Q&A: Diet and Parkinson's

Maryanne Harrison is a dietitian who specialises in neurological conditions. She joined our discussion forum in January 2011 for a questions and answers (Q&A) session covering all aspects of diet and Parkinson's.

Transcript of the session

Maryanne Harrison: Hello, I'm Maryanne Harrison.

I have worked for many years as a dietitian and am currently a specialist neurological dietitian for the Hertfordshire Neurological Service.

I have a particular interest in Parkinson's and have been working towards establishing best practice for working with people with the condition.

I am a member of the Parkinson's UK Professionals' Network. I also work with a large case load of Parkinson's patients as a part of a multi-disciplinary team. I hope that I can use my experience to answer your questions.

Questions and answers

Question via Facebook: I've heard vegetarian/vegan diets can help symptoms... any evidence to support that?

Maryanne Harrison: It is important to use the eatwell plate as the basis for optimum nutrition. Vegetarian diets can provide optimum nutrition which in my clinical opinion is vital for long-term conditions such as Parkinson's.

The timing of meals and enough carbohydrate can also be very helpful, but there is no concrete evidence that a vegetarian/vegan diet will help alleviate Parkinson's symptoms.

John Rothwell via our website: Why do I go off after food. Is it better to take Madopar before food or after?

Maryanne Harrison: Have you established which foods?

The consensus from the Neuroscience Dietitians' Interest Group is that carbohydrate should be taken with all levodopa medications as this increases absorption and prevents nausea associated with levodopa. For the best effect Parkinson's medications should be taken 3/4 hour before meals, not with main meals.

Joyce Baines-Holgate via the website: Is it better to take ropinirole with food and does protein interfere with its effectiveness?

Maryanne Harrison: The advice for dopamine agonists is the same as for levodopa medications. Please see the previous answer.

Question via Facebook: When I started taking rasagiline (5 months ago), I was very concerned about the warnings about tyramine. I started by avoiding cheeses and sundry other foodstuffs that I knew were likely to contain it, but have since been reassured that the note about tyramine should be regarded as a 'caution' (more relevant to older drugs in the same class), and that I should be OK with these foods.

I don't seem to be encountering any problems at present. I understand that tyramine is a dopamine-releasing agent but that it cannot cross the blood-brain barrier. Does tyramine have any role in a Parkinson's-related diet?

Maryanne Harrison: I would agree with the person who has reassured you about tyramine. If you follow the eatwell plate model and have carbohydrate in liquid or solid form with your medications, for example fruit juice, fruit smoothie or squash containing sugar, or toast and jam or marmalade or fruit loaf or malt loaf.

Avoiding tyramine containing foods would mean avoiding certain foods which could cause deficiencies.

Question via Facebook: I have been wondering whether common stimulants like coffee are likely to have any effects, good or ill, and also whether alcohol is best avoided.

Maryanne Harrison: There is some evidence that coffee plays a protective role in Parkinson's but it is minor and the evidence is not concrete. Speak to your consultant/ GP or clinical nurse specialist if you have any concerns about alcohol and its interaction with any of your medications.

My advice on alcohol is that, provided none of the medications you are taking state no alcohol, 'a little bit of what you fancy will do you no harm'.

Philippa via our website: My father has had Parkinson's for 20 years now (since he was 45) and requires constant care. One of the side effects of his medication is that he suffers from hallucinations (day and night) and I was wondering whether there has been any research as to whether eating certain foods could intensify/reduce these symptoms.

Maryanne Harrison: Unfortunately there is no evidence that food has any beneficial or adverse effect on the your father's symptoms. It is widely recognised that hallucinations are a common side effect of Parkinson's medication.

English country dancer via our website: I notice that the diet recommend by Parkinson's UK follows the recommendations for the general public in that it recommends a large percentage of the diet comprise of grains and/or potatoes and says aim for 5 fruit and vegetables a day, rather than aim for at least 5 fruit and vegetables a day. Would it not be better if carbohydrate was obtained from vegetables and fruit?

Surely, any calorie and fibre deficiency could made up from starchy vegetables. As vegetables and fruit contain antioxidants as well as higher levels of vitamins and minerals, surely it would be better and preferable to encourage the use of more vegetables and fruit in the diet. Vegetables make lovely thick soups and would be easier to swallow than bread, pasta or rice.

What is so good about grains apart from providing energy and fibre? Prunes, figs and other fruit would help to alleviate constipation. Apart from cost I can see no reason for these recommendations. Please could you explain.

