132ad9713ef23c5ad8d506b065a055bfcbcd65f6

66--MayMay--0909 11

PendahuluanPendahuluan Ilmu Gizi Ilmu Gizi KlinikKlinik

Dr. Sri Sukmaniah MSc, SpGKDr. Sri Sukmaniah MSc, SpGKDepartemenDepartemen IlmuIlmu Gizi, FKUIGizi, FKUI

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Ilmu Gizi Ilmu Gizi KlinikKlinik

PendahuluanPendahuluan PetaPeta kesehatankesehatan didi indonesiaindonesia gangguangangguan nutrisinutrisi

salahsalah satusatu masalahmasalah kesehatankesehatan utamautama PrevalensiPrevalensi MalnutrisiMalnutrisi pasienpasien rawatrawat inapinap SurveiSurvei didi AmerikaAmerika ::

* 50 % * 50 % pasienpasien yang yang akanakan dirawatdirawat sudahsudah KEPKEP 10% 10% diantaranyadiantaranya KEPKEP beratberat

* * SisanyaSisanya yang yang tidaktidak KEP KEP > > 50%50% BB BB saatsaatkeluarkeluar daridari rumahrumah sakitsakit

PasienPasien mengalamimengalami KEPKEP selamaselama perawatanperawatan didi

rumahrumah sakitsakit

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HOSPITAL MALNUTRITIONHOSPITAL MALNUTRITION

Di rumah sakit Cipto MangunkusumoDi rumah sakit Cipto Mangunkusumo::MMalnutrisi 40alnutrisi 40--60% (Simanjuntak,1985; Siagian, 1995; 60% (Simanjuntak,1985; Siagian, 1995; Witjaksono, 2000). Witjaksono, 2000).

Penelitian oleh mahasiswa tingkat V FKUI (2007) di Unit Penelitian oleh mahasiswa tingkat V FKUI (2007) di Unit Luka Bakar, di Departemen Bedah Saraf, dan Luka Bakar, di Departemen Bedah Saraf, dan Subdepartemen Bedah Digestif, menggunakan Subdepartemen Bedah Digestif, menggunakan instrumen SGA, IMT, kadar hemoglobin, hematokrit, dan instrumen SGA, IMT, kadar hemoglobin, hematokrit, dan albumin, menunjukkan prevalensi malnutrisi berturutalbumin, menunjukkan prevalensi malnutrisi berturut--turut sebesar 52%, 15%, 55%, 26%, dan 93% (Reza, turut sebesar 52%, 15%, 55%, 26%, dan 93% (Reza, dkk., 2007)dkk., 2007)

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HOSPITAL MALNUTRITION HOSPITAL MALNUTRITION (cont..)(cont..)

Hasil yang samHasil yang samaa di RSPAD Gatot Subroto (2001)di RSPAD Gatot Subroto (2001)::

AAngka malnutrisi pasien di ruang perawatan Penyakit ngka malnutrisi pasien di ruang perawatan Penyakit Dalam 41,42% (Diryanmed spesialistik, 2007)Dalam 41,42% (Diryanmed spesialistik, 2007)

Pengalaman dari negara majuPengalaman dari negara maju::

BBahwa ahwa hospital malnutrition hospital malnutrition problema yang problema yang kompleks dan dinamik kompleks dan dinamik keterpaduan dalam perawatanketerpaduan dalam perawatan

PPelayanan kesehatan yang paripurna tidak mungkin elayanan kesehatan yang paripurna tidak mungkin ditangani oleh satu kelompok keahlian saja.ditangani oleh satu kelompok keahlian saja.

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PELAYANAN NUTRISI PASIENPELAYANAN NUTRISI PASIEN

Pelayanan nutrisi Pelayanan nutrisi RSRS bukan hanya sekedar memberi bukan hanya sekedar memberi makan pasien dengan standar diet yang diolah oleh para makan pasien dengan standar diet yang diolah oleh para ahli masak, tetapi merupakan pelayanan yang ahli masak, tetapi merupakan pelayanan yang membutuhkan kualifikasi khusus dengan dasar membutuhkan kualifikasi khusus dengan dasar pengetahuan dan keterampilan kedokteran. pengetahuan dan keterampilan kedokteran.

