Workshop

BASIC CLINICAL NUTRITION

PIT PAPDI Cab. KALTIM KALTARA

2018

dr. Meiliati Aminyoto, M.Kes, Sp.GK

 Curriculum Vitae
Nama : dr. Meiliati Aminyoto, M.Kes, Sp.GK
TTL : Samarinda, 19-11-1980
Pendidikan:
- Dokter -- Universitas Airlangga (2003)
- S2 Gizi Kesehatan Masyarakat -- Universitas Airlangga (2008)
- Spesialis Gizi Klinik -- Universitas Hasanuddin (2015)
Pekerjaan dan Organisasi
- Dosen Prodi Pendidikan Dokter FK Unmul
- SMF Gizi Klinik RSUD AW Sjahranie
- Sekretaris PDGKI Kalimantan
- Wakil Sekretaris IDI Kalimantan Timur
 TERMINOLOGY
Nutrition science deals with all aspects of the
interaction between food and nutrients, life,
health and disease, and the processes
by which an organism ingests, absorbs,
transports, utilizes and excretes food
substances

Clinical Nutrition is discipline that deals with

the prevention, diagnosis and management
of nutritional and metabolic changes related
to acute and chronic diseases and conditions
caused by a lack or excess of energy and
nutrients.
Cederholm T, et. al. ESPEN guidelines on definitions and terminology of clinical nutrition.
Clinical Nutrition 36 (2017) 49-64
 Why we should concern on nutrition?

US and Europe Britain Latin America

• Prevalence of • 44% of general • Hospital

malnutrition on US medicine patients malnutrition
hospitals >30% malnourished at prevalence 39% -
• In Europe hospitals admission 62%
37% • 33% of
surgical/orthopedic
patients
• 77% of critical
patients

Tappenden KA, et al. JPEN 2013; 37: 482-497

Lamb CA, et al. Br J Nutr. 2009; 102:571-575
Correia MI, et al. Nutrition 2003; 10;823-825
 Malnutrition Concequences
Reduced GI Reduced muscle
Impaired immunity
function function

Decreased cardiac Altered drug Slow wound

function pharmacokinetics healing

Higher rate of Increase of

Increase in LOS
complication mortality

Increase in
Increase in
hospital
treatment cost
readmission
The Assessment of Nutritional Status

Physical
Food Health
Intake

Quantity
&
Quality

Nutritional Status
Nutritional Status of an individual is often the result
of many inter-related factors
The spectrum of nutritional status spread from
obesity to severe malnutrition
Methods of Nutritional Assessment

Direct Indirect

• Individual • Use community

• Measure health indices
objective • Reflects
criteria nutritional
influences
Direct Methods of Nutritional Assessment

Biochemical,
Clinical
laboratory

Dietary
Anthropometric
evaluation

Direct
Method
Anthropometry

A branch of anthropology that

involves the quantitative
measurement of the human body

It is the single most portable,

universally applicable, inexpensive
and non-invasive technique for
assessing the size, proportions and
composition of the human bocy
 Anthropometric Parameters

Some measurements used for nutritional

assessment include:
• Height (length)
• Weight (mass)
• BMI (Body Mass Index)
• Triceps skin-fold
• Waist and hip circumference
• Mid arm circumference
BMI (Body Mass Index)
 Fat mass

MUAC (Mid Upper Arm Skinfold

Circumference) Thickness
BODY COMPOSITION

Bio-electrical
Impedance
Analysis (BIA)
Nutrition Assessment
“a comprehensive approach to diagnosing
nutrition problems that uses a combination of
the following: medical, nutrition, and
medication histories; physical examination;
anthropometric measurements; and laboratory
data.”
 Subjective Global Assessment
(SGA)
• SGA is a tool that uses 5 components of a
medical history (weight change, dietary
intake, gastrointestinal symptoms, functional
capacity, disease and its relation to nutritional
requirements) and 3 components of a brief
physical examination (signs of fat and muscle
wasting, nutrition-associated alternations in
fluid balance)
• A, B, C original or 7-point scale SGA
• SGA has been adopted by the Canadian
Nutrition Society for diagnostic purposes
 Interpretation

SGA rating

A. Well Nourished

B. Mildly-Moderately
Malnourished

C. Severely
Malnourished
 Energy Requirement
TEE = REE x AF x SF
TEE = Total Energy Expenditure
REE = Resting Energy Expenditure
AF = Activity Factor
SF = Stress Factor

weight in kilograms
in centimeters
age in years
Physical Activity Level
 Rule of Thumb
(kkal/kgBB)

SEDENTARY MODERATE ACTIVE

OVERWEIGHT
20-25 30 35
NORMAL
WEIGHT
30 35 40
UNDERWEIGHT
35 40 45-50
 Stress Factor
Stress Stress Factor Stress Stress Factor
Starvation 0.9 Minor Injury 1.2
Elective Operation 1.1 Minor Surgery 1.2
Peritonitis, major infection 1.25 Clean wound 1.2
Long Bone fracture 1.25
Infected wound 1.3
Multiple blunt trauma 1.5
Major Surgery 1.3
Thermal Injury
Bone fracture 1.3
10% BSA 1.25
20% BSA 1.5 Major trauma 1.5
30% BSA 1.5 Major Infection 1.5
40% BSA 1.75 Severe Burn 2.0
50% BSA 2.0
Combination 2.0
Smoke Inhalation 1.5
Mild Infection 1,2
Respiratory Failure 1,5
Trauma Skeletal 1,2 Moderate Infection 1,4

