Parkinson's disease: diet and nutrition

Eating the right food is important for any person, but for people with Parkinson's (PD) it is essential to maintain the right dietary intake. Difficulty with swallowing and chewing, or manipulating a knife and fork, are not excuses for eating the wrong foods. With medication having to be taken before or after meals, it is important to eat regularly and well, as this will not only help in digestion, but will aid the absorption of medication.
Medication and meals


It is usual to take medication 15-20 minutes before meals to assure more predictable absorption, or take tablets divided in half (i.e. same amount but cut in two). Take levodopa 30 minutes before meals if response fluctuations are worsening.

People with PD are often advised to take levodopa with meals. By reducing levodopa absorption, food may reduce side effects such as nausea on first exposure to levodopa medication but when people start experiencing motor (or movement) fluctuations, other factors need to be considered.

Unpredictability is a major feature of severe motor fluctuations. Although people experience the fluctuations every day, the timing of dramatic changes in motor disability, and the amount of 'on' and 'off' time per day, vary even if the medication regime is constant. Research is now indicating the role that food plays in this unpredictability.

Different food causes the stomach to empty at different rates, which means that the time taken for levodopa to get from the stomach to the part of the gut where it is absorbed will vary as well.

Another factor leading to unpredictable motor fluctuations is that the effect of the medication on symptoms may not correspond to the amount of levodopa in the bloodstream. This is because of the competitive effect of amino acids (found in protein) which are also in the blood.

Protein competes with or interferes with Sinemet or Madopar absorption at 2 sites: during absorption at the part of the gut nearest to the stomach, and as it passes from the blood to the brain. If a meal high in protein is eaten at the same time as medication is taken, less levodopa will be absorbed into the intestine and less absorbed across the blood/brain barrier.

For people on Sinemet or Madopar noticing fluctuations in mobility, protein manipulation may be helpful. For example, reducing protein earlier in the day may help avoid the unpredictable motor fluctuations and may aid the response to the medication. Having the day's protein meal in the evening may also be useful, as slow response to medication may not be as important as at other times of the day.

It would be most unwise for any person with PD to put themselves on a low protein diet without consulting their doctor or dietician. Problems such as weight loss, poor immunity and other complications from lack of sustenance could result if the diet is too low in protein.
Weight loss


Weight loss is common in PD, in spite of increased caloric intake. A special programme must be worked out with each person to determine individual needs.
Causes of weight loss


* Tremor may use extra calories: energy is used while inactivity is increased.
* The desire for food may be reduced because of reduced sense of smell, nausea, depression and cognitive impairment.
* There may be changes in the brain thermostat for weight control, raising the metabolic rate.
* Damage to the hypothalamus can cause central appetite suppression.
* Tiredness and weakness in the arms can slow down speed of eating, making people give up before the meal is finished.
* Difficulty chewing and swallowing makes meal times tiring, as do poor-fitting dentures.

Types of food


High protein foods

* All meat — red and white, fish, sausages, preserved meats.
* Dairy products — milk, yoghurt, ice cream, cheese and egg whites.
* Legumes — kidney beans, lima beans, lentils, soya beans.
* Gelatin.
* Nuts of any kind, including peanut butter.

Some of these foods are essential in order to achieve a balanced diet. A very low protein diet is not balanced and can lead to deficiencies in zinc, iron and calcium, and other elements.

Foods low in protein

* Cereals — wheat biscuits, rice bubbles, corn flakes, semolina, rice, pasta, white bread (not enriched), tapioca, sago.
* Vegetables — green and yellow, cooked or raw, potatoes.
* Fruit — all fresh, tinned, stewed or dried.
* Soups — clear, vegetable, not creamed or containing lentils or peas.
* Spreads — honey, jam, Vegemite, marmalade, treacle.
* Sweets — boiled lollies, butterscotch, jelly beans, gum (very little nutritional value: included for interest and variety only).
* Fats — margarine, unsaturated oils, salad dressing, mayonnaise.
* Beverages — tea, coffee, soft drinks, cordial, soda water.

High fat foods (providing maximum calories)

* Oils, butter, margarine.
* Cream, sour cream, ice cream, mayonnaise, cheese.
* Peanut butter.
* Chocolate, Milo, Ovaltine, cocoa, drinking chocolate, full-cream milk.
* Eggs.
* Meats such as ham, luncheon meat and sausages.
* Biscuits, cakes and pastry.

