Expert Briefing Webinar: Nutrition and Parkinson’s Disease

Expert Briefing Webinar: Nutrition and Parkinson’s Disease



hello there and welcome to the first of six briefings in the Parkinson's Foundation's ninth expert briefing series our topic today is going to be nutrition and Parkinson's disease I'd like to introduce myself I'm dr. James Beck I'm the host for our discussion today and before we begin I just want to take care of some House cup housekeeping items and first I want to point out that these webinars were not created by a bunch of pointy-headed phd's like myself but these expert briefings are created for the pd community by the pd community the topics for expert briefings are suggested through our annual survey of the pd community and we collate those and in collaboration with our colleagues and the regional organizations Parkinsons organizations to bring these together into a our series we have here today so I certainly would like to make a shout out to our our collaborators who are partners and they're members of the Alliance of independent regional Parkinson's organizations or airpo and finally I'd like to acknowledge our the important role our sponsors play for these series Abbie synovium and loon Beck without their generous support these webinars would not be possible I'd like to say thank you to them for those of you who haven't heard looking now at the screen you can download the PowerPoint slide deck on the viewing page that you're looking at right now if you look at the bottom left for the download size link you can download a PDF file any time during this webinar and so for those of you who've joined us and previously in familiar with our history you may see a new format for our slides we are now the Parkinson's foundation we've merged with with National Parkinson foundation in Miami and the Parkinson's disease foundation here in the organs we've in the process of changing our logo and format and so this is our interim side and we hope to have some new colors to share with our next webinar that we're going to have later on this fall I'd also like to acknowledge that many people in our community are experiencing floods or fires or hurricanes and so I hope that they're doing well and who cannot join us today we'll be starting to archive this for a future listening health professionals who are joining us can earn one free CEU through the American Society on Aging if you register it as a health professional and indicated you like see you you'll receive an email by the end of today with steps on how to collect that CEU just remember you have 30 days though until October 12th to collect that free CEU so I encourage you to do so and now it's my pleasure to welcome our guest speaker for today dr. John Gouda dr. Duda is the associate professor of neurology at the University of Pennsylvania it's a center of excellence for the Parkinson's foundation he's director of the Parkinson's disease research education and clinical Center iPad rack at the corporal Michael Crescent VA Medical Center in Philadelphia dr. Duda is research focuses on understanding the role of alpha-synuclein in Parkinson's disease and he's authored numerous scientific papers which have been in the likes of JAMA science neuron and New England Journal Medicine and so he currently serves on the Editorial Board of movements orders dr. du to receive his medical degree from Thomas Jefferson University and Bachelor of Science in psychology from Penn State he completed residency in neurology and Penniman University Hospital in Philadelphia and followed up with a fellowship in neuropathology of neurodegenerative diseases at the University of Pennsylvania so it's a great honor to have him here today to speak on the topic of nutrition so dr. Duda welcome thank you Jim for that kind introduction it's really my pleasure to be with you guys and I understand that there are over 1100 people registered for this conference I'm flattered with the attention that this topic is getting it always does seem to be a very high on the minds of patients and caregivers and for good reason I think I wanted to start out with a brief disclosure statement there are no personal financial conflicts of interest on this talk I don't take any money from pharmaceutical industries or food industries for that matter I declined the compensation for this presentation I do receive research grant support from the Department of Veterans Affairs the National Health Michael J Fox foundation the Department of Defense and frankly I am personally biased by my own anecdotal experience in how healthy lifestyle can impact your well-being for both myself and my patients I've been running a brain wellness clinic at my center for over a year now and talking about nutrition and exercise and other wellness modifications and have really been impressed and how just taking control of your own well-being by by starting to eat right and exercise and getting a proper sleep leads to an empowerment that that this is really powerful in in your experience of Parkinson's disease there are three objectives for this talk the first one is understanding how dietary choices can affect symptom control in Parkinson's is the second Objectivist discussed how the gut microbe microbiome may be involved in Parkinson's disease and lastly we're going to talk about the possibility that sound nutritional choices may provide disease modifying effects in Parkinson's disease so the get started right off I would just want to say that I'm going to focus obviously as most of you are or patients or caregivers on a practical points that that you can use in your lives to modify your your lifestyle choices in ways that I think will likely help your Parkinson's symptoms and modify the way that the disease affects your life one question that I always get is how does the die interfere with Parkinson's disease medications and many of you are probably aware that levodopa one of the components of cinemates is a large neutral amino acid amino acids are the building blocks of proteins and levodopa is like one of those