GOOD NUTRITION IN PARKINSON'S DISEASE

Good nutrition is important for everyone and has a significant role in the management of Parkinson’s
disease (PD). In general, a healthy diet can increase energy, optimize the effect of medications, and
promote overall well-being, especially in a patient with PD.


Patients with PD may experience constipation, delayed stomach emptying,drug-nutrient interactions, and weight loss. Parkinson's disease affects the autonomic nervous system, resulting in slowed movement of the GI tract. An individual may experience constipation and/or delayed gastric emptying. Gastric emptying may delay or decrease effectiveness of medications. With adequate intake of fluids and fiber, constipation may be prevented. Signs and symptoms of delayed gastric emptying should be observed when determining the timing of meals and medications.


Some individuals, particularly those who experience fluctuations of PD symptoms with their
medications, may be very sensitive to the amount of protein in their diets. For these individuals, the
timing of medications and meals/snacks containing protein becomes important. With the right amount of  protein consumed at the proper intervals throughout the day, that is 30-60 minutes after medications, both optimal absorption of medications and protein needs are met.


Parkinson’s disease symptoms such as tremor and the medication side-effect of dyskinesia may increase one’s caloric needs. When caloric needs are not met, the individual may experience unintentional weight loss and even malnutrition in instances of continuous low calorie intake. Adequate intake of vitamins and minerals is also important for many bodily functions. Each individual’s diet varies greatly, so you should first consult your doctor or dietitian before taking any supplements.


Eating a well-balanced, nutritious diet will greatly benefit a patient with Parkinson's disease so he
can have more energy and his medications will work properly. There are ten basic tips of having a
proper diet, namely:
1. Eat a variety of foods from each food category based on the food pyramid (see below).
2. Ask your doctor if there is a need for a daily vitamin supplement.
3. Maintain your weight through a proper balance of exercise and food.
4. Ask your doctor about your ideal body weight and how many calories you should consume each day.
5. Include high-fiber foods such as vegetables, cooked dried peas and beans (legumes), whole-grain
foods, bran, cereals, pasta, rice, and fresh fruit in your diet.
6. Choose foods low in saturated fat and cholesterol.
7. Moderate your intake of sugars.
8. Limit your salt intake.
9. Drink eight 8 oz. glasses of water per day.
10. Ask your doctor about drinking alcoholic beverages since alcohol may interfere with some of your medications.

CARBOHYDRATES


Carbohydrates are starches and sugars which are the main energy source for the body. One gram of
carbohydrates provides 4 calories. These are found in fruits, breads and cereals, milk products, and
vegetables. These are also found in most desserts, candy, and sweetened foods.
The“good” carbohydrates are the complex carbohydrates which are found in foods that are less refined and closer to their natural state. Good sources include foods made with whole grains, brown rice, and fresh fruits and vegetables. These are usually good sources of vitamins, minerals, and fiber, too. These are broken down slowly in the digestive tract, and gradually enter the bloodstream.
Dietary carbohydrates play a role in the absorption of levodopa, the usual first line drug  used in
PD, by triggering a release of insulin which lowers the blood levels of large neutral amino acids
(LNAA's).  Lower levels of  LNAA's in the blood may enhance the delivery of levodopa to the brain . The recommended allowance for carbohyrates is 55 to 60 percent of the calories in your diet.


PROTEINS


Proteins are combinations of amino acids that build, repair, and maintain all of your body’s tissues.
Dietary proteins are broken down into amino acids in the stomach and intestine and then absorbed into the blood, where they become the “building blocks” for new proteins. Your body makes nonessential amino acids. The “essential” amino acids are not synthesized in the body so these are obtained through the diet. To get the necessary amino acids, it is important to eat a variety of foods, including good sources of protein in amounts to meet your needs. If you don’t consume enough carbohydrates and fats, tissue proteins can be broken down into amino acids and used by the body for energy instead of maintenance. When you consume more protein than you need, the protein is broken down and stored as body fat. Protein provides 4 calories per gram.
Good sources of protein include foods from animal and plant sources. Animal sources include meat,
poultry, fish, eggs, milk, and cheese. Plant sources include legumes (lentils, dry beans and peas),
seeds, nuts, breads, and cereals.