Disamping itu, pelayanan nutrisi di Disamping itu, pelayanan nutrisi di RS RS dituntut mampu dituntut mampu mengenal masalah gizi pasien secara menyeluruh mengenal masalah gizi pasien secara menyeluruh sampai ke tingkat seluler serta mampu sampai ke tingkat seluler serta mampu menanggulanginya (Duperuis dkk., 2003; Schwartz & menanggulanginya (Duperuis dkk., 2003; Schwartz & Gudzin, 2003). Gudzin, 2003).

Hal ini menunjukkan bahwa untuk mengatasi masalah Hal ini menunjukkan bahwa untuk mengatasi masalah nutrisi pasien membutuhkan pelayanan nutrisi klinik oleh nutrisi pasien membutuhkan pelayanan nutrisi klinik oleh dokter dengan kompetensi khusus dokter dengan kompetensi khusus gizigizi klinik (klinik (Clinical Clinical Nutrition Specialist Physician).Nutrition Specialist Physician).

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DampakDampak negatifnegatif K E P K E P didi rumahrumah sakitsakit

ResikoResiko komplikasikomplikasi mortalitasmortalitas PengobatanPengobatan tidaktidak efektifefektif ProsesProses penyembuhanpenyembuhan terhambatterhambat waktuwaktu perawatanperawatan

lebihlebih lama lama biayabiaya WaktuWaktu Convalescence Convalescence lebihlebih lama lama

kualitaskualitas hiduphidup produktivitasproduktivitas kerjakerja

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KEP KEP pasienpasien didi rumahrumah sakitsakit masalahmasalah KompleksKompleks dandandinamikdinamik

PerluPerlu keterpaduanketerpaduan disiplindisiplin ilmuilmu dalamdalam perawatanperawatan

DefinisiDefinisi Ilmu Gizi :Ilmu Gizi :Prof.Dr. Prof.Dr. PoorwoPoorwo SoedarmoSoedarmoIlmu yang mempelajari hubungan makanan dan kesehatan

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KamusKamus GroliersGroliers InternasionalInternasional

Nutrition is the process of nourishing or being Nutrition is the process of nourishing or being nourished especially the interrelated steps by nourished especially the interrelated steps by which a living organism assimilates food and uses it which a living organism assimilates food and uses it for growth and for replacement of tissues for growth and for replacement of tissues

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IlmuIlmu Gizi Gizi kaitannyakaitannya dengan :dengan :

**PengetahuanPengetahuan bahanbahan makananmakanan / / makananmakanan

**PengetahuanPengetahuan kesehatankesehatan

hhMakanMakan memeliharamemelihara dan dan meningkatkanmeningkatkan

kesehatankesehatan

hhMakananMakanan penyembuhanpenyembuhan penyakitpenyakit

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DefinisiDefinisi ilmuilmu gizigizi klinikklinik (I.G.K.)(I.G.K.)American society for clinical nutrition (ASCN)American society for clinical nutrition (ASCN)

Clinical nutrition is a science that is concerned with Clinical nutrition is a science that is concerned with basic knowledge relating to the diagnosis and treatment basic knowledge relating to the diagnosis and treatment of diseases affecting the intake, absorption and of diseases affecting the intake, absorption and metabolism of dietary constituents, and to the promotion metabolism of dietary constituents, and to the promotion of health by prevention of diet related diseasesof health by prevention of diet related diseases

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IGK IGK mempunyaimempunyai dasardasar pengetahuanpengetahuan::

a.a. DiagnosisDiagnosis ilmuilmu dasardasarb.b. PengobatanPengobatan penyakitpenyakit kedokterankedokteranc.c. PengetahuanPengetahuan makananmakanan dan IBM dan IBM diluardiluar lingkuplingkup

ilmuilmu kedokterankedokteran

DasarDasar pengetahuanpengetahuan IGK IGK LintasLintas sektoralsektoral

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IGKIGK bagianbagian daridari ilmuilmu gizigizi, yang , yang melibatkanmelibatkanmetabolismemetabolisme tubuhtubuh untukuntuk mendukungmendukungpengobatanpengobatan gizigizi

