PARKINSON’S DISEASE AND A PLANT-BASED DIET

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PARKINSON’S DISEASE AND A PLANT-BASED DIET

JoAnn Guest

Mar 21, 2005 14:12 PST

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Kathrynne Holden, MS, RD

Summer 2000

http://www.nutritionucanlivewith.com/vegetarian.htm

 

The nature of Parkinson’s disease

 

Parkinson’s disease (PD) afflicts about one to one and one-half million

people in the United States (Tanner 1992). PD is a progressive

neurological disorder that results in the death of dopamine-producing

cells in the brain. Loss of dopamine affects movement, both of skeletal

muscle and the smooth muscle of the gastrointestinal (GI) tract. This

can result in slow, shuffling gait, resting tremor, and/or slowed

peristalsis. Individuals with PD may experience frequent falls (Dolinis

et al., 1997; Northrid ge et al., 1996), d ifficulty handling cooking

and eating utensils, and such GI-related problems as slow stomach

emptying, gastroesophageal reflux, and chronic constipation (Jost WH,

1997; Edwards et al, 1993; Edwards et al., 1994; Byrne et al., 1994).

 

Nutrition-related problems

 

Individuals with PD have been found to have a higher incidence of bone

thinning and fractures than age-matched control groups (Ishizaki et al.,

1993; Kao et al., 1994; Taggart, et al., 1995; Revilla et al., 1996;

Koller et al., 1989; Johnell et al., 1992, Sato et al., 1997). Loss of

the olfactory sense and sense of taste are frequently present

(Huttenbrink, 1995; Hawkes et al., 1997), along with xerostomia (dry

mouth) (Clifford and Finnerty, 1995), and sometimes loss of appetite

(Starkstein SE, 1990). These, along with other factors, may contribute

to the high rate of unplanned weight loss in this population (Markus et

al., 1993; Davies et al., 1994; Beyer et al., 1995).

 

There are also indications that B vitamin deficiencies may be of

concern, although the causes are not clearly understood. In 1979, Bender

et al. reported the possibility that users of levodopa-carbidopa

(Sinemet, Sinemet CR, a medication used to treat the symptoms of PD)

could be at risk for both niacin and vitamin B6 deficiencies. Long-time

users of levodopa-carbidopa have since been found to have increased

levels of serum homocysteine (Kuhn et al., 1998, Muller et al., 1999),

implicating vitamins B6, folate, and B12. In attempts to determine the

etiology of PD, Hellenbrand et al. compared the dietary habits of

patients vs. a control group; patients were found to have consumed

significantly less niacin than controls (Hellenbrand et al. 1996). In a

more recent Swedish study researchers note that consumption of

niacin-containing foods appeared to reduce risk for PD (Fall et al.,

1999). Finally, in an unpublished study, pellagra was discovered in

several patients using levodopa-carbidopa (Iacono et al.). Thus,

patients could have increased risk for vascular disease, pellagra, and

other conditions resulting from deficiencies of B vitamins.

 

Constipation is very common due to the disease and/or to the medications

used to treat PD (Jost, 1997; Jost and Schrank, 1998; McIntosh and

Holden, 1999). Chronic constipation can raise the risk for fecal

impaction (Sonnenberg et al., 1994) and colon cancer (Jacobs and White,

1998; Will et al., 1998), therefore, safe methods of controlling

constipation are desirable.

 

Furthermore, PD brings with it a food-medication interaction that has

been generally under-addressed by dietetics professionals. Levodopa, the

primary medication used to treat PD, competes with the five large

neutral amino acids for carriers, both in the gut and at the blood-brain

barrier (Lieberman, 1992). Thus, levodopa absorption is effectively

blocked if taken with meals.

 

How can a vegetarian or plant-based diet be of help to people with PD?

 

While research has failed to conclusively show a link between diet and

PD, nevertheless, fiber, nutrients found particularly in plants, and

protein, are excellent reasons to choose among the various vegetarian

and plant-based eating plans. Animal foods are often high in protein and

lack fiber. Plants in general have a high proportion of carbohydrate,

with moderate amounts of protein. Plants also contain fiber and many

phytochemicals, which animal products do not.