FATS


Fats are complex substances made up of combinations of fatty acids which supply energy in the form of calories. They are a concentrated source of energy, providing 9 calories per gram.  Fats have some
positive health benefits although they are best avoided or kept at a minimum in certain disease
conditions like hypertension, obesity and heart ailments.  These help to support the work of other
nutrients in your body. The fat-soluble vitamins A, D, E and K wouldn’t be effective without dietary
fats to dissolve them and provide transport in the bloodstream.


Linoleic acid and alpha-linolenic acid are fatty acids (the “building blocks” of fat) that are
considered essential because they are not synthesized in the body and have to be obtained from the
diet. Alpha-linolenic acid converts to omega-3 fatty acids, which help to keep your brain and nervous
system healthy. Linoleic acid is an omega-6 fatty acid. Both may promote heart health by lowering
total and LDL cholesterol.Both of these essential fatty acids are easily available to the body in a
varied diet. Fatty fish, soy, flaxseed, canola, nuts, and seeds are good sources of omega-3 fatty
acids. Soy, corn, and safflower oil are good sources of omega-6 fatty acids.


Fat intake should be no more than 30 percent of your total calories, with an emphasis on fewer
saturated fats. Fat takes longer to leave the stomach than carbohydrate or protein; therefore, it’s
best to avoid large, high-fat meals if you’re taking Sinemet because it can decrease the effectiveness
of the medication by delaying gastric emptying.


FIBER


Fiber is the indigestible part of a food of plant origin. It can’t be used by the body for energy, but
is still necessary for good health by helping to promote regular bowel movements. Dietary fiber can be soluble or insoluble. Both types of fiber have significant health benefits, but they work in different
ways.


Insoluble fiber helps to prevent constipation by adding bulk and softness to stools. Adequate fluid
intake is necessary, since insoluble fiber works by absorbing fluid. Good sources of insoluble fiber
are whole wheat products including wheat bran, vegetables, fruit, flaxseeds, and legumes.


Soluble fiber helps to lower blood cholesterol levels, and regulate blood sugars. Good sources of
soluble fiber are legumes, oats and oat bran, barley, flaxseeds, and many fruits and vegetables.


Constipation is a common problem in Parkinson’s disease. It can be caused by medications, decreased fluid intake, or the condition itself. The nerves controlling the gastrointestinal tract can be
affected by PD, causing increased intestinal content transit time. Dietary fiber is very important in
the management of constipation. To ensure adequate fiber intake, try to eat at least five servings of
fruits and vegetables each day, and choose whole grains over refined foods. In addition, try to drink
6 to 8 glasses of fluid each day, preferably noncaffeinated.


VITAMINS


Vitamins are organic compounds necessary for life, although they do not, independently, provide
energy. Vitamins are essential to many bodily functions, including growth, metabolism, blood clotting, preventing diseases, body growth and maintenance, immune function, and many more.


Vitamin D


Vitamin D promotes the absorption of two minerals - calcium and phosphorus - and regulates the calcium levels in the blood. It also helps in depositing these minerals in your bones and teeth, making them stronger. Fortified foods such as milk and specially fortified orange juice are common sources of Vitamin D. Milk products such as cheese and ice cream are generally not fortified with Vitamin D.
Sunshine is a significant source of Vitamin D because your body makes Vitamin D from UV light touching your skin.


The RDA for adults is 400 IU per day, and 600 IU by the age of 70. The increased amount for older
adults is due to the fact that as we age, our skin isn’t able to produce as much Vitamin D. If you do
not go outdoors, you cover up, or use a sunscreen, you need to pay special attention to getting
Vitamin D from fortified foods or consider taking a supplement. One cup of Vitamin D fortified milk
contains 100 IU.


Vitamin C & E


Vitamin C, or ascorbic acid, and Vitamin E have antioxidant properties and were once speculated to be protective against the progression of PD. Theoretically, free radicals are produced by metabolic
processes in the brain and they can damage nerve cells, including dopaminogenic cells. Antioxidants
are known to break down free radicals or prevent their formation. Studies, however, do not show any
significant benefit of consuming more than the recommended dietary allowance (RDA) for Vitamin C and E for people with PD.


