AMINO PCC EAMSC 2019: Thailand

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TREADMILL : Treat Diabetes To Minimize More Complex Illness Tarumanagara University, Jakarta, Indonesia Gita Manerlin Kasihita Simatupang, Josephine Alicia Bierhuijs, Maria Jessica In Indonesia, diabetes is one of the highest factors of mortality. With total of 6.7% diabetes become the third largest cause of death after stroke (21.1%) and coronary heart disease (12.9%). Unhealthy lifestyle such as, lack of physical activity, unbalanced diet, smoking along with conditions like overweight, central obesity, hypertension, dyslipidemia and high blood glucose level are risk factors that lead to diabetes.

Therefore, diabetes as a result of unbalanced diet and obesity are the main topic on this campaign. As the prevention, Indonesian health ministry held “CERDIK� program. One of the components is to raise awareness of physical activity in daily living. Not only physical exercise, healthy diet with balanced calories have to be maintained as well. Being a developing country, Indonesia has low economy rates that impacts to the incapability of having a good and healthy lifestyle.

“LET’S CHANGE” Obesity Prevention Project Brawijaya University Authors: 1. Farrah Ziva P.H.A. 2. Nisa Aprilia 3. Candra Dewi Q.A. 4. Kezia Rukmana Background Obesity and type 2 diabetes mellitus are international health problems that caused deaths in every cases. The prevalence of obesity has been increasing these past years. WHO stated 650 millions adults were obese in 2016. Obesity is strongly correlated to diabetes. It is predicted that the widespread extensiveness of said type 2 diabetes mellitus in adult will increase in the next two decades, and much of the increase will occur in developing countries. Obesity is characterized by BMI higher than 30, while type 2 diabetes mellitus is characterized by insulin insensitivity as a result of insulin resistance.

Obesity and diabetes in general caused health disadvantage such as cardiovascular disease which leads to silent death. Most people that suffered from this problem are likely living with unhealthy lifestyle, such as; sedentary lifestyle, cigarette smoking, and generous consumption of alcohol.

Objective Our project focused on obesity since it is one of the causality of diabetes. We aim to promote healthy lifestyle, emphasizing physical activity, and healthful dietary by social media with hashtag #chance2change. Supporting physically and mentally by providing tips, check-ups, challenge, and motivation. Our goal is to help people with obesity and diabetes reach their healthy weight with healthy lifestyle.

#chance2change

#chance 2change

Go workout

Sedentary lifestyle

Junk food

stress/unhealthy lifestyle

Decrease the Grease, Beat the Obese, Bye-Bye Type 2 Diabetes Satria Angga Widitama. Kiran Shadentyra Akbari, Tsabitah Amaluna Zahra Universitas Padjadjaran

Introduction Although largely preventable, type 2 diabetes is much more common than type 1 diabetes. 1 One of the main causes that lead to high prevalence is the ignorance of people of their individual’s risk of developing the disease. Obesity is a major risk factor.2 Adults can reduce their risk and improve insulin through (1) regular and adequate levels of physical activity and (2) healthy diets that include sufficient consumption of dietary fiber, and replacing saturated fatty acids with polyunsaturated fatty acids. 3 WHO has developed recommendations on healthy diet and physical activity that, if implemented, can reduce the risk of developing the disease.

Even though the recommendations to prevent type 2 diabetes has been established, the number of cases doesn’t seem to decline. This indicates that there’s a lack of awareness of the public. More movement initiated by those who already knew the urgency of preventive acts upon this disease is imperative. Through this poster, we want to escalate the public’s understanding of the disease and hopefully will help in alleviating type 2 diabetes cases.

Objective To inform the public about the risk factors of diabetes type 2 and what we can do to lower the chances of developing the disease.

Sources 1. Obesity and overweight [Internet]. World Health Organization. 2018 [cited 22 October 2018].

Available from: http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

2. International Diabetes Federation - What is diabetes [Internet]. Idf.org. 2018 [cited 22 October 2018]. Available from: https://www.idf.org/aboutdiabetes/what-is-diabetes

3. Global report on diabetes. Geneva: World Health Organization; 2016.

Project Title: Stop Too Much Diabetes with “SUGAR” Name of Authors: 1. Adeela Sandria Fitri A 2. Dinda Sayyidah Laela Fx 3. Nabila Chantikarizky H 4. Satria Angga W University of Padjadjaran Content: Background Diabetes mellitus type 2 is a chronic disease caused by the body's inability to respond properly to the action of insulin produced by the pancreas. The number of people with diabetes is 422 million and its counts 8,5% of total population in the world.

50% of patient diabetes mellitus type 2 don’t know that they are suffering from it. Commonly, they come to practitioner with severe complication and cause bad possible outcome. it will be better outcome with early Diabetes Mellitus 2 symptom’s detection, that are concluded into a “triad”: 1. Polydipsia 2. Polyphagia 3. Polyuria 80% of cases could be prevented with several ways by knowing the factors that give risk for it.

The most important of the risk are genetic and lifestyle. The only risk factor that we can change is lifestyle.

Objectives To inform people what we can do to prevent us from diabetes mellitus 2: 1. stop smoking 2. use your muscle 3. get healthy diet 4. avoid too much sweets 5. refine carbs

sources; 1. WHO. Diabetes. Retrieved from: http://www.who.int/mediacentre/factsheets/fs138/en/ 2. Minister of Health of Republic Indonesia. 2016. MENKES: Mari Kita Cegah Diabetes dengan Cerdik. Retrieved from: http://www.depkes.go.id/article/print/16040700002/menkes-mari-kitacegah-diabetes-dengan-cerdik.html

Diabetes Mellitus is an Hourglass Universitas Pelita Harapan Nixie Elvaretta Liono, Christine Nathalia, Vanessa Angelica Diabetes Mellitus (DM) type 2 is one of the most prevalent non-communicable disease in the world and the most common type of diabetes in Indonesia. DM type 2 is primarily caused by the unhealthy lifestyle of the patient. Based on the data that was received by Department of Health in Indonesia, the predicted prevalence rate of DM type 2 in Indonesia in 2030 will reach approximately 21,3 million people. This means that DM type 2 will become a huge burden on global health in the future.

Nowadays, one of the main causes of DM in Indonesia is excessive weight and obesity, deriving from unhealthy lifestyle which developed inadvertently since childhood. This situation can be prevented by increasing the awareness of the population regarding unhealthy lifestyle and its correlation to diabetes mellitus. By changing the children’s lifestyle, we believe that we can reduce the negative impact that diabetes mellitus presents to the population.

eat healthy

ENOUGH SLEEP

maintain weight

exercise

with these

WEAPONS

ABSTRACT OVERWEIGHT LEAD YOU TO OVER BLOOD-PRESSURE Authors : Annisa Brata Angraini, Marrera Paramitha, Ayu Herlina Jambi University Background Diabetes is a group of disorders characterized by chronic high blood glucose levels (hyperglycemia) due to the body's failure to produce any or enough insulin to regulate high glucose levels. Diabetes and its related complications result in an estimated 200,000+ deaths each year, making diabetes one of the major causes of mortality in the U.S. People who are overweight or have obesity have added pressure on their body's ability to use insulin to properly control blood sugar levels, and are therefore more likely to develop diabetes.

There are many risk factors for diabetes such as age, race, pregnancy, stress, certain medications, genetics or family history, high cholesterol and obesity. In 2012, the NIH reported an estimated 29.1 million Americans (9.3% of the population) living with diabetes. Of these, an estimated 8.1 million persons were unaware that they had the diseases.

Objectives To inform people what can we do to keep ourselves and our enviroment safe from overweight (obesity) or diabetes to reduce incidence of deaths caused by obesity and diabetes.

References Center for Disease Control and Prevention (CDC). Living with Diabetes: http://www.cdc.gov/diabetes/living/index.html The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Statistics on Diabetes: www.diabetes.niddk.nih.gov/dm/pubs/statistics/http://www.diabetes.niddk.nih.gov/dm/ pubs/statistics/

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Project Title : ‘Understanding Obesity’ University : Krida Wacana Christian University Authors : Berlianti Salamahu, Singgih Ang & Maudy Putri

Introduction Obesity is a condition of the body with a high amount of fat accumulation and a body mass index measured above normal limits. This excess fat mass can cause various problems such as insulin resistance in diabetes mellitus type 2. Diabetes mellitus is a serious chronic disease and dangerous complications may arise if we do not prevent it properly and correctly. Prevention can be done with several things such as regular exercise at least 1 hour a day, adequate rest, consuming healthy foods and eating moderately. A healthy body is one with ideal height and weight.

Objective Through this poster, we hoped that people will be more aware of the importance of maintaining an ideal body weight to avoid dangerous diseases such as type 2 diabetes.

Diabetic Foot Ulcer : Sugar Kills Your Foot!

Devina Afraditya Paveta, Thania Lathifatunnisa Putri Agusti, Shalsabila Refithania Yanata Faculty of Medicine, Diponegoro University Corresponding e-mail: devinaap@student.undip.ac.id, thania.lpa@student.undip.ac.id, ryanata1810@gmail.com

ABSTRACT Background : Diabetic foot ulcer is one of the most common, costly and severe complications of diabetes. Amputation in people with diabetes is 10 to 20 times more common than in people without diabetes and it is estimated that every 30 seconds, a lower limb or part of a lower limb is lost somewhere in the world as the consequence of diabetes. Based on the latest study, diabetic foot ulcer in Asia is 5.5% and contributes 85% cause of all amputation in diabetic patients. Diabetic foot ulcer can result in an important economic, social, and public health burden; especially in low-income communities, if there is neither an appropriate educational programme, nor adequate and suitable footwear. Public poster is a magnificent way to warn people about how dangerous the diabetic foot ulcer is. But still, there are challenges while introducing this project especially in areas with illiterate people. Therefore, routine reeducation will be highly recommended for those areas.

Objective : This project is designed to persuade people, especially diabetic patients, to prevent diabetic foot ulcer by “Triple C” consists of clean foot, controlled blood sugar, and comfort shoes.

Keyword: Diabetic foot ulcer, amputation, comfort, clean, controlled blood sugar.

References : 1. Ibrahim, A. (2017). "IDF Clinical Practice Recommendation on the Diabetic Foot: A guide for healthcare professionals." Diabetes Res Clin Pract 127: 285-287.

2. Pengzi Zhang, J. L., Yali Jing, Sunyinyan Tang, Dalong Zhu & Yan Bi. (2015). “Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis." Annals of Medicine.

3. Bus SA, Van Netten JJ, Lavery LA, Monteiro-Soares M, Rasmussen A, Jubiz Y, et al. (2015).

“IWGDF Guidance on the prevention of foot ulcers in at-risk patients with diabetes.” Diabetes Metab. Res. Rev. 4. Bus SA, Armstrong DG, Van Deursen RW, Lewis J, Caravaggi CF, Cavanagh PR. (2015). “IWGDF Guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes.” Diabetes Metab.Res.Rev. 5. Hinchliffe RJ, Brownrigg JR, Apelqvist J, Boyko EJ, Fitridge R, Mills JL, et al. (2015). “IWGDF Guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes.” Diabetes Metab. Res. Rev.

SUGAR KILLS YOUR

F O OT

I

< 37 C

Will Save Your Life

It Takes a Family to Fight Diabetes Peter Ivan Hadiprajitno, Epifani Angelina Chandra, Qorina Putri Srisantoso Faculty of Medicine, Diponegoro University Background : Type 2 diabetes is a disease that occurs when the body cannot effectively use the insulin it produces leading to increased blood glucose level. Globally, an estimated 422 million adults (8,5% in the adult population) were living with diabetes in 2014, while in South-East Asia Region is 8,6% in the adult population(WHO, 2016).

Objectives : Lifestyle intervention could bring big impact as it is feasible and cost-effective. Since the incidence of diabetes is mainly affected by lifestyle and also family history, family-based lifestyle modification intervention should be applied(Arenaza et al., 2017). Establishing healthy lifestyle habit since childhood will be effective as it is difficult to modify lifestyle behaviours when reaching adulthood.

Therefore, there are some actions that can be done to prevent it.

1. Find out about diabetes type 2 and its risk factors.

2. Encourage family members to take screening test.

3. Healthy and balanced diet.

4. Regular physical activity for at least 150 minutes/week.

5. Body mass loss at least 5-7% of body weight.

(WHO, 2003) (AADE, 2013) Most people don’t see the importance of implementing family-based healthy lifestyle before being diagnosed diabetes. Therefore, comprehensive promotions should be done. Social media influencers should also be utilized to promote family-based healthy lifestyle.

References : American Association of Diabetes Educators. (2013). Primary prevention of type 2 diabetes. The Diabetes Educator, 38(1), 147–150. https://doi.org/10.1177/0145721711431926 Arenaza, L., Medrano, M., Amasene, M., Rodríguez-Vigil, B., Díez, I., Graña, M., … Labayen, I. (2017). Prevention of diabetes in overweight/obese children through a family based intervention program including supervised exercise (PREDIKID project): Study protocol for a randomized controlled trial. Trials, 18(1), 1–12. https://doi.org/10.1186/s13063-017-2117-y World Health Organization. (2003). Screening for Type 2 Diabetes Screening for Type 2 Diabetes, 48.

World Health Organization. (2016). Global Report on Diabetes. Isbn, 978, 88. https://doi.org/ISBN 978 92 4 156525 7

Presentation Title : Baymax “Better Activity for Max Healthy” Research Focus : Prevent People Diabetes by changing life style with 150 BEAM School : Universitas Airlangga Member :

Alexa Surya Romansyah

011811133108

Nabil Alfin Juhri

011811133089

Adiarsya Ghifari

011811133112

I Made Agus Dwipayana

011811133111

Abstract : In this work, we intended to decrease diabetes prevalence. The global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014.

It will increase rapidly if we don’t stop it. Baymax stands for “Better Activity for Max Healthy” is our project emphasize. The main problem in this case is people life style and diabetes is noncommunicable disease. By this poster, we want to educate how to prevent diabetes by changing life style, the easy way to remember is 150 BEAM. The way are: •

150 minutes aerobic physical activity;

• be physically active – at least 30 minutes of regular, moderate-intensity activity on most days. More activity is required for weight control; •

eat a healthy diet, avoiding sugar and saturated fats intake; and

• avoid tobacco use – smoking increases the risk of diabetes and cardiovascular diseases.

•

maintain healthy body weight;

We use 150 BEAM beacuse if blood glucose level above 150mgdl it is warning. We hope people around the world persuaded by this poster, so it can decrease diabetes prevalence.

If diabetes sufferers decrease, we can decrease the world mortality.

WANNA BE A SUPER GRANDPARENTS? BEAT DIABETES FROM NOW! Fatimah Zahra , Ni Made Adnya Suasti, Amalia Citra Octavia Universitas Airlangga

BACKGROUND Diabetes Mellitus (DM) is a metabolic disorder of multiple etiology and characterized by chronic hyperglicemia resulting from defects in insulin secretion, action or both (WHO,1999). It is number 6 of death cause in the world and eldery patients have an increased risk for coronary heart disease, stroke, and vascular diseases (NCDWHO,2010). In Indonesia itself, there were approximately 12 millions people suffering from DM in 2013 (Kemenkes,2014). Those number prove that DM is a huge problem in the medicine world. That’s why we need to encourage people to realize that we can help ourself and beat DM from now. We believe by spreading this poster, we can prevent DM. OBJECTIVES •

To prevent Diabetes Mellitus as early as possible

•

To promote SUPER as a way to beat diabetes, so that in the future they can be a super grandparents without getting the complications of Diabetes Mellitus that usually occurs in elderly

•

To encourage people to set up a healthy meal, use less sugar and salt, pay attention to their lifestyle, exercise regularly, and remember to check and maintain their ABC (A1C blood glucose,Blood Pressure,and Cholesterol)

•

To help government to decrease the number of Diabetes Mellitus especially Indonesia

ABSTRACT Project Title

: Say No to Obesity

University

: Universitas Airlangga

Authors

: Fauziah Adhima Sarah Nia Amru Ayurveda Zaynabila Heriqbaldi

Introduction Obesity is defined as abnormal or excessive fat accumulation that may impair health. Overweight and obesity are the fifth leading risk for global deaths (Kearns, et al., 2014). At least 2.8 million adults die each year (WHO, 2017). Obesity is a major contributor to heart disease, kidney stone, stroke, dysfunction immune, and many more. Many people donâ&#x20AC;&#x2122;t realize that those are common diseases among us. There are a lot of factors that can lead to obesity, such as exercise and dietary habit. In fact, obesity is preventable. Therefore, this project is made to inform people about obesity and its prevention.

Objective To inform people the definition of obesity, the illness that caused by obesity, and how to prevent obesity.

Reference WHO.

(2018).

Obesity.

Retrieved

from

http://www.who.int/news-room/facts-in-

pictures/detail/6-facts-on-obesity Kearns, K., Dee, A., Fitzgerald, A., Doherty, E., & Perry, I. (2014). Chronic disease burden associated with overweight and obesity in Ireland: the effects of a small BMI reduction at population level. BMC Public Health, 14(1). doi: 10.1186/1471-2458-14-143

SAY NO TO OBESITY What Is Obesity?

Abnormal or excessive fat accumulation

100 kg?!

The fifth leading risk for global deaths (Kearns, et al., 2014) At least 2.8 million adults die each year (WHO, 2018)

Obesity is

Obesity can cause:

C

preventable

Deteriorate Sight

Stroke

Heart Failure

Kidney Stone

Risk of Cancer

Dysfunction in Immune System

Prevent Obesity with CHIPS!

onsistent Meal Times

H

ealthy Food

I

ndividual Portion

P

ositive Life

S

port

WHO. (2018). Obesity. Retrieved from http://www.who.int/news-room/facts-in-pictures/detail/6-facts-on-obesity Kearns, K., Dee, A., Fitzgerald, A., Doherty, E., & Perry, I. (2014). Chronic disease burden associated with overweight and obesity in Ireland: the effects of a small BMI reduction at population level. BMC Public Health, 14(1). doi: 10.1186/1471-2458-14-143

Beware of Diabetes, Dracula Comes to Save Your Life Universitas Airlangga Innas Safira Putri, Deandra Maharani W, Mahrumi Dewi Tri Utami, Alif Lutvyani Diabetes is a serious, chronic disease that occurs either when the pancreas does not produce enough insulin (a hormone that regulates blood sugar, or glucose), or when the body cannot effectively use the insulin it produces. Diabetes is an important public health problem, one of four priority non communicable diseases (NCDs) targeted for action by world leaders.

Both the number of cases and the prevalence of diabetes have been steadily increasing over the past few decades (WHO, 2016). One every eleven people in the world is a diabetes sufferer (WHO, 2015). Certainly it is a serious health problem in the world. It can cause heart failure, renal failure, blindness, and even amputation if the disease is getting worse. Diabetes can be prevented by using â&#x20AC;&#x153;Draculaâ&#x20AC;?. Starts with do not eat too much sweets, rest enough, aware the importance of medical check up, consume healthy food, understand what is diabetes, lot of moves, and avoid stress. Society should know and realize how to prevent theirselves from diabetes.

Stop! Obesity & Diabetes with ACTHYOO Universitas Airlangga Authors : Marsananda Yunitasari Abdurrahman Hasyim Asy’ari Neilil Muna Mufidana Anggia Gracia Marlina Situmorang

Obesity is the excessive weight precipitated by imbalance between the number of calories eaten and used. The obesity in children and adolescents can cause diabetes mellitus. Both problems of this disease are related to low family income, inherited disease history, and environmental factors. (Pulgaron et al, 2014).

The cause of environmental factors is urbanization, therefore it can change people's habits to eat fast food. Fast food can lead to obesity which is at risk for diabetes melitus. Diabetes mellitus can cause lung infections and impaired function in the eyes, kidneys, nerves, heart and blood vessels. Infection occurs when hyperglycemia can decrease the ability of cells for phagocytes, while impaired organ function due to work disorders and insulin secretion (Lathifah, 2017).

Type 1A and type 2 are the two major types of diabetes mellitus which account for >95 per cent of cases of diabetes in children (Menon, Thomas, and Sperling, 2016). Meanwhile in Asia, countries with the largest number of children and adolescents with diabetes is India as the second, China as the fourth, and Saudi Arabia as the eighth place in world rank. This research is used to prevent the occurrence of obesity and diabetes mellitus in children (International Diabetes Federation, 2017).

References : Pulgaron, ER & Delamater, AM. 2014. ‘Obesity and Type 2 Diabetes in Children:Epidemiology and Treatment’. Current Diabetes Reports. 14(8), pp. 508.

Menon, RK, Inas HT & Mark, AS. 2016. ‘Childhood diabetes mellitus: Advances & challenges’. Indian Jounal of Medical Research. 144(5), pp. 641–644.

International Diabetes Federation Committee. 2017. IDF Diabetes Atlas - 8th Edition. International Diabetes Federation

Fight Childhood Obesity with Healthy DIETS! Universitas Airlangga Authors: Marselia Febriyanti Sihotang Tasya Wikassa Chelssi Gloria Tessari Jonathan Christopher Wewengkang ABSTRACT Introduction/Background Obesity is defined as abnormal or excessive fat accumulation that presents a risk to health (WHO, 2014). Obesity is a serious problem in our society. Obesity is not only a problem for adults, but also attacks children. According to CDC (2018), the prevalence of obesity was 18.5% and affected about 13.7 million children and adolescents. Obesity prevalence was 13.9% among 2- to 5-year-olds, 18.4% among 6- to 11-year-olds, and 20.6% among 12- to 19-year-olds.

The causes of childhood obesity are bad dietary intake, lack of physical activities, genetics, and psychological factors. There are many ways to prevent childhood obesity, such as decrease sugar intake, increase physical activities, eat healthy food, reduce the amount of gadget use, and also sleep well.

Objectives 1. To introduce the dangers of childhood obesity.

2. To give information about the prevention of childhood obesity.

Reference Allen, S. 2018. 2018. Preventing Obesity in Children. Lake Union Herald. Available at: https://digitalcommons.andrews.edu/luh-pubs/22. [Accessed on October 16, 2018].

Centers for Disease Control and Prevention. 2018. Overweight & Obesity. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/obesity/data/childhood.html [Accessed October 16, 2018].

Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar, R., & Bhadoria, A. S. 2015.

Childhood obesity: causes and consequences. Journal of Family Medicine and Primary Care, 4(2), 187â&#x20AC;&#x201C;192. Available at: http://doi.org/10.4103/2249-4863.154628. [Accessed on October 2018].

World Health Organization. 2014. Obesity. World Health Organization. Available at: http://www.who.int/topics/obesity/en/ [Accessed October 21, 2018].

‘Grow-besity’ – Alter the Culture!

Nadhifah1, Junjungan Nimasratu Rahmatsani1, Kevin Yuwono1 1

Faculty of Medicine, Universitas Airlangga, Indonesia

AMSA Universitas Airlangga, AMSA-Indonesia

Abstract Background: ‘Grow-besity’ derived from ‘grow’ and ‘obesity’ is a term for obesity affecting growing children and adolescent, which has been a significant worldwide issue, especially in middle-income countries (WHO, 2016). This is especially crucial as childhood obesity is a strong predictor of adult obesity and is very impactful for the individual and society. The number has since continue to grow, yet the effort in tackling the problem has not yet shown significant progress. This would lead to further difficulty as both physical and psychological consequences could accompany children obesity, such as early onset of cardiovascular disease, type-2 diabetes, and emotional difficulties (WHO, 2016). Our utmost attention is needed as contributing factors can be prevented using multi-sectorial approach.

Objective: Our poster aims to propose early prevention through “BE HAPPY!”, a multi-sectorial approach (including exclusive breastfeeding, healthy diet, antenatal care, weight management, increasing physical activity, and mental care) to prevent further increasing of children and adolescent obesity occurrence. Our main challenge regarding this purpose would be overcoming the obesogenic environments which encourages weight gain and obesity. The possible solution is to tackle the negative norms and addressing critical elements in obesity prevention.

Reference World Health Organization. 2016. ‘Report of the Commission on Ending Childhood Obesity’. Geneva: World Health Organization.

TITLE

: PICK UP DIET TO PREVENT DIABETES CAUSED BY HABITS

UNIVERSITAS AIRLANGGA AUTHORS

:

-

Nadyalifa Tania Putri

-

Faida Ufaira

-

Clara Alverina

-

Khansa Raihani Rosmalika

CONTENT Obesity is defined as abnormal or excessive fat accumulation that presents a risk to health. A crude measure of obesity is the body mass index (BMI), a personâ&#x20AC;&#x2122;s weight (in kilograms) divided by the square of his or her height (in metres). A person with a BMI of 30 or more is considered as obese.

Based from WHO (2016), worldwide obesity has nearly tripled since 1975. In 2016, more than 1.9 billion adults, 18 years and older, were overweight, and over 650 million considered obese. The conditions we face is very unfortunate, because obesity can be prevented. Obesity is caused by many factors. Poor lifestyles, such as lack of physical activity, addiction to gadget and irregular sleep. Other factor is physiological condition, such as stress. Poor eating behaviour will cause fat to accumulate and wrong lifestyle makes the metabolism become slower.

There are ways to prevent obesity. People must improve their lifestyle by improving sleep hour. Exercise and increasing physical activity to increase body metabolism and maintain organ function. Starting good eating behaviour is also important, drink enough water will create good metabolism and a balanced food consumption will not increase the accumulation of certain substances in the body.

Source : World Health Organization. 2018. Obesity and Overweight. Available at: http://www.who.int/topics/obesity/en/ [accessed : 17 October 2018].

nadyalifa tania putri faida ufairA PRAMESWARI clara alverina khansa raihani

D

ep rev ented by

Worldwide obesity has nearly tripled since 1975 and over 650 million people considered obese (WHO, 2018).

an b

IMPORTANT

PICK UP DIET TO PREVENT DIABETES CAUSED BY HABITS

IN

RINK ENOUGH WA TER

CREASE ACTIVITY

E eal at h thy and suffici ent T

c y t i s obe

V LESS

CAUSES OF OBESITY: HORRIBLE LIFE STYLE | a LOT OF STRESSFUL THINGS | BUNCH OF JUNK FOOD | INSUFFICIENT SLEEP | TOO MUCH SWEETS | SODAS FOR LIFE

Prevent Obesity with Love Fact Universitas Airlangga Nofita Fachryandini Kintan Adelia Farahannisa Karindra Amadea Susetiyo Nabila Annisa Harum One of the biggest problems of humanity nowadays is obesity. In this era, humans have been suffering from this eating disorder much more than before. Obesity is when one has too much body fat, and is unable either by genetic or environmental factors to control it. This problem has become more frequent as the society of today is all about consumption, fast food, calories and lack of exercise, as a simple machine is able to do everything one is too lazy to do.

There are many complications when being obese like cataract, mouth infection,hypertension, stroke and coronary heart disease. All of these complications if combined with obesity can cause serious problems to human body. The key treatment for obesity is a healthy lifestyle which includes many healthy habits. An appropriate weight management program usually combines physical activity, healthy diet, and change in daily habits. Simple habits like climbing the stairs instead of taking the elevator, walking or cycling to work and leaving the car at home (if at all possible), or going for a walk at lunchtime with coworkers makes a big difference.

DA NG ER S

S T C A F

Hypertension

Obese = BMI > 30

Stroke

PREVENT OBESITY WITH

Cataract Mouth Infection

Coronary Heart Disease

Lo w fat Vegetable & sugar

Nofita F., Kintan A., Karindra A., Nabila A.

1 out of 4 Indonesian suffers from obesity

F ruit

Act ivity

Source: WHO, 2018

Prevention of Obesity Through Food Putri Aliya Ahadini, Ramidha Syahrani, Safira Raissa Dwi Putri, Sitti Khofifah Yuliana Universitas Airlangga,, Surabaya 2018

Abstract Obesity is a condition where a person has excess of fat in the body, which is generally deposited in subcutaneous tissue, under the skin, and sometimes there is expansion into the tissues of the organ.

Background/Introduction Along with the development of the times and changes in trends and patterns of life which is less healthy, now there are a lot of people who suffer obesity. Obesity is considered as the first signal of the emergence of a group many non-infectious diseases occurs.

Effect of Obesity 1. Cancer 2. Heart Disease 3. Fatty Liver 4. Sleep Apnea 5. More Sick Days (Rossi, 2018) Objective The purpose of the public poster with the theme of obesity is so that people can manage their diet well and balance between eating, sports, and consuming healthy and nutritious foods. several ways that we can avoid obesity: 1. Eat Breakfast Every Day. 2. Eat High Fibre Foods.

3. Eat Raw, Leafy Green Vegetables.

4. Turn to Fish, Chicken and Beans for Protein.

5. Eat Healthy Nuts.

6. Get Plenty of Calcium (Rossi, 2018)

G4ET Obesity is a condition where a person has excess of fat in the body and also obesity shows an imbalance between height weight.

Effect: 1. Cancer 2. Heart Disease 3. Fatty Liver 4. Sleep Apnea 5. More sick days

http://digilib.unimus.ac.id/files/disk1/120/jtptunimus-gdl-wahyusarig-5984-2-babii.pdf https://www.fitnessmagazine.com/health/conditions/obesity/effects-of-obesity/

Let’s Prevent Obesity and Diabetes with Alphabet!

Rafiv Fasya Agustianto, Andro Pramana Witarto, Putu Garry Cory Aditya, Ifan Ali Wafa Universitas Airlangga

Type 2 Diabetes Mellitus (T2DM) is still being one of the leading causes of worldwide morbidity and mortality. Of many risk factors in T2DM cases, the most important one is obesity. Based on World Health Organization (WHO) data, in 2016, there were 650 million obese adults. It was nearly tripled in number compared to the data in 1975. Obesity in Asia region – including Indonesia – is a condition of which the Body Mass Index (BMI) is equal to or greater than 25. In this case, besides obesity, family history of diabetes also increases the risk of developing diabetes by 2 until 4-fold. Smoking increases the chances of developing diabetes by 1.4-fold. Furthermore, lack of regular exercise will cause a 2-fold increase in the risk of developing diabetes. Therefore, diabetes still becomes a burden for worldwide healthcare expenditure. Indonesia’s healthcare expenditure on diabetes in 2017 was 1,712.3 million USD. In conjunction with this statement, preventing diabetes will hopefully decrease the worldwide burden significantly, one of which is by preventing obesity. A simple algorithm on diabetes prevention will help high-risk people to be more aware and easily apply it on their daily activities.

Project Title

: Diabetes? Draculant is Searching For You

Name of University

: Universitas Airlangga

Authors

: Rakha Achmad Maulana Addia Salsabila Visuddho

Content

:

Introduction Diabetes mellitus or often referred as high blood sugar is one of the diseases caused by an unhealthy lifestyle. Unhealthy lifestyle is like eating foods that contain high sugar, lack of physical activity, smoking, and stress. Cases of diabetes in the world are predicted to reach a higher rate of 4.4% by 2030 . Diabetes can refer to various diseases such as dry skin, cracked skin, cataract, glaucoma, and fatigue. These diseases are dangerous, so good preventive measures are needed. Preventive measures is like reduce stress, avoid smoking, lose body excess fat and training. It is hoped that people will know and avoid the causes of diabetes mellitus and also take good precautions to reach a community free of diabetes mellitus.

Objective Diabetes mellitus is dangerous disease that needs to be handled quickly. It can only be done if the community understands the importance of healthy lifestyle. Through the public poster, community knows about the impact of a disease so they will learn how to prevent this problem.

Project Name: HERE DIABLO University’s Name: Universitas Airlangga Author’s Name: Tutus Rachkutho Abstract Diabetes is well known illness which spread out through the world. In 1980, there are over one hundred million people who are infected by diabetes. In 2014, the infected one raised by three hundred percent (422 million people). This diabetes can make the death massacre because forty three percent of adult die.

Moreover diabetes can damage the heart, blood vessels, eyes, kidneys and nerves, leading to disability and premature death. Our objectives are to spread out this projects program to ensure that the diabetes could be prevented and controlled by the people in the worlds. The more people knows HERE DIABLO, (Healthy Eating, Regular Exercise, DIAbetes medication, Blood Sugar Monitoring), the more people’s awareness for diabetes.

FACULTY OF MEDICINE UNIVERSITAS AIRLANGGA VALENSIA IRAWAN

011811133022

EDEN LEONITA

011811133050

INTAN ALDA SAFIRA

011811133056

NATASYA ARIESTA SELLYARDI PUTRI

011811133064

The Necessary of Preventing Obesity with INSTANT Obesity is a condition when calories taken is so much higher than burned, gives result in storing too much fat in the body. It is different with overweight because overweight can be caused by extra muscles or water. The BMI of overweight is >25, but when it comes to >30, it is obesity. Based on WHO data in 2016, 650 million of 1.9 billion people were obese and 2.8 million of them died in a year because of overweight and obesity. Its prevalence was tripled than in 1975.

Obesity is mostly caused by poor diet and lifestyle, which are consuming too much fast food or too frequently, eating more than the need without balancing it with exercising, and over drinking alcohol. Obese people easily get deadly illness, such as diabetes type II, stroke, cardiac arrest, or even colon cancer. To prevent obesity, people can intake enough food, not too much drinking alcohol anymore, eating vegetables, decrease fast food consumption, exercising more, arrange healthy diet, and control the emotion, which we call INSTANT. In conclusion, it is necessary to re-arrange healthy diet and lifestyle for preventing obesity so wonâ&#x20AC;&#x2122;t be attacked with dangerous medical illness and increasing the value of life.

INSTANT Movement!

A condition when calories taken is so much higher that burned, gives result in storing too much fat in the body

over 200 million men and nearly 300 million women were obese. more than 10% of the worldâ&#x20AC;&#x2122;s adult population was obese (WHO, 2008)

a simple index commonly used to classify overweight and obesity BMI greater than or equal to 25 is overweight BMI greater than or equal to 30 is obesity

ntake enough food

650 million were obese 2.8 million of died in a year its prevalence was tripled than 1975 (WHO, 2016)

o more alcohol

ctive exercising

ay YES to veggies

ote healthy diet!

ightly limiting fast food

ake over your emotion wisely

VALENSIA IRAWAN-EDEN LEONITA- NATASYA ARIESTA-I NT AN AL DA

Junk Food Make Your Life "Junk" !

Jambi University Amelia Minarfah Salim, Fani Nadila, Halimatusadiah, Santa Febbila

In this modern era, everyone doing instant life. One of their habits is consume junk food. Junk food refers to fast food, which are easy to make and easy to consume. Consumption of fast food is one factor that can caused obesity. Excess sugar and fat can accumulate in your body causing weight gain that can make obesity. This has other affects on your body it can increase the risk of developing type 2 diabetes.

The relation between obesity and type 2 diabetes is both type 2 diabetes and obesity are associated with insulin resistance. Our pancreas still producing insulin normally. Due to the obesity, fats lying in the vessels that make insulin unable to enter body effectively therefore glucose levels become increased.

Therefore, we present this poster to show that we only get "junk" if we eat junk food. Here we show the changes in our body if us become obesity and get diabetes melitus. We want everyone start doing healthy life by changes their bad habit to healthy life. Remember ! Junk Foods Make Your Life "Junk" !

Eat Wise, Drop A Size - Be Diabetes Free!

Jambi University Pelangi Rizqeeta, Marisa Prafita Isman, Tiwi Lestari, Jesi Pebriani

Diabetes is the condition in which the body doesnâ&#x20AC;&#x2122;t properly process food for use as energy. Type 2 diabetes (Diabetes Mellitus) is the most common accounts for around 90% of all diabetes cases worldwide. The increase in the prevalence of diabetes mellitus is influenced by risk factors that can be modified in particular due to a lack of physical activity, overweight, and obesity. In people with diabetes mellitus, insulin produced by the pancreas canâ&#x20AC;&#x2122;t work optimally to help body cells absorb glucose because it is disrupted by complications of obesity. Obesity is at risk of developing diabetes mellitus 2.26 times higher than non-obese. Obesity is the biggest risk factor of Diabetes Mellitus.

Nowdays people donâ&#x20AC;&#x2122;t care about their food, their often eat junk food cause they are busy with their activities. Through this poster, we would like to persuade the public to take preventive measures of obesity to avoid diabetes. A healthy lifestyle is a key to prevention. If it is not prevented from now it will have a bad impact and moreover death. Even small steps can add up to big differences in your health over time. So, Eat wise drop size be diabetes free and enjoy better life.

Donâ&#x20AC;&#x2122;t Sugar Coat It! Clarissa Surya; Michelle Griselda; Michelle Octaviani P; Ongky Satria Pelita Harapan University Background Diabetes mellitus is a non-communicable disease, that is resulted from bodyâ&#x20AC;&#x2122;s inability to produce insulin or wronged usage of insulin. As referred from WHO, an estimation of 422 million of adults were living with diabetes in Asia. On recent years, diabetes contributes 60% of deaths in Asia (2014). Almost half of them were diagnosed with overweight or even obesity. Diabetes and obesity are two of the major etiologies of atherosclerosis that may cause a heart attack.

Aim The aims of this Public Poster are: (1) to educate the society about diabetes and obesity. (2) to inform the society about role of diabetes and obesity with Heart attack (Atherosclerosis) (3) to enlighten the society about the right prevention of diabetes and obesity.

Conclusion Driven from the information stated above, this poster has the purpose of encouraging the society about the danger of Diabetes and Obesity and its prevention that may lead to its complications such as Heart attack (Atherosclerosis). We decided to design our poster with an obese background that aims in giving a higher impact to the readers about obesity as one of the risk factor of diabetes.

ABSTRACT Most parents are proud if their child is plump and chubby, but most of them don’t know that it’s not an ideal condition for their child. The stigma “fat kids are healthy” should be re-justified because the reality is being fat as a kid increases the risk to become obese later. Don’t let parents’ pride for having a fat kid affects the kid’s health in the future.

41 million preschool children were overweight in 2016 (WHO, 2017) and 2.8 million people dying each year globally because of obesity (WHO, 2015). Obesity increases the risk of having type 2 diabetes mellitus (DM) and ≥80% of people with type 2 DM are obese (Powers, 2018). Type 2 DM causes a lot of complications and most of those complications can lead to death.

Prevention is always better than medication and for that reason it’s important to educate people, especially parents, to reduce number of obesity. Healthy lifestyle from proper activities and dietaries should be implemented since early life. Through this poster is expected to raise awareness especially for parents that having a fat kid isn’t a good idea and we want to guide them on how to prevent their kid from becoming obese.

References: Riddle, M. C. (Ed.). (2018). Standards of Medical Care in Diabetes – 2018. Diabetes Care,41(Supplement_1). doi:10.2337/dc18-SPPC01 Pandita, A., Sharma, D., Pandita, D., Pawar, S., Tariq, M., & Kaul, A. (2016). Childhood obesity: prevention is better than cure. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 9, 83–89. http://doi.org/10.2147/DMSO.S90783 Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J. (2018).

Harrison's principles of internal medicine (20th edition.). New York: McGraw Hill Education.

Departemen Kesehatan. 2013. Laporan Riset Kesehatan Dasar (Riskesdas) 2013 Bidang Biomedis.

Jakarta: Badan Litbangkes, Depkes RI, 2013.

Kementerian Kesehatan RI. (2017, January 20). Bayi Gendut, Lucu Tapi Belum Tentu Sehat. Retrieved October 14, 2018, from http://www.depkes.go.id/article/print/17012300002/bayi-gendut-lucu-tapibelum-tentu-sehat.html

Volkov, S., & Robinson, K. WHO. (2017, October 16). 10 facts on obesity. Retrieved October 14, 2018, from https://www.who.int/features/factfiles/obesity/en/ WHO. (2015, February 01). Obesity. Retrieved October 14, 2018, from http://www.who.int/gho/ncd/risk_factors/obesity_text/en/ Mayo Foundation for Medical Education and Research (MFMER). (2018, September 15). Type 2 diabetes.

Retrieved October 14, 2018, from https://www.mayoclinic.org/diseases-conditions/type-2diabetes/symptoms-causes/syc-20351193

Project Title: Chubby is not the Same as Healthy Universitas Gadjah Mada Authors: Ignatius Evan Santosa, Axel Brahmantyo Maynardo Nugroho, Margaretha Cempaka Sweety

ABSTRACT No More Junk Food for Your Kiddie, Let Them Be Diabetic-free Karunia Widhi Agatin Putri1, Azzahra Asysyifa1, Sharqi Muhammad Ash-Shiddiqi1 1

Faculty of Medicine, Public Health, and Nursing Universitas Gadjah Mada

Type-2-Diabetes Mellitus (T2DM) was known as a disease which commonly affected adult and geriatric. However, the prevalence of T2DM in children and adolescent has increased dramatically. This condition is strongly related to obesity because the most common comorbidities associated with obesity is T2DM (Pulgaron and Delamater, 2014).

According to WHO, there are 340 million children and adolescent who are obese in 2016.

Sedentary life style and unhealthy diet, such as junk food and high glucose food, are responsible for this condition. Excessive time spent on sedentary behavior can increase the risks of obesity regardless of engagement in physical activity (Kim, 2015). One of the phenomenon which happens quite frequently is when parents spoil their children with junk food and high glucose food. They believe that junk food is their kidsâ&#x20AC;&#x2122; favourite. Moreover, it is convenient and easily available.

The problem of diabetes and obesity correspond to a significant public health issues with potentially great personal and societal cost. That is why raising awareness of parents about the danger of pediatric obesity and diabetes will be a great move to prevent the increasing number of people living with the disease.

References Kim, Y. (2015). Sedentary Lifestyle and Obesity in Adults. [online] Lib.dr.iastate.edu. Available at: https://lib.dr.iastate.edu/cgi/viewcontent.cgi?article=5422&context=etd [Accessed 23 Oct. 2018].

Pulgaron, E. and Delamater, A. (2014). Obesity and Type 2 Diabetes in Children: Epidemiology and Treatment. Current Diabetes Reports, 14(8).

Julia, M., Utari, A., Moelyo, A. and Rochmah, N. (2015). Konsensus Nasional Pengelolaan Diabetes Mellitus Tipe 2 pada Anak dan Remaja. [online] IDAI. Available at: http://www.idai.or.id/professional-resources/guideline-consensus/konsensus-nasional-pengelolaandiabetes-tipe-2 [Accessed 23 Oct. 2018].

WHO (2018). Obesity and Overweight. [online] World Health Organization. Available at: http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweigh [Accessed 23 Oct. 2018].

340 million children & adolescent are obese

!!!

GLU G LU

Obesity leads to type 2 diabetes mellitus

No more junk food for your kiddie, let them be diabetic free.

ABC of Surviving Diabetes Abstract Keisha Athiyyawara Lyubiana, Fransisca Dias Laksmayanti, Christina Wunardi Universitas Gadjah Mada

In Indonesia, prevalence of uncontrolled diabetes remains high especially in rural area. Ironically, most Indonesians still regard metabolic disease as non-threatening condition as the following complications do not rise immediately, making it hard for patients to be aware of their conditions.

However, the fact is, complications could arise all together as comorbidities and will hamper quality of life.

Aiming to prevent that, we promote simple yet easy way for people with diabetes to adapt healthy lifestyle. ABC stands for aerobic exercise, blood sugar level, and calorie intake. Aerobic exercise is the most suitable type of exercise for diabetic patient, routine blood sugar checking is important to monitor treatment and overall condition of patient, and calorie intake is the key to control blood sugar level.

While we already make it simple, our campaign still faces challenges, mainly from patients who still find it hard to incorporate healthier and correct diet and exercise, recalling that those two lifestyles are still uncommon in Indonesia. In order to tackle that issue, we use visual and easy percentage for better understanding of calories intake. We also state minimum exercise needed per week as supportive lifestyle.

Run for Your Life! Before It (Cardiovascular Diseases) Catches You by Surprise…

Authors: 1. Shania Quency Alexandra Waelauruw (Universitas Gadjah Mada) 2. Amanda Natalie Wijaya (University of Indonesia) Background Cardiovascular disease (CVD) presents itself as one of the top global leading causes of death.1 It is estimated that death by CVDs makes up about 31% of all deaths worldwide. 2 Despite being very common, people tend to take CVDs very lightly and are not aware about the risks. There are many risk factors of CVDs, such as people with obesity and diabetes are more likely to contract CVDs due to metabolic stress on the heart and clogging of the blood vessels. 3 One of the easiest ways to decrease the risk of developing CVDs is through exercise. Today, sedentary lifestyle has become more familiar as an effect of technology and globalization. This is detrimental for our health, specifically our cardiovascular system.4 Objectives This public poster is intended to raise awareness about CVDs that are very easy to contract especially during this time. We highlight that CVDs shows no mercy, it can affect people of all ages, genders, and race, at any time and place. By informing one of the things we can do which is through routine cardio exercises 30 minutes per day, such as, running, we hope to prevent more CVDs from happening in the future.5

References: 1. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2017 update. Circulation. 2017 Mar 7; 135(10): e146–e603.

2. On world heart day WHO calls for accelerated action to prevent the world’s leading global killer [Internet]. World Health Organization; 2016 [cited 2018 Oct 15]. Available from: https://www.who.int/cardiovascular_diseases/en/ 3. Scherer PE, Hill JA. Obesity, diabetes, and cardiovascular diseases: a compendium. Circ Res. 2016 May 27; 118(11): 1703–1705.

4. Agarwal SA. Cardiovascular benefits of exercise. Int J Gen Med. 2012; 5: 541–545.

5. Dohrn IM, Kwak L, Oja P, Sjostrom M, Hagstromer M. Replacing sedentary time with physical activity: a 15-year follow-up of mortality in a national cohort. Clinical Epidemiology, 2018; 10: 179-86.

Stop Hypertension with Proper Nutrition Balance your Diet with More Vegetables and Fruits, Less Salt, No Trans-Fat Authors: Mariska Andrea Siswanto, Pamela Basuki, Amanda Natalie Wijaya, Andreas Suryo Wijaya Universitas Indonesia, Depok Background Hypertension or high blood pressure is a condition where blood pressure is higher than 130/80 1

mmHg. As a major health issue, hypertension is in fact one of the leading causes of deaths worldwide.

According to WHO, approximately 1 billion people suffered from hypertension in 2008. Other adverse health consequences of hypertension are heart attack, stroke, kidney failure, blindness, and cognitive impairment.2 Obesity and diabetes is a risk factor for developing hypertension. This triad usually occurs together and is commonly known as the metabolic syndrome. Both obesity and diabetes causes clotting of the arteries known as atherosclerosis. This will increase vascular resistance and eventually lead to hypertension.3 Diets play the biggest role to prevent hypertension. Appropriate diet includes salt reduction to maximum 1 teaspoon (5 g) daily, trans-fat replacement to polyunsaturated fats which is contained in fish or nuts, and consumption of 5 servings (400 g) of fruits and vegetables daily. This diet should also be accompanied by yearly blood pressure check-up.2 Objectives To raise awareness of regular blood pressure check-up and to promote a healthy lifestyle in the community by eating more vegetables and fruits, limiting consumption of salt, and replacing trans-fat.

References: 1. Whelton PK, Carey RM, Aronow WS, et al. 2017 guideline for high blood pressure in adults [Internet]. Washington DC: American College of Cardiology; 2017 [updated 2018 May 7; cited 2018 Oct 22]. Available from: https://www.acc.org/latest-in-cardiology/ten-points-toremember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults 2. World Health Organization. A global brief on hypertension. Geneva: World Health Organization; 2013.

3. International Diabetes Federation. The IDF consensus worldwide definition of the metabolic syndrome. Belgium: International Diabetes Federation; 2006.

Abstract Project Title

: Tackling Obesity with Courage

Name of the University : Universitas Indonesia Authors

: - Jason Phowira - Mochammad Izzatullah A - Sakinah Rahma Sari - Varalisa Rahmawati

Background Obesity is one of the most dangerous health problems worldwide. It has become an important global health issue and requires urgent attention. In 2014, according to World Health Organizations, 700 million people are regarded as obese. Particularly in developing countries, peopleâ&#x20AC;&#x2122;s awareness of the danger of obesity are low in spite of the fact that obesity and diseases linked to obesity are the leading cause of death. Medical complications associated with obesity are increased risk of diabetes mellitus, hypertension, fatty liver, heart disease, osteoarthritis, sleep apnea and numerous types of cancer. Asians are proven to have a higher fat percentage, thus, prevention of obesity is vital to combat the harmful effects of obesity.

Objective -

To inform people how to prevent obesity by adapting a healthy lifestyle, which we summarize as a mnemonic, COURAGE. Consume food rich in Omega 3 and Fatty Acid Obtain and monitor ideal weight Utilize more time for physical activities and exercise Reduce consumption of processed/junk food and food high in sugar Always drink sufficient amount of water Get enough quality sleep per day Eat more fruits and vegetable

-

To raise peopleâ&#x20AC;&#x2122;s awareness regarding the danger of obesity along with its complications.

Reference 1. World Health Organizations. 2015.

2. Asian Development Bank Institute. The imminent obesity crisis in asia and the pacific: first cost estimates. 2017.

3. Cheong WS. Overweight and obesity in Asia. Barkshire Hathaway Company. 2014.

ABSTRACT

Cut The Sweet Tea, So You Won’t Get Sweet Pee Daniell Edward Raharjo*, Fabiola Cathleen, Marco Raditya *daniell.edward.raharjo@me.com

Diabetes Mellitus type 2 is among the top 10 leading cause of mortality worldwide and commonly leads to kidney failure, blindness, amputation, even death. WHO estimated 422 million adults have it and 3,7 million died due to diabetes in 2012. Unfortunately, these numbers are rising.

One to be concerned is the kinds of sweet tea consumption, such as bubble milk tea which lately has become very trending. One cup has almost 50 grams of sugar which is far beyond the recommended daily sugar intake for women and men. This explains how over consumption of sweet tea can lead to DM type 2 with glucose-containing urine—sweet pee.

This becomes the foundation to our poster and campaign concept, since a popular topic can draw more people to engage in the poster and be warned about DM, which is our main objective. Furthermore, since reduction of other risk factors is also needed to prevent DM type 2 as a lifestyle disease holistically, we creatively made “S-WE-E-T-T-EA.” an mnemonic of those factors from sedentary lifestyles to poor diet. As the title says, cutting “sweet tea”, literally and in terms of the mnemonic, will be the best way to prevent sweet pee.

Reference: 1. World Health Organization. (2016). Global report on diabetes. Geneva. Retrieved from http://apps.who.int/iris/bitstream/handle/10665/204871/9789241565257_eng.pdf;jses sionid=A7912CC161AA96C10897A5FDFD182DA4?sequence=1 2. Min, J.E., Green, D.B., Kim, L. (2017) Calories and sugars in boba milk tea: implications of obesity risk in Asian Pacific Islanders. Food Science and Nutrition, 5(1):38-45. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217910/ 3. American

Heart

Association.

(2018).

Added

sugars.

Retrieved

https://www.aarp.org/food/wine-beverages/info-09-2010/sweet-tea-nation.html

from

Public Poster Abstract PCC EAMSC 2019: Thailand Project title: ​Let’s Nurture our Children’s Future Author:

Amino Aytiwan Remedika, Nathasha Brigitta Selene, Fransesco Bernado Hubert Jonathan

(AMSA-Universitas Indonesia) Objective: ​To increase awareness of diabetes during pregnancy (gestational diabetes) which has been associated with adverse health outcomes for the mothers and their newborns.

Introduction Diabetes is a serious chronic disease which has been rendered as the health burden worldwide. The global prevalence has doubled from 4.7% (1980) to 8.5% of adult population in 2014. In regards to socioeconomic status, diabetes prevalence has faster growth in low to middle-income countries in which plethora of Asian countries are situated in this level economically.​1 The prevalence of gestational diabetes (GDM) in Eastern and Southeastern Asia is estimated to be 10.1% which is considered as high.​2 ​GDM is associated with increased risk of fetal macrosomia, large-for gestational-age neonates, perinatal mortality, glucose intolerance, and metabolic syndrome from the fetal side (in conjunction to fetal programming hypothesis) as well as increase risk of preeclampsia, maternal type 2 diabetes, and obesity. ​Therefore we purpose NURTURE (Nutritional therapy, Undergo postpartum follow up, Routine physical activity, Two step approach of screening GDM, Use oral antidiabetic agents and insulin therapy, Realize risks and complications of GDM, Ensure routine antenatal care) to minimize the adverse pregnancy outcomes and complications, maternal and fetal risks of chronic health conditions in later life.​3,4 References: 1. World Health Organization. Global report on diabetes. World Health Organization; 2016.

2. Nguyen CL, Pham NM, Binns CW, Duong DV, Lee AH. Prevalence of Gestational Diabetes Mellitus in Eastern and Southeastern Asia: A Systematic Review and Meta-Analysis. Journal of diabetes research. 2018.

3. Xiong X, Saunders LD, Wang FL, Demianczuk NN. Gestational diabetes mellitus: prevalence, risk factors, maternal and infant outcomes. Int J Gynaecol Obstet 2001;75:221–8.

4. Wang C, Yang HX. Diagnosis, prevention and management of gestational diabetes mellitus.

Chronic diseases and translational medicine. 2016 Dec;2(4):199.

IDEAL LIFESTYLE TO DEAL WITH YOUR OBESITY

ABSTRACT Alieftya Paramitha, Shintya Kurniawati, & Raditya Widya Surianata University of Muhammadiyah Malang, Malang, Indonesia Currently, obesity becomes an emergent public health problem. It is a condition of excessive fat accumulation affecting someoneâ&#x20AC;&#x2122;s health and reducing productive life. The prevelance of obesity has incresed 28% in ASEAN-6 (Indonesia, Malaysia, Philippines, Singapore, Thailand, and Vietnam) in four years, since 2010. Obesity itself is caused by imbalance between calories intake and expendible calories.

This imbalance occurs through some factors such as genetics, behaviour, psychology, and enviroment.

Obesity increases risk of other serious health problems like diabetes, depression, asthma, cancer, hypertention and so on. Body Mass Index (BMI) is used as the parameters to evaluate obesity statussomeone is categorized as obese if BMI shows 30.0 or higher. However, IDEAL are the simplest thing to do in treating obesity : Increase sleep duration (7 â&#x20AC;&#x201C; 8 hours per day), Drinking plenty of water without adding any sugar, Eating small amount of food which has a lot of calories, Activating physical exercise at least 30 minutes everyday, and Lessening 'screen time' by watching TV or working on computer in just less than 2 hours per day.

DON’T LET THEIR WORDS BECOME A WIELDING SWORD ABSTRACT Gede Subhaga, Evelin Aronggear, Muhammad Ridho AMSA-Universitas Muhammadiyah Malang Most people love to hear praises from others but they don’t realize that those praises can be double-edged sword, that either save them or kill them. For example, praises for people with obesity like “you are fine even though you are fat”, “you’re fit”, “fat is beautiful”, “it is okay to be fat” and etc. Those words unfortunately would make them become close-minded and think that being obese is okay as long as they’re healthy. Sadly, they don’t know that they will face big threats such as Coronary disease, Osteoarthritis, Osteoporosis, breast cancer, infertility and etc.

It is time for people with obesity to change for better future by getting rid of those praises, being out of their comfort zone and change their mindset that being obese will bring them negative impact rather than the positive one. Let’s start healthy lifestyle by decreasing junk food consumption and do more exercise because if not now, then when will it be? If you are not the one who started it, then who else? Don’t make your life full of regrets because of a word that can wield to your heart, womb, bone, and other body parts.

Diabetes Mellitus? Just Dance it Away!

--------------------------------------------------------------------------------------------------------------------------Radya K. Ardianto1, Airenda Mutiara P.N1, Prima Sultan H.1 1

University of Muhammadiyah Malang

Sustainable Development Goals (SDGs) are 17 global goals which is supported by United Nation Development Programme. SDGsâ&#x20AC;&#x2122; main target is to make all people in this world find their peacefulness and prosperity. One of main point in SDGs is point number three, concerning about universal health which is to ensure healthy lives for all at all ages. However, nowadays, there are abundant of diseases which can obstruct people to get their prosperity. One of them is diabetes mellitus. Diabetes mellitus is a chronic disease, indicates with raised blood sugar over time leads to serious damage to many of the bodyâ&#x20AC;&#x2122;s systems, especially the nerves and blood vessels. Based on WHO (2016), 1.5 million deaths in the world caused by diabetes. Also based on Obesity Society, almost 90% people with Type 2 Diabetes are obese or overwight. Therefore, this phenomenon has evoked a question. How do we do to prevent it? The answer is simple. Yep, just dance it away! Do regular check up once in a while, Avoid tobacco and smoking, Note a healthy intake of food in your diet, Conserve a healthy weight, and Exercise regularly, at least 30 minutes a day.

ASIA DIABETES : THE WHITE RICE YOU EAT THAT MATTER , Amy Tryabto Arifin, Muh. Arham Harun, Azizah Pridayanti Septiman, Nurul Fadhilah Fakultas Kedokteran Universitas Hasanuddin (AMSA-Unhas)

More than 90% of rice is produced and consumed in Asia. In terms of food consumption, what distinguishes Asia from the rest of the world is its great dependency on rice: it is the basic staple for the majority of the population. A meta-analysis of seven cohort studies following 350,000 people for up to 20 years found that higher consumption of white rice was associated with a significantly increased risk of type 2 diabetes, especially in Asian populations. They estimated each serving per day of white rice was associated with an 11 percent increase in risk of diabetes.

Consuming excess amount of white rice will lead you to certain problems. White rice has a high glycemic index which it is easily broken down into simple sugars in the body and raises the blood sugar level of the body. The simplest solution of the problem is to control the portion of the rice.

Our poster shows you that by doing simple thing such as take a spoon and cut a small amount of the rice will gradually changes â&#x20AC;&#x153;your shapeâ&#x20AC;?. By doing it continuously, you will not only gain a better shape, but also a better health.

CONSUME LESS , CONTROL YOUR DIABETES.

White rice consumption in asia are three times higher than the nutritionistâ&#x20AC;&#x2122;s recommendation.

ITâ&#x20AC;&#x2122;S CALLED HAM-BURGER Andi Azizul Nukita, Nadhifah Nurul, Nurul Khairurrizki Faculty of Medicine, Hasanuddin University â&#x20AC;&#x201C; Makassar, Indonesia Obesity is overweight or excess weight due to excessive accumulation of body fat. An estimated 1.7 billion people on this earth are overweight. Obesity is one of the risk factors for degenerative diseases, such as cardiovascular disease, diabetes mellitus, several types of cancer, etc.

One of the risk factor of it is by comsuming junk food.

One problem with junk foods is that they're low in satiation value that is, people don't tend to feel as full when they eat them which can lead to overeating by that it can cause obesity. Another problem is that junk food tends to replace other more nutritious foods. By that it can interfere with the balance in the body, and if it is disturbed the person will get sick more easily.

We aim to spread the effect of consuming junk food towards people by this poster and send the knowledge that junk food. Reducing consumption of junk food can reduce the incidence of obesity which is one of the diseases with a high mortality rate such as, reducing the habit of consuming junk can prevent people for cardiovascular disease, which is the disease with the highest mortality rate.

Junk Food : The New Addictive Drug Andi Nurul Azizah Maruddani, Dhiya Muthiah Ghaffari, Ismi Nuranggraeni Guntur, Anis Ammar Mihdar Hasanuddin University, Indonesia.

Nowadays, Junk food is leading us to a whole new level of bad impact. Not only being a risk factor of overweight and obesity but also becoming an addictives. We usually think of food and drugs as distinct categories. But they have a lot of similarities. They're both substances you put in your body, and many people find it hard not to go overboard. Also, Studies have shown that junk foods flood the reward system in the brain with dopamine, stimulating the same areas as drugs of abuse like cocaine.1 Furthermore, Everyone knows that junk food and drugs are unhealthy but still unable to control their consumption. Cravings are a common symptom when it comes to both junk foods and addictive drugs. The obsessive nature and thought processes are identical.

