Kuliah Ilmu gizi materi gizi klinik.pdf

Gizi klinik

1. Pendahuluan IImu Gizi Klinik

UNIVERSIIAS
JNIDSCEN SIA,

Dr. Sri Sukmaniah MSc, SpGK
Departemen llmu Gizi, FKUI

2. IImu Gizi Klinik

Pendahuluan

+ Peta kesehatan di indonesia > gangguan nutrisi
salah satu masalah kesehatan utama

« Prevalensi Malnutrisi pasien rawat inap 4
+ Survei di Amerika :
* 50 % pasien yang akan dirawat > sudah KEP >
10% diantaranya KEP berat
* Sisanya yang tidak KEP >> 50% BB | saat
keluar dari rumah sakit

Pasien mengalami KEP selama perawatan di
rumah sakit

3. HOSPITAL MALNUTRITION

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

Q Penelitian oleh mahasiswa tingkat V FKUI (2007) di Unit

Luka Bakar, di Departemen Bedah Saraf, dan
Subdepartemen Bedah Digestif, menggunakan
instrumen SGA, IMT, kadar hemoglobin, hematokrit, dan
albumin, menunjukkan prevalensi malnutrisi berturut-
ee xO 52%, 15%, 55%, 26%, dan 93% (Reza,

2)

4. HOSPITAL MALNUTRITION cont.)

a Hasil yang sama di RSPAD Gatot Subroto (2001):
Angka malnutrisi pasien di ruang perawatan Penyakit
Dalam 41,42% (Diryanmed spesialistik, 2007)

a Pengalaman dari negara maju:

Bahwa hospital malnutrition > problema yang
kompleks dan dinamik — keterpaduan dalam perawatan

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

5. PELAYANAN NUTRISI PASIEN

a Pelayanan nutrisi RS bukan hanya sekedar memberi
makan pasien dengan standar diet yang diolah oleh para
ahli an merupakan pelayanan yang
membutuhkan kualifikasi khusus dengan dasar

pengetahuan dan keterampilan kedokteran.
a Pei itu, pelayanan nutrisi di RS dituntut mampu

mengenal masalah gizi pasien secara menyeluruh
sampai ke tingkat seluler serta Denen
menanggulanginya (Duperuis dkk., 2003; Schwartz &
Gudzin, 2003).

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

6-May-09

6. Dampak negatif K E P di rumah sakit

Resiko komplikasi À > mortalitas À

Pengobatan tidak efektif

Proses penyembuhan terhambat > waktu perawatan
lebih lama > biaya 4

Waktu Convalescence lebih lama >

kualitas hidup Y > produktivitas kerja Y

7. KEP pasien di rumah sakit >masalah Kompleks dan
dinamik

y
Perlu keterpaduan disiplin ilmu dalam perawatan

Definisi IImu Gizi :
Prof.Dr. Poorwo Soedarmo
IImu yang mempelajari hubungan makanan dan

kesehatan

8. Kamus Groliers Internasional

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

9. Ilmu Gizi kaitannya dengan :

*Pengetahuan bahan makanan / makanan

*Pengetahuan kesehatan >
* Makan > memelihara dan meningkatkan
kesehatan
* Makanan > penyembuhan penyakit

10. Definisi ilmu gizi klinik (1.G.K.)

American society for clinical nutrition (ASCN)

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

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11. IGK mempunyai dasar pengetahuan:

Diagnosis } ilmu dasar
Pengobatan penyakit kedokteran

Pengetahuan makanan dan IBM > diluar lingkup
ilmu kedokteran

y
Dasar pengetahuan IGK > Lintas sektoral
y

12. |

IGK> bagian dari ilmu gizi, yang melibatkan
metabolisme tubuh untuk mendukung
pengobatan gizi

> Makanan konvensional & non konvensional

> Fungsi organ

> Jenis gangguan fungsi organ

> Kemampuan tubuh mencerna, mengabsorpsi zat gizi
dan zat lain dalam makanan

13. Lingkup IGK

“Pathogenesis-based specialization”
Bukan “Organ-based specialization”