Maryanne Harrison: The eatwell plate forms the basis of good nutrition for the whole population. You are right: The 5 a day message from fruit and vegetables is a minimum but many people in this country do not achieve it. This group provides vitamins A, C, E and folic acid, fibre and some carbohydrate.

The bread, rice, potatoes and pasta group is important too as it provides us with our main source of energy. It also provides fibre, some calcium, iron and B vitamins. Wholegrains and seeds provide us with B vitamins.

There is no harm in increasing your intake of starchy vegetables, however they shouldn't cut out carbohydrate-rich foods such as pasta, bread, rice, etc completely.

For people who suffer from swallowing difficulties should be formally assessed by a speech and language therapist. A texture modified diet may be required.

Kathleen via our website: Any advice on constipation? I don't wish to continue taking laxatives indefinitely.

Maryanne Harrison: The 3 main things that need to be considered when trying to avoid or manage constipation are adequate fluid, enough and the right type of dietary fibre, and physical activity.

It helps if the bread and cereals eaten are wholegrain. It also helps to eat peas, beans and lentils daily and up to 8 to 10 fruit and or vegetables a day. But if these measures are not adequate the most effective and easy ways to help are linseeds or flaxseeds (the same thing) and prune juice.

I advise starting with one or the other at breakfast, eg 1 tablespoon of linseeds/flaxseeds on breakfast cereal or cooked in porridge, or 100-200ml prune juice. Both of these can be taken in more frequent and increasing amounts if necessary at each meal until the constipation has resolved. Having found what works for you, you will usually need to continue permanently. The linseeds/flaxseeds can be put into yoghurt, custard, soups or stirred into meals.

Parkinson's patients can suffer from a neurogenic bowel and may require the use of laxatives along with diet to prevent or manage constipation.

It is advisable to speak with your GP/consultant or clinical nurse specialist before you stop taking your laxatives.

Question via Facebook: Hi Maryanne, which vitamins, antioxidants, supplements or foods would you advise for me/ Parkinson's sufferers? The problem being that they might interfere with absorbtion of certain meds.

Maryanne Harrison: Dietitians do not routinely advise the use of vitamins, antioxidants or supplements.

If you are able to follow the principles outlined in the eatwell plate model, you should be able to meet your requirements for all vitamins and minerals. However, if you are struggling to eat full meals, are housebound, or have a poor appetite it may be beneficial to have a well rounded vitamin and mineral preparation.

Wilco via the forum: I have read somewhere that certain enzymes can help prevent the production of saliva, hence calm the nasty side effect of Parkinson's disease: drooling. Pineapple juice, cranberry juice... can you give us any guidelines?

Last year in France I was eating a meal of entrecote seignon when a piece too big to swallow sort of sat there in my oesophagus neither moving up nor down. I rushed from the terrace, leaned over the chateau wall and attempted to spit out the offending morsel. You know what, I had  a piece of sticky, gummy drool hanging 12" beneath me before it would break away - why? Where does it arise from, the oesophagus or the lungs, and perhaps more importantly, how may I control it?

By the way, I suffered a bad bout of acid reflux about 5 years ago, a year before my Parkinson's diagnosis, which the consultant informed me, had I neglected treatment for another month might well have resulted in Barrett's Syndrome. All help gratefully received!

Maryanne Harrison: There is anecdotal evidence that pineapple juice can help reduce the viscosity of saliva and that milk and dairy products can sometimes increase the stickiness of it but neither of these has a robust evidence base. It is obviously important that you are well hydrated.

Also, there are medications that your doctor can prescribe that can help. It would be helpful to discuss this problem with your consultant/clinical nurse specialist or GP for more advice.

About Maryanne Harrison

Maryanne Harrison is a specialist neurological dietitian working for the Hertfordshire Neurological Service. She has been instrumental in setting up a neurological specialist dietitians' group with other neurological dietitians working at The National Hospital for Neurology and Neurosurgery, Northwick Park, the Royal Free and other London hospitals.

The specialist group has been working on agreeing on best practice for Parkinson's. As the recently-elected chair, she is working towards having it recognised as a specialist group of the British Dietetic Association.

She is a reviewer for Practice-Based Evidence in Nutrition (PEN) which is a global resource for nutrition practice.

Maryanne is a member of our Professionals' Network and presents on nutrition and Parkinson's nationally to doctors, dietitians and nurses. She works with a large case load of Parkinson's patients as a part of a multi-disciplinary team.

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