Keywords:
Nutritional Status - Eating - Parkinson Disease
Palavras-Chave:
Estado Nutricional - Ingestão de Alimentos - Doença de Parkinson
INTRODUCTION
Parkinson's disease (PD) was described for the first time in 1817 by the English physician
James Parkinson, who named the condition "paralysis agitans"[1]. It is a degenerative disease that affects the central nervous system (CNS) and
results in the death of dopamine-producing neurons in the substantia nigra[±].
Motor symptoms include tremors at rest, stiffness, bradykinesia, postural instability,
and locomotion problems. These symptoms allow the classification of the disease stage,
which is essential to the identification of the needs and the definition of the approach[³] to be used. Other clinical manifestations may occur, such as melancholy, problems
with self-esteem, lack of appetite, dysphagia, and eating difficulty[4],[5].
As the disease progresses, food intake is affected and nutritional complications may
arise, causing weight loss and, in more severe cases, malnutrition[6]. Among the causes of weight loss, the abnormal and involuntary movements such as
rest tremors and dyskinesias result in an increased energy output and hypercatobolism[7]. Dyskinesias can even directly influence the quality of life of the patients, as
they can negatively interfere in the physiological process of swallowing, making food
intake even more difficult[8].
Due to the clinical symptoms associated with the pathology, food has an influence
on certain aspects of the disease, and a proper nutrition helps in weight recovery
and maintenance, promoting well-being and preventing complications associated with
the evolution of PD[5].
A study by Mischley[9] found that the consumption of processed and ultra-processed foods by Parkinson’s
patients such as ice cream, heavy cream, sodas, and canned fruits and vegetables was
associated with higher rates of PD progression. On the other hand, the food items
of the Mediterranean diet have been associated with a reduction in the incidence and
progression of PD[9].
The Mediterranean diet is based on a healthy and balanced diet composed of grains,
preferably whole, with intact fibers, different types of vegetables, fruits, which
are present in most meals, and high-water intake. In addition, this type of diet includes
fresh and minimally processed foods, rich in nutrients, antioxidants, and protective
substances[10].
Through food consumption and nutritional status assessment, it is possible to identify
nutritional deficits early[11]. Several methods can be used to assess the nutritional status of adults and the
elderly, and the ones worth mentioning are: body mass index (BMI), calf circumference
(CP), and the Mini Nutritional Assessment (MAN), which associated with the Food Frequency
Questionnaire (FFQ), offer important information for the global nutritional status[11].
The aims of this study were to assess the nutritional status and food consumption
of patients diagnosed with PD, identify the sociodemographic profile, and evaluate
the association between stage of disease and nutritional status.
METHODS
This was a descriptive, quantitative, cross-sectional study carried out with 40 patients
attending the Neurology Outpatient Clinic of Hospital Ophir Loyola from June to September
of 2019. The sample was defined by convenience, considering the flow of patients treated
at the referred outpatient clinic. Only those who signed the consent form participated
in the study. The research was approved by the Research Ethics Committee of the Centro
Universitario do Estado do Pará (CESUPA) and the Research Ethics Committee of Hospital
Ophir Loyola, complying with the legal requirements of the National Health Council.
Female or male patients, aged over 18 years and undergoing PD treatment, were included
in the study. Two consent forms were available: one for the participants able to answer
the questionnaires by themselves and another for the companions or legal guardians
that would fill the questionnaires in case the patient could not do it.
A structured questionnaire with restricted questions was applied to the research participants
for the collection of patient information (age and date of birth), sociodemographic
data (marital status, education level, and average family income), and anthropometric
measures (weight, height, calf circumference, knee height, and BMI).
To evaluate the PD stage, the modified Hoehn & Yahr scale (HY - Degree of Disability
Scale) was used, which assesses how disable individuals with PD are. The signs and
symptoms were observed at the time of the data collection, and the scale was applied
by the researchers, who were duly trained by a neurologist.
PD has 5 stages and patients were grouped into stages 1-3 and 4-5. Stage 1 is the
initial phase of the disease, stage 2 is characterized by bilateral symptoms, stage
3, by moderate postural instability, stage 4, severe postural instability, and stage
5, total physical impairment[12]. The association of stage with nutritional status was later verified.
The assessment of nutritional status was carried out by two methods: the Anthropometric
Assessment for adults and the Mini Nutritional Assessment (MAN) exclusive for the
elderly. Weight was measured on an electronic digital scale and height, by a 200-cm
portable stadiometer, with 1 cm accuracy.
