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Diet

A Healthy Balance


The most important dietary advice for a person with Parkinson’s disease (PD) is to eat a healthy, balanced diet, with plenty of fibre and fluids. It’s as simple as that. A routine of three balanced meals a day is a good start, although some people with PD may find it easier to manage more frequent and smaller meals.

At different times, certain foods, vitamins or unusual diets may be advertised as being able to help PD, but there is no proof that this is the case. One common story is that broad beans (fava beans) are able to help relieve PD symptoms. It is true that broad beans do contain levodopa, but in variable, small amounts, and at nowhere near the level that is found in levodopa medications. The number of beans you would have to eat for them to have an effect would probably make you ill in other ways. If you are tempted by any unusual ‘dietary therapies’ like this, then please discuss the idea with your medical team. Members of the team who may be able to advise on diet and practical issues with eating include the doctor/specialist, registered dietician, occupational therapist, speech and language therapist, and PD nurse.

If you already eat a healthy, balanced diet, then you may not need to make any changes to your routine. However, in some specific cases, there may be other factors to consider, and many of these are discussed in the following pages.

Managing your weight


Developing PD may have an effect on body weight. In some people, movement problems mean less exercise, and they find that they put on weight. Excess weight can put a strain on the joints, and make movement difficult, worsening the problems of PD. Therefore, if people do put on a lot of weight, or are overweight already, then they may be advised to go on a calorie-controlled diet.

However, in most cases, people with PD find that they lose weight. Weight loss can occur for several reasons:

  • coping with the symptoms of PD can use up a lot of energy
  • there may be a loss of appetite
  • eating can become more difficult as PD progresses, and meals may be left unfinished
  • the body may absorb fewer nutrients

Therefore, people with PD often need to be encouraged to eat more calories. Rather than trying bigger portions, smaller tempting meals and snacks at regular times during the day may be more acceptable. High calorie foods like peanut butter, biscuits/desserts and milkshakes can help to increase weight. If you find that you are eating more sugary snacks to increase your calories, then remember to brush your teeth more often too.

To make sure that your weight is under control, weigh yourself regularly and keep a record of any changes.

Food and medication

If you have been prescribed levodopa, your doctor will have given you instructions on how your dose should be taken in relation to food. Most other PD medications do not have specific instructions for whether they should be taken with or without food.

Protein in the diet


Some people with advanced PD and motor fluctuations may be advised to alter their protein intake (examples of foods rich in protein include meat, eggs and cheese – see section on ‘Nutrients’). Protein can interfere with the uptake of levodopa into the body and the brain and, as a result, reduce the effectiveness of the drug.

Therefore, it may improve matters if the normal daily intake of protein is taken all together in one meal at the end of the day. If you need to do this, foods low in protein, e.g., bread, cereals, vegetables, fruit, clear or vegetable soups (not creamed or containing lentils or peas), spreads (honey, jam, vegemite), sweets and fats, should make up the bulk of your other meals. This prevents the protein interfering with the effect of levodopa during the day. However, this does not help in all cases, and some doctors will not recommend this change in diet. Therefore, the diet should never be altered in this way before speaking to a doctor or registered dietician. Also, it should be noted that although protein may be taken at a different time of day, the total daily amount of protein should not be reduced, as it is needed by the body for repair and to fight infection.

Another way to avoid the ‘protein effect’ is to take levodopa on an empty stomach (1 hour before or after a meal), as long as this doesn’t cause nausea.

As well as protein worsening motor fluctuations, people with advanced disease may find that their dyskinesias become worse after eating foods high in carbohydrate/sugar. However, carbohydrates should not be excluded from the diet – a good overall balance of foods is still recommended, and carbohydrates are needed to maintain body weight and energy levels.