MakananMakanan konvensionalkonvensional & non & non konvensionalkonvensional FungsiFungsi organ organ JenisJenis gangguangangguan fungsifungsi organ organ KemampuanKemampuan tubuhtubuh mencernamencerna, , mengabsorpsimengabsorpsi zatzat gizigizidandan zatzat lain lain dalamdalam makananmakanan

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LingkupLingkup IGKIGK

PathogenesisPathogenesisbased specializationbased specializationBukanBukan OrganOrganbased specializationbased specialization

-- KardiologiKardiologi-- GastroenterologiGastroenterologi-- NefrologiNefrologi

LingkupLingkup IGK IGK meliputimeliputi aspekaspek spesialisasispesialisasi IlmuIlmuKedokteranKedokteran lainnyalainnya,,

**NutrisiNutrisi dan dan hepatologihepatologi**NutrisiNutrisi dan dan penyakitpenyakit kardiovaskulerkardiovaskuler**NutrisiNutrisi dan dan nefrologinefrologi

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PengembanganPengembangan IGK IGK meliputimeliputi

KomposisiKomposisi tubuhtubuh

FaktorFaktor nutriennutrien dan nondan non--nutriennutrien dalamdalam makananmakanan

TraceTrace elementselements

Dan lainDan lain--lainlain

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LingkupLingkup spesialisasispesialisasi IGKIGK

A. Diagnosis A. Diagnosis gangguangangguan nutrisinutrisi dan dan metabolikmetabolik

* * AsupanAsupan makananmakanan, , nutriennutrien dandan estimasiestimasipengeluaranpengeluaran energienergi

* * PengukuranPengukuran komposisikomposisi tubuhtubuh* * PemeriksaanPemeriksaan biokimiabiokimia* * PenilaianPenilaian status status immunologiimmunologi

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B.B. PenangananPenanganan klinikklinik gangguangangguan nutrisinutrisi dan dan metabolismametabolisma

MultidisiplinMultidisiplin PelayananPelayananpasienpasien terpaduterpadu

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C.C. DukunganDukungan nutrisinutrisi dalamdalam menunjangmenunjang optimasioptimasikesembuhankesembuhan

MeliputiMeliputi : : * * BentukBentuk dukungandukungan nutrisinutrisi* * KomposisiKomposisi nutrisinutrisi* Cara * Cara pemberipemberi

EvaluasiEvaluasi

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NUTRITIONAL ASSESSMENTNUTRITIONAL ASSESSMENT

ANTROPOMETRIANTROPOMETRI

1.1. BMI (kg/mBMI (kg/m22

2.2. FFMI: FFM/BL (kg/mFFMI: FFM/BL (kg/m22) ) Bedridden patientBedridden patient

Cut off (the Copenhagen City Heart Study)Cut off (the Copenhagen City Heart Study)Low FFM: Low FFM: 14.62 kg/m2 and for 14.62 kg/m2 and for

17.05 kg/m217.05 kg/m2

SchollsScholls, et al, et al

Low FFM: Low FFM: 15 kg/m15 kg/m22

16 kg/m16 kg/m22

VestboVestbo, , et al. (2006). Am J et al. (2006). Am J RespirRespir CritCrit Care Med. 173: 79Care Med. 173: 79--8181

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TabelTabel 1 Model 4 1 Model 4 kompartemenkompartemen komposisikomposisi tubuhtubuh dengan dengan beberapabeberapa caracara pemeriksaannyapemeriksaannya

OsteoporosisOsteoporosisDEXA, CTDEXA, CTMassaMassa tulangtulang

DehidrasiDehidrasi, , gangguangangguandistribusidistribusi cairancairan tubuhtubuh