 

Fiber. A plant-based diet is generally richer in fiber, which can

alleviate constipation, and thereby reduce risk for fecal impaction and

colorectal cancer. In a pilot study, McIntosh and Holden found that

while 21 out of 24 patients reported frequent constipation, analysis of

three-day food diaries showed that 18 patients reported intake of fewer

than 25 grams of dietary fiber daily. Education in the need for greater

fiber intake, and its benefits to health, is necessary for PD patients.

Additionally, a high-fiber eating plan may promote bioavailability of

levodopa. Astarloa et al. found a correlation between a diet rich in

insoluble fiber and plasma levodopa concentration, and postulate that

the improvement of constipation may have a positive effect upon levodopa

availability (Astarloa et al., 1992). While there is no research as yet

on benefits of a vegetarian diet for people with PD, nevertheless, a

vegetarian or plant-based diet may have special significance for people

with PD.

 

Unplanned weight loss. To combat weight loss, patients must consume more

calories. Yet delayed stomach emptying, if present, may require moderate

use of fatty foods, while those using levodopa may need to control their

use of protein. Such restrictions sometimes necessitate small, frequent

meals and snacks, and a diet high in carbohydrates. A vegetarian diet

adapts very well to such an eating plan, as it can be both high in

carbohydrates and low in fat, whereas animal foods are often high in

fat.

 

Chewing/swallowing difficulty. Patients in mid-to-late stages of PD may

experience difficulty chewing food, and/or moving the tongue to position

food properly for swallowing. The normal esophageal peristalsis may be

slowed, resulting in choking. While a swallowing evaluation should be

performed, along with education in safe swallowing techniques, it should

be noted that plant foods may be easier to chew than many meats; plant

foods also can be chopped, mashed, or pureed easily to provide the best

consistency for the individual’s needs while retaining valuable fibers

and phytochemicals.

 

Nutrients. Plant foods are rich in magnesium and vitamin K, important to

bone health. This should be emphasized, as PD patients, due to the

nature of the disease, may be prone to falls (Ishizaki et al., 1993; Kao

et al., 1994; Taggart, et al., 1995; Revilla et al., 1996; Koller et

al., 1989; Johnell et al., 1992, Sato et al., 1997), and therefore more

susceptible to fractures (Dolinis et al., 1997; Northridge et al.,

1996). Good sources of calcium and vitamin D must be highlighted, also,

as there may be a greater need for these in this population; in a

controlled study, Sato et al. found increased incidence of vitamin D

deficiency and reduced bone mass in individuals with PD (Sato et al.,

1997).

 

A vegetarian or plant-based diet can provide excellent amounts of the B

vitamins (with the possible exception of B12), especially folate; and

education regarding need for B vitamins is important. The vegan patient

may need to use a supplement of vitamin B12, and in fact, if

deficiencies are suspected, a B complex may be required, at least

temporarily. It should be noted that large amounts of vitamin B6 (over

ten mg per day) may reverse the effects of levodopa; therefore,

supplements should be taken with meals, with levodopa taken at least 30

minutes prior to meals, to avoid this food-medication interaction.

 

Protein-levodopa interactions. As stated before, protein breaks down in

the gut to individual amino acids, with which levodopa must compete for

carriers across the intestinal wall. For this reason, patients must take

levodopa at least 30 minutes prior to meals or snacks. As the disease

progresses, individuals often begin to experience fluctuations in their

response to levodopa, resulting in the " on-off " phenomenon, a condition

wherein a dose of levodopa wears off before the next dose is due.

Without levodopa, the individual may be able to move only very slowly,

or not at all, and is effectively disabled.

 

To cope with these motor fluctuations, it has long been advised that

patients avoid protein during the day, limiting intake to no more than

ten grams prior to the evening meal. The bulk of protein needs is met at

the evening meal, allowing the patient optimal use of levodopa during

the daytime hours. However, this often means that the patient cannot

move all night long, which can be very frustrating and even frightening,

as s/he cannot turn over in bed, get up to use the bathroom, or adjust

the bedclothes. If diabetes, hypoglycemia or other conditions are

present, this protein restriction is even less desirable.

