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