BIA, FTIRBIA, FTIRCairanCairan tubuhtubuh totaltotal

ObesitasObesitasA, BIA, DEXA, CT, A, BIA, DEXA, CT, MRIBIA, FTIRMRIBIA, FTIR

MassaMassa lemaklemak

KurangKurang energienergi protein, protein, stresstres katabolikkatabolik

A, BIA,TBC, A, BIA,TBC, IVNAA,DEXA, CTIVNAA,DEXA, CT

MassaMassa tanpatanpa lemak(FFMlemak(FFMatauatau LBM)LBM)

ContohContoh keadaankeadaan klinisklinisCara Cara pemeriksaanpemeriksaanKompartemenKompartemen tubuhtubuh

A= anthropornetry; BIA= bioelectrical impedance analysis; TBC=total body counting; IVNAA=invivo neutronactivation analysis; DEXA= dual energy x-ray absorptiometry; CT= computerized tomography; MRI= magnetic resonance imaging; FTIR=fourier transformed infra-Red spectromrtry; FFM= fat-free mass; LBM= lean body mass

Nutritional assessment

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Resorpsi tulang/Osteoporosis.Piridinolin urin, osteokalsin serum, Ntx, Ctx serum

Osteoporosis dan OsteomalaciaCa dan P serum dan urin, Alkali Fosfatase serum, vit D serum,

Defisiensi energi-protein, stres katabolisme

Status protein Dislipidemia Profil lipid serum

Gangguan pertumbuhan, defisiensi zinc

Status zinc Defisiensi asam folat, vit B6, B12Homosistein serum

Anemia defisiensi asam folat dan Vit B12

Status asam folat dan vitamin B12

Anemia defisiensi besiStatus zat besiGangguan Nutrisi/MetabolismePemeriksaan

Nutritional assessmentTabel-2: Beberapa pemeriksaan biokimia untuk

gangguan Nutrisi spesifik

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1.1. HitungHitung limfositlimfosit totaltotal2.2. DelayedDelayed typetype hypersensitivity testhypersensitivity test untukuntuk menilaimenilai PNIPNI3.3. PengecatanPengecatan limfositlimfosit dengan dengan metodemetode flowflow cytometrycytometry4.4. PengukuranPengukuran kapasitaskapasitas proliferasiproliferasi limfositlimfosit

Sistem Imun :

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Nutrition assessmentNutrition assessment

HaemostasisHaemostasisProthombinProthombin timetime Vitamin KVitamin KPlateletaggregationPlateletaggregation Vitamin E, ZnVitamin E, Zn

ReproductionReproductionSperm countSperm count Energy, ZnEnergy, Zn

Nerve functionNerve functionDark adaptationDark adaptation Vitamin A, E, ZnVitamin A, E, ZnColourColour discriminationdiscrimination Vitamin AVitamin ACentral Central scotomascotoma Vitamin AVitamin AOlfactory acuityOlfactory acuity Vitamin A, BVitamin A, B1212, Zn, ZnTaste acuityTaste acuity Vitamin A, ZnVitamin A, ZnNerve conductionNerve conduction P/E, vitamin BP/E, vitamin B11, B, B1212Skin conductivitySkin conductivity P/EP/EAbducensAbducens (VI cranial nerve) function(VI cranial nerve) function Vitamin BVitamin B11ElectroencephalographyElectroencephalography P/EP/ESleep patternSleep pattern P/EP/E

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Nutrition assessmentNutrition assessment

Work capacity Work capacity haemodynamicshaemodynamicsTask performance enduranceTask performance endurance P/E, vitamin BP/E, vitamin B11,B,B22, B, B66,Fe,FeVOVO2 2 max max P/E, FeP/E, FeVOVO2 2 submaxsubmax P/E, FeP/E, FeHeart rate (cumulative)Heart rate (cumulative) P/E, FeP/E, FeVasopressorVasopressor responseresponse Vitamin CVitamin C

UnclassifiedUnclassifieddd--UridineUridine suppression test suppression test Vitamin BVitamin B1212, folic acid, folic acid

