APLIKASI 21 MACAM DIET DIABETES HASIL

PENELITIAN DAN PENGALAMAN KLINIK

SEJAK 1978

Askandar Tjokroprawiro, Sri Murtiwi

Pusat Diabetes dan Nutrisi Surabaya
RSUD Dr. Soetomo-Fakultas Kedokteran Universitas Airlangga
Jember 23 April 2017
 Goal of Medical Nutrition Therapy
ADA-2014

1. To promote and support healthful 5. Maintain the pleasure of eating by

eating patterns. To attain providing positive message
o A1c <7%
o Blood pressure < 140/80 mmHg
6. Provide the person with diabetes
o LDL < 100 mg/dl
with practical tools for day to
o HDL > 40 for men > 50 mg/dl women
day meal planning

2. Achieve and maintain body

MNT has reported decreases
weight goals
o A1c 1% (type1 DM)
o A1c 1-2% (type2 DM)
3. Delay and prevent complications o LDL by 15-25 mg/dl

4. Address individual nutrition need

based on personal and cultural
preferences
 History of the B-Diet

• Before 1978, Dr. Soetomo Hospital used to apply the diet that was
basically Western in type for diabetic patients (A-Diet), but it did not suit
the eating habits of Indonesian people.

• Askandar Tjokroprawiro conducted a research on diabetic diet adapted

to the eating habits of Indonesian people (B-diet)

• A comparative study using a crossover design was carried out on 200

OAD-treated and 60 insulin-treated outpatients. The A-diet and the B-
diet were maintained isocalorically during the study

Askandar Tjokroprawiro Doctoral Program 1978

 Basic compositions of the A-diet and the B–diet
Askandar Tjokroprawiro, 1978

the A-diet the B-diet *)

• Calories • Isocaloric isocaloric
• Carbohydrate • 50% 68%
• Protein • 20% 12 %
• Fat • 30% 20%
• P:S ratio • ±0.6 ±1.0
• Average cholesterol • 500 mg 300 mg
daily intake
• Fiber • 6% vegetable 9 % vegetable
(25-35 g/day)
• Meal frequency • 3 meals equidistance 6 meals
• Distribution of meal • 30%,40%,30% 20%,10%,25%,
10%, 25%, 10%

*) Disertation-1978 (the B-Diet as The Mother-Diet

ASK-SDNC
 The result of the study showed

• The fasting blood sugar (FBS) value remained the same in both
diets.
• The two -hour post breakfast blood sugar (PBBS) level was of
anything a little bit lower in the B-diet.
• The serum cholesterol level fell in the B-diet, while the serum TG
levels were the same either in the A-diet or in B-diet.
• The socio-economic analysis was in favour of the B-diet

Conclusions : Although the B-diet was high in CHO, there was no

increase of glucose and TG levels
 The Diet-B 1978 (Revised-2002) : The Mother - Diet
Prospective Study (1978) and Clinical Experiences
(Tjokroprawiro 1978-2016)

