Parkinson’s disease and vegetarian diet

Parkinson’s disease (PD) affects approximately one million to one and a half million people in the US alone [ 1 ]. PD is a progressive neurological disorder that causes the destruction of dopamine-producing cells in the brain. The decrease in dopamine impairs the movements of both the skeletal muscles and the smooth muscle of the gastrointestinal tract. The result is a slow, shuffling walk, tremor at rest and / or a slowing of peristalsis. People with PD can fall frequently [ 2 , 3 ], have difficulty handling cutlery and kitchen utensils, and gastrointestinal problems such as slowed gastric emptying, gastroesophageal reflux and chronic constipation [4 , 5 , 6 , 7 ].

Problems associated with nutrition

It was found that subjects with PD have a higher incidence of bone demineralization and fractures compared to age-matched control groups [ 8 , 9 , 10 , 11 , 12 , 13 , 14 ].

Loss of smell and taste are common [ 15 , 16 ], along with the presence of xerostomia (dry mouth) [ 17 ] and sometimes loss of appetite [ 18 ]. These problems, together with other factors, may contribute to the high incidence of involuntary weight loss in these patients [ 19 , 20 , 21 ].

There are also reports of the possibility of developing B Vitamin deficiencies, although the causes are not entirely clear. In 1979, Bender and collaborators reported the possibility that taking the Levodopa-carbidopa combination (Sinemet and Sinemet CR, drugs used in the symptomatic therapy of PD) carries the risk of niacin and vitamin B6 deficiencies [ 22 ]. It has also been found that patients chronically taking the Levodopa-carbidopa combination have elevated blood levels of homocysteine ​​[ 23 , 24 ] secondary to Vitamin B6, B12 and folate deficiency.

In an attempt to determine the etiology of PD, Hellenbrand and collaborators compared the eating habits of a group of patients, comparing them with those of a control group; patients were found to have taken significantly less niacin than controls [ 25 ]. In a more recent Swedish study, researchers noted that consuming niacin-containing foods appears to reduce the risk of developing PD [ 26 ]. Finally, in an unpublished study, the presence of pellagra was diagnosed in several patients using the Levodopa-carbidopa combination [ 27 ]. Therefore, patients may have an increased risk of developing vascular diseases, pellagra and other syndromes caused by deficiency of B vitamins.

Constipation caused by the disease and / or the drugs for its treatment is very common in PD [ 4 , 28 , 29 ]. Since chronic constipation can increase the risk of intestinal blockage [ 30 ] and colon cancer [ 31 , 32 ], the use of safe methods for its prevention is recommended. Furthermore, PD involves food-drug interaction problems that have generally been underestimated by nutritionists. Levodopa, the pivotal drug used in the treatment of PD, competes with the carriers of the five largest neutral amino acids, both in the gut and at the blood brain barrier [ 33]. Therefore the absorption of Levodopa is strongly reduced if the drug is taken with meals.

Vegetarian diet and Parkinson’s disease

Although research has not been able to establish with certainty the presence of a relationship between diet and PD, nevertheless the content of fibers, proteins and nutrients that are contained in plants are excellent reasons for choosing vegetarian or diet-based diets. plant foods. Animal foods often contain a lot of protein and low fiber, while vegetables generally contain a high percentage of carbohydrates and moderate amounts of protein. In addition, vegetables contain fiber and many phytochemicals that are not present in animal foods.

Fibers. A plant-based diet is generally higher in fiber, which can reduce constipation and thus reduce the risk of intestinal blockage and colorectal cancer. In a pilot study, McIntosh and Holden found that while 21 out of 24 patients reported frequent constipation, an analysis of their three-day food diaries found that 18 patients reported consumption of less than 25 grams of fiber per day [ 29]. Patients with PD need more information on the benefits of fiber and the need for higher fiber consumption. Additionally, a high-fiber diet can improve the bioavailability of Levodopa. Astarloa and colleagues found a correlation between a diet rich in insoluble fiber and the blood concentration of Levodopa, hypothesizing that the improvement of constipation may produce a positive effect on the bioavailability of Levodopa [ 34 ]. Although there is currently no research on the benefits of a vegetarian diet for patients with PD, it appears possible that the higher fiber content of a vegetarian diet or of a diet based on plant foods, may be helpful for those affected. by MdP.