Antioxidants

Antioxidants are a group of vitamins and minerals that can help lessen the damage caused by a normal body process called oxidation. Oxidation occurs inside the cells of the body, and can produce substances known as free radicals, which cause damage to the body and may play a part in conditions such as heart disease, cancer and PD. However, there is presently no evidence that intake of antioxidants will slow the progression of PD or increase the effects of PD drugs. In addition, anyone consuming a regular well-balanced diet should already have an adequate intake of antioxidants.

Constipation

Constipation is a common problem with PD, because the condition reduces the action of muscles in the bowel. However, it is one problem that can be easily managed – and remember that the bowels only need to be emptied 3 or 4 times a week. If relief can be achieved with a natural diet, then that is the ideal and most healthy way. If constipation becomes a more serious problem, then your doctor will be able to recommend some medication.

Drinking fluids

Drinking plenty of fluids (8-10 glasses a day) is beneficial in many ways (remember, coffee and tea are dehydrating, so they don’t provide as much fluid as other drinks). It is an essential part of a healthy diet and, as described earlier, it helps to relieve constipation.

Dry mouth is a common problem in PD, and this can be eased by drinking more fluids, taking frequent sips of water, sucking ice chips or using a mouth spray or oral rinse (pharmacists sell these specifically for dry mouth). Sucking a sweet, or chewing gum, can also help to produce more saliva and relieve a dry mouth.

Unless your doctor advises you otherwise, the drinking of moderate amounts of alcohol is allowed in people receiving PD medication.

Tips


Swallowing

  • If the throat tenses up while eating, try yawning several times before a meal to relax the throat.
  • If swallowing is difficult, then keeping the chin tucked down to the chest may make things easier. Taking regular sips of water will also help.
  • Good posture and a comfortable position while eating will also aid swallowing.
  • Only put a small amount of food on the fork or spoon – this prevents spills and helps with swallowing.
  • If a semi-solid or puréed diet is required due to swallowing difficulties, then you should ask to be referred to a speech and language therapist and a dietician. Not all swallowing problems are due to PD and the cause of the problem should be confirmed before changing the diet.

Meal times

  • If eating is slow and tiring, then it may be easier to cope with several small meals a day, rather than three main meals.
  • If it is a hot meal, serve the food on a warming mat, in an insulated bowl, or microwave the food during the meal – this stops the food getting cold if eating is a slow process.

Practical Aids

  • Hot drinks can be served in an insulated cup to stop them getting cold. Sometimes these cups have a lid and spout, which can stop spillages and help with drinking.
  • Don’t overfill cups, and consider the use of a straw.
  • Using weighted cups can help to prevent tremor when drinking.
  • Serve the meal on a raised level, e.g., put the plate on a small box or stand, so that the food is nearer the mouth. This helps with transferring the food from the plate to the mouth.
  • It may help to place the elbows on the table to steady the hands/arms when eating.
  • If spillage is a problem, use an apron/bib with a plastic or easy-clean cloth for the table.
  • A plate can be placed on a rubber mat to prevent it slipping, and a clip-on ring can be added around the edge, to stop any food being accidentally pushed off the edge.
  • Other eating aids that are available include a combined fork/knife, a ‘rocking’ knife that cuts one-handed, and cutlery that is easier to hold.
Contact Parkinson’s Queensland for specific information about practical aids that are available to you, and how they can be obtained.

Creating a Balanced Diet


The following section contains information about the different elements that make up a balanced diet, and how to ensure healthy eating throughout the day. These ideas can be simply fitted into the daily routine in place of (not in addition to!) current eating habits. However, if you have particular concerns about any aspect of your diet, then speak to your doctor or PD nurse, who may recommend speaking to a dietician.