- Kardiologi
- Gastroenterologi
- Nefrologi

Lingkup IGK meliputi aspek spesialisasi llmu
Kedokteran lainnya,
*Nutrisi dan hepatologi
*Nutrisi dan penyakit kardiovaskuler
*Nutrisi dan nefrologi

14. Pengembangan IGK meliputi

Komposisi tubuh

Faktor nutrien dan non-nutrien dalam makanan
Trace elements

Dan lain-lain

15. Lingkup spesialisasi IGK

A. Diagnosis gangguan nutrisi dan metabolik

* Asupan makanan, nutrien dan estimasi
pengeluaran energi

* Pengukuran komposisi tubuh

* Pemeriksaan biokimia

* Penilaian status immunologi

16. Penanganan klinik gangguan nutrisi dan
metabolisma

y
Multidisiplin Pelayanan

pasien terpadu

17. Dukungan nutrisi dalam menunjang optimasi
kesembuhan

y
Meliputi :

* Bentuk dukungan nutrisi
* Komposisi nutrisi
* Cara pemberi

Evaluasi

18. NUTRITIONAL ASSESSMENT

ANTROPOMETRI
1. BMI (kg/m?
2. FFMI: FFM/BL (kg/m?) > Bedridden patient

Cut off (the Copenhagen City Heart Study)
Low FFM: © 14.62 kg/m2 and for
3 17.05 kg/m2
Scholls, et al
Low FFM: © 15 kg/m?
3 16 kg/m?

Vestbo, et al. (2006). Am J Respir Crit Care Med. 173: 79-81

19. Nutritional assessment

Tabel 1 Model 4 kompartemen komposisi tubuh dengan
beberapa cara pemeriksaannya

Kompartemen tubuh Cara pemeriksaan Contoh keadaan klinis

Massa tanpa lemak(FFM A, BIA,TBC, Kurang energi protein,
atau LBM) IVNAA,DEXA, CT stres katabolik

Massa lemak A, BIA, DEXA, CT, Obesitas
MRIBIA, FTIR

Cairan tubuh total BIA, FTIR Dehidrasi, gangguan
distribusi cairan tubuh

Massa tulang DEXA, CT Osteoporosis

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

6-May-09

20. Nutritional assessment
Tabel-2: Beberapa pemeriksaan biokimia untuk

gangguan Nutrisi spesifik

Status zat besi

Anemia defisiensi besi

Status asam folat dan vitamin B;,

Anemia defisiensi asam folat dan Vit
Bio

Homosistein serum

Defisiensi asam folat, vit B¿ By»

Status zinc

Gangguan pertumbuhan, defisiensi
zinc

Profil lipid serum

Dislipidemia

Status protein

Defisiensi energi-protein, stres
katabolisme

Ca dan P serum dan urin, Alkali
Fosfatase serum, vit D serum,

Osteoporosis dan Osteomalacia

Piridinolin urin, osteokalsin serum,
Ntx, Ctx serum

Resorpsi tulang/Osteoporosis.

6-May-09

21. Sistem Imun :

Hitung limfosit total
Delayed type hypersensitivity test > untuk menilai PNI

Pengecatan limfosit dengan metode flow cytometry
Pengukuran kapasitas proliferasi limfosit

22. Nutrition assessment

Haemostasis

Prothombin time Vitamin K

Plateletaggregation Vitamin E, Zn
Reproduction

Sperm count Energy, Zn
Nerve function

Dark adaptation Vitamin A, E, Zn

Colour discrimination Vitamin A

Central scotoma Vitamin A
Olfactory acuity Vitamin A,B,,, Zn
Taste acuity Vitamin A, Zn
Nerve conduction P/E, vitamin B,, B,,
Skin conductivity P/E

Abducens (VI cranial nerve) function Vitamin B,
Electroencephalography P/E

Sleep pattern

6-May-09

23. Nutrition assessment

Work capacity haemodynamics
Task performance endurance
VO, max
VO, submax
Heart rate (cumulative),
Vasopressor response