Closed head injury 1,4 Severe Infection 1,8

Protein Requirement
 Micronutrients

Depending on clinical status of the patients

No set levels for micronutrient
requirements. Aim for the normal RDA
(Recommended Dietary Allowance)
May increase for some specific disease
states (refeeding syndrome, gastrectomy,
total ileal resection, alcoholic patients, etc)
Micronutrient supplementation in patients
with renal failure needs to be undertaken
cautiously
LATIHAN MENGHITUNG
 Case (Outpatient Setting)

Seorang perempuan berusia 50 tahun

penderita DM tipe 2.
` Food recall 24 hr = 2100 kkal
BB = 70 kg
TB = 155 cm
HbA1c: 9,5%
Tingkat aktivitas sedentary (sebagai
pegawai kantor)
Bagaimana pengaturan dietnya?
 Tentukan Status Gizi

BMI

BMI = 70 = 31,1 kg/m2

(1,5)2

Obesitas
BB Ideal = 90% x (TB dalam cm – 100) x 1 kg = 90% x 55 kg = 49,5 kg
 Tentukan Kebutuhan Energi
SEDENTARY MODERATE ACTIVE
OVERWEIGHT
20-25 30 35
NORMAL
WEIGHT
30 35 40
UNDERWEIGHT
35 40 45-50

25 kkal/kgBB/hari
= 25 x 70 = 1750 kkal Rule of
Thumb
 Cara Lain (Konsensus Perkeni)

Jenis Kelamin • Kebutuhan basal untuk perempuan 25 kkal/kgBB

• Kebutuhan basal untuk laki-laki 30 kkal/kgBB

• > 40 tahun dikurangi 5% untuk setiap dekade (40-59 tahun)

Umur • 60 – 69 tahun dikurangi 10%
• > 70 tahun dikurangi 20%

• Ringan ditambah 20%

Aktivitas Fisik • Sedang ditambah 30%
• Berat ditambah 40%

Stress • Penambahan 10-30% tergantung beratnya stress

metabolik (sepsis, operasi, trauma)
Metabolik

Berat Badan • Gemuk dikurangi 20-30%

• Kurus ditambah 20 – 30%
Jenis Kelamin
25 kkal/kgBB = 25 x 70 = 1750 kkal
Umur
- 5% = 1663 kkal
Aktivitas Ringan
+ 20% (dari basal)
Berat Badan 1663 kkal ~
1700 kkal / hari
- 20% (dari basal)
Bagaimana Implementasi Diet?
Komposisi Makronutrien

Karbohidrat

Protein

Lemak
Bagaimana Implementasi Diet?
Komposisi Makronutrien

Karbohidrat 45 – 60% dari total kebutuhan

energi terutama karbohidrat kompleks

Protein 10 – 20 %

Lemak 20 – 30%
(MUFA 32%, PUFA 35%, sisanya SFA
(LCT:MCT = 1:2)
 Komposisi
1 gram Karbohidrat = 4 kkal
1 gram Protein = 4 kkal
1 gram Lemak = 9 kkal

Dari 1700 kkal

Karbohidrat 55% = 935 kkal = 234 gram
Protein 15% = 255 kkal = 64 gram
Lemak 30% = 510 kkal = 57 gram
Serat 25 – 30 gram per hari
Jalur Pemberian Nutrisi

Sesuaikan dengan kondisi pasien

Enteral
Oral (Tube
Feeding)

Parenteral
 Bentuk
Jenis Makanan
• Biasa
• Lunak
• Saring
• Cair (Full liquid, clear liquid)
Perlu Formula?
Jenis Formula
Polimerik
Semi elemental
Elemental
 FORMULA KOMERSIAL

JENIS FORMULA INDIKASI

RENDAH / BEBAS LAKTOSA INTOLERANSI LAKTOSA
DENGAN MCT MALABSORBSI LEMAK.
DENGAN BCAA SIROSIS HATI
PROTEIN TINGGI KATABOLISME MENINGKAT
PROTEIN RENDAH GAGAL GINJAL
RENDAH SERAT RESEKSI USUS
INDEKS GLIKEMIK RENDAH DIABETES MELLITUS
PROTEIN TERHIDROLISA ALERGI SUSU
Jadwal Makan
 Lihat bahan makanan penukar

40 g 5g

5g 10 g
1 porsi bahan makanan sumber karbohidrat
setara dengan
175 kal, 4 gr protein, 40 gr karbohidrat

¾ gelas 2 gelas 3 potong sedang

2 gelas 2 biji sedang 1 potong sedang

Daftar Bahan Makanan Penukar
Data Komposisi Pangan Indonesia

http://www.panganku.org
Nutrisurvey for Windows
 Sajian/kemasan

energi : (kalori)…..

KARBOHIDRAT
 Edukasi

• Kepatuhan terhadap diet dan pengobatan

• Motivasi konsumsi makan sesuai anjuran
(3J – Jumlah Jenis Jadwal)
• Pengetahuan mengenai bahan makanan
sumber karbohidrat
• Pengetahuan tentang indeks glikemik dan
beban glikemik bahan makanan
• Latihan jasmani