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Breast-milk as the Natural Functional Food:

Nutrition and the gut microbiota to brain development

(A report by Saptawati Bardosono)

Following all the talks regarding to the use pre and probiotics during the two days meeting, the following are the reports:

Milk, is the only food ever “designed” specifically to feed human, in which its composition is used as gold standard for estimating nutrient and energy requirements for infants, and manufacturing infant formulas. We still need to understand thoroughly what is in human milk and what it all does may improve human health than other food, which makes human milk or breast milk as natural functional food.

Human milk has long been considered sterile unless contaminated or collected from infected gland. And, even as human milk banks it is a pasteurize milk, in which no one would have ever suggested adding bacteria back to the milk. Until recently, formula manufactures would not dream of adding bacteria to their products. But, why the paradigm shift? It is because of the evolution of methods and then the fact that nothing is likely sterile. As now we characterizing microbial communities in human milk, i.e. diverse bacterial genera identified in every sample with high level of variability among women and in which there are bacterial fingerprints within a woman (McGuire, Espghan 2017). Again, the paradigm shift as milk, even when produced by healthy women, contains bacteria, and many of these bacteria would/could be considered as potentially pathogenic.

There are several factors that are believed associated with variation in the milk microbiome, such as:

  • Time of postpartum, i.e. milk microbial community structure is relatively stable over time,

  • Delivery mode, i.e. C-section associated with decrease diversity in milk, increase total bacteria, and trend toward higher relative abundance of propionibacterium,

  • Maternal diet, i.e. there is positive correlations between fermiculates to total energy, lipids, carbohydrates and fiber in diet, additionally when women consume probiotic bacteria, they find their way to the milk,

  • Other milk components, i.e. HMO and immune cells. HMO stimulate growth of milk-derived Staphylococcus, and milk also have immune cell distributions in which there is a relationship between immune cells in milk ad microbial community in milk,

  • Childcare, i.e. increase of milk microbiome diversity related to the increase of social networks,

  • Maternal genetics and environmental microbial exposure, i.e. skin, infant mouth, environment and maternal GI tract are the origin of milk microbiota.

Starting to learn the evolution of gut symbiont, then Lactobacillus reuteri can be used as a model of vertebrae gut symbiont evolution. Along the way, there is a diversification of the gut symbiont Lactobacillus reuteri as a result of host-driven evolution. This happened to all vertebrae species, i.e. rodent, poultry, pig and also human. Specifically for Lactobacillus reuteri, the epithelial selection is highly specific in rodent as compare to the non-rodents, i.e. pig and human, because there is a fundamentally different trend of genome evolution in Lactobacillus reuteri. The phenomenon is caused by several factors, including the very homogeneous, smaller genome, reductive evolution, and population bottleneck. It is also evident in human population, in which the gut microbiota in rural Papua New Guineans significantly different as compared to the Americans.

What are the roles of Lactobacillus reuteri? From the animal study, firstly, it plays role as aryl hydrocarbon receptor (AHR) ligands derived from tryptophan catabolism from the diet that works in lamina propria of the gut as protection against colitis. Secondly, it plays role in the astrocyte as protection against central nervous system inflammation. Thus, Lactobacillus reuteri is beneficial both for gastrointestinal tract and the brain of the host. However, there is a harmful issue for the “modern” lifestyle that might have been unfavorable to L. reuteri. For further detailed, please find it in Marsland, Nature Medicine, 2016.

Next is, what is already known about L. reuteri?

  • Wu et al (2013) from Neurogastroenterol Motil 25, explained how L. reuteri DSM 17938 increased colon propulsive peristaltis. Dunn’s multiple comparisons tests shows how loperamide decreases propulsive contractile clusters frequency and velocity ex vivo and decreases defecation frequency in vivo. And, decreased motility ex vivo or in vivo is reversed by L. reuteri DSM 17938;

  • Perez-Burgos et al (2015) from J Physiol 593(17):3943-57 shows how L. reuteri DSM 17938 block the capsaicin stimulation of transient receptor potential cation channel subtype V1 (TRPV1) as receptor within minutes to reduce pain.