Nutrients

A balanced diet should contain a combination of all the nutrients that are required to keep the body healthy and in good repair. There are two main types of nutrients needed by the body:

1. Macronutrients

  • Carbohydrates break down inside the body to form glucose, which is the basic fuel for the body, providing energy. Foods containing carbohydrate include products rich in starch and/or sugar, e.g., bread, pasta, rice, cakes, and biscuits, and provide 4 kilocalories per gram.
  • Proteins are the building materials of the body, helping with growth and repair of body tissues, e.g., muscles, skin. Foods containing protein, e.g., dairy products, meat, nuts and pulses, provide 4 kilocalories per gram.
  • Fats are also required for a healthy body, serving as an energy store and insulator. They also supply ‘essential fatty acids’, which are required to help the body absorb some necessary vitamins. Fats are high in calories (9 kilocalories per gram), and although certain types should be eaten in moderation, some people who have difficulty gaining weight may be advised to eat more high-fat foods.

Saturated and unsaturated fats
Saturated fats can cause an increase in blood cholesterol. They are also known as animal fats as they are found mainly in animal products such as fatty cuts of meat, lard and dripping, some margarines and dairy products such as full fat milk, hard cheese, cream and butter, and in cakes, biscuits, pies and pastries. Saturated fat may also be found in some vegetable oils such as coconut and palm oil.

Unsaturated fats may lower blood cholesterol, and include the polyunsaturated fats found in sunflower, corn or soya oil, and the mono­unsaturated fats found in rapeseed (canola) and olive oil.

2. Micronutrients
Consuming a varied and balanced diet, including foods rich in micronutrients, can remove the need for vitamin and mineral supplements. If you are taking supplements containing large amounts of vitamins or minerals and/or need further advice, then speak to your doctor or dietician.

  • Vitamins A, D, E and K are fat-soluble, and remain in the body for weeks before being depleted. They tend to be found in milk and dairy foods.
  • Vitamins B (complex) and C are water-soluble and need to be replenished daily. B vitamins are found in bread and cereals, and vitamin C is mostly found in citrus fruit.
  • Minerals are found in many foods, often in tiny (trace) amounts, and include calcium, chloride, chromium, fluoride, iodine, iron, magnesium, manganese, molybdenum, phosphorus, potassium, selenium, sodium, sulphur, and zinc.

Food groups
All the foods we consume fall into one of the following five groups, each containing different amounts of the nutrients listed previously.

  1. Breads and cereals (starchy foods) provide mostly carbohydrate (starch), fibre, and some protein, calcium, iron, and B vitamins.
  2. Meat, fish and the vegetarian alternatives provide mostly protein with some fat, and vitamins and minerals, including iron, zinc, magnesium and B vitamins.
  3. Fruit and vegetables provide some carbohydrate and fibre, as well as many vitamins and minerals, including vitamin C, carotenes, and folates. Fruit and vegetables tend to be lower in calories due to the high proportion of water and fibre found in these foods.
  4. Milk and dairy products contain carbohydrate, protein, fat, and some vitamins and minerals, including calcium and vitamins B12, A and D. Some people feel that milk contributes to excess mucus, but there is no evidence to show that this is the case.
  5. Extras – food and drinks containing fat, sugar and/or alcohol, e.g., chocolate, biscuits, sweets, butter, mayonnaise, and cream. Depending upon the particular type, these foods provide fat and carbohydrate and can be used to increase the calorie intake of people who are unable to achieve their body’s energy needs with a standard balanced diet. In addition, the intake of fluids – basically, plenty of water (8–10 glasses daily) – is an essential part of the balanced diet.

Daily intake

f you have a special requirement for food intake in relation to your PD medication, then you should consult your doctor or dietician about the best choice of daily diet. For those without specific medication guidelines, a balanced daily food intake, or diet, contains the items in the list on the right.

If your medication means that you need to have most of your protein intake at the end of the day, omit foods from the meat, fish and alternatives, and milk and dairy products groups earlier in the day, and instead take these protein-rich foods for your evening meal or supper. In order to determine how balanced your diet is, try comparing the amount you eat and drink in one day with the tables on the following page. (Please note that this only serves as a rough guide, as people differ in the amount of energy/ calories they require, according to their age, gender, body size, activity level, and whether or not they need to eat extra amounts to gain weight.)

