Parkinson’s Disease

NUTRITION MATTERS

What exactly is Parkinson’s Disease?• Progressive degenerative disorder affecting the central nervous system, primarily the motor

system, due to decreased dopamine (a neurotransmitter in the brain)

• Dopamine connects thoughts about movement to muscle activity

• When dopamine is reduced, the first systems affected are movement-related: shaking, instability, tremors, slowness, rigidity, and difficulty walking

• There is no known cause of Parkinson's Disease (PD), but its understood that chronic neuroinflammation exacerbates the loss of the dopamine neurons

• First described 200 years ago by James Parkinson, MD

• As many as 1 million Americans with 60,000 new cases per year.

Symptoms of Parkinson’s Disease

• Motor and Non-motor symptoms• Symptoms can vary greatly from person to person• Can change over time• Most people who develop the symptoms of PD do so

sometime after the age of 50, but PD can affect younger persons as well

Theories about cause of Parkinson's• The cause of most cases of PD is still unknown

• Genetics

• Environmental factors: significant exposure to pesticides or certain heavy metals, repeated head injuries. Many years can pass between exposure to an environmental factor and the appearance of PD symptoms.

• Age: more common in older adults (>50 years of age)

• Gender: Men have a higher risk of PD than women

• Race: Caucasians > African Americans or Asians.

Motor symptoms• Individuals may experience trouble with posture, balance and coordination.

• Symptoms can vary greatly from individual to individual both in terms of intensity and how they progress

• Tremor: can start in the hand, foot, or leg and can affect both sides of the body.

• Rigidity: tightness or stiffness of the limbs or torso

• Bradykinesia (slow movement) Ex: difficulties buttoning a shirt, slow handwriting, having trouble turning over in bed

• Postural instability: Inability to maintain a steady, upright posture or to prevent a fall

• Walking/gait problems

• Vocal symptoms: may become softer, some speaking may be rapid, fading, loss in normal variation in volume and emotion.

Non-motor symptoms• Depression/anxiety• Sleeping problems:

insomnia • Disturbances in the

sense of smell• Fatigue• Weight loss• Gastrointestinal issues

• Lightheadedness• Urinary

frequency/urgency/hesitancy

• Sweating• Mental processes:

thinking, word finding, and judgement.

Diagnosis• PD is usually diagnosed clinically and is often identified by a general neurologist.

• Movement disorder specialists may also be recommended

• Neurologic exams, brain imaging, MRI’s DaTscan, and PET scans are all studies that can help diagnose Parkinson’s

• Unfortunately, there are no standard biological tests for PD, such as a blood test

• Usually a team approach to help treat and manage your symptoms: nurses, physical therapists, dietitian, social workers, occupational therapists, speech therapists, neuropsychologists among others.

Treatment• Once you have been diagnosed, one should focus on improving your symptoms and

maintaining an active and positive lifestyle.

• It is possible to successfully manage symptoms through healthy choices, medications, and, in some cases, surgery

• Treatment needs change over the course of the disease

• At every stage, it is important to maintain physical activity, eat a healthy diet, and pay attention to your mental health

• Medications are adjusted throughout the course of the disease, in order to maintain the best control of symptoms and avoid major side effects.

Medications for Motor Symptoms

• Although there is no cure for PD, there are several classes of medications available for the successful treatment of motor symptoms

• Carbidopa-levodopa (Parcopa, Rytary, Sinemet): increase brain levels of dopamine. Can cause nausea, orthostatic hypotension, sleepiness, hallucinations, confusion and impulse control behaviors

• Dopamine agonists (Apokyn, Mirapex, Requip, Neupro): mimic the activity of dopamine. Can cause impulse control disorders, nausea and sleepiness

• COMT inhibitors (Comtan, Tasmar): prevent the breakdown of levodopa before it reaches the brain. Can cause abdominal pain, diarrhea, discolored urine

Medications for Motor Symptoms• MAO-B inhibitors (Azilect, Xadago, Zelapar, Eldepryl): block MAO-B enzyme in the brain which

breaks down dopamine. Can cause nausea, dry mouth, lightheadedness, constipation, and hallucinations/confusion

**Limit foods high in tyramine: aged cheeses, red wine, draft beers, smoked/fermented meats

Anticholinergics (Cogentin, Artane): reduce the characteristics of tremor or to ease the problems associated with the wearing off of levodopa therapy. Can cause confusion/hallucinations, constipation, dry mouth, and urinary problems

Amantadine: can help ease tremors as well as muscle rigidity

Deep brain stimulation (DBS): used for advanced PD, is an implantation of permanent, thin electrodes into selected deep parts of the brain. It helps “rebalance” your brain circuits and stimulate specific points for motor control.