Otherwise, studies have shown that both food and drug cues activate the same brain regions when people crave either junk food or drugs.2, 3 Through this poster, we would like to gain people awareness that we are becoming unconscious of being addicted and still enjoy junk food, and it is the time for us to break our habit. So, still lovinâ&#x20AC;&#x2122; it? We are quitting it.

References : 1. Luis Hernandez, Bartley G. Hoebel. Food reward and cocaine increase extracellular dopamine in the nucleus accumbens as measured by microdialysis. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/0024320588900367 2. Blumenthal DM, Gold MS. Neurobiology of food addiction. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/20495452 3. Gene jack wang et al. Imagine of Brain Dopamine Pathways Implications for Understanding

Obesity.

Retrieved

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3098897/

from

Let the gadget help your diet.

Anis Ammar Mihdar, Ahmad Taufik Fadillah Zainal, Dhiya Muthiah Gaffari, Ismi Nuranggraeni Guntur Hasanuddin University, Indonesia.

Obesity has reached epidemic proportions globally, with at least 2.8 million people dying each year as a result of being overweight or obese.1 The truth is obesity, as well as their related noncommunicable diseases, are largely preventable. Supportive environments and communities are fundamental in shaping peopleâ&#x20AC;&#x2122;s choices, by making the choice of healthier foods and regular physical activity the easiest choice (the most accessible, available and affordable), and therefore preventing obesity.2 Surprisingly, there are tens of thousands of health-related gadget applications (apps), including hundreds of diet apps, are effective to control your consumption and physical activity.3 The apps can track your daily foods and activities that will improve your health behaviours. Beside of that, you can access your apps anytime and anywhere. Not only accessible, but also cost-effectiveness through the free apps. with all the benefit on diet apps, you can prevent yourself, your friend and your family from obesity and contribute to WHO campaign about save the world from obesity.

Through this poster, we would like to inform the people that your gadget can save yourself, your friends, and your family from obesity by tracking daily foods and activities in accessible, available and affordable way.

References : 1. WHO. 10 Facts on obesity. Retrieved from http://www.who.int/features/factfiles/obesity/en/ 2. WHO.

Obesity

and

overweight.

Retrieved

from

http://www.who.int/news-room/fact-

sheets/detail/obesity-and-overweight 3. Brian Yoshio Lainget al. Effectiveness of a smartphone application for weight loss compared to usual care in overweight primary care patients: a randomized controlled trial. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4422872/

EAT MORE TO LOSE MORE , Azizah Pridayanti Septiman, Nurul Fadhilah, Amy Tryabto Arifin, Muh. Arham Harun Fakultas Kedokteran Universitas Hasanuddin (AMSA-Unhas)

The famous technique of losing weight is by drastically reduce your daily intake. Cutting your meals is not a good strategy to lose weight. The truth is, in order to lose weight you need to eat more food in several intake. Eating more is about eating more of the right kind of food.

In order to lose weight, you need to eat protein (whole eggs, fish, beef), fat (butter and coconut oil), and low-carb vegetables (broccoli, tomatoes, and spinach). First you need to know and count what your body needs. Then, divide your needs to several portion of meals.

You can absolutely eat more than three times and have a view healthy snacks. Snacks are easily prepared food like fruits or yoghurt.

This poster aimed to inform people that it is possible to lose weight by eating more of wellmanaged meals.

Losing weight isn't about skipping meals it's about eating right amount, on the right time.

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HACKING DIABETES : THE POWER OF ARTIFICIAL PANCREAS Author : Gabrielle Natasha Sutanto, Leony Octavia, Liani Elisabeth Enggy, Firshan Makbul Hasanuddin University, Makassar

Background : Diabetes Type 2, or more commonly known as diabetes mellitus, is a disease caused by the inability of pancreas to produce insulin to control the sugar level in the blood in a long time. It is one of the leading cause of death, and has been increasing significantly especially in middle and low-income countries. The current tool that is used for detecting blood glucose level is glucometer, and the patient have to inject the insulin by his/herself.

As the medicinal technology grows along technological development, thereâ&#x20AC;&#x2122;s a new technology, not quite talked about in public, named artificial pancreas device system. It impersonates the work of healthy pancreas. It uses a computer-controlled algorithm that connects to the continuous glucose monitoring (CGM) system and the insulin infusion pump to allow continuous communication between the two devices. If the CGM detects low blood glucose level, it will notify the insulin infusion pump to pump insulin to the blood, to control the blood glucose level. It can prevent low and high blood glucose level with little or no input from the patient.

Objectives : To inform other people about these brand new technology, that can save lives from the complication of diabetes mellitus, either because of negligence or unaware. We hope that by promoting this new, automated technology, we can save loved ones that are currently battling through their diabetes, and help create a better life

References : http://www.who.int/news-room/fact-sheets/detail/diabetes https://www.joslin.org/info/10_Things_You_Might_Not_Know_About_Diabetes.html

https://www.fda.gov/medicaldevices/productsandmedicalprocedures/homehealthandconsumer/consumerp roducts/artificialpancreas/ucm259548.htm https://www.diabetes.org.uk/about_us/news/artificial-pancreas-type-2

LIMIT THE FAST FOOD OR OTHERWISE IT WILL BE THE LAST FOOD Author : Liani Elisabeth Enggy, Gabrielle Natasha Sutanto, Leony Octavia, Firshan Makbul Hasanuddin University, Makassar

Background : Junk food is a generic term for all kinds of foods which are rich in energy, because they contain a lot of fat and sugar, as well as salt, but are relatively low in other important nutrients such as protein, fiber, vitamins, and minerals. However, fast food is extremely attractive to most children because of the taste, comparatively lower price, and doesnâ&#x20AC;&#x2122;t require any cooking or preparation. Since children typically do not understand how this kind of food negatively impacts their health, it can be quite addictive. Globally, an estimated 3.4 million deaths, 3.9% years of life lost, and 3.8% of Disability Adjusted Life Years (DALYs) are related to overweight and obesity. Parents of young children face an increasingly complex world the ever increasing availability of prolific marketing, confusing product labels and misleading health claims create an environment that promotes unhealthy food and drink choices. We must change the environment to make the healthy choice the easy choice for parents and their children.

Objectives : We would like to inform and increase society awareness regarding to particularly relating to disturbances in junkfood, and how the consequences of such exposures can promote weight gain and obesity. Therefore, promoting a healthy life style such as education for parents and environment behavioural for children are essentials.

Refrences https://ije-blog.com/2018/03/06/junk-food-in-childhood-contributes-to-socioeconomic-inequalitiesin-overweight-and-obesity/ https://healthyeating.sfgate.com/junk-food-affects-children-5985.html Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, Mullany EC, Biryukov S, Abbafati C, Abera SF, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980â&#x20AC;&#x201C;2013: a systematic analysis for the global burden of disease study 2013

Gupta N, Goel K, Shah P, Misra A. Childhood obesity in developing countries:epidemiology, determinants, and prevention. Endocrine Review. 2012

SPOIL YOUR KIDS, NOT THEIR HEALTH Muh. Arham Harun, Azizah Pridayanti Septiman, Nurul Fadhilah, Amy Tryabto Arifin, Fakultas Kedokteran Universitas Hasanuddin (AMSA-Unhas) For many years type 2 diabetes was seen only in adults but it has begun to occur in children. It was once considered a rare condition in the pediatric population, now accounts for about 15% to 45% of all newly diagnosed cases of diabetes in children and teenagers. High intake of sugar-sweetened beverages, which contain considerable amounts of free sugars, increases the likelihood of being overweight or obese, particularly among children. Early childhood nutrition affects the risk of type 2 diabetes later in life. Parents have a direct role in encouraging the child to control their food intake and give them knowledge about healthy eating.

There are many levels of intervention required to prevent overweight in children, one critical intervention target is the parent. Because childrens equipped with a biological set of taste predispositions: they prefer sweets, salty tastes and energy-dense foods, parents have the role to control their intake by limit sugar-sweetened beverages and junk foods, provide more vegetables and fruits, and serve reasonably-sized portions.

This poster aimed to spread the role of parents on prioritizing actions to prevent their children becoming overweight and obese by control the childrenâ&#x20AC;&#x2122;s intake and give them exposure about healthy eating habits in order to prevent Diabetes.

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WHERE THERE IS AWARENESS, THERE IS HOPE! Nurul Fadhilah, Amy Tryabto Arifin, Muh. Arham Harun, Azizah Pridayanti Septiman Fakultas Kedokteran Universitas Hasanuddin (AMSA-Unhas)

In 2016, more than 60% of the people with diabetes live in Asia. South-East Asia is home to one fifth (19 %) of the total number of people with diabetes in the world in 2017. Factors such as age, gender, diet and lifestyle changes, including a lack of physical activity caused by modernization and urbanization, are major contributory factors. The maintenance of physical activity are critical focus for blood glucose management and overall health in individuals with diabetes and prediabetes. Physical activity includes all movement that increases energy use, whereas exercise is planned, structured physical activity. Exercise improves blood glucose control in type 2 diabetes, reduces cardiovascular risk factors, contributes to weight loss, and improves well-being.

This poster aimed to spread the word about how important it is to fight obesity and Diabetes due to the high number of incident found in Asia. One of the act of prevention is by maintain physical activities as simple as walking, jogging, cycling, and swimming.

Therefore by this awareness, we hope people will be able to start doing exercise, little by little, and together workout against obesity and Diabetes because every bit sweat and action counts.

TURN FAT INTO FIT.

There is a healthy person inside just dying to get out.

OBESITY: THE ULTIMATE TIME BOMB TO DEFUSE Suandih Zulkarnain, Akhmad Alya Maulana, Muh. Nur Cholis, Ahmad Ezra Saleh Hasanuddin University

ABSTRACT: Although genes play a role in body weight, there are other factors involved. In Indonesia, there are plenty of nutrient-rich food to eat and easy access to fattening fast foods and sweets. Also, because of modern lifestyles, we are not as active as we once were. The end result: We're eating more calories than we can burn. Being overweight or obese can cause a whole cascade of health problems, from heart disease, until diabetes. Body mass index has a strong relationship to diabetes and insulin resistance. In obese individuals, the amount of nonesterified fatty acids, glycerol, hormones, cytokines, proinflammatory markers, and other substances that are involved in the development of insulin resistance, is increased. The pathogenesis in the development of diabetes is based on the fact that the βislet cells of the pancreas are impaired, causing a lack of control of blood glucose. The development of diabetes becomes more inevitable if the failure of β-islet cells of the pancreas is accompanied by insulin resistance. Weight gain and body mass are central to the formation and rising incidence of type 1 and type 2 diabetes. These diseases can seriously impact a person's quality of life and slowly lead to premature death.

Would You Dare To Eat Them?

Authors: Vania Noviantika, Siti Nur Djaalna, RifkiWardana Hasanuddin University, Makassar, South Sulawesi

The World Health Organization (WHO) declares obesity as a global epidemic problem.

Globally, obesity is a health crisis that's greater than hunger and a major cause of death also disability in the world. Meanwhile in 2015, diabetes was the direct cause of 1.6 million deaths. International Diabetes Federation states 425 million people suffer from diabetes in the world, will increase to 183 million in 2045. There are more than 10,276,100 cases of diabetes in Indonesia in 2017.

This rising number of obesity and diabetes are correlated with the skyrocketing consumption of junk food.Junk food refers to fast food, which loads of saturated fats and MSG (Flavoring). Excess of saturated fat and MSG in diet has been shown to cause obesity. Most of the fast foods have exceeding levels of sugar which are associated with diabetes. Obesity, preferentially of visceral as well as ectopic fat depots, is specifically associated with insulin resistance leads diabetes.

Diabetes leads diseases such as heart disease, stroke, and blindness. 90% cases of those terrors are caused by junk food. Therefore,we would like to gain the public awareness about the harmful of junk food. Based on those facts, would you still dare to eat them?

REFERENCES International Diabetes Federation.

Ministry of Healt Republic of Indonesia, 20 januari 2017 Shilpa N. Bhupathiraju and Frank B. Hu.Epidemiology of Obesity and Diabetes and Their Cardiovascular Complications. Retrieved from :https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4887150/ World Health Organization.Retrieved from: http://www.who.int/news-room/fact-sheets/detail/diabetes Bhaskar

Rajveer

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Monika.

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CONCERNED WITH OBESITY Author : Al Asâ&#x20AC;&#x2122;Ari and Adpriyanti Candra S Obesity is a metabolic disease that has reached epidemic proportions. The World Health Organization (WHO) has declared obesity as the largest global chronic health problem in adults which is increasingly turning into a more serious problem than malnutrition. In clinical practice, the body fatness is usually estimated by BMI. BMI is calculated as measured body weight (kg) divided by measured height squared (m2). Patients with a BMI of 25 kg/m2 or greater are classified as being overweight. Pre obesity and obesity class I, II and III (extreme obesity) are defined as a BMI of 25 kg/m2 to 29.9 kg/m2, 30 kg/m2 to 34.9 kg/m2, 35 kg/m2 to 39.9 kg/m2, and 40 kg/m2 or greater, respectively.

Promoting healthy behaviours to encourage, motivate and enable individuals to lose weight by eating more fruit and vegetables, as well as nuts and whole grains; engaging in daily moderate physical activity for at least 30 minutes; cutting the amount of fatty, sugary foods in the diet; moving from saturated animal-based fats to unsaturated vegetable-oil based fats. .

PREVENT DIABETIC FOOT OR GET AMPUTATED Agnes Debora, Ave Maria, Desak Gede Yuliana, Shantidewi AMSA-Universitas Brawijaya Diabetic foot is one of the complications of diabetes, besides another long-term complication that affect significantly on quality of life. Diabetic foot can lead to lower limb amputation. According to WHO, lower limb amputation rates are 10-20 times higher among people with diabetic foot. Diabetes is on the rise. No longer a disease of predominantly rich nations, the prevalence of diabetes is steadily increasing everywhere, most markedly in the worldâ&#x20AC;&#x2122;s middle-income countries.

The ability to identify the signs and symptoms of diabetic foot ulcer is essential to reduce the morbidity the disease may cause to diabetic patients. In patients with at-risk lower limbs should be careful to changes such as numbness, weakness, malformation, limited joint morbidity, burning pain of the lower back, changing of skin color, warmness, and shiny skin. The important caution signs are preulcerative signs, which include callus, blisters, hemorrhage, or predisposing ulcer that do not heal.

Diabetic foot is one of the most preventable complication of diabetes. Some preventive recommendation are: daily checking of the feet for at-risk diabetic patients, because diabetic people may be less aware of pain in their feet; keeping the feet clean; using therapeutic shoes; not smoking to prevent vascular complication.

EXIT Ahmad Abdilla Adiwangsa, Muhammad Zayyaan Ba’abdullah, Ricco Armando Coaniago Faculty of Medicine, Brawijaya University, Malang Background: Globally, the prevalence of non-communicable diseases is increasing at an alarming rate.

Diabetes is one of the major causes, with its prevalence is strongly enhanced by obesity. Diabetes may lead to several complications such as heart disease, stroke, nerve damage, and death. In 2015, an estimated 1.6 million deaths were directly caused by diabetes.

Obesity affects the majority of adults in most developed countries and are increasing rapidly in developing countries. If current worldwide trends continue, the number of overweight people (BMI ≥ 25 kg/m2) is projected to increase from 1.3 billions in 2005 to nearly 2.0 billions by 2030. According to World Health Organization’s report, Indonesia and several Asian countries are included in the world’s top countries suffering from diabetes. Those facts are the main reasons which encourage us to reduce the number of people suffering from obesity by increasing awareness against it.

Objective: Through our poster, we aim to increase awareness against the complications of obesity and diabetes. We present two combined pictures, a man and a corpse to show the risks of type-2 diabetes mellitus so the audiences can perceive its severity. We hope that they can change their habit with healthy lifestyles such as regular exercise, healthy diet, no smoking, and least but not least, limit alcohol intake. We try to convey it creatively by using an acronym named EXIT. Our reason in using said acronym is to encourage people to leave their unhealthy lifestyles into healthy ones. One difficulty which may arise from our project is the unfamiliarity about the dangers of obesity that may lead to type-2 diabetes mellitus. The solution which we can provide is by educating not only the person with the higher risk of diabetes, but also their closest ones such as family members and friends so that they can help giving support for them to pursue healthy lifestyles.

References: 1. Gregg EW, Li Y, Wang J, Rios Burrows N, Ali MK, Rolka D, Williams DE, Geiss L. Changes in diabetes-related complications in the United States, 1990–2010. New England Journal of Medicine. 2014 Apr 17;370(16):1514-23.

2. Kelly T, Yang W, Chen CS, Reynolds K, He J. Global burden of obesity in 2005 and projections to 2030. Int J Obes (Lond), 2008; 32:1431–1437 3. Mathers CD, Loncar D.Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med, 2006, 3(11):e442.

4. Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of Obesity, Diabetes, and ObesityRelated Health Risk Factors, 2001. JAMA. 2003; 289(1): 76–79

DIABETES ACTION PLAN Ardhy Ihza Mahindra, Alexander Fernando, Novelina Gracea, Yohana Hartya Dwi Frastari, 1 2

Third Year Medical Student, University of Brawijaya

second year Medical Student, Unoversity of Brawijaya

Abstract In 2017, it is estimated that there are 451 million people living with diabetes worldwide. Despite advances in diabetes therapy, many people with diabetes still fail to achieve treatment targets thus remaining at risk of complications. It is estimated that the global healthcare expenditure on people with diabetes is about USD $850 billion. As diabetes is a growing threat to human health and economic growth, political stakeholders are aiming to identify options for improved response to the challenges of prevention and management of diabetes. Personalized therapy is a current trend in health care, particularly for chronic diseases.Personalizing the management of diabetes according to the patient's individual profile can help in improving therapy adherence and treatment outcomes. To enchance healthcare provider therapeutic decisions based on individual patient profiles, a decision support tools or algorithms are needed to evaluate diabetes patients. One of the supporting tools is Diabetes Action Plan (DAP). This action plan consist of pateint personal information, health infomation of the patient, motivational section, checklist related to the action plan, and also danger sign of diabetes. Through this Diabetes Action Plan, treatment of diabetes will focus on the patient (Patient-centered), not only to the disease.

Keywords: Diabetes, Personalized therapy, Diabetes Action Plan

Stay on TRACK To Prevent Diabetes Mellitus Desak Gede Yuliana Eka Pratiwi, Putu Ayu Tania Krisna Putri, Putu Sri Maharani Utami, Kadek Putri Paramita Abyuda Faculty of Medicine, Brawijaya University, Malang

Globally, the prevalence of diabetes mellitus is increasing at an alarming rate. Diabetes is one of the major causes, with its prevalence strongly enhanced by obesity. Diabetes may lead to several complications such as cardiovascular disease, stroke, nerve damage, and in 2012, diabetes was the direct cause of 1.5 million of deaths. In particular, the prevalence of diabetes is growing most in low- and middle-income countries. According to World Health Organizationâ&#x20AC;&#x2122;s report, Indonesia is included in the worldâ&#x20AC;&#x2122;s top country who suffering from diabetes. Those facts are the main reasons that encourage us to reduce the number of people suffering from diabetes by increasing awareness against it.

Through our poster, we aim to increase awareness against diabetes. We present some prevention for maintain our healthy body and can stay away from diabetes mellitus. We try to convey it creatively by using an acronym untitled stay on TRACK. Our reason in using this acronym is to encourage people to stay on healthy lifestyle and leave their unhealthy habits, by: T: Take a balanced diet R: Reach and maintain healthy weight A: Add physical activity to your daily routine C: Control your blood pressure and cholesterol levels K: Kick the smoking and drinking alcohol habit One difficulty that may arise from our project is the unfamiliarity about the dangers of obesity that may lead to diabetes mellitus. The solution that we can provide is by educating people and remind each other to stay on TRACK.

Obesity is More than Just Being Fat 1

Emanuel Hananto , Andreas Dexter G.1, Bernadus Bernardino B.1, Andra Danika2 1

First Year Medical Student, University of Brawijaya

2

Second Year Medical Student, University of Brawijaya

People with diabetes have many serious health problems. Consistently high blood glucose level can lead to serious diseases heart and blood vessels, eyes, kidneys and nerves. In almost all countries, diabetes is a leading cause of cardiovascular disease, blindness, kidney failure, and lower limb amputation. Indonesia has became top 10 countries of most people living with diabetes in the world, with prevalence 10.2 million people for 18-99 years old and 10 million people for 20-79 years old (IDF, 2017).

Obesity is one of another problem that people with diabetes has to concern about. Obesity comes from bad habit such as eating to much, lazy to do exercise, etc. People with obesity has account for 80%90% of the risk developing to Diabetes type 2. According to WHO, Indonesia does not have policy/action plan to reduce overweight and obesity (WHO, 2016). Because of the fact above, we decided to encourage the nation about the danger of obesity and complication of diabetes and how we can prevent obesity and the diabtes complication.

In the end, we hope that people takes a serious attention to this issues by not underestimating overweight, obesity and diabetes. Cause obesity is more than just being fat.

The Chubby Kid is at Risk Irene Yasmina Vilado, Nurul Izzatuzzahra, Serri Rivally, Christine Ayu Maharani Universitas Brawijaya Background Childhood obesity is one of the most serious public health challenges of the 21st century. Worldwide, prevalence of childhood overweight and obesity combined rose at an alarming rate, 47.1% between 1980 and 2013. However, this is often underrecognized as a public health issue, where, culturally, an obese child is often considered to be healthy. Based on a cohort study done by Abbasi in 2017, childhood obesity quadruples risk of developing type 2 diabetes and increasing the risk of cardiovascular and other noncommunicable diseases.

According to a report done by WHO, obesity arises from exposures of the child to an obesogenic environment. Many children today are growing up in environments that encourage weight gain. In some settings, obesity are becoming social norms and thus contributing to the perpetuation of the obesogenic environment. The easy access to energy-dense, low-nutrient foods and sugar-sweetened beverages have also contributed to this. American Heart Association recommends children over age 2 years should consume no more than 25 grams of added sugar each day.

Objective To raise the awareness of childhood obesity and its correlation with the increasing risk of noncommunicable diseases.

To give education about the importance of limiting the consumption of several unhealthy foods and sweetened beverages.

.

A CHAIR MIGHT KILLS YOU BRAWIJAYA UNIVERSITY AUTHOR : 1. Maria Harin Danintya 2. Maulana Wildan Seputra The continued development of today's technology, people are increasingly experiencing a decrease in physical activity. Americans spend 55% of their waking time, or 7.7 h/day, sedentary, while Europeans are estimated to spend on average 40% of their leisure time watching TV [3].

This problem lead to another problems. People tend to develop a new habit, where physical activity is less than before. A habit which people are more passive and less active can be called sedentary lifestyle [1][3].

Sedentary lifestyle isn’t something to be taken so lightly. If it’s not handled seriously, it can cause many complications, such as obesity and diabetes melitus. In Indonesia, number of people with DM in 2013 increased twice as much as in 2007 [2]. According to WHO, The global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014 [4]. While sedentary lifestyle can lead into diabetes, it has lots of deathly complications if not treated well [2].

Because of this problems, we hope with this public poster, we can remind people to keep active, increase their moderate-to-vigor physical activities, so we can prevent a lot of diseases, specially obesity and diabetes melitus prevalence.

References : 1. KURDANINGSIH, Septi Viantri; SUDARGO, Toto; LUSMILASARI, Lely. Physical activity and sedentary lifestyle towards teenagers’ overweight/obesity status. International Journal Of Community Medicine And Public Health, [S.l.], v. 3, n. 3, p. 630-635, feb. 2017.

ISSN 2394-6040.

2. Kementerian kesehatan RI. INFODATIN Pusat Data dan Informasi Kemeterian Kesehatan RI Situasi Kesehatan Remaja. 2015.

3. Henson J., Edwardson C.L., Davies M.J., Yates T. (2018) Sedentary Behaviour, Diabetes, and the Metabolic Syndrome. In: Leitzmann M., Jochem C., Schmid D. (eds) Sedentary Behaviour Epidemiology. Springer Series on Epidemiology and Public Health. Springer, Cham 4. World Health Organization. Fact Sheet: Obesity and Overweight, 2015. Available from URL: http://www.who.int/mediacentre/factsheets/fs311/ en/. Accessed on 10 January 2015.

A CHAIR MIGHT KILLS YOU BRAWIJAYA UNIVERSITY AUTHOR : 1. Maulana Wildan Seputra 2. Maria Harin Danintya The continued development of today's technology, people are increasingly experiencing a decrease in physical activity. Americans spend 55% of their waking time, or 7.7 h/day, sedentary, while Europeans are estimated to spend on average 40% of their leisure time watching TV [3].

This problem lead to another problems. People tend to develop a new habit, where physical activity is less than before. A habit which people are more passive and less active can be called sedentary lifestyle [1][3].

Sedentary lifestyle isn’t something to be taken so lightly. If it’s not handled seriously, it can cause many complications, such as obesity and diabetes melitus. In Indonesia, number of people with DM in 2013 increased twice as much as in 2007 [2]. According to WHO, The global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014 [4]. While sedentary lifestyle can lead into diabetes, it has lots of deathly complications if not treated well [2].

Because of this problems, we hope with this public poster, we can remind people to keep active, increase their moderate-to-vigor physical activities, so we can prevent a lot of diseases, specially obesity and diabetes melitus prevalence.

References : 1. KURDANINGSIH, Septi Viantri; SUDARGO, Toto; LUSMILASARI, Lely. Physical activity and sedentary lifestyle towards teenagers’ overweight/obesity status. International Journal Of Community Medicine And Public Health, [S.l.], v. 3, n. 3, p. 630-635, feb. 2017.

ISSN 2394-6040.

2. Kementerian kesehatan RI. INFODATIN Pusat Data dan Informasi Kemeterian Kesehatan RI Situasi Kesehatan Remaja. 2015.

3. Henson J., Edwardson C.L., Davies M.J., Yates T. (2018) Sedentary Behaviour, Diabetes, and the Metabolic Syndrome. In: Leitzmann M., Jochem C., Schmid D. (eds) Sedentary Behaviour Epidemiology. Springer Series on Epidemiology and Public Health. Springer, Cham 4. World Health Organization. Fact Sheet: Obesity and Overweight, 2015. Available from URL: http://www.who.int/mediacentre/factsheets/fs311/ en/. Accessed on 10 January 2015.

DIABETIC NEPHROPATHY Vanessa Carolina Gunawan1, Silvia Husodo2, Ivanna Yuhan3, Melisa Ivoryanto4 University of Brawijaya Background Diabetes become a major public health problem that is approaching epidemic proportions globally.

Diabetes is a disease where your blood glucose level is too high because you cannot produce or cannot use insulin properly. Obesity can increase the risk of insulin resistance that can lead to diabetes. WHO’s South-East Asian region estimated that 96 million people have diabetes in the region and 90% of whom have type 2 diabetes. Around 30% ─ 40% people with type 2 diabetes develop kidney disease. Diabetic nephropathy is a chronic loss of kidney function caused by diabetes. Therefore, obesity, diabetes, and diabetic nephropathy are corelated to each other and we have to cut their vicious circle.

Objective •

To give information about diabetic nephropathy

•

To prevent obesity and reduce the risk diabetes and diabetic nephropathy

•

To promote healthy lifestyle and change people bad habit

ABSTRACT Live Healthy, Prevent Obesity Alfi Rizky, Galih Setya N., Maria Angela S., Rebecca Gracella.

Sebelas Maret University, Surakarta Background: Obesity is defined as abnormal or excess accumulation of adipose tissue that may impair health (defined by BMI >30). Obesity has become massive public health problem globally, and is the number one cause of death and disabilities around the world.[3] The World Health Organization shows dramatic increases in the prevalence of obesity where it has nearly tripled between 1975 and 2016. In the most recent WHO data, in 2016, about 13% of the worldâ&#x20AC;&#x2122;s adults population (aged â&#x2030;Ľ20 years), around 650 million, were obese.[3] Obesity is a multifactorial condition influenced by genetic, demographic and lifestyle factors such as sedentary behaviours, physical inactivity and unhealthy dietary choices. [2] Obesity is major risk factor for many medical condition, one of which is the type 2 diabetes.[3] If the BMI is greater than 35 kg/m2 the risk of diabetes is increased by 93 times.[1] Objective: To create better understanding of the relationships between obesity and lifestyle factors in order to show effective prevention for both obesity and type 2 diabetes.

References: 1. Barnes AS. 2011. The Epidemic of Obesity and Diabetes: Trends and Treatments. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3066828/ Accessed on October, 20th 2018 2.10 PM 2. Otang-Mbeng W., GA Otunola, and AJ Afolayan. 2017. Lifestyle factors and co-morbidities associated with obesity and overweight in Nkonkobe Municipality of the Eastern Cape, South Africa. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5445301/. Accessed on October, 20th 2018 2.10 PM 3. World

Health

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ALFI RIZKY

GALIH SETYA N.

MARIA ANGELA S.

REBECCA GRACELLA

LIVE HEALTHY, PREVENT OBESITY Obesity is

generally caused by eating too much and moving too little. It can lead to DIABETES

OBESITY IS PREVENTABLE

Increase YOUR physical activity

Make YOUR healthier dietary choicesÂ

Measure YOUR weight regularly

Powered by TCPDF (www.tcpdf.org)

Intergenerational Association between Early Maternal Menarcheal Age and Risk of Childhood Obesity: A Systematic Review of Large Prospective Cohort Studies Angela K. Tjahjadi1, Angga W. Lokeswara1, Joanna E. Hanrahan1 From Faculty of Medicine, Universitas Indonesia1 Corresponding author: Angela K. Tjahjadi, Universitas Indonesia Medical School, Jl. Salemba Raya No. 6, Jakarta 10430, Ph. +6287852349810; e-mail: kimmtjahjadi@gmail.com.

Abstract Background Obesity is currently a rapid growing global issue among children. Most current studies focus on childâ&#x20AC;&#x2122;s own risk factors, leaving the intergenerational influence, including maternal factors, underestimated. Early maternal menarcheal age may have an intergenerational impact on childrenâ&#x20AC;&#x2122;s growth and risk of childhood obesity development.

Aim To evaluate the association between early maternal menarcheal age and risk of childhood obesity.

Methods A systematic review was performed in 5 electronic databases from August 1985 - October 2018. Our review included all English language publications on large prospective birth cohort studies in children. The outcomes were body mass index or z score according to 2006 WHO Child Growth Standard. Risk of bias was assessed using the Revised Cochrane Collaboration Risk of Bias Tool for cohort studies (RoB 2.0).

Results The search yielded 4 large prospective cohort studies. All reviewed studies revealed that children from mothers with earlier age of menarche were seen to have higher BMI compared to those whose mothers had older age of menarche, thus increasing the risk of developing childhood obesity in these children. However, this association was not consistently apparent from birth of the offspring to childhood period, and only in the childhood period the increased BMI and increased risk of obesity became more obvious. Epigenetics on hormonal programming were hypothesized to be the underlying cause of this association, yet environmental aspect also ought to play a role in the association.

Conclusion This study affirms the association between early maternal menarcheal age and increased risk of childhood obesity. Understanding the knowledge gap of intergenerational impact may help to create multi-level approach to alleviate the burden of obesity.

Keywords: early maternal menarcheal age, childhood obesity, body mass index

Intergenerational Association between Early Maternal Menarcheal Age and Risk of Childhood Obesity: A Systematic Review of Large Prospective Cohort Studies Angela K. Tjahjadi1, Angga W. Lokeswara1, Joanna E. Hanrahan1 From Faculty of Medicine, Universitas Indonesia1 Corresponding author: Angela K. Tjahjadi, Universitas Indonesia Medical School, Jl. Salemba Raya No. 6, Jakarta 10430, Ph. +6287852349810; e-mail: kimmtjahjadi@gmail.com.

Abstract Background Obesity is a rapidly growing global issue among children. Most current studies focus only on childâ&#x20AC;&#x2122;s own risk factors, leaving the intergenerational influence including maternal factors underestimated. Early maternal menarcheal age may have an intergenerational impact on childrenâ&#x20AC;&#x2122;s body mass index and risk of developing childhood obesity.

Objective To evaluate the association between early maternal menarcheal age and risk of childhood obesity.

Methods A systematic review was performed in 5 electronic databases from August 1985 - October 2018. Our review included all English language publications on large prospective birth cohort studies in children. The outcomes were body mass index or z score according to 2006 WHO Child Growth Standard. Risk of bias was assessed using the Revised Cochrane Collaboration Risk of Bias Tool for cohort studies (RoB 2.0).

Results The search yielded 4 large prospective cohort studies. All reviewed studies revealed that children from mothers with earlier age of menarche were seen to have higher BMI compared to those whose mothers had older age of menarche, thus increasing the risk of developing childhood obesity in these children. However, this association was not consistently apparent from birth of the offspring to childhood period, and only in the childhood period the increased BMI and increased risk of obesity became more obvious. Epigenetics on hormonal programming were hypothesized to be the underlying cause of this association, yet environmental aspect also ought to play a role in the association.

Conclusion This study affirms the association between early maternal menarcheal age and increased risk of childhood obesity. Understanding the knowledge gap of intergenerational factors might help to create the novel and multi-level strategy to end the vicious cycle of obesity.

Keywords: early maternal menarcheal age, childhood obesity, body mass index

1. Introduction The World Health Organization (WHO) defines obesity in children (5-18 years old) based on 2006 Child Growth Standard as z score of body mass index (BMI) above +2 SD (equivalent to BMI 30 kg/m2 at 19 years old) for children of the same age and sex (World Health Organization [WHO], 2007).

Global prevalence of childhood overweight and obesity had increased from 4.2% in 1990 to 6.7% in 2010 (WHO, 2010). The number of overweight children under the age of five, is estimated to be over 41 million in 2016 (WHO, 2017). Nearly one of six children is overweight or obese according to OECD countriesâ&#x20AC;&#x2122; Obesity Updates 2017. This trend is expected to reach 9.1% or 60 million in 2020 (OECD, 2017). Furthermore, Indonesia is included among 10 countries with the highest numbers of estimated overweight and obese children (5-12 years) of 11.9% based on Riskesdas 2013 (Depkes RI, 2013).

Obesity in childhood are more likely to persist until adulthood, thus risking in the development of premature metabolic syndrome which precedes various non-communicable diseases, such as diabetes and cardiovascular diseases (Sahoo et al., 2015; Rankin et al., 2016). Raised body mass index is also a major risk factor for gastrointestinal cancers, cognitive and motor function impairment leading to reduction in the quality of life and a greater risk of teasing, bullying and social isolation (Rankin et al., 2016). In addition, increasing overall age morbidity, premature mortality, school attainment and forgone labor market productivity due to obesity in childhood have already been acknowledged (GNP, 2017).

In the midst of this rapidly changing era, obesity in children is a global inevitable effect due to major alteration of daily dietary and physical activities pattern. In Indonesia, new emerging risk factors of obesity in children are still debated. Mueller et al. had reported that early age at menarche was associated with risk factors of cardio-metabolic diseases, such as wider waist circumferences, high nutritional status, elevated triglycerides and higher risk of adult diabetes (Mueller et al., 2014).

Moreover, an association between early menarcheal age and higher risk of adulthood obesity in women was already established. A cross sectional study conducted among 13-15 years-old adolescent girls in Indonesia found that early menarche subjects had significantly higher nutritional status including higher body mass index (BMI) (p<0.001), CDC-percentile (p<0.001), WHO Z-score (p<0.001), and waist circumference (WC) values (p=0.02) compared to those with older age of menarche (Hariani R, Nouvrisia V, Yustikarani D, 2018). Unfortunately, existing studies merely confine to evaluate risk factors within one generation life-span, yet the possibility of current risk factors influencing the next generationâ&#x20AC;&#x2122;s quality is frequently overlooked. This may become the unrecognized cause of continuously growing of obesity.

Driven by the gap above, researcher nowadays instigate to learn about the relationship of early maternal menarche age to their offspringâ&#x20AC;&#x2122;s characteristics, particularly obesity through an inherited trait. Some previous studies showed significant association between early maternal menarcheal age with offspring rapid infancy growth, thus causing higher BMI or even obesity. Early maternal menarche age may become a significant potential risk factor of childhood obesity. However, until now, no agreement about the causality between the two conditions has been made. Therefore, this systematic review was conducted with the aim of evaluating association between early maternal menarcheal age and the offspringâ&#x20AC;&#x2122;s risk of developing childhood obesity.

2. Methods 2.1 Search strategy We searched all relevant published journal articles in MEDLINE, EBSCOHost, ProQuest, ScienceDirect, and ClinicalKey between August 1985 and October 15, 2018. We searched for articles containing maternal menarcheal age terms and body mass index analysis terms in children. The search strategy used both subject heading and text word searches. Initial search terms were updated after searching the reference lists of relevant articles. Table 1 summarizes the search terms used and Figure 1 shows the overview of the study selection process using a PRISMA flowchart.

Table 1. Search terms used Database

Search terms

Pubmed

("maternal menarche age" OR "early menarche age" OR "maternal age of menarche") AND (child* OR offspring*) AND (obese OR obesity OR BMI OR body mass index)

ProQuest

("maternal age of menarche" OR "maternal menarcheal age") AND (offspring OR childhood) AND obesity

EBSCOHost

("maternal age of menarche" OR "maternal menarcheal age") AND (offspring OR childhood) AND obesity

ScienceDirect

("maternal early menarche" OR "maternal age of menarche" OR "maternal menarche") AND ("offspring") AND "obesity"

ClinicalKey

("maternal age of menarche" OR "maternal menarcheal age") AND (offspring OR childhood) AND obesity)

We searched the Cochrane Database for Systematic and Complete Reviews to identify systematic reviews and/or meta–analyses to ensure that no previous similar studies were conducted on this topic. Manual search of reference lists was also conducted to identify relevant articles that were not identified by the databases. The authors selected potential articles by screening titles and abstracts independently from each other. After accounting for duplication, we reviewed the titles and corresponding abstracts of all studies to identify articles that fulfill the inclusion criteria. If a study was deemed to potentially fulfil the inclusion criteria, full-text versions were retrieved and assessed to determine final study selection. Reference lists of all retrieved articles were also searched.

2.2 Selection of studies Criteria were developed in an iterative process after preliminary searches. We included studies based on original data from analytical epidemiological studies, among children (at birth-17 years). Body mass index (BMI) or weight-height z score had to be a study’s outcome. We included maternal menarcheal age (MMA) as a risk factor. Studies assessing not only MMA as a risk factor but also sex, age, gestational age, parity, mother's education and mother's BMI, and feeding practice during first 6 months were required to treat MMA as a continuous exposure (ie, linear models). We omitted non-observational studies and one cross sectional study is excluded due to homogeneity and consistency of cohort design of study in etiologic studies. All reviewed studies are English articles; however, we did not place any restriction on language, study location, publication status or year of publication.

2.3 Data extraction From each study, we extracted the study design, subjects’ characteristics, offspring’s BMI or weight-height z score according to 2006 WHO Child Growth Standard, and compared the results between the exposed and unexposed groups.

2.4 Assessing risk of bias The risk of bias assessment was based on the the Revised Cochrane Collaboration risk of bias tool for cohort studies (RoB 2.0), as shown in Figure 2. Each study is assessed separately for prespecified bias domains including confounding factors, missing outcome data or lost to follow-up, exposure measurement, outcome measurement, and selection bias. We also considered the validity of each cohort study based on the sampling of mother during pregnancy, children growth, numbers declining to participate, and their baseline characteristics. Overall bias of each articles was classified as low, unclear risk/some concerns and high risk.

3. Results 3.1 Search results We identified 174 papers based on the search terms used in respective databases. The articles were then analyzed for duplicates, screened for relevance, inclusion and exclusion criteria as shown in Figure 1. Five relevant observational studies were selected and assessed for eligibility. In order to maintain heterogeneity, 1 cross-sectional study was excluded, resulting in 4 cohort studies reviewed.

3.2 Study characteristics and findings The summary of the characteristics and results of the studies can be found in Table 2. All studies included were large, prospective cohort studies, conducted by following the pregnant mothers until their children are born and grown until the age of childhood. A pooled total of 558,351 children and their mothers were considered in the study. The ages of the children range from 2 â&#x20AC;&#x201C; 9 years old, except one study which included an extra set of analysis of BMI of the puberty group (8 â&#x20AC;&#x201C; 14 years

old). The maternal menarcheal age considered in the study ranges from 11 to 15 years old, the data of which is mostly taken from a self-reported questionnaire during mothersâ&#x20AC;&#x2122; pregnancies. Two of the studies are from Asian population, one from British population and one from American population.

In terms of results, all four studies unanimously agree that earlier maternal menarcheal age is significantly associated with higher offspringâ&#x20AC;&#x2122;s childhood BMI, even after adjusting with various factors in the respective studies. One study even showed a nearly 3-fold increase in risk of obesity in mothers with menarcheal age of 11, compared to that of 15. Another study showed that even after adjusting with gestational weight gain (GWG), earlier maternal menarcheal age is still associated with higher childrenâ&#x20AC;&#x2122;s BMI and their rapid growth.

Table 2. Summary of Cohort Studies Article

Population

Risk Factor (Maternal Menarcheal Age)

Authors Study Method of Measures and Country Study size (Year) design Identification Classification Min J, Li Z, China Cohort 54,184 women Self reported MMA is divided into: Liu X, Wang and their recall interview a. early (≤13 years) Y (2014) children's (523, b. intermediate 096) growth c. late (≥ 16 years) trajectories during first 5 years of life (2000-2005) in South China

Lai TC, Hong Yeung SLA, Kong Lin SL, Leung GM, Schooling CM (2016)

Cohort 3172 children Maternal age from Children of menarche of 1997 obtained from (Chinese birth postal Survey cohort) in 2008-2009. recruited from Maternal and Child Health Centres in Hong Kong.

Outcome (Offspring BMI) Age 4-5 yr

Maternal age of menarche 2-8 yr is classified as: and ≤ 11 8-14 yr 12 13 14 ≥15

Method of Measurements Measuring weight and height using z score based on 2006 WHO Child Growth Standard

Results Children with early MMA (≤ 13 years) were more likely to be rapid growers (OR = 1.3 [1.2 – 1.4]) and overweight (OR = 1.4 [1.0 – 1.9] compared to those with late MMA.

BMI = weight/height2 Z score of BMI : After adjusted with GWG, MMA was ≥1: at risk of overweightstill associated with children's BMI ≥2: overweight and their rapid growth during the first and rapid weight gain 2 years of life. Children with early during infancy MMA and excessive GWG were more (Difference of weight z likely to have rapid weight gain (OR = scores between age 2 1.6 [1.4 – 1.8]) and overweight at age and birth >0.67) 4-5 (OR = 5.2 [2.0 – 13.5]) Birth weight was converted into sexspecific z scores, and BMI and height were converted into sexspecific z scores from scheduled measurements at 3, 9, and 36 months, relative to the 2006 WHO Child Growth Standards

Earlier maternal menarcheal age was not associated with infant BMI, yet associated with higher BMI in childhood and puberty.

Older maternal age of menarche was associated with lower BMI in childhood (-0.037 Z score per year older maternal menarcheal age, 95% CI : -0.064 – -0.010) and at puberty (0.073 z score, 95% CI : -0.10 – -0.042) Adjusting for pregnancy conditions Height was ascertained made little difference. Adjusting for as supine length in maternal BMI attenuated the infancy, but as standing associations (-0.019 z score, 95% CI : height subsequently.

0.043 – 0.0052)

Table 2. (continued) Article

Population

Risk Factor (Maternal Menarcheal Age)

Authors Study Method of Country Study size (Year) design Identification Ong KK, United Cohort 6009 children Self reported Northstone Kingdom from UKthrough K, Wells population questionnaire JCK, Rubin based Avon MMA during C, Ness AR, Longitudinal pregnancy Golding J, Study of Parents Dunger DB and Children (2007) birth cohort

Measures and Classification Mother’s age at menarche is divided into : a. ≤ 11 yr b. 12 yr c. 13 yr d. 14 yr e. ≥ 15 yr

Outcome (Offspring BMI) Age

Method of Measurements

Results

9 yr

Anthropometric measurement on children at age 9 yr; weight measured by Seca 724 or 835 scales and standing heights using Liester height measures (socks and shoes removed

Earlier mother's menarche predicted increased BMI (0.29 kg/m/y) ; all p <0.001. Most of the gain in BMI was attributed by fat mass index rather than lean mass index. Adjusted to mother's BMI : BMI in child (0.18 kg/m2/y; p<0.001

BMI = weight for height2 unit :(kg/m 2 ) Obesity in children was defined as BMI > 97th percentile for sex and age by comparison with the UK 1990 growth reference

Basso O, United Cohort 31,474 US Data was Pennel ML, States of Black and available, yet Chen A, America White children methods are Longnecker born from 1959 unclear MP (2010) to 1966 in the Collaborative Perinatal Project

MMA is divided into : a. ≤ 11 yr b. 12 yr c. 13 yr d. 14 yr e. ≥ 15 yr

Compared with children of mothers in the oldest menarche quintile (≥15 y), children of mothers in the earliest menarche quintile (≤11 y) had a nearly 3-fold increased risk of obesity (OR 2.91, 95% CI [2.02–4.19]; p < 0.001, adjusted for sex, age, and mother’s education). The risk of obesity was similar in boys and girls (p-value for interaction = 0.9 adjusted to mother's BMI : (OR 2.15, 95% CI [1.46–3.17]; p <0.001)

7-8 yr Measure BMI at birth, At age 7 yr, a difference of increased ages of 1,3,4,7,and 8 year BMI 0.4 kg/m 2 among early MMA using linear mixed models (adjusted with many factors). Children of women with earliest MMA on Children were measured average were taller and had a higher according to standardized BMI at ages 7 and 8 than children of procedures by trained women with latest MMA, adjusted personnel. Length/height with mother's BMI, study center, race, was measured to the child's sex, socioeconomic index, nearest 0.5 cm, in a s child/s age at measurement, p < 0.05 supine position through with linear tren.

20 months age, and standing thereafter. Scales Earliest MMA group had highest mean were calibrated at least BMI at 8 y =16.4, yet the latest MMA semi-manually group had lowest BMI = 15.9

3.3 Risk of bias assessment The results of the risk of bias assessment are shown in Figure 2, along with the justifications of the assessment in Appendix 1. In general, all four studies have low risk of bias in most of the criteria used in the assessment. The study by Ong KK, et al. is assessed to have the lowest risk of bias as it meets all the criteria. The other three studies were subject to high risk of bias due to either lack of information, or high percentage of loss to follow up. The studies by Lai TC, et al. and Min J, et al. also omitted the explanation and details of how the measurements of weight, height and BMI were performed, whereas the study by Basso, et al. and Min J, et al. pretermitted the explanation of how other prognostic factors were measured. However, each of the study was assessed to have low risk of bias in at least 4 out of 7 criteria. With that, the confidence put in drawing conclusions from these studies can be considered reasonable and justified.

Figure 2. Risk of bias assessment for individual studies 1 Selection of exposed and nonâ&#x20AC;?exposed cohorts drawn from the same population 2 Confidence in the assessment of exposure 3 Confidence that outcome of interest was not present at the start of study 4 Matching exposed and unexposed for all variables or statistical analysis adjust for these prognostic variables 5 Assessment of presence or absence of prognostic factors 6 Confidence in the assessment of outcome 7 Adequacy of follow-up 4. Discussion 4.1 Summary and interpretation of evidence Association between early maternal menarcheal age and childhood obesity Our systematic review analyzed 4 cohort studies investigating the intergenerational association between maternal menarcheal age and offspringâ&#x20AC;&#x2122;s obesity. We intend to explore whether earlier maternal menarcheal age could predict the development of obesity in the offspring. All

reviewed studies revealed that children from mothers with earlier age of menarche were seen to have higher BMI compared to those whose mothers had older age of menarche (Ong et al., 2007; Basso, Penell, Chen, & Longnecker, 2011; Lai, Au Yeung, Lin, Leung, &Schooling, 2016; Min, Li, Liu, & Wang, 2016). Ong KK et al (Ong et al.,2007) reported that the gain in BMI in these children was attributable to greater fat mass index rather than lean index, hence increasing the risk of obesity in these children. At the age of 9, compared to children whose mothers were in the oldest menarche quintile, children of mothers in the earliest menarche quintile had nearly 3-fold higher risk of developing obesity (OR = 2.91, 95% CI [2.02 - 4.19]; p < 0.001). The similar trend was also found in the study by Basso O et al. and Lai TS et al. where early maternal menarcheal age was associated with higher risks of obesity in childhood (Basso, Pennell, Chen, & Longnecker, 2011; Lai, Au Yeung, Lin, Leung, & Schooling 2016). The risk was found to be similar in boys and girls (p value of interaction = 0.9) (Ong et al., 2007). As mothers with earlier age of menarche tend to be heavier themselves, results of these studies (Ong et al., 2007; Basso, Pennell, Chen, & Longnecker, 2011; Lai, Au Yeung, Lin, Leung, & Schooling 2016) were adjusted by mother’s BMI or mother’s anthropometry. After the adjustment, the association between earlier maternal age of menarche and higher risk of developing obesity in childhood remained and was just slightly attenuated (Ong et al., 2007; Basso, Pennell, Chen, & Longnecker, 2011; Lai, Au Yeung, Lin, Leung, & Schooling 2016).

However, Min J et al. (Min, Li, Liu, & Wang, 2014) did not state clearly whether the association between maternal menarcheal age and increased risk of overweight in the offspring was adjusted by the mother’s size. All these results provided good evidence in that mother’s age at menarche was not only a marker for her own risk of obesity, yet also a factor affecting the child’s obesity risk through the intergenerational relationship.

Interestingly, the association of earlier maternal menarcheal age with higher offspring’s BMI was not consistently apparent throughout the period of children’s growth (from birth to childhood). At birth, it was reported that earlier maternal age of menarche was actually unrelated to the offspring’s size (Ong et al.,2007). In the first 2 years of life, though, the infants born from these mothers became rapid growers. However, from the second year of age to the years leading to childhood, the trend of increasing BMI was not seen clearly in these children. Then, only in childhood, the increased BMI and increased risk of obesity became more obvious (Basso, Pennell, Chen, & Longnecker, 2011).

Later on as adults, these children may eventually attain shorter stature, leading to the tendency towards higher body max index and finally risk of obesity itself. In light of these unclear and inconsistent signs of obesity throughout the growth of the children, close monitoring on these children’s early growth parameters becomes a crucial aspect in the preventive efforts against childhood obesity, in the hope to lessen the risk of developing metabolic diseases in adulthood.

Vicious cycle of obesity Combining the results of this systematic review with previously established findings, we uncover an underemphasized vicious cycle of obesity. All 4 studies also provided evidence on the association between early maternal menarche age with faster weight gain and growth during infancy.

This rapid growth during infancy leads to increased risk in developing childhood obesity (Basso, Pennell, Chen, & Longnecker, 2011; Ong et al., 2007; Lai, Au Yeung, Lin, Leung, & Schooling, 2016; (Min, Li, Liu, & Wang, 2014). This is consistent with the findings of a systematic review by Ong KK et al. in 2006 where he reported that rapid infancy weight gain predicted subsequent higher BMI and thus obesity in childhood (Ong & Loos, 2006). Moreover, it was also stated in a study by Keim et al. (Basso, Pennell, Chen, & Longnecker, 2011) that girls with higher BMI tend to experience earlier menarche and further, would have higher BMI as an adult. This is also supported by the results of the reviewed studies, where it was found that there was a tendency of mothers who had earlier age of menarche to develop adulthood obesity (Ong et al., 2007; Basso, Pennell, Chen, & Longnecker, 2011). Ong KK et al. (Ong et al.,2007) reported that mothers with earlier age of menarche (≤11 years old) were likely to have 5-fold increased risk of developing obesity herself compared to mother’s with older age of menarche (≥ 15 years old) (OR = 5.11, 95% CI [3.41-7.67]; p < 0.001). This trend was also seen in the study by Basso O et al. (Basso, Pennell, Chen, & Longnecker, 2011) where women with earlier age at menarche (≤ 11 years old) were frequently found to be overweight compared to those with older age of menarche (>15 years old). As the cycle went on, it was also found by Ong KK et al. (Ong et al., 2007) that daughters of mothers with earlier age of menarche were likely to report also an early menarche (before age 11) compared to that of mothers with oldest age of menarche.

However, all 4 studies have also shown that the associated increased offspring BMI is seen in both boys and girls, suggesting that early maternal menarcheal age might be one of many markers related to the programming of the offspring’s overall growth, rather than being specific to female development only (Basso, Pennell, Chen, & Longnecker, 2011; Ong et al., 2007; Lai, Au Yeung, Lin, Leung, & Schooling, 2016; Min, Li, Liu, & Wang, 2014). Greater understanding of this intergenerational relationship would help shed a light on the potential intervention to reduce the global burden of obesity that is continuously growing.

Proposed underlying mechanism The four studies have already summarized the evidence of intergenerational effects of early puberty and obesity, such as the strong association between early maternal menarcheal age and the risk of childhood obesity and infancy growth rate. There are two proposed theories underlying this association. First, hormonal programming and epigenetics in childhood growth and puberty have been acknowledged. Rapid growth during childhood may have a programming effect on later body composition in adulthood (Basso, Pennell, Chen, & Longnecker, 2011). Ong et al. also revealed

consistent association between early maternal menarche age, rapid infancy weight gain and later obesity risk is an inherited or transgenerational influence, related to genes that regulate early appetite and satiety (Ong et al., 2007). Second, Min et al. found that in-utero modification is a crucial period of controlling offspringâ&#x20AC;&#x2122;s growth trajectories. Increased maternal leptin level associated with gestational weight gain may enhance the transfer of fat storage and energy to the fetal growth, thus elevating risk of childhood obesity development. All in all, it remained unclear which theory is more likely to be the underlying mechanism of this association (Min, Li, Liu, & Wang, 2014).

Environmental factors In terms of the external factors, Basso et al. and Min J et al. (Basso, Pennell, Chen, & Longnecker, 2011; Min, Li, Liu, & Wang, 2014) showed that mothers with higher socioeconomic class and level of education were inclined to have early age of menarche. It was not stated in both studies which aspect of socioeconomic status were assessed. One study showed an association between living in urban areas, representing one aspect of higher socioeconomic status, and higher BMI. It was hypothesized that nutritional factors might play a role in creating the association (BastoAbreu et al., 2018). Social environmental determinants, such as declined physical activity and increased consumption of dietary fat in urban areas, may enhance the expression of genetic factors relating to rapid maturers and obesity in children (Basso, Pennell, Chen, & Longnecker, 2011; Min, Li, Liu, & Wang, 2014; Lai, Au Yeung, Lin, Leung, & Schooling, 2016; Min, Li, Liu, & Wang, 2014).

In this vein, childhood growth not only depends on genetic inheritance but also sociodemographic factors, as the estimated proportion of heritable factors is only 50-78% in childâ&#x20AC;&#x2122;s growth pattern and pubertal timing (Basso, Pennell, Chen, & Longnecker, 2011), thus environmental and behavior aspect ought to be considered as impactful risk factor.

4.2 Strengths and limitations of the selected studies The strengths and limitations of the four studies have also been considered in this systematic review. The strengths of the studies are largely based on their large number of subjects and their study design of prospective cohort. With prospective cohort, the mothers were inquired about the maternal menarcheal age during pregnancy, that is, before the children were even born. This means that when recalling their menarcheal age, the mothers had no idea of whether the children will be obese or not and the mothers would have put in the equitable amount of effort in recalling the menarcheal age, hence preventing bias in recalling the event. Unfortunately, this method of measurements of menarcheal age through recall is still the main limitations of the four studies. However, it is reasonable to take faith in the fact that menarche is known to be a hallmark, significant and one-in-alifetime event in a womanâ&#x20AC;&#x2122;s life. Therefore, it is more likely for mothers to give an estimate of their

menarcheal age with decent accuracy. Although it is unwise to overgeneralize this assumption, the recall method seems to be the only feasible method even at present, hence it was most likely to be the best available option during the time of the studies. In all four studies, confounders such as childâ&#x20AC;&#x2122;s diet and physical activity were not considered. This might lead to overestimation of the role of early maternal menarcheal age in causing childhood obesity. Nonetheless, it is important to acknowledge that multivariate analysis had been performed in all studies, in order to take into account some of the confounding factors.

In the assessment of risk of bias, we have also found that three studies might be subjected to selection bias due to either high number or inadequate information regarding loss-to-follow up. This selection bias might lead to underestimation of risk factors which might otherwise affect the results of the studies. However, all the four studies are considered to have low risk of bias as each one of them met a minimum of 4 out 7 criteria. This means that these studies can still be reasonable and justified evidences to draw conclusions from.

4.3 Strengths and limitations of the review The strength of this review mainly lies on the uniformity of study design across the four studies. All four studies are large, prospective cohort studies whereby all the data of the maternal menarcheal age was obtained from the mothers during pregnancy, and the BMI of the children was then measured until the age of 5 â&#x20AC;&#x201C; 9 years old. This homogeneity in study design makes the studies comparable and hence, helps in drawing a fair and justified conclusion from the four studies. This review also considered a large number of subjects due to the large study done in all four articles.

Looking to the subjects included in this review, there is a heterogeneity in the ethnicity of the subjects in that subjects were ranged from British, American, and Asian races. This could be a strength to this review as the different races might represent the global children population. More importantly, to the best of our knowledge, there has not been any similar systematic review on the association of maternal menarcheal age and increased risk of childhood obesity published previously.

However, this systematic review is limited by the fact that the results of the studies were presented differently from one another, whereby only two studies expressed the odd ratios, and one study used beta value and another used z-score. This difference makes it difficult to have a pooled result in drawing quantitative conclusions. Nevertheless, this can be compensated by the confidence in the qualitative conclusion drawn. Another limitation would be that some of the studies only associate earlier maternal menarcheal age with higher BMI, not necessarily obesity. However, the association between earlier menarcheal age and obesity can still be justified based on the previous studies which have proven increased risk of obesity in children with higher BMI.

4.4 Recommendation In the future, it is recommended that similar cohort studies should be taken into account confounding external factors such as the childâ&#x20AC;&#x2122;s nutritional intake and physical activity. This will make the results of the assessment more comprehensive and applicable to real life situations.

Moreover, it is also hoped that there will be more prospective cohort studies done, possibly following from the time the subject has menarche until pregnancy and until her children reach childhood. This will allow a more accurate dating of the menarche, relying less on the motherâ&#x20AC;&#x2122;s recall.

Based on our results combined with previous studies, it seems that there is a vicious cycle whereby earlier menarcheal age may lead to obesity in childhood which in females may lead to earlier menarcheal age and so on. Therefore, the recommended strategy is a multi-level approach which consists of several plans to cut this vicious cycle targeted at various points, as shown in Figure 3.

These strategies include: 1.

For women who have undergone puberty, to maintain a balanced diet and regular physical

activity, in order to prevent obesity and increased risk of excessive gestational weight gain.

2. For pregnant women with excessive gestational weight gain, to be educated on healthy weight gain and weight gain chart, self-monitoring and healthy diet options and physical activity designed for expecting mothers.

3.

For children with higher BMI, to be educated regarding healthy food and exercises early and

to have their diet and physical activity closely monitored by parents.

It is also important to recognize that a concerted effort from different parties is necessary in alleviating the problem of obesity. Aside from individualâ&#x20AC;&#x2122;s own responsibility and awareness, parents play a monumental role in ensuring healthy lifestyle and inculcating healthy habits for their children since young. Schools and universities, as second home and place of education to many, are also responsible in enabling and enforcing healthy diet and exercises in their students. Doctors, as the leaders of community health also play pivotal role in becoming role models and educators for the community around them. Most importantly, the government is also responsible in ensuring the appropriate laws and measures are in place to support healthy lifestyle of its citizens such as nutrition labelling in goods. Last but not least, international community has to support countries and create an amiable social, environmental and political climate for the people to maintain a healthy lifestyle.

