To the List,
I've received several requests for further information regarding protein
restriction, so I will post this. But please remember, protein
restriction is potentially harmful. It's extremely important to discuss
dietary changes with both your physician and a registered dietitian
before beginning such a plan.

Best regards,
Kathrynne
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D

        NUTRITION AND PARKINSON'S DISEASE

Kathrynne Holden, MS, RD
Five Star Living, Inc.
Nutrition you can live with!
604 East Pitkin
Fort Collins CO 80524
Tel: 970-493-6532
Fax: 970-493-6538
Copyright 1997, all rights reserved
http://www.fortnet.org/~fivstar
[log in to unmask]

   1. Before making any dietary changes, be sure to consult your
personal physician and/or registered dietitian, particularly if you have
other diagnoses (such as diabetes, hypertension, lung disease, high
triglycerides, or other conditions).
   2. If you decide to make the dietary changes described here,  please
allow 1-2 weeks for the changes to take effect. Studies have shown that
about two-thirds of people with PD receive some degree of benefit from a
lower-protein diet.
    3. Be sure to distinguish between Sinemet and Sinemet CR [controlled
release]. Both Sinemet and Sinemet CR's effects are best when taken on
an empty stomach, unless nausea makes this too difficult. However,
Sinemet CR may be taken with food. In either case, it may be best to
lower protein intake.

        * * *

        A nutritious, balanced daily menu is always important for good health.
While we each have slightly different needs, everyone must have
carbohydrates, fats, and protein. Minerals like calcium, magnesium, and
potassium help manage our blood pressure and keep our bones strong.
Vitamins like A, D, K,  E, and folate are responsible for good vision,
heart health, proper blood clotting, and healthy bones. And new
nutrients are being discovered in foods every day -- flavonoids,
phytochemicals, genistein, omega-three fatty acids -- we've all seen
these words in the news lately. All these nutrients, and many more, are
important, especially for people with Parkinson's disease.
        Yet those with PD have special needs with regard to nutrition. While
they must have carbohydrates, fats, and protein just like everyone else,
some foods can interfere with the absorption of the special medications
used for PD. Let's take a look at nutrient needs, then see how the
medications work, and how food affects them. Then we'll explore ways to
get a balanced menu while getting the full benefits from medications.


CARBOHYDRATES
        Carbohydrates can be starches, sugars, or fiber. The best sources of
starch are whole-grain breads, cereals, rice, and pasta. They contain
not only starch, but fiber, too.  We need more grain-based foods than
any other type of food in our daily menu. Carbohydrates provide the
steady supply of energy needed by the brain, internal organs, and
muscles all day and throughout the night. If we don't get enough
carbohydrates, the body will break down the proteins of our own muscles
and organs, in order to get the energy supply it needs. Stored fat is
used in a different way; it can't replace starch. We must get plenty of
carbohydrate daily.

        Fruits and vegetables are also rich in carbohydrates; many of these are
simple carbohydrates (sugars). Vegetables and fruits contain other
fibers, minerals and vitamins not found in grains; they are equally
important in the daily menu.

         A serving from the bread group is: one slice bread, 1 ounce
ready-to-eat cereal,  =BD cup cooked cereal, rice or pasta; 4 small
crackers or 2 large crackers; =BD bagel or English muffin. A very small o=
r
inactive woman needs about six servings a day. A large or very active
man needs eleven servings or more daily. =


FATS
        Fats are very important, and we need to get them every day. They're
part of the coating around each nerve; also, the vitamins A, D, E, and K
cannot be absorbed without first being dissolved in fat; finally, a
layer of fat protects our vital organs and cushions our bones,
protecting them from shock and injury.

        It's important to keep fat in the right proportion in the daily menu,
though. Fat takes a long time to get out of the stomach. This is
important in PD, because when eaten together, Sinemet mixes with the fat
and stays in the stomach along with it. This means it takes a long time
for the Sinemet to get to the brain and do its work. And, since Sinemet
has a very short lifespan, its life may be nearly over by the time it
gets to the brain.