Medications for Non-Motor Symptoms• Droxidopa: helps treat orthostatic hypotension. May cause headaches,

dizziness, nausea, hypertension, fatigue, fever and confusion

• Pimavanserin: helps treat hallucinations and delusions that may develop in advanced PD. May cause swelling of the ankles, constipation, and confusion

• Rivastigmine: can help with dementia associated with PD. May cause nausea, vomiting and loss of appetite.

Research in PD is ongoing, and new treatments may be on the way.

Nutrition Therapy• No singular diet can treat Parkinson's disease or its symptoms,

but a healthy and balanced diet can improve general well-being

• Eating fruits and vegetables may help keep you energized and hydrated

• Fiber-rich foods and fluids may help ease symptoms of constipation or low blood pressure.

Nutrition Goals for Parkinson’s Disease• Improving fiber intake

• Reducing constipation

• Maintaining hydration status

• Assessing for dysphagia and gastrointestinal problems

• Providing adequate energy to prevent weight loss or excessive weight gain due to lack of physical activity

• Preventing bone thinning and vitamin D deficiency.

Exercise and Daily Activity• In the management of PD, lifestyle is one of the first things you will want to focus on

• Several research studies have shown that regular exercise routines of walking and strength training can help to maintain or even improve mobility, balance and coordination in people with PD.

• If you did not exercise regularity before you diagnosis, or if you are unsure about your level of fitness or stamina, talk to your primary care physician

• A physical therapist is also a great resource for finding out what your body can tolerate and what you can do safely on a regular basis.

• Your PCP or neurologist can provide you with a referral to a physical therapist.

Five Food Groups• Starches: 6-11 servings/day

• Meat, fish, eggs, beans and other non-dairy proteins: 2-3 servings/day

• Milk and dairy products: 3-4 servings/day

• Fruits and vegetables: 5-9 servings/day

• Fats and Sugars: Anywhere between 1-7 portions/day depending on the needs of the individual.

Five Food Groups: Starches• Carbohydrates provide the basic fuel or energy for the body

• Typical carbohydrates are bread, potatoes, pasta, rice, cereals, biscuits, and cakes

• Those with long-term Parkinson’s may find that foods rich in carbohydrates and sugar can worsen dyskinesia.

• It is important not to exclude carbohydrates from you diet as they are important in maintaining body weight and energy levels

• Try to find a sensible balance.

Five Food Groups: Protein, Milk and Dairy• Proteins are the basic building blocks that you body needs for growth and

repair.

• Typical proteins are meat, dairy products, nuts, eggs and fish

• Dairy foods provide all three macronutrients: carbohydrates, protein and fat

• If you choose to not eat dairy products, you must ensure you are getting sufficient calcium and other nutrients by consuming other non-dairy sources of these nutrients

Protein considerations• The medication Levodopa (Sinemet) is a protein building block, so it

competes for absorption with other proteins

• Eating a high-protein meal reduces the likelihood of effectively absorbing Levodopa

• Taking medication on an empty stomach—30 minutes before or 60 minutes after a meal allows the drug to reach the small intestine and absorb faster

• However, a carbohydrate snack (crackers, toast, oatmeal) with the medication may be necessary to prevent nausea.

Protein Distribution• Some like to divide protein equally throughout the day to help with medication absorption

• Others like to use a protein redistribution diet which includes a low-protein breakfast and lunch with a high-protein dinner

• The ideal ration of protein to carbohydrates ratio is 1:5. If this is not helping you maintain optimal body weight, the ration may be increased to 1:6 and 1:7

• Decisions between these methods of protein distribution depend on the dosage, severity of the disease, and one’s lifestyle

• Always consult your physician or dietitian before implementing one of these plans.