and it gets absorbed into the into the godsends to the brain with the same mechanisms that these other amino acids do but there's some people with Parkinson's disease will notice that if they take their cinema at the same time that they're taking a lot of protein that has these other amino acids it might have a loss of efficacy if they do that so generally we recommend that people take carbohydrate tense meals with in the morning and lunchtime and save a lot of there I'm sorry that's the next play generally we recommend that people take their Sinemet 30 minutes before or 60 minutes after their meals to minimize the amount of interference from the amino acids in the in the protein in their meal if that doesn't work then we recommend other dietary modifications which I'll talk about in a sec in a second the other thing that a lot of people don't know is that iron can interfere with the absorption of carbon don't believe in Opa so that iron supplements or multivitamins with iron should not be taken within 2 hours of taking cinnamon as I mentioned some people even if they take their cinnamon half an hour before a meal or after will still have problems with absorption and it is possible that those problems can lead to motor fluctuations which are variability in the way that a patient experiences their symptoms and that may improve by a change in the in the diet pattern and several people have studied this it's not changing sorry and a meta-analysis in 2010 included 16 studies of people who have studied different dietary patterns and they looked at low protein diets and what are called protein redistribution diets and protein redistribution diets are ones in which most of the protein that you take during the day is taken at the last meal at the dinner time meal so that the interference that you see from the amino acids in the mat is minimized during the bulk of the day this meta-analysis suggested that there was no support for a low protein diet about two thirds of the studies reported about an 80 percent response rate for protein redistribution meaning that 80 percent of people didn't know some benefit and motor fluctuations when changing through a protein redistribution diet several the studies looked at what were the characteristics of people who did benefit from such a strategy and the the take-home message is that the patients who started the protein redistribution diet earlier in the course of the disease with less severity of their motor fluctuations were more likely to get a benefit so those of you who have some motor fluctuations where either you simply wear off your symptoms get worse before you take your next dose or you have more complex motor fluctuations with at times not getting any benefit from a dose or having rapid changes might benefit from trying a protein redistribution diet now I'm going to go through a couple symptoms that have clear strategies with nutritional modifications that might be helpful for you one of them is sleepiness which is highly prevalent in Parkinson's disease a lot of people with PD are sleepy during the day I'm not surprisingly caffeine can help with sleepiness this has been studied in a couple studies by Ron costume and his colleagues and they found that the equivalent of two to four cups of coffee a day clearly improves daytime sleepiness and there's a second trial called cafe PD which hasn't been published yet to my knowledge but confirmed a significant benefit as you can see in the in figure on the left the left half of the figure the black line is the kepler's sleepiness scale which is a measurement of how sleepy someone is during the day and you can see that the red line of the people who took the caffeine clearly had more of a decline in those symptoms so the clear benefit orthostatic hypotension is another symptom that is fairly common in Parkinson's disease hanging up to 50% of people over the course of the illness it's defined as a drop in blood pressure upon standing so patients will typically notice is that when they go from lying to sitting or sitting to standing they'll feel a little lightheaded as if they're going to st. the disease itself can cause this and the medications can cause it as well so it can be tricky to manage general we start with behavioral modifications including dietary ones avoiding large meals because when you take a lot of food at one time a lot of blood is diverted to the digestive system stealing it away from other parts of your your body increasing a dietary salt intake and I highlight an increase because one of the few times will recommend increasing dietary salt increasing fluid obviously can help maintain the volume in your blood vessels and increasing alcohol how much water should you drink well it's there's a little debate and not a lot of evidence to support it but around one and a half to two quarts of bay the old adage being eight cups a day or eight 8-ounce glasses or sixty-four ounces is a is it ruffle some people probably don't need that much and some people may need more than that in general I tell people to drink enough so that their urine is not clear should urine is clear all the time you're probably drinking too much but not darky there should be just a light yellow color there are some assistive devices that can help maintaining your fluid intakes some of which I pictured here from a company and called hydrate that I've been using with my patients with some success that have just lines on the bottle that tell you you know you should be drinking this much by this time during the day and ask patients they found this helpful bowel nourishment and weight loss is another problem that occurs commonly in Parkinson's disease one reason may be that most people with PDL in fact almost all people with PD lose some of their sense of smell and in reality taste is mostly driven by smell so people often show that their food tastes bland and they won't their appetite will be decreased because of that some people will have significant weight loss in that case I certainly recommend a patient with a neurologist I sorry with a