INTRODUCTION
Diabetes mellitus
(DM) is a chronic, progressive disease characterized by the body's inability
to metabolize carbohydrates, fats and proteins(Jiantari et al., 2021; Sari et al., 2023). This metabolic
disease occurs due to high
blood glucose levels (hyperglycemia)(Lede et al., 2018). Hyperglycemia plays an important
role in the development of DM-related complications. Increased glucose levels can pose a risk of microvascular
damage (retinopathy, nephropathy and neuropathy) and can cause cardiovascular
disease, stroke, peripheral
blood vessels and decreased quality
of life.(Definition, 2006). Nearly 80% of people who
have a history of diabetes will die, usually due
to cardiovascular disease, especially hypertension and stroke, in patients who have
a history of diabetes and develop hypertension.(Tadesse et al., 2018).
Based on 2018 WHO data, it is explained
that there are 422 million people suffering from diabetes mellitus in the world and will
continue to increase by around
8.5% per year. The largest number of DM sufferers
according to the IDF (International Diabetes Federation)
is around 40-59 years old, while
according to the Ministry of
Health in 2020, most
diabetes mellitus sufferers
are aged 20-79 years.(L'heveder & Nolan, 2013). The prevalence of DM based on
Perkeni 2015 in the adult population continues to increase
to 10.9%. The incidence of DM in East Java is also high
and is ranked
fifth with a prevalence of diabetes mellitus of 2.6%. This is also
supported by 2018 Riskesdas data, which explains that the
prevalence of diabetes mellitus in East Java continues to increase.(Association, 2014)
Efforts to control
the increase in disease prevalence with pharmacological therapy and non-pharmacological therapy. Non-pharmacological management for people with
diabetes is used so as not to worsen
the condition of diabetes and not to aggravate the
complications. Eating management in diabetes mellitus
(DM) sufferers can be one way
of preventing complications. Therefore, people with diabetes or people with
diabetes can follow a DM
diet which has the 3J principle (schedule, amount and type).
Efforts are made to use the
3J principles to ensure a regular diet for people with
diabetes. The DM diet takes into
account that the food portions for
people with diabetes should not be too
much or too
little, the eating schedule for people with
diabetes must be on schedule or
regularly to avoid hypoglycemia or hyperglycemia. Choosing the right
type of food
can affect blood glucose levels,
especially the type of carbohydrate(PG Indonesia, 2019).
RESEARCH METHODS
Case
The patient, Mrs MST, is 54 years old.
The patient is a housewife. The patient was referred from
the community health center and
came to the
hospital with complaints of weakness in half of the
body since � 2 days ago, dizziness
and slurred speech. The patient's medical history includes diabetes mellitus and hypertension but he does not seek treatment or control his disease regularly. If the patient is
sick, seek treatment at the
nearest independent health practice. The patient was diagnosed
with CVA Infarction, DM Hyperglycemia and Hypertension.
The patient said he had difficulty moving his body, especially the right side of
his body, his ability to swallow/chew
food was reduced and he sometimes choked when drinking water,
this was because his tongue became stiff/sluggish.
However, the patient still has enthusiasm to consume
the diet presented.
Before being diagnosed with diabetes mellitus, the patient was
overweight and now this can
be seen from
his body shape, where his weight has decreased by 10-15 kg. During the observation,
the results of anthropometric measurements based on % LILA were 96.98 (normal nutritional
status) and knee height was 45 cm so the estimated
TB was 154.27 cm (Arisman, 2009)
����������� When the initial
examination was carried out on
admission to the hospital, it was found that
blood pressure was: 212/119 mmHg, pulse: 120 beats/min, GCS 456, CT
scan results showed acute ischemic
infarct. Biochemical results are GDA: 348 mg/dL, cholesterol: 362 mg/dL, triglycerides:
187 mg/Dl, Bun 36.28 mg/Dl, Creatinine
2.24 mg/dL
The 1x24 hour recall results at the start of
hospital admission included
severe deficits. Average patient food intake <60%. Previously, the patient's eating history often consumed
sweet foods and drinks, rarely
consumed vegetables and fruit and
sometimes drank herbal medicine and the
processing process was often fried.
RESULTS
AND DISCUSSION
Nutritional Diagnosis
Based on the cases
above, a nutritional
diagnosis can be made in the patient,
namely:
NI-2.1 Deficiency in oral food and drink
intake related to limited food
intake due to decreased ability
to swallow/chew, indicated by intake before
MRS less than standard requirements, namely energy 53.8%, protein
53.9%, fat 61.6%, KH 50 .6%.
NI-5.4 Decreased need for specific
nutrients for simple carbohydrates related to endocrine
metabolic disorders characterized by GDA 348 mg/dL.
NI-5.4 Decreased need for the
specific nutrient sodium related to hypertension
as indicated by the results of
a clinical physical examination, blood pressure of 212/119 mmHg.
NC-2.2 Changes in laboratory results related to special
nutrients related to kidney function
disorders are characterized
by abnormal BUN and creatinine levels.