After measuring weight and height, the body mass index of the patients (BMI = weight/height[2]) was calculated. The BMI classification was performed according to the recommendations
by the World Health Organization (WHO)[13]. In order to measure the brachial circumference, an inelastic measuring tape was
used. When the patient was unable to walk, anthropometric measurements were estimated
according to the equations of the Chumlea[14] method.
Food consumption was assessed by the adapted Food Frequency Questionnaire (FFQ)[8]. The frequency of consumption categories included: 1x a day, 2x or more per day,
4 to 6x per week, 2 to 3x per week, 1x per week, 1x per month, 2x or more a month,
and rarely or never.
The FFQ was divided into two categories. The first one included foods considered to
be protective, associated with reduced incidence rates and progression of the disease,
such as omega-3, zinc, magnesium, iron, vitamin A, vitamin C, and vitamin B6 and B12
(micronutrients considered relevant for cognition and neurological health of individuals
with PD[15]). The second category included high-risk foods, with high levels of fats and sugars,
which promote high metabolic demand of neurons and make cells more susceptible to
oxidative damage, with a negative impact in neurodegeneration[9],[15].
The protective foods category included: pineapple, kiwi, banana, watermelon, orange,
tangerine, acerola, chia seeds, linseed, nuts, chestnut, oats, whole wheat bread,
brown rice, olive oil, and fish. The high-risk category included: soda, diet soda,
ice cream, heavy cream, yellow cheese, canned foods, red meat, pork, juice boxes,
filled sandwich cookies, and fried foods.
For the analysis of the food profile, the methodology adapted from the Sichieri study[16] was used, where the level of consumption was obtained from the transformation of
the frequencies informed into fractions of the daily frequency. Then, the weighted
average frequency of consumption was calculated and the following cut-off points were
applied to categorize the level of consumption: <0.33 for low consumption; > 0.33
and <0.66 for average consumption; and >0.66 for high consumption.
The information gathered with the questionnaires was organized in a database in the
Microsoft Office Excel 2010 program. For the statistical analysis of the data, the
program BioEstat version 5.3 was used, with the application of the G test to verify
possible associations between the variables related to nutritional status, food consumption,
and symptoms of disease progression, considering a significance level of 0.05.
RESULTS
Forty PD patients were evaluated, the majority of whom were male over 60 years old,
single, with high school education, retired, and with an income of up to one minimum
wage ([Table 1]).
Table 1
Characterization of the sociodemographic profile of patients with Parkinson's disease
treated at a Neurology Reference Center.
|
Sociodemographic profile
|
N
|
%
|
|
Sex
|
|
Female
|
16
|
40.0
|
|
Male
|
24
|
60.0
|
|
Age
|
|
40 to 50 years
|
4
|
10.0
|
|
> 50 to 60 years
|
15
|
37.5
|
|
> 60 years
|
21
|
52.5
|
|
Marital status
|
|
Single
|
22
|
55.0
|
|
Married
|
10
|
25.0
|
|
Widower
|
3
|
7.5
|
|
Common law partners
|
4
|
10.0
|
|
Divorced
|
1
|
2.5
|
|
Educational level
|
|
Illiterate
|
5
|
12.5
|
|
Elementary school
|
14
|
35.0
|
|
High school
|
17
|
42.5
|
|
University education
|
4
|
10.0
|
|
Occupation
|
|
Retired
|
32
|
80.0
|
|
Working
|
6
|
15.0
|
|
From Home
|
2
|
5.0
|
|
Family income
|
|
Until 1 MS (minimum wage)
|
17
|
42.5
|
|
>1 MS to3 MS
|
15
|
37.5
|
|
>3 MS to 6 MS
|
6
|
15.0
|
|
>6 MS
|
2
|
5.0
|
Source: Field Research 2019.
[Table 2] shows the results of the nutritional status according to BMI and the stages of the
disease. There was a higher prevalence of individuals classified as eutrophic and
overweight. Most patients were in stage 1 of the disease. Therefore, no association
between nutritional status and disease progression was found (p = 0.6058).
Table 2
Nutritional status and stages of disease progression according to the modified scale
of Hoehn & Yahr of Patients with Parkinson's Disease treated at a Neurology Reference
Center.
|
|
Under weight
|
Eutrophy
|
Overweight
|
Total
|
Value-p*
|
|
Stages
|
N
|
%
|
N
|
%
|
N
|
%
|
N
|
%
|
|
|
Stage 1-3
|
4
|
12.5
|
14
|
43.8
|
14
|
43.8
|
32
|
100
|
0.6058
|
|
Stage 4-5
|
2
|
25.0
|
3
|
37.5
|
3
|
37.5
|
8
|
100
|
|
*G test.
Source: Field Research 2019.