Vitamin C is important for wound healing, absorption of iron, increasing resistance to infection, and
the synthesis of neurotransmitters. Good sources of Vitamin C are citrus fruits, broccoli, brussel
sprouts, green peppers, strawberries, cauliflower, cabbage, tomato, cantaloupe, and spinach. The RDA for Vitamin C for an adult is 60mg per day. This is equal to approximately 1/2 cup of orange juice or 1 cup of cantaloupe.


Along with its powerful antioxidant capabilities, Vitamin E is also important in energy and cell
metabolism. The RDA for Vitamin E for adult males is 10mg and 8mg for females. This is equal to
approximately 1.5 oz. almonds or 3 tablespoons of corn oil. Other good sources of Vitamin E are
vegetable oils, wheat germ, spinach, collards, nuts, and dried beans.


Both Vitamin C and E are easily consumed in the diet in the recommended amounts per day; therefore, supplementation in mega doses is not warranted. Depending on your individual diet, a multi-vitamin formulation or supplement may be beneficial. Please consult your doctor or dietitian for further information.


MINERALS


Minerals are inorganic substances essential to life. Theses help regulate the various body processes
such as circulation, respiration, digestion, and elimination. These are also found in water and in
natural foods but are used to fortify some processed foods.


Mineral toxicity is possible but unlikely if you are not taking megadoses of a mineral over a period
of time. Mineral deficiencies are also possible but not common if you are eating a wide variety of
foods from all five food groups.


CALCIUM


Calcium builds bones, and helps them to remain strong, by slowing the rate of bone loss as you age. It also assists in muscle contraction, promotes normal nerve function, and helps your blood clot if you’re bleeding. Milk and milk products such as yogurt and cheese are excellent sources of calcium. In addition, some dark green leafy vegetables (kale, broccoli, bok choy), canned salmon and sardines with bones, calcium-fortified soy milk and orange juice, and tofu made with calcium sulfate are good
sources.


The RDA for adults is 800 IU until age 50, when it is increased to 1200 IU. People with Parkinson’s
disease have an increased risk of bone loss, and should be sure their diet isn’t deficient in calcium.
If you find it hard to get enough calcium in your diet, you may want to consider a supplement. Calcium carbonate is the most commonly used supplement; however, it reduces stomach acid, which can interfere with nutrient absorption. It can also be constipating for some people. Calcium citrate is a better choice; it doesn’t affect stomach acidity, and it isn’t constipating.


Excellent sources of calcium:
(approximately 300mg per serving)
1 cup of low fat milk
1 cup of yogurt
1 1/2 ounce of hard cheese
1 1/4 cup cottage cheese
1 to 2 cups of cooked dark green, leafy vegetables
2 cups of cooked broccoli


IRON


Iron forms part of hemoglobin, the molecule that enables your red blood cells to transport oxygen
throughout the body. It also helps the immune and central nervous systems and aids in energy
production.


The body is very efficient at storing and reusing iron, and stored levels tend to increase with age;
however, iron deficiency can be a problem for younger women because of blood loss from menstruation and for older people because of a poor diet. A suspected deficiency should always be evaluated by your healthcare provider before taking supplements because excess iron can be harmful. The RDA for iron for adult women is 10 mg and 15 mg for adult men. Meat, poultry, and fish are excellent sources of iron. Fortified grain products, like cereals and breads, legumes (especially soybeans), nuts, and vegetables also provide iron in the diet. Foods that are high in Vitamin C, such as strawberries, broccoli, or citrus fruits, enhance iron absorption.


Iron supplements can interfere with Levodopa absorption, so they should be taken separately, although the small amount of iron in a standard multivitamin preparation shouldn’t be a problem.


COENZYME  Q10


Coenzyme Q10, or ubiquinone, or CoQ10 for short, is a naturally occurring compound produced in the heart, liver, kidneys, and pancreas. CoQ10 is used by the body for energy production and as a powerful antioxidant. The amount of CoQ10 produced by the body declines with age, heart disease, and with some medications i.e., statins, some diabetes drugs, and perhaps coumadin.
CoQ10 is present in food in small amounts, primarily in organ meat, chicken, beef, soy oil, sardines,
mackerel, and peanuts. Because CoQ10 is in food only in scarce amounts, it is commonly consumed as an oral supplement.