1 Diet-B*) : The Mother-Diet (1978) 11 Diet-KV : for CVD (1999)

2 Diet-B Fasting (Ramadhan) (1978) 12 Diet-GL (2000)
3 Diet-B1 (60% Cbh, 20% P, 20% L) (1980) 13 Diet-H (Hepar) (2001)
4 Diet-B1 Fasting (Ramadhan) (1980) 14 Diet KV-T1 (2004)
15 Diet KV-T2 For (2004)
5 Diet-B2** ) : DN(CKD)-Stage 2 (1982)
16 Diet KV-T3 Pre GDM (2004)
6 Diet-B3** ) : DN(CKD)-St 3 & 4 (1983)
17 Diet KV-L (2004)
7 Diet-Be** ) : REGULAR HD (1983) 18 Diet B1-T1 (2004)
8 Diet-M (Malnutrisi) (1989) 19 Diet B1-T2 For (2004)
9 Diet-M Fasting (Ramadhan) (1989) 20 Diet B1-T3 GDM (2004)
10 Diet-G*** ) : for Gangrene (1999) 21 Diet B1-L (2004)
From the End of the First Trimester with 2 g Myo-inositol plus 200 g Folic Acid Twice a day:
Myo-Inositol Supplementation in Pregnant Women with a Family History of T2DM may Reduce GDM
Incidence and the Delivery of Macrosomia Fetuses. (D’Anna, et al – Diabetes Care 36:854, 2013)
*) Diet-B : 68% CHO 12% Protein 20% FATs Prospective-Cross Over Design (1978)
SAFA 5% PUFA 5% PS = 1.0 MUFA 10% Chol. <300 mg/day Fiber 25-35 g/day
DN : Diabetic Nephropathy CKD : Chronic Kidney Disease CVD : Cardio Vascular Disease
ASK-SDNC (GDM : Gestational Diabetes Mellitus)
How to practice the medical nutrition
therapy in dr. Soetomo Hospital

Askandar Tjokroprawiro Guidelines

2 steps for meal planning

1. Select the right composition (out of the 21 diabetic diets)

2. Calculate daily calorie intake
 Calculation of Energy Intake
Askandar Tjokroprawiro, 1978-2016

RBW = Relative Body Weight BMI = Body Mass Index

BW BW in kg
X 100 % BMI =
H - 100 (H)2

Under nutrition < 80 % Underweight < 18.5

Under Weight < 90 %
Normal 18.5 – 22.9
Normal 90 – 100 %
Overweight > 110% Overweight > 23
Obesity mild 120 - 130 % at Risk 23 – 24.9
Intermediate 130 - 140 %
Obese I 25 – 29.9
Severe > 140 %
Morbid > 200 % Obese II > 30

Under weight BW x 40 – 60 Kcal

Pregnant TM I = (H-100)x30 +100
Normal BW x 30 Kcal TM II = (H-100)x30 +200
Over weight BW x 20 Kcal TM III = (H-100)x30 +300
Lactation = (H-100)x30 +400
Obesity BW x 10 – 15 Kcal
ASK-SDNC
 Distribution Energy Intake & Schedule
Askandar Tjokroprawiro, 1978-2016

At. 06.30 Breakfast 20% Kcal. Fasting Month/ Ramadhan Formula 4.3.1
At. 09.30 Snack 10% Kcal.
At. 12.30 Lunch 25% Kcal. At. 18.00 (30% Kcal) : Main Course I

At. 15.30 Snack 10% Kcal. At. 20.00 (25%Kcal) : Main Course II

At. 18.30 Dinner 25% Kcal. At. 21.00 (10%Kcal) : Snack

At. 21.30 Snack 10% Kcal. At. 03.00 am (25%Kcal) : Main Course III

3J
J1 = Jumlah (Amount of Energy Intake)
J2 = Jenis (Kind of Food)
J3 = Jadual (Schedule )
ASK-SDNC
The Indonesian Moslems Fast During Ramadhan Month
Askandar Tjokroprawiro Guidelines, 2016

• Diabetisi on diet and or OAD with the glucose level 1 hour post prandial <
200 mg/dL safe on fasting

• In clinical practice on insulin injection (basal-bolus) with blood glucose level

< 300mg/dL , basal insulin 2/3 dose at fast-break, rapid acting insulin before
Tarawih and Sahur (2/3 dose) (Fomula 4.3.1)

• Combination therapy OAD + insulin : basal insulin on fast-break (2/3 dose),

OAD at fast-break and Tarawih exception gliptin group can be given at Sahur
(Formula 4.3.1)

• Don’t give strong hypoglycemia agent on Sahur, exercise can be done after
Tarawih
 RAMADHAN−DIET (DIET−4.3.1) Plus FORMULA 2/3
RAMADHAN−DIET (DIET−4.3.1) : DIETETIC REGIMEN DURING RAMADHAN
Insulin and OAD Doses : 2/3 of Its Previous Ones
(Clinical Experiences, as Observed in Daily Practice, Surabaya 2010-2016)