Medical students have a particularly focal role in the joint efforts to prevent obesity. Medical students are the agents of change in the community, responsible to educate and influence the society to implement a healthy lifestyle. This can be done through social projects, where medical students work with community health workers to promote healthy eating, adequate physical activity and routine health check-ups. This can also be achieved through a more relevant and cost-effective strategy through social media campaign to reach a larger scope of audience. All things considered, it

is imperative for medical students to recognize and fulfil their responsibilities as agents of change to actively participate in relieving the unrecognized burden of obesity.

Figure 3 The scheme of recommended multi-level strategy to interrupt the vicious cycle of obesity 5. Conclusions This study confirms the association between early maternal menarcheal age and increased risk of childhood obesity. Our current understanding of the underlying mechanism is still limited, involving intergenerational epigenetics influence on hormonal programming and environmental factors. Although some studies only showed higher BMI as the outcome, the association of early maternal menarcheal age and increased risk of childhood obesity is still justifiable as previous studies have shown that higher BMI leads to increased risk of childhood obesity. Understanding the knowledge gap of intergenerational impact may be the primary key to alleviate the burden of obesity.

Multi-level approaches on high risk populations, including women who have undergone puberty, pregnant women with excessive gestational weight gain and children with higher BMI, are recommended. These include having a balanced dietary intake, performing regular physical activities and watchful growth monitoring to interrupt the vicious cycle of obesity and eventually to relieve the unrecognized burden of obesity.

Conflict of interest None declared.

Funding The authors received no specific grant from any funding agency in public, commercial, or not-forprofit sectors.

References 1. World Health Organization. (2007). Growth Reference: Body Mass Index-for Age 5-19 years old. Retrieved from: https://.who.int/growthref/who2007_bmi_for_age/en/ 2. World Health Organization. (2017). Commission on ending Childhood Obesity. Retrieved from: https://www.who.int/end-childhood-obesity/facts/en/ 3. World Health Organization. (2010). Global prevalence and trends of overweight and obesity among

preschool

children.

Retrieved

from:

https://www.who.int/nutgrowthdb/publications/overweight_obesity/en/ 4. Organisation for Economic Co-operation and Development. (2017). Obesity Update 2017.

Retrieved from: https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf 5. Departemen Kesehatan Republik Indonesia. (2013). Riset Kesehatan Dasar 2013. Retrieved from: http://www.depkes.go.id/resources/download/general/Hasil%20Riskesdas%202013.pdf 6. Sahoo, K., Sahoo, B., Choudhury, A. K., Sofi, N. Y., Kumar, R., & Bhadoria, A. S. (2015).

Childhood obesity: causes and consequences. Journal of Family Medicine and Primary Care, 4(2), 187–192.

7. Rankin, J., Matthews, L., Cobley, S., Han, A., Sanders, R., Wiltshire, H. D., & Baker, J. S. (2016). Psychological consequences of childhood obesity: psychiatric comorbidity and prevention. Adolescent Health, Medicine and Therapeutics, 7, 125–146.

8. GNP. (2017). Global Nutrition Report 2017: Nourishing the SDGs. Global Nutrition Report 2017, 115.

9. Mueller, N. T., Duncan, B. B., Barreto, S. M., Chor, D., Bessel, M., Aquino, E. M. L., …

Schmidt, M. I. (2014). Earlier age at menarche is associated with higher diabetes risk and cardiometabolic disease risk factors in Brazilian adults: Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Cardiovascular Diabetology, 13, 22.

10. Hariani R, Nouvrisia V, Yustikarani D, B. S. (2018). Early-menarche as Determinant Factor for Metabolic-risks: An Epidemiology Perspectives among Adolescent Girls Age 13-15 years old in Jakarta-Indonesia. World Nutrition Journal, 66–73.

11. Ong, K. K., Northstone, K., Wells, J. C. K., Rubin, C., Ness, A. R., Golding, J., & Dunger, D. B. (2007). Earlier mother’s age at menarche predicts rapid infancy growth and childhood obesity. PLoS Medicine, 4(4), 737–742.

12. Basso, O., Pennell, M. L., Chen, A., & Longnecker, M. P. (2011). Mother’s age at menarche and offspring size. Int J Obes (Lond), 34(12), 1766–1771.

13. Lai, T. C., Au Yeung, S. L., Lin, S. L., Leung, G. M., & Schooling, C. M. (2016). Brief Report: Maternal Age of Menarche and Adiposity: Evidence from Hong Kong’s “Children of 1997” Birth Cohort. Epidemiology (Cambridge, Mass.), 27(3), 433–437.

14. Min, J., Li, Z., Liu, X., & Wang, Y. (2014). The association between early menarche and offspring’s obesity risk in early childhood was modified by gestational weight gain. Obesity (Silver Spring, Md.), 22(1), 19–23.

15. Ong, K. K., & Loos, R. J. F. (2006). Rapid infancy weight gain and subsequent obesity: systematic reviews and hopeful suggestions. Acta Paediatrica (Oslo, Norway : 1992), 95(8), 904–908.

16. Basto-Abreu, A., Barrientos-Gutierrez, T., Zepeda-Tello, R., Camacho, V., Gimeno Ruiz de Porras, D., & Hernandez-Avila, M. (2018). The Relationship of Socioeconomic Status with Body Mass Index Depends on the Socioeconomic Measure Used. Obesity (Silver Spring, Md.), 26(1), 176–184.

Appendix 1. Risk of Bias Assessment (detailed notes) Criteria

Basso O, et al. (2010)

Lai TC, et al. (2016)

Min J, et al. (2014)

Ong KK, et al. (2007)

1

Women enrolled from 12 US Academic Hong Kong’s “Children of 1997” birth cohort Exposed and unexposed drawn for 6009 were randomly recruited Medical centres during pregnancy and consisting a large, prospective, populationsame population-based health from UK-population based followed through delivery representative Chinese birth cohort recruited at surveillance system in four provinceALSPAC birth cohort 31.474 US Black and White children bornthe 49 Maternal and Child Health Centres of China at same points of care from 1959 to 1966 in the Collaborative (MCHCs) in Hong Kong over the same time frame (2000Perinatal Project.

2005) Exclusion : other than Black and White, low birth weight, infants with major malformation.

Inclusion : valid birth weight and at least one later weight measurement

2

Available data was shown in tables and figures,yet it was not written explicitly

Maternal age of menarche were obtained from MMA is a hallmark event with a MMA is recorded using postal Survey in 2008–2009, good recall reliability questionnaire during pregnancy self-reported recall bias is unlikely because the assessment of exposure before the outcome occurred

3

Offsprings have not been delivered

Offsprings have not been delivered

4

Using multivariate analysis Using multivariate analysis Using chi-square test, t-tests, and Using chi-square test and adjusting for study centre, race, child’s adjusting for age, sex, maternal age, maternal multivariate statistical analysis multivariate logistic regression sex, socioeconomic index, child’s age at education, parental occupation and household multinomial logistic regression adjusting for sex, age, measurement, mother's age at recruitment, income, latest height z score. Linear regression models, adjusting for all possible gestational age, parity, mother's and mother’s height (in the length/height was used to obtain the adjusted associations for prognostic variables: education, mother's BMI, and model), weight (in the weight model) or birth weight z score and generalized estimating sex, gestational age, birth weight, feeding practice BMI (in the BMI model) equations for BMI exclusive breast feeding during first 6 months, parity, maternal age at pregnancy and height, education, occupation and urban or rural residences

Offsprings have not been delivered Offsprings have not been delivered

Appendix 1. (continued) Criteria

Basso O, et al. (2010)

5

Self-reported pre-pregnancy height and weight.

Data was available, yet methods and timing were unclear

A self-administered questionnaire in Obstetricians examined the Chinese was used at baseline women's health before, during including parental birthplace, parental and after pregnancy and from height, parental BMI were obtained from filled individual booklets with postal Survey in 2008–2009 demographics data insufficient information about prognostic factor's measurement, hence impeding reproducibility

Loss to follow up reached 25% from 31.474 samples

Loss to follow up is found > 20%

6

7

Lai TC, et al. (2016)

Min J, et al. (2014)

Ong KK, et al. (2007)

Mother’s parity, smoking during pregnancy, mother’s highest educational achievement, prepregnancy mother's height and weight were recorded by a questionnaire completed during pregnancy.

Gestation was estimated using the date of last menstrual period and confirmed by antenatal ultrasound reports; in cases of discrepancy the data were reviewed by a single experienced clinician.

Measure BMI at birth, ages of Birth weight was converted into sex- Measuring weight and height Anthropometric measurement on children at age 1,3,4,7,and 8 years using linear specific z scores, and BMI and height using z score 2006 WHO Child 9 y; weight measured by Seca 724 or 835 scales mixed models were converted into sex-specific z scores Growth Standards and standing heights using Liester height from scheduled measurements at 3, 9, measures (socks and shoes removed) Children were measured and 36 months, relative to the World according to standardized Health organization (WHO) Growth BMI = weight for height^2 unit :(kg/m^2) procedures by trained personnel. Standards 2005 and, from annual Obesity in children was defined as BMI > 97th Length/height was measured to measurements at 6 to 13 years, relative to percentile for sex and age by comparison with the nearest 0.5 cm, in a supine the WHO Growth reference 5–19 years the UK 1990 growth reference position through 20 months age, and standing thereafter. Scales Height was ascertained as supine length All weight and length measurements were were calibrated at least semiin infancy, but as standing height converted to sex- and age-independent standard manually. subsequently. deviation (SD) scores in each participant by comparison with the UK 1990 growth reference At birth, 2 yr, 4 yr, 5 yr At birth,2 yr,5 yr, 7 yr, 9 yr no drop out information given consistent number of children in the beginning of the study and the last measurement of children's growth at age of 9 yr

ABSTRACT The Role of Probiotics in Managing Obesity and its Progression in Healthy Overweight and Obese Individuals: A Systematic Review of Clinical Trials Jessica Audrey1, Anthony William Brian Iskandar1, Christianto1, Elvan Wiyarta1 1

Faculty of Medicine, Universitas Indonesia

BACKGROUND: Obesity has been known to cause various metabolic diseases. Clinical trials regarding probiotic consumption in obesity have been conducted, but the results are not fully consistent. These probiotics exhibit various results regarding management of obesity progression.

OBJECTIVE: We conducted a systematic review to assess the use probiotics as an effective and safe method in managing obesity and its associated metabolic diseases.

MATERIALS AND METHODS: A comprehensive search was performed through PubMed and EBSCOhost, searching for randomized controlled trials (RCTs) published within the last five years which study the effect of probiotics administration on overweight and obese individuals. Studies were then further assessed for risk of bias with seven criteria from Cochrane Risk of Bias Tool for Randomized Controlled Trials.

RESULTS: Twelve RCTs were included, with a total of 1099 subjects and intervention duration ranging from 4 to 24 weeks. We find that probiotics significantly reduces body fat, in both single and multi-species probiotic supplementation. It is also found to improve lipid profiles, by reducing triglycerides and LDL cholesterol levels, although effects on HDL cholesterol levels are still limited. Furthermore, probiotics is shown to reduce insulin resistance and inflammatory markers, which is often associated with the aggravation of obesity into various metabolic diseases. They also affect the gut-brain axis, helping to control appetite and eating behaviors, although the exact mechanism still remains unclear. The use of probiotics is proven to be safe without any reported serious adverse effects.

CONCLUSION: We concluded that probiotic consumption presents beneficial effects in managing obesity and its related metabolic diseases, highlighting its potential as a possible adjunct therapy for obesity, aiming to reduce its global prevalence and associated health burdens.

Keywords: obesity; probiotics; clinical trial

Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference (PCC EAMSC) 2019 Scientific Paper

The Role of Probiotics in Managing Obesity and its Progression in Healthy Overweight and Obese Individuals: A Systematic Review of Clinical Trials

By: Jessica Audrey Anthony William Brian Iskandar Christianto Elvan Wiyarta

The Role of Probiotics in Managing Obesity and its Progression in Healthy Overweight and Obese Individuals: A Systematic Review of Clinical Trials Jessica Audrey*, Anthony William Brian Iskandar, Christianto, Elvan Wiyarta *jsaudrey8@gmail.com, (+62) 89690781450 INTRODUCTION Obesity is defined as body-mass index (BMI, which is the weight in kilograms divided by the square of height in meters) of 30 kg/m2 or greater, while BMI between 25 to 30 kg/m2 is considered overweight (Heymsfield & Wadden, 2017; World Health Organization, 2018). Beneath these numbers is a more complicated phenotype, which is primarily associated with excess adiposity, which could manifest as serious diseases, such as type II diabetes mellitus, cardiovascular disease, respiratory conditions, osteoarthritis, and certain cancers (e.g. esophageal and colon cancer) (Hruby & Hu, 2015). Therefore, some organizations has pronounced obesity as a disease itself (Heymsfield, et al., 2017; Hruby, et al., 2015).

Globally, the number of obese and overweight people has increased since the last three decades. By 2016, WHO estimated that more than 2.5 billion adults were affected, 1.9 billion were overweight and the remaining 650 million were obese. It is also estimated that by 2030, 57.8% of adult population around the world would have a BMI of 25 kg/m2 or higher. Furthermore, about 124 million children and adolescents are obese, double of the number in 1908 (WHO, 2018). This prevalence of obesity and its comorbidities accounts for an average of 0.7-2.8% of a countryâ&#x20AC;&#x2122;s total healthcare costs, which translates up to US$ 2 trillion (Mathur & Barlow, 2015; GonzĂĄlez-Muniesa, et al., 2017).

The cause of obesity itself is multifactorial, involving interactions between genetic and environmental factors (WHO, 2018), though the most mentioned ones are the dysregulation of food intake and energy expenditure (Heymsfield, et al., 2017). Currently, personalized lifestyle intervention (control in diet and physical activity) remains as one of the most effective treatment for obesity. Additional physiological treatments induce peripheral signals to influence the neurons which act as main controllers of energy balance in the hypothalamus. Normally, these signals are reciprocally produced by cells and microbiota within adipose tissue, pancreas, stomach, or internal colonic microbiota (Heymsfield, et al., 2017).

Microbiota or microbiome is a collection of microbes (bacteria, archaea, and eukaryotes) that colonize human body (Mathur, et al., 2015). In the last decade, gut microbiota has been studied in relation to obesity, energy metabolism, and macronutrient digestion (Hruby, et al., 2015; Mathur, et al., 2015).

These organisms may contribute to obesity by influencing nutrient breakdown and absorption, gut permeability, and inflammatory responses. Many of these studies have observed changes in gut

microbiota in obese individuals, whether in range of diversity or ratio (Mathur, et al., 2015). For example, Firmicutes to Bacteroidetes ratio is increased in obesity and vice versa in weight loss (Mathur, et al., 2015; GonĹşalez-Muniesa, et al., 2017).

Studies has shown that phenotype of obesity could be transferred through individuals via the donorâ&#x20AC;&#x2122;s microbiota, which is characterized by significant increase of body fat (Mathur, et al., 2015). This impact, which is majorly caused by microbiota interaction, reveals promising alternative therapy to alleviate the burden of obesity (Hruby, et al., 2015). Thus, consumption of probiotics, which are collections of one or more strains of microorganisms (mainly bacteria or yeast) is vigorously researched as a therapeutic agent to manipulate composition of gut microbiome (Hruby et al., 2015; Mathur, et al., 2015).

Latest researches on the effect of probiotic consumption in obesity has developed into clinical trials, yet the results are not fully consistent. This in turn stresses the need of a comprehensive review, whether the use probiotics is an effective and safe method in reducing obesity. In this study, we conducted a systematic review on clinical trials on the use of probiotics, involving healthy overweight and obese individuals. We analyzed the resultant effects in these individuals, mainly the related benefits of probiotics. In the long term, we hope that probiotics may have a role in managing obesity and its progression, encouraging its application as a novel adjunct therapy in obesity and its associated metabolic diseases, thereby helping to reduce its global prevalence and burden.

MATERIALS AND METHODS a. Study Search Strategy We conducted a systematic review of randomized controlled trials based on PRISMA statement from PubMed and EBSCOhost using the keywords ((probiotics) OR (lactobacillus) OR (bifidobacterium) OR (streptococcus) OR (enterococcus)) AND ((obesity) OR (overweight)) AND ((randomized controlled trials) OR (randomized controlled trial)). Afterward, inclusion criteria were set to filter the results including: randomized controlled trials, studies on the effect of probiotics administration on overweight and obese individuals, and published within the last five years, that is, studies published between January 2013 and September 2018. In addition, exclusion criteria were also set: studies involving immunocompromised patients, pregnant subjects or subjects with metabolic diseases were excluded. We also exclude unauthentic articles, studies with incompatible language, and inaccessible full-text articles. b. Data Extraction Subsequently, we set necessary data to be extracted from articles including: author and year of

publication, study design, location of study, participantsâ&#x20AC;&#x2122; characteristics including sample size, subject range of BMI, and subject mean or range of age, probiotic used in the trials, intervention and duration, and outcome which is presented by p value for each findings. c. Risk of Bias Assessment Finally, the articles will be assessed with Cochrane Risk of Bias Tool for Randomized Controlled Trials which consists of seven criteria. The assessment was conducted by four reviewers collaboratively and concluded after consensus were reached.

RESULTS The literature search was conducted through PubMed and EBSCOhost. Articles were screened for relevancy and eligibility. The search yielded 12 randomized controlled trials with a total of 1099 subjects. The data extracted and characteristics of included studies are shown in Table 1. The probiotic supplementation given varies between groups, with six trials using single species of probiotics, and six others with multi-species probiotics. Intervention duration ranges from 4 to 24 weeks. The study selection process is shown in Figure 1. The studies were then further assessed with Cochrane Risk of Bias Tool for Randomized Controlled Trials. The result of risk bias assessment is shown in Table 2 in the Appendix at the last part of this paper.

Figure 1. PRISMA flow chart of search strategies

Table 1. Characteristics of included studies Author and Year

Study Design

Location

Participants characteristics

Probiotic

Intervention and duration

Outcome

Minami et al (2018)

Randomized, double-blind, Placebocontrolled trial

Japan

80 healthy pre-obese (placebo: 40, intervention: 40)

B. breve B-3

B. breve B-3 capsules

Probiotic group compare to placebo group: ↓ body fat mass (p=0.03, η2=0.060) ↓ percent body fat (p=0.02, η2=0.068) No significant changes in BMI

Szulińska et al (2018)

Randomized, double-blind, Placebocontrolled trial

Poland

BMI: 25 ≤ BMI < 30 kg/m2 Mean age: 45.50 years 81 obese Caucasian postmenopausal women (placebo: 24, low-dose: 24, highdose:23) BMI: 30–45 kg/m2 Mean age: 56.75 years

Dosage: 2 × 1010 CFU/day Duration: 12 weeks

Ecologic® Barrier containing: B. bifidum W23, B. lactis W51, B. lactis W52, L. acidophilus W37, L. brevis W63, L. casei W56, L. salivarius W24, L. lactis W19, Lactococcus lactis W58

2 g of freeze-dried powder of the probiotic mixture Ecologic® Barrier Dosage: Low-dose group: 2.5 × 109 CFU/day High-dose group: 1 × 1010 CFU/day Duration: 12 weeks

High-dose group: ↓ LPS (p=0.0008, SMD= – 0.77) ↓ waist circumference (p=0.0199, SMD= –0.54 ↓ fat mass (p=0.03974, SMD= –0.83) ↓ subcutaneous fat – (p=0.0002, SMD= –0.77) ↓ TC (p = 0.0019, SMD= −0.57 ↓ TG (p= 0.014, SMD= −0.43) ↓ LDL (p = 0.0149, SMD = −0.41) ↓ HOMA-IR (p = 0.0001, SMD = −0.82) Low-dose group:

↓ waist circumference (p=0.0001, SMD= –1.06 ↓ fat mass (p=0.0099, SMD= – 0.62) ↓ subcutaneous fat – (p=0.0022, SMD= –0.99) ↓ visceral fat (p=0.0336, SMD=–0.58) ↓ TC (p = 0.0124, SMD= −0.49) ↓ LDL (p = 0.0168, SMD = −0.59) ↓ HOMA-IR (p = 0.0001, SMD = −0.54)

Sanchez et al (2017)

Randomized, double-blind, Placebocontrolled trial

Quebec

45 obese men (placebo: 22, intervention: 23) and 60 obese women (placebo: 31, intervention: 29) BMI: 29 – 41 kg/m2 Mean age: 36.0 years

L. rhamnosus CGMCC1.3724 (LPR)

LPR formulation given twice a day (10 mg of LPR = 1.6 x 108 CFU/capsule, 210 mg of oligofructose, and 90 mg of inulin) Dosage: 3.24 × 108 CFU/day Duration: 24 weeks (Phase 1: first 12-weeks

Both groups show no significant effect in BMI and body mass Women: ↑ satiety efficiency (↑SQ) (Δ=3.5 ± 1.5; p = 0.02) ↓ TFEQ cognitive restraint (Δ=−2.0 ± −0.8; p = 0.01) ↓ TFEQ disinhibition (Δ=−1.1 ± 0.6; p = 0.05) ↓ TFEQ hunger (Δ=−1.7 ± 0.7; p = 0.02) Men:

Gomes et al (2017)

Randomized, double-blind, parallel, placebocontrolled trial

Brazil

43 healthy women, overweight and obese (placebo: 22, intervention: 21) BMI: 24.9 ≤ BMI ≤ 40 kg/m2 Age: 20-59 years

Stenman et al (2016)

Randomized, double-blind, parallel, placebocontrolled trial

Finland

134 healthy, overweight and obese (placebo: 36, B420: 25, LU: 36, LU + B420: 37)

Lactobacillus acidophilus, Lactobacillus casei, Lactococcus lactis, Bifidobacterium bifidum, Bifidobacterium lactis

of weight loss program; Phase 2: second 12-weeks of weight maintenance program)

↑ satiety efficiency (↑SQ) (Δ=2.6 ± 1.2; p = 0.03) ↓ TFEQ cognitive restraint (Δ=−3.4 ± 1.2; p = 0.05)

Probiotic mix sachets (109 CFU/strain/sachet) Dosage: 4 sachets/day (2 × 1010 CFU/day) Duration: 8 weeks

Greater change in waist circumference (-5.48% vs 3.40%, p=0.03), waist-height ratio (-5% vs -3.27%, p=0.02), conicity index (-4.09 vs -2.43, p=0.03), and plasma PUFA (18.63% vs +5.65%, p=0.04) compared to controls

Both groups: normocaloric diet (25-30 kcal/kg)

Bifidobacterium animalis ssp. lactis 420

1) Placebo (MC 12 g/day) 2) B420 (1010 CFU/day) 3) LU (12 g/day) 4) B420 (1010 CFU/day) + LU (12 g/day) Duration: 6 months

↑GPx activity (+15.62% vs 16.67%, p<0.01) ↓body fat mass in group 4 (4.5%, p=0.02) No significant changes in body fat mass between group 2 and placebo (p=0.28), group 3 and placebo (p=1.00)

Pediococcus pentosaceus LP28

1) Placebo (dextrin powder 7.5 mL/day)

↓BMI (0.45 kg/m2 (0.04, 0.86); p=0.035),

BMI: 28.0 ≤ BMI ≤ 34.9 kg/m2

Higashikaw a et al (2016)

Randomized, double-blind,

Japan

Age: 18-65 years 62 healthy, overweight (placebo:

placebocontrolled trial

20, living LP28: 21, heat-killed LP28: 21)

2) LP28 powder (10 mL/day or 1011 CFU/day) 3) Heat-killed LP28 powder (7.5 mL/day or 1011 CFU/day) Duration: 12 weeks

↓percent body fat (1.11% (0.39, 1.82); p=0.002), ↓body fat mass (1.17 kg (0.43, 1.92). p=0.004), ↓waist circumference (2.84 cm (0.74, 4.93), p=0.009)

Streptococcus thermophiles, Lactobacillus bulgaricus, Lactobacillus acidophilus LA5, and Bifidobacterium lactis BB12 Total minimum of 1x107 CFU

PY was to be consumed with the main meals (200 g twice/day) daily.

PY decrease total cholesterol better than LF (p = 0.024) PY decrease LDL better than LF (p = 0.018) PY decrease insulin resistant better than LF (p<0,001) PY decrease fasting insulin concentration better than LF (p=0,002)

VSL#3: Streptococcus thermophilus DSM24731, L. acidophilus

VSL#3 with ice cream and coconut milk (463 g) and contained 65 g of saturated fat and 81 g

BMI: 25 ≤ BMI ≤ 30 kg/m2 Age: 20-70 years Madjid et al (2016)

RCT, doubleblind

Tehran, Iran

89 healthy overweight and obese (Low-fatyogurt: 45, probiotic yogurt: 44) BMI: 27-40 kg/m2 Women aged 18–50 years, premenopausal status, habitual daily consumption of lowfat yogurt (200–400 g)

Osterberg et al (2015)

Randomized, double-blind, Placebocontrolled trial

Virginia, USA

20 healthy non-obese (Placebo: 11, intervention (VSL#3): 9)

Dosage: 1x107 CFU/dose Duration: 12 weeks

No significant differences were found for weight reduction, fasting plasma glucose, high-density lipoprotein cholesterol, or triglycerides between both groups Weight-loss diet with probiotic group: ↓ BMI (p<0.001) ↓ fat percentage (p<0.001)

BMI < 30 kg/m2 Mean age: 22,9 ± 0,9 years

Zarrati et al (2014)

Sanchez et al (2014)

Randomized doubled-blind controlled clinical trial

Tehran, Iran

Randomized, double-blind, Placebocontrolled trial

Quebec City

All participants were sedentary (<2 days, 20 min day 21 of lowintensity physical activity) 75 healthy overweight and obese individuals (RLCD: 25, PLCD: 25, PWLCD:25) 48 overweight men (placebo: 24, intervention: 24) and 77 overweight women (placebo: 39, intervention: 38) BMI: 29 ≤ BMI ≤ 41 kg/m2 Age: 18-55 years

DSM24735, L. delbrueckii ssp. bulgaricus DSM24734, L. paracasei DSM24733, L. plantarum DSM24730, B. longum DSM24736, B. infantis DSM24737, and B. breve DSM24732 L. acidophilus La5, B. BB12, and L. casei DN001

of total fat all combine in the form of milk shake 250 kcal for the high fat diet period.

Duration: 4 weeks

200 g/day of conventional yogurt or probiotic yogurt Dosage: 108 CFU/g Duration: 8 weeks

Lactobacillus rhamnosus CGMCCI.3724 (LPR)

↓ leptin level (p<0.001)

LPR formulation capsules (10 mg of LPR powder = 1.62 x 108 CFU/capsule,300 mg of a mix of oligofructose and inulin (70:30, v/v), and 3 mg of magnesium stearate) Dosage: 2 capsules/day (3.24 × 108 CFU/day)

Weight-loss diet with probiotic group: ↓ BMI (p<0.001) ↓ fat percentage (p<0.001) ↓ leptin level (p<0.001) Women: ↓ Body weight (Δ=−2.6 ± 1.1; p=0.02) ↓ Fat mass (Δ=−2.54 ± 1.01; p=0.01) ↓ Leptin (Δ=−11.0 ± 2.9; p=0.0004) ↓ Lachnospiraceae family in faeces (38.2% vs 27.6 %, p=0.001 with V123 and 32.6% vs 24.5%, p=0.03 with V456) compared to placebo group

Zarrati et al (2013)

Randomized, doubled-blind, controlled clinical trial

Tehran, Iran

75 obese and overweight men and women (RLCD: 25, PLCD: 25, PWLCD: 25) BMI: 25 ≤ BMI ≤ 35 kg/m2 Age: 20-50 years

Streptococcus thermophiles, Lactobacillus bulgaricus, Lactobacillus acidophilus LA5, Lactobacillus casei DN001, Bifidobacterium-lactis Bb12

Duration: 24 weeks (Phase 1: first 12 weeks of weight-loss phase with supervised dietary restriction (500 kcal/day); Phase 2: second 12 weeks of weight-maintenance phase with supervision of dietary habits without restriction 200 g/day of either conventional yogurt or probiotic yogurt Conventional yogurt containing: S. thermophiles, L. bulgaricus Probiotic yogurt containing: S. thermophiles, L. bulgaricus, LA5, DN001, Bb12 Dosage: 108 CFU/g (each strain) Duration: 8 weeks

Men: No significance changes by treatment in body weight and fat mass

↓ IL4 (PLCD, p=0.01; RLCD, p=0.03; PWLCD, p=0.02) ↓ IL17 in PLCD and RLCD (Δ = −617 and −670 pg/mL, p<0.05 vs −217 pg/mL) compared to PWLCD ↓ ROR-γt (p=0.007) ↑ FOXP3 (Δ= 11.2 ± 6.7, 6.0 ± 2.5, and 6.3 ± 1.9 in PLCD, RLCD, and PWLCD groups respectively, p<0.001) ↓ T-bet gene (p<0.001) in PLCD and PWLCD groups ↓ IFN-γ (PLCD, p=0.001; PWLCD, p=0.01) ↓ TNFα (RLCD and PLCD, p<0.001)

Kadooka et al (2013)

Multi-centre, double-blind, parallel-group RCT

Japan

105 men with large visceral fat areas (107 dose: 33, 106 dose: 36, control: 36) 105 women with large visceral fat areas (107 dose: 36, 106 dose: 35, control: 34) Age: 35-60 years Large visceral fat areas: 80.2-187.8 cm2

Lactobacillus gasseri SBT2055 (LG2055)

200 g FM/day (as two portions of 100 g) containing LG2055 Dosage: 107 CFU/g, 106 CFU/g, or 0 CFU/g Duration: 12 weeks

↓ Abdominal visceral fat areas (Δ = −8.5%, 95% CI −11.9, −5.1; p<0.01 and (Δ = −8.2%, 95 % CI −10.8, −5.7; p<0.01) in 107 and 106 dose group repectively ↓ BMI, waist, and hip circumferences (p<0.01) ↓ Fat mass (p<0.01) No significant changes in the control group

Notes: ALT: alanine aminotransferase; AST: aspartate aminotransferase; BMI: body mass index; CFU: colony forming unit; HOMA-IR: homeostatic model assessment for insulin resistance; HDL: high-density lipoprotein; LDL: low-density lipoprotein; LPR: Lactobacillus rhamnosus CGMCC1.3724; LPS: lipopolysaccharide; LF: low fat yogurt; PY: probiotic yogurt; RLCD: regular yogurt with a low calorie diet; PLCD: probiotic yogurt with a low calorie diet; PWLCD: probiotic yogurt without a low calorie diet; SMD: standardized mean difference; SQ: satiety quotient; TFEQ: Three-Factor Eating Questionnaire; TC: total cholesterol; TG: triglycerides; PUFA: polyunsaturated fatty acids; GPx: glutathione peroxidase; LU: dietary fiber Litesse® Ultra polydextrose; MC: microcrystalline cellulose; LDL: low-density lipoprotein; TNF-α: tumor necrosis factor α; IL-6: interleukin 6; V123: hypervariable region (V) 1-3; V456: Hypervariable region (V) 4-6; LCD: low calorie diet;

DISCUSSION a. Analysis of Studies Plenty of studies have found the association between gut microbiota and several metabolic disorders such as obesity and type II diabetes. Further researches regarding gut microbiota highlight the beneficial role of probiotics in such metabolic disorders, especially obesity. Outcomes from studies selected for the above systematic review vary, including anthropometric measurements, lipid profiles, eating behavior, as well as inflammatory markers. Such variations show the numerous possible mechanisms by which probiotics modification of gut microbiota can affect bodily metabolism.

Several researches found that probiotic supplementation plays a role in reducing body fat. A study by Minami et al (2018), shows significant reduction of percentage body fat and body fat mass in groups given capsules of B. breve B-3, confirming previous experimental study performed on induced obese mice.1 This result is consistent with seven other studies included in the systematic review, which also find a decrease in body fat mass of intervention groups when compared to placebo, although strains of probiotics given differ between studies, including various strains of Bifidobacterium, Lactobacillus, Streptococcus, or a combination of them (Szulińska et al., 2018; Stenman et al., 2016; Osterberg et al., 2015; Zarrati et al., 2014; Sanchez et al., 2014; Kadooka et al., 2013). The exact mechanism by which microbiota affects body weight still remains unclear; however, it is thought that that intestinal microflora plays an important role in determining host metabolism, thus affecting energy homeostasis and adiposity (Kobyliak et al., 2016). Furthermore, several studies also show a reduction in waist circumference, verifying the decrease in abdominal adiposity (Szulińska et al., 2018; Gomes et al., 2017; Higashikawa et al., 2016; Kadooka et al., 2013). However, although fat mass decreases in general in most studies, BMI outcomes show variations instead.

Lipid profiles were also assessed in several studies included above, comprising of total cholesterol, triglycerides, LDL, and HDL levels. Szulińska et al (2018) found a reduction in total cholesterol, triglycerides, and LDL levels in groups given low-dose and high-dose of probiotic mixture Ecologic® Barrier, containing mixture of Bifidobacterium and Lactobacillus strains, as well as study by Minami et al (2018) proving a slight decrease in triglyceride level. On the other hand, effect on HDL levels is still limited in both studies, showing non-significant increase of its level. Obesity is highly associated with dyslipidaemia, with increase of both LDL and triglycerides level with low HDL cholesterol level, posing an increased risk of cardiovascular diseases (Klop et al., 2013). Another study

by Madjid et al (2016), which compares low-fat yogurt with and without probiotic supplementation, also exhibit similar results. Probiotic yogurt is shown to decrease total cholesterol, LDL, insulin resistance, and insulin concentration better than the standard low-fat yogurt, that highlights the role of

probiotics in improving lipid profiles of obese individuals. These roles show its potentials in reducing the risk of cardiovascular diseases in obese individuals.

Obesity is also highly associated with the risk of developing metabolic diseases, with insulin resistance acting as a crucial link between the two. Inflammation is found to be involved in the pathogenesis of such diseases. In obesity, adipose tissue is found to secrete pro-inflammatory cytokines, such as TNFα, IL-6, C-reactive protein (CRP), and plasminogen activator inhibitor-1 (PAI-1), as well as an elevated leptin level. These cytokines would then inhibit insulin signalling activity, contributing to insulin resistance (Ye, 2013). Several studies on the effects of probiotics show reduction in inflammatory markers as well as improvement in insulin resistivity. A study by Zarrati et al (2013) found a reduction in levels of IL-4, IL-17, IFN- γ, ROR-γt and TNF-α in subjects treated with probiotic Lactobacillus gasseri SBT2055 and low-calorie diet. IL-17 is associated with Th-17 cell activation, in which the transcription factor ROR-γt also plays a role in its differentiation. Th-17 is involved in inflammation and autoimmunity, further aggravating the obesity-induced inflammation. Furthermore, researches by Szulińska et al (2018) and Madjid et al (2016) found a decrease in insulin resistance, shown by a significant decrease in HOMA-IR (homeostatic model assessment for insulin resistance) values. These results show that probiotic supplementation has an excellent possibility in interfering with the progression of obesity into further metabolic diseases, such as type II diabetes.

Aside from its direct impact in lowering adiposity and lipid levels, probiotics is also found to affect the gut-brain axis, though the exact mechanism is still unclear. Gut microbiota is thought to link enteric functions to the brain, both emotional and cognitive centres. Modulation of gut microbiota by probiotics therefore can possibly exert beneficial effects on appetite control and eating behaviours (Carabotti et al., 2015). Study by Sanchez (2017) found that supplementation of LPR containing the probiotic L. rhamnosus CGMCC1.3724 significantly increases satiety efficiency and decreases TFEQ cognitive restraint. Lower scores of cognitive restraint shows a lower restriction in energy intake needed to control weight. Moreover, TFEQ disinhibition and hunger scores are also significantly reduced in women, though not significant in men. Lower disinhibition and hunger values represents a lower susceptibility to overeat. This highlights the potential of probiotic supplements in decreasing energy intake by improving appetite control, thus help in obesity management.

Finally, the use of probiotics has also been proven clinically safe. All studies included in our review reported no serious adverse effects following probiotic supplementation in the trials. This, therefore, further suggest probiotics as an excellent potential for adjunct therapy in obese individuals.

b. Limitation of the Study This study is not without limitations. Language restriction and the inaccessibility of several articles limited our systematic review. Furthermore, two of these trials are performed in only women, and some other trials also show unequal distribution of samples between gender, thus the results may not be equally applicable in men and women. The small number of sample in several studies as well as bias in the included studies may also affect the results. Thus, further clinical trials with reduced bias and larger sample size are still needed to confirm these results. c. Future Application and Research Although plenty of studies have shown a strong association between probiotics and its beneficial effects in obesity and its associated metabolic diseases, the mechanism by which probiotics exert these effects and the exact doses needed are still unclear. We therefore recommend further studies done to investigate this, as it would serve as a foundation for future research in probiotics. In addition, we also recommend more researches done in Asian countries to further confirm its applicability in Asia.

CONCLUSION In conclusion, probiotics supplementation has an important role in body fat reduction, obesity intervention, and gut-brain-axis modulation. Probiotic supplementation, both containing single or multi-species probiotics, is found to reduce percentage body mass in obese individuals. It also shows its ability to interfere with the progression of obesity into further metabolic diseases, such as type II diabetes, due to its action in reducing inflammatory markers. Probiotics are also found to play a role in affecting the gut-brain axis, thus help control appetite. The use of probiotics is also proven to be safe, with no serious adverse effects reported in the studies.

Our systematic review provides an evidence for the use of probiotics as a suitable adjunct therapy in treating obesity and its associated metabolic diseases. We hope, these results can be applied further to help governments consider the importance of encouraging the population to consume food rich in probiotics as well as giving probiotic supplementation to help halt the rise in obesity, thereby reducing its prevalence and healthcare burden worldwide

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Gomes, A. C., de Sousa, R. G. M., Botelho, P. B., Gomes, T. L. N., Prada, P. O., Mota, J. F. (2016). The additional effects of a probiotic mix on abdominal adiposity and antioxidant status: a double!blind, randomized trial. Obesity, 23(1), 30-38.

González-Muniesa P., Mártinez-González M.A., Hu F.B., Després J.P. Matsuzawa Y., Loos R.J., . . . Bray G.A. (2017). Obesity. Nature Reviews Disease Primers, 3:17034.

Heymsfield, S.B. & Wadden, T.A. (2017). Mechanisms, pathophysiology, and management of obesity. The New England Journal of Medicine, 376:254-266.

Higashikawa, F., Noda, M., Awaya, T., Danshiitsoodol, N., Matoba, Y., Kumagai, T., Sugiyama, M. (2016). Antiobesity effect of Pediococcus pentosaceus LP28 on overweight subjects: a randomized, double-blind, placebo-controlled clinical trial. Eur J Clin Nutr, 70(5), 582587.

Hruby A. & Hu F.B. (2015). The epidemiology of obesity: a big picture. Pharmacoeconomics, 33(7), 673-689.

Kadooka, Y., Sato, M., Ogawa, A., Miyoshi, M., Uenishi, H., Ogawa, H., . . . Tsuchida, T. (2013).

Effect of Lactobacillus gasseri SBT2055 in fermented milk on abdominal adiposity in adults in a randomised controlled trial. Br J Nutr, 110(9), 1696-1703.

Klop, B., Elte, J. W. F., Cabezas, M. C. (2013). Dyslipidemia in obesity: mechanisms and potential targets. Nutrition, 5(4), 1218-1240.

Kobyliak, N., Conte, C., Cammarota, G., Haley, A. P., Styriak, I., Gaspar, L., . . . Kruzliak, P. (2016). Probiotics in prevention and treatment of obesity: a critical view. Nutr Metab, 13:14.

Madjid, A., Taylor, M. A., Mousavi, N., Delavari, A., Malekzadeh, R., Macdonald, I. A., Farshchi, H. R. (2016). Comparison of the effect of daily consumption of probiotic compared with low-fat conventional yogurt on weight loss in healthy obese women following an energy-restricted diet: a randomized controlled trial. Am J Clin Nutr,103(2), 332-329.

Mathur R. & Barlow G.M. (2015) Obesity and the microbiome. Expert Review of Gastroenterology & Hepatology, 9(8), 1087-1099.

Minami, J., Iwabuchi, N., Tanaka, M., Yamauchi, K., Xiao, J. Z., Abe, F., Sakane, N. (2018).

Effects of Bifidobacterium breve B-3 on body fat reductions in pre-obese adults#: a randomized , double-blind. Biosci Microbiota Food Health, 37(3), 67–75.

Osterberg, K. L., Boutagy N. E., McMillan, R. P., Stevens, J. R., Frisard, M. I., Kavanaugh, J. W., Davy, B. M., . . . Hulver, M. W. (2015). Probiotic supplementation attenuates increases in body mass and fat mass during high-fat diet in healthy young adults. Obesity (Silver Spring), 23(12), 2364-2370.

Sanchez, M., Darimont, C., Drapeau, V., Emady-Azar, S., Lepage, M., Rezzonico, E., . . .

Tremblay, A. (2014). Effect of Lactobacillus rhamnosus CGMCC1.3724 supplementation on weight loss and maintenance in obese men and women. Br J Nutr, 111(8), 1507-1519.

Sanchez, M., Darimont, C., Panahi, S., Drapeau, V., Marette, A., Taylor, V. H., Tremblay, A. (2017). Effects of a diet-base weight-reducing program with probiotic supplementation on satiety efficiency, eating behaviour traits, and psychosocial behaviours in obese individuals. Nutrients, 9(284), 1-17.

Stenman, L. K., Lehtinen, M. J., Meland, N., Christensen, J. E., Yeung, N., Saarinen, M. T., . . .

Lahtinen, S. (2016). Probiotic with or without fiber controls body fat mass, associated with serum zonulin, in overweight and obese adultsâ&#x20AC;&#x201D;randomized controlled trial.

EbioMedicine, 13, 190-200.

Szulinska, M., Lonieski, I., van Hemert, S., Sobieska, M., Bogdanski, P., (2018). Dose-dependent effects of multispecies probiotic supplementation on the lipopolysaccharide (LPS) level and cardiometabolic profile in obese postmenopausal women: a 12-week randomized clinical trial. Nutrients. 10(773), 1-16.

World Health Organization. (2018). Obesity and overweight. Retrieved from http://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight.

Ye, J. (2013). Mechanisms of insulin resistance in obesity. Front Med, 7(1), 14-24.

Zarrati, M., Salehi, E., Nourijelyani, K., Mofid, V., Zadeh, M. J., Najafi, F., . . . Shidfar, F. (2014). Effects of probiotic yogurt on fat distribution and gene expression of proinflammatory factors in peripheral blood mononuclear cells in overweight and obese people with or without weight-loss diet. J Am Coll Nutr, 33(6), 417-425.

Zarrati, M., Shidfar, F., Nourijelyani, K., Mofid, V., Hossein zadeh-Attar, M. J., Bidad, K., . . .

Salehi, E. (2013). Lactobacillus acidophilus La5, Bifidobacterium BB12, and Lactobacillus casei DN001 modulate gene expression of subset specific transcription factors and cytokines in peripheral blood mononuclear cells of obese and overweight people. Biofactors, 39(6), 633-643.

APPENDIX Table 2. Risk of bias assessment

Study

Randomization

Concealed allocation

Cochrane Risk of Bias Tool Blinding of Blinding of Incomplete participants outcome outcome and personnel assessment data

Selective reporting

Other bias

Minami et al (2018)

+

+

+

?

+

?

+

SzuliĹ&#x201E;ska et al (2018)

+

+

+

?

+

?

+

Sanchez et al (2017)

?

+

+

?

+

?

+

Gomes et al (2017)

+

+

+

?

+

+

-

Stenman et al (2016)

+

+

+

+

+

?

?

Higashikawa et al (2016)

+

+

+

+

+

?

?

Madjid et al (2016)

+

+

+

?

+

-

?

Osterberg et al (2015)

?

+

+

?

?

+

?

Brahe et al (2015)

+

+

+

+

?

?

?

Sanchez et al (2014)

+

?

+

?

+

?

+

Zarrati et al (2013)

+

?

+

?

+

?

+

Kadooka et al (2013)

-

?

+

?

+

?

+

Note: “+”: low risk of bias, “–“: high risk of bias, “?”: unclear risk

ABSTRACT Childhood Obesity as a Predictor of Diabetes Mellitus Type 2 in Adults: A Systematic Review and Meta-Analysis *Marco Raditya, Fabiola Cathleen, Daniell Edward, Kristian Kurniawan *marco.raditya@gmail.com

Introduction: DM type 2 is now on the troubling rise to become a global emergency. It is now the top 10 leading causes of deaths worldwide and WHO estimated 422 million adults worldwide are diabetic. DALY generated by diabetic complications has also increased from 49.7 million (1990) to 64.1 million (2015). Escalation in DM type 2 prevalence despite governmentenforced programs like SDGs suggests its ineffectiveness, necessitating the discovery of a novel risk factor in DM type 2, such as the relationship between childhood obesity and adultonset diabetes.

Objectives: This review is conducted to conclude the link between childhood obesity and adulthood obesity type 2. Results are hoped to increase public awareness, be implemented into the preexisting practical evidence-based guideline of diabetes screening and prevention, and to achieve WHOâ&#x20AC;&#x2122;s Sustainable Development Goals by 2030.

Materials and method: This review was conducted based on PRISMA Statementsâ&#x20AC;&#x2122; flow diagram and checklist to improve quality of reporting. Cohort studies were chosen for its long term follow-up. For bias and quality assessment, Newcastle-Ottawa Scale for Cohort was used for included studies and Cochrane Handbook was used towards this review. Analysis was depicted in forest plot and funnel plot using RevMan 5.3 Software for Mac. Results: From 8 databases and additional searches, total 237 records with 73,533 participants were retrieved, and final 5 studies were included in meta-analysis. The most common bias from NOS were inadequacy of follow-up. Analysis through forest plot show statistically significant association of childhood obesity to adulthood diabetes (OR: 3.89; 95% CI 2.97-5.09; I2 :0%; p-value<0.00001). Funnel plot assessment is symmetrical.

Discussion: Based on forest plot, individuals with childhood obesity is 3.89 times more likely to have adult-onset diabetes. Studies suggest that childhood obesity cause early insulin resistance and

early adiposity rebound, which promotes adulthood obesity, a diabetic risk factor. Review limitation includes few included studies, missing obesity universal definition, and questionable study results validity.

Conclusion: In conclusion, childhood obesity can be used as a predictor for adulthood diabetes. Early diabetes screening and prevention guidelines should include childhood obesity as plausible risk factor.

Keywords: Childhood obesity, Adult diabetes mellitus type 2, Meta-analysis

Childhood Obesity as a Predictor of Diabetes Mellitus Type 2 in Adults: A Systematic Review and Meta-Analysis Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference 2019

By: Marco Raditya* Fabiola Cathleen Daniell Edward Raharjo Kristian Kurniawan

Faculty of Medicine Universitas Indonesia Depok 2018

INTRODUCTION

efforts against the disease. The UN itself has

Rationale

set an ambitious goal to reduce premature

Long acclaimed as a silent killer, diabetes

mortality by one third before 2030 as part of

mellitus type 2 (DM type 2) is now on the

the Sustainable Development Goals (World

troubling rise to become a global emergency.

Health

This non-communicable disease characterized

myriad of screening tools, obesity is often

by the bodyâ&#x20AC;&#x2122;s insensitivity to insulin, impaired

considered as it is the greatest risk factor of

hormonal production by the pancreas, and

DM type 2, with over 90% of patients being

resulting hyperglycemia has now become the

obese

top 10 leading causes of deaths worldwideâ&#x20AC;&#x201D;a

However, the seemingly unaffected escalation

whopping 3.7 million deaths in 2012. WHO

in

estimated that 422 million adults globally are

ineffectiveness of these programs in curbing

burdened with diabetes, beyond double the

the

prevalence recorded in 1980 and data gathered

discovery of a novel risk factor in DM type 2

across the world also proved a rampant rise in

which was previously unseen. Surrounding

diabetes-associated deaths between 2000 and

this matter, many research has been performed

2012 (World Health Organization, 2016). This

lately to assess the relationship between

undisputable burden of DM type 2 is further

childhood obesity and adult-onset diabetes,

corroborated by an increase in disability

and whether prevention of childhood obesity

adjusted life years generated by diabetic

can reduce the risk of diabetes during

complications

adulthood.

such

as

nephropathy

and

Organization, 2016). Among the

or

DM

overweight type

disease,

2

(Whitmore, prevalence

therefore

2010). suggests

necessitating

the

neuropathy of 49.7 million in 1990 to 64.1 million in 2015, (Kassebaum et al., 2016).

Objectives

Unfortunately, collateral damage of this

As comprehensive reviews surrounding this

disease to the economy has also yielded US$

specific matter has yet to be done, this is the

827 billion in losses in 2013â&#x20AC;&#x201D;3 times higher

first systematic review and meta-analysis

than in 2003 according to the International

conducted to draw a sound and statistically

Diabetes Foundation. With such economic

significant conclusion on the link between

fall-out, DM type 2 is likely to impede

childhood obesity and diabetes in adulthood

national and global development if not

by comparing the occurrence of DM type 2

handled effectively (International Diabetes

across two variables: adults with and without

Foundation, 2013).

childhood obesity. To ensure feasibility of international

application,

research

from

As a result, the epidemic surge in DM type 2

various countries among different regions have

prevalence worldwide has mandated the

been reviewed. Furthermore, retrospective and

implementation

government-enforced

prospective cohort studies have also been

programs as both curative and preventive

specifically chosen as it allows exploration of

of

causative factors in DM type 2 alongside being

type 2 OR DM OR Diabetes Mellitus) AND

long term, follow-up studies.

(abdominal obesity OR central obesity OR Visceral Obesity) AND (Children OR Child

Through these endeavors, this review is

OR Pediatric OR Kid OR Childhood) AND

anticipated to increase public awareness on the

(Cohort) AND (Risk OR Factor). The concept

importance of dealing with childhood obesity

is then modified based on each database

along with its implication on future diabetes

boolean terms and conditions. Cohort studies

comorbidity. Furthermore, we hope that the

were used for this review as its time-approach

results of this review can be implemented into

design is more compatible to identify and

the

evidence-based

follow-up the association between childhood

guideline for early diabetes screening and

obesity and adulthood diabetes, which requires

prevention. We believe that by applying the

a long period of time. Only published studies

objectives stated above, this review will stand

with full text availability were searched.

in the forefront of new strategies in combating

Additional records were identified through

DM type 2 as a silent threat in achievement of

manual search, similar articles suggestion, and

the global Sustainable Development Goals by

bibliographies from other studies not identified

2030.

in electronic searches.

MATERIAL AND METHODS

Study selection

This systematic review and meta-analysis were

The study selection process follows the

conducted based on PRISMA Statements’

PRISMA Statements’ flow diagram. All of the

flow diagram and checklist to improve quality

records retrieved will be tested for duplicates,

of reporting. It is a four-phase flow diagram

then all duplicates found will be removed.

while the checklist consists of 27 items

Studies left after duplicates removal will be

pertaining to the content of systematic review

screened based on its titles and abstracts, and

and meta-analysis, including the title, abstract,

exclusion will be done to those irrelevant to

introduction, methods, results, discussion, and

the topic or objectives of this review. After

funding (“PRISMA,” 2015).

screening, the process continued to eligibility

pre-existing

practical

assessment of full-text articles based on Study Search

inclusion and exclusion criteria. The inclusion

A range of databases, including PubMed,

criteria of this review are cohort studies with

Scopus, PLOS, Cochrane, Science Direct,

minimum 1,000 participants at follow up, age

Clinical Key, ProQuest, and Wiley, was

of participants at baseline ≤ 18 years old,

sought up to 14th of October 2018. The search

measures obesity and diabetes mellitus type 2

strategy was structured using the following

indicators using any methods (such as BMI or

concept of keywords: (adult onset diabetes

CDC’s growth chart for obesity and HbA1c or

mellitus OR diabetes mellitus type 2 OR DM

fasting plasma glucose for diabetes), and

assessment of long-term association between

publication year, study design, definition of

childhood obesity and adult onset diabetes

childhood obesity and adult diabetes, study

mellitus type 2 is present. The sample size

location, statistical analysis, sample size, and

restriction was to ensure higher quality studies

outcome of study) and participants details (age

(as larger size reduces the risk of loss of

in baseline, follow-up age, numbers of control,

follow up and has higher power in detecting

exposure, positive outcome, and negative

any association of childhood obesity and adult

outcome group). When available, adjusted

onset diabetes) and to establish a more

outcome for potential confounders were used

statistically significant results in reporting.

if value is adjusted by exact age and gender

Moreover, exclusion criteria are language

only, without adjustment from other factors..

besides

Bahasa

Indonesia

and

English,

incomplete articles or insufficient data, and

Quality and Bias Assessment

publication year older than 2000. Records that

Quality and bias assessment within studies

are incompatible with inclusion criteria or

were done after the data extraction of every

corresponds with exclusion criteria were

included studies had been finished. The

excluded, resulting in studies directly included

methods used to assess quality and bias of

in qualitative synthesis. Only some of those

each study was the Newcastle-Ottawa Scale

were included in quantitative synthesis or

tools designed for Cohort Studies (NOS-

meta-analysis due to different definition of

Cohort). This scale uses a â&#x20AC;&#x153;star systemâ&#x20AC;? in

obesity or diabetes mellitus type 2 from our

which a study is judged on three broad

study, and unspecified number of control,

perspectives: the selection of the study, the

exposed, positive outcome, and negative

comparability

outcome group. This selection process were

ascertainment of either the exposure of

done by 2 reviewers and consulted to a third

interest.

reviewer.

categories, which only a star can be given to

Each

of

the

groups,

perspective

has

and

the

several

each category (Wells et al. 2018). The quality Data extraction

of individual studies was assessed by two

Data were extracted by 2 reviewers using

reviewer and then independently checked by a

standardized

were

third reviewer. Based on the result of the

independently checked and confirmed by a

assessment, studies with lesser bias and higher

third reviewer. Any consultation was done

quality will be taken more into consideration

with the third reviewer as well. There were no

in qualitative analysis, however no primary

multiple publications of identical studies.

included study was excluded.

forms.

Then,

they

Duplicates also have already been removed in the prior process, therefore identical data will

For the assessment of bias across this review,

not be extracted twice. Extraction of study

reviewer will refer to the handbook of

characteristics includes study details (author,

Cochrane regarding summary assessment of

risk of bias in 4 levels: Outcome, Domains,

Result for participants are reported as a unity

Studies, and Study as a Whole (“Cochrane

to represent all ages of children due to lack of

Handbook,” 2011).

studies available. Reason to group the result based on the age of the children was denied

Analysis

since they are considered indefinite and may

Studies included in qualitative analysis may

overlap. For example, children <7 years old

reported varieties of metabolic outcome, such

are often grouped as they may experience

as

and

adiposity rebound (AR), yet the universal

hypertension. Those were neglected and only

agreement for AR occurrence age has yet to be

data regarding diabetes mellitus type 2 is

done—adiposity rebound may happen to age

taken. A variety of definition in obesity and

3-7, 5-7, or even above 7 (WHO, 2006; Cole,

diabetes was also found. Any definition is

2004).

coronary

heart

disease,

stroke,

accepted for qualitative analysis. However, only those with similar manner for specific sex

The pooled size of control, exposed, positive

and age group will be included in meta-

and negative outcome group, or the OR, then

analysis to allow calculation of pooled ORs.

tabulated and analysed into a forest plot using

The accepted definition for obesity are BMI ≥

Review Manager 5.3 Software for Mac. To

95th percentile (CDC Growth Chart 2000) and

estimate the effect from individual studies

BMI ≥ +3SD Z Score in BMI for age per sex

against measure of each study’s size or

chart. Accepted definition for adult onset

precision and to assess publication bias, this

diabetes type 2 are fasting glucose plasma

meta-analysis used funnel plots, also generated

>7.0 mmol/L, 2-hr plasma glucose >11.1

by Review Manager 5.3 Software for Mac.

mmol/L,

and

physician.

self-reported

The

BMI

diagnosis standard

by was

RESULTS

acknowledged in this meta-analysis based on

Initaly, searches identified 218 total records

the assumption and evidence that BMI follows

from database searching, which are 37, 36, 2,

a normal distribution (Kapetanakis et al.,

2, 71, 70, 0 and 0, from Pubmed, Scopus,

2014).

also

PLOS, Cochrane, Science Direct, Clinical

acknowledged because it is a standardized

Key, ProQuest, and Wiley respectively. The

WHO’s recommendation and can be applied to

additional records were identified from manual

everyone.5

by

search (n=5), similar articles suggestion (n=8),

physician was accepted in assumption that the

and bibliographies from other studies not

physician also follows WHO’s guideline or

identified in electronic searches (n=6). From

other proven clinical guideline. Studies that

that, there were 237 total records retrieved.

use any other definition will be excluded,

Duplicates (n=7) is immediately removed,

unless it is accompanied by other accepted

leaving 230 records to be screened. 196

definition or acts as just an accessory.

records were further excluded as it is irrelevant

Diabetes

standard

Self-reported

was

diagnosis

to topic or objectives of this review, resulting

follow up, no loss, or less than 20% loss.

in 34 studies to be assessed for its eligibility. 1

These 5 studies either have a follow up rate

study has incompatible study design, 10

less than 80% or show no description of

studies were review articles, data of 5 studies

follow up process. Erickson JG and Forsen T

did not correlate with topic, full-text articles of

did not define follow up, Hypponen had 74.7%

3 studies cannot be found, and 4 studies did

of follow up, Mamun AA et al. only had

not have sufficient data. With those 24 records

36.5%, and Power C had a 52.7% follow up.

had been excluded, there were 10 studies to be

This may arise from the extensive study

included in the qualitative synthesis.

length, which could result in loss of interest, migration or death. The most unbiased studies

Furthermore, there were 4 studies that did not

were by Hou D, 2016 and Liang Y, 2015 as a

use any of the accepted definitions of obesity

star was given to all categories.

and diabetes as mentioned above (Erickson et al., Forsen et al., Mamun et al., and Tirosh, et

Table 1 portrays the characteristics of the 10

al.). Lawlor et al. did not specify the number

studies with a total of 73,533 participants

of positive and negative outcome group

included in this review. All study uses Cohort

therefore impossible to calculate the OR. This

as

resulted in the exclusion of the 5 studies

retrospective. 5 studies were included in the

above, and the final 5 studies to be eligible for

meta-analysis. In the studies, the definition of

quantitative analysis (Hou D, 2016; Hyponnen

childhood obesity and adult diabetes type 2

E, 2003; Liang Y, 2015; Morrison JA, 2010;

still varied. Since these definitions were only

Power C, 2011). The summary of study search

used alongside the accepted definitions and act

and selection is depicted in accordance to the

as

four-phase PRISMA Statementsâ&#x20AC;&#x2122; flow diagram

appropriate for meta-analysis. Other childhood

in Figure 1.

obesity definition is Chinaâ&#x20AC;&#x2122;s Working Group

study

design,

either

prospective

or

an ancillary, the studies were still

on Obesity (WGOC) growth chart in studies The result of risk of bias and quality

by Hou D and Liang Y. Other definitions of

assessment

the

diabetes type 2 in adult are current use in

Newcastle-Ottawa Scale is depicted in Figure

blood-glucose lowering agents by Liang Y and

2. Overall result suggests that all studies have

Power C, and HbA1c in Hou D and Power C.

for

each

study

using

the minimum score of 8/10, implicating low risk of bias and high validity. The most

The locations of the studies was fairly

apparent bias from the individual studies was

scattered, as it ranges from Asia, Europe,

from the Outcome Section number 3, whereas

Oceania, America, and Middle East. This is

5 studies did not manage to do follow up to a

beneficial meaning that these studies were able

number of subjects thatâ&#x20AC;&#x2122;s unlikely to introduce

to represent the global community. The age at

bias. An adequate follow up includes complete

which obesity was measured varied, however

the age of 7-16 is the most often represented (6

driven by the considerable consistent findings

studies). The outcome of the studies varied

across the studies that obese BMI in childhood

across studies. Lawlor et al. (2006). showed

increases the risk of diabetes in adulthood, the

the lowest OR in this review, which is 1.22,

similarity in obesity and diabetes cut off, and

while the OR reached 5.49 in the study from

the fairly equal distribution of age in baseline.