nutritionist but or others who just have a mild amount of weight loss I think one dietary strategy is increasing the amount of herbs spices and other foods other flavors in the food that can help to make the food more palatable to increase consumption constipation is obviously another very common symptom in Parkinson's disease something that your doctor really should be talking with you about because it's so common and distressing for most patients in fact some people suggest that we should think of constipation as the fifth vital sign we should be talking about our movements every time you come to the doctor I think that may be excessive but certainly if you're having less than one bowel movement but they it's worth talking to your physician about the real definition of constipation is less than three or so about once a week but in reality we should most people should be having about one a day and if it suggests that there may be issues with your diet the Bristol stool chart on the right is to find the different types of stools and a healthy diet that will have stools like type 3 and type 4 in general whereas constipated stools are often type 1 and type 2 to manage constipation with dietary changes we always talk about increasing fluid intake including coffee obviously some people drink coffee in the morning so stimulate their bowel function but then at least as important is increasing the dietary fiber intake from fruits vegetables beans whole grains nuts and seeds the whole grain fiber and other sources of fiber cause a bulk effect in the stool so that the stool retain water and will move through the bowels better increasing constipation and decreasing the hardness of the stools how much fiber should you eat well ideally if you eat a whole foods plant-based diet you won't have to worry about it because you'll be getting more than you need but for people who are not doing that one general rule of thumb is that you should aim for 30 to 40 grams of fiber per day and it's been estimated about 93% of Americans don't get that much so instead of worrying about how much protein you're taking in most people should probably worry about how much fiber you're getting the way to assess it from foods that that have nutrition labels is to look at the dietary fiber content as you can see on the right I've circled dietary fiber it comes under total carbohydrates a dietary source that has more than five or more grams of fiber and one serving as an actual earth source this this hypothetical food on the right has three grams so it's a good source for that great but then maybe even a better rule is to take the total carbohydrates which in this case is 27 and divide that by the dietary fiber and that number you'd like to see around five or less in this case it's mine so it's a little high so there's there's too much added sugar in this product but it's it's better than some worse than others in general obviously I'd prefer the you ate foods that didn't have a nutritional label all of the the fresh foods vegetables fruits nuts seeds whole grains they don't typically come with a nutrition label and those are the ones we want to focus on primarily obviously one of the scariest things for people with Parkinson's disease is the possible risk of dementia or cognitive impairment and I think it is is very well established that the diet can affect your risk of becoming demented this is in in all people not just in Parkinson's disease so there's these are justifications for three meta-analyses that all agreed that a Mediterranean diet which is obviously a plant-based diet that can have some fish low amounts of dairy and meat products some some amount of alcohol high high in olive oil olive oil things like that can clearly decrease your risk of getting dementia the last symptom I want to talk about is bone health obviously people with Parkinson's disease later in the course the illness are prone to fall and there's some reason to believe that the concomitant osteoporosis can make their bones more likely to break in that situation so but we want to pay attention to that and for whatever reason is not really clear but people with Parkinson's disease are more likely to have low vitamin D levels and everyone with Parkinson's should have their vitamin D level checked and frankly most of them don't so that's something you can take your own physician and talk to him about but the overwhelming majority of people I checked with Parkinson's disease have low and often very low levels of vitamin D to the point where it's very difficult to reach adequate levels by dietary intake alone from supplemented foods or from on exposures most patients should end up taking supplement and should aim for a 25 hydroxy vitamin D level which is not kind of how we measure vitamin D in the forty to sixty nanogram per milliliter level not to own another and vitamin D has also been thought to be more of a hormone and involved in mental function as well so it may decrease your risk of getting depression and dementia as well so an important thing to keep in mind when you're talking to your doctor about nutrition the second objective as I mentioned is the discussion of the gut microbiome in Parkinson's disease and I want to start out by saying I certainly am no expert in microbiome analysis we are conducting a study here at the Philadelphia Medical Center but I have colleagues who are specialized in understanding how they got microbiome plays a role in in health and disease and I it really is one of the the big stories in medicine in the last couple years and I think will continue to be for years to come and in Parkinson's he's got a lot of attention recently keep going off sorry it is the 10 10 micro sorry there are 10 times as many bacteria yeast viruses and other organisms living in your and your gut and on your skin as every cell in your body so it is an important part of who you are and it's essential for your health without the gut microbiome you won't be absorbing a lot of compounds that they're making some compounds that the bacteria in your gut are making