The Significance of Nutrition in Parkinson’s

Kathrynne Holden, M.S., R.D.

Why is nutrition of special importance for those with Parkinson’s disease (PD)?

Nutrition won’t cure PD, or slow its progression, so why is itimportant?

The answer is that PD impacts many aspects of health. It can slow the gastrointestinal tract, causing constipation, slowed stomach emptying, and swallowing problems; it can lead to loss of the sense of smell, and of taste. Medications used to treat PD can cause nausea and appetite loss. And, one of the most important medications, levodopa, must compete with protein for absorption from the small intestine.

People with PD are at increased risk for malnutrition; yet, with attention to diet, you will feel better, ward off nutrition-related diseases, and prevent hospitalization. A stay in the hospital can be costly, traumatic, and painful, but for those with PD, there are additional concerns.

• Some hospital staff members are unfamiliar with the special medications used with PD.

• Timing of medications can be difficult for staff, who may already have complicated schedules in place.

By following good nutrition practices, you’ll feel better, and are much more likely to stay healthy and avoid the hospital.

What is optimal nutrition for people with PD?

There is no single answer. PD affects each individual quite differently; some factors that can change your dietary needs include your age, your gender, whether you haveany other diagnosed conditions such as elevated blood pressure, food allergies, diabetes, etc. Also, medications used may have a wide range of side effects that can impact nutritional health. That includes medications for heart disease, blood pressure, and other conditions, as well as PD medications; it also includes many over-the-counter medications.

We will therefore discuss some of the most common concerns, some of which can become serious enough over time to require hospitalization. These include:

1. Bone thinning. Studies have shown that people with PD are at increased risk for bone thinning – both men and women alike. Other research has demonstrated that malnutrition, unplanned weight loss, and falls greatly increase the risk for bone fracture and other disabilities. As PD advances, it can increase the likelihood of falls. For those with PD, therefore, it’s especially important to eat meals that provide the bone-strengthening nutrients — particularly calcium, magnesium, and vitamins D and K. Also important is regular exposure to sunlight (which provides vitamin D, a bone-strengthening vitamin), and weight-bearing exercise, such as walking. Nutrients, sunlight, and weight-bearing exercise will help to keep the bones strong, preventing fractures and hospitalization.

2. Dehydration. PD medications can raise the risk for dehydration. Many people with PD don’t realize how important water is for health. Dehydration can lead to confusion, weakness, balance problems, respiratory failure, kidney failure, and death. In the United States, dehydration is responsible for about 1.8 million days of hospital care each year (about ten days per patient), and costs more than $1 billion annually.

3. Bowel impaction. PD can slow the movement of the colon, causing constipation. This makes it extra important to get enough fiber in the daily menu. If not dealt with properly, constipation can lead to a mass of dry, hard feces, impossible to pass normally. This is called bowel impaction. People with bowel impaction may require hospitalization, sometimes even surgery.

4. Unplanned weight loss. People with PD often lose weight without meaning to, due to nausea, loss of appetite, depression, and slowed movement. Unplanned weight loss together with malnutrition can lead to a weakened immune system, muscle wasting, loss of vital nutrients, and risk for other diseases. A loss of ten percent of the maximum lifetime adult weight is a predictor for illness and death. For example, if a man’s normal adult weight was 150 pounds, and he loses 15 pounds without meaning to -- even if over a period of several years -- he is at increased risk for illness and death.

5. Medication side effects. Medications perform important roles in helping to manage PD symptoms; however, in some people they can have unwanted side effects. Taking more than one medication increases the likelihood of these adverse effects, and it’s a good idea to watch carefully for any changes upon starting a new medications.

Furthermore, many people with PD use drugs for other conditions, such as high blood pressure, elevated cholesterol, etc. These medications may also have undesirable side effects or contribute to additive side effects. Some common side effects of PD medications include:

• nausea

• appetite loss, often followed by weight loss

• edema (fluid retention in the tissues)

• compulsive eating, and weight gain

6. Protein-levodopa interaction. One of the most important medications used to treat PD is levodopa (Sinemet, Sinemet CR, Madopar, Dopar, Larodopa, Prolopa, Syndopa). However, levodopa must compete for absorption from the small intestine with proteins in food, and it may be necessary to take care with the timing of meals and medication.

PD is a complicated disease, that affects each person differently. Still, there are many similar needs, such as the need for dietary fiber, fluids, and nutrients, that are common to most people with PD.

Your general nutrition needs

The Food Guide Pyramid can be adapted for use as a general guide to nutrition for those with PD. However, the pyramid does not distinguish among whole-grains vs. refined grains, or plant proteins and animal proteins, and these are important differences for those with PD. Studies have found that a high-fiber diet with plenty of plant foods can enhance the absorptionof levodopa, alleviate constipation, and provide the nutrients most needed in PD. So we must adapt the Food Guide Pyramid to obtain the best foodchoices to combat PD.

A daily menu based on whole grains, with plenty of vegetables and fruits, calcium-rich foods, and smaller portions of high-protein foods is the best possible choice for people with PD. The whole grains contain the fiber that helps control the constipation that often occurs in PD, as well as aiding in the management of blood sugar, blood pressure, cholesterol, and heart disease. Vegetables and fruits provide the antioxidants, phytochemicals, minerals, and vitamins that nourish and support the muscles, nervous system, and organs of the body. Calcium is particularly important, as it helps keep the bones strong, preventing fractures. And protein keeps the muscular system healthy; strong, toned muscles help to maintain balance and strength.