        Good fatty foods are raw nuts, seeds, and avocadoes. They all have
heart- protective fats, as well as special vitamins and minerals not
found in other foods. Fatty foods to use in moderation are fried foods,
meats, high-fat dairy products, butter and other spreads, desserts,
candy, gravies and sauces.
        A good idea is to eat some raw nuts daily, and eat small portions of
lean meats, fish, eggs, and poultry daily. Desserts and fried foods are
OK once in awhile.


PROTEIN
        A protein is a long string of tiny molecules called amino acids. Foods
highest in protein  are meats, poultry, and fish. Next highest are
cheese,  milk, nuts, seeds, and cooked dried beans. Vegetables, and
starchy foods, like potatoes and breads, have protein, too, but only a
very small amount. Fruits have little or no protein.

        Inside the stomach and intestine, the body breaks up the protein string
into separate amino acids. The aminos then are absorbed into the
bloodstream and delivered around the body to build new muscle, repair
damages, and form special chemicals in the brain.

        We need about =BD gram of protein per pound of body weight per day. A
150- pound person needs about 55 grams (two ounces) of protein.  Most
Americans eat far more protein than that.  If your Sinemet isn't
absorbed well, it could help to check the amount of protein you're
getting each day.

PARKINSON'S VS PROTEIN
        Each of us has different calorie and protein needs. People with
Parkinson's have further complications, because protein interferes with
levodopa (Sinemet) absorption, both in the intestine and at the brain.
And, each person takes different amounts of levodopa, at different
times, and in combination with different additional medications.
Finally, PD has different stages, and these stages can affect a person's
absorption of medications.

        During the early stages of PD, the brain continues to make some
dopamine, so it doesn't have to rely totally on Sinemet. Later on,
however, the brain stops producing dopamine. It's at this point that
protein may become important. Digestion of protein can greatly affect
absorption of Sinemet. Why? Because amino acids need a special "carrier"
to get across the intestine and into the blood. Then they need another
carrier to get from the blood into the brain. The Sinemet uses the same
carrier as the aminos. So the aminos and the Sinemet all compete for
carriers -- to get into the bloodstream, and to get into the brain. When
we eat lots of protein, the aminos win the race.

        Another problem is that Sinemet doesn't last very long. It's "lifespan"
is about an hour-and-a-half.  Once it's gone, the "off" period or
"freezing" may return, especially in the later stages of PD. This means
that it's important for the Sinemet to get to the brain as fast as
possible. =



        When taken by itself, Sinemet can travel quickly through the stomach,
into the intestine, and from there to the bloodstream. Food, however, =

takes longer to get out of the stomach--especially fatty foods and
fiber. If you take Sinemet with food, its short lifespan may be half
over by the time it gets out of the stomach. Then it has to compete with
the protein to get out of the intestine. By the time it gets into the
bloodstream, and up to the brain, its life is almost at an end. So it's
important to get the Sinemet into the bloodstream as quickly as
possible.

 TO GET THE MOST OUT OF YOUR SINEMET:
1)      If your Sinemet works well, and you don't experience any "off" or
"freezing" periods, your brain is most likely making some dopamine.
That, plus the Sinemet, is probably sufficient for your needs, and
unless your doctor says otherwise, you don't need to worry about protein
at this time.

2)      If you have begun to experience some "off" times or "freezing" it's
possible that your brain's production of dopamine has slowed or stopped.
Excess fat may be preventing the Sinemet from leaving the stomach
quickly, or protein may be preventing it from being absorbed by the
brain. =


        The recommendation is to take Sinemet 30 to 60 minutes before a meal,
although  Sinemet CR may be taken with food. The stomach needs about 45
minutes to empty; so the Sinemet passes out of the stomach into the
intestine without interference from protein.  The medication is absorbed
from the intestine into the bloodstream, and gets to the brain before
the food can get out of the stomach. If you find that Sinemet by itself
makes you nauseous, try taking it with some carbohydrates, such as fruit
juice and crackers. Then eat your meal 30-60 minutes later.