and being absorbed or in quantities well over what we're taking for medical purposes for other compounds so it pretty clearly play a role in health and disease and understanding how much of a role the ideas in Parkinson's disease is a pretty hot topic right now there's the reference I'll show you that on the bottom there from MGP Parkinson's disease there's a review article it's free access to everybody that discusses I'm just going to discuss a few studies that have been done and try to give you a bird's eye picture of what what I think the take-home message is this was one study 72 patients with parkinson's disease in 72 controls and so you take a stool sample and you just do an analysis and try to find out what bacteria in the stool and interestingly in this study patients with parkinson's disease had a 77 percent reduction in the abundance of a bacterial genus called prevotella compared to controls stool samples private ella is a it's a bit confusing because there has been some species of private ella have been implicated in infections and dental caries and things like that but other species have been thought to be health promoting and and anti-inflammatory because of the production of something called short chain fatty acids which are compounds that the bacteria make from the fiber that you eat that gets absorbed by the lining of your gut and not only feeds those cells but also probably has changes throughout your body so that's one of the mechanisms where why we think that bacteria and you got may play a role in your health and wellness the second study also showed a decrease in prevalent but it wasn't specifically significant yeah in stool in colonic biopsies they actually took a piece of the tissue from your colon but similar to the previous study did show that some other short chain fatty acid producing bacteria were significantly more abundant in controls in arkinson so that the short chain fatty acid efficiency was consistent across both of these studies there were also some other bacteria that was thought to be pro-inflammatory which were significantly more abundant in the mucosa of Parkinson's disease and controls inflammation obviously is one of the things that we think is involved in the pathophysiology of Parkinson's so anything that we can do to increase our wresting inflammatory State may may in fact be helpful there's a third study that came out more recently that essentially confirmed the high loss those private le species as you can see with the red box in the bottom right in the Parkinson disease stool samples compared to control people aah at the same age so another study that showed that these this big genus of bacteria seems to be underrepresented and in the same study they showed that the short chain fatty acid were also decreased in the stools of Parkinson's disease patients and acetate propionate and butyrate were the three that were decreased in in those samples in this study so the take-home message is that there seem to be large classes of bacteria that are underrepresented in the stool of people with Parkinson's disease and those bacteria in general produced short chain fatty-acids which we think are helpful for maintaining gut health that are also underrepresented in Parkinson's disease now how does that relate to what you're eating well in general this is a little controversial I must say there are people that have some concerns about this this body of research but previously in 2011 a group of researchers looked at the stool from about a fairly large group of people and found that in general if you look at all the different bacteria in the gut of people you can there are three different types of micro biomes in people that are commonly seen and one of the main distinguishing factors between those types of micro biomes is the prevalence of private Ella as you can see in the the middle of the figure the entero type 2 has a large abundance of cavatelli species compared to the other two common enterotypes and Bacteroides on the left is more highly expressed in the other two enterotypes what is interesting about that is that your long term diet patterns seem to be strongly associated with the intera type or the microbiome signature that you have in your stool this study looked at 100 healthy people and basically determined that people can be divided into two general categories people who have lots of profit ella and lo Bacteroides than people have lots of Bacteroides and low profit ella and the dietary patterns correlated well with those patterns so that people who eat a lot of protein and animal fats have high Bacteroides low and low profit ella that people consume a lot of carbohydrate not so much protein in animal fat have the other entero type so that people eating mostly plant foods that have carbohydrates and that animal foods that have animal protein in fact have the higher abundance of patella another study looked at people in the list of Italians 153 of them who label themselves as vegan vegetarian and omnivores obviously it can be an unhealthy vegan if you're eating french fries and Wonder Bread and white rice and Twinkies you're your vegan but that's not necessarily a health promoting diet so instead of going by what they their self-reported dietary pattern was they looked at their actual food consumption and looked at how well they match the the Mediterranean diet by giving each one a score they found that majority of vegans and vegetarians did have high Mediterranean diet scores but also 30% of the omnivores that people who said that they'd eaten fish had high died scores two suggestions they probably ate less than those meat products and dairy products and what they found when they looked at their microbiome was that the people had high Mediterranean diet scores had higher levels of private pella species and higher levels of short-chain fatty acids as you can see on the bottom compared to people with lower Mediterranean diet scores supporting the notion that if what you eat has an effect on the bacteria in your gut and how that the short chain fatty