In conclusion on the issues, the following are the mode of action of L. reuteri DSM 17938:

  1. Decreased inflammation

  2. Reduced dysbiosis

  3. Improved gut motility

  4. Decreased visceral pain.

In clinical practice, there are evidences regarding to L. reuteri DSM 17938 and infant’s colic. RCT double-blinded studies design that showed the treatment success (i.e. decreasing crying time) in breast-fed infants by providing 108 CFU of L. reuteri as compared to placebo for 21–28 days are study by Savino (J Pediatr 2010), Szajewska (J Pediatr 2013), Chau (J Pediatr 2014), and Miu (2015). While one study by Sung (BMJ 2014) failed to prove it, which might be due to the use of mix breast-milk and formula milk. However, a meta-analytical approach by pooled results of the five RCTs in reporting on crying assessed on day-21 shows that L. reuteri DSM 17938 reduce the crying time in day-21 by 47 minutes (95%CI: -68 to -19). Another preventive trial (“Prophylactic use of a probiotic in the prevention of colic, regurgitation and functional constipation”) also shows approximately 40 minutes reduction in crying time in infants with infantile colic.

In the case of functional constipation in children, the evidences on the use of probiotics are shown by seven studies, i.e. Coccorullo (2010) by using L. reuteri DSM 17938, Guerra (2011) by using B. longum, and Bu (2007) by using L. casei rhamnosus Lcr 35, were significantly proven, while Wojtyniak (2017) by using L. casei rhamnosus Lcr 35, Banaszkiewicz (2005) by using LGG, Tobers (2011) by using B. lactis DN 173010, and Sadeghzadeh (2014) by using mixture of 7 strains, were not significantly proven.

And, in the case of functional abdominal pain, five RCTs with the use of L. reuteri DSM 17938 showed the evidences as follows:

  • Romano (2014) provided 2x108 CFU to 6–16 years old children for 4 weeks proved the reduction of both severity and frequency of pain;

  • Weizman (2016) provided 108 CFU to 6–15 years old children for 4 weeks proved the reduction of both severity and frequency of pain;

  • Jadresin (2016) provided 108 CFU to 4–18 years old children for 12 weeks proved the increased days free of pain;

  • Eftekhari (2015) provided 108 CFU to 4–16 years old children for 4 weeks showed no significant finding;

  • Maragdkoudaki (2017) provided 2x108 CFU to 5–16 years old children for 4 weeks showed no significant finding.

By a meta-analytical approach of pooled results from the four RCTs (minus Eftekhari), Szajewska (unpublished) shows on more than 50% reduction in pain score (95% CI of 42% to 68%) with relative benefit increased by 57% and number needed to treat (NNT) was 4 (3–8). However, given the positive evidences to use L. reuteri to help functional gastro-intestinal disorders (FGID), we should still consider the five steps of safety, tolerability, effectiveness, price and simplicity.

New issue is released on the association between periodontitis and preterm delivery. By definition, gingivitis is the inflammation of the gingival tissue without loss of teeth, in which gingivitis can advance to periodontitis or less and is considered a reversible form of periodontal disease. In which, periodontitis is a chronic infection that involves the destruction of the structures “around the tooth” to the loss of teeth themselves. Abhijit N Gurav (E World J Diab 2016;7:50-66) explain that there are associations between periodontitis and systemic disease, including preterm delivery. There is direct pathway to reach placenta, in which either trough vaginal or cesarean delivery, as stated as in utero colonization hypothesis: the placenta harbors its microbiome, i.e. colonization of the gut begins in utero. This is controversially to the sterile womb paradigm, i.e. fetus and placenta are sterile and the gut microbiome is acquired after birth (Perez-Munoz Microbiome, 2017).

In the oral cavity more than 900 species are present, and there is indirect pathway to reach placenta. First, it will reach the gut entering the epithelial villus to reach lamina propria and then it will be captured by lymphocyte to be able to flow through mesenteric lymph node to the blood stream.

In relation to preterm delivery, it starts from the maternal microbiomes’ status from the oral, vagina and intestinal, whether it is in a normal or dysbiosis condition. In a normal condition, it will lead to normal metabolome (e.g. short-chain fatty acids), normal inflammasome (e.g. IL-6, IL-8, IL-4 and IL-10), and normal T-cell subsets (Th-1, Th-17 and T-reg), resulting to a term delivery. On the other hand, a dysbiosis condition will lead to altered metabolome, inflammasome and T-cell subsets, resulting to a preterm delivery. Further explanation is through fetal intestine derived inflammation, in which there are bacterial translocation and induction of inflammation, resulting to the synthesis and release of uterotonins that trigger preterm labor. A related RCT on regular consumption of Lactobacillus reuteri-containing lozenges was proven to reduce pregnancy gingivitis (J Clin Periodontal, 2016). In conclusion, the oral microbiota plays an important role during pregnancy. Thus, the effects of the change of the oral microbiota with probiotic supplementation may have beneficial effects on pregnancy and the health of the newborn.