A
A During Fasting Month/Ramadhan: There are 4 Meals

which consist of 3 Main Meals and 1 Snack

B
B The 3 Main Meals : FAST-BREAKING, TARAWIH, SAHUR

1. The First Main Meals : FAST-BREAKING (Buka Puasa)

2. The Second Main Meals : TARAWIH
3. The Third Main Meal : SAHUR
C
C The Only 1 Snack : BEFORE SLEEP
Insulin Dose During Fasting : 2/3 from Usual, and Injected at Fast-Breaking
ASK-SDNC
 COMPOSITION AND INDICATIONS
(Summarized : Tjokroprawiro 1978-2016)
1 B-Diet ,1978
• 68% CHO, 12% Protein, 20% Fat
• Low-moderate economic status
• Hunger to their diet
• Cardiovascular complication
• DM > 5 yrs
•  Cholesterol level
2 B-Fasting Diet,1978
Formula 4.3.1
3 B1-Diet,1980
• 60% CHO, 20% Protein, 20% Fat
• Used to high protein diet
• Youth with diabetes
• Under weight
• Fracture, TBC, Surgery
• Grave’s disease
• Malignancy
ASK-SDNC
4 B1-Fasting Diet,1980
Formula 4.3.1
Diabetic Nephropathy Diet,1982,1983
5 B2-Diet : Pra-HD
High calorie, low protein 0,6 gr/kg BW
6 B3-Diet : Pra-HD
• High calorie, low protein 0,8 gr/kg BW
• Indication : -  Protein Loss
-  Catabolism
7 Be-Diet : HD
• High calorie, low protein 1 gr/kg BW
• Indication : end stage renal failure on
hemodialysis (HD)
• High calorie : 2100-2300 kcal
 COMPOSITION AND INDICATIONS
(Summarized : Tjokroprawiro 1978-2016)
8 M-Diet (Malnutrition),1989 12 GL-Diet (Sugar Diet), 2000

• CHO 55%, Protein 25%, Fat 20% • 30 gr sugar: GL1, GL3, GL5
• Cholesterol < 300mg/dl • 15 gr sugar: GL2, GL4, GL6
• Indication : MRDM • Indication : Severe Renal Failure
+ SRMD
9 13 H-Diet (Hepar), 2001
M-Fasting Diet, 1989
Formula 4.3.1 •G-Diet
Pregnant & Lactation Diet, 2004

Vascular Complications,1999 • Pregestational (KV-Diet)

14 - KV-T1 = TM I
10 G-Diet (Gangren) 15 - KV-T2 = TM II
16 - KV-T3 = TM III
 B1-diet rich in arginin
Folic acid, B6, B12 vitamins 17 - KV-L = Lactation
• Gestational DM (B1-Diet)
11 KV-Diet (Kardiovaskuler) 18 - B1 – T1 = TM I
 B-diet rich in arginin 19 - B1 – T2 = TM II
Folic acid, B6, B12 vitamins 20 - B1 – T3 = TM III
ASK-SDNC
21 - B1 – L = Lactation
 Medical Nutritional Therapy for DM in Pregnancy
SDNC (Surabaya Diabetes and Nutrition Centre)-Clinical Experiences
(Summarized : Tjokroprawiro, Indrawati, Frieda et al 1999-2016)

TRIMESTER Additional
LACTATION Diet-KV for PGDM Diet-B1 for GDM Calories (AC)
1st TRIMESTER KV-T1 B1 -T1 100 Kcal

2nd TRIMESTER KV-T2 B1 -T2 200 Kcal

3rd TRIMESTER KV-T3 B1 -T3 300 Kcal

LACTATION KV-L B1 -L 400 Kcal

PDGM : PreGestational Diabetes Mellitus KV-T1: Prescribed KV-Diet plus 100 Kcal B1-T1: Prescribed B1-Diet plus 100 Kcal