acid production so finally I want to talk about how sound nutritional choices may provide a disease modifying effect in Parkinson's disease and then conclude with a short discussion of what I tell my patients based on what I know about nutrition disease-modifying effects are clearly the holy grail of Parkinson's disease research with for for example of what the Holy Grail may have looked like perhaps but it really is one of the the main targets of research we've been looking for one for twenty years now and and even James Parkinson 200 years ago this year suggested that there appears to be a sufficient reason for hoping this time remedial process may ere long be discovered by which at least the progress of the disease may be stopped unfortunately James Parkinson was a better clinician than a prognosticator because in two hundred years and we still don't have anything that clearly slows the progression of Parkinson's we've tried many things and there are still many ongoing trials so hopefully we can say the same thing that before long we'll have something but it at this time we really don't that being said we know a lot more about Parkinson's disease and what causes it and we did 20 years ago and certainly 200 years ago this is a wonderful review our a call from Verna Polly that came out recently this year pretty sure is also really available online and it just kind of reviews Parkinson's disease not just the pathophysiology or what we think causes it but but everything else so if you can get it I recommend it this is one figure from that paper that tries to summarize the major concepts that we think are involved in Parkinson's disease onca physiology and obviously this talks I can't tell them at the time to go into these topics in general but I just want to point out that the major topics for or areas of research interests are included in just figuring including out the role of alpha-synuclein how it a great sin to cripple their forms and then microscopically detectable forms like Lewy bodies and Louise neurite another concept is oxidative stress that we've been focusing on and we think it's involved in Parkinson's that's why we always talked about antioxidants and and how they may help scavenge free radicals and mitochondrial function is another topic that we think is important in Parkinson's disease pathophysiology is related to oxidative stress because a lot of those free radicals generated in the cell are formed in the mitochondria which are the power systems of the cell and people with Parkinson's disease have been found to have dysfunction in mitochondria as I mentioned before inflammation is another component of what we think is important in Parkinson's disease the ology with inflammatory cells in the brain perpetuating neuro inflammation and leading to ronald dysfunction and possibly demise so what can nutrition or our dietary choices do to change any of this well the possibilities are really highlighted by the recognition that in every plant food you take especially whole plant foods there are dozens and hundreds of chemicals called phytochemicals or green chemicals that are only produced in plants that have wide reaching chemical function and and likely in combination may may work in an anti-inflammatory and antioxidant capacity to change many of the processes going on in the brain in in in other chronic disease states as well and people have been researching different phytochemicals in different aspects of Parkinson's disease in cell cultures and animal models and things like that and have shown that there is enormous potential for these phytochemicals to affect reverse some of the changes that we believe are involved in Parkinson's I don't have time to go over all of these but flavonoids and phytochemicals have been shown to affect every every component that we talked about and more if you're interested in more detailed description of this I colleague sheeple Shah and I wrote a mattifying pasta cheese review about it a couple years ago and so I suggest you take a look at that but there are other resources as well and obviously just like the medications moment these things have been proven to modify the disease progression or change of course the illness but the difference between some medications and and these recommendations are that the downsides are completely different taking whole food plant-based therapies for Parkinson's disease has wide reaching side effects that include things that we mentioned about mentioned decreased risk of dementia decreased risk of depression less constipation all kinds of side effects that are probably beneficial not to mention all the all of the other kind of disease conditions that have been shown to benefit from that type of dietary choice either Mediterranean diet or a Whole Foods plant-based diet so to conclude just a couple slides on what I tell my own patients to do and obviously you're not my patient for the most part so please talk with your own physician who knows your own medical history and medications and things like that before you make any big changes to your your lifestyle but in general these are some simple nutritional recommendations that I think I'm comfortable making to everybody given the low risk of problems so as I said I believe the Parkinson disease might be treated by increasing the level of antioxidants and anti-inflammatory compounds in your and your blood and brain and the best way to do that is the lure of the sources of these compounds which are plants and you know all the different parts of the plant fruits vegetables mushrooms not seeds beans the goom's whole grains peas spices increase your consumption of all these things in ideally and on process as unprocessed as possible so eating the whole foods as much as possible where some of the federal nutrients have not been taken out and any kind of box drawer or canned food has processing that affects these phytonutrients and probably it's entirely possible to believe decreases their their potential benefits so sticking to the produce aisles in the in the grocery store and