Morrison et al (2010).

Moreover, funnel plot generated showed a symmetrical appearance (Figure 4), proving the homogeneity of this review and a rather low publication bias.

Figure 1. Study search and selection process.

Figure 2. Bias and quality assessment of included studies with NOS-cohort

Figure 3 shows the forest plot for the association between childhood diabetes for all

The summary of risk of bias for this review

ages based on BMI and diabetes type 2 in

was done based on the four-level assessment

adulthood. The association found from this

in Cochrane Handbook as stated before. The

meta-analysis of 5 studies was positive and

potential bias could result from authorsâ&#x20AC;&#x2122;

significant (OR: 3.89; 95% CI 2.97-5.09) with

assumptions in accepting definitions used for

a p-value of <0,00001.

childhood obesity and adulthood diabetes type 2, such as the self-report of physician

Heterogeneity in this study with I2 statistics

diagnosis to DM type 2. This could lead to a

was 0% across cohort used. The p-value for

lower quality of evidence of this meta-

this heterogeneity test was 0.6. This describes

analysis.

the homogeneity of this review, which was

Figure 3. Forest plot analysis of included studies

of this meta-analysis is valid.

Based on all the studies included in the systematic

review,

childhood

obesity

is

discovered to be a risk factor to adult-onset diabetes. The OR of the studies ranged from 1.22 - 5.49, all of which are higher than 1.

Thus, it can be concluded that all studies have Figure 4. Funnel plot assessment of included studies

shown childhood obesity as a risk factor to adult-onset diabetes, and none of the studies has declared otherwise (Ericksson et al., 2015;

DISCUSSION

Forsen, 2000; Hou et al., 2016; Hypponen et

Based on this systematic review and metaanalysis, it is found that childhood BMI, particularly BMI >+3SD Z-score, is related to the

occurrence

of

adult-onset

children with obesity is more likely to become diabetic in adulthood with the OR: 3.89 [95% 2.97,

5.09].

Thus,

individuals

with

childhood obesity is 3.89 times more likely to have adult-onset diabetes. The variability between studies are I2 = 0% (P = 0.60), signifying

that

the

studies

2015; Mamun et al., 2009; Morrison et al., 2010; Power et al., 2011; Tirosh et al., 2011).

diabetes.

Through the forest plot, it is discovered that

CI

al., 2013; Lawlor et al., 2006; Liang et al.,

shows

no

heterogeneity between one another. This means that results of the studies are highly similar with one another. P value for this metaanalysis is p < 0.00001, meaning that the result

In this meta-analysis, the study with the highest weight is Liang Y with 28.6%. This study, along with Hou D (second highest weight of 25.1%), suggests that childhood obesity promotes adulthood obesity due to early adiposity rebound. Early adiposity rebound would result in an increase in body fat composition

and

weight

gain,

causing

individual to enter the obesity cycle. Based on the obesity cycle, as the individual gains more and more weight, physical inactivity becomes more prominent as it becomes physically

Table 1. Summarize of study characteristics

harder for individuals to do physical activity.

becomes

As obesity progresses, performing physical

adulthood. Thus, the outcome of this review

activity becomes excruciating and exhausting,

could be implemented on early screening for

increasing sleep and eating frequency due to

diabetes and pediatric health guidelines.

fatigue. As it progresses further, it becomes

Childhood obesity should be added as a risk

harder and harder to reduce oneâ&#x20AC;&#x2122;s BMI, which

factor evaluated on diabetes early screening,

along with social pressure, could lead to

while pediatric health guidelines should also

mental

Increased

include this information in order to further

cortisol due to stress would result in increased

imply the necessity to prevent and reduce

appetite, aggravating the condition. Early

childhood obesity. Public awareness regarding

onset of this cycle increases risk for adult-

this study should also be increased to raise

onset obesity, where adulthood obesity itself is

awareness regarding this risk factor to parents,

a major risk factor to adult diabetes (Liang et

to further imply the need to reduce their

al., 2015; Hou et al., 2016). As both of this

childrenâ&#x20AC;&#x2122;s obesity.

stress

and

depression.

a determinant for diabetes

in

studies also has the least of risk of bias, with the score of 10/10, this explanation is largely

Strength and Limitations

possible.

The strength of this study includes: usage of structural guideline, low risk of bias in

A study by Hypponen E, which has the third

included studies, large cohort population,

highest weight, suggests that high numbers of

various countries representation, symmetrical

adipocyte

in

funnel plot, no study heterogeneity and high

sustained increment of insulin, as insulin

study specificity. This review is made based

functions to inhibit adipose tissue breakdown.

on

Prolonged high insulin concentration would

completion and comprehensiveness of the

result in insulin resistance. Childhood obesity

study, NOS as risk of bias in included studies

suggests that an individualâ&#x20AC;&#x2122;s adipocyte amount

assessment tools, and Cochrane Handbook as

is higher than normal, causing a sustained high

risk of bias across this review assessment

insulin condition. This mechanism explains

tools. 100% of included studies has the

how childhood obesity causes adult-onset

minimum scale of 8/10. All included studies

diabetes as it requires a certain amount of time

has minimum of 1,000 participants to ensure

for insulin resistance progression to reach a

the quality of each study. There are 8 countries

diabetic state (Hypponen et al., 2003).

included in this review, all of which originates

tissues

would

also

result

PRISMA

Statement

to

ensure

the

from either Europe, Asia, America, Oceania, The results of this review revealed that risk

and Middle-East. Funnel plot data has also

factors

proven to be symmetrical, meaning that

of diabetes

adulthood.

Health

are not limited to conditions

during

studies included are highly homogen. As

childhood, in this case childhood obesity,

stated above, the result of this study shows no

heterogeneity and p value < 0.00001, which

adult-onset diabetes. The most likely cause is

represents a specific and trusted result as it has

due to early adiposity rebound and early-onset

statistically included enough studies and

insulin resistance from childhood obesity (Hou

enough data varieties.

et al., 2016; Hypponen et al., 2013; Liang et al., 2015).

On the other hand, limitation of this systematic review

and

few

The findings of this study are applicable in the

accepted

field of public health, both as a screening

definitions, and lifestyle changes. Out of the

method and prevention for adult diabetes. As

230 original studies retrieved, only a total of

the determinant for childhood obesity in this

10 studies are used in the qualitative review,

review uses BMI for age, further research

and 5 studies in the quantitative review.

regarding

Though there are no heterogeneity and high

obesity itself and other body compositions

specificity, the final OR from this review

could also be done to discover presence of a

would be more representable for worldwide

more

use if there are more studies included in the

measurement and to analyse other variables

forest plot. Though BMI is believed to follow

during childhood that is related to adult-onset

normal distribution, bias can occur. Definition

diabetes respectively. As BMI-for-age is not

of self-reported diagnosis by physician for

the only value used to evaluate childhood

adulthood diabetes was accepted, but bias can

obesity, research on other markersâ&#x20AC;&#x2122; specificity

also arise. Third, as cohort studies needed for

and sensitivity towards adult-onset diabetes is

this review requires a long follow up period,

crucial to increase treatment effectivity. Other

and our review includes studies published

body compositionsâ&#x20AC;&#x2122; effect on adult-onset

from the year 2000, the childhood lifestyle of

diabetes should also be evaluated as obesity is

cohort samples belong to lifestyle in the 1900s

a broad term used for general changes to the

instead of 2000s. The follow up period ranged

body composition. This is also essential in

from 12 years up to 52 years. As obesity is

order to provide a more detailed and precise

highly correlated with lifestyle, evaluation of

guideline in early screening and prevention of

these studies might not represent the condition

adult-onset diabetes itself. Age stratification

of

of

and area-specific research should also be done

childhood obesity today might differ from the

in order to have a more detailed causality for

results included in the review.

each age group and certain areas.

Conclusion

Funding

In conclusion, this systematic review and

This review is not funded by any organisation,

meta-analysis has found that individuals with

institution or other third-parties.

included

meta-analysis

studies,

children

today.

bias

Thus,

includes: from

incidence

childhood obesity has higher risk of having

other

sensitive

measurements

and

specific

evaluating

obesity

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TYPE 2 DIABETES MELLITUS: AN ETHNICITY BASED ANALYSIS ON DAILY GLYCEMIC LOAD Arief Abdurrazaq Dharma1, Imam Amriadi A.S2, Andi Muhammad Zharfan3, Eddy Zulfikar4 ABSTRACT Introduction Type 2 Diabetes Mellitus (T2DM) is the most common type of Diabetes that characterized by insufficient insulin amount that it needs and/or the insulin resistance. One of the Risk factor of T2DM was Glycemic Index (GI) and Glycemic Load (GL) that highly affected with the consumption habit of each people. Carbohydrates are the dietary components that have the greatest effect on blood glucose concentrations. Parents are determinants of their children's nutrition up to 70% of what they eat. The behavior of one's food consumption, in this case the parents and their children, is influenced by knowledge and other factors such as the socio-cultural background in which they live.

Aim This study aimed to know about consumption culture in South Sulawesi, associated with the increasing risk if T2DM. Material and Methods This was a descriptive study using consecutive sampling with focusing on housewives from four major ethnicities in South Sulawesi. From the total population household with 10% of error value, 100 number of sample were accounted in this study. The data then collected by using an online questionnaire which contain fifteen foods that have high level of GI. The result then used to assess the GL that each children consume daily based on the assessment standard of GL. Result Among 100 eligible subjects, the age category is divided based on the Republic of Indonesia Ministry of Healthâ&#x20AC;&#x2122;s. Mean data of daily GL was highest in Makassarese, followed by Buginese, Toraja, and Mandar and this type of order was applied to median data of GL as well. Makassarese is an ethnic that has a high risk of developing diabetes with 25 peoples. Compared to the Toraja ethnic, 23 people have a high risk and only 2 people have moderate to low risk. While for Buginese and Mandar ethnic groups, 22 of them have a high risk and 3 have moderate to low risk.

Conclusion All four ethnicities group in South Sulawesi considered as high risk of T2DM based on their daily GL.

Keywords Type 2 Diabetes Mellitus, Culture, Glycemic Load, Glycemic Index.

TYPE 2 DIABETES MELLITUS: AN ETHNICITY BASED ANALYSIS ON DAILY GLYCEMIC LOAD Asian Medical Students’ Association Universitas Hasanuddin

Written By: Arief Abdurrazaq Dharma Imam Amriadi A.S Andi Muhammad Zharfan Eddy Zulfikar

ASIAN MEDICAL STUDENTS’ ASSOCIATION UNIVERSITAS HASANUDDIN MAKASSAR 2018

INTRODUCTION Diabetes prevalence has been rising more rapidly in middle and low-income countries. The number of people with diabetes has risen from 108 million in 1980 to 422 million in 2014 (World Health Organization [WHO], 2017). Type 2 Diabetes Mellitus (T2DM) is the most common form of diabetes (American Diabetes Association [ADA], 2015). T2DM mostly happens because the pancreas doesn’t produce enough insulin in amount of the body needs and/or the insulin that is produced does not work correctly (insulin resistance) (British Dietetic Association [BDA], 2018). Insulin itself is a hormone that regulates blood sugar, which helps glucose enter the body cells.

In 2015, an estimated 1.6 million deaths were directly caused by diabetes. Another 2.2 million deaths were attributable to high blood glucose in 2012 (WHO, 2017).

Carbohydrates are the dietary components that have the greatest effect on blood glucose concentrations. Because carbohydrates differ in their ability to increase blood glucose, the concept of Glycemic Index (GI) was introduced in the early 1980s. The GI is a ranking of carbohydrates according to their effect on postprandial glycemia (Fiona, Kaye, & Jennie, 2008). Although the GI can effectively rank foods on the basis of their blood glucose response, it does not account for the amount of carbohydrate in a typical serving. Therefore, the new concept of Glycemic Load (GL) was developed as the product of the GI and the amount of carbohydrate in a serving (Livesey G et al., 2013).

Three meta-analyses (Barclay, 2008; Dong, 2011; Livesey, 2013) of prospective cohort studies found a higher risk of T2DM with higher GI and GL. Furthermore, three large prospective cohorts of US men and women conducted by Shilpa et al (2014), succeed to prove a positive association between GI, GL, and the risk of T2DM. On their research, Shilpa et.al found that participants who consumed a combination diet that was high in GI or GL and low in cereal fiber had an approximately 50% higher risk of T2DM compared with those whose diets were high in cereal fiber and low in GI or GL. Several physiologic mechanisms have been proposed to explain the positive association of GI and GL with T2DM (Ludwig, 2002; Willet, 2002). High-GI and -GL diets are known to stimulate the increased production of insulin, resulting in a state of hyperinsulinemia, which, in turn, can induce insulin resistance. The consumption of highGI and -GL diets for several years can increase the demand on β-cells and lead to β-cell exhaustion and failure (Pawlak, Kushner, & Ludwig, 2004). Furthermore, because high-GI and -GL diets increase concentrations of blood glucose and free fatty acids (Thomas & Elliott, 2010), chronic exposure to these elevated concentrations can also induce β-cell

failure. The biological plausibility of an association between GI and T2DM is evident from results of metabolic and intervention studies. In a meta-analysis of 12 randomized controlled trials that comprised 612 subjects, low-GI diets reduced glycated hemoglobin by 0.4% (95% CI: −0.7%, −0.2%) over that produced by the control diets (Thomas & Elliott, 2010). Furthermore, the Study to Prevent NonInsulin Dependent Diabetes Mellitus (STOP-NIDDM) trial, which showed that acarbose, an oral α-glucosidase inhibitor, which effectively converts the diet to a low-GI/GL diet, reduced T2DM risk by 25% over a mean follow-up of 3 y provides a proof-of-concept for low-GI diets (Chiasson et al., 2002).

Unfortunately, in Indonesia, based on the data from RISKESDAS, about 53.1% of the population aged over 10 years, was known to have excess sugar consumption habits (Riset Kesehatan Dasar [RISKESDAS], 2013), no exception for South Sulawesi. Makassar is a capital city of South Sulawesi, which is dominated by Buginese ethnics (Ciptakarya 2004). Common foods of Buginese Makassarese that are mostly found including coto makassar, jalangkote, beppa tori, pallu butung, pisang ijo, sup saudara and sup konro which are identical with high sugar and fat content. In a study conducted by Wahyu Rizky Kartikasari (2014) about Analysis of Community Eating Habits Around Waduk Cirata, Bogor, by comparing eating habits of Buginese with Sundanese population which living around, it is known that the tea consumption of Buginese is higher than Sundanese. In depth, there are differences in the way of serving the tea between the two. The Buginese are used to drinking tea by adding sugar, while the Sundanese are used to drinking plain or tasteless tea. Furthermore, in Wahyu Research, stated as many as 92.9% of Bugis people are known to have a habit of frequent consumption of snacks. Snacks that are usually eaten are more likely high-carbohydrate snacks such as biscuits, sukro beans, fried foods, banana chips and cassava chips. This kind of habits led to the presentation of the high rate of obesity in Buginese (50%) compared to the Sundanese (34.4%). This is in line with the research of Burhan et al. (2013) who found that in Jeneponto, South Sulawesi, factors that were proven to influence the incidence of central obesity were high intake of sucrose sugar, fat, and low intake of fruit and vegetable. This can be a major problem of society because people whose living with obesity have a 7.14 times greater risk of developing diabetes mellitus than individuals who are not obese in the future (Kurnia & Setyorogo, 2013). This is proven by data from RISKESDAS 2013 that the prevalence of diabetes mellitus diagnosed by doctors or symptoms in South Sulawesi, is the third highest in Indonesia, namely 3.4%, after Central Sulawesi (3.7%) and North Sulawesi (3.6%). This is four times higher than the previous data on RISKESDAS in 2007, whose prevalence is only around 0.8%.

It is concluded that eating habits are formed from the beginning of life, so that high consumption of sugar in children still become a major concern. Parents are determinants of their children's nutrition up to 70% of what they eat (Dallacker, Hertwig R, & Mata J, 2017). Therefore, reducing sugar consumption in children is a parent's decision regarding food (Hertwig & GrĂźne-Yanoff, 2017).

The behavior of one's food consumption, in this case the parents and their children, is influenced by knowledge and other factors such as the socio-cultural background in which they live (Aminuddin, 2016). Indonesia is a country that has diverse cultures, and South Sulawesi province is one of them. The population of South Sulawesi consists of 4 major ethnic groups, namely Buginese, Makassarese, Toraja, and Mandar (Ubbe, 2005).

Until now, there have been no studies related to the influence of local culture on consumption behavior. Therefore, based on the problem, researchers are interested in knowing more about the consumption culture in South Sulawesi, associated with the increasing risk of types 2 diabetes mellitus.

METHOD This was a descriptive study using consecutive sampling. This study focusing on housewives from four major ethnicities in South Sulawesi (Buginese, Makassarese, Mandar, and Toraja). The housewives included in this study should be at least have one child and made their own dishes for their family. Total number of household in Sulawesi Selatan from Badan Pusat Statistik becoming the parameter of population to be used in Slovinâ&#x20AC;&#x2122;s formula to get the number of sample for this study.

From the total population of 1.976.250 household with 10% of error value, 100 number of sample were accounted in this study. This total number of sample then divided equally into four representing of the four major ethnicities in South Sulawesi.

The data then collected by using an online questionnaire which contain fifteen kinds of food that have high level of Glycemic Index. This questionnaire aimed to know how the pattern of food intake given by the housewives to their children, especially in daily carbohydrate content of the food per person. The result then used to assess the Glycemic Load that each children consume daily based on the assessment standard of Glycemic Load used by the former research conducted by Rozanska et al (2016). The final data then analyzed through IBM SPSS 23 software before finally transformed into tables and chart.

RESULT Table 1. Age category Valid

Frequency Percent

Valid Percent

Cumulative Percent

17-25

1

1.0

1.0

1.0

26-35

3

3.0

3.0

4.0

36-45

38

38.0

38.0

42.0

46-55

51

51.0

51.0

93.0

56-65

6

6.0

6.0

99.0

>65

1

1.0

1.0

100.0

Total

100

100.0

100.0

Among 100 eligible subjects, the age of the study participants ranged from 18 to 67 years with a mean and median age of 46.42 and 47.00 respectively. The age category is divided based on the Republic of Indonesia Ministry of Healthâ&#x20AC;&#x2122;s decision from 17-25, 2635, 36-45, 46-55, 56-65, and >65 where the frequencies are 1(1%), 3 (3%), 38 (38%), 51 (51%), 6 (6%), and 1 (1%) (Table 1).

Table 2. Descriptive distribution of daily glycemic load for each ethnicity Ethnicity

Mean

Median

Max

Min

Buginese

244.8025738

201.9625105

940.6887288

90.566995

Makassarese

256.3505613

212.8594409

860.17585

120.8799048

Toraja

202.1371256

168.8267355

458.714

53.71225314

Mandar

202.0179253

162.0084821

743.068

83.93212986

Table 2 Showed that Mean data of daily glycemic load was highest in Makassarese, followed by Buginese, Toraja, and Mandar Ethnicity and this type of order was applied to Median data of glycemic load as well. Moreover, maximum value of daily glycemic load was highest in Buginese, Followed by Makassarese, Mandar and Toraja ethnicity. Minimal value of daily glycemic load was lowest in Toraja, and followed by Mandar, Buginese and Makassarese Ethnicity.

According to previous research by Rozanka et. al (2016), Glycemic Load (GL) of daily food ration (DFR) were calculated by summing GL values of consumed foods. GL of 80 g or below was considered low, a GL of 80-120 g was considered medium, and a GL of 120 g or above was considered high. It is stated in Shilpa (2014) research, the more the food has high in GI or GL and low in cereal fiber content, it has 50% higher risk of developing T2DM. Using that kind of classification, we found that Makassarese is an ethnic group that has a highest risk of developing diabetes with 25 peoples (100%).

Compared to the Toraja ethnic group, where 23 people have a high risk and only 2 people have moderate to low risk. While for Buginese and Mandar ethnic groups, 22 of them have a high risk and 3 have moderate to low risk. For more detail, look at the figure 1 below.

Figure 1. Distributon of daily glycemic load for each ethnicity

DISCUSSION South Sulawesi is one of major provinces in Indonesia. It has 45 764,53 km2 area which include 21 regencies and 3cities. In those liveable space, there are four major ethnics dominating the population, which are Makassar, Bugis, Toraja and Mandar (Ubbe 2005).

Based on the daily glycemic load (GL) classification from Rozanka et. al (2016), we found that the Mean data of daily glycemic load of the four ethnics group (Makassar, Bugis, Toraja, Mandar) considered as high, thus all the four major ethnics have the greater risk of developing Types 2 Diabetes Mellitus. It might due to the condition that all those four ethnics live in the close area one to another, which leads to similiar altitude, geographical condition, land and climate profile. Most of the regencies in South Sulawesi classify as a low land that vary from 20- 3.469 m from sea level. Just like the city in Indonesia in general, climate found in South Sulawesi is only dry (June to September) and rainy (December to March) season. All of those factors caused the crops, fruits, vegetables, and main meals produced in South Sulawesi are mostly the same. Rice is still the main food consumed by the four ethnicities in South Sulawesi. South Sulawesi is one of the national rice barns. In 2009, rice production of Sulawesi Selatan was 4 324 178 tons harvested from the 862 017 hectares of rice field, which meant that the productivity was about 5,02 tons per hectare.

According to Purwantini (2012), the rate of rice consumption in South Sulawesi reported to reach 98%. South Sulawesi is the highest producer of food crops in the east region of Indonesia. Besides the rice commodity as an item of trade, another food crops of South Sulawesi are corn, cassava, Sweet Potatoes, Soyabeans, Peanuts, and small green pea.

Production of Vegatables mostly dominated by red onion, garlic, French beans, carrot, potatoes, cabbage, and tomatoes. Otherwise avocado, orange, pineapple, mango, banana, and jack fruit are the dominant fruit found in this province (BPS, 2010).

The current study somehow shoed that eventhough the four ethnicity groups had a quite high daily glycemic load, there is still a litter difference between those ethnicities.

100% of Makassarese involved in this study were reported to be in high risk. Compared to the Toraja ethnic group, where 23 people have a high risk and only 2 people have moderate to low risk. While for Buginese and Mandar ethnic groups, 22 of them have a high risk and 3 have moderate to low risk. This diversity was due to several factors, including socioeconomic factor such as level of education, occupation, income, family scope, culture, and knowledge about nutrition. People who had higher level of education tends to understand more about nutrition. This knoledge of nutrition will ease people to choose what kind of food they want to eat based on nutritional guidance. Therefore, the higher level of education people have, the better they will accept, process, interpret, and use the

information (Contento, 2007). Moreover, the current study focusing more on the level of knowledge of the mother, since knowledge about nutririon owned by a mother will determine the nutritional status of the whole family (Suhardjo, 1989).

Environment will play a big role on eating habit. People are forced to adapt with their living environment in order to survive life. Moreover, culture also plays a very important role to eating habit for several cultures even prohibit their followers to eat particular foods especially those who are in the period of pregnancy, lactation, baby or even toddler (Rizki wahyu, 2014). Lack of food variety that is consumed might due to the low level of income which impacting family’s ability to buy foods. The better the occupation is, the bigger income a family will get (Megiyawati, 2004).

CONCLUSION All four ethnicities group in South Sulawesi (Makassar, Bugis, Toraja, Mandar) considered as high risk of type 2 Diabetes mellitus based on their daily glycemic load.

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International tables of glycemic index and glycemic load values. Diabetes care, 31, 12, 2281-2283.

3. Barclay AW, Petocz P, McMillan-Price J, Flood VM, Prvan T, Mitchell P, BrandMiller JC. (2008). Glycemic index, glycemic load, and chronic disease risk—a meta-analysis of observational studies. Am J Clin Nutr, 87, 627–37.

4. Dong JY, Zhang L, Zhang YH, Qin LQ. (2011). Dietary glycaemic index and glycaemic load in relation to the risk of type 2 diabetes: a meta-analysis of prospective cohort studies. Br J Nutr, 106, 1649–54.

5. Livesey G, Taylor R, Livesey H, Liu S. (2013). Is there a dose-response relation of dietary glycemic load to risk of type 2 diabetes? Meta-analysis of prospective cohort studies. Am J Clin Nutr, 97, 584–96.

6. Shilpa N Bhupathiraju, Deirdre K Tobias, Vasanti S Malik, An Pan, Adela Hruby, JoAnn E Manson, Walter C Willett, and Frank B Hu. (2014). Glycemic index, glycemic load, and risk of type 2 diabetes: results from 3 large US cohorts and an updated meta-analysis. Am J Clin Nutr, 100(1), 218–232.

7. Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI (2013). Laporan Hasil Riset Kesehatan Dasar 2013. Jakarta, Indonesia: Riskesdas.

8. Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI. (2007). Laporan Hasil Riset Kesehatan Dasar 2013. Jakarta, Indonesia: Riskesdas.

9. Dallacker M., Hertwig R., & Mata J. (2017). Parents’ considerable underestimation of sugar and their child’s risk of overweight. International Jurnal of Obesity.

10. Hertwig R., Grüne-Yanoff T. (2017). Nudging and boosting: steering or empowering good decisions. Perspect Psychol Sci. 11. Aminuddin M. (2016). Hubungan antara pengetahuan dan sikap dengan perilaku konsumsi jajanan sehat. FKM Unair.

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Departemen hukum dan hak asasi manusia. Badan pembinaan hukum nasional.

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14. Willett W, Manson J, Liu S. (2002). Glycemic index, glycemic load, and risk of type 2 diabetes. Am J Clin Nutr, 76, 274S–80S. 15. Pawlak DB, Kushner JA, Ludwig DS. (2004). Effects of dietary glycaemic index on adiposity, glucose homoeostasis, and plasma lipids in animals. Lancet, 364, 778–85.

16. Thomas DE, Elliott EJ. (2010). The use of low-glycaemic index diets in diabetes control. Br J Nutr, 104, 797–802.

17. Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M. (2002).

Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet, 359, 2072–7.

18. American Diabetes Association (ADA). (2015). Facts About Type 2. http://www.diabetes.org/diabetes-basics/type-2/facts-about-type-2.html 19. British Dietetic Association (BDA). (2018). Food fact sheet: Diabetes Type 2. https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=r ja&uact=8&ved=2ahUKEwitlZW73JLeAhXJLI8KHYtpBG8QFjABegQICBAC &url=https%3A%2F%2Fwww.bda.uk.com%2Ffoodfacts%2Fdiabetestype2.pdf& usg=AOvVaw2wwtdgXWugY-jkxfaovbW4 20. Kurnia, S., & Setyorogo, S. (2013). Faktor resiko kejadian diabetes mellitus tipe II. Jurnal Ilmiah Kesehatan.

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ABSTRACT Introduction:Type 2 Diabetes Mellitus (T2DM) is a common and increasingly preventable disease worldwide.There are many factors that contribute to the occurrence of T2DM. Better lifestyle as well as better educationare believed to increase the chance of someone to avoid diabetes mellitus. Yet, it is still questionable whether this better education and lifestyle already been good enough for those in risk.

Objective:This study aimed to knowthe knowledge and attitude of non-diabetic subjects particularly those in risk of it.

Methods:This was a descriptive study using random sampling method involving 321 participants from three groups of occupation; housewives, private employees, and government employee/civil servants. There were 2 section of questionnaire where the first section was aimed to know the workerâ&#x20AC;&#x2122;s knowledge on diabetes mellitus andthe second one was aimed to assess the attitude of respondents towards their risky occupation, either being ignorant or positively aware to it. Finally, we also analyzed the link of knowledge and attitude in the context of preventing T2DM. The data was analyzed trough IBM SPSS Statistics 23 before finallytransformedinto tables and charts.

Result: Among 108 subjects from government employee group, 104 were found to be knowledgeable and 47 had negative attitude towards diabetes. Moreover, among 106 subjects of housewife, 102 were found to be knowledgeable and 55 reported to have negative attitude towards diabetes. Finally, among 107 subjects of private employee, 105 were found to be knowledgeable and 63 sadly showed negative attitude towards diabetes. On the other hand, there were264 out of 321 participants who werereported to not knowing that they are in risk.

Conclusion:Majority of people who work as either housewife, government or even private employee already been knowledgeable enough for any information about type 2 diabetes mellitus, yet this level of knowledge unfortunately not in line with their attitude which tended to show less aware even more to ignorant for the risk of diabetes they are facing because of their occupations.

Key words: Diabetes Mellitus, Knowledge, Attitude, Occupation

Type 2 Diabetes Mellitus: A Descriptive Analysis On Knowledge And Attitude Of Those In Risk Asian Medical Student Association Hasanuddin University

Written By: MuhKhairil Hasyim Indah Nurul Khairunnisa Trixie Nathania Zelig Nurul Fadhilah

ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION INDONESIA 2018

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INTRODUCTION Diabetes is a common and increasingly prevalent disease worldwide. There are 382 million people livingwith DM in the world, and is expected toincrease to 592 millionin 2035. Among 382 million people living with diabetes, 175 million of them were untreated and led to complicationswithout any efforts of prevention(International Diabetes Federation, 2013). Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin (Type 1) or when the body cannot effectively use the insulin it produces (Type 2). Diabetes is a disease that is strongly associated with both

microvascular

and

macrovascular

complications,

including

retinopathy,

nephropathy, and neuropathy (microvascular) and ischemic heart disease, peripheral vascular disease, and cerebrovascular disease (macrovascular), resulting in organ and tissue damage in approximately one third to one half of people with diabetes. (Cade, 2008) Type 2 Diabetes Mellitus (T2DM) is the most common form of DM, which accounts for 90% to 95% of all diabetic patients (R John, Srivastava 2014). T2DM develops through abnormal insulin action and insulin secretion that characterized by insulin insensitivity as a result of insulin resistance, declining insulin production, and eventual pancreatic beta-cell failure. This leads to a decrease in glucose transport into the liver, muscle cells, and fat cells. There is an increase in the breakdown of fat with hyperglycemia (Fujioka K, 2013). Based on World Health Organization (WHO) National diabetic group criteria for diagnosing, is a single raised glucose reading with symptoms (polyuria, polydipsia, polyphagia and weight loss), otherwise raised values on two occasions, of either fasting plasma glucose 7.0 mmol/L (126 mg/dL) or with an oral glucose tolerance test (OGTT), two hours after the oral dose a plasma glucose Âł11.1 mmol/L (200 mg/dL).

The risk factors for T2DM are better known with predisposing factors that consist of modifiable and non modifiable factors. One of modifiable factors is lifestyle, includinglack of physical activity, poor diet, stress, and others. (Williams Textbooks of Endocrinology. 12th edition 1371-1435). Diabetes keeps a steady increase in developed countries which possibly caused byrapid technological development and instantaneous lifestyle (Weigensberg MJ, Goran MI I 2015.)

There are several factors related to the incidence of T2DM, including sociodemographic factors that given the risefor occupation. In this 21stcentury,

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peoplemostly spendtheir time pursuing their professions which subconsciously lead them to

T2DM.

After

conducting

pre-research

literature

study

using

several

journals(Adikusuma, Perwitasari, & Supadmi, 2014; Bertalina, 2016; Dini, Sabila, Habibie, & Nugroho, 2017; Lubis & Susilawati, 2017; Srikartika, Cahya, & Hardiati, 2016)we found out that there are several professions that show their tendency to T2DM includingPrivate employees, Housewives,and Government employee (Figure 1).

35 Health Journal vol VII no 3 of Indonesia November 2016

30 25

Indonesian Journal Of Human Nutrition, Desember 2017 Vol 4 No 2

20

Journal of Management and Pharmaceutical services Vol 6 No 3 September 2016

15 10

Pharmaceutical Media Vol 11 N0 2 September 2014

5 Vocational Health Journal Vol 2 No 2 November 2017

0 Housewifes

Private Employees

Goverment Employee

Figure 1. The number of T2DM cases for each profession in five studies.

Correlationof Lifestyle and Occupation to the silent killer T2DM In 4.0 Revolutionary era, the vast majority of society is being pampered by the existence of technology that has an impact on consumptive and instantaneous characteristic of human nature. In line with the freedom that is received, this also causes various problems in everyday life. Instant things can give more probability for people to suffer from a disease namely as Type 2 Diabetes Mellitus. Facilities which aimed to ease us to work will somehow becoming the reason for us to have less physical movement but still need to face a high level of stress at work. This combination of less physical movement and high level of stress will significantly lead to T2DM. Physical activity is another important part of diabetes management plan proven in several studies. While

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doing our daily activities, the muscles will use sugar (glucose) as the source of energy.

Regular physical activity also helps our body to use insulin more efficiently. These factors will sequentially work together to lower the level of blood sugar. The more strenuous workout done, the longer the effect lasts. Another factor related to the risk of T2DM is the level of stress. We live in a very stressful society which is constantly putting us underpressure. Stress is a potential contributor to chronic hyperglycemia in diabetes.

Stress has long been shown to have major effects on metabolic activity. Energy mobilization is a primary result of the fight or flight response. Stress stimulates the release of various hormones, which can result in elevated blood glucose levels. Although this is of adaptive importance in a healthy organism, in diabetes, as a result of the relative or absolute lack of insulin, stress-induced increases in glucose cannot be metabolized properly. Furthermore, regulation of these stress hormones may be abnormal in diabetes.

(Guariguata L, Whiting DR, Hambleton I2013). Whether type 2 diabetes can be prevented by interventions that affect the lifestyles of subjects at high risk for the disease is sadly still unclear. This can be due to misconceptions, misinformation, or a lack of current information about diabetes. Therefore, it is really important to make a reasearch about the influence of knowledge on T2DM for people at risk for it, as well as their behavior to face such risks. The outcome of this research is expected to give wider perspective for government and any stakeholders that are willing to create a healthy lifestyle that improves active movement and seeks solutions to stress levels that can prevent T2DM. METHOD This was a descriptive study using random sampling method. There are three occupations included in the study; housewives, private employees, and government employee. Each occupations becoming the parameter of population to be used in Slovinâ&#x20AC;&#x2122;s formula before finally proceeded to randomization process. Finally, there were 106, 107, 108 number of samples for housewives, private employees, and government employee, respectively.

There were 2 sections of questionnaireused in the study. The questionnaires were distributed to people staying at Makassar, South Sulawesi, Indonesia. The first section was aimed to know the workerâ&#x20AC;&#x2122;s knowledge on diabetes mellitus, by measuring the specific knowledge on etiology, risk factors, symptoms, management, and the complication of diabetes mellitus. The second section of the questionnaire was aimed to

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assess the respondents about their attitude towards their risky occupation, either being ignorant or positively aware to it. The data was analyzed trough IBM SPSS Statistics 23 before finallytransformed to tables and charts.

RESULT Demography Data Table 1.Demographic data Demographic data

n

%

Gender

Male Female Total

106 215 321

33.0 67.0 100.0

Age

20-29 30-39 40-49 50-59 60-69 Total

120 91 62 46 2 321

37.4 28.3 19.3 14.3 0.6 100.0

Level of Education

Elementary Junior High Senior High Bachelor degree Master degree Doctoral degree D3 Total

8 12 63 150 74 5 9 321

2.5 3.7 19.6 46.7 23.1 1.6 2.8 100.0

Occupation

Government employee Housewife Private employee Total

108 106 107 321

33.6 33.0 33.3 100.0

Source: Primary data This study involving 321 people of nondiabetic population where 106 (33.0%) of them are male and 215 (67.0%) are female.The age range of participants are vary from 20-29, 30-39, 40-49, 50-59, and 60-69 range of age where the frequencies are 120 (37.4%), 91 (28.3%), 62 (19.3%),46 (14.3%),and 2 (0.6%), respectively.33.6% of

5

participants aregovernment employee, 33.0% are housewives, and 33.3% are private employees (Table 1).

Figure1. Knowledge about diabetes

Figure 1 showed that among 108 government employee or government employees,104 of them already knowledgeable and just 4 of them considered as less knowledgeable. Moreover, among 106 of housewives, 102 of them already knowledgeable and only 4 of them considered as less knowledgeable. Finally, among 107 of private employees, 105 of them are knowledgeable and only 2 of them are less knowledgeable.

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Figure 2. Attitude towards diabetes Figure 2 showed that among 108 of government employees, 61 of them considered as having positive attitude while 47 of them are negative attitude towards diabetes.Moreover, among 106 ofhousewives, 51 of them considered as having positive attitude while 55 of them are negative attitude towards diabetes.Finally, among 105 of government employees, 44 of them considered as having positive attitude while 63 of them are negative attitude towards diabetes.

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Figure 3. Attitude towards the level of knowledge

Figure 3 showed that among 311 participants who are knowledgeable for diabetes, 152 of them had positive attitude and 159 had negative attitude toward diabetes.

Moreover, among 10 participants who are less knowledgeable for diabetes, 4 of them had positive attitude and 6 had negative attitude toward diabetes respondent know how to prevent and 159 respondent still arenâ&#x20AC;&#x2122;t know the prevents, and about 10 respondents who less knowledge about diabetes.

8

Figure 4.Number of people who know they are in risk

Figure 4 showed that most of the participants don’t know that they are in risk for having diabetes. Among 108 of government employees, 21 of them already know that they are in risk, and 87 didn’t know at all. Moreover,among 106 housewifes, 17 of them already know that they are in riskwhile 89 of them didn’t. Finally, from 107 of private employees, 19 of them already know that they are in risk and surprisingly 88 of them didn’t even know that they are in risk.

DISCUSSION Type 2 Diabetes Mellitus is a commonly found preventable disease which can lead to several complications. Knowledge and attitude are of all factors associated with the incidence of diabetes mellitus. Those factors also can be influenced by the type of occupation people working in. This study aimed to know the occupational-based correlation between knowledge and attitude toward diabetes in Makassar, South Sulawesi, Indonesia.

9

Out of 321 participants, majority of them are 20-29 years old age range, and the majority of the respondents are female (67%). Regarding the level of education, 46,7% last education is bachelor degree.

Occupation was found to be in line with knowledge on diabetes mellitus. This study showed that majority of participants in all study groups; government employee, private employee, and housewife are knowledgeable (96,8%). This result is even higher than the number of knowledgeable participants in previous studies done in South East Ethiopia (55,9%) and Sri Lanka (>75%). (Naveena, 2016)This might be because the current study only covered groups of government employee, private employee, and housewife, where most of them have high level of education which was presumed to be the factor that contributed to the ability of participants in answering the questions provided in the study(Ong, Chua, & Ng, 2014). A better educated person be more inquisitive and more open while being informed or educated in diabetes. Not only that, working population would have the chance to get different information to contented materials, media and other source of information, including radio, magazine, and internet which mke the more knoeledgeable about diabetes mellitus(Gautam, Bhatta, & Aryal, 2015) Attitude was observed to be more positive in the group of Government employee (56,4%)and on the other hand it tended to be more negative in the group of private employee (41,9%)as well as housewives(48,1%). The finding was consistent with the study conducted in Bangladesh in which the attitude score was significantly lower in housewives respondents than the respondents of other occupations because in developing countries, female tend to left behind compared tomale in every aspect (Ong et al., 2014)Many participants were found to be ignorance to seek for medical services and to regularly check the blood glucosebecause of they have to work hours and did not have time to get medical chec up. Not only that, being anxiety of the possible bad result is one of the reason to4 not seek for medical chec up, because the result might backfired them and make them more depressed which led to more negative attitudes(Islam et al., 2014).

This explains why housewivesgave more negative attitude compared to others because housewives are having more anxiety (Kassahun & Mekonen, 2017) which support the result of current study. It is different with government employee, that even if they feel anxiety about of the possible bad result, they still have to do the medical check up as the part of their job that has been rule by government that is why more positive attitude could

10

be see in this occupation.

Even though the majority of our respondents had good knowledge (96,8%), yet it was not in line with the result of attitude which showed the tendency to be more negative, proving that most of them still not aware about the risk and complications of T2DM or even don’t have any abilities to stay away from it. This might be because attitude is not just affected by person’s knowledge, but beliefs, emotions, environment, or even the presence of other person while answering the questionnaire. This finding is consistent with the results reported by H. M.M. Herath in Sri Lanka owing to the fact that most of diabetes health promotion efforts are presented in uncoordinated strategy and this lead to false beliefs among general public. (Mumu, Saleh, Ara, Haque, & Ali, 2014)As for the environment, in developing countries like Indonesia, many myth remains still and affects people’s beliefsfor there’s still a lot of people in the community who thinks checking their health and knowing their true condition would making them weak and disturbing their daily activities(Herath, Weerasinghe, Dias, & Weerarathna, 2017).

One the other hand, most of respondents were found to be less knowledgeable regarding the risk of their occupation towards diabetes (82,24%). This concerning situation happen because occupation are rarely reviewed as one ofrisk factors of diabetes, there are limited source of literature and study that talking specifically on a particular occpuation that lead to diabetes mellitus (Herath et al., 2017). That is why when we do pre research by searching the data of diabetic patient’s occupation, unfortunately majority of endocrinology outpatient clinic did not register the occupation of diabetic patient, where in fact occupation is one determination of diabetic risk factor due to high stress level that they get at workplace which have a mojor effect on releasing various hormones that act to imbalance the metabolism and glycemic status in established(Harris et al., 2017). On the other hand to cath up the working load, people have to undergo sedentary lifestyle that lead to less physical activity and ended up as imbalance on energy intake and expenditure that will contribute to the occurence of diabetes mellitus (Colberg et al., 2010)

CONCLUSION

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This study concluded that majority of people who work as either housewife, government or even private employee already been knowledgeable enough for any information about type 2 diabetes mellitus, yet this level of knowledge unfortunately not in line with their attitude which tended to show less aware even more to ignorant for the risk of diabetes they are facing because of their occupations.

Further studies in a bigger community are needed to analyze more on the analytic correlation of knowledge and attitude toward type 2 diabetes mellitus to give better understanding, particularly for the risky occupations.

REFERENCES Adikusuma, W., Perwitasari, D. A., & Supadmi, W. (2014). Evaluasi kepatuhan pasien diabetes melitus tipe 2 di Rumah Sakit Umum PKU Muhammadiyah Bantul, Yogyakarta [in Bahasa Indonesia]. Media Farmasi, 11(2), 208–220. https://doi.org/10.3406/arch.1977.1322 Bertalina. (2016). Hubungan Pengetahuan Terapi Diet Dengan Indeks Glikemik Bahan Makanan Yang Dikonsumsi Pasien Diabetes Mellitus. Jurnal Kesehatan, VII(3), 345–513.

Cade, W. T. (2008). Diabetes Special Issue Diabetes-Related Microvascular and Macrovascular Diseases in the, 1322–1335. https://doi.org/10.2522/ptj.20080008 Colberg, S. R., Sigal, R. J., Fernhall, B., Regensteiner, J. G., Blissmer, B. J., Rubin, R. R., … Braun, B. (2010). Exercise and type 2 diabetes: The American College of Sports Medicine and the American Diabetes Association: Joint position statement.

Diabetes Care, 33(12). https://doi.org/10.2337/dc10-9990 Dini, C. Y., Sabila, M., Habibie, I. Y., & Nugroho, F. A. (2017). Asupan Vitamin C Dan E Tidak Mempengaruhi Kadar Gula Darah Puasa Pasien DM Tipe 2. Indonesian Journal of Human Nutrition, 4(2), 65–78.

Gautam, A., Bhatta, D. N., & Aryal, R. U. (2015). Diabetes related health knowledge, attitude and practice among diabetic patients in Nepal. BMC Endocrine Disorders,

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15(1), 1–8. https://doi.org/10.1186/s12902-015-0021-6 Harris, M. L., Oldmeadow, C., Hure, A., Luu, J., Loxton, D., & Attia, J. (2017). Stress increases the risk of type 2 diabetes onset in women: A 12-year longitudinal study using causal modelling. PLoS ONE, 12(2), 1–13. https://doi.org/10.1371/journal.pone.0172126 Herath, H. M. M., Weerasinghe, N. P., Dias, H., & Weerarathna, T. P. (2017).

Knowledge, attitude and practice related to diabetes mellitus among the general public in Galle district in Southern Sri Lanka: a pilot study. BMC Public Health, 17(1), 1–7. https://doi.org/10.1186/s12889-017-4459-5 Islam, F. M. A., Chakrabarti, R., Dirani, M., Islam, M. T., Ormsby, G., Wahab, M., …

Finger, R. P. (2014). Knowledge, attitudes and practice of diabetes in rural Bangladesh: The Bangladesh Population based Diabetes and Eye Study (BPDES).

PLoS ONE, 9(10). https://doi.org/10.1371/journal.pone.0110368 Kassahun, C. W., & Mekonen, A. G. (2017). Knowledge, attitude, practices and their associated factors towards diabetes mellitus among non diabetes community members of Bale Zone administrative towns, South East Ethiopia. A cross-sectional study. PLoS ONE, 12(2), 1–18. https://doi.org/10.1371/journal.pone.0170040 Lubis, I. K., & Susilawati. (2017). Analisis Length Of Stay ( LOS ) Berdasarkan Faktor Prediktor Pada Pasien DM Tipe II di RS PKU Muhammadiyah Yogyakarta.

Kesehatan Vokasional, 2(2), 161–166.

Mumu, S. J., Saleh, F., Ara, F., Haque, M. R., & Ali, L. (2014). Awareness regarding risk factors of type 2 diabetes among individuals attending a tertiary-care hospital in Bangladesh: A cross-sectional study. BMC Research Notes, 7(1). https://doi.org/10.1186/1756-0500-7-599 Naveena, T. (2016). Variations in prevalence of diabetes in various occupations : a quantitative and qualitative review, 3(10), 2705–2708.

Ong, W. M., Chua, S. S., & Ng, C. J. (2014). Barriers and facilitators to self-monitoring of blood glucose in people with type 2 diabetes using insulin: A qualitative study.

Patient Preference and Adherence, 8, 237–246. https://doi.org/10.2147/PPA.S57567

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Srikartika, V. M., Cahya, A. D., & Hardiati, R. S. W. (2016). Analisis Faktor Yang Memengaruhi Kepatuhan Penggunaan Obat Pasien Diabetes Melitus Tipe 2.

JURNAL MANAJEMEN DAN PELAYANAN FARMASI (Journal of Management and Pharmacy Practice), 6(3), 205â&#x20AC;&#x201C;212. https://doi.org/10.1038/jcbfm.1993.4

14

AUO “Are U Obese?” as a Mobile Application for Secondary Prevention of Obesity

by Framingham Method

Aleyda Zahratunany Insanitaqwa 1, Putri Fadriyana2, Maulida Mardhatillah 3 University of Brawijaya Aim With the available evidence of the correlation of Framingham risk factor for Cardiovascular Vascular Disease, and the evidence in variation of people’s respon for obesity. We sought to analyze AUO application as the simple way to give the right information about secondary detection of obesity, known the epidemiology of one’s area that have obesity disease, and by technology in hand we can maintain the healthy life.

Background Obesity has become the public health issue of the day—and for good reason. The data outline a dismal picture and a more foreboding future. The prevalence of obesity has doubled in adults and children and tripled in adolescents over the past 2 decades. Two thirds of Americans are overweight or obese. Each year in the United States, 400 000 deaths and $117 billion in health-care and related costs are attributable to obesity. In Indonesia, obesity has been increasing as the income has been raising. In 2016, the prevalence of obesity in Indonesia is 33,5% (20,6% has a BMI more than 27 or more) (Kemenkes RI, 2017).

Material and Method The study was conducted with retrospective observational study design. This community based descriptive study was conducted in ithe identified localities during the period of September 2018 to October 2018. Data were retrieved from Faculty of Medicine, Brawijaya University. These data were collected per month and specific parameter of obesity, which is body mass index (BMI) Result This application can take a risk that will be an instruction to fill the blank spaces provided. You have to write the name, age, address, sex, height, weight, medication used, and how often you exercise. After these, click result. The result will come out in percent. You will know how much the possibility of you having obese in the future. The advices are also provided for you to maintain a healthy body. We also provide a

guidebook about food calories so you would have a consideration of what to eat. Contacts of doctors nearby are also provided to have further counseling about your weight.

Conclusion The results of this study are that we as the pioneer of health applications (AUO apps) as early detection of the severity and complications of obesity that are processed with the development of data method from Framingham risk factors that correlate between obesity and CVD. So by combinig technology development and health problem, this application aims to provide an epidemic of obesity in an area, increasing awareness to the public about the dangers of obesity and give education to the society about how to overcome obesity.

Keywords : Obesity, Framingham risk factor, application

PRE-CONFERENCE COMPETITION EAST ASIAN MEDICAL STUDENT COMPETITION 2019

AUO: “ARE U OBESE?” AS A MOBILE APPLICATION FOR SECONDARY PREVENTION OF OBESITY

BY FRAMINGHAM METHOD By : 1. Aleyda Zahratunany Insanitaqwa 2. Aulia Putri Fadriyana 3. Maulida Mardhatillah

batch 2017 batch 2017 batch 2017

FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY MALANG

INTRODUCTION Obesity is defined as excessive fat accumulation that presents a risk to health (WHO, 2018). A measure of obesity is the body mass index (BMI), a person’s weight (in kilograms) divided by the square of his/her height (in metres). A person with a BMI of 30 or more is considered obese (WHO).

Indonesian Ministry of Health define a person with obesity if having a BMI of 25 or more. Obesity is major risk factors for some chronic disease, such as diabetes mellitus and cardiovascular disease.

This problem now may be high not only in high income countries, but also dramatically rising in low and middle income countries.

In 2016, over 650 million adults were obese (WHO, 2018). That number is about 13% of the world’s adult population (11% of men and 15% of women). This shows a rapidly triple increase since 1975 (WHO, 2018). Still in the same year, an estimated 41 million children under the age of 5 years were overweight or obese and half of them lived in Asia (WHO, 2018). The prevalence of obesity among children and adolescent aged 5-19 has risen dramatically from just under 1% in 1975 to just over 6% (of girls) and 8% (of boys) in 2016 (WHO, 2018). This shows that obesity is one of the major health problem that should be solved.

In Indonesia, obesity has been increasing as the income has been raising. In 2016, the prevalence of obesity in Indonesia is 33,5% (20,6% has a BMI more than 27 or more) (Kemenkes RI, 2017).

Women with obesity are greater (41,4%) than men (24.0%). Prevalence is higher in urban areas (38.3%) than rural areas (28.2%). Whereas according to the age group, obesity was highest in the age group 40-49 years (38.8%). (Kemenkes RI, 2017).

There is no direct relationship between obesity and a country’s economic status. In fact, developing countries, such as Marshall Islands, Kuwait, Palau, and Nauru have made it to the top 10 most obese countries. The reason why small Pacific Island nations are topping the list is almost all of the food there are imported and therefore expensive, but fast-food offer cheap and convenient alternative. As per WHO, food scarcity and its rising prices are responsible for obesity in developing countries such as Venezuela, where public finds it difficult to eat a healthy diet. For them, the option is filling up with junk or dried food. Easily available calorie-rich processed food and low education about nutrition among citizens are major reasons behind Mexico’s 28.9% obese population. Most population of Middle Eastern nations are also obese or overweight because of its hot temperatures.

Regular exercise is not common there with an increasing embrace for western fast food restaurant.

At its basic level, the pathogenesis of obesity seems simple: Calories are consumed in excessed amounts above energy expenditure. However, growing evidence shows that obesity pathogenesis involves more complex processes that the passive accumulation of excess calories. The regulation of obesity has been learned as it relates to molecular regulation of appetite that affects energy homeostasis, especially lipid and glucose metabolism. Obesity also play a central role in

dysregulation of cellular metabolism that accounts for insulin resistance in diabetes mellitus type 2 (Michael et al., 2017).

The excess of stored fat is required for survival during nutritionally deprived states such as starvation or fasting. However, in times of prolonged abundance of food, very efficient fat storage results in the excessive storage of fat, eventually resulting in obesity (Michael et al., 2017).

Individuals who are not obese are >99% accurate in matching energy intake to expenditure. There are qualifications to such calculations relating to the fact that increased body mass increases energy expenditure (further reducing the balance error), but form a thermodynamic perspective, it is apparent that obesity is the consequence of small and cumulative imbalance of energy intake and expenditure. Although the causes of these imbalances can involve genetic, developmental, and environmental factors, once individuals who are obese and individuals who are never obese achieve their usual body weights and compositions, they tend to maintain and defend those weights (Michael et al., 2017).

Studies shows that there is adaptive response to weigh loss and gain. Weight loss induced by caloric restriction, for example, result in an increased control to eat and a reduction of energy expenditure.

There response both resist further weight loss and favor recovery of lost weight, and they can persist for years, provided body fat stores have not returned to baseline. These adaptive responses to weight loss are resulted in both individuals who are obese and lean individuals, suggesting that obesity pathogenesis involves the physiological defense of a higher level of body fat. Normal weight subjects respond to weight gain by increasing energy expenditure and reduced hunger. Once the overfeeding id discontinued, a combination of decreased control to eat and increased energy expenditure tends to restore body weight to normal. This shoes that it is difficult for normal-weight individuals to achieve and sustain experimentally induced weight gain. Individuals who are obese also resist excess weight gain induced by forced overfeeding. Their elevated levels of body-fat mass appear to be similarly subject to biological defense. Indeed, individuals who are obese and individuals who are not obese appear to use the same homeostatic mechanism to defend different levels of body-fat mass.

Dysfunction of the energy homeostasis system is both necessary and sufficient for the defense of elevated body weight in obese individuals (Michael et al., 2017).

Leptin, the adipocyte hormone, plays a significant role in the relationship between obesity and energy homeostasis. Leptin would give a signal that the human body doesnâ&#x20AC;&#x2122;t need any energy intake. A deficiency of leptin cause obesity in both human and animals. However, these studies do not suggest that genetic deficiencies of leptin are important causes of obesity. In contrast, most individuals who are obese have increased plasma leptin levels (in proportion to increase of body-fat content) due to leptin resistance. These plasma leptin levels are required to overcome tissue resistance to leptin and enable energy intake and energy expenditure to match one another. Because adipocytes secrete leptin

in proportion to body-fat content, the only way to increase plasma leptin levels is to become obese (Michael et al., 2017).

Several studies have shown that the effect of specific diet on insulin secretion contributes to obesity pathogenesis. Carbohydrates are proposed to promote hyperinsulinemia that in turn drives glucose and fatty acids into adipose tissue. This process is proposed to cause obesity by both direct effects on adipocytes that favor fat deposition and by lowering circulating metabolic substrates that stimulate food intake. Additional “lowering” effects on energy expenditure are proposed to worsen the tendency toward increased fat deposition. This hypothesis remains controversial and has yet to receive many support needed for public acceptance. One of the concern is that differences in diet composition has not been proved to cause differences in body composition when provided in isocaloric manner (when total calorie consumption is matched between diets). This does not mean that hight diets on carbohydrate do not predispose to obesity, but the underlying mechanism is likely to involve excessive intake of calories , rather than nutrient-specific or hormonal effects (Michael et al., 2017).

Obesity is risk factor of some medical comorbidities. People with obesity are at increased risk for many serious diseases, such as hypertension, dyslipidemia, type 2 diabetes mellitus, cardiovascular disease, and stroke. Obesity could also cause gallbladder disease, osteoarthritis. People with obesity are also at increased risk for some cancers, such as endometrial cancer, breast cancer, and colon cancer (CDC, 2015).

Studies show that people aware the diseases caused by obesity, such as hypertension, diabetes and heart disease, but their scope of knowledge beyond this is limited. Only half of the subjects recognized that obese are risk factor for cancer. Furthermore, more than a quarter are unaware of the impact obesity has on respiratory problems, thromboembolism, wound infection, heart attack or longer operating time and hospital stay.

WHO has been holding some policies to improve diets and physical activity patterns. Adopted by the World Health Assembly in 2004, “WHO Global Strategy on Diet, Physical Activity and Health” describes actions needed to support healthy diets and regular physical activity. WHO also has developed the “Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020” which will contribute to progress on 9 global NCD targets to be attained by 2025, including a halt in the rise of global obesity (0% increase). The World Health Assembly welcomed the report of the Commission on Ending Childhood Obesity (2016) and its 6 recommendations to address the obesogenic environment and critical periods in the life course to lessen childhood obesity. The implementation plan to guide countries in taking action to implement the recommendations of the Commission was welcomed by the World Health Assembly in 2017 (WHO, 2018) .

In Indonesia, government has developed a program called Rencana Aksi Nasional Gerakan Nusantara Tekan Angka Obesitas (RAN GENTAS) to decrease the prevalence of human obesity (Kemenkes RI, 2015). Some program are made to improve healthy diet, physical activity and healthy lifestyle. Official regulations are revised to be more detailed, including regulation about food labelling and regulation of sugar, salt, and fat consumption.

Doctors as a health care provider should give a contribution to improve healthy life in society, especially to prevent excess weight gaining. But, studies show that obese patients who had seen a healthcare professional 74.2% did not receive any advice and just 17.4% had received some advice about their weight (Hooper et al., 2017). In short, only one in five respondents had been given any advice about their weight and if advice was provided, it was focused on losing weight. But, these studies tried to prove â&#x20AC;&#x153;causationâ&#x20AC;? between the weight of respondent and receipt of advice. The result is the group receiving advice to lose weight most often reported as being obese (38.3%) but this was not the case individuals who were overweight (11.7%) (Hooper et al., 2017). It is important that advice on weight is provided by health professionals to individuals who are overweight and therefore at higher risk of becoming obese.

A public health approach for obesity prevention is of great importance and has been advocated in recent years. A proposed framework by Sacks (2009) suggest that policy actions to the development and implementation of effective public health strategies to obesity prevention should (1) target the food environments, the physical activity environments and the broader socioeconomic environments; (2) directly influence behavior, aiming at improving eating and physical activity behaviors; and (3) support health services and clinical interventions (Chan, Woo, 2010). But, obesity prevention and reduction essentially involve lifestyle modification through behavioral change at the individual level.

Policy alone is hardly to achieve this, merely facilitating the process. The key to control the obesity epidemic lies at the level of individuals, since they have to act on health promotion advice and efforts.

However, many factors act as barriers to change, such as the universal use of information technology in all setting that reduce physical activity and resulting stress that contribute to excessive eating.

There is no effective public health approach to prevent and reduce obesity. Therefore, weâ&#x20AC;&#x2122;re going to make a mobile application that is more practical, free, and solving the problem. We make an application that could give a calculation of obesity risk factor by answering some questions and also give advice of preventing and reducing obesity. So, this application is not just an early detection of obesity, but also a health promotion. We also provide a guidebook about food calories so the customer would have a consideration of what to eat. Contacts of doctors nearby are also provided so the customer could have a further counseling about their weight. Hopefully, customer would have better chance to lose weight effectively.

This software is made in the form of mobile application due to the development of information technology. Mobile phones have changed the dimension of portability of technology. Today, they are more than just call making devices. We are surrounded by Gadgets everywhere. So, the writers suggest that a mobile application would be a perfect channel to make a change in society effectively.