We know that human milk beside containing probiotic (e.g. Lactobacillus reuteri), it contains oligosaccharides that plays role as prebiotic, along with other macronutrients, i.e. protein 12%, fat 35%, lactose 65%, and oligosahharides 5–15 % (Bode L, J Nutr 2006;136:2127-30; Bode L, Nutr Rev 2009;67:S183-91; Bode L, Glycobiology 2012;22:1147-62; Bode L, Early Hum Dev 2015;91:619-22). If we compare them to the contents of cow’s milk, then cow’s milk containing protein 35%, fat 35%, lactose 45%, and oligosaccharides 0.05%. We also know that human milk oligosaccharides (HMO) are complex sugars, that can be broken down to glucose, galactose, fructose, N-acetyl-glucosamine, and N-acetylsuraminic acid sialic acid. There are 150–200 different HMO in accordance to its structural diversity and effects of the highly structure-specific, that could be affected by maternal factors as drivers of HMO composition, as follows: genetic (secretor/Lewis) factor, epigenetics (?), environment (diet, lifestyle/exercise), exposures (smoking, drugs etc.), health/disease, parity, and infant gender.

In relation to infant health and disease, there is a hypothesis that HMO contributes to lower necrotizing enterocolitis (NEC) incidence in breast-fed infants. Jantscher-Krenn E et al (Gut 2012;61:1417-25) can prove that:

  • HMO improve survival and reduce pathology scores,

  • HMO with two sialic acids are most effective in reducing pathology score,

  • HMO 2 (disialyl-lacto-N-tetraose) is most effective in reducing pathology scores.

Last but not least, for priming for health, there is a microbiome-gut-brain axis in early life (by Prof. John F. Cryan). By animation we can recall how “Geppetto”, made up and controlling the moving puppet “Pinocchio” by using several strings, and the control of the movement is actually the microbiome. The detailed explanations are by using articles on 1) neuroscience, molecular biology, and the childhood roots of health disparities, and 2) maternal prenatal stress is associated with the infant intestinal microbiota. There are prenatal and postnatal influences of infant’s microbiome, in which it is a missing part of the early life and we have to realize that we are living in a microbial world in each part of our body.

It is clearly understood that the uterus is sterile and the first major exposure to bacteria was during birth resulting to post natal colonization in the gut. Thus, the programming of the infant gut microbiota is from several sources, i.e. delivery mode, maternal microbiota status, first feeding, the use of antibiotics, etc. An infant born from a mother with maternal inflammation caused by prenatal stress, with gut microbiome dysbiosis and delivered by Caesarian section will have a gastro-intestinal dysfunction leaky gut. This will lead to metabolic disorders and disturbed crosstalk gut-brain system that result to cognitive and behavior deficits resulting from disturbance in signaling along the brain-gut-microbiota axis via the role of vagus nerve.

In relation to the signaling along the brain-gut microbiota axis, there is also a crosstalk between diet-derived macro and micronutrients, the microbiota and its metabolites, and the brain.

This will result to the fact that normal gut microbiota modulates brain development and behavior. Even it is proven to play role in the regulation of prefrontal cortex myelination, and also resulting to social deficit in mice lacking microbes. It is then leading toward effective probiotics for autism ad other neurodevelopment disorders. Thus, microbes are thought to be our friends with social benefits as drivers of brain evolution and development.

There are inter-connections between visceral pain, stress and microbiota, in which microbiota controls visceral hypersensitivity. Several studies show as follows:

  • There are changes in pain-related brain areas of germ free mice;

  • Early life antibiotic administration increases visceral pain in adulthood;

  • There are association between microbiota, neurodevelopment and metal illness

Thus, pre- and probiotics could play role as psychobiotics, as a novel class of psychotropic through a psychobiotic revolution. Prebiotics have anxiolytic and antidepressant-like effects and reserve the impact of chronic stress in mice. In the future, there might be a fecal microbiota transplantation that could modifiy behavior from healthy to depressed person.