staying away from the defender aisles is a good idea and I'm obviously we don't there is no magic bullet we don't have any one particular food source that we think is clearly gonna split on the disease progression but we know that certainly for other diseases like heart disease and stroke and cancer but a variety is important and all of these fret of nutrients probably play synergistic roles so the more you have he the more that you eat they may work together so have allowed a different variety don't just eat broccoli and rice every day eat different plant foods every day general people don't eat enough doctrine Steve that's one of the clearest things that people have found looking at large populations and he's rich so people are nuts and seeds whichever ones you like walnuts are great but just about any nut seed is good the and one recommendation that I make for most people is the one to two tablespoons of ground flaxseed today they're inexpensive nutritionally dense with lignans and fiber and omega-3 fatty acids in the form of ala so a really good dietary change then they don't taste like much so you can ground them up and put them on anything you do have to grind them up because they go through the digestive system unchanged if you don't obviously I don't want you to live twice as long with Parkinson's even be miserable the whole time so eat what you need to eat to be happy but try to eat it as a treat don't eat it as every time you eat and eat more of the food that that's probably good for your health the rest of the time you know if you have to have a cheeseburger every once in a while then be happy then have a cheeseburger every once in a while like I said none of this is clearly proven it it's highly possible and I do believe that it probably will change your disease experience but you know it's not conclusive and it's not at the stage where we state we should say I'm specific changes you should make the the problem with some people is that they think they have to do everything all at once dr. Duda told me to become a vegan and I can't do it well don't don't try to do that although let's just try to you know give up some things that you know are unhealthy and include some more things that you know we are pretty sure are healthy and make those small changes over time become larger ones if you're interested unfortunately it just came out yesterday so I can't I didn't include in this slide set but there's a new article that just came out in the in the journal oxidative medicine and cellular longevity regarding a large observational study conducted by dr. Lori Misha Li at the past year University where they've looked at over 1,000 people with Parkinson's looked at what they've eaten and have a novel patient reported outcome of their symptoms and this this paper which is just published two days ago suggests that if you want to slow down or the foods that are associated with a slower rate of progression include fresh vegetables fresh fruit not modified fish olive oil line coconut oil fresh herbs and spices and foods that are associated with a more rapid progression and just remember this doesn't necessarily mean causing but it's associated with an include canned fruits and vegetables diet non die so to find food East and berry products so more support for the idea that a Mediterranean or a Whole Foods plant-based diet may be beneficial and what about organics I'm sure people are going to ask me that question so I'm just going to address it now it's not clear that eating organic clearly affect PD just like everything else I'm talking about but it is plausible so in that case I think there is a source of information that is reliable called the Environmental Working Group but they analyzed passage that's the side residues on different foods and come up with what's called the clean fifteen or fifteen foods that are low in pesticide residue even if they're not organic and the Dirty Dozen foods that if they're not organic will have lots of pesticides on them so you can look up those but actually they rank 48 different foods from worst to best with the lowers numbers indicating more pesticides I've included that whole list for you here and so again the foods in the 1 to the top 10 are the Dirty Dozen or top 12 would be the Dirty Dozen so strawberries spinach nectarines those things either often have lots of pesticides or when you eat the food you take them in on the other side who's like sweet corn may be using pesticide but obviously it only eat the husk so maybe not getting them and things like avocados and pineapples she obviously don't eat the skin as well so a whole list of pesticide who burden in different foods if if you do decide to go to Whole Foods plant-based diet there are some things to keep in mind obviously if you dramatically change how much fibers in your diet your microbiome has to catch up so you will experience some GI discomfort or flatulence in many cases you will have a change in bowel movements which is less constipation there's some concerns to discuss with your primary care doctor regarding interactions with leafy greens and grapefruit and some medication but then don't forget obviously to tell your doctor about your your choice because often people can cure hypertension and diabetes and decrease the risk of heart disease in fact we reverse heart disease so other medications may have to be adjusted as well finally I don't know everything these are just my opinions in fact most of what I think I know I probably really just believe I think that's true for all of us so educate yourself about health and wellness here's some books that I think are are useful obviously you can write anything in a book so it doesn't just take everything in a book with a grain of salt I hear some books that I've looked at and I think are good sources of reliable information and then also these are websites that I think are good sources of information and recipes for a whole food plant-based diet Nutrition Facts org is my favorite and I highly recommend you guys look at that website and the book from