Oral CoQ10 supplementation has been used to treat heart failure because of its role in energy
production. It may also be beneficial in treating a number of other diseases as well as Parkinson’s
disease due to its antioxidant effects. A theory is that it protects cells from damage caused by PD.
Research suggests a positive trend for CoQ10 and the slowing of the progression of the disease with
little side effects. Recent studies have shown that a dose of 1,200 mg per day may have the most
benefit in PD patients; however, CoQ10 recommendations are premature at this time and further research is warranted. Please consult your doctor beforehand.


PARKINSON'S MEDICATIONS AND FOOD INTERACTIONS


The primary drug used in the treatment of Parkinson’s disease is Levodopa. There are several diet
components that interfere with the absorption and thus, ultimately, with the effectiveness of this
medication.


   PROTEIN AND LEVODOPA INTERACTION


Compounds called amino acids make up dietary protein. Levodopa is structurally similar to certain
amino acids (large neutral amino acids, or LNAAs), and they compete for the same transport system
across the blood-brain barrier. Levodopa must arrive at its destination in the brain to be converted
to dopamine, and this competition can decrease the amount of Levodopa reaching the brain. Some people with Parkinson’s disease are not affected by protein in the diet, but others notice a reduced
effectiveness of Levodopa when it is taken too close to meals. Also, some people find that the
proteins in milk and milk products block the Levodopa absorption to a greater extent than other
proteins.


     GASTRIC EMPTYING


Before it can reach the transport mechanism at the blood-brain barrier, Levodopa must reach the small intestine for absorption. Food in the stomach can slow the progress of the Levodopa by delaying the emptying of stomach contents into the small intestine. The longer Levodopa remains in the stomach, the more vulnerable it is to enzymes that prematurely convert it to dopamine, which is ineffective if not produced in the brain. Once in the small intestine, the Levodopa must compete with any LNAAs present for absorption into the bloodstream. Also, Levodopa has a very short plasma half-life, which means that it will start to disappear from the blood in 60 to 90 minutes. Therefore, it needs to reach the brain before this occurs.


Parkinson’s disease can affect the nerves of the GI tract causing delayed gastric emptying. If you
experience symptoms of bloating, delayed uptake of medications, quick fulfillment after eating,or
gastroesophageal reflux, consult your doctor or dietitian for helpful hints and/or medication changes.


     TIMING OF MEDICATION


Levodopa should be taken at least 30 minutes prior to meals, except in cases where the drug produces
nausea, or if there is an excess of dyskinesia after taking Levodopa. It generally works best when
taken on an empty stomach, about ½ hour before meals or at least one hour after meals. It should be
taken with 4-5 oz. of water so the drug will be absorbed in the body more quickly.
For some patients, levodopa may cause nausea when taken on an empty stomach. Your doctor may prescribe a combination of levodopa and carbidopa (called Sinemet) or carbidopa by itself (called Lodosyn). If nausea persists, your doctor may prescribe another drug to relieve these symptoms. There might also be a need to modify your daily protein intake. In rare cases, a diet high in protein limits the effectiveness of levodopa. For nausea, which is common during the early adjustment to Levodopa, it should be taken with a light, low-protein snack.


There are ways to contol nausea, namely:
1. Drink clear or ice-cold drinks. Drinks containing sugar may calm the stomach better than other
liquids.
2. Avoid orange and grapefruit juices because these are too acidic and may worsen nausea.
3. Drink beverages slowly.
4. Drink liquids between meals instead of during meals.
5. Eat light, bland foods (such as saltine crackers or plain bread).
6. Avoid fried, greasy, or sweet foods.
7. Eat slowly.
8. Eat smaller, more frequent meals throughout the day.
9. Do not mix hot and cold foods.
10. Eat foods that are cold or at room temperature to avoid getting nauseated from the smell of hot or
warm foods.
11. Rest after eating, keeping your head elevated. Activity may worsen nausea and may lead to
vomiting.
12. Avoid brushing your teeth after eating.
13. If you feel nauseated when you wake up in the morning, eat some crackers before getting out of bed
or eat a high protein snack before going to bed (lean meat or cheese).
14. Try to eat when you feel less nauseated.