We know already about feeding the brain and nurturing the mind but still lacking to know on the linking between nutrition and the gut microbiota to brain development. It was long postulated by Hippocrates to let food be our medicine. Thus, we can use foods to heal our body because there is association between stress and the microbiota-gut-brain axis in health and disease. And, our first food is breast-milk that it can be certainly called as functional food.

PT Sarihusada Generasi Mahardhika (Sarihusada) dan PT Nutricia Indonesia Sejahtera(Nutricia) bersama Indonesia Nutrition Association (INA) yang didukung oleh Pemerintah Kota Yogyakarta mengajak warga kota Gudeg mengikuti acara Karnaval Ayo Melek Gizi (AMG) 2017.

Karnaval yang dilakukan dari Benteng Vrederburg menuju Taman Pintar ini merupakan bagian dari rangkaian program edukasi gizi seimbang yang dilakukan oleh Sarihusada dan Nutricia yang tergabung dalam Danone Early Life Nutrition (ELN) dalam rangka memperingati Hari Gizi Nasional 2017 yang jatuh di tanggal 25 Januari setiap tahun.

Hari Gizi Nasional merupakan momen yang tepat untuk mengingatkan pentingnya kerja sama antar pemangku kepentingan dalam mendukung peningkatan status gizi masyarakat.

Saat ini Indonesia masih menghadapi masalah gizi ganda, yaitu kekurangan dan kelebihan gizi. Riskesdas 2013 mengungkapkan 1 dari 3 anak tergolong pendek (stunting) akibat kekurangan gizi menahun sehingga berisiko mengalami gangguan pertumbuhan dan perkembangan.

Di sisi lain, prevalensi kelebihan gizi juga meningkat. Angka overweight dan obesitas pada pria adalah 20% sementara wanita sebesar 35%. Obesitas dapat menjadi awal dari berbagai penyakit.

Di Yogyakarta sendiri, meskipun angka malnutrisi masih jauh di bawah angka nasional, 15,2% anak usia 5-12 tahun masih mengalami kekurangan energi, terutama mereka yang tinggal di daerah perkotaan.

Sementara itu penduduk yang tinggal di daerah perdesaan lebih banyak mengalami kekurangan protein (41,0%) dibanding yang tinggal di daerah perkotaan sebesar 36,5%1.

Drs. Sulistiyo, SH.CN.M.Si, Penjabat Walikota Yogyakarta mengungkapkan pemerintah Kota Yogyakarta sangat mendukung upaya pihak swasta dalam mengedukasi masyarakat tentang gizi seimbang melalui Karnaval Ayo Melek Gizi 2017.

"Untuk menghadapi permasalahan gizi memang dibutuhkan kolaborasi antara pemerintah, sektor industri, asosiasi dan masyarakat,” ungkap Drs. Sulistiyo, SH.CN.M.Si.

Sementara itu, Dr. dr. Luciana B Sutanto, MS, SpGK mengatakan bahwa orang tua harus memahami apa yang baik dikonsumsi oleh seluruh anggota keluarga. Pengetahuan tentang gizi seimbang sebaiknya mudah diaplikasikan dalam pola makan sehari-hari dan tepat nilai gizinya.

“Keluarga bisa berpedoman pada Piring Makanku kala menyediakan hidangan dalam porsi sekali makan, sehingga anak maupun orang tua selalu memeroleh variasi asupan gizi seperti karbohidrat, lemak, protein, vitamin, mineral, serat dan air dalam jumlah yang cukup,” jelas Dr. dr. Luciana B Sutanto, MS, SpGK.

Menurut dr. Luciana, untuk porsi sekali makan, piring bisa diisi detengahnya dengan makanan pokok seperti nasi atau roti dan lauk-pauk, sementara setengah bagian sisanya dipenuhi dengan sayur dan buah-buahan. Di samping itu, konsumsi gula, garam dan minyak harus dibatasi.

Untuk mendukung pola makan bergizi seimbang sekaligus mempromosikan keunggulan bahan pangan lokal, sebelum memulai jalan sehat peserta Karnaval AMG 2017 yang berjumlah lebih dari 500 orang diajak untuk menikmati sarapan bersama berdasarkan pedoman Piring Makanku.