Isn’t it best to eat fresh vegetables and fruits?

Not necessarily. The processes of canning and freezing produce have advanced greatly, so that more nutrients are retained. Ideally, it’s best to eat some raw and some cooked or processed produce. However, if chewing or swallowing is difficult, or if it takes too long to eat raw vegetables and fruits, it’s fine to eat canned foods or cooked frozen foods.

How many servings should I have daily?

Each group in the Pyramid has a minimum and a maximum number of servings. The Breads and Grains group, for example, recommends six to eleven servings per day. A small or inactive woman needs about six servings, whereas a man or a larger or more active woman needs more servings.

What’s a serving size?

Servings are small and not difficult to incorporate into a daily eating plan. Here are some examples:

Serving sizes from the food guide pyramid:

Breads and grains group

6-11 servings daily

(Choose whole grain foods as often as possible, rather than refined flours and grains)

1 slice bread

1 6" corn or flour tortilla

1 oz ready-to-eat cereal

1/2 cup cooked cereal, rice or pasta

4 small crackers

2 large crackers

1/2 bagel or English muffin

Vegetable group

3-5 servings daily

(Choose several servings of red, yellow, orange, and dark green leafy vegetables each week; these are especially rich in antioxidants)

1/2 cup cooked vegetable

1/2 cup chopped raw vegetable

6 oz vegetable juice

1 cup raw leafy greens

Fruit group

2-4 servings daily

(choose several servings of citrus fruits, berries, and cherries each week; these are high in protective phytochemicals and antioxidants)

1 medium apple, banana, or orange

1/2 cup fresh berries or cherries

15 grapes

1/2 cup applesauce

1/4 cup dried fruit

3/4 cup fruit juice

Calcium (dairy) group

3 servings daily

4 oz canned sardines or salmon, including bones

2 cups cooked kale, chard, or collard greens

2 cups cooked navy beans

1 cup milk or yogurt, or fortified milk alternate (such as soy or rice “milks” fortified with calcium and vitamin D)

1 1/2 oz natural cheese

Protein (meat) group

2-3 servings daily

(Choose several servings of cooked dried beans each week, for their fiber, folate, and minerals)

1 cup cooked dry beans, split peas, or lentils

2 large eggs

4 TB peanut butter

2-3 oz cooked meat, fish or poultry

Fats, oils, & sweets

Use sparingly; choose non-hydrogenated vegetable oils and nut butters

Fats: Butter, margarine, sour cream, mayonnaise, salad dressing, oil

Sweets: sugar, jam, jelly, honey, syrup, soft drinks, desserts.

What about taking nutritional supplements, such as vitamins and minerals?

A multivitamin-mineral supplement is a good idea for most people, especially as we age. The aging metabolism is less well able to absorb and use vitamins and minerals, and supplements may help.

However, you should always discuss supplements with your registered dietitian. After age 50, iron supplements are not recommended unless you are anemic. Use of many medications, such as diuretics and blood thinners, in conjunction with supplements, can seriously impact your health. If you are at risk for hemorrhagic stroke, high-dose supplements of vitamin E may not be advisable. Also, some diseases, such as kidney disease, can be worsened by use of supplements. Discussion with a physician and a registered dietitian can help you choose the right supplements in the right amounts for your unique needs. Your pharmacist can help you select inexpensive, high-quality brands.

Vitamin B6 and Parkinson’s disease.

Before the combinations of levodopa/carbidopa and levodopa/benserazidewere produced, people with PD were prescribed levodopa alone. It was found that vitamin B6 prevented the absorption of the levodopa, so people were advised not to eat foods rich in B6, or to take B6 supplements.

Now, however, the medication commonly used combines carbidopa orbenserazide with the levodopa. These “protect” the levodopa, so that vitamin B6 in reasonable amounts is no longer thought to be a problem. It’s generally recommended that vitamin supplements for people using carbidopa-levodopa or benserazide-levodopa contain no more than about ten-fifteen milligrams of B6 daily; some people can tolerate more than that, others may be more sensitive. If you are sensitive to B6, or if you need to take very large amounts (over 15 mg), take the B6 at least two hours apart from the levodopa. You should inform your physician if you intend to use such large supplements of B6. Food sources of B6 include chicken, fish, pork, eggs, brown rice, soybeans, oats, whole wheat, peanuts, and walnuts, also fortified products such as cereals.

Bloating, obsessive eating, weight gain.

Some people find that after beginning PD medications, they experience abdominal bloating. They may also find that they have an urge to eat excessive amounts of food, which contributes to both abdominal bloating and weight gain. They may also have edema (fluid retention), often in the feet or lower legs, sometimes in the upper body.

A compulsion to eat should be reported to your doctor. Some people find that counseling is therapeutic and helps them to control the urge to over eat. Edema should also be reported, because it can cause both weight gain and elevated blood pressure.

If you experience edema, it will be important to control salt and sodium intake, because this can aggravate fluid retention in the tissues. Also, increase use of vegetables and fruits, which contain potassium and other minerals that help to flush fluids out of the tissures. It may be helpful to elevate the legs several times a day: sit back with your feet and legs resting on a chair or stool that is the height of the chair you are sitting in. This can help to drain fluids from the feet and legs.