Table of Contents
Primary Category
Nutrition
P-Category
Secondary Category
S-Category
Introduction
- Parkinson’s disease is a neurodegenerative diseases chronic and progressive functional loss of the neurons resulting in motor and sensory deficits
- Parkinson’s disease is the second most common neurodegenerative disease worldwide
- The cause of diseases are multifactorial, however recent researches show nutrition as one of the pathological factors involved in disease progression
- Adequate nourishment can improve the quality of life
- Focusing on diet as a whole has been shown as more beneficial compared to micronutrient management
Nutritional concerns
- Low BMI(Body Mass Index). Levodopa can also cause lipolysis and weight loss
- Dopaminergic drugs side effects like decreased gut motility nausea or vomiting further exacerbate weight loss or appetite loss
- Gastrointestinal involvement
- This is likely due to Alpha-synuclein deposition in the dorsal motor nucleus leading to parasympathetic dysfunction.
- This can cause esophageal dysphagia, drooling due to dysphagia, gastroparesis, and constipation
Figure 1: Causes of weight loss in Parkinson’s disease
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Dietary Modifications
- Among various diets, following dietary changes have been shown to prevent and slow the progression of the disease.
Mediterranean
- The diet mainly consists of whole foods, nuts, vegetables and legumes.
- PREDIMED (Prevención con Dieta Mediterránea) study found that Mediterranean diet with olive oil was associated with higher cognitive function.
- Various studies have further shown that adherence to Mediterranean diet was associated with slow progression of neurodegenerative disease.
- MIND diet (Mediterranean-DASH intervention for neurodegenerative delay) is a modification of Mediterranean diet that focuses on 10 healthy food groups and 5 unhealthy food to be avoided.
Ketogenic
- The goal of ketogenic diet is to mimic fasting metabolic state.
A RCT(randomized control trial) study done in 2017 showed about 41% improvement in non-motor symptoms of Parkinson’s disease
Vitamins
- Low Vitamin D levels have been associated with development of Parkinson's disease.
- Levodopa can decrease the levels of Vitamin B12
- CoQ-10 has some benefit in Parkinson’s disease
Nutritional Assessments
These can be done annually as or as needed based on symptoms
- BMI [Body Mass Index - weight (kg) × height2(m)].
- DBS(Deep brain stimulation) usually causes weight gain. Sometimes the excess weight can induce metabolic syndrome and obesity
- Nutritional status focused physical examination with emphasis on nutritional deficiencies, signs of lower extremity edema and muscle wasting
- Barium swallow study, Water swallow test, volume-viscosity swallow test to assess nature of dysphagia.
FEES (Flexible endoscopic evaluation of swallowing) and VEFS(Video fluoroscopic swallow study) are the gold standard tests for dysphagia
- Vitamin status mainly serum Vitamin B12, D and folate levels
- In case of cognitive decline, history should be obtained from family members or caregivers
Management
- Protein Intake
- Protein re-adjustment in diet to minimize carbidopa/levodopa interaction. Advise to take levodopa/Carbidopa at least 30 minutes before meal.
- Weight Management
- Dopaminergic treatment in the early stages of disease can increase or maintain weight.
- Maintain BMI with high quality protein and increased food intake
- TPN (total parenteral nutrition) if needed
- Dietary Preferences
- Encourage to follow whole food diet instead of focusing on micronutrients. Discuss options on MIND-DASH, ketogenic or anti-inflammatory diet.
- Vitamin Supplements
ESPEN guideline of clinical nutrition (2018) suggests adding Vitamin D, Folic acid and Vitamin B12 for Parkinson's disease
- Non-Motor Gastrointestinal Symptoms
- Evaluation by speech therapist or dietitian.
- Recommend mechanical soft diet and thicken liquids.
- PEG tubing if unable to swallow.
- Expiratory muscle strength training has been shown to improve the function of swallowing
Figure 2: Nutritional optimization in Parkinson’s disease
MNA- Mini Nutritional assessment; EN-Enteral Nutrition
Further Reading
- Burgos R, Bretón I, Cereda E, Desport JC, Dziewas R, Genton L, Gomes F, Jésus P, Leischker A, Muscaritoli M, Poulia KA, Preiser JC, Van der Marck M, Wirth R, Singer P, Bischoff SC. ESPEN guideline clinical nutrition in neurology. Clin Nutr. 2018 Feb;37(1):354-396. doi: 10.1016/j.clnu.2017.09.003. Epub 2017 Sep 22. PMID: 29274834.
Bibliography
- Alcalay RN, Gu Y, Mejia-Santana H, Cote L, Marder KS, Scarmeas N. The association between Mediterranean diet adherence and Parkinson's disease. Mov Disord. 2012 May;27(6):771-4. doi: 10.1002/mds.24918. Epub 2012 Feb 7. PMID: 22314772; PMCID: PMC3349773.
- Phillips MCL, Murtagh DKJ, Gilbertson LJ, Asztely FJS, Lynch CDP. Low-fat versus ketogenic diet in Parkinson's disease: A pilot randomized controlled trial [published correction appears in Mov Disord. 2019 Jan;34(1):157]. Mov Disord . 2018;33(8):1306-1314. doi:10.1002/mds.27390
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Founder NeuroCare.AI, Practicing Neurologist, sub-specialized in the field of Neurocritical Care, Stroke & Epilepsy