P/E = proteinP/E = protein--energy energy nutriturenutriture

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Nutritional Nutritional assesmantassesmant of food sensitivityof food sensitivity1.1. Origin of belief*Origin of belief*2.2. Time courseTime course3.3. SymptomsSymptoms4.4. SeriousnessSeriousness5.5. Can it be managed by patient by simple exclusions?Can it be managed by patient by simple exclusions?6.6. Nutritional consequences of exclusionsNutritional consequences of exclusions7.7. Elimination dietElimination diet

Minimally allergenic foodsMinimally allergenic foodsElemental foodsElemental foods

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LanjutanLanjutan

Host Host defencedefenceLeukocyte Leukocyte chemotaxischemotaxis P/E, ZnP/E, ZnLeukocyte Leukocyte phagocyticphagocytic activityactivity P/E, FeP/E, FeLeukocyte bactericidal capacityLeukocyte bactericidal capacity P/E, Fe, SeP/E, Fe, SeLeukocyte Leukocyte metabolism(glycolysismetabolism(glycolysis-- P/EP/Eiodination, etc)iodination, etc)Serum Serum opsonicopsonic activityactivity P/EP/EWhite cell interferon productionWhite cell interferon production P/EP/ELymphocyte(TLymphocyte(T--cell) cell) blastogenesisblastogenesis P/E,ZnP/E,ZnDelayed Delayed cutaneouscutaneous hypersensitivity hypersensitivity P/E,ZnP/E,ZnRebuckRebuck skin windowskin window P/EP/E

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Problem evaluation and solvingProblem evaluation and solving

ObesityObesity Family history of obesityFamily history of obesity Lower Lower sosioeconomicsosioeconomic status, especially for status, especially for

womenwomen Recent change in personal or family Recent change in personal or family

circumstances (marriage, purchase of car, etc)circumstances (marriage, purchase of car, etc) Sedentary lifeSedentary life--stylestyle Preference for energyPreference for energy--dense foodsdense foods Alcohol abuseAlcohol abuse Need for oral satisfaction of psychological Need for oral satisfaction of psychological

needsneeds Low selfLow self--esteemesteem

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AtheroscleroticAtherosclerotic vascularvascular diseasedisease

Excess energy intakeExcess energy intake

Preference for foods whit a high saturated fat Preference for foods whit a high saturated fat and/or cholesterol contentand/or cholesterol content

Preference for sodiumPreference for sodium

Relative lack of Relative lack of dieterydietery--fibrefibre--richrich foodsfoods

Elevated serum cholesterol and/or triglyceride Elevated serum cholesterol and/or triglyceride and low serum high density lipoproteinand low serum high density lipoprotein

HypertensionHypertension


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NeoplasticNeoplastic disease (especially colorectal, breast, uterus, disease (especially colorectal, breast, uterus, respiratory tract and prostate)respiratory tract and prostate)

a.a. Excess energy intake Excess energy intake b.b. Excess fat intake Excess fat intake c.c. Preference for fat of animal origin Preference for fat of animal origin d.d. Low intake of vegetables and fruitsLow intake of vegetables and fruitse.e. Lack of dietaryLack of dietary--fibrefibre--rich foodrich foodf.f. Relative alcohol abuseRelative alcohol abuse

NonNon--insulininsulin--dependent diabetes mellitusdependent diabetes mellitus

a.a. Excess energy intake Excess energy intake b.b. Excess intake of concentrated refined carbohydratesExcess intake of concentrated refined carbohydratesc.c. Avoidance of vegetables and fruitsAvoidance of vegetables and fruitsd.d. Relative lack of dietaryRelative lack of dietary--fibrefibre--rich foodrich foode.e. Alcohol abuseAlcohol abuse


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Upper gastrointestinal Upper gastrointestinal haemorrhagehaemorrhage-- Alcohol abuseAlcohol abuse

Joint disease (gout and osteoarthritis)Joint disease (gout and osteoarthritis)

a.a. Excess energy intake with consequent obesityExcess energy intake with consequent obesity

b.b. Alcohol abuse with consequent Alcohol abuse with consequent hyperuricaemiahyperuricaemia

