Fuadiyah Nila K., S.Gz , MPH Leny Budhi Harti , S.Gz Jurusan Gizi FKUB

Basic Carbohydrate

CountingFuadiyah Nila K., S.Gz, MPH

Leny Budhi Harti, S.GzJurusan Gizi FKUB

Diet Diabetes Mellitus

Nutrition Care Process (ADA,2003)

Relationship between

Patients/client/group and

Dietetics Professional

Nutrition assessment • obtain/collect timely and appropriate data• analyze/interpret with evidence-based standards• document

Nutrition diagnosis • identify & label

problem• determine cause/

contributing risk factors

• cluster signs & symptoms/ defining

characteristics• document

Nutrition interventions

• plan nutrition Intervention

- Formulate goals & determine

a plan of action• implement nutrition

intervention- Care is delivered & actions are carried out

• document

Nutriton monitoring & Evaluation • monitor progress• measure outcome indicators• Evaluate outcomes• document

Practice Settings

Social Systems

Econ

om

ics

Healt

h C

are

S

yste

ms

Code

of E

thics Skills &

competencies

Dietetics Knowledge

Communication Collaboration

Cri

tical Th

inkin

g

Evid

en

ce-b

ased

P

racti

ce

XAsuhan Gizi Standard-Sosio Kulture- Ekonomi Keluarga- Kebiasaan

Asuhan Gizi Individual

Nutritional Care Process

XPantang Makanan Pengaturan Diet

Lena has been overweight for a few years. She is 52 years old, and she found out that she has type 2 diabetes 1 year ago. She has been seeing a doctor at her physician’s office for nutrition information, and the doctor has referred her to a registered dietitian (RD) in the outpatient clinic at the nearby hospital.

Kulkarni, KD.Clin. Diabetes 23: 120 - 122

Lena brings her food records to her initial visit with the RD. The RD reviews the records, which consist only of Lena’s food choices with no portion sizes or amounts consumed listed. The RD recommends that Lena consider weighing and measuring her portion sizes andwriting them down along with her food choices. The RD provides Lena with a copy of the American Diabetes Association (ADA) basic carbohydrate counting pamphlet1 and uses food models to demonstrate appropriate portions of the foods Lena might select.

Kulkarni, KD.Clin. Diabetes 23: 120 - 122

Content :

1. Definition of carbohydrate counting

2. Level of carbohydrate counting3. Indication of using carbohydrate

counting4. Why should people with diabetes

use carbohydrate counting????5. Steps to count carbohydrate

counting

Definition of carbohydrate counting

Carbohydrate counting is a meal-planning approach and not a specific diet

It places emphasis on the total amount of carbohydrate consumed, rather than on the source or type of carbohydrate consumed

Kulkarni, KD.Clin. Diabetes 23: 120 - 122

Level of carbohydrate counting

Carbohydrate countingBasic Advance

understanding the relationship among food, physical activity, and blood glucose levels

includes understanding

pattern management and

how to use insulin-to-carbohydrate

ratios

Kulkarni, KD.Clin. Diabetes 23: 120 - 122

introduces patient to the concept of

carbohydrate counting and for

carbohydrate consistency

Level of carbohydrate counting

Carbohydrate counting

Level 1 Level 2 Level 3

Chiesa, G, et al. Acta Biomed 2005; 76; suppl. 3 : 44-48

Focuses on the relationships among food,

diabetes medication,

physical activity and blood glucose

level and

Level of carbohydrate counting

Carbohydrate counting

Level 1 Level 2 Level 3

Chiesa, G, et al. Acta Biomed 2005; 76; suppl. 3 : 44-48

how to match short-acting insulin to

carbohydrate using

carbohydrate-to- insulinratios.

Level of carbohydrate counting

Carbohydrate counting

Level 1 Level 2 Level 3

Chiesa, G, et al. Acta Biomed 2005; 76; suppl. 3 : 44-48

Level 1 / Basic CarbingGoals

61. Carbohydrate Counting: Getting Started, The American Diabetes Association and The American Dietetic Association, 1995. 2. Practical Carbohydrate Counting, American Diabetes Association, 2001. 3. Using Carbohydrate Counting in Clinical Practice, JADA, 1988, v98, n8

• Regulate blood glucose by balancing carbohydrate intake with the diabetes medication and physical activity

• Achieve and maintain consistency of carbohydrate intake at meals and snacks at similar times each day

• Eating similar amounts of carb foods at each meal or snack helps “even out” the ups-and-downs in your blood glucose level.

Who Can Use Carbing

Carbohydrate counting can be used by anyone with diabetes, not just people taking insulin

Why Should People with Diabetes Use Carbohydarte Counting????