Unclassified
d-Uridine suppression test

P/E = protein-energy nutriture

P/E, vitamin B,,B,, B¿,Fe
P/E re

P/E, Fe

P/E, Fe

Vitamin C

Vitamin By, folic acid

24. Nutritional assesmant of food sensitivity
Origin of belief*
Time course
Symptoms
Seriousness

Can it be managed by patient by simple exclusions?
Nutritional consequences of exclusions

Elimination diet

Minimally allergenic foods

Elemental foods

25. Host defence
Leukocyte chemotaxis
Leukocyte phagocytic activity
Leukocyte bactericidal capacity
Leukocyte metabolism(glycolysis-

iodination, etc)

Serum opsonic activity

White cell interferon production
Lymphocyte(T-cell) blastogenesis
Delayed cutaneous hypersensitivity
Rebuck skin window

26. Problem evaluation and solving

Obesity
= Family history of obesity
Lower sosioeconomic status, especially for
women

Recent change in personal or family
circumstances (marriage, purchase of car, etc)

Sedentary life-style
Preference for energy-dense foods
Alcohol abuse

Need for oral satisfaction of psychological
needs

Low self-esteem

27. Problem evaluation and solving

Atherosclerotic vascular disease
Excess energy intake

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

Preference for sodium

Relative lack of dietery-fibre-rich foods
Elevated serum cholesterol and/or triglyceride
and low serum high density lipoprotein

Hypertension

28. Problem evaluation and solving

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

Excess energy intake

Excess fat intake

Preference for fat of animal origin
Low intake of vegetables and fruits
Lack of dietary-fibre-rich food
Relative alcohol abuse

Non-insulin-dependent diabetes mellitus

Excess energy intake

Excess intake of concentrated refined carbohydrates
Avoidance of vegetables and fruits

Relative lack of dietary-fibre-rich food

Alcohol abuse

29. Problem evaluation and solving

Upper gastrointestinal haemorrhage
- Alcohol abuse

Joint disease (gout and osteoarthritis)

a. Excess energy intake with consequent obesity
b. Alcohol abuse with consequent hyperuricaemia
Urinary calculi

a. Inadequqte water intake
b. Alcohol abuse

ce. High purine intake

d. Short bowel syndrome
Dental caries

a Sucrose abuse

b. Snacking

30. Problem evaluation and solving

Osteoporosis

is
a:

Physical activity

Nutrient intake :
Protein,Calcium, Phosphate,
Sodium, Copper, Vitamin C,
Non-nutrient intake :
Caffeine

Other metabolic disease:
Homocystinuria

Presence of amenorrhoea
History of pregnancy

31. Problem evaluation and solving

Obesity
Evaluation of problems
Physical activity-past, present and potential
Adiposity (BMI)
Body fat distribution — abdominal, hip
Food and beverage intake pattern
Eating circumstances
Knowledge of food
- Energy density
- Nutrien density
Reasons for wanting to lose weight
Consideration of non-weight outcomes
Well-being, body composition, fitness, reduction in
chronic disease risk

Long-term commitment

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32. Problem evaluation and solving

Diabetes
1. Obesity
Level of physical activity
Plant food intake
Fat intake
Distribution of food intake

33. Problem evaluation and solving

Hypertension
Obesity
Sodium intake

Discretionary (about one-third in developed
contries)

Processed food (about two-thirds in developed
contries)

Intake of potassium, calsium, magnesium
Alcohol intake
Plant food intake

34. Problem evaluation and solving

Malabsorption

1. Cause

2. Energy balance
3. Nitrogen balance
4.

Micronutrient status :
- Folate, vitamin B;,
- Vitamin A, D, E, K
- Iron, zinc

Essential fatty acids

35. Problem evaluation and solving

errr
Obesity
Alcohol
Dietary fat intake :
- Saturated
- Polyunsaturated- omega 6/ omega 3

- cholesterol

Plant food intake :

- Legumes

- Whole-Grain cereals (oats)

- Pectin- containing fruits (papaya, citrus)

- Saponin- containing vegetables (chick-peas,
etc)

36. Hyperlipidaemia (tanjutan)

5. Physical activity

6. Exclude secondary cause :
Hypothyroidism
Diabetes
Renal disease
Primary biliary cirrhosis
Auto-immune disease
Drugs