Unwanted loss of body weight. To counteract body weight loss, patients must consume more calories. Furthermore, delayed gastric emptying, if present, may require moderate use of fatty foods, while those taking Levodopa should control the amount of protein they eat. To enforce these restrictions, frequent meals and snacks, and a high-carbohydrate diet are required. A vegetarian diet is perfectly suited to such a food program, since it is a diet high in carbohydrates and low in fat, as opposed to animal foods, which often contain a lot of fat and protein.

Difficulty chewing and swallowing. Patients in the intermediate to advanced stage of PD may have difficulty chewing food and / or coordinating tongue movements to arrange food correctly for swallowing. Normal esophageal peristalsis can be slowed down resulting in dysphagia. Even if a functional evaluation and a possible re-education to a safe swallowing should be done, it must however be said that plant foods are easier to chew than many meat foods; plant foods can also be cut into small pieces, pureed or pureed in a simple way to provide the best texture for individual needs, while maintaining the content of fibers and phytochemicals.

Nutrients. Plant foods are rich in Magnesium and Vitamin K, which are important for skeletal health. This should be emphasized as PD patients, due to the nature of their disease, may be at risk of falls [ 8 , 9 , 10 , 11 , 12 , 13 , 14 ] and therefore more susceptible to fractures [ 2 , 3]. Also good sources of Calcium and Vitamin D must be enhanced in the diet, as there may be a greater need for these nutrients in this population; in a controlled study, Sato and collaborators found a higher incidence of vitamin D deficiency and reduced bone mass in individuals with PD [ 14 ].

A vegetarian or plant-based diet provides significant amounts of B vitamins (with the possible exception of Vitamin B12), and especially folate. It is important to educate patients on the need for B vitamins. The vegan patient may require a vitamin B12 supplement and, if deficiencies are suspected, supplementation, at least temporarily, with a B polyvitamin complex may be necessary. However, it must be said that large quantities of Vitamin B6 (over 10 mg per day) can cancel the therapeutic effects of Levodopa; therefore supplements should be taken with meals, while Levodopa should be taken at least 30 minutes before meals to avoid this food-drug interaction.

Interactions between Levodopa and Proteins. As aforementioned, the proteins are broken down in the intestine into individual amino acids, with whose transporters (carrier) Levodopa has to compete to pass through the intestinal walls. For this reason, patients should take Levodopa at least 30 minutes before meals or snacks. As the disease progresses, patients often begin to experience fluctuations throughout the day in their response to Levodopa, defined as an “on-off” phenomenon, which occurs when one dose of Levodopa wears off before the next dose has reached therapeutic levels. Without Levodopa, patients are able to move only very slowly or become completely stuck, which is greatly disabling.

To counteract these motor fluctuations as much as possible, patients have long been advised to avoid protein intake throughout the day, limiting their intake to no more than ten grams before the evening meal. Most of the protein requirement will then be introduced with the evening meal, thus allowing the patient to make optimal use of the therapeutic action of Levodopa during the daytime (during which the patient needs to be in the best motor conditions, Ed.). However, this often means that the patient is stuck all night, which is very frustrating and terrible, since he cannot independently turn over in bed, get up to go to the bathroom or adjust the blankets. If diabetes, hypoglycemia or other conditions are present, these restrictions in protein intake are less advisable. Although little considered, a high-carbohydrate diet with a ratio of at least 5 parts of carbohydrates to one part of protein (5: 1) or higher can be very effective [35 ]. Once in circulation, the high level of carbohydrates causes an insulin spike which also removes amino acids from the blood, thus allowing Levodopa to reach the blood brain barrier without interference [see 36 , 37 ]. A plant-based diet is an ideal way to achieve a high-carbohydrate meal plan, as plant-based proteins are often present in a carbohydrate: protein ratio of 3: 1 or higher, while meats contain virtually no carbohydrates. Legumes, seeds, and nuts are great foods and can easily be included in a meal that has a carbohydrate: protein ratio of 5: 1 or higher.