dr. Michael Greger who runs that website called how not to die thank you bye Jim back to starts the question and answer session thanks very much dr. Deuter that was a fantastic presentation we actually number of folks have written in to say what a great job you've done they really appreciate the hands-on practical tips that you're giving and they're really useful for both professionals and the caregiver as well I've also come in and how it can help with helping the person with Parkinson's disease so thank you very much that's it's been a great opportunity to hear your thoughts on this so a couple questions that have come through needless to say and I think you did address one of them which was the issue about organics and I think that's really great and one of the things that's you know I think you I think may know the answer but people come through with a couple of these questions as well as care partners and some professionals what about supplements I mean we are in a society where GNC is on every corner people take vitamins I think you are I think advocating something a bit different than that though you know how would you how would you explain it to your joy in Italian what I tell my patients supplements are like dietary choices there there's none that have really clearly been proven to help Parkinson's I mean I think obviously I mentioned vitamin D supplementation for people who are low I think that's very important and if you really are going to be eating a completely plant-based diet then vitamin b12 is a critical supplement to be taking but all the other ones in general you know obviously there I have some concerns with them that the research that we've done today hasn't proven to me that any of them are clearly beneficial you know there's some reason to believe that vitamin E may help Parkins these but there's also reasonable data suggested that people who take vitamin D you know don't live as long so in general I don't recommend the my patient patients take anything other than vitamin D if they need it vitamin b12 they need it I think coenzyme q10 is an interesting one you know obviously it disappointing that the trials didn't work out I you know that the problem obviously is that these supplements are not regulated so you don't really know what you're getting a lot of the time and there have been in fashion people took a lot of people took a given element they were found to be imperfections in the manufacturing process and people got sick from that so I cautiously recommend that people stay away you know educate themselves well and think twice about cell phones they're not the the magic bullet in most cases that sometimes they get it out to be and yeah you know I'd prefer that people take up you know all the money they're spending on supplements and and I'm good healthy plant-based foods well you know I to follow up on that I mean one of the things that we think about is supplements are often pills or something like that you might get out of a bottle but you're just beyond supplements could be things like you know people care partner in Michigan's asking about a ketogenic diets like adding coconut oil and then there's you know the flip side of that nurse in Pennsylvania is concerned that you know the Mediterranean diets heavily in olive oil you know so these oils and that might be not such a good thing for heart health how do you how do you how do you rationalize that what are your thoughts on on the heart issue but also these these kind of plant-based supplements or additives but not not something like you can pick up in a bottle but something that you might be able to pick up it at the grocery store and you know the in the in the food aisle okay so um I forget who said it first but I'm kind of an advocate of the philosophy of the separation of church and plate I don't think there's any reason to think that any one particular food item is completely good or completely bad and I eat a whole food plant-based diet but at times I'll eat you know some sardines are or something and and I don't beat myself up over it I think they're you know for these in general these these particular foods like coconut oil there are a lot of really striking claims made about coconut oil and and for me it's hard to just sort it all out I mean I think that the meaning chain triglycerides concept is interesting but they're saturated and so if you really look at the data I don't I think for your overall health it's not really supported that you should be eating a lot of coconut oil and but everything I think has to be compared to something else like I said there's nothing that that's really good or bad so you know coconut has to be compared to butter is better than butter but it's probably worse than certainly whole food sources of fat like avocados and nuts and things like that how it compares the extra-virgin olive oil is you know it's probably similar in my mind I mean I think obviously depending on what you use it different oils for you can have different fish with smoking points coming into play with you when you're cooking with oils and things I think extra-virgin olive oil like I said it's better than some things and probably not as good as others if you know I tell my patients that in general if you're using oils than extra-virgin olive oil is probably decent choice it is fairly high I don't do tree and their flavonoid content but you know if you're making a salad and you want some fat in it to help you absorb the fat soluble phytonutrients then making your own dressings with nuts or seeds is probably even better idea okay so I think you're really talking about having a broad diet and not just loading up on one particular thing yeah yeah about moderation I don't I don't believe there's any silver bullets out there and I think very variety is concept I'm not really an advocate of everything in moderation I think there are certain health promoting which is not to say that issue if you need to have something to be happy will then have that thing to Gabby but I think everything in moderation is a bit of a cop-out