MATERIAL AND METHOD The published results is from high-quality human observational studies which analyzed the effect of the obesity management and their effect of their behavior to face the obesity were all included in this literature based analysis. Electronic search of PubMed, Nature, Springer, Scopus, Google Scholar, WHO and Unicef database up to 2018 was conducted. Search was done in keyword: Framingham method, Framingham analysis, Obesity, Determinants of obesity, High risk of obesity, individual behabiours on food consumption and choice (energy intake) and physical activity (exercise and sedentary patterns), obesity mental health. Our inclusion criteria are journal with : 1) intervention and observational studies, 2) have measurement before and after use the application, 3) enclose the user the guidebook (recommendation and suggestion for their obesity level), 4) the study done in developing country. Our exclusion criteria are obesity and metabolic disease and review article.

From 3 publication that consist of journals and articles, we conclude 12 journal that correlate with our topic. We define obesity according database, UNMAP by WHO about obesity in developung country increasing until now. Then we breakdown each of their behavior, how to solve their obesity without knowing the knowledge.

Study sites : The data is collected from Medical Faculty of Brawijaya University from early September until October 2018.

Study design The study was conducted with retrospective observational study design. This community based descriptive study was conducted in ithe identified localities during the period of September 2018 to October 2018. Data were retrieved from Faculty of Medicine, Brawijaya University. These data were collected per month and specific parameter of obesity, which is body mass index (BMI).

The data regarding of the Firmingham risk score which is gender-specific algorithm used to estimate teh 10-year cardiovascular risk of an individual. The Framingham Risk Score was first developed based on data obtained from the Framingham Heart Study, to estimate the 10-year risk developing coronary heart disease. The Firmingham risk score has been developed to calculate the obesity risk factor, The relationship between the degree of obesity and the incidence of cardiovascular disease (CVD) was reexamined in the 5209 men and women of the original Framingham cohort. Recent observations of disease occurrence over 26 years indicate that obesity,

measured by Metropolitan Relative Weight, was a significant independent predictor of CVD, particularly among women. Multiple logistic regression analyses showed that Metropolitan Relative Weight, or percentage of desirable weight, on initial examination predicted 26-year incidence of coronary disease (both angina and coronary disease other than angina), coronary death and congestive heart failure in men independent of age, cholesterol, systolic blood pressure, cigarettes, left ventricular hypertrophy and glucose intolerance. Relative weight in women was also positively and independently associated with coronary disease, stroke, congestive failure, and coronary and CVD death. These data further show that weight gain after the young adult years conveyed an increased risk of CVD in both sexes that could not be attributed either to the initial weight or the levels of the risk factors that may have resulted from weight gain. Intervention in obesity, in addition to the higher established risk factors, appears to be an advisable goal in the primary prevention of CVD.

RESULT The result of this paper is an application that will show the possibility of people having obese in the future. The following step is, once you open the application, the logo will come out. Then, there will be an instruction to fill the blank spaces provided. You have to write the name, age, address, sex, height, weight, medication used, and how often you exercise. After these, click result. The result will come out in percent. You will know how much the possibility of you having obese in the future. the advices are also provided for you to maintain a healthy body. We also provide a guidebook about food calories so you would have a consideration of what to eat. Contacts of doctors nearby are also provided to have further counseling about your weight. The following design of the application is given below.

DISCUSSION This “Are U Obese” program provides calculation of obesity risk factors that could be influenced by many things. Obese is a multifactor-caused disease, which could be caused by lack of physical activity, imbalanced between energy intake and energy expenditure, and hormone. This calculation would combine all of the risk factor involved to know the obese possibility percentage in the future.

So, the customer would have an early behavior change to prevent or reduce obesity.

This application is acted as a primary and secondary prevention which could be a health promotion and early detection of obesity. As a health promotion, this application would provide advices how to prevent and reduce obesity, such as physical activity, healthy diet, and many more. A guidebook which contains list of daily food calories is also provided to guide the customer living with a healthy diet. As an early detection, this application would tell the customer the possibility of them obese so they will not have a disease caused by obese. If this application is used by citizens in some areas, the incidence rate of obesity in those areas could be calculated. In short, this application is also helping the government to calculate the incidence rate in a short amount of time.

By using this mobile application, the customer could know the possibility of them having obesity earlier and how to prevent obesity effectively. Hopefully, the advices provided in the application could lead the customer to live a happy lifestyle. A list of food calories provided could be a consideration for the customer to choose what to eat. A contact of doctor nearby could ease the customer to have a consultation about losing weight effectively and correctly. For the government, this application could ease collecting data process for health statistics, especially incidence rate of obesity. It would be quicker, easier, and more practical than having a survey in health services.

But, this application couldn’t ensure that the customer would follow the advices provided. The self efficacy is the key to this behavior change. All of the advices and doctors provided in the application would not be valuable unless the customer behavior change. In addition, this mobile application has not yet had a patent so it would be so easy for someone to make the imitation of this application.

Hopefully after this competition, we could register this mobile application to have a patent.

CONCLUSION Obesity has become the public health issue of the day—and for good reason. The data outline a dismal picture and a more foreboding future. The prevalence of obesity has doubled in adults and children and tripled in adolescents over the past 2 decades. But we know, in the other sides, that technology nowadays was developed for make a simple life.The results of this study are that we as the pioneer of health applications (AuO apps) as early detection of the severity and complications of obesity that are processed with the development of data methods from Firmingham risk factors that correlate between obesity and CVD. So by combinig technology development and health problem,

this application aims to provide an epidemic of obesity in an area, increasing awareness to the public about the dangers of obesity and give education to the society about how to solve obesity.

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https://www.cdc.gov/healthyweight/effects/index.html Chan, Ruth and Jean Woo. (2010). Prevention of Overweight and Obesity: How Effective is the Current Public Health Approach. Int J Environ Res Public Health, 7(3): 765-783.

GORDON, T., CASTELLI, W. P., HJORTLAND, M. C., KANNEL, W. B., & DAWBER, T. R. (1977). Diabetes, blood lipids, and the role of obesity in coronary heart disease risk for women: the Framingham Study. Annals of internal medicine, 87(4), 393-397.

Hooper, L, et al. (2017). Public awareness and healthcare professional advice for obesity as a risk factor for cancer in the UK: a cross-sectional survey. Journal of Public Health, 1-9.

Kannel, W. B., Cupples, L. A., Ramaswami, R., Stokes III, J., Kreger, B. E., & Higgins, M. (1991).

Regional obesity and risk of cardiovascular disease; the Framingham Study. Journal of clinical epidemiology, 44(2), 183-190.

Kannel, W. B., & McGee, D. L. (1979). Diabetes and glucose tolerance as risk factors for cardiovascular disease: the Framingham study. Diabetes care, 2(2), 120-126.

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http://www.depkes.go.id/article/print/15052000003/indonesia-tekankan-pentingnyapenanganan-global-untuk-atasi-tantangan-double-burden-of-nutritions.html Kementerian Kesehatan RI. (2016). Profil Kesehatan Indonesia Tahun 2016. Jakarta: Kementerian Kesehatan Republik Indonesia.

Kim, J. H., Cho, J. J., & Park, Y. S. (2015). Relationship between sarcopenic obesity and cardiovascular disease risk as estimated by the Framingham risk score. Journal of Korean medical science, 30(3), 264-271.

Saydah, S., Bullard, K. M., Cheng, Y., Ali, M. K., Gregg, E. W., Geiss, L., & Imperatore, G. (2014).

Trends in cardiovascular disease risk factors by obesity level in adults in the United States, NHANES 1999â&#x20AC;?2010. Obesity, 22(8), 1888-1895.

Schnabel, R. B., Yin, X., Gona, P., Larson, M. G., Beiser, A. S., McManus, D. D., ... & Seshadri, S. (2015). 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study. The Lancet, 386(9989), 154-162.

Schwartz et al. (2017). Obesity Pathogenesis: An Endocrine Society Scientific Statement.

Endocrine Reviews, 38, 267â&#x20AC;&#x201C;296.

WHO. (2018). Obesity [online]. http://www.who.int/topics/obesity/en/ WHO. (2018). Obesity and overweight [online]. http://www.who.int/en/news-room/factsheets/detail/obesity-and-overweight

Wilson, P. W., D'agostino, R. B., Sullivan, L., Parise, H., & Kannel, W. B. (2002). Overweight and obesity as determinants of cardiovascular risk: the Framingham experience. Archives of internal medicine, 162(16), 1867-1872.

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THE POTENCY OF SAFFRON EXTRACT FROM CROCUS (Crocus Sativus) STIGMA AND PETAL EXTRACT AS ANTI-DYSLIPIDEMIC IN OBESITY AND DIABETES 1

1

1

Andreas Dexter G. , Bernadus Bernardino B. , Emanuel Hananto , Andra Danika

2

1

First Year Medical Student, University of Brawijaya

2

Second Year Medical Student, University of Brawijaya

Abstract Dyslipidemia is becoming one of major complications from diabetes mellitus type 2 and risk factor for Cardiovascular disease. In worldwide, dyslipidemia occurance is becoming a serious threat with arround a quarter of adults in low income country and more than double the level of the high income country. In Indonesia, the prevalence of dyslipidemia in adult is about 36%. Nowadays, the choice of theraphy remained patient centered, where safety, efficacy, cultural acceptability, and lesser side effect is the main concern. Which leads to the choosing of Herbal Theraphy. Saffron is the extract of Crocus (Crocus Sativus) an eastern mediteranian herb which come with three major components, including crocin, safranal, and crocetin. These major components work by modulating the balance of oxidant-antioxidant system, stimulation and regeneration of β-cells of islets of Langerhans, correction of insulin resistance, and the inhibition of pancreatic lipase. Which leads into: Decreased serum levels of TC, TG, and LDL-C, reduced blood glucose level, and the increased of GSH, CAT, GST and SOD which activities used to be decreased by diabetic conditions. In conclusion, the hypoglycemic and hypolipidemic effects of saffron and its main components show that crocus extracts may hold the potential to be considered as a novel therapeutic approach for the treatment of obesity, diabetes, and dyslipidemia.

Keywords: Dyslipidemic, Obesity, Diabetes, Crocus Sativus Extract

CORRELATION BETWEEN BMI AND GLYCEMIC CONTROL USING HBA1C AS THE INDICATOR IN TYPE 2 DIABETES MELLITUS (T2DM) Andro Pramana Witarto, Nabila Ananda Kloping, Ihsan Fahmi Rofananda, Melvanda Gisela Putri Universitas Airlangga Abstract Background: Type 2 Diabetes mellitus is mainly caused by insulin resistance in obesity due to body fat accumulation. The aim of this study is to find the correlation between BMI and glycemic control using HbA1c as the indicator in type 2 diabetes mellitus (T2DM) patients.

Method: This cross-sectional study was conducted at Surabaya Orthopedic and Traumatology Hospital using patients’ medical records ranged from January 2015 to September 2018. The variables were BMI (underweight: <18.5 kg/m2; normal: 18.5-22.9 kg/m2; overweight: 23-24.9 kg/m2; obesity: ≥25 kg/m2) and glycemic control (controlled T2DM: HbA1c < 7%; uncontrolled T2DM: HbA1c ≥ 7%). The correlation between both variables was evaluated using chi-square test with p < 0.05 to be considered as significant.

Result: There was no significant correlation between categorized BMI and glycemic control (p = 0.935) in 121 T2DM cases. Among all BMI groups, only overweight patients have higher controlled HbA1c level and it was not significant. We found that one time measurement of BMI could not be put together with the HbA1c as the picturesque of glycemic control. The BMI measurement should be done in sequential period of time.

Conclusion: Our study finds no correlation between BMI and HbA1c level as the indicator of glycemic control in T2DM patients.

Keyword: Type 2 diabetes mellitus, BMI, Glycemic control, HbA1c

THE PROFILE OF CHRONIC COMPLICATION IN TYPE II DIABETES MELLITUS PATIENTS WITH PHARMACOLOGICAL THERAPY UNDERGOING TREATMENT IN RSUP. DR WAHIDIN SUDIROHUSODO IN INDONESIA Karina Jesslyn Sung1, Valentina Febriani Tando1, Andi Sitti Nurul Haerunnisa1, Vania Noviantika1 1

Faculty of Medicine Hasanuddin University (AMSA-Unhas)

Background: Type II Diabetes Mellitus is a metabolic disease with the characteristics of hyperglycemia that occurs due to a progressive loss of đ?&#x203A;˝-cell insulin secretion frequently on the background of insulin resistance, insulin performance or both. In 2014 there were 8.5% or about 422 million people over the age of 18 had Type II Diabetes mellitus. This non-insulin-dependent type of diabetes mellitus can cause macrovascular and microvascular complications.

Aim: This research aims to identifiy the profile of chronic complication in type II diabetes melitus based on gender and chronic complications type II diabetes melitus patients with pharmacological therapy undergoing treatment.

Material and Methods: A cross-sectional study was conducted among 325 medical records at the Endocrine Polyclinic of the Wahidin Sudirohusodo General Hospital in Makassar as one capital city in Indonesia from January 1st 2017 to June 30th 2017.

Results: The distribution of type 2 diabetes melitus with diabetes complication based on gender in Wahidin Sudirohusodo Hospital Makassar between January 1st 2017 to June 30th 2017, the patients are dominated by female gender as many as 181 people (55.69%) while male patients are 144 people (44.31%). Distribution based on age group, the highest number of patients were in the age group of 61-70 years, as many as 148 people (45.54%), and The highest number of complications is diabetic neuropathy as many as 226 cases (44.84%).

Conclusion: From the results of this research, it can be concluded that most of patients with type II diabetes melitus accompanied by complications of diabetes are female with percentages 55.69% and the most are in the age range of 61-70 years (45.54%). Most of type II diabetes melitus patients are followed by microvascular complications in the form of diabetic neuropathy and macrovascular complications in the form of diabetic foot.

Keywords: profile of chronic complication, Type II Diabetes Mellitus, pharmacology, treatment

Knowledge and Attitude of Undergraduate Students in Yogyakarta towards Diabetes Mellitus Kristina Fianiyanti, Fabian Jeremy Prasetyo, Gabriela Claudia, Kiara Hanna Quinncilla AMSA-Universitas Sebelas Maret

Aim This study aimed to determine the level of knowledge and attitude of undergraduate students in Yogyakarta towards Diabetes Mellitus.

Background The prevalence of Diabetes Mellitus in Indonesia increased from 2007 to 2013 with the highest increasing number in Yogyakarta. This prevalence shifts to the younger group of age, including the group of 15-24 years of age.

Material and Methods An observational descriptive study with incidental sampling was conducted in this study. The total samples were 384 undergraduate students with the age range of 15-24 with confidence level of 95%.

Samples were surveyed from three A-grade universities in Yogyakarta: Universitas Gajah Mada, Universitas Atma Jaya Yogyakarta, and Universitas Islam Indonesia. The survey included questions regarding knowledge and attitude of the respondents towards Diabetes Mellitus and their sources of information.

Results The majority of the respondents (54.90%) showed good results on knowledge survey. Most of them knew that obesity was one of the risk factors of Diabetes Mellitus, but very few of them (8.30%) knew that pregnancy was also a risk factor. Many of the respondents didnâ&#x20AC;&#x2122;t know excessive hunger and reduced weight were signs and symptoms of Diabetes Mellitus. The responses regarding management and control of Diabetes Mellitus were varied. Most of the respondents were unfamiliar with complications of Diabetes Mellitus other than amputation. The majority of the respondents (52.10%) showed good results on attitude either.

Conclusion The majority of respondents showed good attitude and knowledge towards Diabetes Mellitus. However, there were some lacks of information among respondents regarding risk factors (pregnancy), sign and symptoms (reduced weight and excessive hunger), and complications (respondents were unfamiliar with complications other than amputation). This means education about Diabetes Mellitus is still

needed. Based on the result, promoting Diabetes Mellitus can be possibly done through internet and schools.

Keywords Knowledge; Attitude; Diabetes Mellitus.

The Correlation Between Dietary and Diabetes in Indonesian Population: A-preliminary Study 1

Patricia Angel1, Felix Wijovi1, Anthony Yusuf1 Faculty of Medicine, Pelita Harapan University, Tangerang, Indonesia

Aim We aim to view the correlation between diet habits and the populationâ&#x20AC;&#x2122;s incidence of diabetes, particularly among Indonesians.

Backgrounds

Indonesia is one of the most populace nations with a great proportion of itâ&#x20AC;&#x2122;s people being diabetics. According to the International Diabetes Federation, there were over 10 million cases of diabetes in adults in Indonesia as of 2017. Diabetes is a disease characterized by high levels of glucose in the blood, closely correlated with diet and nutrition, and can lead to many complications. Indonesia, as a developing country, has minimal awareness of the consequences of diet and nutrition.

Materials and Method

We used a prospective double blind cross-sectional study. The sampling was randomized in terms of age, race, and background on 48 people. All respondents are Indonesian in nationality and settlement. Data collection was done using NHANES FFQ(Food Frequency Questionnaire). The FFQ includes 131 food items with specified serving sizes described using natural portions or standard weight and volume measures of the servings commonly consumed in the study population.

Results

20 out of the 48 respondents were diabetics with a daily calorie intake exceeding 2000 kkal. There are 12 other respondents with diabetes, however with a daily calorie intake less than 2000 kkal, with 4 among them consuming high-glucose containing food. 6 among those 12 were above 40 in age and had a family history of diabetes. 2 other respondents had a low fat and low-glucose diet summing up to an average below 2000 kkal, however were diabetic. 14 respondents had a daily intake below 2000 kkal who were not diabetic. The P value is 0,05.

Conclusion

There is a correlation between diet and diabetes, where high-glucose and high-calorie diet promotes the possibility of diabetes Keywords: Diabetes, FFQ, Nutrition, Food intake

The correlation Between Dietary and Diabetes

Discussion Indonesia is one of the most populous nations with a great proportion of it’s people being diabetics. According to the International Diabetes Federation, there were over 10 million cases of diabetes in adults in Indonesia as of 2017. Diabetes itself is a disease that is closely correlated with diet and nutrition. Indonesia, as a developing country, has minimal awareness of the consequences of diet and nutrition (I).

Diabetes is a disease which is characterised with high blood glucose level. Diabetes should be our concern because diabetes can lead to complica ons of several diseases like diabe c neruopathy or re nopathy.Higher prevalence of diabetes in indonesia is correlated with lower awareness of the conseuquences of diet and nutri on from Indonesian (IV).

From our study, we can conclude there is a correla on between diet and diabetes due to several factors, including high-calorie diet, high-glucose diet, and a family history of diabetes. Higher amounts of calorie intake or glucose consump on can also lead to obesity and metabolic syndrome.

Therefore, factors that affect diet can also affect the risk or diabetes through choice of diet.

Results

Aim We aim to view the correla on between diet habits and the popula on’s incidence of diabetes, par cularly among Indonesians.

Material We used a prospec ve double-blind cross-sec onal study. The sampling was randomized in terms of age, race, background on 48 people. All respondents are Indonesian in na onality and se lement. Data collec on was done using NHANES FFQ(Food Frequency Ques onnaire). The FFQ includes 131 food items with specified serving sizes described using natural por ons or standard weight and volume measures of the servings commonly consumed in the study populaon.

20 out of the 48 respondents were diabe cs with a daily calorie intake exceeding 2000 kkal. There are 12 other respondents with diabetes, however with a daily calorie intake less than 2000 kkal, with 4 among them consuming high-glucose and high-carbohydrate containing food. 6 among those 12 were above 40 in age and had a family history of diabetes. Apart from the men oned above, 2 respondents had a low-fat and low-glucose diet summing up to an average exceed 2000 kkal, however were nevertheless non-diabe c. 14 respondents had a daily intake below 2000 kkal who were not diabetic, although others were. P value is 0,05

For detec on of diabetes, simple procedures such as blood sugar tests or urinalysis can detect the risk factors of diabetes of the development of the disease. Glycated hemoglobin test can also be used to check the level of hemoglobin with glucose a ached unto it. Diabetes can be prevented with lower consump on of glucose or calorie intake, along with healthier diet with balanced nutrients. Exercise is an other preven ve method. For the management of diabetes, non-pharmacologic methods include a healthy diet consis ng of high fiber and low fat, such as vegetables and fruits. Foods with low glycemic indexes are more helpful owing to their low sugar level. Pharmacologic theraphy can include me ormin or megli nides which sensi ze human ssue to insulin, also glucose lowering theraphy such as DPP-4 inhibitors or GLP-1 receptor agonists, or direct injecDP on of insulin itself. Weight-loss surgery is a possible alterna ve for obese pa ents (II) Promo ng a healthy lifestyle against diabetes is a tough challenge due to the low awareness and limited resources of communica on towards people in remote areas. Health campaigns are one of many simple ways to evoke public awareness, and can be done online or live presen ng the preven ve and management methods. Other than that, health-focused websites, or social medias can be u lized through well-informed bases. th

Implementa ons by the healthcare system to accomodate the need of preven ng or trea ng diabetes can be done through simpler methods such as health insurances, providing ubiquitous methods of diabetes tes ng and medica ons, increasing the number of welfare and healthcare providers throughout a wider range to reach remote areas

There is a correla on between diet and diabetes, where high-glucose and high-calorie diet promotes the possibility of diabetes

Keywords: Diabetes, FFQ, food intake, Nutri on

References:

Contact Person: Pa cia Angel (+62 8121 860 6807) IV. Olokoba A. B., Obateru O. A., Olokoba L. B. (2012). Type 2 diabetes mellitus: a review of current trends. Oman Medical Journal. 27(4), 269–273

THE EFFECTIVENESS OF HUMAN FIBROBLAST COMPLEX IN ACCELERATING THE WOUND-HEALING RATE IN PLANTAR FOOT ULCER PATIENT: SYSTEMATICAL REVIEW Serri Rivally1, Vanessa Gunawan2, Silvia Husodo3, Desak Gede Yuliana Eka Pratiwi 4 University of Brawijaya Background: Diabetic foot ulcer is a serious complication of diabetes, which aggravate the patientâ&#x20AC;&#x2122;s condition whilst also having significant socioeconomic impact. Numerous research had resulted in vast knowledge about diabetic foot ulcers include its possible disorders and types of treatment. Diabetic foot ulcer can result in amputation, as global it accounts for 14-24% amputation on patient with diabetic foot ulcer. The amputation are the result of unresponsive to the classical therapy of diabetic foot ulcer.

Objective: This review aims to assess the efficacy of human fibroblast implants cultivated with several combination base on its significacy on accelerating wound healing rate in plantar side of diabetic foot ulcer.

Material and method: This research design that used in this study is systematic review of resources such as articles and journals in PubMed Central, Ovid, and Science Direct. We used several keywords, such as diabetic foot ulcer, treatment, and human fibroblast. Four independent reviewers conducted the screening and the leader of the team consulted to resolve discordance.

Results: This review used extracted data of four included studies. This review shows case two that used apligraft is effective in its significant rate to accelerate wound healing of diabetic foot ulcer on the plantar side with 25,2 % prevalance. This treatment is more effective than other combination because apligraft composed of living keratinocytes and living fibroblast, which does not undergo cryopreservation that impairs cell activities for recovery of chronic wound.

Conclusion: This systematic review proves that human fibroblast implants cultivated with keratinocytes (Apligraft) is effective in its significat rate to accelerate wound healing of diabetic foot ulcer on the plantar side. So that this treatment can be developed again in the future to make the safety and efficacy become higher.

Keywords: Diabetic foot ulcer, plantar, efficacy, treatment, human fibroblast

CORRELATION OF CHRONIC COMPLICATIONS OF TYPE II DIABETES MELLITUS AND PHARMACOLOGY TREATMENT PATTERN IN RSUP. DR WAHIDIN SUDIROHUSODO IN INDONESIA Valentina Febriani Tando1, Karina Jesslyn Sung1, Andi Sitti Nurul Haerunnisa1, Vania Noviantika1 1

Faculty of Medicine Hasanuddin University (AMSA-Unhas)

Background: Type II Diabetes Mellitus is a metabolic disease with the characteristics of hyperglycemia that occurs due to a progressive loss of đ?&#x203A;˝-cell insulin secretion frequently on the background of insulin resistance, insulin performance or both. In 2014 there were 8.5% or about 422 million people over the age of 18 had Type II Diabetes mellitus which can cause macrovascular and microvascular complications.

Aim: To analyze the incidence of chronic complications in type II DM patients and an analysis of the relationship between chronic complications in type II Diabetes Mellitus patients with pharmacological therapy undergoing treatment.

Material and Methods: A cross-sectional study was conducted among 325 medical records at the Endocrine Polyclinic of the Wahidin Sudirohusodo Makassar General Hospital in Indonesia from January 1st 2017 to June 30th 2017.

Results: The complications of diabetes in the form of peripheral artery disease didnâ&#x20AC;&#x2122;t show a significant relationship to the selection of type 2 pharmacological therapy for diabetes mellitus (p> 0.05).

Meanwhile, disease complications that have a relationship with pharmacological patterns of type 2 diabetes mellitus are cardiovascular disease (V = 0.279, p <0.001), cerebrovascular disease (V = 0.246, p <0.05), diabetic nephropathy (V = 0.172, p <0.05) and diabetic neuropathy (V = 0.228, p <0.05), diabetic foot (V = 0.181, p <0.001), diabetic retinopathy (V = 0.344, p <0.001). Peripheral arterial viewers do not have a relationship with the choice of therapeutic pattern (p> 0.05).

Conclusion: The most patients suffering diabetic neuropathy complications. This study has a complication of disease in the form of cardiovascular disease has a relationship with the pattern of pharmacological therapy with a moderate level of correlation strength. While cerebrovascular disease, diabetic nephropathy, diabetic neuropathy, diabetic foot and diabetic retinopathy have a significant relationship with weak correlation strength.

Keywords: chronic complication, Type II Diabetes Mellitus, pharmacology, treatment

PERCEIVED BARRIER OF HEALTHY LIFESTYLE AMONG HIGH SCHOOL STUDENTS IN SURABAYA, EAST JAVA, INDONESIA: A STUDY BETWEEN OVERWEIGHT-OBESE AND NON OVERWEIGHT-OBESE STUDENTS Kevin Luke, Ivan Angelo Albright, Tiffany Konstantin, and Muhammad Jafâ&#x20AC;&#x2122;ar Shodiq AMSA-Airlangga University, Surabaya, Indonesia kevinluke19@gmail.com Background: Pediatric obesity is serious problem because it progression in adults will cause metabolic and degenerative diseases such as heart disease, diabetes mellitus type 2, malignancy, and osteoarthritis.Prevalence of obesity in 16-18 years old group is increasing from 1,4% in 2010 to 7,3% in 2013. Moreover, East Java is included as fifteen province with highest rate of obesity nationally.

Obesity is related with social, psychological, and environmental factors that may influence healthy eating and physical activity.

Aim: To compare perceived barriers of healthy lifestyle among obese and non-obese high school students in Surabaya, Indonesia Material and Methods: This cross-sectional study was conducted from 1 October 2018 to 5 October 2018. Accidental sampling was used to recruit participants from public schools and private schools in Surabaya. One or two researcher came to schools to assess perceived barrier by using assisted selfadministered questionnaire from previous study that has been translated into Bahasa Indonesia.

Translated questionnaire consists of informed consent, participantâ&#x20AC;&#x2122;s identity, self-reported heightweight, self-reported levels of healthy lifestyle, and agree/disagree statements about barriers in healthy eating and physical activity. Collected data was checked and excluded if incompletely answered.

Checked data was analyzed in Microsoft Excel 2013 and IBM SPSS Statistics 23.

Result: Total of 93 students from 6 schools (2 public and 4 private schools) were enrolled in this study. Based on this study, students with >P85 was 24,73%. Both group have same perception of how healthy their lifestyle, diet, and physical activity. Overall, there is no significant difference in both group in all aspects except total score for environmental factors that is higher in >P85 group. Other significant differences are teacher support on healthy eating and Weather in Surabaya is not suitable for physical activity Conclusion: There is difference in environmental factors of physical activity in overweight-obese student compared with non overweight-obese student. Hopefully, this study can be references for larger and comprehensive study in the future.

Keywords: Adolescent, Barriers, Obesity, Prevention, School-based program.

PERCEIVED BARRIER OF HEALTHY LIFESTYLE AMONG HIGH SCHOOL STUDENTS IN SURABAYA, EAST JAVA, INDONESIA: A STUDY BETWEEN OVERWEIGHT-OBESE AND NON OVERWEIGHT-OBESE STUDENTS Kevin Luke, Ivan Angelo Albright, Tiffany Konstantin, and Muhammad Ja’far Shodiq AMSA-University of Airlangga, Surabaya, Indonesia

INTRODUCTION Pediatric obesity is serious problem because it progression in adults will cause metabolic and degenerative diseases such as heart disease, diabetes mellitus type 2, malignancy, and osteoarthritis(1). According to Riset Kesehatan Dasar 2013, prevalence of obesity in 16-18 years old group is increasing from 1,4% in 2010 to 7,3% in 2013. Moreover, East Java is included as fifteen province with highest rate of obesity nationally(2).

Obesity is related with social, psychological, and environmental factors that may influence healthy eating and physical activity(3).

AIM To compare perceived barrier of healthy lifestyle among obese and nonobese high school students in Surabaya, East Java, Indonesia.

MATERIAL AND METHOD This cross-sectional study was conducted from 1 October 2018 to 5 October 2018. Accidental sampling was used to recruit participants from schools in Surabaya. One or two researcher came to school to assess perceived barrier by using assisted self-administered questionnaire from previous study(3) that has been modified and translated into Bahasa Indonesia. Translated questionnaire consists of informed consent, participant’s identity, self-reported height-weight, self-reported levels of healthy lifestyle, and agree/disagree statements about barriers in healthy eating and physical activity. Collected data was checked and excluded if incompletely answered. Overweight-Obese students are defined if have percentile above 85 using CDC 2000 Growth Chart(1,4). Checked data was analyzed in Microsoft Excel 2013 and IBM SPSS Statistics 23.

RESULTS

Table 3. Baseline Characteristics

Overall, there is no significant difference in both group in all aspects except total score for environmental factors that is higher in >P85 group.

Other significant differences are teacher support on healthy eating (No. 8) and Weather in Surabaya is not suitable for physical activity (No. 22). There is also difference is majority answer in teacher support on healthy eating (No.6); parents support on physical activity (No. 14); Weather in Surabaya is not suitable for physical activity (No. 22); Lack of skills doing physical activity (No. 23); and Do not want to spend money for physical activity club (No. 24)

DISCUSSION Picture 1. Participants were answering questionnaire

Total of 93 students from 6 schools (2 public and 4 private schools) were enrolled in this study. Based on this study, students with >P85 was 24,73%.

Participants characteristics is shown in Table 1.

Table 1. Baseline Characteristics

Both group have same perception of how healthy their lifestyle, diet, and physical activity (Table 2.)

Table 2. High School Students Perception 1. RI KK. Pedoman Pencegahan dan Penanggulangan Kegemukan dan Obesitas. 2011.

2. Kementerian Kesehatan Republik Indonesia. Riset Kesehatan Dasar. 2013;1–384.

Although obesity is related with social, psychological, and environmental factors, this study shows no significant different in both group. This result is consistent with previous study on university student by Musaiger et al.

(2014) in Kuwait(3). Higher perceived physical activity environmet level of >P85 group may be caused by weight-related victimization(WRV)(5). WRV is not generally related with physical activity because the student may show low physical activity at school , but higher physical activity outside the school to prevent being evaluated by their teacher or their peers.

However, this study has several limitations. (1) Sample size was small; (2) sampling technique may cause bias in the result; (3) participant may be ashamed to report actual body weight and height; (4) researcher may explain the questionnaire differently, causing any bias.

CONCLUSION There is difference in environmental factors of physical activity in overweight-obese student compared with non overweight-obese student.

Hopefully, this study can be references for larger and comprehensive study in the future. Moreover, further result can be used to make school-based intervention program of obesity in the future.

3. Musaiger AO, Al-Kandari FI, Al-Mannai M, Al-Faraj AM, Bouriki FA, Shehab FS, et al. Perceived barriers to weight maintenance among university students in Kuwait: The role of gender and obesity. Environ Health Prev Med. 2014;19(3):207–14.

4. Centers for Disease Control and Prevention. Growth Charts - Clinical Growth Charts [Internet]. 2017 [cited 2018 Oct 23]. Available from: https://www.cdc.gov/growthcharts/clinical_charts.htm 5. Maïano C, Lepage G, Aimé A, Bayard C, Dansereau-Trahan É, Granger L, et al. Perceived weight-related victimization and physical activity outcomes among adolescents with overweight and obesity: Indirect role of perceived physical abilities and fear of enacted stigma. Psychol Sport Exerc. 2018;34:70–8.

Assessment of Dietary Risk Factors Associated with Childhood Obesity in Asia: A Systematic Review and Meta-analysis Ko Abel Ardana Kusuma, Johan Cahyadirga, Ariel Valentino Soetedjo, Christine Lieana Universitas Indonesia AIM The objective of this review and meta-analysis is to evaluate dietary risk factors of childhood obesity in Asia which can be used as recommendation and consideration to develop future health interventions.

INTRODUCTION Childhood obesity is a serious emerging global health problem and is projected to be a much bigger burden in the later years. Childhood obesity leads to various complications later in adulthood. The WHO has responded to this problem by supporting governmental policies and developing plausible interventions. However, the incidence of childhood obesity keeps on increasing. Public knowledge regarding risk factors associated with childhood obesity must be enhanced. Thus, this review and metaanalysis is conducted to assess dietary risk factors associated with childhood obesity in Asia.

METHOD A systematic literature search was conducted in the PubMed database. There were 334 studies identified, then 210 studies that did not meet the inclusion criteria were eliminated. From the 124 studies left, 16 studies were considered eligible for full-text screening. Out of the 16 studies, 3 did not meet metaanalysis criteria. The 13 studies that were left was then assessed with STROBE statement.

RESULT Out of 13 studies, 460,771 participants were included. The best study according to STROBE statement is the study by Guo X (2013) with a score of 18.17 out of 22. The most discussed dietary risk factor is consumption of fatty food and snacks and the most contributing risk factor is unhealthy snacks with proportion of 6.90%. The highest odds ratio is consumption of fatty foods more than 7 times a week with OR=7.14. The overall dietary factor has an OR of 2.12.

CONCLUSION The most contributing risk factor for childhood obesity is the consumption of unhealthy snacks while the most discussed risk factor category is excessive consumption of fatty food. Therefore, these dietary risk

factors are essential to increase public awareness of childhood obesity and to help develop future evidence-based interventions.

Keywords: Risk factor, dietary, childhood, obesity, Asia

ASSESSMENT OF DIETARY RISK FACTORS ASSOCIATED WITH CHILDHOOD OBESITY IN ASIA: A SYSTEMATIC REVIEW AND META-ANALYSIS Ko Abel Ardana Kusuma*, Johan Cahyadirga, Ariel Valentino Soetedjo, Christine Lieana abelardanakusuma@gmail.com

METHODS

INTRODUCTION According to the World Health Organization (WHO), childhood obesity is a serious emerging global health problem, as over 41 million children are obese in 2016, when compared to 32 million in 1990. If left untreated, this number would trend up to 70 million in 2025. Moreover, this potentially pathological condition affects mainly urban settings in low and middle-income countries, most of which are located in Asia. The rate of burden increase in developing countries is 30% higher than developed countries. This is serious because obesity in children tend to persist until adulthood and cause various complications such as cancers, musculoskeletal degenerative disorders, cardiovascular diseases, and diabetes. In addition, children with obesity has higher risk to have those adult-onset diseases in a younger age. Moreover, together, malnutrition and obesity are a double burden that affects all countries globally.

The WHO has responded to this problem by applying recommendations from the reports of the Commission of Ending Childhood Obesity in 2016 to address obesity in children. To achieve this target, WHO supports the making of childhood obesity prevention policies and interventions, population-based initiatives and community-based policies. Among these interventions, the population-based policies rely heavily on nutritional control. Sadly, even though these initiatives have been implemented, the incidence of childhood obesity still keeps on increasing. In order to aid the WHO and other governmental and non-governmental health organizations, it is important to address dietary risk factors to spread the importance of decreasing the worldwide burden of childhood obesity and reducing the incidence of obesity-related complications. Identification of dietary risk factors was chosen as childhood eating habits may persist and become lifelong dietary habits. This review will assess the dietary risk factors associated with higher incidence of childhood obesity in Asia.

Figure 1. Study Screening Method

Excluded studies (n=210) 1. Duplication (n=6) 2. Topic nonconformities (n=204)

Study screening (n=124)

Excluded studies (n=104) 1. Not extractable data (n=38) 2. Discussing other aspects besides risk factors (n=48) 3. Adult research subjects (n=1) 4. Studies not found (n=5) 5. Irrelevant outcome (n=12)

Studies included (n=16)

RESULTS

Studies included (n=13), assessed with STROBE Statement

Table 1. Characteristics of Studies and STROBE’s Scoring No.

Author (Year)

Method of Analysis

Guo X (2013)

Study Location China

Study Type

1

Cross-sectional

2

Shan XY (2010)

China

Cross sectional

multivariable logistic regression Multinominal logistic regression analysis

4094 21198

He Q (2000)

China

Case control

Logistic regression analysis

208513

Do LM (2015)

Vietnam

Cross-sectional

Multiple logistic regression

5354

5 6 7

Zong XN (2015) Naja F (2015) Gokler ME (2015)

China Lebanon Turkey

Case-control Cross-sectional cross-sectional

Multivariate logistic regression Multivariate logistic regression Multiple logistic regression

3298 446 3918

Zhang J (2015)

China

cross-sectional

Multivariate analysis

1282

10 11 12 13

Rathnayake KM Sri Lanka case-control (2014) Gonzalez-Suarez CB Phillipines Cohort (2013) Zong X-N (2012) China Case-control Kim B (2011) Korea Cross-sectional Lim H, 2013 South Korea cross-sectional

STROBE Risk Factor (95% ci) Score For girls not having breakfast everyday (OR: 1.45) 18.17 Snack consumption >=3 times a week (OR: 1.53); Fast food consumption 2-18 17.2 >= 3 times/week (OR: 1.50) For children age 0.1-2.9 years old: High eating speed (OR: 1.8). For 0,1-6,9 17.9 children age 3-6.9 years old: High eating speed (OR: 3.04) Fatty foods ≥7 times/week (OR=7.64), fried food ≥7 times/week 4.3 17.1 (OR=1.72) 3-7 fast eating speed (OR=4.351) 16.7 13-19 3rd tertile western diet (OR=2.31) 16.7 15.72 ± 0.99 having no breakfast (OR=1.3) 15.9 highest quartiles of the modern and traditional north dietary patterns 7-17 16.2 (OR=3.1) Skipping breakfast (OR=3.99), consumption of fruits < 4 days per week 14-18 16.5 (OR=2.18)

Multivariate logistic regression

200

5-18

Multivariate logistic regression

396

10-12

nighttime snacking (OR = 1.59)

17.8

Conditional logistic regression Multilevel logistic regression logistic regression

138029 1644 72399

1month-7 10-13 12-18

fast eating speed (OR = 3.986) high fat content of school lunch (OR = 2.35) fast food consumption (OR: 1.18); unhealthy snacks (OR: 1.11)

17.1 15.2 14.4

Table 2 and Figure 3. Meta-analysis of Risk Factors of Obesity No. Author (Year) 1 He Q (2000) 2 He Q (2000) 3 Shan XY (2010) 4 Shan XY (2010) 5 Kim B (2011) 6 Zong XN (2012) 7 Lim H (2013) 8 Lim H (2013) 9 Guo X (2013) 10 Gonzalez-Suarez CB

Risk Factor of Childhood Obesity High eating speed for children age 0.1-2.9 years old High eating speed for children age 3.6-9 years old Fast food consumption 3 times/week or more Snack consumption 3 times a week or more High fat content of school lunch Fast eating speed Fast food consumption Unhealthy snacks Girls not having breakfast everyday Nighttime snacking

OR (95% CI) 1.80 (1.32-2.45) 3.04 (2.49-3.71) 1.5 (1.12-2.01) 1.53 (1.35-1.73) 2.35 (1.14-4.85) 3.99 (3.07-5.18) 1.18 (1.00-1.39) 1.11 (1.03-1.20) 1.45 (1.11-1.89) 1.59 (0.78-3.24)

Proportion 6.20% 6.60% 6.30% 6.80% 4.10% 6.40% 6.70% 6.90% 6.40% 4.20%

Log[OR]±SE 0.5878±0.1582 1.1119±0.1018 0.4055±0.1491 0.4253±0.0639 0.8544±0.37 1.3828±0.1336 0.1655±0.0844 0.1044±0.0382 0.3716±0.1363 0.4637±0.3634

11 Rathnayake KM (2014)

Skipping breakfast

3.99 (1.81-8.80)

3.80%

1.3828±0.1336

12 Rathnayake KM (2014)

Fruit consumption less than 4 days/week

2.18 (1.02-4.66)

3.90%

0.7793±0.3875

4.80% 5.70% 6.70% 4.10% 6.10%

2.0334±0.2944 0.5423±0.2098 0.2624±0.0852 0.8372±0.3694 1.4704±0.1679

4.20%

1.1314±0.3636

13 14 15 16 17

Do LM (2015) Do LM (2015) Gokler ME (2015) Naja F (2015) Zong XN (2015)

18

Zhang J (2015)

Fatty foods ≥7 times/week 7.64 (4.29-13.60) Fried food ≥7 times/week 1.72 (1.14-2.59) Skipping breakfast 1.30 (1.10-1.54) 3rd tertile western diet 2.31 (1.12-4.76) Fast eating speed 4.35 (3.13-6.05) Highest quartiles of the modern and traditional 3.10 (1.52-6.32) north dietary pattern Total OR (95% CI) 2.12 (1.69-2.66) 2 2 Heterogenity: Tau = 0.19; Chi = 259.76. df= 17 (p < 0.00001); i2=93% Test for overall effect: Z-score= 6.44 (p < 0.00001)

100%

VARIABLE DISTRIBUTION OF OBSERVATIONAL STUDIES Special dietary patterns 2 studies

Breakfast habits 3 studies

Consumption of fruits 2 studies

Eating speed 3 studies

Study quality assessment with STROBE Statement and

Qualitative and quantitative analysis

DISCUSSION

Study Size Age (years)

4

9

13 observational studies in Asia

460,771 total samples

OBJECTIVES

8

Systematic review and meta-analysis

Studies did not meet metaanalysis criteria (n=3)

This scientific poster is aimed to evaluate dietary risk factors associated with childhood obesity among Asian population, which can potentially be used as recommendation and consideration to develop future health interventions.

3

Figure 2. Conceptual Framework

Study identification using Pubmed Database (n = 334)

BREAKFAST INTAKE HABIT Guo X (2013) explains that lack of breakfast in girls (aOR = 1.45) is an important determinant of obesity in childhood, as breakfast in associated with higher intake of carbohydrate, micronutrients, and fibers, along with lower intake of fat.

This habit is common in girls as girls are more likely to be concerned about their body weight and shape. In another studies, Gokler (2015) found that having no breakfast (OR = 1.3) makes children at a higher risk to acquire obesity, while Rathnayake (2014) found that lack of breakfast is a stronger risk factor for obesity (OR = 3.99).

CONSUMPTION OF FATTY FOODS AND SNACKS Shan (2010) states that frequent consumption (≥3 times/week) of snacks (aOR = 1.53) and fast food (aOR = 1.50) is associated with obesity through increase of fat intake, as well as the fact that snacks and fast food are also widely affordable throughout the country. Lim (2013) also shows slight correlation between fast food (OR = 1.18) and snacks (OR = 1.11). Gonzalez-Suarez (2013) found that among Filipino girls, consumption of snacks especially at night (OR = 1.59) is also risk factor. Nighttime is described by lack of physical activity and the rest-and-digest state of the body. The similar mechanism of excess fat intake is also demonstrated in consumption of fatty foods ≥7 times/week (OR = 7.64) and fried foods ≥7 times/week (OR = 1.72) in a study by Do (2015). In another study, Kim (2011) explains that high fat content of food, particularly school lunch in the study, renders children at 2.35 times higher risk of acquiring obesity.

EATING SPEED He (2000) explains the discrepancy of eating speed in children below 3 years old (OR = 1.8) and children aged 3-6.9 years (OR = 3.04). Higher eating speed causes delay of satiety and increased hunger through mechanical stimulation mechanisms of the small intestine along with release of hunger-associated peptide hormones (ghrelin and cholecystokinin). Results regarding higher risk of obesity caused by higher eating speed is also shown by Zong (2015) (OR = 4.351) and Zong (2012) (OR = 3.986).

CONSUMPTION OF FRUITS Rathnayake (2014) also found that consumption of fruits <4 days/week (OR = 2.18) is considered inadequate, hence it is considered as a risk factor because it is associated with lower intake of dietary fibers. Furthermore, a study done by Sharma SP (2016), explains the anti-obesity mechanisms of fruit consumption. The various ways are by decreasing the total calorie intake, prolonging satiety, provision of micronutrients and non-essential phytochemicals as well as modulation of gut ecology. Consumption of fruits with a high dietary fiber will delay gastric emptying and also slows down enzyme activity responsible for digestion of carbohydrate and fat. Fruits rich with micronutrients such as vitamins A, E and C are also known to have a negative association with central obesity. The mechanism involved is by reducing adipocyte generation and differentiation through leptin resistance and downregulation of the genes involved. Fruits containing non-essential phytochemicals such as blueerries and blackberries, are also shown to reduce incidence of obesity through reduction of oxidative stress.

SPECIAL DIETARY PATTERN Other than aforementioned dietary habits, there were special kinds of dietary pattern discussed. In a study by Naja (2015), western dietary pattern (OR = 2.31) is associated with unhealthy lifestyle, characterized by less breakfast consumption, higher frequency of eating out (in restaurants), and less physical activity, all of which contributes to excess fat deposition and thus, higher body mass index (BMI). Zhang (2015) discusses about modern and traditional north dietary patterns in China. Modern dietary pattern (OR = 3.1) is described by high intake of eggs, milk, and fast food, while traditional (OR = 3.1) north dietary pattern is described by high intakes of wheat, tubers, and cereals. Higher intake of eggs, milk, and fast food in the modern pattern is associated with higher cholesterol levels which contributes to increased adiposity. Traditional pattern is a carbohydrate-rich diet, which may induce dyslipidemia by increasing triglycerides and decreasing high-density lipoprotein (HDL), resulting in higher BMI. This review has several strengths, which includes having a vast study scope of Asia. Other than that, it has a relatively large sample size, with a total of 460771 participants. These strengths make our findings potentially be used in a larger population. Aside from the strengths, this review also has a limitation. Almost half of the studies presented in the results section are conducted in China, making its' representability of Asia rather questionable.

Consumption of fatty foods & snacks 4 studies

• The total of participants included were 460,771 from 13 observational studies • STROBE Statement or Strengthening the Reporting of Observational Studies in Epidemiology, was used to evaluate included observational studies for systematic review and meta-analysis to enhance the quality of reporting. The best study regarding to the protocol is by Guo X, 2013 with score 18.17 out of 22.

• Dietary factors which are most discussed in Asia is consumption of fatty foods and snacks (4 studies) • Unhealthy snacks become the most contributing risk factor of childhood obesity (proportion: 6.90%) • Highest Odds Ratios is consumption of fatty foods ≥7 times/week (OR:7.64) • Overall, dietary habits has OR:2.12 as a risk factor of childhood obesity shown by meta-analysis

CONCLUSION From this systematic review and meta-analysis, we found that the most contributing risk factor for childhood obesity is consumption of unhealthy snacks with proportion of 6.90% and overall OR of dietary habits is 2.12. The most discussed risk factor category is the excessive consumption of fatty foods. Hopefully, these risk factors can be utilized as consideration by the government, scientific communities, and health professionals to develop evidence-based interventions to reduce global burden of childhood obesity. To the general public, we hope that these risk factors can increase childhood obesity awareness. Future interventions should mainly focus on reduction of unhealthy foods while maintaining a proper dietary pattern.

REFERENCES 1. World Health Organization (2018, February 16). Obesity and overweight. Retrieved from http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight 2. World Health Organization (2017, October 13). Facts and figures of childhood obesity.

Retrieved from http://www.who.int/end-childhood-obesity/facts/en/ 3. World Health Organization (2017, February 3). Childhood overweight and obesity. Retrieved from https://www.who.int/dietphysicalactivity/childhood/en/ 4. Bhuiyan, M. U., Zaman, S., & Ahmed, T. (2013). Risk factors associated with overweight and obesity among urban school children and adolescents in Bangladesh: a case–control study. BMC Pediatrics, 13(1). https://doi.org/10.1186/1471-2431-13-72 5. Li, M., Deng, Y., Ren, Y., Guo, S., & He, X. (2013). Obesity status of middle school students in Xiangtan and its relationship with Internet addiction. Obesity, 22(2), 482–487. https://doi.org/10.1002/oby.20595 6. Guo, X., Zheng, L., Li, Y., Zhang, X., Yu, S., Yang, H., … Sun, Y. (2013). Prevalence and risk factors of being overweight or obese among children and adolescents in northeast China.

Pediatric Research, 74(4), 443–449. https://doi.org/10.1038/pr.2013.116 7. Shan, X.-Y., Xi, B., Cheng, H., Hou, D.-Q., Wang, Y., & Mi, J. (2010). Prevalence and behavioral risk factors of overweight and obesity among children aged 2–18 in Beijing, China. International Journal of Pediatric Obesity, 5(5), 383–389. https://doi.org/10.3109/17477160903572001 8. Lafta, R. K., & Kadhim, M. J. (2005). Childhood obesity in Iraq: prevalence and possible risk factors. Annals of Saudi Medicine, 25(5), 389–393. https://doi.org/10.5144/0256-4947.2005.389 9. He, Q., Ding, Z., Fong, D., & Karlberg, J. (2000). Risk factors of obesity in preschool children in China: a population-based case–control study. International Journal of Obesity, 24(11), 1528– 1536. https://doi.org/10.1038/sj.ijo.0801394 10. Do, L. M., Tran, T. K., Eriksson, B., Petzold, M., Nguyen, C. T. K., & Ascher, H. (2015).

Preschool overweight and obesity in urban and rural Vietnam: differences in prevalence and associated factors. Global Health Action, 8(1), 28615. https://doi.org/10.3402/gha.v8.28615 11. Zong, X.-N., Li, H., & Zhang, Y.-Q. (2015). Family-related risk factors of obesity among preschool children: results from a series of national epidemiological surveys in China. BMC Public

Health, 15(1). https://doi.org/10.1186/s12889-015-2265-5 12. Naja, F., Hwalla, N., Itani, L., Karam, S., Mehio Sibai, A., & Nasreddine, L. (2015). A Western dietary pattern is associated with overweight and obesity in a national sample of Lebanese adolescents (13–19 years): a cross-sectional study. British Journal of Nutrition, 114(11), 1909– 1919. https://doi.org/10.1017/s0007114515003657 13. Gökler, M. E., Buğrul, N., Metintaş, S., & Kalyoncu, C. (2015). Adolescent Obesity and Associated Cardiovascular Risk Factors of Rural and Urban Life (Eskisehir, Turkey). Central European Journal of Public Health, 23(1), 20–25. https://doi.org/10.21101/cejph.a3958 14. Zhang, J., Wang, H., Wang, Y., Xue, H., Wang, Z., Du, W., … Zhang, B. (2015). Dietary patterns and their associations with childhood obesity in China. British Journal of Nutrition, 113(12), 1978–1984. https://doi.org/10.1017/s0007114515001154 15. Minematsu, K., Kawabuchi, R., Okazaki, H., Tomita, H., Tobina, T., Tanigawa, T., & Tsunawake, N. (2014). Physical activity cut-offs and risk factors for preventing child obesity in Japan.

Pediatrics International, 57(1), 131–136. https://doi.org/10.1111/ped.12446

16. Rathnayake, K. M., Roopasingam, T., & Wickramasighe, V. (2014). Nutritional and behavioral determinants of adolescent obesity: a case–control study in Sri Lanka. BMC Public Health, 14(1). https://doi.org/10.1186/1471-2458-14-1291 17. Nasreddine, L., Naja, F., Akl, C., Chamieh, M., Karam, S., Sibai, A.-M., & Hwalla, N. (2014).

Dietary, Lifestyle and Socio-Economic Correlates of Overweight, Obesity and Central Adiposity in Lebanese Children and Adolescents. Nutrients, 6(3), 1038–1062. https://doi.org/10.3390/nu6031038 18. Gonzalez-Suarez, C. B., Lee-Pineda, K., Caralipio, N. D., Grimmer-Somers, K., Sibug, E. O., & Velasco, Z. F. (2013). Is What Filipino Children Eat Between Meals Associated With Body Mass Index? Asia Pacific Journal of Public Health, 27(2), NP650-NP661. https://doi.org/10.1177/1010539513491416 19. Zong, X.-N., & Li, H. (2012). Secular Trends in Prevalence and Risk Factors of Obesity in Infants and Preschool Children in 9 Chinese Cities, 1986–2006. PLoS ONE, 7(10), e46942. https://doi.org/10.1371/journal.pone.0046942

20. Kim, B., Lee, C. Y., Kim, H. S., Ko, I. S., Park, C. G., & Kim, G. S. (2011). Ecological Risk Factors of Childhood Obesity in Korean Elementary School Students. Western Journal of Nursing Research, 34(7), 952–972. https://doi.org/10.1177/0193945911401430 21. Chan, T.-F., Lin, W.-T., Huang, H.-L., Lee, C.-Y., Wu, P.-W., Chiu, Y.-W., … Lee, C.-H. (2014).

Consumption of Sugar-Sweetened Beverages Is Associated with Components of the Metabolic Syndrome in Adolescents. Nutrients, 6(5), 2088–2103. https://doi.org/10.3390/nu6052088 22. Yamborisut, U., Kosulwat, V., Chittchang, U., Wimonpeerapattana, W., Suthutvoravut, U. (2006). Factors Associated with Dual Form of Malnutrition in School Children in Nakhom Pathom and Bangkok. Journal Medical Association Thailand, 89(7), 1012-1023.

23. Lim, H., & Wang, Y. (2013). Body weight misperception patterns and their association with health-related factors among adolescents in South Korea. Obesity, 21(12), 2596–2603. https://doi.org/10.1002/oby.20361

Effectiveness of Ketogenic Diet on Body Fat as An Obesity Management in Adult: A Systematic Review Ugiadam Farhan*, Aruni Cahya, Ekida Rehan, Yehezkiel Alexander *ugiadamfarhan@yahoo.co.id, +6281287970973 Universitas Indonesia Introduction Obesity or overweight can lead to various adverse metabolic effect including blood cholesterol, blood pressure, triglycerides and insulin resistance. In 2016, 1.9 billion adults at 18 years or older were overweight and 650 million were obese. Diet and change of lifestyle are becoming the main treatment of type 2 diabetes mellitus and obesity. One recommendation to treat obesity is very low calories ketogenic diet. Although many studies are still being continued to demonstrate the effects and effectiveness of low carbohydrate diet in order to treat obesity.

Objectives (1) To review several types of ketogenic diet (2) To analyse the effectiveness of ketogenic diet as obesity management (3) develop further holistic approach to manage obesity through diet intervention Methods This systematic review of several randomized controlled trial studies of ketogenic diet effect on obese or overweight adult. We searched literatures through PubMed, ScienceDirect, and Scopus (n = 16907) journal database. Six eligible studies which meet inclusion and exclusion criteria were assessed with Cochrane Collaboration Tools for assessing risk of bias for further review.

Results and Discussion 1) Mechanism of ketogenic diet 2) Type of ketogenic diet 3) Effect of ketogenic diet Conclusion This systematic review concluded that ketogenic diet significantly can increase body fat loss in obese people. The most effective type of ketogenic diet is very-low ketogenic diet. Correspond with WHO programs to decrease number of obesity which lead to many NCD, ketogenic diet could simply applies as treatment of obesity.

Keywords Adult, ketogenic diet, body fat, obesity, overweight

Table 1. Characteristic of Studies

Figure 2. Cochrane Collaboration Tools

Figure 1. Literature Search We compare between ketogenic diet, VLCK diet, isocaloric KD, and low calories diet.

Inclusion criteria: RCT, publication year 2014 or sooner, full-text only, human participants, adult.

Exclusion criteria: suplement modification in ketogenic diet, effect of ketogenic diet on other diseases

THE PROTECTIVE EFFECT OF OBESITY IN CORONARY ARTERY DISEASE IIN FADHILAH UTAMI1, KHAIRIL HASYIM 1, ILHAM AKBAR RAHMAN, MD1 1

Faculty of Medicine Hasanuddin University

Introduction: Although for decades there has been controversy regarding the relationship between obesity and coronary artery disease (CAD), it has been assumed that high body mass index (BMI) is a risk factor for CAD. However, the findings of some recent studies were paradoxical.

Aim: The aim of this study was to analyze deeper about BMI as well as its correlation with severity of coronary artery disease.

Material and Methods: This is observational study with cross sectional approach. The samples taken were 131 patients of coronary artery disease from August 2015 to Januari 2016, then were assessed with coronary angiography in Cardiac Center of Wahidin Sudirohusodo Hospital, Indonesia Results: Of 131 coronary artery disease patients examined 40 (30,5%) were normal, 34 (26,0%) were overweight, 46 (35,1%) obese stage 1 and 11 (8,4%) were obese stage 2. The profil of coronary artery disease patients examined using coronary angiography with gensini scoring system showed that 47 (35,9%) were mild coronary artery disease, 31 (23,7%) were moderate coronary artery disease and 53 (40,5%) were severe coronary artery disease. Among mild coronary artery disease patients, 37 (78,7%) of them were overweight/obese. With p value 0,027 and -3<r<0, our results found that the severity of coronary artery disease was negatively correlated with body mass index. The lipid profile of the patients showing about 111 (84,7%) of the patients had dislipidemia status and among 111 patients with dislipidemia, 81 (73%) were overweight or obese. With p value 0,037 our results showed that there was significant correlation with BMI and dislipidemia. The gender distribution of patients were 100 (76,3%) with male and 31 (23,7%) with female. From 31 of female, approximately 20 (64,5%) of them were obese. While for male, among 100 male, only 37 (37%) of them were obese. With p value 0,002, our results showed that there was significant correlation with gender and body mass index.

Conclusion: . The severity of coronary artery disease is negatively correlated with patientâ&#x20AC;&#x2122;s body mass index. High body mass index has protective effect in coronary artery disease patients. We concluded that obesity is associated with less severe coronary arter disease.

Keywords: Coronary Artery Disease (CAD), Body Mass Index (BMI), Gensini Scoring System (Severity of CAD), Dyslipidemia, Gender

The TheProtective ProtectiveEffect Effectof of Obesity Obesityin inCoronary Coronary Artery ArteryDisease Disease

IIN IIN FADHILAH FADHILAH UTAMI UTAMI11,, KHAIRIL KHAIRIL HASYIM HASYIM 11,, ILHAM ILHAM AKBAR AKBAR RAHMAN, RAHMAN, MD MD11 11AMSA Hasanuddin University AMSA Hasanuddin University

METHODS

INTRODUCTION

This was observational study with cross sectional approach. The samples taken were 131 patients of coronary artery disease from August 2015 to Januari 2016, then were assessed with coronary angiography in Cardiac Center of Wahidin Sudirohusodo Hospital, Indonesia

Although for decades there has been controversy regarding the relationship between obesity and coronary artery disease (CAD), it has been assumed that high body mass index (BMI) is a risk factor for CAD. However, the findings of some recent studies were paradoxical. Therefore, the aim of this study was to analyze deeper about BMI as well as its correlation with severity of coronary artery disease.