So-called ‘free foods’ do not count towards the daily nutritional intake, although some of them do contain high levels of salt (marked with *), and should therefore be avoided in large quantities. ‘Free foods’ include:

  • some drinks – diet soft drinks, carbonated or mineral water, squashes with no added sugar, instant soup*

The following snacks and alcohol each count as three ‘extra’ portions (150 kcal):

  • condiments – very low fat mayonnaise, sauce (tomato, brown or barbecue), horseradish, lemon or lime juice, pickles, chutney, mustard, salsa, vinegar
  • seasonings – herbs, spices, fresh or dried chillies, Worcestershire sauce*, soy sauce*
  • other – sugar-free jelly, sugar-free hard sweets, vegemite*.

Meal Ideas

To help you put these guidelines for a balanced diet into practice, here are some ideas that allow you to eat a healthy combination of the different food groups together in one meal. If you require extra fibre in your diet, remember to choose wholegrain breads and cereals, and have at least five portions of fruit and vegetables daily. Increase your fibre intake gradually to avoid bloating or flatulence (wind) – introduce one new high-fibre food every three days to allow your system to adapt.

All the meal ideas listed below should be accom­panied by plenty of fluids, e.g., a glass of water or fruit juice.

Breakfast
If you have a good appetite in the morning, a full breakfast gives you a good start to the day – meat, cheese, yoghurt, bread and fruit.

  • Half a grapefruit (with or without sugar), and a bowl of breakfast cereal with milk.
  • A glass of fruit juice, a slice of wholemeal toast with butter and/or jam, and a pot of fromage frais.
  • A glass of milk, and a bagel or bread roll (with or without butter) with a slice of ham.
    A bowl of fruit salad or melon, topped with plain yoghurt and sprinkled with nuts.
  • A bowl of porridge or breakfast cereal with milk and served with sliced banana or a handful of dried fruit.
  • A banana sandwich and a pot of yoghurt.
  • A piece of fruit or glass of juice, with an egg and toast/bread.
  • A bacon sandwich and hot milky drink.

Light meals

  • Baked potato – with cheese, tuna, or coleslaw, with a side salad.
  • Spanish omelette – eggs, cheese, ham, green pepper with a tomato salsa sauce, and rice or bread.
  • Sandwiches – made with various breads (pitta, tortilla wrap, granary, French, rustic), and fillings such as egg, tuna, chicken, cheese, beef, or salmon, and mayonnaise/butter, along with salad and appropriate seasonings.
  • Pasta salad – made with tuna and/or vegetables such as red or green pepper, tomatoes, sweetcorn and a mayonnaise, salad cream or oil and vinegar dressing.
  • Toast with a topping – beans, cheese, pilchards, sardines, scrambled egg or tinned spaghetti.
  • Scrambled egg – with ham, bacon, grilled tomatoes and/or mushrooms.
  • Soup – containing meat or pulses (such as lentil).
  • grated cheese and wholemeal bread.

Main meals
Main meals can be simple to prepare, and don’t always need to be homemade – frozen, chilled or tinned ready meals are convenient when you don’t feel like cooking.