3)      If this approach doesn't work well, the next step is to cut back on
the amount of protein in your daily menu. Our food chart shows the
approximate amounts of carbohydrate and protein in the main food groups.
For more exact amounts, you need a diet manual.

        NOTE: Some people with PD burn extra calories, leading to weight loss.
If you are losing weight, you need extra servings, especially of breads,
grains, fruits, and vegetables. You can eat these as snacks between
meals, for extra calories.
        You may need to locate a source of low-protein breads, to cut down on
protein. Aproten, Paygel, and Cellu make such low-protein products. You
may be able to find them at health food stores, larger supermarkets, or
specialty food stores. If not, contact your local hospital; they may
have a source.


        FOOD SERVING SIZES / APPROXIMATE GRAMS OF PROTEIN

Breads, grains: 1 slice bread, =BD bagel or English muffin
                        1 cup cold cereal
                        =BD cup cooked cereal, rice, or pasta   =

15 grams carb/ 3 grams protein/ 80 calories
-------------------------------------------------------------------------=
--------------------------
Vegetables              =BD cup cooked veg.
                        =BD cup chopped raw veg.
                        6 oz veg. juice
                        l cup raw leafy greens  =

5 grams carb/ 2 grams protein/25 calories
-------------------------------------------------------------------------=
--------------------------
Fruit                   1 medium apple, banana, or orange; =

                        =BD cup fresh berries; =

                        15 grapes; =

                        =BD cup applesauce; =

                        1/4 cup dried fruit; =

                        3/4 cup fruit juice     =

15 grams carb/ 0 protein/ 60 calories
-------------------------------------------------------------------------=
--------------------------
Dairy (low or reduced fat choices)              =

                        8 oz milk or yogurt : 12 grams carb/ 8 grams pro/ 3 grams fat/ =

                                100 calories
                                1 =BD oz cheese : 1 gram carb/ 10 grams protein/ 8 grams fat/  150
calories
                                1 cup cottage cheese : 6 grams carb/ 28 grams protein/ 3 grams fat/ =

160 calories
-------------------------------------------------------------------------=
--------------------------
Protein (meat and poultry choices should be low-fat or medium-fat)      =

                                1 oz meat, poultry, fish: 3 grams carb/ 7 grams protein/ 3 grams
fat/  75 calories
                        1 cup cooked dried beans : 30 grams carb/ 7 grams protein/ 225                          =

calories
                        1 egg : 0 grams carb/ 6 grams protein/ 5 grams fat/ 80 calories
                                Mixed nuts, 1 ounce (4 TB) : 5 grams carb/ 7 grams protein/ 14 grams
fat/ 175 calories
                                Peanut butter, 2 TB: 5 grams protein/ 9 grams carb / 14  grams fat /
185 calories    =

-------------------------------------------------------------------------=
--------------------------


Fats                    Butter, margarine,  1 tsp: 0 carb/ 0 protein/ 45 calories
                        Avocado, 1/4 :  3 grams carb/ 1 gram protein/  75 calories
-------------------------------------------------------------------------=
--------------------------

MENU PLAN =

(Protein is mainly restricted to the evening meal; this may improve
daytime mobility for people who have greater shifts "on and off" in
their ability to move. Calories and protein are about right for a
150-pound person -- 2000 calories and 55 grams protein. Discuss this
plan with your physician before you start. Allow about two weeks for
dietary changes to take effect; if you don't notice any changes,
discontinue.)