Protein Distribution

Dividing protein equally• Breakfast: 15g protein• Lunch: 15g protein• Dinner: 15g protein

High protein dinner• Breakfast: 10g protein• Lunch: 10g protein• Dinner: 25g protein

• Most difficult to follow• High-protein dinners would interact with

Levodopa in the evening = resulting in poor control of symptoms at night.

Protein to Carbohydrate Ratio• Balances carbohydrate and protein

• Each meal and snack is planned in this ratio for best results

• The total grams of protein to be eaten at each meal is calculated (reading food labels)

• Based on the amount of protein at each meal, the grams of carbohydrate that should be eaten are calculated

• If using the 7:1 carb to protein ratio: For example, if 10g of protein is included at breakfast, 7 times that amount (7x10) or 70g of carbohydrate should be included at breakfast as well

• Balancing carbs and protein in this ratio results in the most stable blood levels, which allows for a consistent, predictable and optimal response to Levodopa.

• Allows for normal daytime eating and more flexibility in meal planning.

Five Food Groups: Fruits and Vegetables • Are good sources of fiber and are essential for healthy bowels and avoiding

constipation.

• They also contain some carbohydrate with many vitamins and minerals

• Fruits and vegetables can be eaten fresh, frozen, canned or dried

• Some studies show that increased intakes of unsaturated fatty acids and a plant-based dietary pattern (consisting of high intakes of fruit, vegetables, legumes, whole grains and nuts), plus fish may help protect against Parkinson’s.

Five Food Groups: Fats and Sugars

• Although fats and sugars can be harmful if consumed in large amounts, they are essential for producing energy so should be eaten in moderation.

• Essential fatty acids are also needed for the efficient absorption of some key vitamins in the body

Calcium and Vitamin D• It is now thought that there is a link between the severity of Parkinson’s and bone density

• Some PD individuals are at risk for falls

• Ask your doctor to assess your calcium and vitamin D to help reduce the risk of osteoporosis.

• Calcium sources: low-fat milk, fortified soy/rice beverages, fortified juice, low fat cheese/yogurt, broccoli, collard greens, spinach, kale

• Vitamin D sources: low-fat milk, fortified soy/rice beverages, fortified juice, fatty fish, fortified yogurt and sunlight

Antioxidants • Molecules that clear out free radicals—toxic substances formed from stresses like air pollution, sunlight,

cigarette smoke, and even the process of converting food to energy

• Oxidative stress is a biological condition caused by too many free radicals. It can be associated with aging and Parkinson’s disease

• A diet high in antioxidants may offset oxidative stress and cellular damage

• Vitamin E was initially thought to slow the progression of Parkinson’s but research has yet to confirm this theory

• Coenzyme Q has strong antioxidant properties, but studies do not suggest that it is an effecting Parkinson’s treatment.

• Fruits, vegetables, grains, eggs, legumes, nuts, dark chocolate and some beverages such as red wine, coffee and tea.

Other Beneficial Oils/Vitamins/Herbs/Minerals• Olive Oil contains phenols, which are powerful antioxidants. Extra-virgin is less processed so it retains more

nutrient’s

• Cinnamon may be good for cholesterol and memory

• Tumeric contains antioxidants and may help lower cholesterol

• Rosemary actually has properties similar to drugs used to treat memory loss

• Vitamin B12 is very important for the health of the brain, spinal cord and nerves. Primarily found in meat, fish and milk and fortified foods

• Folic acid is also very important for brain health. Can be found in asparagus, green leafy vegetables as well as meats, beans, seeds, fruits and fortified grain products.

• Walnuts contain omega 3 and a variety of minerals, which can be associated with a decreased risk of dementia.

What is the scoop on Fava Beans?• Fava beans contain levodopa

• Unfortunately the concentration and availability of levodopa in fava beans are unknown and likely minimal.

• The quantity that would be necessary in order to obtain an effective amount of levodopa would probably cause illness or other side effects (dyskinesia)

Other Drug-Nutrient Interactions• Iron supplements can decrease absorption of Levodopa. They should be separated from

medications by at least 2 hours.

• Antacid or indigestion tables should not be taken at the same time with Parkinson’s medications as they can also interfere with absorption.

• High-fat meals can decrease the effectiveness of medication by delaying gastric emptying.