[Table 3] shows the results for the FFQ. The protective foods most commonly consumed were
banana and fish. Among the high-risk foods, red meat stood out.
Table 3
Food consumption according to FFQ of patients with Parkinson's disease treated at
a Neurology Reference Center.
|
|
Daily
|
Weekly
|
Monthly
|
Rare / Never
|
|
Protective foods
|
N
|
%
|
N
|
%
|
N
|
%
|
N
|
%
|
|
Pineapple
|
0
|
0.0
|
11
|
27.5
|
13
|
32.5
|
16
|
40.0
|
|
Kiwi
|
0
|
0.0
|
0
|
0.0
|
3
|
7.5
|
37
|
92.5
|
|
Banana
|
11
|
27.5
|
24
|
60.0
|
4
|
10.0
|
1
|
2.5
|
|
Watermelon
|
0
|
0.0
|
15
|
37.5
|
9
|
22.5
|
16
|
40.0
|
|
Orange
|
1
|
2.5
|
13
|
32.5
|
15
|
37.5
|
11
|
27.5
|
|
Tangerine
|
0
|
0.0
|
6
|
15.0
|
20
|
50.0
|
14
|
35.0
|
|
Acerola
|
4
|
10.0
|
18
|
45.0
|
6
|
15.0
|
12
|
30.0
|
|
Chiaseeds
|
0
|
0.0
|
0
|
0.0
|
1
|
2.5
|
39
|
97.5
|
|
Oats
|
11
|
27.5
|
5
|
12.5
|
4
|
10.0
|
20
|
50.0
|
|
Linseed
|
1
|
2.5
|
0
|
0.0
|
1
|
2.5
|
38
|
95.0
|
|
Nuts
|
1
|
2.5
|
0
|
0.0
|
2
|
5.0
|
37
|
92.5
|
|
Chestnuts
|
2
|
5.0
|
1
|
2.5
|
13
|
32.5
|
24
|
60.0
|
|
Olive oil
|
12
|
30.0
|
10
|
25.0
|
2
|
5.0
|
16
|
40.0
|
|
Brown bread
|
7
|
17.5
|
3
|
7.5
|
3
|
7.5
|
27
|
67.5
|
|
Brown rice
|
5
|
12.5
|
1
|
2.5
|
1
|
2.5
|
33
|
82.5
|
|
Fish
|
2
|
5.0
|
21
|
52.5
|
14
|
35.0
|
3
|
7.5
|
|
Risk foods
|
|
Soda
|
6
|
15.0
|
7
|
17.5
|
9
|
22.5
|
18
|
45.0
|
|
Diet soda
|
0
|
0.0
|
1
|
2.5
|
1
|
2.5
|
38
|
95.0
|
|
Ice cream
|
0
|
0.0
|
1
|
2.5
|
15
|
37.5
|
24
|
60.0
|
|
Heavy cream
|
0
|
0.0
|
10
|
25.0
|
5
|
12.5
|
25
|
62.5
|
|
Yellow cheese
|
1
|
2.5
|
9
|
22.5
|
3
|
7.5
|
27
|
67.5
|
|
Canned food
|
3
|
7.5
|
6
|
15.0
|
7
|
17.5
|
24
|
60.0
|
|
Read meat
|
2
|
5.0
|
33
|
82.5
|
1
|
2.5
|
4
|
10.0
|
|
Pork
|
0
|
0.0
|
4
|
10.0
|
6
|
15.0
|
30
|
75.0
|
|
Juice box
|
1
|
2.5
|
5
|
12.5
|
3
|
7.5
|
31
|
77.5
|
|
Stuffed biscuits
|
0
|
0.0
|
10
|
25.0
|
6
|
15.0
|
24
|
60.0
|
|
Fried food
|
6
|
15.0
|
12
|
30.0
|
10
|
25.0
|
12
|
30.0
|
Source: Field Research 2019.
DISCUSSION
In general, PD incidence does not vary with race, social class, or gender, but studies
have found evidence that there is a higher prevalence in men[7],[5]
[13]. In this study, the population was mainly composed of males (60%), similar to the
findings by Carmo and Freire[7], where 57.5% of the patients were male and 52.5% were over 60 years old.
The occupation results were related to the age of the patients, since the majority
reported being retired, corroborating the findings by Silva‘s et al[17] research, in which the majority the participants were also retired. As a degenerative
disease, PD can cause disability 10 to 15 years after diagnosis, resulting in a high
social and financial impact[18].
In this study, a higher prevalence of eutrophic individuals was found, followed by
overweight. Similar result were found in the study by Moraes et al[5], in which 81.2% of the sample were eutrophic or overweight, and in the study by
Guerdão et al[3], where 70% were overweight and obese.