BREAKFAST                       =

6 oz orange juice : 15 grams carb/ 0 protein/ 60 calories
3/4 cup Whole Grain Total : 24 grams carb/ 3 grams protein/ 110 calories
4 oz non-dairy creamer : 16 grams carb/ 0 protein/ 176 calories
1 cup fresh fruit : 30 grams carb/ 0 protein/ 120 calories

Total for Breakfast: 85 grams carb/ 3 grams protein/ 466 calories

LUNCH                   =

1-1/2 cups vegetable soup (no meat, poultry or beans) : 30 grams carb/ 3
grams   protein/ 195 calories
2 large rye crackers : 15 grams carbohydrate/ 2 grams protein/ 80
calories
1 medium banana : 15 grams carb/ 0 protein/ 80 calories
8 oz tomato juice : 5 grams carb/ 0 protein/ 45 calories

Total for lunch: 65 grams carb/ 5 grams protein/ 400 calories

DINNER                  =

8 oz 1% or skim milk : 12 grams carb/ 8 grams protein/ 100 calories
Cheeseburger, containing -- =

4 oz hamburger : 0 carb/ 28 grams protein/ 300 calories
1-1/2 oz cheese : 0 carb/ 7 grams protein/ 150 calories
1  bun : 30 grams carb/ 5 grams protein/ 160 calories
1 sliced tomato : 5 grams carb/ 1 gram protein/ 25 calories
1 cup ice cream : 31 grams carb/ 5 grams protein/ 300 calories
2 oatmeal cookies : 16 grams carb/ 1.5 grams protein/ 120 calories

Total for Dinner: 94 grams carb/ 55.5 grams protein/ 1155 calories
TOTAL FOR DAY:  244 grams carb/ 64.5 grams protein/ 2021Calories





        Because PD may follow several stages, and is further complicated by
different types of medications, in different dosages, this plan may
require experimenting. One person may get along fine getting most
protein in the evening, while another may find sleep impossible due to
"freezing."

        You will need to try the plan for about two weeks; if you don't feel
any better by then, protein changes are probably not the answer.  The
amount of Sinemet you use and the stage of PD are important factors.

        Also, some people find that a particular protein food blocks absorption
of Sinemet.  This seems to be especially true in the case of milk and
other dairy products. Yet fortified milk is an important source of
calcium and other minerals,  vitamins A and D, and some B vitamins.
Animal protein is rich in iron and zinc. If you have difficulty with
Sinemet absorption, first try using smaller amounts (example, 1/4 cup of
milk, =BD ounce of cheese, one ounce of meat, fish, or poultry) at a meal=
=2E =

        =

        If symptoms still persist, it may be necessary to adopt a vegetarian or
semi- vegetarian menu plan. Cooked dried beans are an excellent source
of protein, minerals, fiber, and carbohydrates. They also have a large
proportion of carbohydrates, compared to protein. Nuts, and seeds such
as sunflower and sesame seeds, contain both protein and heart-protective
fats, as well as important trace minerals not easily found in other
foods.

        Finally, studies have shown that eating a proportion of seven times as
much carbohydrate as protein can help greatly in Sinemet absorption.
This also allows for greater variety in meal planning. The 7:1 plan
should be discussed with your physician and a registered dietitian,
however, to be sure you're getting enough of all nutrients.

        People with PD who make long-term dietary changes are at risk for
nutrient deficiencies, including calcium, zinc, iron, vitamins A and D,
and certain B vitamins.  Deficiency of calcium and vitamin D, combined
with a sedentary lifestyle, can lead to weakened bones. This is of
special concern with PD, because there is greater risk of falling and
breaking a bone.

        If you're not able to tolerate milk at all, you may require a calcium
supplement, as well as vitamins A, D, K, and magnesium. And if you can't
tolerate any animal protein, such as meat, poultry, fish, dairy
products, or eggs, you may need a B12 supplement that meets the RDA of
two micrograms per day. Ask your doctor if there is any reason you
should not use vitamin or mineral supplements; some conditions can make
supplements dangerous. Also, ask for a referral to a registered
dietitian for help with a balanced menu program.

-- =

Kathrynne Holden, MS, RD
Editor-in-Chief,
"Spotlight on Food--nutrition news for people 60-plus"
http://www.fortnet.org/~fivstar
and NUTRITION TOPICS copy-ready handouts
http://www.dietetics.com/class/fivstar/
Tel: 970-493-6532   Fax: 970-493-6538