Food contains many nutrients such as

1. Macronutrients : carbohydrate, protein, and fat

2. Micronutrients : vitamins and minerals

Why Should People with Diabetes Use Carbohydarte Counting????

In fact, 90-100 % of the carb you eat appears in your bloodstream as blood glucose within a few hours after you have eaten.

Protein and fat have much less effect on your blood glucose

Why Should People with Diabetes Use Carbohydarte Counting????

Bolderman, K.M, 2007. Educational Information From BD Medical Diabetes Care

Steps to Count Carbohydrate Counting

1. Step 1 : Make healthy food choices

2. Step 2 : Focus on carbohydrate

3. Step 3 : Set carbohydrate goals

4. Step 4 : Determine carbohydrate content

5. Step 5 : Monitor effect on blood glucose level

Canadian Diabetic Association, 2005

Step 1 Make healthy food choices Enjoy a variety of

vegetables, fruits, whole grains,

Use added fats in small amounts.

Choose portion sizes

Canadian Diabetic Association, 2005

Steps to Count Carbohydrate Counting

1. Step 1 : Make healthy food choices

2. Step 2 : Focus on carbohydrate

3. Step 3 : Set carbohydrate goals

4. Step 4 : Determine carbohydrate content

5. Step 5 : Monitor effect on blood glucose level

Canadian Diabetic Association, 2005

Step 2 Focus on Carbohydrate

Step 2 Focus on Carbohydrate

Steps to Count Carbohydrate Counting

1. Step 1 : Make healthy food choices

2. Step 2 : Focus on carbohydrate

3. Step 3 : Set carbohydrate goals

4. Step 4 : Determine carbohydrate content

5. Step 5 : Monitor effect on blood glucose level

Canadian Diabetic Association, 2005

Step 3 : Set Carbohydrate Goals

dietitian will help to set a goal for grams of carbohydrate at each meal and snack

This may be the same from day to day or may be flexible, depending on patient needs

Canadian Diabetic Association, 2005

Step 3 : Set Carbohydrate Goals

Pilih obat yang diperlukan sesuai jumlah karbohidrat

Jumlah energi

Distribusi energi

selama 24 jam

Analisis terhadap komposisi

zat gizi

Perhitungan KH setiap

sajian

Step 3 : Set Carbohydrate Goals

Analisis zat gizi dari kebiasaan makan pasien

Food record

Food Record

Food Record

Food Record

Food Record

Energi dari hasil record : ....... Kkal

Distribusi energi :- pagi : .....%- snack : .....%- siang : .....%- malam : .....%

Komposisi zat gizi :- protein : ....%- KH : ....%- Lemak : ....%

Serving KH per sajian

Perhitungn zat gizi yang diperlukan pasien

Energi

Distribusikan dalam 24

jam

Komposisi zat gizi sesuai dengan

kebiasaan

Perhitungan jumlah

karbohidrat per sajian

Perhitungn zat gizi yang diperlukan pasien

Perhitungn zat gizi yang diperlukan pasien

Status Gizi IMT IMT = BB (kg)/ {TB (m)}² Berikut ini pembagian IMT berdasar

standard Asia menurut IOTF, WHO (2000) :

<18,5 = Underweight18,5-22,9 = Normal23-24,9 = At risk25-29,9 = Obese I>=30 = Obese II

Perhitungan Kalori

BMI Normal : 25 – 30 cal/kg BW Kurus : > 40 cal/kg BW Overweight : < 20 cal/kg BW (BMI

requiring and /obese 130 g/day of CHO)

Perhitungn zat gizi yang diperlukan pasien

Energi Distribusikan dalam 24

jam

Komposisi zat gizi sesuai dengan

kebiasaan

Perhitungan jumlah

karbohidrat per sajian

Perhitungn zat gizi yang diperlukan pasien

Distriusi kalori dalam 24 jam disesuaikan dengan kebiasaan

makan pasien

Perhitungn zat gizi yang diperlukan pasien

Energi Distribusikan dalam 24

jam

Komposisi zat gizi sesuai dengan

kebiasaan

Perhitungan jumlah

karbohidrat per sajian

Perhitungn zat gizi yang diperlukan pasien

Karbohidrat sebesar 45-65% total asupan energi.

Protein sebesar 10 – 20% total asupan energi.

Asupan lemak sekitar 20-25% kebutuhan kalori.