Some Parkinson's disease medications may make you thirsty. Here are eight tips to help relieve thirst
or dry mouth:
1. Drink eight or more glasses of liquid each day. However, those PD patients with concommittant heart
problems may need to limit their fluids so it is better to seek advice from your doctor.
2. Limit caffeine (contained in coffee, tea, cola, and chocolate) because it may interfere with some
of your medications and may actually make you more dehydrated.
3. Dunk or moisten breads, toast, cookies, or crackers in milk, decaffeinated tea or coffee to soften
them.
4. Take a drink after each bite of food to moisten your mouth and to help you swallow.
5. Add sauces to foods to make them soft and moist. Try gravy, broth, sauce, or melted butter.
6. Eat sour candy or fruit ice to help increase saliva and moisten your mouth.
7. Don't use a commercial mouthwash. Commercial mouthwashes often contain alcohol that can dry your mouth. Ask your doctor or dentist about alternative mouthwash products.
8. Ask your doctor about artificial saliva products which may be available by prescription.


Sometimes, a PD patient may be too tired to eat later in the day or has poor appetite. Here are some
tips to help improve your appetite and make each meal enjoyable:
1. Choose foods that are easy to prepare and eat.
2. Ask your family/caregiver to help with meal preparations.
3. Keep healthy snack foods on hand such as fresh fruit and vegetables, pretzels, crackers, high-fiber
cold cereals.
4. Freeze extra portions of what you cook so you have a quick meal when you're too tired.
5. Rest before eating so you can enjoy your meal.
6. Try eating your main meal early in the day so you have enough energy to last you for the day.
7. Consult your doctor especially when you're showing signs of depression aside from poor appetite.
Your appetite will probably improve after depression is treated.
8. Avoid non-nutritious beverages.
9. Eat small, frequent meals and snacks.
10. Walk or participate in another light activity to stimulate your appetite.
11. Make eating a pleasurable experience by using colorful place settings and play background music
during meals.
12. Try not to eat alone. Invite a guest to share your meal or go out to dinner.
13. Use colorful garnishes such as parsley and red or yellow peppers to make food look more appealing
and appetizing


Here are some tips to help you eat more at meals and at snacks.
1. Drink beverages after a meal instead of before or during a meal so that you do not feel full before
you begin eating.
2. Plan meals to include your favorite foods.
3. Try eating the high-calorie foods in your meal first.
4. Use your imagination to increase the variety of food you're eating.
5. Don't waste your energy eating foods that provide little or no nutritional value such as potato
chips, candy bars, colas, and other snack foods.
6. Choose high-protein and high-calorie snacks. High calorie snacks include: ice cream, cookies,
pudding, cheese, granola bars, custard, sandwiches, nachos with cheese, eggs, crackers with peanut
butter, bagels with peanut butter or cream cheese, cereal with half and half, fruit or vegetables with
dips, yogurt with granola, popcorn with margarine and parmesan cheese, or bread sticks with cheese
sauce.


WEIGHT MAINTENANCE IN PARKINSON'S DISEASE


Malnutrition and weight maintenance is often an issue for people with Parkinson's disease. Here are
some tips to help you maintain a healthy weight:
1. Weigh yourself once or twice a week, unless your doctor recommends weighing yourself more often. If you are taking diuretics or steroids, such as prednisone, you should weigh yourself daily.
2. If you have an unexplained weight gain or loss (2 pounds in one day or 5 pounds in one week),
contact your doctor. He or she may want to modify your food or fluid intake to help manage your
condition.
3. Ask your doctor about nutritional supplements. Sometimes supplements in the form of snacks, drinks (such as Ensure or Boost), or vitamins may be prescribed to eat between meals to help you increase your calories and get the right amount of nutrients every day. But, be sure to check with your doctor before making any dietary changes or before adding supplements to your diet. Some can be harmful or interfere with your medication.
4. If you are underweight, avoid low-fat or low-calorie products. (unless other dietary guidelines
have been recommended). Use whole milk, whole milk cheese, and yogurt.



REFERENCES:


1. http://www.webmd.com/parkinsons-disease/guide/eating-right
 2. Jenny E. Loew, MS, RD, CSN, LDN and Carol Pratt , LDN. Good Nutrition and Parkinson's Disease (American Parkinson Disease Association, Inc)Copyright 2005 Revised 2007