NB-1.1 The patient's family's lack of
knowledge regarding food and nutrition
is related to the patient's
family having never received nutrition education, indicated by a history of frequent
consumption of sweet foods and
drinks, the processing method is often fried.
Nutritional intervention
Energy is given gradually according to the
patient's needs and ability to
accept food, helping to achieve
blood sugar and blood pressure levels within normal limits and avoiding
acute complications, provided the diet is met.
Energy is calculated according to needs based
on basal energy with an activity
factor for bed mobilization patients (10%), a stress factor for complicated
DM patients (30%) and a correction for age (10%) of 1625 kcal(PE Indonesia, 2021).
Carbohydrates are given at 65% of
total energy, namely 264 grams. Sucrose (sugar) � 5% of total energy, namely 20 gr and
fiber 25 gr/day.
Protein is given at 10% of
the total requirement, namely 40.63 grams.
Fat is given
at 25% of total energy of 45 grams
and cholesterol in the menu is <300 mg/day.
Sodium intake is limited to
≤ 1500 mg/day, adjusted for the
severity of salt, water retention
and hypertension.
Consume 39 mg/kg BW/day of
potassium to help lower blood
pressure
Vitamins and minerals are given according to recommended nutritional adequacy.
Liquids in drinks or food
sauce are sufficient to be � 2 liters/day.
The form of food is
appropriate to the patient's abilities.
Process the menu by reducing table
salt, replacing it with spices
and garlic.
Reduce consumption of sweet, savory foods,
preserved/canned foods, biscuits, crackers, sweet soy sauce. Patient's
understanding of nutrition and proper
food with the 3J principle (Schedule/j)
Apart from dietary interventions,
patients are also given education and counseling to increase knowledge
and type/quantity) as well as safe processing methods.
Table 1. Monitoring and Evaluation
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Parameters/indicators
|
Target
|
Execution time
|
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Food intake
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Intake is increased
gradually from 50% to 60%, then to 80% according to the patient's
ability
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Every day for
3 days
|
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Physical-clinical
Vital signs: blood pressure, pulse
Patient complaints: nausea, vomiting, dizziness, difficulty swallowing/chewing, sluggishness, hemiparesis
|
Vital signs: within normal range
Patient complaints: improved or reduced
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Every day
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Biochemistry: GDA, creatinine
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In normal vulnerability
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During hospitalization
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|
Knowledge
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There is an
increase in knowledge and patients apply it to
the patient's next diet
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Every day
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Discussion
Implementation of the
intervention was carried out for
3 days, where on the first
day of intervention,
patients were given food with a target intake of >60% orally in soft (porridge) and chopped
(side dishes) because the patient
experienced nausea, vomiting,
dizziness and decreased ability to swallow and
chew. . The diet provided is low in simple
carbohydrates, low in fat and low
in salt, to help lower the
patient's blood sugar and blood pressure.
The frequency given is 3 x main meals and 3 x snacks.
On the second day of
implementation, clinical physical complaints such as difficulty swallowing, nausea began to decrease so
that food intake began to
increase. And patients begin to learn to
mobilize (sit/stand) around the bed
and nutrition education regarding nutrition begins to be given
gradually. It is hoped that
patients can begin to understand
the patient's eating arrangements from the diet presented.
On the third day of
implementation, the diet
order was given in a somewhat rough form in the form
of team rice
but still a simple low carbohydrate
and low salt
diet. The patient's intake began to increase
to (>70%). Changes to the patient's
diet are always coordinated
with the doctor, nurse, waiter, patient and patient's family.
The results of monitoring the patient's food intake for 3 days
can be seen
in graph 1.
Graph 1. Monitoring Food Intake
Based on graph
1 showing the comparison of patient
food intake during 3 days of
observation, it can be seen
that the average patient food intake is
still in the moderate deficit and normal categories. Energy intake 76.16% (moderate deficit), protein 90.09% (normal), fat
98.5 (normal) and KH 67.3 (severe
deficit). The results of calculating the patient's needs
are 1625 kcal of energy, 61 grams of protein, 36 grams of fat, 264 grams
of carbohydrates.
Patients received a simple low carbohydrate
diet intervention of 1700 kcal, Low Salt and Low Fat. The hospital diet presented
still uses simple carbohydrates but is still
in accordance with the patient's needs
and is balanced.
According to the ADA (2015), carbohydrate consumption depends on the amount
of intake and type of
food consumed per day. The amount of carbohydrate consumed from main meals and snacks
is more important
than the source or type
of carbohydrate.
From the results
of the 24-hour recall carried out at the
beginning of admission to the
hospital and the results of monitoring
the patient's intake for 2 days,
it was found
that the percentage of the
patient's food consumption was increasing because the patient's condition
began to improve day by
day, although the increase in intake was still
gradual. For monitoring, intake
on day 3 experienced a slight decrease because the form of
food was replaced with a coarser one, namely
from rice porridge to rice.