From the End of the First Trimester with 2 g Myo-inositol plus 200 g Folic Acid Twice a Day: Myo-
Inositol Supplementation in Pregnant Women with a Family History of T2DM may Reduce GDM
Incidence and the Delivery of Macrosomia Fetuses. (D’Anna, et al – Diabetes Care 36:854, 2013)
ASK-SDNC
Myo-inositol is a member of the B Vitamins (Vit.B8)
and a component of the cell membrane

Founded in : fruit (oranges), Beans, Grains, Nuts

Function in Insulin Signal Tranduction

D’Anna R et al., Diabetes Care 2013, 36 (4) :854-857

 Pregnant Outpatients with
the Family History T2DM
The end of the 1st trimester

Myo-inositol 200 mg + 200 ug folic acid Placebo :Folic acid 200 ug

n=110 N=110

GDM 6% GDM 15.3%

P=0.04

Conclusions :Myo-inositol supplementation in pregnant

women with a family history of T2DM may reduced GDM
incidence and delivery of macrosomia fetuses
D’Anna R et al., Diabetes Care 2013, 36 (4) :854-857
RELATION OF THE INSULIN PATHWAY TO PHOSPHATIDYLINOSITOL
Coustan DR. Diabetes Care 2013, 36:777-778
 COCOA FLAVONOIDS
Martin MA et al.,
Molecular Nutrition and Diabetes
http://dx.doi.org/10.1016/B978-0-12.801585.8.00015-4

Cocoa powder is rich source of Cocoa mainly contains high

Fiber (26-40%) amounts of flavanols:
Protein (15-20%) Epicatechin (EP)
CHO (about 15%) Catechin
Lipid (10-24%), Vitamins and minerals Procyanidins B2and B1

In a randomized crossover trial, healthy volunteers were given either flavanol rich
dark chocolate (100 g/day)
White chocolate (100 g/day) for 15 days
Ingestion dark chocolate significantly : lower insulin resistance (HOMA -IR)
Increase insulin sensitivity (ISI)

Similar result on hypertensive subject with or without glucose intolerance

Dark chocolate : decreased HOMA-IR, increased insulin sensitivity and increased β-cells
function compared to white chocolate
 In a longer study , overweight and obese
adults that consumed a high-flavanol cocoa
(902 mg flavanols/day) for 12 weaks
significantly improved insulin sensitivity
compared with low flavanol cocoa

Davidson K et al., Int J Obes (Lond) 2008;32:1289-1296

MOLECULAR MECHANISM OF ACTION OF COCOA AND ITS FLAVANOLS
Main Source: Martin et al 2016, Other Journals : Vazquez-Prieto et al 2012, Yamashita et al
2012, Cordero-Herrera et al 2013, Fernandez-Millan et al 2014, Provided : Tjokroprawiro 2016

 IR, IRS-2, AKT, AMPK, IRS-1, GLUT-2

 PEPCK, GLUCOSE PRODUCTION
 PKC, IKK, JNK, PTP1B  IR, IRS-1, IRS-2, AKT, AMPK, GLUT-4
 PPAR-  PKC, IKK, JNK, PTP1B,  PPAR-, ERK, IL-6
 ADIPONECTIN

COCOA FLAVANOLS:
Catechin, Epicatechin,
LIVER Procyanidins WHITE ADIPOSE TISSUE (WAT)

 Insulin Secretion
 -Cell Survival

 GLUT-4 and TRANSLOCATION

SKELETAL MUSCLE PANCREAS

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 SUMMARY

• There are 20 variation of the B-diet, thus up to now 21 diabetic

diets totally available at Dr. Soetomo Hospital Surabaya

• Indications of each type of diet are based on metabolic findings

and clinical complications and or situations (kidney, liver,
cardiovascular risks, diabetic ulcers, pregnancy, etc)

• Supplementation of myo-inositol (grain, bean, nuts, etc), onion,

tomato, grapes, and cocoa flavonoids are recommended
Surabaya Diabetes and Nutrition Center Staffs, 2016