Uniknya, makanan yang disajikan berbahan dasar bahan pangan lokal Yogyakarta seperti thiwul, telur bacam dan sayur lombok ijo.

“Bahan pangan lokal biasanya harganya lebih ekonomis, sehingga masyarakat berkesempatan untuk memperoleh jenis makanan yang lebih bervariasi,” lanjut Dr. dr. Luciana.

Sedangkan Ni Wayan Suriastini, Pemerhati Anak dari Yayasan Pendidikan Integral Satu Bumi mengatakan pengetahuan gizi yang baik dan benar sangat dibutuhkan oleh orang tua untuk membantu memenuhi hak-hak anak.

"Ketika membicarakan kesehatan anak secara khusus, ada dua topik penting, yaitu hak memperoleh akses kesehatan dan hak memperoleh makanan bergizi. Pada Karnaval Ayo Melek Gizi 2017 ini, kita bisa bersama-sama mengingatkan masyarakat, terutama orang tua, tentang pentingnya memberikan makanan yang bergizi pada anak,” papar Ni Wayan Suriastini.

Di tempat yang sama, Communications Director Danone di Indonesia, Arif Mujahidin mengatakan “Karnaval Ayo Melek Gizi telah memasuki tahun ketiga.

"Kali ini Sarihusada bersama Nutricia sebagai bagian dari Danone Early Life Nutrition mengajak publik menyadari pentingnya gizi seimbang dengan cara yang menyenangkan. Dengan demikian, masyarakat diharapkan memeroleh pengetahuan lebih dalam tentang nutrisi yang berujung pada perubahan perilaku konsumsi yang lebih baik dan sesuai dengan pedoman gizi seimbang,” papar Arif Mujahidin.

Karnaval AMG 2017 diisi dengan sejumlah aktivitas menarik bagi karyawan Sarihusada dan Nutricia, keluarga, maupun masyarakat umum. Salah satunya adalah funwalk atau jalan sehat dari Benteng Vrederburg menuju Taman Pintar, karena Sarihusada dan Nutricia meyakini pola makan yang baik juga harus didukung oleh aktivitas fisik yang cukup.

Para peserta funwalk mengenakan kostum tradisional dan membawa sejumlah makanan khas Yogyakarta sambil menyerukan pesan-pesan penting terkait gizi seimbang.

Seusai funwalk, semangat kolaborasi dalam mengedukasi para peserta juga dituang melalui kegiatan mendongeng untuk para peserta yang dipersembahkan oleh karyawan Sarihusada dan Nutricia bersama relawan Ayo Dongeng Indonesia dengan tema mengenal dan menikmati makanan bergizi. Selain itu, para karyawan juga berpartisipasi membawa makanan sehat buatan rumah dalam bazaar makanan bergizi.

Pada kesempatan ini, Indonesia Nutrition Association (INA) juga memberikan layanan konsultasi gratis dan edukasi yang dibuka untuk seluruh peserta dengan melibatkan 2 dokter spesialis gizi klinik dan 8 ahli gizi.

Untuk melengkapi upaya Sarihusada dan Nutricia dalam meningkatkan kesadaran tentang pola makan gizi seimbang, donasi berupa ribuan produk susu bergizi untuk keluarga juga diserahkan kepada GKR Mangkubumi selaku Ketua Forum CSR Kessos D.I. Yogyakarta.

Rangkaian kegiatan peringatan Hari Gizi Nasional 2017 oleh Sarihusada dan Nutricia berlangsung dalam periode Januari - Februari 2016.

Sebelum Karnaval AMG, Sarihusada dan Nutricia menggelar kampanye tentang pola makan bergizi dengan pedoman Piring Makanku di kanal digital. Rangkaian akan ditutup dengan peluncuran buku tentang tumbuh kembang optimal ibu dan anak, hasil kerja sama Danone ELN dengan Asosiasi Jurnalis Kesehatan.

APCCN (Asia Pacific Conference on Clinical Nutrition) merupakan seminar ilmiah tahunan bertaraf internasional yang menjadi wadah bagi para klinisi, pakar gizi dan pakar kesehatan lainnya mempresentasikan pengalaman dan keilmuannya terkait pengatasan masalah gizi di masyarakat.