It can be
seen that the patient's swallowing
and chewing condition has not yet completely improved, but the patient's
food intake motivation is still
good. Difficulty swallowing liquids and/or food
often occurs in stroke patients, where there is dysfunction
and incoordination of the pharyngeal
and central nervous muscles which result in loss of control
over swallowing function.(Gold et al., 2014).
����������� Average fat intake
and protein intake are in the normal category. This is because
the animal and vegetable side
dishes given by the patient
are consumed well. The side dishes are given to patients
in chopped form, making it easier for
patients to consume them. Apart
from this, the patient's food
processing process does not use too
much oil or coconut milk,
where the diet given is low
in fat. Diets tend to be high
in protein, fat and high in calories but low in fiber, which will lead
to an imbalance
in nutritional intake. This condition is a risk factor
for stroke and diabetes mellitus. There is a relationship between fat intake
and blood sugar levelsblood of diabetes mellitus sufferers(Widyasari et al., 2022).
����������� Based on the
graph above, it can be
seen that sodium intake for 3 days
is a deficit/still below the
threshold limit, namely the standard low
salt diet≤1500mg
(AHA, 2020). Sodium intake needs
to be limited
to reduce blood pressure and disease severity.
Setting a low salt diet is very
important for stroke sufferers who have
a history of hypertension. For patients who are given a low salt diet, more education is needed so
that it does
not reduce their appetite. The implementation of a low salt
diet can be implemented well if hypertension sufferers have good knowledge, attitudes and family
support regarding the implementation of a low salt
diet and have the awareness to
control their blood pressure.(Zahidah, 2020).
����������� Based on the
graph above, the average potassium
intake for 3 days is still
classified as a deficit compared to the
standard. Food sources that contain more
potassium are vegetables and fruit. In presenting
the patient's diet, the portion of
vegetables and fruit is still
considered insufficient because the patient's
condition is still difficult to swallow (has not fully recovered) and it is
difficult to consume coarse/fibrous foods.
The average amount of fiber in the hospital diet served to Mrs MST for
3 days was 10.8 grams. Consuming 25 grams of fiber per day is useful
for helping lower blood sugar levels, namely by increasing feelings
of fullness for longer and
preventing constipation and cholesterol. Too much cholesterol
in the blood vessels will inhibit
blood flow, resulting in an increase in blood pressure(Waloya et al., 2013).
����������� From the results
of the clinical
data examination above, there are changes in the patient's blood
pressure which have decreased but have not yet
reached normal. For physical
data, it is known that the
patient's general condition has begun to improve gradually,
although the physical symptoms are still there, such
as the patient's body is still
weak and he cannot sit or stand
independently and his speech is still
slurred. Uncontrolled and untreated diabetes mellitus can cause
complications. The main complications
that can arise are heart attack, kidney failure, gangrene and stroke (Price & Wilson, 2006).
����������� From the results
of the examination
above, it can be concluded
that the GDA, GDP and 2JPP values have decreased but have not yet
reached normal. This indicates that the medical therapy
and nutritional care provided can
change the patient's blood sugar values for the better. In principle, diabetes mellitus sufferers must adjust their diet. This can be
done by paying
attention to the number of
calories and nutrients needed, the type of
food ingredients, etcrate of regularity
of eating schedule(Susilowati & Waskita, 2019). A bad diet will cause an increase
in glucose levels in the blood and
if this continues
for a long time it can cause
complications(Widiyoga et al., 2020).
����������� Nutrition diagnosis in overcoming
patient disease problems through a standardized nutritional care process (PAGT) during the 3 day
intervention, namely the lack of
oral intake has improved and the problem of lack of
knowledge related to nutrition can
be improved. This can be
known from the patient's knowledge
based on daily education and nutritional counseling. Patients and their families
enthusiastically ask questions and can
mention foods that need to
be avoided and limited for
patients with diabetes mellitus complicated by stroke as well as regulatory principleseat 3J (amount/type/schedule).
Furthermore, while at home, further
monitoring of compliance and implementation of the recommended diet is required. The research results show that there
is a strong relationship between diet and the 3J principles
which will affect the blood
sugar of people with diabetes mellitus(Bistara, 2018).
CONCLUSION
The intervention given for 3 days
in the form of diet and education
can change the patient's general
condition for the better. There
was an increase
in food intake, clinical physical and biochemical values improved. Nutritional diagnosis for intake and knowledge
can be carried
out and completed.
Patient knowledge based on education
and counseling can be said
to increase because patients can mention foods
to avoid or consume. We conducted this research only over a period of 3 days,
the data we collected was incomplete
so the discussion
was not yet sharp. In the future,
interventions and longer observations of patients can
be carried out so that
sharper discussions provide more benefits
for researchers and society.
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Copyright
Holder:
Endah Bardiati, Binasari,
Fuadiyah Nila Kurniasari(2024)
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First Publication Rights:
Journal of Health Science
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article is licensed under:
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Volume 5, No. July 7, 2024