RESULTS Of 131 coronary artery disease patients examined 40 (30,5%) were normal, 34 (26,0%) were overweight, 46 (35,1%) were obese stage 1 and 11 (8,4%) were obese stage 2. The profile of coronary artery disease patients examined using coronary angiography with gensini scoring system showed that 47 (35,9%) were mild coronary artery disease, 31 (23,7%) were moderate coronary artery disease and 53 (40,5%) were severe coronary artery disease. Among mild coronary artery disease patients, 37 (78,7%) of them were overweight/obese. With p value 0,027 and -3<r<0, our results found that the severity of coronary artery disease was negatively correlated with body mass index. The lipid profile of the patients showing about 111 (84,7%) of the patients had dislipidemia status and among 111 patients with dislipidemia, 81 (73%) were overweight or obese. With p value 0,037 our results showed that there was significant correlation with BMI and dislipidemia. The gender distribution of patients were 100 (76,3%) with male and 31 (23,7%) with female. From 31 of female, approximately 20 (64,5%) of them were obese. While for male, among 100 male, only 37 (37%) of them were obese. With p value 0,002, our results showed that there was significant correlation with gender and body mass index.

Diagram 1. The Severity Profile of Coronary Artery Disease Patients

60 50 40 30 20 10

0 Mild Coronary Artery Disease Moderate Coronary Artery Disease Severe Coronary Artery Disease

Table 1. BMI Profile of Coronary Artery Disease Patients

BMI

Number of Cases

Percent

Normal

40

30.5

Overweight

34

26.0

Obese 1

46

35.1

Obese 2

11

8.4

Total

131

100.0

Table 2. Gender Distribution of CAD Patients Gender

Table 3. The Correlation of BMI and Severity of Coronary Artery Disease

Normal BMI

p value : 0.004 (<0.05) Normal Overweight BMI Obese 1 Obese 2 Total

Count % within BMI % within Severity Count % within BMI % within Severity Count % within BMI % within Severity Count % within BMI % within Severity Count % within Severity % of Total

Mild 10 25.0% 21.3% 8 23.5% 17.0% 21 45.7% 44.7% 8 72.7% 17.0% 47 100.0% 35.9%

Severity Moderate 16 40.0% 51.6% 7 20.6% 22.6% 7 15.2% 22.6% 1 9.1% 3.2% 31 100.0% 23.7%

Severe 14 35.0% 26.4% 19 55.9% 35.8% 18 39.1% 34.0% 2 18.2% 3.8% 53 100.0% 40.5%

Obese

Total 40 100.0% 30.5% 34 100.0% 26.0% 46 100.0% 35.1% 11 100.0% 8.4% 131 100.0% 100.0%

Total

Female

63

11

74

% within BMI

85.1%

14.9%

100.0%

% within Gender

63.0%

35.5%

56.5%

Count

37

20

57

% within BMI

64.9%

35.1%

100.0%

% within Gender

37.0%

64.5%

43.5%

Count

100

31

131

% within Gender

100.0%

100.0%

100.0%

% of Total

76.3%

23.7%

100.0%

Table 4. The Correlation of BMI and Dyslipidemia Dyslipidemia

p value : 0,037 (<0.05) Normal

DISCUSSION

Overweight

Our findings suggest that obese patients have a paradoxically lower CAD burden compared to their non-obese comparators. Although it seems logical that obesity or adiposity should be accompanied by more accumulation of fat cells everywhere in the body, including vascular walls (atherosclerotic plauques), it must be clarified that first of all, obesity per se is not adiposopathy, and second, the process of atherosclerosis is not a simple process of fat accumulation but is as a result of adipose tissue dysfunction, or sick fat. This is in line with study conducted by Rubinshtein (2006), in their study on 923 patients with CAD, showed that obesity had an inverse relationship with the severity of CAD.3 Greater metabolic reserves, less cachexia, younger presenting age, more aggressive diagnostic and revascularization procedures, and increased muscle mass have been proposed as possible mechanisms of protection effect.2 Our results also suggest that female patients tend to have lower (mild) in severity of coronary artery disease then male. Female was associated with higher body mass index (overweight/obese), meanwhile male was associated with normal body mass index. According to the landmark “Women’s Ischemia Syndrome Evaluation (WISE) Study”2 they indicated that normal-weight women with the metabolic syndrome have a significantly increased cardiovascular risk. Similarly, overweight and obese women with normal metabolism have a relatively low cardiovascular risk.3

Total

Male Count

BMI Obese 1

Obese 2

Total

Total

Yes

No

Count

30

10

40

% within BMI

75.0%

25.0%

100.0%

% within Dyslipidemia

27.0%

50.0%

30.5%

Count

29

5

34

% within BMI

85.3%

14.7%

100.0%

% within Dyslipidemia

26.1%

25.0%

26.0%

Count

42

4

46

% within BMI

91.3%

8.7%

100.0%

% within Dyslipidemia

37.8%

20.0%

35.1%

Count

10

1

11

% within BMI

90.9%

9.1%

100.0%

% within Dyslipidemia

9.0%

5.0%

8.4%

Count

111

20

131

% within Dyslipidemia

100.0%

100.0%

100.0%

% of Total

84.7%

15.3%

100.0%

CONCLUSION The severity of coronary artery disease is negatively correlated with patient’s body mass index. High body mass index has protective effect in coronary artery disease patients. We concluded that obesity is associated with less severe coronary artery disease.

REFERENCES REFERENCES

1. Khan, H.S., Javed A, Azis S, Alli J. (2011). Relationship Between BMI and Severity of Coronary Artery Disease in Female Population of Pakistani Origin.

Pakistani Heart Journal Vol 44 No 1-2.

2. Gregory A.B., Lester K., Gregory D, Twells L, Midodzi W, and Pearce N. (2017). The Relationship between Body Mass Index and the Severity of Coronary Artery Disease in Patients Referred for Coronary Angiography. Cardiology Research and Practice Vol 2017.

3. Chiha J, Mitchell P, Gopinath B, Plant A, Kovoor P, and Thiagalingam A. (2015). Gender Differences in the Severity and Extent of Coronary Artery Disease. IJC Heart and Vasculature 161-166.

East EastAsian AsianMedical MedicalStudents’ Students Conference

(EAMSC (EAMSC 2019) 2019)

ABSTRACT

Introduction: Type 2 Diabetes Mellitus (T2DM) is a common and increasingly preventable

disease worldwide. There are many factors that contribute to the occurrence of T2DM , the modifiable and non-modifiable, the modifiable are less activity and stress, and they are affected by occupation , after conducting a pre-research literature study using several journal , we found government employee, housewifes and private employee are the occupation that have most T2DM. Objective: This study aimed to know the knowledge and attitude of non-diabetic subjects particularly those in risk of it.

Methods:method involving 321 participants from three groups of occupation; housewives, private employees, and government employee/civil servants. There were 2 section of questionnaire where the first section was aimed to know the workerâ&#x20AC;&#x2122;s knowledge on diabetes mellitus andthe second one was aimed to assess the attitude of respondents towards their risky occupation, either being ignorant or positively aware to it. Finally, we also analyzed the link of knowledge and attitude in the context of preventing T2DM. The data was analyzed trough IBM SPSS Statistics 23 before finally transformed into tables and charts.

Result:Among 108 subjects from government employee group, 104 were found to be knowledgeable and 47 had negative attitude towards diabetes. Moreover, among 106 subjects of housewife, 102 were found to be knowledgeable and 55 reported to have negative attitude towards diabetes. Finally, among 107 subjects of private employee, 105 were found to be knowledgeable and 63 sadly showed negative attitude towards diabetes. On the other hand, there were 264 out of 321 participants who werereported to not knowing that they are in risk Conclusion:Majority of people who work as either housewife, government or even private employee already been knowledgeable enough for any information about type 2 diabetes mellitus, yet this level of knowledge unfortunately not in line with their attitude which tended to show less aware even more to ignorant for the risk of diabetes they are facing because of their occupations

Integrated Multimodal Preventive Approach for Type 2 Diabetes Mellitus in Asia: Systematic Review Adriana Viola Miranda1,*, Eko Ngadiono1, Refael Alfa Budiman1, Aji Wahyu Wardhana1 1

Undergraduate Program, Faculty of Medicine, University of Indonesia *

adriana.viola@ui.ac.id

Background: Type 2 diabetes mellitus has shown a rapid prevalence increase since 1980 â&#x20AC;&#x201C; from a total of 102 million to 422 million. Around 60% of these numbers are contributed by Asian countries.

Without proper management, it will cause detrimental effects. Therefore, in alignment with Sustainable Development Goals (SDG) number 3, numerous diabetes prevention programs have been developed. Asian populations, on the other hand, require distinct preventive approaches as their population characteristics differ from populations from other region. In this review, we systematically evaluate diabetes prevention approaches in Asia.

Objective: This review aims to evaluate preventive approaches of type 2 diabetes mellitus in Asian countries and synthesize a multi-modal prevention program based on the evaluations.

Method: This review was conducted based on PRISMA Statement. From database searching, a total of 538 articles were found. Articles that do not align with our inclusion criteria were eliminated. We then assessed 22 studies for eligibility. Twelve articles were selected as our final research database in this study.

Results and Discussion: The total participants of this review were 10,601 people. Intervention programs collected from these studies can be categorized as lifestyle modification, educational programs, as well as nutraceuticals and pharmacological strategies. While each intervention shows significant improvement in diabetes condition in Asia, a combination of interventions at all levels is needed. Based on this approach, we proposed an integrated multimodal preventive approach consists of three layers of prevention, which are universal, selective and indicated. Limitation of our study is the number of studies available for reviewing.

Conclusion and Recommendations: Integrative multimodal preventive approach is needed in order to achieve universal health coverage of diabetes in Asia. However, this model needs to be researched extensively before implementation could be done widely. Further research opportunity includes adaptation of the model into various cultural backgrounds.

Keyword: diabetes prevention approach, Asia, SDG, universal health coverage

Integrated Multimodal Preventive Approach for Type 2 Diabetes Mellitus in Asia: Systematic Review Adriana Viola Miranda1,*, Eko Ngadiono1, Refael Alfa Budiman1, Aji Wahyu Wardhana1 1Undergraduate

Program, Faculty of Medicine, University of Indonesia

*adriana.viola@ui.ac.id

4 Results

Type 2 diabetes mellitus (T2DM), or non-insulin-dependent diabetes, is a condition when the body lacks the capacity to utilize insulin effectively. It has shown a rapid prevalence increase since 1980 – from a total of 102 million to 422 million (Roglic, 2018) Around 80% of patients with T2DM originated from low and middle-income countries. Asia region contributes to 60% of those number. This is important to notice as diabetes in Asia differs from other parts of the world due to distinct profile of genes and diet (Nanditha et al, 2016).

Without a proper management, diabetes may cause long-term consequences that impact quality of life, as well as large economical burden (Zhang et al, 2017). To address the issue, researchers around the world have been developing numerous amount of effective preventive programs, aligning with Sustainable Development Goals (SDG) number 3 (UNSC, 2017). Based on differences in population characteristics, Asian populations require distinct preventive approaches from other regions (Ramachandran et al, 2012). Here, we systematically review preventive programs that have been done in Asia.

2 Objective This review aims to: 1. Evaluate preventive approaches of type 2 diabetes mellitus in Asian countries 2. Synthesize a integrated multimodal prevention program of diabetes mellitus type 2 based on evaluation of currently-available preventive approaches in Asia

Table 1. Study characteristics and quality assessments result. Assessments were done using Jadad scoring for RCT and STROBE Statement for cohort studies.

Study

Location

Study Design

Quality Assessment

Preventive Approach(es)

Bani Salameh, 2017

Irbid, Jordan

RCT

3

School-based n Intervention = educational preventive 205, n control = Adolescent (mean age = programs 196 15.3 years)

Significant reduction in body weight (p <0.000) and fasting blood glucose (p <0.000)

Significant reduction in diabetes incidence (x2 = 13.4; p <0.01),reduced LDLc (low density lipoprotein cholesterol, p <0.05), reduced FPG (p <0.05) and post prandial blood glucose (p <0.01); significant increase in serum insulin level (p <0.01) and HOMA IR (p <0.05); treatment positively associated with serum insulin (p <0.01) and negatively associated with HOMA IR (p <0.001)

12 Observational Studies

Demography of Participants

Outcome

Gaddam et Hyderabad, al, 2015 India RCT

3

n intervention = 74, n control = Adult Male & Female (aged 30-70 years) Fenugreek consumption 66

Rekha K et Chennai, al, 2014 India

2

n = 53, divided Significant difference in fasting blood into control and glucose level and quality of life; reduced Home-based monitored intervention Males and females (35 to FPG (p <0.0001);); significant increase in aerobic exercise 55 years old) group quality of life (QoL) (p <0.0001)

3

Educational and motivational advice Reduced diabetes incidence (p <0.015) about lifestyle n intervention = 271; n control= modification through mobile phone messaging 266 Adult male (35-55 years)

RCT

Ramachandran A South East et al, 2013 India, India RCT

TanigunichFukatsu A Tokushima, et al, 2012 Japan RCT

Reduced acute glucose and insulin responses; improvements in composite insulin sensitivity index (CISI, p <0.05); significant decrease in levels of serum total cholesterol, LDL-cholesterol, Overweight subjects with malondialdehyde-modified LDL and N 1IGT and hyperinsulinaemia carboxymethyllysine

1

Natto (viscous fermented soybeans) and viscous vegetables consumption 11

Weight reduction (p <0.001) at 36 months

Japan

RCT

2

Lifestyle modification (control dietary intake of fat and increased n intervention = 311; n control = Adult male and female physical activity to 330 200kcal/day) (aged 30-60 years)

Kawamori R, et al 2009 Japan

RCT

5

High risk Japanese n intervention = individuals with glucose 897; n control = tolerance (average age 55.7) Voglibose consumption 883

Lower risk of progression to type 2 diabetes (HR = 0.595, p = 0.0014)

2

Diet modification and increased physical activity

n intervention = 102; n control = Adult male (aged 30-60 356 years)

Significant decrease in weight (p <0.001); glucose tolerance improvement from impaired glucose tolerance (IGT) to non IGT (p <0.001); decreased FPG (p <0.02)

1

Diet, exercise, combination of diet & exercise

577; divided into three group (diet Individual classified (using only, exercise WHO criteria) as having only, diet plus impaired glucose tolerant exercise) (IGT)

Fasting glucose of the diet, exercise, and diet-plus-exercise interventions were associated with 31% (p <0.03), 46% (p <0.0005), and 42% (p <0.005) reductions in risk of developing diabetes, respectively Reduced risk of T2DM onset (p = 0.04) and IGT onset (p = 0.002)

Saito T et al, 2011

Kosaka et Tokyo, al, 2004 Japan

3 Method Systematic Review

Number of Participants

RCT

Pan XR et Da Qing, al, 1997 China

RCT

Wijesuriya, 2014 Sri Lanka

RCT (Abstract) 1

Intensive Lifestyle Modification (I-LSM)

Aged 5-40 years, 50% n I-LSM= 1807, n subject under 16 years, 48% males LI-LSM=1878

Momma H Tokyo, et al, 2017 Japan

Cohort

Exercise

2235

19,5

Yoon DH et Cohort al, 2016 South Korea (Abstract) N/A

Workplace improvement program 83

Males = mean age 43 years; median follow-up periods : 15 years

Significant difference between fit and unfit category based on cumulative incidence curve of Type 2 diabetes mellitus (T2DM) with age-adjusted (HR = 1.72) and multivariate-adjusted (HR = 1.33)

Employee

Improvement in HDLc, HbA1c,body weight, BMI, body fat percentage and waist hip circumference (p not available)

From Pubmed, ScienceDirect, Scopus, Google Scholar and additional records

Quality Assessment Jadad Scoring for RCT, STROBE Statement for cohort studies

Qualitative Analysis

Total Samples

Figure 1. Selection and Analytical Methods

Records identified through Google Scholar database searching (n = 343)

Records identified through ScienceDirect database searching (n = 54)

Records identified through Pubmed database searching (n = 73)

Records identified through Scopus database searching (n = 60)

Additional records identified through other sources (n = 8)

Records after duplicate removed (n = 538) Records screened (n = 538)

Records excluded (n = 516)

Full-text articles assessed for eligibility (n = 22)

Full-text articles excluded, with reasons (n = 10)

Studies included (n = 12)

Figure 2. PRISMA Flow Diagram

References Bani Salameh, A., et al. (2017). Effectiveness of a 12-week school-based educational preventive programme on weight and fasting blood glucose in "at-risk" adolescents of type 2 diabetes mellitus: Randomized controlled trial. Int J Nurs Pract, 23(3). doi: 10.1111/ijn.12528.

Roglic, G. (2016). WHO Global report on diabetes: A summary. Int J Non-Commun Dis,1, 3-8. Available from: http://www.ijncd.org/text.asp?2016/1/1/3/184853 Cha, E., et al. (2016). Understanding how overweight and obese emerging adults make lifestyle choices. Pediatr Nurs, 31(6), e325-e332. doi: 10.1016/j.pedn.2016.07.001 Gaddam, A., et al. (2015). Role of Fenugreek in the prevention of type 2 diabetes mellitus in prediabetes. J Diabetes Metab Disord, 14, 74. doi: 10.1186/s40200-015-0208-4 Glanz, K., Rimer, B.K., Viswanath K., (Eds.). (2015). Health behavior: theory, research, and practice (5th ed). San Francisco: Jossey-Bass. p. 49.

Kawamori, R., et al. (2009). Voglibose for prevention of type 2 diabetes mellitus: a randomised, double-blind trial in Japanese individuals with impaired glucose tolerance. Lancet, 9, 373(9675), 1607-14. doi: 10.1016/S0140-6736(09)60222-1 Kosaka, K., et al. (2005). Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males. Diab Res Clin Pract, 67(2),152-162. doi: 10.1016/j.diabres.2004.06.010 Ma R., C., W., Chan, J., C., N. (2013 Apr). Type 2 diabetes in East Asians: similarities and differences with populations in Europe and the United States. Ann N Y Acad Sci, 1281(1), 64–91. Epub 2013 Apr 1. doi: 10.1111/nyas.12098.

Momma, H., et al. (2018). Importance of achieving a “fit" cardiorespiratory fitness level for several years on the incidence of type 2 diabetes mellitus: a Japanese cohort study. J Epidemiol, 28(5), 230-236. doi: 10.2188/jea.JE20160199 Nanditha, A., et al. (2016). Diabetes in Asia and the Pacific: implications for the global epidemic. diabetes care. Diabetes Care, 39(3), 472-485. doi: 10.2337/dc15-1536 Pan, X., R., et al. (1997). Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and diabetes study. Diabetes Care, 20(4),537-544 Phillips, J. & Springer, J., F. (2007). The Institute of Medicine framework and its implication for the advancement of prevention policy, programs and practice. Santa Rosa: Center for Applied Research Solutions.

Ramachandran, A., et al. (2012). Trends in prevalence of diabetes in Asian countries. World J Diabetes, 3(6), 110–117. doi: 10.4239/wjd.v3.i6.110 Ramachandran, A., et al. (2013). Effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle modification in men in India: a prospective, parallel-group, randomised controlled trial.

Lancet Diabetes Endocrinol, 1, 191-198. doi: 10.1016/ss2213-8587(13)70067-6 Rekha, K., et al. (2014). Home based therapeutic intervention for type 2 diabetes mellitus. J Chem Pharm Sci (Online), 7, 275-280.

Saito, T., et al. (2011). Lifestyle modification and prevention of type 2 diabetes in overweight Japanese with impaired fasting glucose levels: a randomized controlled trial. Arch Intern Med, 171(15), 1352-1360. doi: 10.1001/archinternmed.2011.275 Taniguchi-Fukatsu, A., et al. (2012). Natto and viscous vegetables in a Japanese-style breakfast improved insulin sensitivity, lipid metabolism and oxidative stress in overweight subjects with impaired glucose tolerance. Br J Nutr, 107, 1184-1191. doi: 10.1017/S0007114511004156 United Nations Statistical Commission. (2017). Resolution adopted by the General Assembly on Work of the Statistical Commission pertaining to the 2030 Agenda for Sustainable Development (A/RES/71/313).

United Nation. Retrieved from: https://unstats.un.org/sdgs/indicators/Global Indicator Framework after refinement_Eng.pdf Wijesuriya, M., et al. (2014, Nov). OP49 a low cost primary prevention tool: effects of non pharmacological lifestyle modification in prevention of type 2 diabetes mellitus in young urban Sri Lankan - “DIABRISK-SL”.

Paper presented at Proceedings of the 10th Internagtional Diabetes Federation-Western Pacific Region Congress and the 6th AASD Scientific Meeting. Diabetes Research and Clinical Practice. doi: 10.1016/ S0168-8227(14)70255-4 Yoon, D., H., et al. (2016, Jun). The effect of circuit training and workplace improvement program on the prevention of metabolic syndrome and the improvement of physical function in office workers [Abstract].

Korean J Health Promot, 16(2), 134-143. doi: 10.15384/kjhp.2016.16.2.134 [Article in Korean] Zhang, P. & Gregg, E. (2017). Global economic burden of diabetes and its implications. Lancet Diabetes Endocrinol, 5(6), 404-405. doi: 10.1016/S2213-8587(17)30100-6

Figure 3. Location map of included studies. Each pointer marks the location of one included study. Most of the studies were conducted in East Asia.

Quantitative measurements of study results 6

Number of studies

1 Introduction

5 4 3 2 1 0

Outcome of study

Figure 4. Outcomes distribution of included studies. Note that while the programs are designed to prevent diabetes, some of which do not directly reduce the disease incidence, but rather reduce the prevalence its risk factors.

• The total participants included in this review are 10,601 people from 12 studies.

• The programs could be divided into three types based on their approach: lifestyle modification, educational programs, as well as nutraceutical and pharmacological strategies.

• The two most discussed outcomes in the study are reduced diabetes incidence and reduced fasting blood glucose, respectively.

5 Discussion Assessed prevention programs focus on improving lifestyle and health literacy Asian populations are more prone to diabetes compared to populations from other region. This is caused by their genetic susceptibility and recent changes in diet; the latter becoming the consequences of westernization (Ramachandran et al, 2012 & Ma et al, 2013). Furthermore, despite health literacy in Asia being considered among the standards, the aspect still needs to be improved (Cha et al, 2016). Based on these situations, many programs designated to prevent diabetes in the region focus on improving lifestyle and health literacy among the populations. This approach is also adopted by the studies assessed in this review, thus helping the programs improve diabetes condition in Asia significantly.

The need to develop an integrated multimodal preventive approach for universal diabetes prevention While the described preventive approaches showed favorable results, each program still focused only on one social ecological level. This is important as theoretically, the most effective approach to public health prevention and control needs to use a combination of interventions at all levels (Yoon et al, 2016). Furthermore, it is known that effects from addressing single risk factor is unlikely to be sustainable (Bani Salameh, 2017). This implies that in order to prevent the increasing prevalence of diabetes in Asia, development of a preventive approach that addresses all levels and risk factors in the region is needed.

Proposed integrated multimodal preventive approach for Asian population Besides considering all levels in social-ecological model and occurring risk factors in Asia, there are several other aspects that need to be assessed before an integrated multimodal preventive approach could be proposed. Considering characteristics diversity among Asian population, generalizability of the program needs to be a priority (Ramachandran et al, 2012 & Ma et al, 2013).

Furthermore, it also needs to be context-specific in order to be successful. This includes consideration of culture and socioeconomic status of the targeted population (Bani Salameh, 2017 & Saito T, 2011). At least, the program should be flexible enough so that when it is adapted into various cultures, it will not lose its core strategy.

We based our proposed approach on IOM Model of Prevention. This model divides prevention strategies into three types based on targeted populations: universal, selective and indicated strategies (Phillips & Springer, 2007).

Asian population

1 Universal

Educational programs

2 Selective

Diet and lifestyle modification

3 Indicated

Nutraceutical & pharmacological intervention

Lower diabetes incidence Figure 5. Proposed integrated multimodal preventive approach of diabetes in Asian population. The first line of diabetes prevention requires universal strategy that targets every individual in a population. For our proposed approach, we believe educational programs, mainly in schools, should implemented in this line considering the need to improve health literacy in Asia. On the other hand, individuals with higher risk of developing diabetes requires ‘selective’ intervention. Diet and lifestyle modifications are highly recommended for this type of intervention. Indicated strategy is addressed to individuals with early symptoms of diabetes. This strategy suggests nutraceuticals & pharmacological interventions as first choice of interventions. (Theory adapted from Phillips & Springer, 2007) Limitation of study Limited number of available studies that match with our inclusion and exclusion criteria may result in the designed preventive approach not universally acceptable for all Asian populations.

6 Conclusion and Recommendations From this systematic review, we were able to conclude that while several programs are significantly proven to reduce diabetes incidence in Asia, they still focus on one social ecological level. Moreover, each study focuses on certain population only. Therefore, to achieve universal health coverage (UHC) on diabetes in the region, we developed a integrated multimodal preventive approach This model accommodates various risk factor management, as well as various characteristics of population in need of diabetes prevention. However, this model needs to be researched more extensively before wide implementation could be done. Other further research opportunity regarding this preventive approach includes adaptation of the model into various cultural backgrounds.

PERCEIVED BARRIER OF HEALTHY LIFESTYLE AMONG HIGH SCHOOL STUDENTS IN SURABAYA, EAST JAVA, INDONESIA: A STUDY BETWEEN OVERWEIGHT-OBESE AND NON OVERWEIGHT-OBESE STUDENTS Kevin Luke, Ivan Angelo Albright, Tiffany Konstantin, and Muhammad Jafâ&#x20AC;&#x2122;ar Shodiq AMSA-Airlangga University, Surabaya, Indonesia kevinluke19@gmail.com Background: Pediatric obesity is serious problem because it progression in adults will cause metabolic and degenerative diseases such as heart disease, diabetes mellitus type 2, malignancy, and osteoarthritis.Prevalence of obesity in 16-18 years old group is increasing from 1,4% in 2010 to 7,3% in 2013. Moreover, East Java is included as fifteen province with highest rate of obesity nationally.

Obesity is related with social, psychological, and environmental factors that may influence healthy eating and physical activity.

Aim: To compare perceived barriers of healthy lifestyle among obese and non-obese high school students in Surabaya, Indonesia Material and Methods: This cross-sectional study was conducted from 1 October 2018 to 5 October 2018. Accidental sampling was used to recruit participants from public schools and private schools in Surabaya. One or two researcher came to schools to assess perceived barrier by using assisted selfadministered questionnaire from previous study that has been translated into Bahasa Indonesia.

Translated questionnaire consists of informed consent, participantâ&#x20AC;&#x2122;s identity, self-reported heightweight, self-reported levels of healthy lifestyle, and agree/disagree statements about barriers in healthy eating and physical activity. Collected data was checked and excluded if incompletely answered.

Checked data was analyzed in Microsoft Excel 2013 and IBM SPSS Statistics 23.

Result: Total of 93 students from 6 schools (2 public and 4 private schools) were enrolled in this study. Based on this study, students with >P85 was 24,73%. Both group have same perception of how healthy their lifestyle, diet, and physical activity. Overall, there is no significant difference in both group in all aspects except total score for environmental factors that is higher in >P85 group. Other significant differences are teacher support on healthy eating and Weather in Surabaya is not suitable for physical activity Conclusion: There is difference in environmental factors of physical activity in overweight-obese student compared with non overweight-obese student. Hopefully, this study can be references for larger and comprehensive study in the future.

Keywords: Adolescent, Barriers, Obesity, Prevention, School-based program.

PERCEIVED BARRIER OF HEALTHY LIFESTYLE AMONG HIGH SCHOOL STUDENTS IN SURABAYA, EAST JAVA, INDONESIA: A STUDY BETWEEN OVERWEIGHT-OBESE AND NON OVERWEIGHT-OBESE STUDENTS Kevin Luke, Ivan Angelo Albright, Tiffany Konstantin, and Muhammad Ja’far Shodiq AMSA-University of Airlangga, Surabaya, Indonesia

INTRODUCTION Pediatric obesity is serious problem because it progression in adults will cause metabolic and degenerative diseases such as heart disease, diabetes mellitus type 2, malignancy, and osteoarthritis(1). According to Riset Kesehatan Dasar 2013, prevalence of obesity in 16-18 years old group is increasing from 1,4% in 2010 to 7,3% in 2013. Moreover, East Java is included as fifteen province with highest rate of obesity nationally(2).

Obesity is related with social, psychological, and environmental factors that may influence healthy eating and physical activity(3).

AIM To compare perceived barrier of healthy lifestyle among obese and nonobese high school students in Surabaya, East Java, Indonesia.

MATERIAL AND METHOD This cross-sectional study was conducted from 1 October 2018 to 5 October 2018. Accidental sampling was used to recruit participants from schools in Surabaya. One or two researcher came to school to assess perceived barrier by using assisted self-administered questionnaire from previous study(3) that has been modified and translated into Bahasa Indonesia. Translated questionnaire consists of informed consent, participant’s identity, self-reported height-weight, self-reported levels of healthy lifestyle, and agree/disagree statements about barriers in healthy eating and physical activity. Collected data was checked and excluded if incompletely answered. Overweight-Obese students are defined if have percentile above 85 using CDC 2000 Growth Chart(1,4). Checked data was analyzed in Microsoft Excel 2013 and IBM SPSS Statistics 23.

RESULTS

Table 3. Baseline Characteristics

Overall, there is no significant difference in both group in all aspects except total score for environmental factors that is higher in >P85 group.

Other significant differences are teacher support on healthy eating (No. 8) and Weather in Surabaya is not suitable for physical activity (No. 22). There is also difference is majority answer in teacher support on healthy eating (No.6); parents support on physical activity (No. 14); Weather in Surabaya is not suitable for physical activity (No. 22); Lack of skills doing physical activity (No. 23); and Do not want to spend money for physical activity club (No. 24)

DISCUSSION Picture 1. Participants were answering questionnaire

Total of 93 students from 6 schools (2 public and 4 private schools) were enrolled in this study. Based on this study, students with >P85 was 24,73%.

Participants characteristics is shown in Table 1.

Table 1. Baseline Characteristics

Both group have same perception of how healthy their lifestyle, diet, and physical activity (Table 2.)

Table 2. High School Students Perception 1. RI KK. Pedoman Pencegahan dan Penanggulangan Kegemukan dan Obesitas. 2011.

2. Kementerian Kesehatan Republik Indonesia. Riset Kesehatan Dasar. 2013;1–384.

Although obesity is related with social, psychological, and environmental factors, this study shows no significant different in both group. This result is consistent with previous study on university student by Musaiger et al.

(2014) in Kuwait(3). Higher perceived physical activity environmet level of >P85 group may be caused by weight-related victimization(WRV)(5). WRV is not generally related with physical activity because the student may show low physical activity at school , but higher physical activity outside the school to prevent being evaluated by their teacher or their peers.

However, this study has several limitations. (1) Sample size was small; (2) sampling technique may cause bias in the result; (3) participant may be ashamed to report actual body weight and height; (4) researcher may explain the questionnaire differently, causing any bias.

CONCLUSION There is difference in environmental factors of physical activity in overweight-obese student compared with non overweight-obese student.

Hopefully, this study can be references for larger and comprehensive study in the future. Moreover, further result can be used to make school-based intervention program of obesity in the future.

3. Musaiger AO, Al-Kandari FI, Al-Mannai M, Al-Faraj AM, Bouriki FA, Shehab FS, et al. Perceived barriers to weight maintenance among university students in Kuwait: The role of gender and obesity. Environ Health Prev Med. 2014;19(3):207–14.

4. Centers for Disease Control and Prevention. Growth Charts - Clinical Growth Charts [Internet]. 2017 [cited 2018 Oct 23]. Available from: https://www.cdc.gov/growthcharts/clinical_charts.htm 5. Maïano C, Lepage G, Aimé A, Bayard C, Dansereau-Trahan É, Granger L, et al. Perceived weight-related victimization and physical activity outcomes among adolescents with overweight and obesity: Indirect role of perceived physical abilities and fear of enacted stigma. Psychol Sport Exerc. 2018;34:70–8.

THE EFFECTIVENESS OF LOW-CARBOHYDRATE KETOGENIC DIET TO IMPROVE GLYCEMIA IN DIABETES MELLITUS TYPE 2 PATIENT: A SYSTEMATIC LITERATURE REVIEW OF PROSPECTIVE STUDIES

ABSTRACT Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. In 2014, 8.5% of adults aged 18 years and older had diabetes. In 2017, there are 425 million people with Diabetes Mellites Type 2 (T2DM) and it was predicted that the cases will increase to 629 million by 2045. WHO predicted that there will be an increase number of cases for Diabetes in Indonesia, from 8.4 Million from 2000 to about 21.3 Million by 2030. A systematic litterature review was conducted to get a suitable journal for this scientific poster . We used several database of medical litterature such as ; NCBI, PubMed, and Google Scholar was condcted. Inclusion and exclusion criteria were included to get the suitable journal and litterature. Form these studies we got the average age of respondents ranged between ± 63 years with a BMI value > ± 33 kg/m2.I t was said that there was a significant decrease in HbA1c (p = 0.03) from 7.8% to 7%, with an average age of 63 years and a BMI of 27 kg/m2. The effectiveness of the LCD method is also able to reduce glucose levels in the blood by 28 mg/dL (Baseline ± 136.9 mg / dL) with intervention for 4 months. The result of the studies showed there was significance decrease in rate from the results we obtained. We can conclude that the LCD method is not only able to reduce blood sugar levels, but can reduce body fat levels which can have an impact on weight loss.

Key Word : Low carbohydtare ketigenic diet, diabetes type II, obesity

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Don’t Quit, Just Switch : Senam Diabetes as an Alternative Exercise for Diabetic Foot Ulcer Patient Cindy Jilbert, Fellicia Naurah Andryas, Veriantara Satya Dhika, Alanis Maryjane Mamahit Faculty of Medicine Universitas Pembangunan Nasional “Veteran” Jakarta

Abstract Indonesia’s demographic shift results in an epidemiologic transition, which non communicable diseases (NCDs) are increasing importantly. NCD is a condition does not result from an infectious process.

Among the NCDs, diabetes happen the most in Indonesia with a prevalence of approximately ten million individuals. Diabetes mellitus is a metabolic disorder characterized by the presence of hyperglycemia due to defective insulin secretion, defective insulin action or both. Two third people of Indonesians don't recognize that they are diabetic which cause delayed medical therapy. In addition, People are likely to seek medication after the complications have arisen. Diabetes - related complications are responsible for the disease-associated morbidity and mortality, including non-traumatic lower extremity amputation.

Diabetes related complication includes diabetic foot ulcer. This paper is made by reviewing literatures listed in the citations. Subject heading and keywords used consist of type 2 diabetes mellitus, complication, diabetic foot ulcer, and senam diabetes. Article in Indonesian and English are included.

Based on Perkeni, management of diabetic patient contain four pillar, which are education, medical nutrition therapy (diet planning), physical activity, and pharmacological intervention. This paper highlights the physical activity management. Diabetic foot ulcer primary prevention can be done by using socks and comfortable footwear, also by switching exercise. One of the exercises is senam diabetes, an aerobic low impact and rhythmic exercise. People who perform diabetes exercise show lower risk of developing diabetic foot ulcer. Other research shows that mice who did low intensity exercised shows faster wound healing. This paper features Diabetes especially diabetes mellitus type II, its complication, four pillars of diabetes management, and senam diabetes.

Keyword: diabetes mellitus, diabetic foot ulcer, senam diabetes, diabetic exercise.

DON’T QUIT JUST SWITCH : SENAM DIABETES AS AN ALTERNATIVE EXERCISE FOR DIABETIC FOOT ULCER PATIENT

Cindy Jilbert, Fellicia Naurah Andryas, Veriantara Satya Dhika, Alanis Maryjane Mamahit 2nd year medical student, 2nd year medical student, 2nd year medical student, 2nd year medical student

ASIAN MEDICAL STUDENTS’ ASSOCIATION FACULTY OF MEDICINE UNIVERSITAS PEMBANGUNAN NASIONAL “VETERAN” JAKARTA 2018

Introduction Indonesia is the largest archipelago in the world with an estimated total of 17,504 islands, a population of more than 240 million, including numerous ethnic, cultural and linguistic groups which speaks 724 distinct languages and dialects. As the working-age population increases relative to the rest of the population, the country is in the midst of a fundamental demographic shift. This macrochanges result in an epidemiologic transition in which non communicable diseases (NCDs) are increasingly important (World Health Organization, 2017).

According to CDC, NCD is a chronic condition that does not result from an (acute) infectious process and hence are “not communicable” (Department of Health and Human Services Centres for Disease Control and Prevention, 2013). Risk factors for NCDs are increasing, this includes high blood pressure, high cholesterol, overweight and smoking (World Health Organization, 2017). Almost 75% of global deaths occur from these causes (M. & Taylor-Robinson, 2018). NCDs accounted for approximately 476 million disability-adjusted life years (DALYs) while communicable ones are estimated for 240 million DALYs (Bloom, et al., 2015).

One of the NCD that mostly occurred in Indonesia is diabetes with a prevalence of approximately ten million individuals (Bloom, et al., 2015). Diabetes mellitus is a metabolic disorder characterized by the presence of hyperglycemia due to defective insulin secretion, defective insulin action or both (Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, 2013). Two thirds of Indonesians don't recognize that they are diabetic. Thus leading to a delayed reception of health access (World Health Organization South East Asia, 2016). This means that they’re likely to seek medication after complications have arisen.

Diabetes-related complications affect many organ systems and are responsible for the majority of morbidity and mortality associated with the disease, including non traumatic lower extremity amputation. Diabetic foot ulcer cases contributed to more than 50% of the total diabetic foot cases.

The presence of peripheral neuropathy and peripheral vascular disease is considered to be the most significant risk factors for all types of diabetic foot complications (Al-Rubeaan K, 2015). Lower extremity amputation caused by diabetic foot ulcer rates range from 15-30% (Pusat Data & Informasi Perhimpunan Rumah Sakit Seluruh Indonesia, 2011). Fortunately, many of the diabetes-related complications can be prevented or delayed with early detection, aggressive glycemic control, and efforts to minimize the risks of complications (Kasper, 2015).

Outlined Problems Diabetes mellitus is a chronic disease caused by inherited and/or acquired deficiency in production of insulin by the pancreas, or by the ineffectiveness of the insulin produced. Such a deficiency results in increased concentrations of glucose in the blood, which in turn damage many of the body's systems, in particular the blood vessels and nerves (World Health Organization, 2018).

The energies that we use are from glucose, or sugar that is contained by most of the food we eat.

Hormone called insulin produced by an organ that lies near the stomach, the pancreas, which help glucose enter the cells of our bodies. The reason why people refer to diabetes as “sugar” is when the sugars in the blood is build up by diabetes, because the body can’t produce enough insulin or can’t use insulin properly (Centers for Disease Control and Prevention, 2017).

Since 1980, prevalence of diabetes in the adult population globally has nearly doubled, starting from 4.7% to now 8.5% and has risen faster in low- and middle-income countries. 43% of 3.7 million deaths happen before the age of 70 years (World Health Organization, 2016). The 45-64 year age group will dominate the world population in developing countries by 2025 and most people with diabetes will be 65 years or more. This can affect the 45-64 year age group’s productive years (World Health Organization, 2018).

According to Conrad R. Economic Encyclopedia, “Definition of Productive Age is a range of age when people can work for paid employment optimally”. People should work during their productive age for paid employment. Indonesia has a specific range of productive age that is from 18 years-of age until 55 years-of-age (Mihardja, Soetrisno, & Soegondo, 2014).

Type 1 diabetes (also known as insulin-dependent) is a condition where the pancreas is unable to produce insulin which is very crucial for survival. This form evolves most often in children and teenager, but is being increasingly known later in life. Type 2 diabetes (also named non-insulindependent) is caused by the body's inability to acknowledge correctly to the work of insulin, hormone produced by pancreas. Globally, type 2 diabetes is estimated for around 90% of diabetes cases. Adult is being noted as the most frequent age group in diabetes followed by adolescents (World Health Organization, 2018).

The increasing prevalence of type II Diabetes Mellitus comes hand-in-hand with the rising number of its complication, one of them being ulceration which commonly effects the lower extremities. It is then termed diabetic foot when the ulceration comes with or without infection and cause tissue damage. Diabetic foot manifestation could be seen in the form of dermopathy, cellulitis, ulcer, gangrene, and ostemyelitis. Diabetics are 15-40 times more prone to amputation than non-diabetics hence why it is the most common etiology of non-traumatic foot amputation (Adiyanto, 2016).

Management on diabetic foot can be divided into two ways. First is primary prevention which prevent patients from getting a wound. In addition, secondary prevention is a way to reduce the disability from foot wound. These preventions aim to eliminate diabetic symptoms and prevent further complications (Tjokroprawiro & Murtiwi, 2006).

Based on Indonesia Endocrinology Association (Perkeni), management of diabetic patient contains of four pillars. The four pillars are education, medical nutrition therapy (diet planning), physical activity, and pharmacological intervention. Patientâ&#x20AC;&#x2122;s health monitoring from physicians is also important (Pengurus Besar Perkumpulan Endokrinologi Indonesia, 2015). The component of four pillars that we are trying to emphasize in this paper is physical activity (PA) Diabetic foot ulcer primary prevention can be done by using socks, comfortable footwear, and also switching exercises to the low impact ones. Senam Diabetes, which will be referred as diabetic exercise in the following, is one of them. Diabetic exercise is an aerobic low impact and rhythmic exercise that is fun and can be done by all age groups. Diabetes exercise has the concept of heart and lung endurance also isometric muscle training (Tjokroprawiro & Murtiwi, 2006).

By doing PA, individuals can reduce their blood glucose level due to the increase use of glucose by the actively-moving muscles. Based on a research conducted in Indonesia by Sunaryo and Sudiro, 69.4% respondents who did not perform diabetic exercise are in moderate risk of having diabetic foot ulcer while 24.5% from the same group are risk-free. On the other hand, 42.3% respondents who did perform diabetic exercise are in mild risk of having diabetic foot ulcer and 57.7 are risk-free. With a P value of 0.001. This research indicates that thereâ&#x20AC;&#x2122;s a correlation between diabetic exercise in lowering the risk of diabetic foot ulcer. A routine diabetic exercise has significantly generate a better vascularization to the lower extremities and avoid Peripheral Arterial Disease from happening as well as maintain a normal Ankle Brachial Index (Adiyanto, 2016).

In research conducted by Keylock on 2017, mice that exercised in low intensity have presented with faster wound healing than mice that remained sedentary. Wounds healed faster in mice that remained sedentary than those who exercised with high intensity. This indicates that low intensity exercise should be recommended to speed up wound healing process (Keylock, Meserve, & Wolfe, 2018).

Proposed Solution Diabetes Mellitus Type II (DM II) is a very important issue in Indonesia’s health sector and it is very concerning to the future of epidemiological perspective. is one of them. Diabetes Mellitus Type II can be present with other complications such as diabetic foot ulcer. Sedentary behaviour and unhealthy lifestyle contributes to the development of diabetic foot ulcer in people with antecedent diabetes.

Reduced mobility often results in unwillingness and inability to perform regular exercise (high impact exercises e.g. soccer, basketball, etc.).

According to Indonesia Endocrinology Association (2015), management of diabetic patient has four pillars to be implemented including education, diet planning, pharmacological intervention and physical activity or exercise. Diabetic foot ulcer patients are confronted by their obligation to exercise and the anxiety for worsening the ulceration by doing so.

As prospective doctors, we have to be aware of this situation and to be able to raise awareness to the community and to patients with diabetes in particular. To solve this problem, we propose senam diabetes, a low impact exercise, as a solution with an additional campaign slogan: “Don’t Quit, Just Switch”. This slogan encourages diabetic patients to keep exercising by introducing a safer and more practical option. It is a better alternative for them to remain as active as possible while minding their foot condition at the same time.

Conclusion Non Communicable Disease is a chronic conditions that do not result from an (acute) infectious process and hence are “not communicable” (Department of Health and Human Services Centers for Disease Control and Prevention, 2013). With a prevalence of approximately ten million individuals, diabetes is one of the NCDs that mostly occurred in Indonesia. (Bloom, et al., 2015). Diabetes mellitus Type II is a concerning disease in Indonesia and can result in various complications, including diabetic foot ulcer. More than 50% of the total diabetic foot cases is contributed by diabetic foot ulcer. (Al-Rubeaan K, 2015) Based on Indonesia Endocrinology Association (Perkeni), management of diabetic patient contains of four pillars, including education, medical nutrition therapy (diet planning), physical activity, and pharmacological intervention. Patient monitoring can also be an addition to this four pillars (Pengurus Besar Perkumpulan Endokrinologi Indonesia, 2015). Low impact exercise is among the physical activity recommended for diabetic patient, mostly with patient with diabetic foot ulcer complication.

To solve this problem, we propose senam diabetes as a solution with an additional campaign slogan: “Don’t Quit, Just Switch”. This slogan encourages diabetic patients to keep exercising by introducing a safer and more practical option. It is a better alternative for them to remain as active as possible while minding their foot condition at the same time.

Recommendation Persatuan Diabetes Indonesia or Indonesia Diabetic Association and government, especially the ministry of health are needed to determine and standardize diabetic exercise or senam diabetes. Every element in health sector are responsible to raise awareness of the situation and to promote senam diabetes. More research on Diabetes Mellitus and its complications, especially diabetic foot ulcer in Indonesia should be conducted for further studies.

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Pusat Data & Informasi Perhimpunan Rumah Sakit Seluruh Indonesia. (2011, November 21). Deteksi Diabetes dari Kelainan Kaki. Retrieved from Pusat Data & Informasi PERSI: http://www.pdpersi.co.id/content/news.php?mid=5&nid=623&catid=23 Tjokroprawiro, A., & Murtiwi, S. (2006). Terapi Non Farmakologi Pada Diabetes Melitus. In S. Setiati, I. Alwi, A. Sudoyo, M. Simadibrata, & B. Setiyohadi, Buku Ajar Ilmu Penyakit Dalam, Jilid III, Edisi ke - IV (pp. 1852-1856). Jakarta: Interna Publishing.

World Health Organization. (2016). Global Report On Diabetes. Geneva: WHO Library Cataloguingin-Publication Data.

World Health Organization. (2017). The Republic of Indonesia Health System Review. Health Systems in Transition Vol. 7 No.1, pp. 1-328.

World Health Organization. (2018). Diabetes Mellitus. Retrieved from World Health Organization Web Site: http://www.who.int/mediacentre/factsheets/fs138/en/ World Health Organization South East Asia. (2016). Diabetes Facts and Numbers of Indonesian. New Delhi: World Health Organization South East Asia.

IT Integrated Diabetic Mellitus Care Shafira Yasmine Anshari, Abi Prasetya, Ghazi Wira Samahita, Shohifa Dzauqiah Sari Faculty of Medicine, Universitas Sebelas Maret Abstract Diabetes mellitus is a chronic condition that occurs when there are raised levels of glucose in the blood because of inability of pancreas to produce enough insulin hormone or use insulin ineffectively.

Indonesia is currently on the 6th place for the top 10 countries for number of adults with type 2 diabetes (20-79 years) with 10,276,100 total cases. Diabetes mellitus in Indonesia is facing many problems from many level. Epidemiology factor, problems regarding self care, problems regarding the use of alternative medicines, and also barriers to access proper medication. In Indonesia a lot of families (especially lowincome families) could not afford these supplies without government or external help. Under its newly implemented social health insurance (SHI) program, Jaminan Kesehatan Nasional (JKN), Indonesia is planning to implement universal health coverage (UHC). JKN is expected to cover health insurance for the entire population. But, JKN program is facing financial problems. These problems occur because of the premium must be paid by the participant not in accordance with the calculation of experts or not according to the usual actuarial calculation used in programs like this. We recommend an implementation of an IT integrated diabetes care system in the form of a Diabetes HOTLINE and also increase the BPJS Health contribution to the actual premium value.

Key finding: diabetes, hotline, premium

EAST ASIAN MEDICAL STUDENTS’ CONFERENCE 2019 ASIAN MEDICAL STUDENTS’ ASSOCIATION – INDONESIA WHITE PAPER AND VIDEOGRAPHY

IT Integrated Diabetic Mellitus Care by: Abi Prasetya Ghazi Wira Samahita Shohifa Dzauqiah Sari Shafira Yasmine Anshari

AMSA-UNS Batch 2017 AMSA-UNS Batch 2017 AMSA-UNS Batch 2017 AMSA UNS Batch 2017

FACULTY OF MEDICINE SEBELAS MARET UNIVERSITY SURAKARTA

1.

Introduction Diabetes mellitus is a chronic condition that occurs when raised levels of glucose

in the blood causes the inability of pancreas to produce enough insulin hormone or use insulin effectively (Kementerian, 2014). Diabetes mellitus is divided into two main category, diabetes mellitus type 1 and diabetes mellitus type 2. Diabetes mellitus type 1 (insulin-dependent or juvenile/childhood-onset diabetes) occur when pancreas cannot produce enough insulin. Type 1 diabetes does not have a currently known cure and is agreed upon on being caused by a combination of environmental and genetic causes and thus no intervention is known. Diabetes mellitus type 2 (non-insulin-dependent or adultonset diabetes) occur when our body cannot use insulin effectively (Kementerian, 2014).

Diabetes mellitus is also known as â&#x20AC;&#x2DC;Silent Killerâ&#x20AC;&#x2122; because of its symptoms are unrecognizable till further complications are concluded.

In 2017, Approximately 425 million adults (20-79 years) were living with diabetes; by 2045 this will rise to 629 million. Also surprisingly, 1 in 2 (212 million) people with diabetes were undiagnosed (IDF, 2017). Diabetes mellitus in Southeast Asia has shown a significant growth in the number of treated, untreated, and undiagnosed patients with a predicted increase of up to 84% in 2045 (IDF, 2017). Many people with diabetes do not control their lifestyles after being diagnosed and tend to go to doctors only after complications have been identified. Based on data from International Diabetes Federation (2017), Indonesia is currently on the 6th place after China, India, USA, Brazil and Mexico for the top 10 countries for number of adults with type 2 diabetes (20-79 years) with 10,276,100 total cases.

The Ministry of Health in view of the increasing number of Non-Communicable Diseases (NCDs) have made several attempts in creating preventive measures and programmes combating NCDs such as community-based NCD risk factor component from 2001 to 2006. Programs that are successful in improving behavioural NCD risk factors and recently creating an action plan such as GERMAS (Gerakan Masyarakat Hidup Sehat) a community movement for the prevention of NCDs, PROLANIS a program to treat chronic illnesses including diabetes with varying levels of success, PISDPK that aims to reduce smoking among the young, and an increase in health awareness for NCDs. The implementation of JKN-BPJS (Jaminan kerja nasional) a state sponsored insurance program for all layers of society, and an increase in the limitation of cigarette sales and control (WHO, 2017). To combat Diabetes The Indonesian Ministry of Health (Kemenkes) and WHO has set up guidelines that includes changes in diet and lifestyle

especially for the intake of dietary fibres, saturated fatty acids and reducing the intake of free sugars to less than 10% of total energy intake, as well as population based interventions and policy change that are more accessible and inclusive (IDF, 2017).

Although Methods has been put forth in combating NCDs The population is going up a trend of urbanization and a modern lifestyle that tends towards an increase number of the population with NCDs and an obese and overweight population which creates a higher threat of NCDs especially for children in rural regions as data has shown an increase of the number of obese children even across socio-economic groups (Rachmi, Li and Alison Baur, 2017).

2.

Problem Discussed

Socio-economic problems Epidemiology patterns in the country have become increasingly complex in recent decades. In rural and hard to reach areas, The local population still needs to travel in some cases up to several hours or days just to reach their respective local medical centre while often than not basic medication are only provided in higher care centres (Snouffer, 2017) especially with a large geographical disparities do exist especially for Papua and West Papua as having the worst-performing region out of the 34 provinces also with a low level of medical personnel such as general practitioners, dentists, and midwives (Ligita et al., 2018) (World Health Organization, 2017).

The problems regarding self care is well known for patients diagnosed with chronic illnesses. After being diagnosed with diabetes people are often faced with low self esteem, lack of motivation and despair, deep feeling of regret and a general sense of negativeness that also affects family members. Lack of freedom also creates a feeling of loneliness and isolation that create increased tension in individuals. Although families have their own dynamics, it is clear that families play a crucial role in self-care (Park et al., 2018) and suboptimal support towards patients are generally impacted by resource constraints, lack of awareness, and support that is not in line with expectations (Badriah and Sahar, 2018). Other studies concluded that several factors affect the level of self-care done by the patients such as becoming bored of the medication given and low perceived benefit of medication, the pain or unease given by the medication such as Insulin shots that take a toll on the body of chronic diabetes patients, a general sense of giving up and loss of hope that the illness could be cured, being constrained by the the maximum quantity of medication provided by BPJS in drug availability especially for the maximal

allowance of subsidized insulin in Indonesia. There are also problems regarding the use of alternative medicines. and also barriers to access proper medication (Rahem, 2017) (Rahmawati and Bajorek, 2018).

A snapshot in indonesia's diabetic prevention act gives light to problems such as that children are not tested for glucose levels because of the lack of essential supplies provided in local health centres, therefore they are not getting adequate insulin. Their families could not afford these supplies without government or external help, and even with abundant insulin that are covered by BPJS, access to more complex education regarding the use and storage are often not explained well and with the low comprehension and problems regarding self-care of patients, the utilization of essential supplies are poor (Snouffer, 2017).

Indonesia has a major problem in the form of changing patterns of morbidity, the general size and health coverage of an archipelagic nation, the mortality rate, and the level of urban development and changing socio-economic tides all create a specific but intertwined problem for the goal of Universal health coverage. In the last 9 years, indonesia has made advances in increasing health coverage by the creation of social insurance programmes for health, such as the Social Safety Net for Health-care, Askeskin, Jamkesmas and the most recent national health insurance scheme, the Jaminan Kesehatan Nasional (JKN).

Under its newly implemented social health insurance (SHI) program, Jaminan Kesehatan Nasional (JKN), Indonesia is planning to implement universal health coverage (UHC). As the first step, the government of Indonesia in 2011 released The Badan Penyelenggaraan Jaminan Sosial (BPJS) law which defined the implementation and administrative arrangements. The BPJS law in 2014 stipulates that all of the SHI programs be merged under the single-payer insurance administrator (BPJS) to provide uniforms benefits. In 2019, JKN is expected to cover health insurance for the entire population.

Program implementation challenges, JKN is facing financial problems. These problems occur because of the premium must be paid by the participant not in accordance with the calculation of experts or not according to the usual actuarial calculation used in programs like this (see in the table 1.1).

Participant Segment

Actuarial Calculation Government DJSN determination

Deviation

1

2

3

4=3-2

PBI

36,000

23,000

(-13,000)

PBPU a. Class I b. Class II c. Class III

80,000 63,000 53,000

80,000 51,000 25,500

(-12,000) (-27,500)

PPU a. Wage deduction b. Upper wage limit c. Under wage limit

6% 5% 6x PTKP K/1 8.000.000 Regional minimal wages

-1%

Tabel 1.1 (BPJS Kesehatan, 2016) According to Peraturan Presiden Nomor 28 Tahun 2016 (Presidential Regulation Number 28 of 2016) concerning Health Insurance is conveyed in terms of contributions for participants of the Contribution Assistance Recipient (PBI) amounting to Rp23,000 per person per month. While contribution for participants of Non-Wage Recipients (PBPU) is Rp80,000 for class I, Rp51,000 for class II, and Rp25,500 for class III (BPJS Kesehatan, 2016).

On the other hand, the National Social Security Board (DJSN) of the Republic of Indonesia has calculated actuarially, for the amount of contributions in 2016, by issuing a short policy related to the imposition of BPJS Health contributions after mixing between the participants' segments, the amount is IDR 36,000 per person per month for PBI participant contributions, while for class I PBPU participants' contribution is IDR 80,000, class II is IDR 63,000 and class III is IDR 53,000 per person per month (BPJS Kesehatan, 2016). The broad contribution proposal based on actuarial calculations by the DJSN above, is still very relevant to the current conditions. The gap between government

determination and actuarial calculation is the main underlying reason of JKN budget deficit.

3.

Proposed Solution

Diabetes HOTLINE We recommend an implementation of an IT integrated diabetes care system in the form of a Diabetes HOTLINE. The function of this service is to provide basic medical support in the form of a consultation reminder, on demand information that can be accessed by automated voice recordings that can be accessed directly from their own phones, on call access to call centres with qualified and trained diabetic professionals that are trained to provide consultation, Q&Aâ&#x20AC;&#x2122;s and supplementary information that can aid in better diabetes self-care management and better education of diabetes care and prevention.

Diabetes HOTLINE will solve three main issues: 1.

Lack of basic medical coverage for rural areas

2.

Resource restraints of medical personnel and the lack of good treatment utilization

3.

Low levels of self-care awareness

Diabetes HOTLINE would consist of three operational levels. First The government that will be the primary financial and service provider. Budgeting will come from allocations from the national health insurance program JKN-BPJS as a form of direct and immediate action on preventive diabetes care, as well as from non-essential expenses. The second are the health provider such as their local primary care givers that will Integrate and coordinate with the government by providing health professionals and provide professional training for future diabetic health professionals, Integrate multisectorial health workers towards patient care, and to provide a health service that is IT integrated and efficient. The third are NGOs (non-governmental organization) that will develop human resource and to provide care and support to complement government coverage.

Increase of JKN-BPJS premium Currently the solution chosen by the government to overcome the budget deficit is to provide additional funds. This additional fund is obtained from the APBN budget allocation to BPJS, hereinafter referred to as the National Health Insurance Program Reserve Fund. The National Health Insurance Program Reserve Fund is a temporary

solution to overcome BPJS budget deficits. This fund cannot be used as a permanent settlement because the main problem of the budget deficit experienced by BPJS is due to a discrepancy between the premium paid by the actuary count. If the government wants to overcome the budget deficit experienced by this BPJS so as not to continue continuously, then the most solutive step is to increase the BPJS Health contribution to the actual premium value.

4.

Conclusion Diabetes mellitus is a chronic condition that occurs when there are raised

levels of glucose in the blood because of inability of pancreas to produce enough insulin hormone or use insulin ineffectively. Indonesia is currently on the 6th place for the top 10 countries for number of adults with type 2 diabetes (20-79 years) with 10,276,100 total cases. Diabetes mellitus in Indonesia is facing many problems from many level.

Epidemiology factor, in rural and hard to reach areas, the local population still needs to travel in some cases up to several hours or days just to reach their respective local medical centre while often than not basic medication are only provided in higher care centres. The problems regarding self care is well known for patients diagnosed with chronic illnesses. And also problems regarding the use of alternative medicines. and also barriers to access proper medication.

We recommend an implementation of an IT integrated diabetes care system in the form of a Diabetes HOTLINE. The function of this service is to provide basic medical support in the form of a consultation reminder, on demand information that can be accessed by automated voice recordings that can be accessed directly from their own phones, on call access to call centres with qualified and trained diabetic professionals that are trained to provide consultation, Q&Aâ&#x20AC;&#x2122;s and supplementary information that can aid in better diabetes self-care management and better education of diabetes care and prevention.

In Indonesia a lot of families (especially low-income families) could not afford these supplies without government or external help, and even with abundant insulin that are covered by BPJS, access to more complex education regarding the use and storage are often not explained well and with the low comprehension and problems regarding selfcare of patients, the utilization of essential supplies are poor. In other hand, under its newly implemented social health insurance (SHI) program, Jaminan Kesehatan Nasional (JKN), Indonesia is planning to implement universal health coverage (UHC). JKN is

expected to cover health insurance for the entire population. But, JKN program is facing financial problems. These problems occur because of the premium must be paid by the participant not in accordance with the calculation of experts or not according to the usual actuarial calculation used in programs like this.