Pada tgl 26-29 Januari 2015 bertempat di Shangri La Hotel, Kuala Lumpur telah diadakan APCCN yang ke - 9 dengan menyajikan tema ""Prevention and management of diseases through the life cycle: The role of nutrition and physical activity"

4 anggota INA berpartisipasi dalam event ini sebagai peserta dan Dr Diana Sunardi, MGizi, SpGK atau yang akrab dipanggil Dr Diana, membagikan pengalamannya untuk kita pada wawancara dibawah ini.

Halo Dr. Diana. Apakah boleh Dokter sharing ke kami pengalaman dokter mengikuti seminar APCCN 2015 kemarin di Kuala Lumpur.

Apa yang membuat dokter tertarik mengikuti Congress APCCN tahun ini?

APCCN merupakan event yang sangat menarik bagi praktisi Nutrisi karena, menyajikan updateilmiah dan update evidence based medicine terkait nutrisi baik untuk di rumah sakit maupun di populasi

Topik-topik sesi seminar apa saja yang dokter hadiri pada APCCN kali ini?

Sesi yang saya ikuti kali ini cukup banyak, karena sangat menarik, mulai dari nutrition and cancer, blood sugar management, probiotics, obesitas, clinical practice (hospital), update tentang lipid, dan sarcopenia

Apakah boleh kami dijelaskan satu sesi seminar yang dokter hadiri?

Judul besar: clinical practice (hospital)

Pembicara: Siti hawa M. Taib, Toh Yoon, Chulaporn R

Highlight dari seminar:

-angka hospital malnutrisi yang masih tinggi, sehingga perlu adanya skrinning dan tatalaksana yang tepat pada pasien Rumah Sakit- perlunya perhatian khusus pada pasien malnutrisi, terutama pada anak-anak, hingga didapatkan penyebab (source) dari masalah/gangguan yang menyebabkan malnutrisi melalui riwayat kesehatan orangtua dan kakak/adik, riwayat ibu selama kehamilan hingga saat melahirkan, asupan sejak lahir (ASI/formula, MP-ASI hingga saat dirawat) dan riwayat sakit, hingga pemeriksaan fisik dan laboratorium

- Pemberian nutrisi enteral juga sangat penting untuk menunjang tatalaksana nutrisi, dan jangan bergantung hanya dengan pipa naso gastrik, apalagi untuk lansia yang membutuhkan nutrisi jangka panjang.

- Pemasangan PEG direkomendasikan untuk mencegah maupun memperbaiki malnutrisi

pendapat dokter dari topik tersebut?

Sangat menarik, karena materi yang disajikan sangat aplikatif di lapangan dan berguna dalam mendukung terapi ke pasien

Apakah manfaat yang dokter rasakan dari sesi tersebut?

Banyak update yang didapat tentunya baik mengenai diagnostik maupun tatalaksana

Apakah dokter-dokter spesialis gizi klinik/ magister gizi sebaiknya mengikuti congress seperti ini? Dan kenapa?

Sangat penting, guna mendukung dalam menjalankan profesi

Apakah topik-topik yang disajikan dapat memperluas wawasan kita dalam menangani pasien di rumah sakit?

Tentunya, karena kongress ini spesifik tentang Clinical Nutrition

Pertanyaan terakhir dok, kami melihat APCCN kali ini topik-topiknya sangat menarik, bagaimana caranya kita menentukan topik yang sebaiknya kita kunjungi, apakah ada kiat tertentu agar kami bisa mendapatkan ilmu yang maksimal selama conference tersebut?

Ya betul, untuk seminar yang sangat menarik topik-topiknya kita harus memilih dan memilah sebelum hadir ke lokasi. Pertama sebagai klinisi kita pasti tahu apa yang sedang jadi "hot issue", misalnya nutrisi kanker, diabetes, obesitas, dan pasien kritis. Kedua kita amati speakernya, tentu kita akan pilih yang pakar dibidangnya. Ketiga, tentu duduk di depan agar fokus

Dr. Diana Sunardi, MGizi, SpGK adalah Dokter Spesialis Gizi Klinik, dokter yang aktif ini kesehariannya merupakan staf pengajar dan peneliti di Departemen Ilmu Gizi Klinik FKUI RSCM, beliau juga praktisi gizi di RSCM. Sebagai anggota INA, Dr Diana banyak menyumbangkan ke ilmuwannya dalam mengembangkan modul-modul dan penyuluhan nutrisi di masyarakat.

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