 

Although less widely understood, a high-carbohydrate eating plan

consisting of a ratio of five parts carbohydrate to one part protein, or

higher, can be very effective (Berry 1991). Once in the bloodstream, the

high ratio of carbohydrates causes an insulin rush that removes amino

acids from the blood as well, thus allowing levodopa to reach the

blood-brain barrier unobstructed. (See Eriksson et al. 1988; Sanchis et

al. 1991.) A plant-based diet is an ideal way to achieve a

high-carbohydrate meal plan, as plant proteins are often found in a

carbohydrate-to-protein ratio of 3:1 or higher, whereas meats have

virtually no carbohydrate. Legumes, seeds, and nuts are excellent foods,

and can easily be incorporated into a meal consisting of a 5:1 or higher

ratio.

 

Most patients gain improved " on time " with some form of protein

adjustment. Some find they can reduce the amount of levodopa needed.

Reduction of levodopa may result in lessened side effects, such as

hallucinations and dyskinesia (unwanted twisting or writhing movements).

Much more research is needed in this area, to document reduction in

medications, improved " on time, lessened dyskinesia, and reduced adverse

effects of medications.

 

Counseling/therapy

 

It will be important to assess nutrition risk, and a three-day food

diary can be of great help in determining whether fiber and nutrient

intake is adequate. Information intake via interview is also important,

paying particular attention to weight changes and risk for bone

thinning. If unplanned weight loss has occurred, determine whether this

is due to depression, excessive calorie expenditure because of tremor,

dyskinesias, or rigidity, inability to self-feed at a normal pace,

chewing or swallowing problems, or other condition. Small, frequent

meals and snacks are often preferable to the usual three meals a day. To

assess delayed stomach emptying, inquire whether the individual

experiences heartburn or acid reflux, often a sign of slowed

peristalsis; also find out how long it takes for medications to take

effect. If the patient is using levodopa, and taking it at least 30

minutes prior to meals without feeling the onset of antiparkinson

effects, delayed stomach emptying is a possible factor. Small

plant-based meals and snacks, moderate in fat, may be an effective way

to counter delayed stomach emptying.

 

If the individual uses levodopa and motor fluctuations occur, consider

protein adjustment. The simplest, and often very effective method, is to

estimate individual protein needs, and divide the protein equally among

meals. If weight loss or slowed stomach emptying is present, I often

suggest small meals with low-protein snacks between meals. This provides

the most natural eating plan. If the person is protein-sensitive, it may

be helpful to increase carbohydrates. Try a ratio of 5:1 initially, as

this provides the most protein and therefore a more natural eating plan.

After two to three weeks, the individual should notice improved " on

time; " if not, increase the ratio to 6:1 or 7:1. This eating plan is

often harder to teach; it may be necessary to provide ready-made menus

for meals and snacks. NOTE: it is difficult to provide a 7:1 eating plan

having less than 1800 kcal per day. This may be too much food for some

people, especially small women. If a 7:1 ratio works well for the

person, s/he may wish to use it throughout the day in small meals and

snacks, then add additional protein at the evening meal. This will

provide for a smaller number of calories and offer sufficient protein,

while still allowing for better levodopa absorption during the day.

 

Some cautions to be aware of are the increased risk for bone thinning,

and need for vitamin B12. It may be necessary for patients to use

vitamin/mineral supplements, especially of calcium, vitamin D, and

vitamin B12. In some cases, a vitamin B complex may be needed as well.

Patients who use levodopa should take supplements containing large

amounts of vitamin B6 with meals, at least 30 minutes after taking

levodopa, in order to avoid the interference of vitamin B6 with levodopa

absorption.

 

Sample high-carbohydrate menu:

 

1 ½ cups split pea or lentil soup

 

1 oz whole-grain crackers

 

1 TB peanut butter

 

8 oz cranberry juice

 

½ cup grapes

 

Ratio 5:1

 

(694 calories, 122 g carb, 24 g pro, 16 g fiber, 66 mg calcium)

 

For more information, see Parkinson's Disease: Guidelines for Medical

Nutrition Therapy, which includes PD-specific Risk Assessment Tools and

Initial Interview Form. The patient-caregiver handbook Eat Well, Stay

Well With Parkinson’s Disease contains patient education information,

including recipes and menus. A two-hour seminar (Level II, 2 CEUs) is

available: Nutrition and Parkinson’s disease: What the health

professional needs to know.

 

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