  • Lasagne – pasta, vegetables, mince and/or beans, and cottage/ricotta/mozzarella cheese.
  • Chilli – beans/mince, vegetables and cheese, with corn tortilla chips (plus salsa and/or guacamole).
  • Pizza – bread base with tomato sauce, vegetables, cheese and/or meat.
  • Stir-fry noodles – noodles with vegetables and/or meat or fish and a tasty sauce.
  • Spaghetti bolognaise – turkey or beef mince, tomato sauce (plus extra vegetables), parmesan or cheddar cheese.
  • Curry – seafood or meat curry with pre-made or homemade sauce, served with vegetables and rice.
  • Kebabs – cubes of meat threaded on skewers with onion, peppers, mushrooms and courgettes, perhaps marinated in soy sauce and honey.
  • Stew or casserole – made with chicken, beef or beans, with onions, carrots and potatoes.
  • Risotto – risotto rice with chicken, cheese, asparagus and mushrooms.
  • Tuna Niçoise salad – potatoes, anchovies, salad leaves, hard-boiled eggs, tuna, green beans, plus dressing.
  • Baked moussaka – lamb mince, aubergine, tomatoes, potatoes and white sauce.
  • Salmon and vegetable pasta – made with low-fat Greek yoghurt, carrots and courgettes.
  • Breaded or plain fish, pork chops or steak – served with oven chips or mashed potatoes, grilled tomatoes, and peas or broccoli spears.
  • Vegetable bake – pasta, tomato sauce and cheese.
  • Roast chicken, pork or beef – served with gravy, new potatoes and vegetables or salad.
  • Shepherd’s or cottage pie – baked minced meat topped with mashed potato, sweet potato, celeriac or parsnip, and served with cooked vegetables.
  • Liver and onions – served with creamed potatoes and carrots.
  • Low-fat sausages – grilled and served with mashed potato and vegetables.
  • Low-fat beef or turkey burgers – grilled and served with a bread roll and salad.

Desserts
Use low-fat varieties of these desserts if you are watching your weight, and regular varieties if you need to gain weight.

  • Fresh fruit and/or milk puddings such as custard, yoghurt, rice pudding, fromage frais or mousse.
  • Fruit-flavoured jelly.
  • Fresh, tinned or stewed fruit.
  • Meringue – topped with custard or yoghurt and/or fresh or tinned fruit.
  • Ice cream or sorbet.
  • Trifle – made with sponge cake fingers (perhaps soaked in sherry for extra calories), custard, and fresh or tinned fruit.
  • Fruit tart (or crumble/cobbler) – with or without custard or ice cream.

Many people find that they need extra snacks between meals – either to raise their calorie intake, or because they find many smaller meals easier to manage than fewer large meals. It is important that these snacks also adhere to a healthy diet, so you might like to try some of the following.

  • Fruit smoothie made with milk or yoghurt and fruit such as strawberries, bananas, blackcurrants and/or mangoes.
  • Raisin toast or bread with cream cheese.
  • Dried fruit (can be stewed in water or fruit juice for easier eating).
  • Plain biscuits, i.e., not chocolate-covered or cream-filled!
  • Scone, English muffin, or crumpet with jam and/or butter.
  • Raw vegetable crudités with cream cheese or yoghurt dip.
  • Pitta bread slices with salsa or hummus dip.
  • Small bowl of cereal and milk.
  • Mug of soup.
  • Fresh fruit or yoghurt.
  • Milky drinks such as hot chocolate/cocoa or malted milk.
  • Cheese and bread/crackers.
  • Fruit cake or malt loaf slice with cheese.

Remember that these snacks should be taken in place of unhealthier choices – not in addition to them!

Although it is always good to include fresh food in your diet, in order to make things a bit easier when deciding on meals to prepare, here are some useful ‘store cupboard’ foods to keep on hand:

  • dried pasta, rice, bread (can be frozen and used as needed), breakfast cereal, potatoes (usual or as instant mash), biscuits, crackers and crispbread
  • tinned fruit, tinned/frozen vegetables, and long-life fruit juice
  • eggs, cheese, long-life milk, and tinned milk puddings
  • baked beans/tinned beans, lentils, and other dried beans and peas
  • frozen or tinned mince, chicken or fish
  • hot chocolate powder/cocoa, malted milk and meal-replacement drinks
  • stock cubes, onion, garlic, tinned tomatoes, tomato purée, dried herbs, chilli powder, and black pepper, to add flavour when cooking.

Remember to use and replace your store cupboard foods, and to regularly check the ‘use by’ dates on the packaging.

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