Currently the solution chosen by the government to overcome the budget deficit is to provide The National Health Insurance Program Reserve Fund. This fund cannot be used as a permanent settlement because the main problem of the budget deficit experienced by BPJS is due to a discrepancy between the premium paid by the actuary count. The gap between government determination and actuarial calculation is the main underlying reason of JKN budget deficit, so the most solutive step is to increase the BPJS Health contribution to the actual premium value.

5.

Recommendation The collaboration between government, BPJS, health workers is needed to define

the policies and procedure. Obedience and awareness of health-worker and society is the key to succeed this program.

6.

References

Kementerian Kesehatan Republik Indonesia. (2014). Situasi dan Analisis Diabetes Melitus. Pusat Data dan Informasi Kementerian Kesehatan Republik Indonesia, 16.

Retrieved

October

20th,

2018

from

http://www.depkes.go.id/download.php?file=download/pusdatin/infodatin/ infodatin-diabetes.pdf International Diabetes Federation. (2017). Diabetes Atlas Eighth Edition. IDF Rachmi, C. N., Li, M. and Alison Baur, L. (2017) ‘Overweight and obesity in Indonesia: prevalence and risk factors—a literature review’, Public Health, 147, pp. 20–29. doi: 10.1016/j.puhe.2017.02.002.

Mboi, N. et al. (2018) ‘On the road to universal health care in Indonesia, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016’, The Lancet. The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license, 392(10147), pp. 581–591. doi: 10.1016/S0140-6736(18)30595-6.

World Health Organization (2017) State of health inequality: Indonesia, STATE OF HEALTH

INEQUALITY

Indonesia.

Available

apps.who.int/iris/bitstream/10665/259685/1/9789241513340-eng.pdf - 2560k.

at:

Snouffer, E. (2017) ‘Indonesia snapshot : access to diabetes care in Bali’, 63(2), pp. 22– 23.

Roemling, C. and Qaim, M. (2012) ‘Obesity trends and determinants in Indonesia’, Appetite. Elsevier Ltd, 58(3), pp. 1005–1013. doi: 10.1016/j.appet.2012.02.053.

Asia Pacific Observatory on Health Systems and Policies (2017) The Republic of Indonesia Health System Review, Health Systems in Transition. doi: Ligita, T. et al. (2018) ‘The profile of diabetes healthcare professionals in Indonesia: a scoping review’, International Nursing Review, 65(3), pp. 349–360. doi: 10.1111/inr.12418.

Rahem, A. 2017, ‘Factors Affecting Medication Noncompliance In Patients With Chronic Diseases’. UNITY IN DIVERSITY AND THE STANDARDISATION OF CLINICAL PHARMACY: Proceedings of the 17th Asian Conference on Clinical Pharmacy (ACCP 2017), July 28-30, 2017, Yogyakarta, Indonesia Rahmawati, R. and Bajorek, B. (2018) ‘Understanding untreated hypertension from patients’ point of view: A qualitative study in rural Yogyakarta province, Indonesia’, Chronic Illness, 14(3), pp. 228–240. doi: 10.1177/1742395317718034.

Badriah, S. and Sahar, J. (2018) ‘Family support in caring for older people with diabetes mellitus: a phenomenology study’, Enfermeria Clinica. Elsevier, 28, pp. 245–249. doi: 10.1016/S1130-8621(18)30077-9.

Park, M. et al. (2018) ‘Patient- and family-centered care interventions for improving the quality of health care: A review of systematic reviews’, International Journal of Nursing Studies. Elsevier, 87(July), pp. 69–83. doi: 10.1016/j.ijnurstu.2018.07.006.

Tandon, Ajay; Pambudi, Eko Setyo; Harimurti, Pandu; Masaki, Emiko; Subandoro, Ali Winoto; Yasmin Chrysanti, Puti; Rajan, Vikram Sundara; Dorkin, Darren W.; Chandra, Amit; Boudreaux, Chantelle; Pei Lyn, Melissa Chew; Suharno, Nugroho.

2016. Indonesia - Health financing system assessment : spend more, right, and better (English). Washington, D.C. : World Bank Group BPJS Kesehatan (2016) ‘Ringkasan Eksekutif Laporan Pengelolaan Program Dan Laporan Keuangan Jaminan Sosial Kesehatan Tahun 2016’, pp. 1–20.

GOVERNMENT INTERFERENCE IN TACKLING DIABETES IN INDONESIA Ricko Eliafiana Gracia Natalia Theresia Ita Tazkiatul Izzati Mustopa Juan Stuart Xaverius Johanes AMSA-Universitas Trisakti

ABSTRACT Diabetes nelitus is a disease that results in an imbalance in the body's ability to use glucose efficiently which is caused by the pancreas failing to produce insulin or a body misfunction that cannot use insulin properly. Diabetes mellitus is a chronic disease that its prevalence continues to increase every year.

Based on data from the Ministry of Health the prevalence rate of diabetes in Indonesia in 2008 reached 5.7% of the total population of Indonesia or around 12 million people. Through this Various ways have been carried out by the Ministry of Health, namely monitoring and early detection of risk factors for diabetes in Posbindu (Pos Pembinaan Terpadu) PTM (Integrated Coordination Post of Noncommunicable disease) and the implementation of CERDIK & PATUH behavior.

Keywords: Diabetes mellitus, Posbindu PTM, CERDIK, PATUH

GOVERNMENT INTERFERENCE IN TACKLING DIABETES IN INDONESIA Ricko Eliafiana Gracia Natalia Theresia Ita Tazkiatul Izzati Mustopa Juan Stuart Xaverius Johanes AMSA-Universitas Trisakti

INTRODUCTION Non-communicable diseases (NCD) such as heart disease, cancer, chronic lung, and diabetes mellitus (DM) are still the most common cause of death in Indonesia. This situation is a burden in health services and development in Indonesia. DM is a serious threat to health development because it can cause blindness, kidney failure, foot diabetic (gangrene) so it must be amputated, heart disease and stroke.

This is clearly frightening for the Indonesian people in general.

DM is a disease that results in an imbalance in the body's ability to use glucose efficiently which is caused by the pancreas failing to produce insulin or a body misfunction that cannot use insulin properly.

Diabetes mellitus is a chronic disease that its prevalence continues to increase every year.(D&apos;Adamo & Caprio, 2011) OUTLINED PROBLEMS The number of people with Diabetes Mellitus in Indonesia in 2000 reached 8.43 million people and is estimated to reach 21.257 million people by 2030, even today the prevalence of DM in Indonesia ranks fourth in the world after India, China, and the United States. WHO estimates that around 4 million people die each year due to DM complications. Based on data from the Ministry of Health the prevalence rate of diabetes in Indonesia in 2008 reached 5.7% of the total population of Indonesia or around 12 million people.(Kementrian Kesehatan RI, 2014) SOLUTION Various ways have been carried out by the Ministry of Health, DM control activities carried out by the Ministry of Health, namely monitoring and early detection of risk factors for DM in Posbindu (Pos Pembinaan Terpadu) PTM or Integrated Coordination Post of Non-communicable disease and the implementation of CERDIK & PATUH behavior.

Posbindu PTM is an activity of community participation in controlling DM risk factors independently and sustainably. Currently there are 7,225 Posbindu throughout Indonesia. Posbindu PTM can be found in public facilities, such as in household groups, schools, workplaces, and other public places. The

activities carried out in Posbindu PTM are early detection and counseling through monitoring of risk factors for non-communicable diseases integrated regularly and periodically. The monitoring carried out were: anthropometric measurements, blood pressure measurements, blood sugar and cholesterol measurements, health counseling (diet, smoking, stress, physical activity).

The PATUH program is P: Periksa kesehatan secara rutin dan ikuti anjuran dokter (Check health regularly and follow doctor's advice) A: Atasi penyakit dengan pengobatan yang tepat dan teratur (Overcome the disease with proper and regular treatment) T: Tetap diet sehat dengan gizi seimbang (Keep a healthy diet with balanced nutrition) U: Upayakan beraktivitas fisik dengan aman (Try physical activity safely) H: Hindari rokok, alcohol, dan zat karsinogenik lainnya (Avoid cigarettes, alcohol, and other carcinogenic substances) CERDIK program, the message of improving healthy lifestyles delivered in the school environment is C: Cek kondisi kesehatan secara berkala (Check health conditions regularly) E: Enyahkan asap rokok (Get rid of cigarette smoke) R: Rajin aktivitas fisik (Improve physical activity) D: Diet sehat dengan kalori seimbang (Healthy diet with balanced calories) I: Istirahat yang cukup (Get enough rest) K: Kendalikan stress (Take control of stress) The next step is to educate through media. The Ministry of Health has also produced 13 book titles about DM including guidelines, standards, technical guidelines and pocket books including Communication, Information, and Education media. In addition, there has also been an increase in human resources capacity for 612 doctors in health facility to improve their ability to control NCD including controlling DM throughout Indonesia.(Association of Indonesian Endocrinology, 2011) CONCLUSION The burden of diabetes is very large especially when complications have occurred. The effort to control diabetes is a very important goal in controlling the effects of complications that cause a heavy burden for both individuals and families as well as the government. Therefore, the government participated in making several programs that were periodic and also accessible to all levels of society such as the

Posbindu PTM program, PATUH and CERDIK behavior, and the government also issued several guidelines that could be used by doctors in health facility.

RECOMMENDATION Suggestions that can be submitted to parties related to the problem of diabetes mellitus in the community are: Public health office (Dinas Kesehatan) to: 1) improve the Posbindu PTM service program by integrating the management of health monitoring and control of people with diabetes mellitus with CERDIK program to improve knowledge, skills and behavior to maintain effective health.

2) Establish a budget for supervision and periodic monitoring of the implementation of Posbindu PTM activities and support groups in health monitoring.

3) Increased budget for the procurement of health examination facilities at the Posbindu level.

4) Empower existing Human Resources, through training on monitoring and evaluation skills regularly for supervision and performance evaluation of program holders and cadre performance in Posbindu activities Health facility nurses to be able to: 1) Improve the ability to develop efforts to manage diabetes mellitus health problems through CERDIK interventions by supervising the ability of trained cadres, government and environmental resources in community and family.(Hastuti & Sahar, 2017) REFERENCE Association of Indonesian Endocrinology. (2011). Consensus of Management and Prevention of Diabetes Melitus Type 2 in Indonesia (in Indonesian). Perkeni, 1. https://doi.org/10.1017/CBO9781107415324.004 D&apos;Adamo, E., & Caprio, S. (2011). Type 2 diabetes in youth: Epidemiology and pathophysiology. Diabetes Care, 34(SUPPL. 2). https://doi.org/10.2337/dc11-s212 Hastuti, H., & Sahar, J. (2017). TERHADAP PENGENDALIAN DIABETES MELLITUS PADA, 4(2), 142â&#x20AC;&#x201C;147.

Kementrian Kesehatan RI. (2014). InfoDATIN: Situasi dan Analisi Diabetes. https://doi.org/24427659

APPENDIX

Introduction to Healthy Lifestyle for Diabetes Prevention by “Go End Diabetes” Univeristas Gadjah Mada Herdifitrianne Saintissa Yanuaristi, Gabriella Eva Victoria Agustina Pangaribuan, Daniel, Deas Makalingga Emiri

Background and Objective Unhealthy lifestyle is a major underlying cause of high prevalence of diabetes, mainly type 2, in Indonesia. This leads to high government’s expenditure for diabetes management, that could actually be prevented by implementing a healthy lifestyle. This white paper aims to introduce healthy lifestyle by means of the tagline “Go End Diabetes” as an abbreviation for ‘Ginseng on every hand, Exercise, Nice sleep, Diet control to prevent Diabetes’ to improve society’s awareness on diabetes prevention.

Research Methodology We conducted a comprehensive literature review from a total 20 journals retrieved from PubMed and Clinical Key along with data from Kementrian Kesehatan Republik Indonesia (Indonesian Ministry of Health), World Health Organization, American Diabetes Association, and BPJS Kesehatan (Badan Penyelenggara Jaminan Sosial Kesehatan) or the Indonesian National Health Insurance without date or language restrictions, using the following search terms: ‘Ginseng; ‘Diabetes’; ‘Sleep effects on diabetes’, ‘Diet intake on Diabetes’, ‘Exercise effects on diabetes’ and ‘Government expenditure’. The reference lists of identified articles were searched for additional relevant reports. Studies presenting evidence on prevalence, incidence, mortality, costs, treatment, and outcomes were included in the analysis.

Key findings Our study found that healthy lifestyle including sufficient amount of sleep, controlled diet, and routine exercise play a significant role in diabetes prevention. Studies of ginseng consumption also shown a positive antidiabetic result and might reduce weight that leads to obesity. Both two findings are the main considerations to publicly promote it to prevent diabetes, as we hope that it will prevent the rise of diabetes prevalence and reduce the government expenditure on the diabetes management processes.

Introduction to Healthy Lifestyle for Diabetes Prevention by â&#x20AC;&#x153;Go End Diabetesâ&#x20AC;?

Herdifitrianne Saintissa Yanuaristi, Gabriella Eva Victoria Agustina Pangaribuan, Daniel, Deas Makalingga Emiri

AMSA-Universitas Gadjah Mada Indonesia

A. Introduction Current Status With the rapidly increasing number of people suffering from the disease, diabetes mellitus persists to be one of the main concerns in the world. The disease jeopardizes both developing and developed countries with no exception, with the total of 422 million patients around the world in 2014 according to World Health Organization (“Diabetes”, 2018). Dr. Hilary King of the WHO before 1999 predicts that this figure will rise to 300 million by the year 2025, and more than 150 million will be in Asia (Soewondo, Ferrario & Tahapary, 2013). Diabetes also becomes a threat to Indonesia, a home to 255.1 million people, with 7% of diabetes patients or 17.85 million people in number (“Diabetes”, 2018).

This high diabetes prevalence impacts are seen in the continuous deficit of Indonesian National Health Insurance (BPJS Kesehatan), which by the end of 2017 reached an annual rate of 16.62 trillion rupiah or equivalent to 1.1 billion USD. This condition is also exacerbated by the economic losses caused by obesity, which includes the health care costs (56.5 trillion rupiah or 3.72 billion USD), early loss of productivity, and short life expectancy (“Problem Kesehatan dan Defisit BPJS”, 2018).

Context Diabetes, by definition, is a chronic disease that occurs either when the pancreas does not produce enough insulin (type 1 diabetes) or when the body cannot effectively use the insulin it produces (type 2 diabetes). Insulin itself is a hormone that regulates blood sugar, that transport glucose from the bloodstream into the cells of the body. The majority of people with diabetes live with type 2 diabetes, while the minority (<5%) have type 1 diabetes ("Type 1 Diabetes", 2018).

The common effect of uncontrolled diabetes is hyperglycemia, or raised blood sugar. In a long run, this condition might give rise to serious damage to many of the body's systems, especially the nerves and blood vessels. In 2015, diabetes was the direct cause of 1.6 million deaths and in 2012 high blood glucose was the cause of another 2.2 million deaths worldwide (“Diabetes”, 2018).

B. Key Objectives & Solution This white paper highlights the importance of healthy lifestyle on preventing diabetes. By means of the tagline “Go End Diabetes” or short for “Ginseng on every hand, Exercise, Nice sleep, Diet control to prevent Diabetes”, we propose a new way for government in achieving

the goal of reducing diabetes prevalence by diabetes prevention. The main objective aimed to achieve in this white paper is: Improving society’s awareness on diabetes prevention.

Objective: Improving society’s awareness on diabetes prevention •

Socializing a program promoting healthy lifestyle to prevent diabetes

Problem World Health Organization on 2016 published the data showing the percentage of risk factors contributing to diabetes prevalence in Indonesia, with 24,4% for overweight, 5,7% for obesity, and 22,8% for physical inactivity (“Diabetes”, 2018). Unhealthy lifestyle, including bad sleep pattern, poor decision in choosing what to consume, and minimum physical activity said to be the underlying cause resulting all risk factors mentioned before.

1. Sleep pattern It’s been a common phenomenon that the more we age, the more sleep time we sacrifice as consequence for the increasing workload. This is a phenomenon we can’t deny yet highly regretful understanding it means we lose numerous amount of time needed for body metabolism. Research shown that duration of sleeping affects the capability of insulin secretion and its sensitivity. Nice sleep duration must not be too short or too long.

Based on the research population with range of age 2.5 – 16 years old, the appropriate duration of sleeping is about 6 - 8 hours with optimal result in around 8 hours (Shan et al., 2018). This duration of sleeping is important to give time for some phases of sleep that give a significant effect on insulin. These phases are stage 1 (N2), a brief transition between wake and sleep; stage 2 (N2); stage 3 (N3), “slow-wave” or “deep” sleep; and rapid eye movement (REM) or “dreamy” sleep. During the N3, there is an increase of parasympathetic nerve activity that results in glucose-induced insulin secretion (Jennum et al., 2018). Growth Hormone (GH) is also produced during this phase of sleep. GH has its effect against insulin, which increases insulin resistance that may cause hyperglycemic condition, a condition where blood sugar level is higher than the normal range (See Appendix B) (Jennum et al., 2018).

In conclusion, too short duration of sleep may cause less insulin secretion and in the other side, too long duration of sleep may cause too much GH secretion that causes insulin resistance. This continuous condition might cause hyperglycemia and trigger the diabetic

condition. Therefore, a balance concentration of GH and insulin is needed to maintain blood sugar level, a condition that could be achieved by enough time of sleep.

2. Dietary consume including coffee consumption •

Mediterranean Diet Diet plays a significant role in diabetes (mainly type 2) condition. Body necessity on macronutrients such as carbohydrate, protein, and lipid must be fulfilled, but it needs to be controlled carefully. In the case of obesity where there is excess of body lipid deposition reserved by adipocytes caused by high lipid consumption and high number of adipocytes. Prolonged condition may lead to insulin resistance to maintain body hemostasis of glucose in the body.

We propose the broad introduction of Mediterranian Diet, a model of diet to prevent diabetes progression. It is best proven type of diet, mostly for patient with type 2 diabetes (Georgoulis, Kontogianni & Yiannakouris, 2014). The implementation of Mediterranean Diet is proven for a greater improvement of glycemic control [HbA1c reductions of −0.12% (p = 0.04), −0.14% (p = 0.008), −0.28% (p < 0.001) and −0.41% (p < 0.001)] (Georgoulis, Kontogianni & Yiannakouris, 2014). HbA1c, or Hemoglobin A1c is a form of hemoglobin that is bound to glucose. The high level of HbA1c may show the high blood sugar. The reduction of this hormone, in contrast, show a low level of blood sugar.

The main goal of this diet is to improve glycemic control resulting in better management of diabetic progression. The key points of this diet are: - consuming more starchy foods such as rice, bread, and pasta - consuming more vegetables and fruit - displacing meat consumption to fish to reduce lipid - choosing products made from vegetable and plant oils, such as olive oil or coconut oil

•

Coffee Consumption Coffee becomes a regular beverage in daily basis for people in Indonesia, with the consumption number estimation of 1.2 kilograms a year by the data of Ministry of Industry in 2015.

Coffee consumption is believed to give some impacts on insulin sensitivity. It contains caffeine that increases catecholamines, plasma FFAs, and systolic/diastolic blood

pressure. Epinephrine, as part of catecholamine, affects the metabolism of glucose by promoting hepatic glucose production and inhibiting glucose uptake in muscles and fats that results in high blood glucose. Caffeine acts on adenosine receptor as antagonist, while adenosine itself increases insulin-mediated glucose metabolism.

Intervention by caffeine in adenosine receptor will decrease the metabolism of glucose in body cell. All of this will result in hyperglycemia, as glucose isn’t processed by body cell and ends up in the blood. Consuming 6 cups of coffee each day are said to give a high relative risk of diabetes type 2 (See Appendix A) (Ding, Bhupathiraju, Chen, van Dam & Hu, 2018). In coclusion, reducing coffee consumption will maintain blood sugar level, so it may prevent the progression of diabetes type 2.

3. Physical activity As lifestyle changes in line with technology development, we utilize our muscle less to work, and this condition negatively impacts on body health. We highlight the importance of exercise as it is proven to increase insulin action to our body. The effective exercise is one with low volume (power force that released by each cycle of exercise) but moderate intensity (quality of stimulus that given during the exercise), as it may increase insulin sensitivity. This means a kind of exercise that doesn’t give powerful force but done frequently. We recommend jogging or walking for a particular time or distance as it can initiate aerobic energy using in our body (Colberg et al., 2018). This type of exercise increases the insulin sensitivity in 16 – 24 hours after the exercise even within 15 days after the exercise. The graphic (see Appendix C) shown by jogging for about 60 minutes. For maximum result, we need to do jogging for about 3 times a week. Walking for minimum 60 minutes each day may also results the same as jogging for 60 minutes 3 times a week (Bajpeyi et al., 2009).

Solution To increase the awareness to healthy lifestyle as major component of preventing diabetes, we propose a program called “Go End Diabetes”. The word “End” in the sentence mainly focuses in three points of healthy lifestyle, that are; 1. Exercise, 2. Nice sleep, 3. Diet control. The tagline is to be promoted in the form of video or posters containing the main idea of those three points stated in “End”. It will then be promoted as national program under cooperation with Kementerian Kesehatan Republik Indonesia (Indonesian Republic Health Ministry) and should be promoted massively with numerous emergence on TV, installation on billboard, as well as printed on leaflets and pamphlets available on every primary healthcare services. Looking back to 2011 where the government’s 3M tagline “Menguras, Menutup, and Mengubur” or “Drain, Close, and Bury” that were massively

promoted by the Ministry as a way to reduce the Dengue Fever prevalence successfully shown significant outcome (Prasetyo Utomo, Ningsih & EBS, 2017), we believe that such massive promotion is effective to raise society’s awareness on specific matter. We hope that this tagline will educate the society regarding importance of healthy lifestyle mainly highlighting on physical activity, sufficient time of sleep, and diet control including coffee consumption control which will lead to the prevention of diabetes.

•

Introducing the benefit of ginseng consumption to prevent diabetes

Problem In 2014, three NCD categories—cardiovascular diseases, diabetes and its complications, and respiratory diseases—accounted for nearly 50 percent of deaths in Indonesia ("Tackling Indonesia’s diabetes challenge: Eight approaches from around the world", 2018). These three NCDs will cost Indonesia an estimated $2.8 trillion from 2012 to 2030 (three times Indonesia’s GDP in 2014, and nearly 107 times Indonesia’s total health spending in 2014), according to the World Economic Forum. Along with the healthy lifestyle enforcement by the society and diabetes management processes by the government, there’s a need for healthcare practitioners with academicians to find alternative for diabetes prevention that costs less with outstanding outcome.

Solution We propose a way of treating diabetes in a more affordable way. We would like to persuade the government to make a policy that obligated all primary health care facilities in high diabetes prevalence area to cultivate ginseng and socialize its benefit against diabetes.

Ginseng is a root plant from the genus Panax that is made famous by its use in Korea.

Recent studies show that ginseng does more than just increasing vitality and strength.

One of the substance found in ginseng is called ginsenoside, which is found to have cardioprotective effect (Lee & Kim, 2014), neuroprotective (Zheng et al., 2018), and even anti-diabetic (Song et al., 2015)(Luo & Luo, 2009) (Attele et al., 2002). In this study, we are mainly observing the effect of Ginsenoside Re that is found mainly on the berries.

Ginseng and its chemical content, is proven to increase insulin sensitivity and b-cell proliferation which is crucial for patient with type II diabetes (Vuksan et al., 2008) (Lee et al., 2011) (Abdelazim et al., 2018) In laboratory test done with obese mice (Attele et al., 2002), it is found that ginseng treatment progressively reduced the blood glucose level of the obese mice.

By far, researches only check the short-term effect (single dose) of the ginseng while for treating type 2 diabetes, it is more important to maintain low glucose in the long term.

Recently, it is proven that the use of ginseng (especially ginsenoside Re) can also lower the glucose levels progressively. The glucose level begins to fall on day 5, and returns normoglycemic on day 12. It also explained that this ginsenoside Re could be used to lower weight where there is a significant lowering weight of the mice in day 12 (See Appendix D). The weight of the control group (scrawny mouse, without the treatment of ginsenoside) tends to rise, but when given the ginseng treatment, the weight increase stops. This is apparently because ginseng itself stimulates transport glucose to the muscles, not stacked on the body or transformed into fat (Attele et al., 2002). Chung et al, recently showed that the antidiabetic effect of ginseng root could also be attributed to blocking intestinal glucose absorption and inhibiting hepatic glucose-6-phosphatase activity.

The giving of ginseng might lower the glucose level in type 2 diabetes where there is insulin resistance that leads to hyperinsulinemia as a way to compensate the resistance itself. With the lowering of glucose level, it will in turn lower the insulin amount of the body and increase the insulin sensitivity.

With those benefits in mind, it is important to introduce the use of ginseng to publicly.

Moreover, ginseng is easily cultivated and grown especially in humid countries in Asia such as Indonesia, takes only a month or so to harvest. Ginseng berries, are found to have higher content of ginsenoside and are more sustainable in a long run. By implementing ginseng farm in primary health care facilities in high risk area, we believe that this may help reduce the number of people with diabetes, and thus could cut the cost of treating diabetes.

C. Conclusion The high diabetes prevalence in Indonesia leads to the high expenditure of government in diabetes management. To help reduce the cost, the diabetes prevention program is highly needed. Societyâ&#x20AC;&#x2122;s awareness on healthy lifestyle plays a big role in diabetes prevention, which later leads to the reduction of diabetes prevalence.

D. Recommendation We propose the tagline â&#x20AC;&#x153;Go End Diabetesâ&#x20AC;? as a national tagline promoting healthy lifestyle that later will be massively installed in public spaces and the ginseng cultivation in every public health care facilities as a program to introduce a cost-less healthy lifestyle to prevent diabetes

prevalence in Indonesia. The use of tagline will ease the society in realizing how easy it is to prevent diabetes and implementing the program.

E. References 1. Abdelazim, A., Khater, S., Ali, H., Shalaby, S., Afifi, M., & Saddick, S. et al. (2018). Panax ginseng improves glucose metabolism in streptozotocin-induced diabetic rats through 5′ adenosine monophosphate kinase up-regulation. Saudi Journal Of Biological Sciences. doi: 10.1016/j.sjbs.2018.06.001 2. Attele, A., Zhou, Y., Xie, J., Wu, J., Zhang, L., & Dey, L. et al. (2002). Antidiabetic Effects of

Panax

ginseng

Berry

Extract

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the

Identification

of

an

Effective

Component. Diabetes, 51(6), 1851-1858. doi: 10.2337/diabetes.51.6.1851 3. Bajpeyi, S., Tanner, C., Slentz, C., Duscha, B., McCartney, J., & Hickner, R. et al. (2009).

Effect of exercise intensity and volume on persistence of insulin sensitivity during training cessation. Journal

Of

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Physiology, 106(4),

1079-1085.

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10.1152/japplphysiol.91262.2008 4. Colberg, S., Sigal, R., Yardley, J., Riddell, M., Dunstan, D., & Dempsey, P. et al. (2018).

Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association.

5. Diabetes.

(2018).

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sheets/detail/diabetes 6. Ding, M., Bhupathiraju, S., Chen, M., van Dam, R., & Hu, F. (2018). Caffeinated and Decaffeinated Coffee Consumption and Risk of Type 2 Diabetes: A Systematic Review and a Dose-Response Meta-analysis.

7. Georgoulis, M., Kontogianni, M., & Yiannakouris, N. (2014). Mediterranean Diet and Diabetes: Prevention and Treatment. Nutrients, 6(4), 1406-1423. doi: 10.3390/nu6041406 8. Jennum, P., Stender-Petersen, K., Rabøl, R., Jørgensen, N., Chu, P., & Madsbad, S. (2018).

The Impact of Nocturnal Hypoglycemia on Sleep in Subjects With Type 2 Diabetes.

9. Lee, C., & Kim, J. (2014). A review on the medicinal potentials of ginseng and ginsenosides on cardiovascular diseases. Journal Of Ginseng Research, 38(3), 161-166. doi: 10.1016/j.jgr.2014.03.001 10. Lee, S., Lee, H., Lee, Y., Lee, B., Cha, B., & Kang, E. et al. (2011). Korean Red Ginseng (Panax ginseng) Improves Insulin Sensitivity in High Fat Fed Sprague-Dawley Rats. Phytotherapy Research, 26(1), 142-147. doi: 10.1002/ptr.3610 11. Luo, J., & Luo, L. (2009). Ginseng on Hyperglycemia: Effects and Mechanisms. EvidenceBased

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423-427.

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12. Prasetyo Utomo, A., Ningsih, S., & EBS, F. (2017). EFEKTIFITAS PELAKSANAAN 3M (MENGURAS,

MENUTUP,

DAN

MENGUBUR)

UNTUK

MENURUNKAN

KEJADIAN DEMAM BERDARAH DENGUE (DBD) DI KOTA BLITAR PADA PERIODE 2010-2011. Saintika Medika, 9(2), 82. doi: 10.22219/sm.v9i2.4134 13. Problem

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http://m.mediaindonesia.com/read/detail/187023-problem-kesehatan-dan-defisit-bpjs 14. Shan, Z., Ma, H., Xie, M., Yan, P., Guo, Y., & Bao, W. et al. (2018). Sleep Duration and Risk of Type 2 Diabetes: A Meta-analysis of Prospective Studies.

15. Soewondo, P., Ferrario, A., & Tahapary, D. (2013). Challenges in diabetes management in Indonesia: a literature review. Globalization And Health, 9(1), 63. doi: 10.1186/1744-86039-63 16. Song, B., Ding, L., Zhang, H., Chu, Y., Chang, Z., Yu, Y., . . . Liu, X. (2017). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5375997/ 17. Type 1 Diabetes. (2018). Retrieved from http://www.diabetes.org/diabetes-basics/type1/?loc=db-slabnav 18. Vuksan, V., Sung, M., Sievenpiper, J., Stavro, P., Jenkins, A., & Di Buono, M. et al. (2008).

Korean red ginseng (Panax ginseng) improves glucose and insulin regulation in wellcontrolled, type 2 diabetes: Results of a randomized, double-blind, placebo-controlled study of efficacy and safety. Nutrition, Metabolism And Cardiovascular Diseases, 18(1), 46-56. doi: 10.1016/j.numecd.2006.04.003 19. Zheng, M., Xin, Y., Li, Y., Xu, F., Xi, X., & Guo, H. et al. (2018). Ginsenosides: A Potential Neuroprotective Agent. Biomed Research International, 2018, 1-11. doi: 10.1155/2018/8174345 F. Appendix

A

B

C

D

Scroll Past Diabetes Kristyo Perdana, Lidya Renaningtyas Setia Budi, Daisy Deriena AMSA Universitas Hang Tuah

ABSTRACT Background Access to information and communication technology is growing in all regions of the world. The potential to use mobile phones for public health information is enormous.

Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin produced. In 2015, diabetes was the direct cause of 1.6 million deaths and in 2012, high blood glucose was the cause of another 2.2 million deaths. Both diabetes type 2 and gestational diabetes can be prevented. By using social media, we can spread the information faster and wider to prevent diabetes.

Social media use has been increasing in public health and health promotion because it can remove geographical and physical access barriers. We distinguish four roles of media: media as an educator, media as a supporter, media as a program promoter, and media as a supplement.

Methods This descriptive research uses content analysis design and conducted in October 2018. This white paper was based on articles published in WHO journals other international journals using the keywords. From 35 articles that were filtered, we used 11 articles as our references in this white paper.

Keyword Diabetes, Diabetes Type 2, Gestational Diabetes, Diabetes Prevention, Media, Social Media, Health Promotion.

Scroll Past Diabetes Kristyo Perdana Lidya Renaningtyas Setia Budi Daisy Deriena

AMSA Universitas Hang Tuah

Introduction Recently, people are so engaged with their gadgets. Now gadgets are reputed as our primary need rather than third need as communication devices. There are more than four billion mobile phone subscribers globally and about one in four people globally is using the internet.[4] Access to information and communication technology is developing in all regions of the world.

Social media nowadays has been the space for us to display ourselves. Our life, our passion and our interest has been displayed clearly there. Some people enjoyed writing about things that theyâ&#x20AC;&#x2122;re passionate about, including health. There are also many resources on social media that can really benefit us, and even save lives. Everything is so easy to access but ironically, only a few people are aware enough to use this access. The truth is, the potential to use mobile phones for public health information is immense.[4]

Outlined Problems Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin produced. Insulin is a hormone that regulates blood sugar. Hyperglycemia is a common effect of uncontrolled diabetes and over time will lead to severe damage to many of the body's systems, especially the nerves and blood vessels. It is also a dominant cause of blindness, kidney failure, heart attack, stroke and lower limb amputation.[1] In 2014, 8.5% of adults aged 18 years and older have diabetes. In 2015, diabetes was the straight cause of 1.6 million deaths and in 2012, high blood glucose was the cause of another 2.2 million deaths.[1] There are some types of diabetes, one of them is Diabetes Type 2. Diabetes Type 2 results from the bodyâ&#x20AC;&#x2122;s ineffective use of insulin. Type 2 diabetes comprises the majority of people with diabetes around the world, and is mostly the result of excess body weight and physical inactivity.[1] Simple lifestyle measures have been shown to be potent in preventing or delaying the onset of type 2 diabetes. To help prevent type 2 diabetes and its complications, people should achieve and maintain a healthy body weight; be physically active â&#x20AC;&#x201C; at least 30 minutes of activity on most days. More activity is required for weight control; eat a healthy diet, avoid sugar and saturated fats intake; and avoid tobacco use because smoking increases the risk of diabetes.[1]

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Another type of Diabetes is Gestational Diabetes which is a type of hyperglycemia with blood glucose values above normal but below those diagnostic of diabetes and occurs during pregnancy. Women with gestational diabetes are at an increased risk of complications during pregnancy and at delivery. They and their children are also at increased risk of type 2 diabetes in the future. Gestational diabetes is diagnosed through prenatal screening, rather than through reported symptoms.[1] Almost half of women who died in low-income countries due to high blood glucose died prematurely, before the age of 70 years.[3] In conclusion, both diabetes type 2 and gestational diabetes can be treated and its consequences can be avoided or delayed with medication, regular screening and treatment for complications. [3] But unfortunately, most of the people do not really understand how. Here, by using social media we can spread the information regarding the prevention methods faster and wider.

Social media should be used more correctly to give the people advantages in promoting healthy behavior and healthy lifestyle. Seventy six percents of the social media users are female which means many young moms are active users of social media, so we can prevent gestational diabetes through this platform.

Proposed Policy Nowadays, accessible health information is important to improve public health outcomes, whether to help people take action during an outbreak or to prevent illness. Increased access to the internet and mobile communications combined with strategic uses of social media can bring public health information to more people, more quickly and directly.[4] Social media use has been increasing in health promotion because it can remove geographical and physical access barriers.[6] Social media is rapidly changing the news business. Publishers, editors and journalists are finding ways to work and compete with social media content providers who often arrive first on the scene and can be the only people with access to information. One resulting change is that health institutions can communicate instantly and directly with the public, bypassing the traditional media filter.[4] The media can be used as the main change agent or as means to support other educational and clinical services. We differentiate four roles of the media: media as an educator, media as a supporter, media as a program promoter, and media as a supplement.[9] In the first role, the media as an educator, the media is the main or sole means for achieving health promotion goals. The Stanford Three Community Study (TCS) provides an example of a long-term (three 2|Page

years), comprehensive media program to achieve cardiovascular risk reduction. The TCS actually compared two different types of interventions: mass media alone and mass media supplemented with intensive face-to-face counseling. The TCS illustrated that media alone can achieve changes in risk behavior over the short term, but the addition of face-to-face interaction enhances long-term change. [9] When using the media as a lifestyle supporter, the media can reinforce old messages, support health changes, encourage maintenance of change, or keep health issues on the public agenda. Although lifestyle reinforcement is not a media outcome that has been well investigated in health promotion, it has been documented in other arenas of media use. For example, Lazarsfeld and colleagues reported that one of the most powerful effects of political campaigns was to support the audience's existing beliefs about candidates. [9] When the media is used to promote existing programs, they can familiarize the audience with health behavior change products and services, and encourage the audience to call, write, or participate in programs. This is perhaps the most common role for the mass media in health promotion and probably the best known by the public. King and colleagues, in a study of the behavioral effects of a smoking contest, examined how participants found out about the event. Promotion efforts included televised PSAs newspaper ads, and fliers distributed through schools, libraries, workplaces, and physiciansâ&#x20AC;&#x2122; offices.

Participants most often mentioned TV as the way they found out about the contest. [9] The media can play a supplementary role by being integrated into a program that includes face-to-face or other forms of intervention. In Flay's review of 40 smoking cessation programs was found that mass media campaigns were reasonably successful in changing knowledge, attitudes and in some instances, smoking behavior. Furthermore, mass-mediated smoking cessation clinics that provide printed materials were more effective than those that did not, and mass-mediated clinics with social support groups were more effective than either of the other methods. [9] People need to be educated in an easy way, because they tend to avoid things that they were forced into.

By using social media as a platform for education, they wonâ&#x20AC;&#x2122;t feel as dictated as if the process of educating them was done in the conventional way.

We use social media as a platform to educate our surroundings through infographics, twibbons or online photo frames, and influencersâ&#x20AC;&#x2122; content that evolve around health. People tend to follow what their favorite idols are doing and the things that are going viral. The twibbons in order to celebrate health-issued day is very educating because it usually have the theories about the health topic in the caption. This is one of the easiest ways to spread awareness to our surroundings.

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Social media, a great information equalizer, is radically transforming the way people communicate around the world. Instant and borderless, it elevates electronic communication to near face-to-face. Until recently, the predominant communication model was “one” authority to “many” – i.e. a health institution, the ministry of health or a journalist communicating to the public. Social media has changed the monologue to a dialogue, where anyone with ICT access can be a content creator and communicator.

Health professionals should ensure that information is correct and accessible.[4] There are innumerable blogs on health topics written by specialists and non-specialists alike that are read, commented on and shared globally. Social networks are used by a hundred millions of people to communicate about a huge range of topics, including health. Type “diabetes” or “maternal mortality” into a search engine or Wikipedia, it is likely to be the first entry referenced. Visuals of unusual health events can be published minutes after they’ve occurred on YouTube or Flickr, video and photo sites with millions of users. Inexpensive video and still cameras, including those on mobile phones, dramatically increase the number of potential publishers globally.[4]

Conclusion Access to information and communication technology is developing in all regions of the world. There are more than four billion mobile phone subscribers globally and about one out of four people are using the internet. The potential to use mobile phones for public health information is enormous.

Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin produced. There are some types of diabetes, one of them is Diabetes Type 2. Diabetes Type 2 results from the body’s ineffective use of insulin. Another type of Diabetes is Gestational Diabetes. It is hyperglycemia with blood glucose values above normal but below those diagnostic of diabetes which occurs during pregnancy. Both diabetes type 2 and gestational diabetes can be prevented and sadly most of the people don’t really understand how. By using social media, we can spread the information faster and wider.

Social media use has been increasing in public health and health promotion because it can remove geographical and physical access barriers. We distinguish four roles of media: media as an educator, media as a supporter, media as a program promoter, and media as a supplement.

The media can be effective in changing health attitudes, especially when supplemented by face-to-face instruction. For highly involved audiences, attitude change can result from learning about health threats, 4|Page

and this can lead to corresponding health behavior changes. Attitudes can also be learned observationally through media portrayals; new attitudes might be adopted if their salient attributes are seen as preferable to previously held attitudes. Although attitudes may not be sufficient to change behavior because of other obstacles to healthy actions, they are supple and do contribute to behavior change.[9] Social media might not bring health to all, but they can help to bring accurate health information to more people than before. After all, one fact sheet or an emergency message about an outbreak can be spread through Twitter faster than any influenza virus. It is an opportunity for health professionals to explore, listen and engage.[4]

Recommendation Social media is increasingly used for public health and health promotion. In some countries, social media has been used as a health care promotion platform. A study in Ghana shows that they view healthrelated messages on social media seriously. Health professionals see social media as an effective tool for sending health-related messages to the public and are concerned about the fact that traditional media are losing their effectiveness as means to share health -related messages. [8] In the United States 60% of state departments use one or more social media applications, the Public Health Agency of Canada has a presence on social media sites including Twitter and Facebook while in Ontario, 34 out of the 36 public health units are using social media. Social media holds promise for public health interventions, reaching a wide number of people as over 60% of adults and 90% of the youth with internet access in Canada are active on one or more forms of social media.[6] Health messaging is an area that has been relatively ignored in the literature and almost no research focuses on the effectiveness of social media and other health messaging technologies, particularly in developing countries. Although the study was conducted in Ghana, health professionals worldwide can use the findings to help improve their health messaging strategies. [8] Governments should be more active in using the social media as a platform to promote health in order to prevent diabetes further. In addition, the government also must socialize the correct way to use social media as a platform to promote health information.

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References 1. WHO (2017) Diabetes. Available at : http://www.who.int/news-room/fact-sheets/detail/diabetes (Accessed : 5 October 2018) 2. WHO (2015) Engaging Young People in Their Own Care Is Key to Improving Adolescent Health.

Available at : http://www.who.int/features/2015/improving-adolescent-health/en/ (Accessed : 7 October 2018) 3. Tania Habjouqa (2017) World Diabetes Day 2017. Women and diabetes: Our right to a healthy future.

Available at : https://www.who.int/diabetes/world-diabetes-day/en/ (Accessed : 7 October 2018) 4. Christine McNab (2009) What Social Media Offers to Health Professionals and Citizens. Available at : http://www.who.int/bulletin/volumes/87/8/09-066712/en/ (Accessed : 13 October 2018) 5.

Communications

function

at

WHO

(2017)

Social

Media.

Available

at

:

http://www.who.int/communicating-for-health/functions/social-media/en/ (Accessed : 13 October 2018) 6. V. Welch, PhD, et al. (2016) Interactive Social Media Interventions to Promote Health Equity: An Overview of Reviews. Available at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4964231/ (Accessed : 14 October 2018) 7. Aizhan Tursunbayeva (2017) Use of Social Media for E-Government in the Public Health Sector: A Systematic Review of Published Studies. Available at : https://www.sciencedirect.com/science/article/pii/S0740624X16302088 (Accessed : 19 October 2018) 8. Richard Bannor, et al. (2017) Effectiveness of Social Media for Communicating Health Messages in Ghana. Available at : https://www.emeraldinsight.com/doi/abs/10.1108/HE-06-20160024?fullSc=1&journalCode=he (Accessed : 19 October 2018) 9. June A. Flora, et al. (1989) The Role Of Media Across Four Levels Of Health Promotion Intervention.

Available at : https://www.annualreviews.org/doi/pdf/10.1146/annurev.pu.10.050189.001145 (Accessed : 19 October 2018) 10. Iris Vermeren (2015) Men vs. Women: Who Is More Active on Social Media? Available at : https://www.brandwatch.com/blog/men-vs-women-active-social-media/ (Accessed : 19 October 2018)

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11. The Statistics Portal (2018) Percentage of Adults in The United States Who Use Social Networks as of January 2018, by Gender. Available at : https://www.statista.com/statistics/471345/us-adults-who-usesocial-networks-gender/ (Accessed : 19 October 2018)

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Appendix Who Uses Social Networking Sites (% of Internet Users Within Each Group Who Use Social Networking Sites) [10]

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Percentage of Adults in The United States Who Use Social Networks as of January 2018, by Gender[11]

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MULTISECTORAL CHANGES AS PREVENTION IN DIABETES, OBESITY, AND ITS COMPLICATION Nadia Afiyani, Amira Nabila, Nur Azzahra Permata Universitas Diponegoro Abstract There have been numbers of reported issues according the urgency of noncommunicable disease (NCD) with 71% deaths globally are caused by it, making NCD a world-wide urgency. The purpose of this white paper is to address the importance of preventive and control measure in noncommunicable disease with a cost-effective way by multisectoral approaches. This white paper draws upon mostly the prevention of risk factor of obesity and diabetes mellitus of unhealthy diet and lifestyle and the control of complications caused by these diseases. Corresponding to the solution based on the WHO NCD Global Action Plan 20132020 in preventing and controlling NCDs with multisectoral approach to release the burden globally. Thus, the interventions given will be focused on prevention and control of obesity and diabetes in the form of conducting an accessible early screening by providing free annual pass detection on birthdays, shifting the environment to support healthy lifestyle by changing habits and applying taxes to sweetened beverages, and also conducting a public campaign to raise awareness in physical activity by education of nutritional intake on the packaging of fast-food restaurant chainsâ&#x20AC;&#x2122; product.

Key findings : Multisectoral, noncommunicable disease, early diagnose, healthy lifestyle

MULTISECTORAL CHANGES AS PREVENTION IN DIABETES, OBESITY, AND ITS COMPLICATION

Nadia Afiyani, Amira Nabila, Nur Azzahra Permata ASIAN MEDICAL STUDENTS’ ASSOCIATION – INDONESIA

MULTISECTORAL CHANGES AS PREVENTION IN OBESITY AND DIABETES Nadia Afiyani, Amira Nabila, Nur Azzahra Permata Faculty of Medicine Diponegoro University

Introductions More than 71% deaths globally are caused by noncommunicable diseases (NCDs), thus making NCDs the biggest cause of death around the world. If this NCDs could have largely been prevented, why are there still more than 41 million early death with more than three quarters of global NCD premature death disproportionately affecting the low- and middle-income countries?

Calling the issue by the WHO in 2013, the attention drawn to step up the prevention and treatment for NCD has been a national and international wide urgency. These diseases are driven by forces that include rapid unplanned urbanization, globalization of unhealthy lifestyles and population aging. Unhealthy diets and lack of physical activities may be manifested in high blood pressure, increased blood glucose, elevated blood lipids and obesity. Globally, 420 million people worldwide have suffered from diabetes and according to the report by the Center of Diabetes Control and Prevention (CDC) in 2017, up to 7.2 million people are left undiagnosed in the United States. This silent killer contributed up to 1.6 million of deaths in 2015 and has been increasing ever since. Indonesia ranks number 5 in mortality rate caused by diabetes according to the WHO World Statistic in 2016 with 73% of all deaths occurred in Indonesia, with obese patients contribute most to a high risk category. Various efforts have been made by countries all over the world under the WHO to create possible solutions to tackle the issue of this chronic disease. But why is the prevalence still going up?

Source : International Diabetes Federation. 2017

Source : Noncommunicable Diseases Country Profiles 2018, WHO

This paper discusses and analyzes the key interventions of the implications for prevention approach of noncommunicable disease and provides ideas of possible solutions regarding the matter of

obesity, diabetes, and their complications thus maximizing early diagnostic approach rather than conducting research, to endorse the life expectancy and increase the quality of life in order to reduce the burden of noncommunicable diseases as the first cause of death in the global epidemic.

Problem Discussed Diabetes mellitus is a serious, chronic disease that occurs either when the pancreas does not produce enough insulin (type 1 diabetes), or when the body cannot effectively use the insulin it produces (type 2 diabetes). One of the risk factors of type 2 diabetes is obesity which are the result of unhealthy lifestyle and lack of physical activity.

Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health and are caused by an increased intake of energy-dense foods that are high in fat and an increase in physical inactivity. In 2016, more than 1.9 billion adults were overweight and 650 million were obese.

Furthermore, overweight children are likely to become obese in adults and develop diabetes and cardiovascular diseases at a younger age, which in turn are associated with a higher chance of premature death and disability. In 2016, over 340 million children and adolescents aged 5-19 were overweight or obese.

Table source : The FrieslandCampina Institute, using WHO standard and study

Excess body fats linked towards higher circumference of waists to higher body mass index (BMI) strongly affects the occurrence of type 2 diabetes. High BMI level has a strong relationship in developing insulin resistance, thus causing type 2 diabetes. In obese individuals, the amount of saturated fatty acids, glycerol, hormones, cytokines, proinflammatory markers, and other substances that are involved in the development of insulin resistance, is increased. The pathogenesis in the development of diabetes is based

on the fact that the β-islet cells of the pancreas are impaired, causing a lack of control of blood glucose.

The development of diabetes becomes more inevitable if the failure of β-islet cells of the pancreas is accompanied by insulin resistance. According to the WHO, a considerable amount of all monosaccharides and disaccharides added to foods contribute in increasing the likelihood of becoming overweight or obese especially in children. Dietary problem such as high intake of saturated fats, over consumptions of carbohydrate, high-sweetened beverages such as sugary sodas and flavored beverages also appear to be one of the key factors to obesity and diabetes in recent evidence. Thus, a controllable nutrition and dietary intake in the early childhood life is an important approach as prevention especially to children who are in the high risk category.

The growing problem will have a significant impact not only on individual but also national and international in health and economies sectors. This burden can be measured through direct medical costs, indirect costs associated through productivity lost, premature mortality, and the negative impact in the nation'sâ&#x20AC;&#x2122; gross domestic products (GDP). Thus, a more cost-effective interventions are in desperate need to tackle these problems.

In the global scale, WHO have already taken so many actions to prevent and control the burden of morbidity, mortality, and disability due to noncommunicable disease by the NCD Global Action Plan 2013-2020 as a standardize, legalized, and recommendations to its member states in a multisectoral approach, providing a road map and

a menu of policy options for all member states and other

stakeholders to take coordinated also coherent actions and emphasizing opportunities for collaborations so as to maximize efficiencies for the mutual benefit in releasing the global burden of NCD. This framework acts as a base for us to produce ideas in the aim to create and implement a suitable solution to tackle NCD in a health-promoting environment.

In Indonesia, a program called GERMAS stands for Gerakan Masyarakat Hidup Sehat (A healthy living movement), a systematic action plan made by the government in order to overcome the burden of NCD by increasing awareness of living a healthy lifestyle. There are seven point of actions in GERMAS which focus on the strategical in the aim of prevention of the NCD, such as (1) Doing physical activity, (2) Consumptions of fruits and vegetables, (3) Avoid smoking, (4) and Alcohol intake, (5) Routine health check-ups, (6) Maintain a clean environment, and (7) Using proper toilets. Although we believe that these approaches have covered several actions possible to be taken by the public, unfortunately those are still lacking in implementations from the target audience and need further cross sectorial involvements in order for this to work and have a significant effect on health service utilizations.

Proposed solution In line with WHO NCD Global Action Plan 2013â&#x20AC;&#x201C;2020, we believe that multisectoral approach is the key to maximizing the intervention on preventing diabetes, obese, and its complication. Start from our closest surrounding to national and international policies have to work together in increasing awareness to create a significant impact in the society.

In this white paper, there are several proposed solutions we would like to introduce are as follows: 1. Detect-on-Your Birthday People can and shall go to the nearest sub-district healthcare facility or primary healthcare facility to be provided with free glucose and BMI checking on their birthday in order to get monitored at least once in a year. We propose a convenient way to conduct an early detection and monitoring the risk of obesity and diabetes by free annual pass detection and monitor. This proposed mechanism is in line with the objective number 4 on WHO Global Action Plan for the Prevention and Control of Noncommunicable Disease 2013â&#x20AC;&#x201C;2020. Furthermore, we believe the burden the government has to overcome by providing a free glucose and BMI checking as to prevent and control is far more less than the burden the government has to overcome by tackling the uncontrollable impact in all sector caused by NCDs. -

An early diagnostic approach to keep in track and reduce the number of undiagnosed diabetes and obesity since the longer a person lives with undiagnosed and untreated diabetes, the worse their health outcomes are likely to be and early diagnosis is the starting point for living well with diabetes and prevent complications.

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Easy access on providing basic diagnostics such as BMI, blood pressure, and glucose level to conduct annual screening for risk of undiagnosed diabetes and obesity.

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Raising the awareness the importance of early diagnose and increasing the urge to do an early screening since the government provide it for free only on their special day, which is their own birthday.

2. Today-Funday Our initiatives of this campaign consists of two main point; the first one is to eat healthy and the second one is to do physical activity regularly (at least twice a week) with your family and friends while having a great time together will create an enjoyable environment to do physical activity and maintain a habit to living a healthy lifestyle. This proposed campaign is correspond to the WHO NCD Global Action Plan objective number 3 in promoting physical activity to conduct

evidence-informed public campaigns and social marketing initiatives to inform and encourage consumers about physical activity practices.

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Physical activities and healthy eating habit are needed to prevent and control noncommunicable disease. Regular physical activity and healthy lifestyle reduce the risk of diabetes and raised blood glucose, and is an important contributor to overall energy balance, weight control and obesity prevention.

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Endorsing the habit of doing regular physical activity and healthy eating starting from the early life with parents involvements as a role model in developing the childrenâ&#x20AC;&#x2122;s habits since habits are formed from the early life. When the long-term regulation of energy balance may be programmed, there is a critical window for intervention to mitigate the risk of obesity and type 2 diabetes later in life.

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Having a great time with your family and friends while doing a positive activity is great to prevent mental health problem and gluttonous caused by depression.

3. Tax on Sugar-Sweetened Beverage With the objective number 3 in NCD Global Action Plan to develop or strengthen national food and nutrition policies, our proposal is to create a policy measure that engage beverages company in controlling the unhealthy diet caused by abundance of consumption relating their product.

Giving tax on sweetened-beverages, including but not limited to sodas and condensed-milk, and also regulation on their commercials, including but not limited to the contain, the packaging and product name to prevent a misconception in the society in the aim to: -

To reduce the intake of excessive sugar and promote the intake of healthy foods and drinks.

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The usage of policy tools include fiscal measures to create environments that support people to maintain healthy body weight with healthy diet.

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To straighten societyâ&#x20AC;&#x2122;s understanding regarding beverage that contain excessive amount of sugar, such as sodas and condense milk.

Policy tools to regulate the marketing of food and nonalcoholic beverages to children; nutrition labelling; and a package of interventions to improve early childhood nutrition, including promotion of breastfeeding

4. Package your calories Encourage fast food restaurant-chains to promote physical activity by giving labels of certain amount of exercise needed to burn the calories regarding the productsâ&#x20AC;&#x2122; consumption in the

packaging of their product. This resembling the objective number 3 in promoting physical activity with the development of policies engaging appropriate stakeholders, across government, NGOs, and civil society and economic operators.

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To educate the society in order to raise awareness of calories intake in order to control the over consumptions of unhealthy diet while balancing it with physical activity

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A cost-effective interventions to engage the populations in doing physical activity in the form of health-message to encourage the society to balance their diet with physical activity. This interventions not only low-cost but provingly effective as seen in the Health-Warning Labels (HWL) used in tobacco packaging as a strategy to reduce smoking habits with intense globally coordinated opposition from the tobacco industry and the World Health Organisation Framework Convention on Tobacco Control (FCTC).

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This health message may include pictures or charts providing informations needed related to calories intake while compensated by the suitable amount of exercise needed to balance the intake.

Conclusions Noncommunicable disease continues to burden the global aim to reach the 2030 agenda for Sustainable Development with up to 41 million of all deaths attributed to NCDs occurring between the ages of 30 and 69 years which counts as productive age, thus threatening the human resource quality by reducing the quality of life. In Indonesia this disease contributed to up to 73% causes of all deaths. This rapid growth in numbers is affected by late diagnosis, continuous uncontrollable unhealthy lifestyle in the growing society, and also habits starting in the early childhood life causing severe complications such as cardiovascular and neurological involvements later in life. While it is preventable, a further interventions from integrated party is needed.

The growing impact caused by NCD does not only affect the health sector but also the socioeconomic area particularly in the low-economic areas by increasing household costs associated with healthcare. Therefore, a cost-effective solutions is needed. To lessen the impact of NCDs on individuals and society, a comprehensive approach is needed requiring all sectors, including healthcare facilities, physicians, government associates, NGO, agriculture, stakeholders, and society, to collaborate in the aim of preventing and controlling the risk and complications associated with NCD in the most cost-effective way possible.

It is time to prevent and control the burden of NCD by focusing on the prevention of risk factors and controlling their complications with multisectoral approach in early diagnostic, creating policies to apply taxes to sweetened beverages, promoting physical activity, and educating the society regarding their

nutritional intake with balance physical activity. This way, we can reduce the damage caused by NCD while promoting healthy lifestyle with cost-effective pathway. If this solutions work, we will be one step closer in releasing the global burden of NCD to achieve the Sustainable Development Goal.

Recommendation Government is needed to define the policies and procedure. Obedience and awareness of socialworker and society has the main role in shifting lifestyle. These proposed solutions will focus on preventing and controlling the risk on NCDs especially diabetes and obesity.

References World Health Organization. (2016). World Health Day 2016: Beat Diabetes. Retrieved October 22, 2018, from https://www.who.int/campaigns/world-health-day/2016/en/ World Health Organization. (2017, November 15). Diabetes. Retrieved October 22, 2018, from http://www.who.int/en/news-room/fact-sheets/detail/diabetes World Health Organization. (2013). Global Action Plan for The Prevention and Control of Noncommunicable Diseases. Retrieved October 22, 2018, from https://www.who.int/nmh/events/ncd_action_plan/en/ World Health Organization. (2018). Noncommunicable Diseases Country Profiles 2018. Retrieved October 22, 2018, from https://www.who.int/nmh/countries/en/ World Health Organization. (2018, February 16). Obesity and Overweight. Retrieved October 22, 2018, from http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight Hruby, A., & Hu, F. B. (2015). The Epidemiology of Obesity: A Big Picture. Pharmacoeconomics. 33(7).

673-689. http://dx.doi.org/10.1007/s40273-014-0243-x Ministry of Health Republic of Indonesia. (2016, November 15). Germas Wujudkan Indonesia Sehat.

Retrieved October 22, 2018, from http://depkes.go.id/article/view/16111500002/germas-wujudkanindonesia-sehat.html World Health Organization. (2007). Growth Reference 5-19 Years. Retrieved October 22, 2018, from http://www.who.int/growthref/who2007_bmi_for_age/en/ Stone, M. A. et al. (2013). Quality of Care of People With Type 2 Diabetes in Eight European Countries.

American Diabetes Association Journal. 36(9). 2628-2638. http://dx.doi.org/10.2337/dc12-1759

Appendix A- Growth reference 5-19 years Interpretation of cut-offs Overweight: >+1SD (equivalent to BMI 25 kg/m2 at 19 years) Obesity: >+2SD (equivalent to BMI 30 kg/m2 at 19 years) Thinness: <-2sd> Severe thinness: <>

Appendix B- Objective number 3 WHO NCD Global Action plan

Appendix C- Objective number 4 WHO NCD Global Action Plan

Dumbbell: Simple Solution to Cut Your Weight Abstract Obesity is a condition in which the body have excessive fat deposition. Obesity is associated with several health issues such as cardiovascular, endocrine, and also psychological issues such as depression, social phobia, and anxiety. Imbalance energy consumption and expenditure is the fundamental cause of obesity.

In 2016, 39% of adults worldwide were overweight and 13% of them were obese. Diabetes Mellitus is one of the most complications of obesity. This disease is associated with insulin hormone resistance in functional cell receptor that accounts glucose deposition in the cell. Diabetes is the seventh global leading cause of mortality in 2016. In Indonesia, 422 million adults have diabetes, but 1 out of 2 person does not realize it. Depression is one of the risk factors for both Diabetes Mellitus and obesity. Moreover, it is also a predictive factor for the number and severity of diabetic complication. A meta-analysis within 39 studies shows 11% of patient with diabetes met criteria for major depressive disorder, 31% related to significant depressive symptoms. Currently, the Indonesian Government through Ministry of Health proposed programs to improve healthy lifestyle to prevent obesity and diabetes, known as “CERDIK” and “GERMAS”. DUMBBELL program is proposed to increase the efficacy of “CERDIK” and “GERMAS” and as a way to decrease Obesity and Diabetes Mellitus in adult through physical activity. Involvement in structured workout show promising in alleviating clinical depression symptom, one of the psychological issues associated with obesity and diabetes. DUMBBELL composed of six training procedures.