High sugar foods

* Dried fruits.
* Chocolate.
* Honey, marmalade, jams.
* Fruit juice.
* Confectionery.
* Biscuits and cakes.

Energy supplements may be added to food without changing the taste.
Other dietary guidelines


Moderation and balance are the keys to any diet. Drink plenty of liquids throughout the day and remember that food that is difficult to swallow can be modified (e.g. moistened, minced or pureed). A qualified dietitian may need to be consulted.

* Eat a balance from all the food groups.
* Maintain calories at 25-30 calories per kilogram of body weight with additional calories if dyskinesias are present.
* Carbohydrate to protein proportion should be 4-5:1.
* Recommended daily protein allowance is 0.8 g/kg of body weight.
* Fibre and adequate fluids (6-8 glasses of water daily) are important in the control of constipation. Fibre is present in breads, vegetables, cereals, and fruit with the skin on.
* If calories are needed, they are best added in the form of complex carbohydrates and unsaturated fats; cholesterol consumption should kept lower than 300 mg daily.
* The benefits of multi-vitamins remain unclear. If a person is taking levodopa rather than Sinemet, only pyridoxine(B6)-free vitamins should be taken.
* Pay careful attention to daily calcium intake; 1000-1500 mg will help reduce the risk of broken bones from osteoporosis.
* Iron supplements may interfere with Sinemet absorption so should be taken separately.
* If appetite is poor, take smaller meals every 2-3 hours, perhaps with a little alcohol (if medically allowed).
* Broad beans contain dopamine; some people find they help in maximising the effects of medication.
* Depression and cognitive impairment may reduce appetite.
* The sense of smell may also be reduced; stronger flavours and aromatic foods can be used to make food more interesting.

Swallowing difficulties


Your speech pathologist can give specific individual advice about swallowing difficulties and food management.

It is important not to eat soft food all the time (unless that is all you can manage safely), as the muscles in the jaw need exercise too. While each individual will have different problems and therefore different solutions, the following suggestions may help.

* Food that is soft and moist, with a good flavour and smell, tends to be easier to swallow: custards, jelly, pureed fruit, sauces, spices and herbs.
* Avoid foods which are hard, dry, crumbly or stringy.
* Avoid mixed consistencies (e.g. solid plus liquid).
* Be careful with foods which stick to the roof of the mouth or get caught around the mouth: dry mashed potatoes, tomato with skin on, biscuits, bran flakes, hard-boiled eggs.
* Thicker fluids (e.g. nectars, milk shakes) may be easier to control and swallow than thin, clear liquids, as they move more slowly.
* Keep food presentation appetising: flavour, smell and appearance of food.
* Relax and enjoy your food. It is good to have a break between mouthfuls and take sips of water during the meal. This will not only help you relax but also allow you to clear your throat and mouth. You may need to swallow twice to clear each mouthful.
* Eat smaller portions more frequently, especially if time for meals is limited.

Possible problem foods


* Mixed textures, such as liquid with 'bits' in it (e.g. minestrone soup or watery mince).
* Flaky biscuits.
* Hard toast or nuts, chocolate, grains, seeds.
* Fresh white bread (try wholemeal bread; it is easier to swallow).

Foods that may be easier to swallow


* Boiled milk.
* Mousse, custard, yoghurt, ice cream.
* Souffle, omelette.
* Casseroles.
* Soup.
* Fruit juice, pureed fruit.
* Pancakes (with syrup etc.).
* Rice.
* Well-cooked vegetables.
* Banana.

If you are using more and more liquid meals, it is important to keep up your energy intake. Your dietitian may recommend appropriate supplements and guidelines. You can make liquid foods thicker by using instant pudding, yoghurt, gelatine or instant potato powder.
Hints to avoid nausea and gastric upset


* Take medication with small amounts of food (usually not protein).
* Eat only when you are hungry.
* Eat foods which you know you enjoy.
* Avoid fatty food.
* Avoid spicy foods or gassy drinks.
* Avoid too much caffeine or nicotine.

Summary


Probably the most important point to remember is that good nutrition is based upon a balanced diet including a variety of foods from the main food groups, in particular, plenty of fruit, vegetables, complex carbohydrates, some protein and fluids. For people with PD, this may also involve a rearrangement of protein-rich meals. Maintaining a balanced diet helps to ensure a minimum of weight loss and a healthy outlook on life.