Regarding the nutritional status and the stage of disease, most of the participants
classified as eutrophic and overweight were in stage 1, which possibly occurred because
they were patients treated at an outpatient basis. Furthermore, in this sample, there
was no significant association between nutritional status and disease stage. The study
by Guerdão et al[3] also found no significant association between nutritional status and disease stage.
The most commonly consumed protective foods were banana, followed by fish, acerola,
watermelon, and orange. Banana is a source of vitamin B6 that, associated with vitamin
B12, can act in the homocysteine purification cycle[19]. Homocysteine is an amino acid that at high plasma concentrations can cause brain
injury associated with neuropsychiatric disorders[19],[20].
The biochemical alteration caused by homocysteine accumulation may cause increased
oxidative stress, a factor related to brain aging and neural damage. This amino acid
is associated with prolonged use of levodopa that can generate hyperhomocysteinemia,
promoting the development of vascular complications, which predispose to CNS disorders[19],[20].
The high fish consumption may be associated with the fact that the northern region
population has a preference for fish in their meals, and fishing has become one of
the main extractive activities, supplying urban and riverside areas[21]. Fish is rich in omega-3, which acts as an anti-inflammatory neuroprotector, essential
for the motor and cognitive functions usually affected in PD, with an important role
in reducing symptoms[22].
The fruits consumed often by patients in our study, such as acerola and oranges, are
rich in antioxidant vitamins and protective substances such as omega-3, which together
act to prevent cell destruction from the oxidation of cell membranes. Among the metabolic
changes, oxidative damage is an important predisposing factor for PD, since neurons
are especially vulnerable to damage from free radicals[19].
In contrast, many other foods that are sources of antioxidant vitamins, omega-3, selenium,
and fiber were reported as consumed rarely or never, including chia seeds, linseed,
chestnuts, kiwi, and brown rice. This result is similar to the study by Moraes et
al[5], in which patients had low consumption of whole foods and oilseeds.
A low consumption of legumes, roots, tubers, fruits, and vegetables may contribute
even more with the progress of the disease[23]. However, among many factors that influence food choices, a study[24] mentions financial problems as the main factor in food purchase decisions. Economic
restrictions on the purchase of food lead to diets with low consumption of fruits
and vegetables.
A study by Borges[25] linked the quality of the diet with social class, and stated that the health status
of individuals belonging to lower social classes would be worse than the status of
those from higher social classes. The food consumption of the low-income Brazilian
population is characterized by the large amount of grains, oils and fats, sugars,
high fat meats, and processed foods, mostly high energy density foods, and in this
study most of the patients evaluated reported having an income of one minimum wage.
As for high-risk foods, the weekly consumption of red meat, fried foods, heavy cream,
filled cookies, and yellow cheese was high, followed by the monthly consumption of
ice cream. Recent research suggests that the meat consumed in the Western diet has
a high fat content. In addition, a high intake of meat has been linked to the incidence
and progression of PD, as it would be associated with the accumulation of alpha-synuclein
in the enteric nervous system, through the activation of immune cells and the cross-reactivity
between antigens. The accumulation of alpha-synuclein in the form of intracellular
filamentous aggregates is one of the pathological features of neurodegenerative diseases[9],[26].
Another relevant aspect about dietetic protein is that the amino acids from animal
proteins and the levodopa drug compete for the same active transport mechanism in
the gastrointestinal tract and blood-brain barrier, thus causing decreased absorption
of the drug and affect its therapeutic action[27].
Other highly consumed items were fried foods in general and dairy products. It is
known that lipid peroxidation is involved in the pathogenesis of many neurodegenerative
disorders[9]. The study carried out by Dalbeth et al[28] mentions some mechanisms responsible for the association of dairy products with
progression of PD. Intake of dairy products reduces uric acid in the CNS (low uric
acid levels are associated with a higher incidence of PD). In addition, dairy products
can contain pesticide residues that are neurotoxic and have pro-oxidant properties.
In the present study, most of the participants were elderly, eutrophic, males with
an income around one minimum wage. Most reported a high consumption of red meat and
processed foods. It is worth noticing that the financial condition of patients may
have made it difficult to include protective foods into the diet.
Regarding the limitations of the study, the sample size was restricted, because the
data collection occurred according to the flow of care in the institution where the
research was conducted, which affected the number of participants. In addition, the
scarcity of studies with this type of analysis also limited the comparison of results.
More studies should be conducted with a higher number of interviewees and in different
groups, in order to obtain more information about the relationship between diet and
PD.