DUMBBELL use depression, especially broken heart and interpersonal social disorder to motivate people to do exercise.

Keywords

: Obesity, Diabetes Mellitus, depression, DUMBBELL

Authors

:

1. Richard Axel 2. Gery Petra 3. Sindy Irenewati 4. Vianney Natasaputra

EAST ASIAN MEDICAL STUDENT CONFERENCE 2019 ASIAN MEDICAL STUDENTS’ ASSOCIATION – DIPONEGORO UNIVERSITY WHITE PAPER AND VIDEOGRAPHY

Dumbbell: Simple Solution to Cut Your Weight

By : Richard Axel Gery Petra Sindy Irenewati Vianney Natasaputra

Dumbbell: Simple Solution to Cut Your Weight Gery Petra, Richard Axel, Sindy Irenewati, Vianney Natasaputra AMSA-Universitas Diponegoro

Introduction Obesity is one of the major problem, affecting several people all around the world. Obesity defined as abnormal and excessive fat deposition in the body that may cause physiological problems. The diagnosis of obesity is based on the Body Mass Index calculation (weight in kilograms divided by height in meters square). A Body Mass Index of 18.5-24.9 is considered as normal, 25-29.9 overweight, and >30 defined as obese. Further, Obesity is categorized into Class I (30-34.9), Class II (35-39.9), and Class III (>40) (Ortiz & Kwo, 2015). Obesity is associated with several impairments of physiological (cardiovascular, respiratory endocrine, hematologic, gastrointestinal, and nutritional) and psychological (depression, social phobia, anxiety, mania, panic disorder, and personality disorder). The fundamental cause of obesity and overweight is related to the imbalance between energy consumed and expended. The Imbalance energy occurs when the consumption of energy is higher than the expenditure of energy that leads to excessive energy deposition in the body. (WHO, 2018) Globally, Obesity has nearly tripled since 1975. In 2016, the occurrence of overweight and obesity granted about more than 1.9 billion adults, over 650 million were obese3. 39% of adults over 18 years old worldwide were overweight and 13% of them were Obese. World Health Organization stated â&#x20AC;&#x153;Most of the worldâ&#x20AC;&#x2122;s population live in countries where overweight and obesity kills more people than underweightâ&#x20AC;?3.

In adolescent and children aged 15-19, over 340 million deal with overweight and obesity problem. (WHO, 2018) One of the most complications of obesity and overweight is Diabetes Mellitus (DM). Diabetes Mellitus is a chronic endocrine disease associated with insulin hormone and pancreas impairment. Diabetes Mellitus is classified by type 1, type 2 and gestational diabetes. Type 1 Diabetes Mellitus is considered when the body does not have adequate insulin hormone concentration that associated with pancreas impairment and tends to be inherited. While Type 2 Diabetes Mellitus is associated with the resistance of insulin hormone with functional cell receptor that accounts glucose deposition in cells, often unhealthy lifestyle is predisposed. Gestational Diabetes mellitus is a temporary condition of elevated blood glucose concentration in pregnancy.

According to the World Health Organization, the global prevalence of diabetes among adults over 18 years old has risen from 4.7% in 1980 to 8.5 in 2014, risen significantly in middle and developing countries. The mortality of Diabetes Mellitus reaches 1.6 million in 2015. In 2016, diabetes is the seventh

global leading cause of mortality with ischemic heart disease (IHD), stroke, chronic obstructive pulmonary disease (COPD), Lower Respiratory Tract Infection, Alzheimer Disease, and respiratory tract cancer (WHO, 2018). In Indonesia, approximately 422 million adults among 18 years old are classified as definite diabetes, 1 out of 2 does not realize it. Sustainable Development Goals has considered diabetes as one of indicator target to be reduced by one-third in 2030. (Kementrian Kesehatan Republik Indonesia, 2016) Problem Discussed Psychological disorder such as depression is one out of several comorbidities in Obesity and Diabetes Mellitus cases. The relation is shown in the Appendix. A population-based epidemiological study of Diabetes Mellitus and Depression correlation shows 501 out of 4,193 (12%) met the diagnostic criteria conducted by Diagnostic and Statistical Manual of Mental Disorder-Fourth Edition (DSM-IV) and 357 participants led to minor depression indication. A meta-analysis within 39 studies shows 11% of patient with diabetes met criteria for major depressive disorder, 31% related to significant depressive symptoms (Katon, 2008). Based on Faith and Colleagues exploration in 2002 and 2004, people with obesity often have other personal characteristics that affect their mood and risk of chronic stressor such as poor health and interpersonal discrimination (Carr, Friedman, & Jaffe, 2007). Interpersonal discrimination may lead to social distress and affect obese peopleâ&#x20AC;&#x2122;s self esteem. Moreover, it may lead them to an unhealthy lifestyle.

Unhealthy lifestyle will lead to diabetes mellitus as the common complication risen from obesity.

World Health Organization as non-profit organization derivative of United Nation proposes health campaign to encounter obesity and diabetes issues, called as WHO Diabetes Programme. WHO Diabetes Programme was established to prevent diabetes and decrease the probability of several complications associated with diabetes. Improving the efficacy of surveillance, monitor, and prevention is the key to reduce diabetes and its complications worldwide. In Indonesia, The Ministry of Health has provided about 13.500 basecamps to improve screening program especially in rural and suburb area. The Ministry of Health has proposed healthy lifestyle to prevent obesity and diabetes, known as â&#x20AC;&#x153;CERDIKâ&#x20AC;?, consist of: a. Cek kesehatan secara teratur untuk mengendalikan berat badan dan tidak beresiko mudah sakit (Routine general check up to control body mass and reduce the risk of illness) b. Enyahkan asap rokok dan jangan merokok ( Stop smoking) c. Rajin melakukan aktivitas fisik minimal 30 menit (Do physical activity for at least 30 minutes routinely) d. Diet seimbang dengan mengonsumsi makanan sehat gizi seimbang, konsumsi sayur minimal 5 porsi per hari, sedapat mungkin menekan konsumsi gula hingga maksimal 4 sendok makan atau 50 gram per hari, hindari makanan/ minuman yang manis atau yang berkarbonasi.

(Consume healthy food for at least 5 portions vegetables per day, reduce consumption of glucose with maximum 50 gram per day, avoid sweets and soda.) e. Istirahat yang cukup (Rest adequately) f.

Kelola stress yang baik dan benar (Manage stress and depression)

“CERDIK” is a part of Indonesian Ministry of Health’s program known as GERMAS or Gerakan Masyarakat Hidup Sehat, which comprised of phisycal activity, consumption of vegetable and fruits, no smoking, avoid alcohol consumption, routine general checkup, cleaning up the environment and utilizing toilet. GERMAS has been introduced since 2016. So far, there are 3 main focus of GERMAS : 1) Physical activity for 30 minutes each day at minimum, 2) Consumption of fruit and vegetable and 3) Routine general checkup. There have been various programs held by each district or even each city in order to support GERMAS. For example, Gorontalo has Gugus Tugas (G-Gas) program to reduce the number of maternal mortality rate, PSIA or Pekan Sayang Ibu dan Anak which provide specific healthcare service for mother and children, and many more. There are also programs which focus on physical activity. Recently, Saka Yoga Festival was held in Jakarta and was participated by 2.000 people. This program was intended to increase physical activity. GERMAS managed to reduce the number of obesity in Indonesia. In 2016, The prevalence of obesity in children 5-12 years old is 4,3%, it is 4,5% lower than in 2013. In adulthood, the prevalence of obesity in men is 11,4% while in women is 29.7%. This number is significantly lower than in 2013, in which the prevalence of obesity in men is 19.7% and in women is 32.9%.

The Ministry of Health also imposed some policy and law to encounter obesity and diabetes issues by standarization monitoring in health center. The law and policy are written in the Peraturan Kemenkes (Ministry of Health regulation) as stated below:

INDONESIAN MINISTRY OF HEALTH PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 43 TAHUN

REGULATION NUMBER 43 YEAR 2016 CONCERNING MINIMUM STANDARD OF

2016 TENTANG STANDAR PELAYANAN

HEALTHCARE SERVICE

MINIMAL BIDANG KESEHATAN Pasal 2

Article 2 (1) Local Government of Disrict/City should organize standard healthcare service based

(1) Pemerintah Daerah Kabupaten/Kota

on Health Sector Community Service

menyelenggarakan pelayanan dasar kesehatan

Standard

sesuai SPM Bidang Kesehatan.

(2) Health

Sector

Community

Service

Standard as mentioned at article (1) (2) SPM Bidang Kesehatan sebagaimana

comprise of :

dimaksud pada ayat (1) meliputi :

1) Each Diabetes Mellitus Patient should get healthcare service

i) Setiap penderita Diabetes Mellitus

according to standard

mendapatkan pelayanan kesehatan sesuai standar;

CHAPTER II: TYPES OF STANDARD SERVICE MINIMUM HEALTHCARE SERVICE IN DISTRICT/CITY

BAB II: JENIS LAYANAN STANDAR PELAYANAN MINIMAL BIDANG KESEHATAN DI KABUPATEN/KOTA

6. Healthcare service at productive age d) Health Screening at 15-59 years old, comprise of : (1) Detect the possibility of obesity by height,

6. Pelayanan Kesehatan pada Usia Produktif . d) Pelayanan skrining kesehatan usia 15â&#x20AC;&#x201C;59 tahun meliputi : .

(1)

weight

and

waist

circumference

measurement 9. Diabetes Mellitus Patient Healthcare Service a. Standard Statement

Deteksi kemungkinan obesitas

Each Diabetes Mellitus patient gets health care

dilakukan dengan memeriksa

service based on the standard. Local District/City

tinggi badan dan berat badan serta

Government has the responsibility to provide

lingkar perut.

healthcare service based on the standard, towards Diabetes Mellitus patient as secondary prevention

9. Pelayanan Kesehatan Penderita Diabetes

effort in their autonomy

Mellitus (DM) a. Pernyataan Standar Setiap penderita diabetes Mellitus mendapatkan pelayanan kesehatan sesuai standar. Pemerintah Kabupaten/Kota mempunyai kewajiban untuk memberikan pelayanan kesehatan sesuai standar kepada seluruh penyandang diabetes Mellitus sebagai upaya pencegahan sekunder di wilayah kerjanya.

Propose Solution Obesity and Diabetes Mellitus lead several psychological issues in the environment. Psychological difficulties may increase the complication degree in Obesity and DM. However, psychological effect also may motivate the patient to reduce their body weight and achieve healthy life. As the new millennial health ambassador, we propose a new solution called as “DUMBBELL: DUMB Be Elicited by Love.”

DUMBBELL program is proposed based on evidence that body exercise is one of the major ways to decrease Obesity and Diabetes Mellitus in the adult. In addition, involvement of structured workout has shown promising in alleviating clinical depression symptom, one of the psychological issues associated with obesity and diabetes. (Craft & Perna, 2004). Based on studies stated, a structured body exercise can alleviate obesity and its complication, especially in psychological term. The reduction of clinical depression degree may enhance self-esteem and confidence for obese and DM patient.

DUMBBELL is a workout program that composed of some training procedures to help people’s body exercise and building. DUMBBELL consists of six easy steps for obese people to reduce their weight based on psychological experience headed. DUMBBELL’s system uses depression, especially broken heart, and interpersonal social disorder to motivate people decreasing their body mass. The steps of DUMBBELL provide body exercises those train most of the body muscles respectively.

Requirement: a pair of dumbbell and a single mattress.

The 6 easy steps of DUMBBELL are: 1. Deltoid Upward (DU) Prepare a pair of dumbbell and put it in front of your hand and place your ex-crush photos in front of you. Steady in standing position. Hold and place the dumbbell each of your hand with prone

position. Straighten your arm and lift your dumbbell. Do it for 10 repetitions in 3 sets. Deltoid Upward movement will train deltoid and triceps muscles 2. Mountain Climber (M) Start in plank position with shoulders over hands and weight on just your toes. Donâ&#x20AC;&#x2122;t forget to place your crush photo in front of your head. Bring your right knee forward under your chest. Return to pole position. Switch to left leg and bring the left knee forward under your chess. Repeat after the steps above until look like a little running for a minute. Imagine the little running is useful to chase your crush in the picture. Mountain climber workout will burn fat on belly and strengthen lower extremities group of muscles 3. Biceps Curl (B) Place a crush photo in front of your head. Stand up straight with a dumbbell in each hand and arm length straight. Curl up the forearms until biceps muscles contracted fully. Hold on the position and slowly lower it to starting position. Repeat step above for 10 repetitions in 3 sets. Biceps curl will train your biceps muscle respectively 4. Bent Knee Sit Up / Crunch (BE) Place your crush photo on your knees as a motivation to do the step. Lie in supine position on the mattress. Bent your knees and place your arm in cross position and with your shoulder. Raise torso to sitting position and slowly lower the torso back to starting position. Imagine the stack of raising torso and lowering torso are equally to kiss given by your crush. Repeat the step for 15 times in 3 sets. Bent Knee Sit Up is effective to gain abdominal wall muscle strength and burn belly fat.

5. Lateral and Full Plank (L) Place your crush photo on your mattress parallel with your head. Lie on right side and upper foot stacked on the lower foot with your right elbow placed directly under your shoulder (Right-sided Plank). Maintain position and alignment of your body for 30 seconds. Prone with your arm directly with your shoulder and donâ&#x20AC;&#x2122;t let your knees lie down to the mattress (Full Plank). Maintain your position for 30 seconds. After 30 seconds, lie on your left elbow and upper foot stacked on the lower foot (Left-sided Plank) for 30 seconds. Prone with your arm and maintain Full Plank position for 30 seconds. Lateral and Full Plank movement will improve body posture and strengthen core muscles.

6. Leg raises (L) Lie down in supine position on the mattress with legs straight. Keep your legs straight together and lift them up. Slowly lower down your legs and hold the position. Lift your legs up again and repeated for 15 times in 3 sets. Leg Raises workout will ensure your core muscle and strengthen your hips muscles

DUMBBELL workout system may enhance government’s “CERDIK” and “GERMAS” programs to promote a healthy lifestyle and reduce the risk of obesity and diabetes complication. As stated in “CERDIK” and “GERMAS” programs, Government encourages the society to do physical activity at least 30 minutes every day. The existence of DUMBBELL program may help the society to do a structural body exercise based on government recommendation. DUMBBELL program may also lead the society to gain motivation for doing exercise and staying in healthy lifestyle.

Conclusion Obesity and Diabetes Mellitus are common issues profound in society. Based on the data stated above, the obesity and diabetes issues are complicated to be solved and keeps on increasing as time goes by. Also, Obesity and Diabetes are associated with the high number of mortality in several countries, especially Indonesia as developing countries. The untreatable obesity and Diabetes Mellitus will lead to several complications related to physiological and psychological aspects.

Obesity and Diabetes Mellitus associated with psychological disorder may lead to worse development in the patient. Government release some regulation and policies related to encounter Obesity and Diabetes Mellitus issues, especially reducing complication risk of Obesity and DM issues. World Health Organization proposed WHO Diabetes Program as social campaign to fight against Diabetes Mellitus and its comorbidities globally. In Indonesia, The Ministry of Health has projected this social campaign as “CERDIK” and “Gerakan Masyarakat Hidup Sehat (GERMAS)” recommendation. As the society health campaign, “CERDIK” and “GERMAS” suggestions promote healthy lifestyle by physical workout, healthy food consumption, and general checkup. Nevertheless, “CERDIK and “GERMAS” are needed to be optimized and implicated in society.

DUMBBELL (DUMB Be Elicited by Love) is one of prior concept to be implemented in society.

DUMBBELL program consists of 6 easy steps such as: Deltoid Upward, Mountain Climber, Biceps Curl, Bent-knee sit up, Lateral and Full Plank, and Leg raises. The expectation of DUMBBELL program is motivating people with Obese and DM issues to gain self-esteem and confidence. In addition, DUMBELL activity program is related to health campaign promotion associated with government recommendation.

DUMBELL program provides an illustration to society for effective and structural physical activity which lead them to promote healthy lifestyle.

Recommendation DUMBBELL program is designed to simplify moderate exercise, especially for obese people.

DUMBBELL will ensure people for doing routine activity and allowing people to express the consciousness of body health. For a significant result, the recommendation of workout duration is 10 minutes for 2 months with routine activity. Controlling diet and healthy lifestyle are also suggested to support DUMBBELL program

DUMBBELL program should be implemented in Indonesia, especially to sustain “GERMAS” and “CERDIK” program those designed by the government. If DUMBBELL workout is implemented in society, it may result in significant reduction of obesity and DM. In addition, it may decrease the number of depression in Indonesia. People with obese in society will gain their optimistic spirit to be their motivation, not as depression instead. As if DUMBBELL program has implemented in Indonesia, we hope DUMBBELL program can be associated with World Health Organization program to cut the number of obesity and DM. We believe that DUMBBELL program can be applied not only in Indonesia, but also worldwide.

Bibliography : Kemenkes. (2018). MENKES: Mari Kita Cegah Diabetes Dengan Cerdik, (April 2015), 2018–2019.

Gordon-larsen, P. (2010). NIH Public Access. International Journal, 43(5), 447–454. https://doi.org/10.1002/eat.20710.Perception Koshizaka, M., Lopes, R. D., Newby, L. K., Clare, R. M., Schulte, P. J., Tricoci, P., … Alexander, J. H. (2017). Obesity, Diabetes, and Acute Coronary Syndrome: Differences Between Asians and Whites. American Journal of Medicine, 130(10), 1170–1176. https://doi.org/10.1016/j.amjmed.2017.03.030 Katon, W. J. (2008). The Comorbidity of Diabetes Mellitus and Depression. American Journal of Medicine, 121(11 SUPPL. 2), 8–15. https://doi.org/10.1016/j.amjmed.2008.09.008 Assari, S. (2016). Psychosocial Correlates of Body Mass Index in the United States : Intersection of Race, Gender and Age, 10(2). https://doi.org/10.17795/ijpbs-3458.Original Menteri Kesehatan Republik Indonesia, Kementerian Kesehatan Republik Indonesia, & Menteri Kesehatan Republik Indonesia.

(2016). Peraturan Menteri Kesehatan Republik Indonesia no,43 tahun 2016 tentang standar pelayanan minimal bidang kesehatan. 31 Agustus 2016. Retrieved from https://djsn.go.id/storage/app/uploads/public/58d/486/f01/58d486f010a3f067108647.pdf%0Ahttp://djsn.go.id/storage/app/ uploads/public/58d/486/f01/58d486f010a3f067108647.pdf Rachmi, C. N., Li, M., & Alison Baur, L. (2017). Overweight and obesity in Indonesia: prevalence and risk factors—a literature review. Public Health, 147, 20–29. https://doi.org/10.1016/j.puhe.2017.02.002 Amu, Y. (2014). Faktor Resiko Kejadian Diabetes Mellitus Tipe II di RSUD. Prof. Dr. Hi. Aloei Saboe Kota Gorontalo. Program Study IlmuKeperawatan, FakultasIlmu- IlmuKesehatandanKeolahragaanUniversitasNegeriGorontalo, 1–13.

World Health Organization. (2016). Diabetes country profile Indonesia. Who, 48(6), 18882A–18882B. https://doi.org/10.1111/j.1467-825X.2011.03931.xinfodatin-diabetes.pdf. (n.d.).

Craft, L. L., & Perna, F. M. (2004). The Benefits of Exercise for the Clinically Depressed. The Primary Care Companion to The Journal of Clinical Psychiatry, 06(03), 104–111. https://doi.org/10.4088/PCC.v06n0301 Carr, D., Friedman, M. A., & Jaffe, K. (2007). Understanding the relationship between obesity and positive and negative affect: The role of psychosocial mechanisms. Body Image, 4(2), 165–177. https://doi.org/10.1016/j.bodyim.2007.02.004 Ortiz, V. E., & Kwo, J. (2015). Obesity: Physiologic changes and implications for preoperative management. BMC Anesthesiology, 15(1), 1–12. https://doi.org/10.1186/s12871-015-0079-8

Badan Penelitian dan Pengembangan Kesehatan. (2013). Riset Kesehatan Dasar (RISKESDAS) 2013. Laporan Nasional 2013, 1â&#x20AC;&#x201C;384. https://doi.org/1 Desember 2013

APPENDIX The Relation between Depression, Diabetes Mellitus, and Obesity Depression is one of the risk factors for the onset of Diabetes Mellitus and obesity, and a predictive factor for the number and severity of diabetic complication. Depression may increase the risk of Diabetes Mellitus in two ways: 1. Direct negative physiologic effects on glucose metabolism Depression may increase immune-inflammatory activation, increase counterregulatory hormone release and action, change glucose transport function and increase insulin resistance which leads to less glucose uptake. Depressive symptoms are associated with decreased glycemic control.

2. Increase the likelihood of unhealthy lifestyle It is common for depressed people to have less urge to do daily activities. This condition may lead the patient to live sedentary lifestyle, which is one of the causes of obesity. Obesity itself is a risk factor of Diabetes Mellitus.

Moreover, patients with depression and a medical comorbidity are 3 times as likely as nondepressed patients to become noncompliant towards treatment recommendation, resulting in poorer clinical outcome. Self-care in diabetes includes lifestyle modification, such as dietary restriction, smoking cessation, adequate physical activity, taking medications as prescribed and blood glucose monitoring.

Studies confirmed that diabetes mellitus patients with depression have worse compliant towards self-care regimens.

Depression in diabetes mellitus patients also associated with the severity of diabetic symptoms and complications. Depression consistently related to increased severity of diabetic complications, such as retinopathy, nephropathy, neuropathy, sexual dysfunction, and macro vascularcomplications.

Nutrition Measuring Bowl for Type Diabetes Mellitus Prevention to Decrease Glucose Level for Making a Better Life Arthur Peter, Bernadinus Beno Bramantyo, Daniel Setyawan P.M, Lazuardi Taniputra

2nd year medical student, 2nd year medical student, 2nd year medical student, 3rd year medical student Asian Medical Studentsâ&#x20AC;&#x2122; Association- University of Brawijaya

Abstract Diabetes Mellitus is a problem with our body that causes blood glucose (sugar) levels to rise higher than normal. The most common form of Diabetes Mellitus is the type 2 diabetes, that our body does not use insulin properly. Indonesia has the seven largest number of diabetic patients. Currently, Indonesia has an estimated 1.2-2.3% prevalence among people over 15 years. Geographically variation appears to be an influential factor, due to differences in ethnics, race, culture and lifestyle.

The Indonesian consumes white rice for their main source of carbohydrate, which in general, generates a stronger postprandial blood glucose response as measured by the glycemic index (GI) then the same amount of the brown rice. The portion of rice needed for According to the new study, diabetes risk rises by about 10% with each increased serving per day of white rice. Calories people aged 20-79 needed for a day is about 1375-2100 kcal per day, can be varied by gender, and other factors. It consists of 45-65% of carbohydrates, which itâ&#x20AC;&#x2122;s white rice as the main source in Indonesia. From this study, we concluded that the ideal measurement for white rice is 200 gram, which stands for 258 kcal and eaten 3 times a day, which is in total 774 kcal, that stands for the 50% of the total calories we need. We made a bowl that has the marker of 200 gram of rice that is easy to use, easy to bring, so we can eat rice without measuring it with scales.

Keywords: diabetes mellitus, white rice, bowl

NUTRITION MEASURING BOWL FOR TYPE DIABETES MELLITUS PREVENTION TO DECREASE GLUCOSE LEVEL FOR MAKING A BETTER LIFE

By : Arthur Peter, Bernadinus Beno Bramantyo, Daniel Setyawan P.M, Lazuardi Taniputra 2nd year medical student, 2nd year medical student, 2nd year medical student, 3rd year medical student ASIAN MEDICAL STUDENTSâ&#x20AC;&#x2122; ASSOCIATION- UNIVERSITY OF BRAWIJAYA

Nutrition Measuring Bowl for Type Diabetes Mellitus Prevention to Decrease Glucose Level for Making a Better Life Arthur Peter, Bernadinus Beno Bramantyo, Daniel Setyawan P.M, Lazuardi Taniputra

2nd year medical student, 2nd year medical student, 2nd year medical student, 3rd year medical student Asian Medical Students’ Association- University of Brawijaya

Diabetes Mellitus is a problem with our body that causes blood glucose (sugar) levels to rise higher than normal, or also called hyperglycemia. The most common form of Diabetes Mellitus is the type 2 diabetes, that our body does not use insulin properly. This is called insulin resistance. Obesity had an impact on insulin resistance. Bays et al reported that an increased BMI was associated with an increased prevalence of diabetes mellitus, hypertension and dyslipidemia. Cokram reported that all studied consistently showed a strong relationship between obesity and type 2 diabetes. The amount of nonseterified fatty acids, glycerol, hormones, cytokines, proinflammatory markers, and other substances that are involved the development of insulin resistance is increased in obese individuals.

Diabetes is very influential on the quality of the source human power and have an impact on increasing health costs which is quite large. Therefore all parties, both the community and the government, should participate actively in prevention efforts.

Indonesia, which is the world’s fourth most populated country, with a population of 237,6 million people, also has the seventh largest number of diabetic patients, including both type 1 and 2 in individual aged 20 – 79 years from the study by Pradana Soewondo’s Challenges in diabetes management in Indonesia. The study also shows that the proportions of overweight and obese people in Indonesia increased rapidly over time, with poorer income groups exhibiting the strongest growth of excessive weight. Studies of people living in rural areas of East Java and Bali show a prevalence rate of 1.5% in 1982 to 5.7% in 1995 among the urban population. Ujung Pandnag also experienced an increase, and recent studies in Manado found a dramatically high rate of 6.1% in urban areas.

Preliminary results indicate varying prevalence between those living in urban and rural areas.

Currently, Indonesia has an estimated 1.2-2.3% prevalence among people over 15 years.

Geographically variation appears to be an influential factor, due to differences in ethnics, race, culture and lifestyle. Studies of diabetic families show a significantly high prevalence and, clinically speaking, the mode of treatment indicates the type of diabetes. Those who respond well to OHA among young diabetics (<40) are assumed to have the MODY variation of the disease. The level of obesity among the general population has increased, due partly to increased calorie intake and is a significant factor in the increased rate of diabetes. It is also more common among the elderly, as our

results will show. The new types of the disease are clinically more difficult to assess than the classical types 1 and 2, as they require relatively costly genetic and immunological studies. The rate of LADA type diabetes was found to be relatively high (>20% for ICA and IAA and 2.3% for GAOA).

The Indonesian consumes white rice for their main source of carbohydrate, sometimes they said that when they hadn’t eaten any white rice, they felt like they haven’t eaten yet. The need of rice and the cultural belief of the people that lives in the village, even cities of Indonesia makes the thinking of eating white rice as many as they can make them feel healthy and energized. The consumption of rice in Indonesia is a must for all occasion, and it’s not weird to see someone eating noodles with white rice. This lifestyle also combined with no activity, which as we can see right now at the age of 17-30 can potentially be the main cause of diabetes. The report points to a shift in lifestyle among the burgeoning middle class as to blame for the increase in noncommunicable diseases, including diabetes.“As elsewhere in the developing and developed world, a modern lifestyle corresponds to a higher calorie intake and sedentary behaviour: fewer people walk to work or school, and more people are spending increasing hours in front of televisions or computer screens.

The level of laziness to measure the right portion of the white rice they actually needed is so high that they cook their rice abundantly. Although not entirely consistent, consumption of white rice, in general, generates a stronger postprandial blood glucose response as measured by the glycemic index (GI) then the same amount of the brown rice. A systematic review found that the mean GI was 64 ± 7 for white rice and 55 ± 5 for brown rice. Higher dietary GI has been consistently associated with elevated risk of type 2 diabetes. The portion of rice needed for According to the new study, diabetes risk rises by about 10% with each increased serving per day of white rice.

Ministry of Health has also produced 13 book titles about DM including guidelines, standards, technical guidelines and pocket books including Communication, Information and Education (KIE) media. In addition, there has also been an increase in HR capacity for 612 Puskesmas doctors to improve their ability to control PTM including controlling DM throughout Indonesia.

According to Prof. Tjandra, in Law Number 40 of 2004 and Law Number 24 of 2011 concerning the National Social Security System (SJSN) has established a Health Insurance Organizing Agency (BPJS) as a substitute for a number of social security institutions in Indonesia such as PT. Askes and PT. Social Security. Every Indonesian citizen must become a participant who will strive to bear all kinds of diseases by making efficient efforts.

What we thought for this problem the first thing to do is the lifestyle modification, from eating to exercising. The carbohydrates limitation is the key to the lifestyle modification. Activities like exercises,

sports, and even cleaning our rooms are some good example too. Even if the medicines have been taken, we still need to change our lifestyle.

Our solution for this lifestyle change is coming up from a reason that the Indonesian people usually use, like ‘Lazy’ or ‘it’s too hard for me’. This statement inspired us to make something practical to use that can limit the portion of the main source Indonesian people eat, white rice. We made bowls that had been marked for 200 gram portion of rice on the bottom. This bowl is light, yet it is easy to be carried anywhere. Just put the rice below the line of the marker and we will get 200 gram of rice. A data from Perkeni 2015 said that the portion of calories people aged 20-79 for a day is about 1375-2100 kcal per day, can be varied by gender, and other factors. It consists of 45-65% of carbohydrates, 200 gram of white rice stands for 258 kcal. So with 3x times a day meal of 200 gram of white rice, we won’t get too much carbohydrates for one day, so we can prevent the cause of diabetes.

Indonesia is still one of the country with highest prevalence ratio on diabetes and obesity, with the lack of information about diabetes and the lifestyle that’s worsening it, and the culture itself supports this kind of lifestyle. We, as a medical student and the agent of change, should be able to change that by our knowledge. So that’s why we propose this invention, a bowl that is measured as much as the white rice we need for a meal. Hopefully, this bowl can reduce the laziness to measure the right portion of white rice, which can prevent the cause of diabetes.

References Al-Goblan, A. S., Al-Alfi, M. A., & Khan, M. Z. (2014). Mechanism linking diabetes mellitus and obesity. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 7, 587–591. http://doi.org/10.2147/DMSO.S67400 American Diabetes Association. Standards of medical care in diabetes--2012. Diabetes Care. 2012 Jan. 35 Suppl 1:S11-63.

Mihardja, L., Soetrisno, U., & Soegondo, S. (2014). Prevalence and clinical profile of diabetes mellitus in productive aged urban Indonesians. Journal of Diabetes Investigation, 5(5), 507–512. http://doi.org/10.1111/jdi.12177 PERKENI (2015). Konsensus Pengelolaan dan Pencegahan Diabetes Mellitus tipe 2 di Indonesia.

Jakarta. PB PERKENI. Sun, Q., Spiegelman, D., van Dam, R. M., Holmes, M. D., Malik, V. S., Willett, W. C., & Hu, F. B. (2010). White Rice, Brown Rice, and Risk of Type 2 Diabetes in US Men and Women. Archives of Internal Medicine, 170(11), 961–969. http://doi.org/10.1001/archinternmed.2010.109 Sutanegara D, Budhiarta AA.Diabetes Res Clin Pract. 2000 Oct;50 Suppl 2:S9-S16.

Love Yourself, Love Your Health Muhammad Revi Ramadhan, Novelina Gracea, Kevin Marcell, Theresa Puspanadi AMSA-Brawijaya

During the past few decades, global and regional prevalence of obesity and diabetes has constantly increased. There are many factors that is responsible for this number. However, one study shows that along with the growth of body positivity movement, prevalence of obesity also grows. body positive movement might have driven the society to normalize larger body weight, which leads people to underestimate their weight status. This needs attention because those who underestimate their overweight and obesity status is 85% less likely to try to lose weight compared with people who accurately identified their weight status.

Even though the original body positivity movement puts health as priority, but there are some people who misinterpret this body image campaign and use this campaign as an excuse for to defend their obesity status.

It is a challenge for the government to create better obesity health campaign that can clarify the essence of true body positivity. The solution we offer is to create a campaign that utilize the social media, work with Indonesian public figures, and contain creative campaign. Hopefully, doing this we can achieve our goal to slow down obesity prevalence increase to 15.9% in late 2019.

Love Yourself, Love Your Health

AMSA-Indonesia AMSA-Brawijaya Muhammad Revi Ramadhan Novelina Gracea Kevin Marcell Theresa Puspanadi

Background According to WHO, worldwide obesity has nearly tripled since 1975. A disease that once thought as high-income countries problem is now invading middle and low income countries, making it a global epidemic1. Each year, obesity kills up to 2.8 million people and costs 35.8 million productive years in the world wasted because of premature death or disability caused by obesity and its complication2. According research by ADBI, prevalence of overweight and obesity in Asia Pacific has rapidly increase from 34.6% in 1990 to 40.9% in 20133. The same thing happens in Indonesia. Prevalence of obesity in population >18 years old is rapidly increasing from 11.7% in 2010 to 15.4% in 2013, according to Riskesdas.

Environmental and societal changes associated with development and the lack of supportive policies of healthy lifestyle are responsible for so many obesity cases4.

Obesity is classified based on body mass index (BMI) which is a personâ&#x20AC;&#x2122;s weight (in kilograms) divided by the square of his or her height (in meters). Raised in BMI is known for increasing risk factors of many non-communicable diseases (NCD), such as: hypertension, heart disease, stroke, dyslipidemia, osteoarthritis, some cancers, as well as insulin resistance and type 2 diabetes mellitus. Globally, WHO classified BMI 25-29.9 as overweight and BMI â&#x2030;Ľ30 as obese. But, since Asians tend to have higher risk of diseases with the same BMI compared with matched white populations, WHO had to adjust the classification1,2.

Similar to obesity, prevalence of diabetes in the world has doubled in the past 3 decades. According to WHO Global Report of Diabetes, number of people escalate form 108 million (4.7%) in 1980 to 422 million (8.5%) people in 2014. During this time diabetes prevalence has not decreased in any country5. In 2013, International Diabetes Federation (IDF) estimated 60% of 382 million diabetic people lived in Asia, with almost one-third in China. Diabetes can lead to many debilitating complications, such as heart attack, stroke, kidney failure, leg amputation, vision loss, nerve damage, fetal death in pregnancy, even increase the overall risk of dying prematurely, as well as substantial economic loss to the patients and their families.

All the reason why we need to give more attention to diabetes prevention and management6.

Outlined Problems One of the major risk factor for diabetes is obesity, so our team started to observe peopleâ&#x20AC;&#x2122;s paradigm of obesity and something interesting came up.

In this globalization era, it is very easy to receive information. We have internet, social media, messenger, television, and all kinds of platforms to exchange information and knowledge. Along with the

information spread, there is also an ease of campaign and belief spread. In the past few decades, there has been a very successful body image campaign called ‘Body Positive’. This movement was started by an educator and psychiatrist in America decades ago, who observed that there are a lot of people, especially young women suffering from eating disorder and depression as a result of body hatred because of the pressure in society to look certain way. This movement help people to make peace with their body, accepting body features that make every person unique, establishing self-esteem and healthy mental and physical state. Over the years, the message behind this campaign has touch and move many people, including global public figures like Ashley Graham, Serena Williams, Alessia Cara, and more, who then use their voice to spread this movement across the globe, including Asia. Although this campaign has not fully bloom in Asia, but thanks to the internet, body positivity campaign has persistently show up in on our media feed7.

Unfortunately, some people misinterpret this body positivity messages. They thought it can be the reason for them to stick to their current weight, even if they are overweight or even severely obese. The quote ‘Love Yourself’ has been their sole defense. They think they have to love their body regardless of the shape and size it is, unaware of the danger behind that kind of paradigm. With this kind of paradigm, these overweight and obese people refuse to lose weight, believing they are already perfect in their own way. Some even take it further, saying the medical world should stop calling overweight and obese people unhealthy because they believe health can come in many shape and sizes, including overweight and obese.

They point out why skinny girls are never told they are unhealthy, but big girls do. These people probably unaware that there is hard evidence supporting the fact that increase in BMI can increase the risk of diabetes and many other preventable diseases.

The relationship between body image and prevalence of obesity is highlighted in the research done

by Muttarak in England. In this research, Muttarak elaborate that body positive movement might have driven the society to normalize larger body weight, which leads people to underestimate their weight status.

The research shows that overtime, there are more and more individuals with overweight and obesity misperceiving their weight status. The most important part is those who underestimate their overweight and obesity status were 85% less likely to try to lose weight compared with people who accurately identified their weight status8.

Actually, body positivity is not to blame, because the original Body Positive movement put ‘Reclaim Health’ as their first core competency of The Body Positive Model. Its goals are to “Uncover the messages that have influenced your relationships with your body, food, and exercise” and to “Develop a weight-neutral, health-centered approach to self-care”. It is the people that misinterpret this message that are becoming the problems.

Indonesia government is aware of the magnitude of obesity problem and in order to slow down obesity prevalence increase to 15.9% in late 2019, they created GENTAS (Gerakan Nusatara Tekan Angka Obesitas), Indonesian movement to decrease obesity prevalence. Unfortunately, the movement is not very popular and impactful. One of the reason might be because it has not really focused on how to evoked obese people who has the wrong body image to start losing weight. Thatâ&#x20AC;&#x2122;s why an effort to clarify this is becoming important9.

Proposed Policy/ Solution We would like to propose the government to reinforce their existing health campaign against obesity with several improvements. The idea is to work harder and smarter to make people, especially those who are obese to understand what is healthy and what is not. It is okay to feel good about our body, be confident, happy, and love ourselves. But using this as an excuse of being ignorant about our health status is simply irresponsible. If we truly love ourselves, we would want to take care of our body and be healthy.

Our campaign will focus on targeting young people, especially women, because they are the most impacted community by the body positivity movement through social media. Also, the data shows that there are more obese women than obese men in the world1,2.

After learning from many successful campaign, here are few strategies that suggest the government to try in terms of modifying their campaign according to what people are interested nowadays: 1. Utilize the social media A survey in January 2018 reveals that Indonesian has the 3 rd fastest annual social media user growth in the world10. As community engagement becoming more and more important in health campaign, social media becoming the perfect platform to achieve this. This move has been done by other Indonesian governmental organization who has active social media account and people love the way their posts are very informative yet still very relatable and fun. We can make funny but informative health tweets on Twitter, creating twibbon campaign to be posted on Instagram, or creating creative health videos to be viewed in Youtube. Adopting this move, we can better raise awareness about the correct body positivity and obesity, one post at a time.

2. Work with Indonesian public figures Public figures have big impact in society because they have lots of fans who adore them and people tend to imitate people they adore. This has been done in Korean public service announcements and it is proved to be successful. Just like in Korea, we can use the help of these public figures to spread

the message to love yourself in healthy way, control our eating habit, do more exercise, and enjoy life. Therefore, we can start influencing society attitude regarding health problems like obesity.

3. Create creative campaign One of the reason why current public health campaigns are not very successful is because the format has been so overused it is not appealing anymore. It is unfortunate because people nowadays are actually very easy to jump on the bandwagon and follow what is viral. So we have design a movement that can go viral. The example would be our video. We make a parody of a famous song while inserting healthy body positivity messages in it. Another way would be creating a fun health challenge that everybody can join or filming a documentary on the devastating effect of obesity to the patient and their family.

There are still so many ways to create a more impactful health campaign, but we hope through these simple strategies, we can raise more awareness of the healthy body positivity and encourage obese people to control their weight and be healthy.

Conclusion Misinterpretation on body positivity campaign has been an excuse for some people to defend their obesity status. This has been a challenge for the government to create better obesity health campaign that can clarify the essence of true body positivity. The solution we offer is to create a campaign that utilize the social media, work with Indonesian public figures, and contain creative campaign. Hopefully, doing this we can achieve our goal to slow down obesity prevalence increase to 15.9% in late 2019.

References (APA style) 1. World Health Organization. (2018, February 16). Obesity and overweight. Retrieved from http://www.who.int/en/news-room/fact-sheets/detail/obesity-and-overweight.

2. World Health Organization. (n.d). Global Health Observatory Data: Obesity. Retrieved from: http://www.who.int/gho/ncd/risk_factors/obesity_text/en/.

3. Helble, M. and Francisco, K. (2017). The Upcoming Obesity Crisis in Asia and the Pacific: First Cost Estimates. ADBI Working Paper 743. Tokyo: Asian Development Bank Institute. Available: https://www.adb.org/publications/imminent-obesity-crisis-asia-and-pacific-firstcost-estimates.

4. Kementerian Kesehatan. (2013). Riset Kesehatan Dasar 2013. Jakarta: Kemenkes RI.

5. World Health Organization. (2016). Global report on diabetes. Geneva: World Health Organization.

6. Nanditha, A. et al. (2016). Diabetes in Asia and the Pacific: Implications for the Global Epidemic.

Diabetes Care 2016, 39:472â&#x20AC;&#x201C;485. DOI: 10.2337/dc15-1536.

7. Scobzak,

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and

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(2018).

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https://www.thebodypositive.org/ 8. Muttarak, R. (2018). Normalization of Plus Size and the Danger of Unseen Overweight and Obesity in England. Obesity 26, 1125â&#x20AC;&#x201C;1129. doi:10.1002/oby.22204.

9. Kementerian Kesehatan. (2017). Panduan Pelaksanaan: Gerakan Nusantara Tekan Angka Obesitas (GENTAS). Jakarta: Kemnkes RI. 10. Kemp,

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https://wearesocial.com/uk/blog/2018/01/global-digital-report-2018.

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ABSTRACT

Background and objectives The expanding diabetes epidemic worldwide could have potentially devastating effects on the development of healthcare systems and economies in developing countries, both in terms of direct health care costs and loss of working time and disability. This study aims to review evidence on the burden, expenditure, complications, treatment, and outcomes of diabetes in Indonesia and its implications on the current health system developments.

Methods We conducted a comprehensive literature review together with a review of published data from the Ministry of Health and lecture books. Studies presenting evidence on prevalence, incidence, mortality, costs, complications and cost of complications, treatment, and outcomes were included in the analysis.

Results In 2015, diabetics in Indonesia were estimated at 10 million people with an age range of 20-79 years (quoted from the International Diabetes Federation). However, only about half of them are aware of their condition. The Riskesdas (Basic Health Research) study from the Indonesian Ministry of Health in 2013 resulted around 12 million Indonesians over the age of 15 suffer from type 2 diabetes. This means 6.9 percent of the total population aged over 15 years. But only 26 percent have been diagnosed, while the rest are not aware of themselves as type 2 diabetics.

The high number of Diabetes Mellitus has led Indonesia to become one of the countries with the number of adult sufferers (20-79 years) Diabetes Mellitus and the highest health care expenditure ranked 9th in the world in 2017 (IDF, 2017).

At present, nearly half a billion people live with diabetes. Low and middle income countries carry almost 80% of the diabetes burden. Rapid urbanization, unhealthy diets and increasingly sedentary lifestyles have resulted in previously unheard higher rates of obesity and diabetes and many countries do not have adequate resources to provide preventive or medical care for their populations.

Up-to-date studies and analysis reveal clearly that we need a robust and more dynamic response not only from different governmental sectors, but also from civil societies, patient organizations, food producers and pharmaceutical manufacturers.(IDF,2017)

Discussion the relationship between obesity and diabetes, and how they relate, what are the risk factors and complications that can occur in the sufferer

Conclusions If left unaddressed, the growing prevalence of diabetes in the country will pose a tremendous challenge to the Indonesian healthcare system, particularly in view of the Governmentâ&#x20AC;&#x2122;s 2010

1

mandate to achieve universal health coverage by 2014. Essential steps to address this issue would include: placing diabetes and non-communicable diseases high on the Government agenda and creating a national plan; identifying disparities and priority areas for Indonesia; developing a framework for coordinated actions between all relevant stakeholders.

Keywords:Â Diabetes mellitus, Diabetes costs, Diabetes complications,

Indonesia

2

PCC EAMSC 2018

DIABETES AND OBESE

GROUP MEMBERS : AGUNG RAHMAT FAUZI FEBRIANTO ADI HUSODO NUR INDAH PITALOKA RAHMA SILFIYANI

Hang Tuah University Surabaya 2018

Introduction Diabetes Mellitus (DM) is a chronic disorder that can alter carbohydrate, protein, and fat metabolism. It is caused by the absence of insulin secretion due to either the progressive or marked inability of the β-Langerhans islet cells of the pancreas to produce insulin, or due to defects in insulin uptake in the peripheral tissue. Insulin is a hormone that regulates blood sugar levels. As a result, there is an increase in concentration in the blood (hyperglycemia). We often encounter people with Diabetes mellitus anywhere, and it is a health problem that the incidence rate continues to increase from year to year.

DM is classified on the basis of the pathogenic process that leads to hyperglycemia, as opposed to earlier criteria such as age of onset or type of therapy. Type 1 DM is the result of complete or near-total insulin deficiency. Type 2 DM is a heterogeneous group of disorders characterized by variable degrees of insulin resistance, impaired insulin secretion, and increased glucose production. Distinct genetic and metabolic defects in insulin action and/or secretion give rise to the common phenotype of hyperglycemia in type 2 DM and have important potential therapeutic implications now that pharmacologic agents are available to target specific metabolic derangements.

Type 2 DM is preceded by a period of abnormal glucose homeostasis classified as impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Two features of the current classification of DM merit emphasis from previous classifications. First, the terms insulin dependent diabetes mellitus (IDDM) and noninsulin-dependent diabetes mellitus (NIDDM) are obsolete. Because many individuals with type 2 DM eventually require insulin treatment for control of glycemia, the use of the term NIDDM generated considerable confusion. A second difference is that age or treatment modality is not a criterion. Although type 1 DM most commonly develops before the age of 30, an autoimmune beta cell destructive process can develop at any age. It is estimated that between 5 and 10% of individuals who develop DM after age 30 years have type 1 DM. Although type 2 DM more typically develops with increasing age, it is now being diagnosed more frequently in children and young adults, particularly in obese adolescents.

From various epidemiological studies in Indonesia conducted by diabetes centers, around the 1980s the prevalence of diabetes mellitus in the population aged 15 years and over was 1.5-2.3% with a prevalence in rural areas lower than urban areas.

In 2015, diabetics in Indonesia were estimated at 10 million people with an age range of 20-79 years (quoted from the International Diabetes Federation). However, only about half of them are aware of their condition. The Riskesdas (Basic Health Research) study from the Indonesian Ministry of Health in 2013 resulted around 12 million Indonesians over the age of 15 suffer from type 2 diabetes. This means 6.9

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percent of the total population aged over 15 years. But only 26 percent have been diagnosed, while the rest are not aware of themselves as type 2 diabetics.

The high number of Diabetes Mellitus has led Indonesia to become one of the countries with the number of adult sufferers (20-79 years) Diabetes Mellitus and the highest health care expenditure ranked 9th in the world in 2017 (IDF, 2017).

At present, nearly half a billion people live with diabetes. Low and middle income countries carry almost 80% of the diabetes burden. Rapid urbanization, unhealthy diets and increasingly sedentary lifestyles have resulted in previously unheard higher rates of obesity and diabetes and many countries do not have adequate resources to provide preventive or medical care for their populations. Up-to-date studies and analysis reveal clearly that we need a robust and more d y n a m i c r e s p o n s e n o t o n l y f r o m d i ff e r e n t governmental sectors, but also from civil societies, patient organizations, food producers and pharmaceutical manufacturers.(IDF,2017) Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health. A crude population measure of obesity is the body mass index (BMI), a personâ&#x20AC;&#x2122;s weight (in kilograms) divided by the square of his or her height (in metres). A person with a BMI of 30 or more is generally considered obese. A person with a BMI equal to or more than 25 is considered overweight.

Overweight and obesity are major risk factors for a number of chronic diseases, including diabetes, cardiovascular diseases and cancer. Once considered a problem only in high income countries, overweight and obesity are now dramatically on the rise in low- and middle-income countries, particularly in urban settings.

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Outlined Problem Diabetes and obesity Cells in the human body need energy from glucose to function normally. The hormone insulin usually controls sugar levels in the blood. Insulin helps cells take and use glucose from the bloodstream. If the body lacks relative insulin, it means that blood sugar levels are very high due to excessive intake so insulin levels appear to be reduced; or resistance to insulin appears on body cells, blood glucose levels will increase dramatically. This is what triggers and causes diabetes (diabetes mellitus).

Type 2 diabetes usually occurs in people who have excess body weight and lack of physical movement. Usually an inactive lifestyle triggers this disease. This is the main reason why type 2 diabetes has always been found in adults. But now, the number of type 2 diabetics in children is also starting to increase.

Obesity is associated with an increased risk of developing insulin resistance and type 2 diabetes. In obese individuals, adipose tissue releases increased amounts of non-esterified fatty acids, glycerol, hormones, pro- inflammatory cytokines and other factors that are involved in the development of insulin resistance. When insulin resistance is accompanied by dysfunction of pancreatic islet β-cells — the cells that release insulin — failure to control blood glucose levels results. Abnormalities in β-cell function are therefore critical in defining the risk and development of type 2 diabetes. This knowledge is fostering exploration of the molecular and genetic basis of the disease and new approaches to its treatment and prevention.

Obesity is associated with several conditions, the most devastating of which may be type 2 diabetes.

At the turn of this century 171 million individuals were estimated to have diabetes, and this is expected to increase to 366 million by 2030.

Both obesity and type 2 diabetes are associated with insulin resistance. But most obese, insulinresistant individuals do not develop hyperglycaemia. Under normal conditions, the pancreatic islet β-cells increase insulin release sufficiently to overcome the reduced efficiency of insulin action, thereby maintaining normal glucose tolerance. For obesity and insulin resistance to be associated with type 2 diabetes, βcells must be unable to compensate fully for decreased insulin sensitivity. β-cell dysfunction exists in individuals who are at high risk of developing the disease even when their glucose levels are still normal. Non-esterified fatty acids (NEFAs) induce insulin resistance and impair βcell function, making them a likely culprit.

Risk Factors Diabetes mellitus risk factors can be grouped into risk factors are modifiable and unmodifiable. Unmodified risk factors are race and ethnicity, age, sex, family history of diabetes mellitus, history of giving birth to babies weighing more than 4000 grams, and history of birth with low birth weight (less than 2500 grams). While the

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risk factors that can be modified are closely related to unhealthy life behaviors, namely overweight, abdominal / central obesity, lack of physical activities, hypertension, dislipidemia, unhealthy / unbalanced diet, history of impaired glucose or disturbed fasting blood sugar, and smoking.

Complications Hyperglycemia that occurs from time to time can cause damage to various body systems, especially nerves and blood vessels. Some of the consequences of diabetes that often occur are: a. Increased risk of heart disease and stroke b. Neuropathy in the legs increases the incidence of foot ulcers, infections, and even the necessity for leg amputation. c. Diabetic retinopathy, which is one of the main causes of blindness, results from damage to small blood vessels in the retina. d. Diabetes is one of the main causes of kidney failure e. The risk of death in general diabetics is double compared to non-diabetics.

With proper metabolic control, keeping blood sugar levels in the normal category, complications due to diabetes can be prevented / delayed.

Percentage of DM complications in Dr. Cipto Mangunkusumo Jakarta (RSCM) is as follows.

" Most complications are neuropathy experienced by 54% of people with diabetes mellitus who were treated at the RSCM in 2011 followed by diabetic reitnopathy and proteinuria.

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Solution Policies to overcome rising obesity The obesity rate is increasing in various places over the last few years. The government has any right change the existing policies, such as increasing the price of fuel for personal transportation in addition to public transportation (such as private vehicles) so we expect that people will prefer to use public transportation rather than private transportation with the consequence that they have to walk to public transportation, for example. So it will increase their daily activities.

For another option, the government has any right to apply such policies in several developed countries. Developed countries like United Kingdom, Japan, and United States, they has a policies that deserve to be imitated like high-priced motor vehicles, so it makes people reluctant to buy their own vehicles. After all, people will prefer to walking on the sidewalk as their daily habit, or using bicycles. This is kind of a good way to get used to healthy life.

Media campaigns increase awareness of healthier food consumption A number of public health media campaigns to raise public awareness about healthy nutrition choices have been launched in developed countries. Mass media campaigns help reach a broadly targeted audience and increase public awareness about the importance of adequate consumption of fruits and vegetables. Like in Australia, the LiveLighter campaign was found to increase population level awareness, compared to other obesity campaigns (Morley et al., 2016). But this campaign must be maintained for a longer period of time to change behavior.

Campaigns in the mass media to reduce consumption of high-calorie foods can use TV, internet, radio, cinema, billboards and public transportation advertisements. like in New York City, the message to reduce the consumption of sugary drinks has been broadcast well in English. which hope this health promotion campaign will encourage parents to provide healthy food choices for children and their families.

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Conclusion Obesity and type 2 diabetes both present significant public health challenges. The link between the two conditions is important because obesity substantially increases the risk of type 2 diabetes. Type 2 diabetes contributes to a range of long-term health conditions including cardiovascular disease and microvasular complications including eye disease, foot disease and chronic kidney disease. People living in deprived areas and some minority ethnic groups are at particularly high risk of developing type 2 diabetes.

The prevalence of both obesity and type 2 diabetes continue to rise in anywhere, along with associated direct patient care costs and wider costs to society.

The purpose of this paper is to describe the relationship between obesity and type 2 diabetes and how to solve it.

Recommendation Healthy lifestyle management Obesity treatment involve more attention to these three important things in lifestyle, these are : dietary habits, physical activity, and behaviour modification. Because obesity is basically causes by an energy imbalance habits, all patients must learn how to and when energy (diet) is consumed, how and when that energy used (physical activity), and how to put it into their daily lives (behavioral therapy). Lifestyle management has been proven to produce regular weight loss (usually 3-5 kg) when compared to usual treatment or no treatmen at all.

Diet therapy The main focus of diet therapy is to reduce overall calorie consumption. Guidelines from the National Heart, Lung, and Blood Institute recommend starting treatment with a 500-1000 kcal / d calorie deficit compared to the patient's diet habits. This decreasement should consistent with the goal of losing ~1-2 lbs per week. Calorie deficits can be institutionalized through food substitution. The examples, include choosing a smaller portion size, eating more fruits and vegetables, consuming more whole-grain cereals, choosing leaner meat and skim milk products, reducing consumption of fried foods and other foods with added fat and oil, and drinking water as a substitute for sugar or sweet drinks. It is important that diet counseling remains patient-centered and that the goals set are practical, realistic and achievable.

Another dietary approach to consider which based on the concept of energy density, is pay more attention to the number of calories contained in food per unit of weight. People tend to swallow a constant volume of food regardless of the calorie content or macronutrients. Adding water to food or consuming fibrous food reduces their energy density by increasing weight without affecting calorie content. Examples of foods with low energy density include soups, fruits, vegetables, oatmeal, and lean meat. Dry foods and highfat foods such as pretzels, cheese, egg yolks, potato chips, and red meat have high density energy. Diets that contain low-energy-dense foods have been shown to control hunger and thus produce a decrease in calorie intake and weight loss.

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Physical Examination Therapy Although only routine exercising is effective enough to lose weight, a combination of dietary modification and exercise is the most effective behavioral approach to the treatment of obesity. The most important role of exercise is to maintain weight. The 2008 Physical Activity Guidelines for Americans (www.health.gov/paguidelines) recommend that adults should be involved in 150 minutes of moderate intensity in exercise or 75 minutes a week of high intensity aerobic physical activity per week, carried out in set of at least 10 min and should be done gradually in one week.

Focusing on simple ways to add physical activity to relaxing daily routines through recreational activities, travel and domestic work should be recommended. Such as walking, using stairs, doing housework and yard work, and being involved in any kind of sports. Asking the patient to use a pedometer or accelerometer to monitor the total accumulation of steps taken as part of daily life activities is a useful strategy. The number of steps is strongly correlated with the level of activity. Research has shown that lifestyle activities are as effective as structured exercise programs to improve cardiorespiratory fitness and weight loss. High levels of physical activity (> 300 minutes of moderate intensity activity per week) are often needed to lose weight and maintain weight loss. This exercise recommendation is a little discomforting for most patients and needs to be implemented in stages. Consultation with a sports physiologist or personal trainer can help.

Prevention - Regularly checking health and follow the doctor's advices - Overcome the disease with appropriate and regular treatment - Maintain a healthy diet with balanced nutrition - Try to doing physical activities in safety ways - Avoiding the cigarettes, alcohol, and another carcinogenic substances

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References World Health Organization (2016) Diabetes Contry Profiles. Available at : https://www.who.int/ diabetes/country-profiles/idn_en.pdf . (Accessed at : 12 October 2018) Organisation for Economic Cooperation and Development (2017) Obesity Update 2017. Available at : http://www.oecd.org/health/health-systems/Obesity-Update-2017.pdf . (Accessed at : 14 October 2018) Kahn, SE. , Hull, RL. , Utzschneider, KM. , Mechanisms linking obesity to insulin resistance and type 2 diabetes. (Accessed at : 17 October 2018) IDF Diabetes Atlas (2017) , eighth edition Kasper, DL. , Braunwald, E. , Hauser, S. , Longo, D. , Jameson, JL. , Fauci, AS. Harrisonâ&#x20AC;&#x2122;s Principle of Internal Medicine. (Accessed at : 17 October 2018) American Diabetes Association (2015) Facts About Type 2. Available at : www.diabetes.org/diabetesbasics/type-2/facts-about-type-2.html . (Accessed at : 17 October 2018) National Center for Biotechnology Information (2014) Mechanism linking diabetes mellitus and obesity.

Available at : www.ncbi.nlm.nih.gov/pmc/articles/PMC4259868/ . (Accessed at : 19 October 2018) National Center for Biotechnology Information (2017) Overweight and Obesity in Indonesia : prevalence and risk factors-a literature review. Available at : https://www.ncbi.nlm.nih.gov/m/pubmed/ 28404492/ . (Accessed at : 20 October 2018) Chinnala, KM. , Boini, KM. (2004) Obesity : An overview on its current perspectives and treatment options. Biomed Central. Available at : https://nutritionj.biomedcentral.com/articles/ 10.1186/1475-2891-3-3 . (Accessed at : 20 October 2018)

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Appendix Both obesity and diabetes mellitus are important independent risk factors for the development of cardiovascular disease. Obesity is the leading risk factor for type 2 diabetes. The Centers for Disease Control and Prevention report that 32% of white and 53% of black women are obese. Women with a body mass index (BMI) of 30 kg/m2 have a 28 times greater risk of developing diabetes than do women of normal weight.

The risk of diabetes is 93 times greater if the BMI is 35 kg/m2.

The presence of diabetes can increase a woman's risk of heart disease 2-fold. In addition, the presence of diabetes overshadows the protective effects of the premenopausal state. In 2007, 11.5 million of all women over the age of 20 (10.2%) had diabetes, and rates were slightly higher in ethnic minority groups: 10.4% in Hispanic women and 11.8% in non-Hispanic black women.2 The national prevalence rates of diabetes have increased in parallel with the rates of obesity

Screening Screening for obesity and diabetes is the 1st step to treatment and often reveals individuals who are at risk for but do not yet have overt disease. The United States Preventive Services Task Force (USPSTF) recommends that all adults be screened for obesity. Obesity signifies excess adipose tissue. The most widely used method for screening is determination of the BMI. The BMI is weight in kilograms divided by height in meters squared (BMI = kg/ m 2 ) ( Ta b l e I ) . M o s t electronic medical records automatically calculate BMI if height and weight are entered. There are also many smart-phone applications and online calculators that can calculate BMI (for example,

http://

www.nhlbisupport.com/bmi). Other screening tools include waist circumference and the waist-to-hip ratio. In women, a waist circumference >35 in (88 cm) or a waist-to-hip ratio >0.7 indicates excess visceral fat and increased risk for disease.

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