gastric emptying.
• long-term use of macrolides  antibiotic resistance and antibiotic-induced diarrhoea
• abdominal distension and vomiting  the 5-hydroxytryptamine 3 receptor
antagonist ondansetron
• abdominal pain and nausea  gastrostomy tube for decompression
Conclusion
• Diabetes mellitus is a complex disease with various metabolic and
nutritional consequences.
• Nutrition therapy is crucial in the comprehensive management and self-
management of diabetes both in DMT1 and DMT2 since it is effective in
improving metabolic control and preventing the transition from prediabetes
to diabetes.
• The nutritional plan should be targeted not only at optimizing glycated
haemoglobin, but also at managing body weight and cardiovascular risk
factors.
• The prescription must be personalized to the individual’s needs and
preferences in order to maximize patient compliance.