• Those who take MAO-B inhibitors (rasagiline, selegiline) should eat with moderation—but not eliminate—foods that contain high concentrations of tyramine (could elevate blood pressure)

**cured/fermented meats or fish, aged cheeses (cheddar, swiss, blue cheese), fermented cabbage, sauerkraut, soybean products, soy sauce, red wine and tap beer

Maintaining a Healthy Weight: Weight Gain

• Parkinson’s may lead to weight gain due to reduced mobility

• Can also be an effect of some PD therapies such as DBS, dopamine antagonists (binge eating), and some psychiatric medications.

• Being overweight can strain the joints, which can make moving around more difficult.

• It can also raise your risk of heart disease and high blood pressure

Tips to Lose Weight• Try to avoid fried foods, sweet desserts, cakes, biscuits and sugary drinks

• Eat three nutritious meals per day, but limit portion sizes

• Be as active as possible

• Consult a nutritionist or dietitian to plan a healthy, gradual weight loss program.

• Be mindful that a diet too strict or low in calories may decrease your energy

Maintaining a Healthy Weight: Weight Loss• More commonly, people with Parkinson’s disease experience weight loss

• Can be due to a number of factors: loss of appetite, depression, difficulty eating/swallowing, nausea, using extra energy to cope with symptoms such as dyskinesia, or malabsorption

• Medications may also affect your body weight

• Being underweight means you can lose muscle mass and strength. It can make you more prone to osteoporosis and infection

Tips to Increase your Weight • Eat small, frequent meals, every 2

to 3 hours or eat a nutritious snack between meals

• Eats foods you enjoy• Save your energy for eating by

keeping easy-to-prepare foods on hand

• Stimulate your appetite by seasoning food with herbs, spices and sauces

• Include some high-calorie foods like cream and butter in your diet

• Consider thinking about a nutritional supplement (Carnation, Boost, Ensure)

• Avoid filling up on coffee, tea, and clear soups

• Limit fatigue by choosing foods that are easy to chew (smoothies, ground meats, soft proteins)

• Ask for help cutting proteins into smaller pieces

• Increase consumption of whole grains

Weight Maintenance• It is a good idea to weigh yourself regularity and record your weight

over a period of time.

• This can provide useful information to your dietitian or doctor if needed.

• General dietary recommendations currently include:- maintaining energy intake at 25-30kcal/kg of body weight with additional calories if you experience dyskinesia- daily protein allowance of 0.8-1g pro/kg BW

Managing Symptoms with Nutrition• Constipation• Poor appetite, nausea and vomiting• Fatigue• Heartburn, reflux and bloating• Dysphagia• Problems moving jaw, lips or tongue• Slow or uncontrolled movements• Orthostatic hypotension

Constipation• Very common in Parkinson’s disease since PD can slow the movement of the colon

• Increased fluid and fiber consumption can help maintain regularity

• Insoluble fiber: helps prevent constipation (whole wheat, vegetables, fruit, legumes, flaxseeds)

• Soluble fiber: helps lower blood cholesterol levels and regular blood sugars (legumes, oats, barley, flaxseeds, and many fruits/vegetables)

• Gradually increase your fiber intake, as too much fiber can actually cause constipation. Balance is needed between fiber and fluid.

Constipation • Choosing and eating complex carbohydrates is more likely to help with constipation than

eating processed foods and sugars.

• Aim to drink six to eight 8oz glasses of water per day

• Fluid is absorbed by the bowel to help soften stools and helps make them easier to pass

• Warm liquids, especially in the morning, can stimulate bowel movements

• Prunes can also help treat constipation

• Exercise can also be beneficial to help stimulate the bowels.

Fluids• It is important to drink plenty of fluids, preferably 8 to 10 cups daily

• Carbonated or fizzy drinks may make you feel bloated, so may be best to be avoided

• As we age, our natural thirst reduces. Some Parkinson’s medications can actually dehydrate the body. Drink regularly!

• If you have problems toileting frequently at night, you may find it better to drink mainly in the morning and early part of the day.

• If your mouth is often dry, frequent sips of water or using an oral rinse spray can help

• Sucking on candy or chewing gum can also stimulate the production of saliva which can alleviate dry mouth

• You can increase your fluid intake by eating foods with a higher water content. These include tomatoes, cucumbers, radishes, celery, broccoli, soup, popsicles, jell-o and grapefruit.