Many patients manage to increase the length of active periods (“on” periods) with some adjustment in protein consumption. Some find that they can reduce the amount of Levodopa needed. The reduction of Levodopa involves a reduction of the side effects related to it, such as hallucinations and dyskinesias (complex involuntary movements of torsion similar in some aspect to dance in the trunk and limbs). Much more research is needed in this field to document positive effects on reducing drug needs, increasing “on” phases, decreasing dyskinesias, and reducing drug side effects.

Typical menu with high carbohydrate content – 5: 1 ratio

  • 1 1/2 cups of pea split or lentil soup
  • 1 ounce of whole grain crakers
  • 1 tablespoon (tbs) of peanut butter
  • 8 ounces of cranberry juice juice
  • 1/2 cup of grapes

(694 calories, 122 grams of carbohydrates, 24 grams of protein, 16 grams of fiber, 66 mg of calcium)

Editor’s note: It should be noted that the indication of quantities such as “teaspoon”, “spoon”, “cup” etc., should not be considered in an approximate way, but represents precise quantities, described in the conversion tables .

For more information, including 5: 1-10: 1 snack, breakfast, lunch and dinner schedules, see Eat Well, Stay Well with Parkinson’s Disease , by Kathrynne Holden.

Recommendations and therapy

It is important to assess nutritional risk, and a three-day dietary diary can be of great help in determining if your intake of fiber and other nutrients is adequate. Gathering information through interviews is also important, with particular regard to changes in body weight and the risk of bone demineralization. If unexpected weight loss occurs, it should be tried to determine whether this is due to depression, excessive energy expenditure secondary to tremors, dyskinesias, stiffness, inability to feed independently with normal frequency, problems with chewing or swallowing, or other problems . Small, frequent meals and snacks are often preferable to the usual three meals a day. To evaluate delayed gastric emptying, investigate whether the person is complaining of heartburn or gastroesophageal reflux, often a sign of reduced peristalsis. Also try to figure out how long after taking the drugs they start to take effect. If the patient is using Levodopa and does not feel the effects while taking it at least 30 minutes before meals, a delayed gastric emptying may be the cause. Still, small meals and snacks with moderate fat content can be an effective way to counteract slowed gastric emptying. delayed gastric emptying may be the cause. Still, small meals and snacks with moderate fat content can be an effective way to counteract slowed gastric emptying. delayed gastric emptying may be the cause. Still, small meals and snacks with moderate fat content can be an effective way to counteract slowed gastric emptying.

If the subject receiving Levodopa experiences motor fluctuations, it is necessary to try to intervene on the consumption of proteins. The simplest and often very effective method is to estimate individual protein needs and divide the protein equally between meals. If weight loss or slowed gastric emptying occurs, suggest small meals interspersed with low protein snacks. This provides the most natural eating plan. If the subject is very sensitive to proteins, it may be useful to increase the carbohydrates of the diet. Try a 5: 1 ratio initially, as this provides almost all protein and is therefore the most natural meal plan. After two or three weeks the subject should notice an increase in the “on” phases; if that doesn’t happen, increase this ratio to 6: 1 or 7: 1. These meal plans are often more difficult to teach. It may be necessary to provide ready-made menus for meals and snacks.

NOTE: It is difficult to come up with a 7: 1 carb: protein meal plan that has less than 1800 Kcal per day. This can be an excessive calorie intake for some people, especially women of small stature. If a 7: 1 ratio works well for the subject, he can try to use it throughout the day in small meals and snacks, adding the extra protein to the evening meal. This will allow for a lower calorie intake and sufficient protein intake, while allowing for better absorption of Levodopa throughout the day. Furthermore, it is important to be aware of the increased risk of bone demineralization and the need for Vitamin B12. It may be necessary for patients to use vitamin and mineral supplements, especially Calcium, Vitamin D and Vitamin B12. In some cases, a vitamin B complex may also be needed. Patients taking Levodopa should take supplements containing large doses of Vitamin B6 with meals, no less than 30 minutes after taking Levodopa, in order to avoid Vitamin B6 interference on Levodopa absorption.

 

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