Perhitungn zat gizi yang diperlukan pasien

Perkeni, 2006

Perhitungn zat gizi yang diperlukan pasien

Perhitungn zat gizi yang diperlukan pasien

Energi Distribusikan dalam 24

jam

Komposisi zat gizi sesuai dengan

kebiasaan

Perhitungan jumlah

karbohidrat per sajian

Karbohidrat sebesar 45-65% total asupan energi

Perhitungn zat gizi yang diperlukan pasien

Dibagi dalam

beberapa kali makan

Pagi.....% = ...g Siang

.....% = ...g

Malam.....% = ...g

snack

snack

Sesuai dengan kebiasaan makan pasien

KH per sajian

Perhitungan jumlah karbohidrat per sajian

Perhitungn zat gizi yang diperlukan pasien

Carbohydrate serving/

choice (carb serving/ choise)

Carb grams

Carb Seving/ Carb Choise

1 carb serving/ choie = 15 g karbohidrat

Kulkarni, KD.Clin. Diabetes 23: 120 - 122

Ex : untuk makan pagi, Tn. H membutuhkan 45 g karbohidrat

45g KH = 3 carb serving↓

2 slice of bread + ½ cup of fruit juice

Carb Seving/ Carb Choise

How Can I Use Nutrition Facts on Food Labels?

Case Study

Tn. Han, usia 37 tahun. Penderita DM type 2. TB 155 cm, BB 75 kg. Bekerja sebagai pegawai yang sebagaian besar aktifitasnya dilakukan dengan duduk. Pulang dan pergi kerja diantar oleh sopir. Pemeriksaan gula darah puasa/dl, DG 2 JPP 310 mg/dl

Food pattern (Hasil Food Frequency Questionnaire/FFQ)

CHO yang paling sering: nasi, mie, roti

Protein hewani ayam, daging, telur Protein nabati tempe dan tahu Sayur jarang hanya 1x/hari Buah frekuensi jarang, konsumsi

dalam bentuk jus Snack dalam bentuk makanan tinggi

kalori

Stage 1

Nutritional Assessment Antropometri : BB = 75 kg, TB= 155 cm BBI = (155-100) x 90% = 49.5 cm IMT = 75/1.5 2 = 31 (0bese)

Record Hari 1

Waktu Makan

MenuBahan

Makanan

Portion SizeJml

karbohidrat

URT Gram GramServin

g

Sarapan

Nasi putihAyam grg

Tempe grg

Pecel

Teh manis

Nasi Ayam MinyakTempeMinyakBayamTaoge Kcang tnhGula pasir

1 gls1 ptg sdg

½ sdm2 ptg sdg

½ sdm½ gls¼ gls2 sdm2 sdm

130505

505

50252020

60--8-5-8

20

6 ½ --½---½1

102 g (…..%)

6.5 serv.

Makan siang Tot Carb

Makan malam Tot

Carb

Hasil Record

Hari E P (gr) F (gr) CHO (gr)

Hari 1 3310.6 76.2 148.8 417.9

Hari 2 3657.3 128.7 179.3 386

Hari 3 3071.2 106.1 138.8 343.8

Rata-rata intake

3346 103.6 155.6 387.2

Stage 3

Nutrition Intervention Perhitungan kebutuhan 20 Kal x 75 = 1500 Kalori KH 55% = 55/100 x 1500 = 825 Kalori=

206.3 gram Lemak 25% = 25/100 x 1500 = 375

Kalori = 41.6 gr Protein 20%= 20/100x1500= 300

Kalori= 75 gr

Stage 4 Meal planning (KH) sesuai dengan

kebiasaan makan Energi = 3346 Kalori, CHO= 382.7 g

yang terbagi dalam :

Sarapan (%) = Snack (%)Makan siang (%)Snack (%)Makan malam (%)

Distribusi konsumsi KH dalam gr dan serving unit

Waktu makan

gram CHO

Unit serving

CHO

Sarapan

100.6 (26%)

6.5

Snack 65.5 (17%) 4

Siang 111.0 (29%)

7.5

Snack 15.4 (4%) 1

Malam 90.2 (24%) 6

Total 382.7 25

gram CHO

Unit serving

CHO

54(26%) 3.5

35 (17%) 2

60 (29%) 4

8 (4%) 1

49 (24%) 3

206 13.5

Kebiasaan mkn = 382.7 g CHO

Kebutuhan = 206.3 g CHO

Steps to Count Carbohydrate Counting

1. Step 1 : Make healthy food choices

2. Step 2 : Focus on carbohydrate

3. Step 3 : Set carbohydrate goals

4. Step 4 : Determine carbohydrate content

5. Step 5 : Monitor effect on blood glucose level

Step 4 : Determine carbohydrate content

1. Write down what you eat and drink throughout the day

2. Be sure to note the portion sizes3. Record the grams of carbohydrate

in these foods and drinks.

Steps to Count Carbohydrate Counting

1. Step 1 : Make healthy food choices

2. Step 2 : Focus on carbohydrate

3. Step 3 : Set carbohydrate goals

4. Step 4 : Determine carbohydrate content

5. Step 5 : Monitor effect on blood glucose level

Step 5 : Monitor effect on blood glucose level

Work with your health care team to correct blood glucose levels that are too high or too low

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