Poor appetite, nausea and vomiting• Try eating small, frequent meals

• Take medications with a small meal or snack (such as juice, a cracker, cookie or fruit)

• Drink some ginger ale; it may help reduce nausea

• To help stimulate your appetite, try bitter greens like collard and beet greens or spicy foods

• Exercise can also increase hunger

Fatigue

• Fatigue and sleep difficulties are also common symptoms of PD.

• Try to limit sugar as it can cause a spike in blood glucose and can keep you awake at night

Heartburn, Reflux and Bloating• Try eating small, frequent meals

• Limit or avoid alcohol, caffeine or carbonated drinks

• Sit upright at meals and for 45-60 minutes after eating

• Avoid smoking

• Boil, steam, bake or roast your foods. Avoid fried foods

• Limit or avoid foods that may trigger symptoms such as spices, peppermint, chocolate, citrus juices, onions, garlic and tomatoes

• Use cumin, coriander, curry leaves and lemon juice.

• Avoid using straws and sucking on hard candy to reduce gas and bloating.

Dysphagia• See your doctor if you have problems swallowing foods or liquids. You may need a swallowing

assessment.

• Can present as coughing, choking or a sensation of food feeling “stuck”

• When swallowing is compromised, food or liquid can get into the lungs and may cause aspiration PNA (leading cause of death in PD)

• A speech therapist can prescribe the appropriate, individualized dietary modifications and adaptive strategies.

• In addition, you may be asked to sit up straight, take smaller bites at a slower pace and allow for longer mealtimes.

Slow or Uncontrolled Movements• Do not skip meals

• Allow enough time to eat

• Have small portions and pre-cut foods or try finger foods

• Eat in a quiet setting.

Low blood pressure: Hypotension• Low blood pressure is a symptom of Parkinson’s and a side effect of some medications.

• Raising fluid and salt intake will help boost blood pressure, but speak with your physician, especially if you have heart or kidney problems

• Increase cold fluids: water, Gatorade, V8 juice to five 8oz glasses per day

• Limit caffeinated beverages, hot liquids and alcohol, as these encourage dehydration and lower blood pressure.

• Eating frequent, small meals can also smooth blood pressure fluctuations.

Other dietary changes to ease symptoms• Some people with Parkinson’s experience painful muscle cramping, especially at night and as

medication wears off

• Eating yellow mustard, which contains the spice turmeric, or drinking tonic water, which contains quinine may help

• Others endorse salt, vinegar or pickle juice

• Maintaining adequate hydration may also help eliminate cramping.

• Ginger can help with nausea

• Papaya is high in antioxidants, but may also contain an enzyme papain that can thin thick saliva

How Can I Help Myself? Shopping and preparing meals

• Plan meals in advance and write a list of the ingredients before going to the store.

• Think about how long you can stand preparing your meal and don’t decide on a menu that will take longer to prepare than you can cope with

• Make use of ready-prepared meals as they can be simply reheated.

• If you do not own a microwave, consider buying a small one as meals or snacks can be very simply and quickly cooked or reheated this way

How Can I Help Myself? Special Food Aids• Special aids are available for eating. Ask your OT for information on what is available to

suit your needs

• Try using cutlery that has specially adapted handles which are angled or weighted for ease of use, or “rocking” knives that can be used one handled

• Try using two-handled cups or a large mug filled only halfway to reduce spillage

• Use specially weighted cups that help prevent tremor.

• Try using a special non-slip mat under your plate to prevent it from moving as you eat.

Conclusion• While there is currently no scientific evidence that any specific

dietary factor is beneficial, a normal, healthful diet can promote overall well-being for people with Parkinson’s disease

• Primary nutrition interventions for individuals with Parkinson’s Disease should focus on healthy dietary intakes and drug-nutrient interactions.

• As your disease progresses, re-evaluation and assessment is an important component in meeting your changing health needs

Caring for those the Parkinson’s• PD not only affects the person who has been diagnosed with the

disease; it also affects family members, friends and co-workers

• If you are a care partner, consider contacting a care partner support group.

• Most groups can provide up to date information on PD, treatment strategies, and tips to assist care partners

• Apdaparkinson.org/community