Urinary calculiUrinary calculi

a.a. InadequqteInadequqte water intake water intake

b.b. Alcohol abuseAlcohol abuse

c.c. High High purinepurine intake intake

d.d. Short bowel syndromeShort bowel syndrome

Dental cariesDental caries

a.a. Sucrose abuseSucrose abuse

b.b. SnackingSnacking


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OsteoporosisOsteoporosis1.1. Physical activityPhysical activity2.2. Nutrient intake :Nutrient intake :

Protein,CalciumProtein,Calcium, Phosphate, , Phosphate, Sodium, Copper, Vitamin C,Sodium, Copper, Vitamin C,

3.3. NonNon--nutrient intake :nutrient intake :CaffeineCaffeine

4.4. Other metabolic disease:Other metabolic disease:HomocystinuriaHomocystinuria

5.5. Presence of Presence of amenorrhoeaamenorrhoea6.6. History of pregnancy History of pregnancy


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ObesityObesity1.1. Evaluation of problemsEvaluation of problems2.2. Physical activityPhysical activity--past, present and potentialpast, present and potential3.3. Adiposity (BMI)Adiposity (BMI)4.4. Body fat distribution Body fat distribution abdominal, hipabdominal, hip5.5. Food and beverage intake patternFood and beverage intake pattern6.6. Eating circumstancesEating circumstances7.7. Knowledge of food Knowledge of food 8.8. -- Energy densityEnergy density9.9. -- NutrienNutrien densitydensity10.10. Reasons for wanting to lose weightReasons for wanting to lose weight11.11. Consideration of nonConsideration of non--weight outcomes weight outcomes 12.12. WellWell--being, body composition, fitness, reduction in being, body composition, fitness, reduction in

chronic disease riskchronic disease risk13.13. LongLong--term commitmentterm commitment


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DiabetesDiabetes1.1. ObesityObesity2.2. Level of physical activityLevel of physical activity3.3. Plant food intake Plant food intake 4.4. Fat intake Fat intake 5.5. Distribution of food intakeDistribution of food intake


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HypertensionHypertension ObesityObesity Sodium intake Sodium intake Discretionary (about oneDiscretionary (about one--third in developed third in developed

contriescontries)) Processed food (about twoProcessed food (about two--thirds in developed thirds in developed

contriescontries)) Intake of potassium, Intake of potassium, calsiumcalsium, magnesium, magnesium Alcohol intakeAlcohol intake Plant food intakePlant food intake


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MalabsorptionMalabsorption1.1. CauseCause2.2. Energy balance Energy balance 3.3. Nitrogen balanceNitrogen balance4.4. Micronutrient status :Micronutrient status :

-- FolateFolate, vitamin B, vitamin B1212-- Vitamin A, D, E, KVitamin A, D, E, K-- Iron, zincIron, zinc

5.5. Essential fatty acidsEssential fatty acids


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HyperlipidaemiaHyperlipidaemia1.1. ObesityObesity2.2. AlcoholAlcohol3.3. Dietary fat intake :Dietary fat intake :

-- SaturatedSaturated-- PolyunsaturatedPolyunsaturated-- omega 6/ omega 3omega 6/ omega 3-- cholesterolcholesterol

4.4. Plant food intake :Plant food intake :-- LegumesLegumes-- WholeWhole--Grain cereals (oats)Grain cereals (oats)-- PectinPectin-- containing fruits (papaya, citrus)containing fruits (papaya, citrus)-- SaponinSaponin-- containing vegetables (chickcontaining vegetables (chick--peas, peas, etc)etc)


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5.5. Physical activityPhysical activity

6.6. Exclude secondary cause :Exclude secondary cause :

HypothyroidismHypothyroidism

DiabetesDiabetes

Renal diseaseRenal disease

Primary Primary biliarybiliary cirrhosiscirrhosis

AutoAuto--immune disease immune disease

DrugsDrugs

HyperlipidaemiaHyperlipidaemia ((lanjutanlanjutan))

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