okay so I guess everything in moderation including moderation so the way to go okay so you know one of the things well where people with Parkinson's disease especially as these progressive weight can be a big issue and you dress it somewhat but you know just wanted to drill down a little bit more on that you know an easy way to gain weight is especially because we think about things that make people happy can be sweets and you know what are your thoughts about because we have a one person asking about this or another allied health professional in Georgia who's you know concerned about you know this balance of you know the balanced diet how do we find something that promotes weight gain yet still is not going to provide increased cardiovascular risk is it is a carbs I mean do we say start eating bagels but that could also counter the problem with the constipation so what are your thoughts so weight weight loss is a tricky problem on a plant-based diet in general people even people living a really healthy Whole Foods plant-based diet it's difficult to be overweight so if you have a condition that some people see hypermetabolic or propensity to lose weight it can be tricky what I tell people is that you know healthy sources of fat situation obviously avocados and nuts and seeds are very calorically bent and are a good source of calories I think you know it depends on the situation sometimes people with Parkinson's disease who are kind of in the late stages of the disease will have a real problem with maintaining their weight but in that scenario you know I'm not so much worried about heart disease and things like that so if it's late in the disease course and the the weight is dropping that I'm like I said before obviously nutritional consultation is imperative but yeah sure give them what what they'll what they'll eat and you know to maintain their weight if you can mix in some healthy food as much as possible of course but for someone on the other on the other side someone who is kind of early in the disease course typically younger patient a lot of trouble maintaining their way that's a little trickier because then you are obviously worried about heart disease and cancer and diabetes I attention so in those cases I guess it would mean more towards the healthy sources of fat and hi-hi calorically dense foods rather than the highly processed and sweet okay so I'm gonna we've got more questions but I just wanted to just interject real quick to remind our audience that we have an online survey which is on your screen and it's the feedback from you our PD community that really is there to help enhance and improve our webinars so that we are able to get the information that you want and that you need so I also want to take a moment to thank our sponsors again at be synovial and Lynn Beck without their support we wouldn't be able to have this series in its ninth year coming up on tenth we're not quite as old as the iPhone which is a ten day I guess where we're working on it so you know you mentioned that a lot of these issues with weight gained and and you know trying to get balanced nutrition and you actually I think earlier in your talk mentioned you know if it's a real issue a person good should go consult a nutritionist how do you find a nutritionist and is that covered by insurance you know that's those are good questions without being overly political I say that I work within the VA health care system which is integrated so I just put in a referral to a nutritionist and don't have to worry about finding one and I don't have to worry about it getting paid for either I guess at this point and I apologize for mostly when I give these talks I start out by thanking the the veterans who are in attendance so all of the veterans who are listening in or their spouses they just want to thank you for your service and make sure you're aware that Parkinson's disease is a service connected condition for many veterans so if you have Parkinson's disease and certain notes are you should definitely look into whether or not you might be eligible for benefits from the Department of Veteran Affairs outside of the VA obviously your Park he's fishing or neurologist obviously or ideally has nutritionists that he has worked with and can refer you to if not that then I got some would refer my patients to people like you guys are support groups that might be able to help identify nutritionists who are you know well versed in caring for people with parking okay and and for our listeners out there I just want to remind you that if you don't get your question in we have our helpline available and to answer these types of issues for nutritionists our helpline is one eight hundred four PD info that's 1-800 for PD info so dr. Duda you know one of the things I hear when we talk about nutrition and in foods is a you know the healthy living that comes with it but a lot of people want to try to extend that to other areas for instance you know fava beans can be a natural source of dopamine and this is slightly off topic but it's one that I thought be interesting natural sources of dopamine is it worth the bother I mean or you're better off best sort of trying to just stick with you know the medication and that is both food plant-based diet to just keep you your engine running right well there was as I'm sure you're aware a recent article that kind of compared the actual source of natural levodopa and the lesion is small unblinded perhaps was minded no I study they they showed that the motor benefits were were similar and or less side effects taken so I think it is an area that deserves more investigation the it I I don't usually recommend it for my own patients I mean I have some patients who are for trying and I tell them that I think it's reasonable thing to try as long as you're not highly processing that's what most of them are paid for you and modest quantity so I'm not aware of any real risk but if as I understand it it's not a trivial thing to kind of get a preparation like that there are obviously commercial preparations derived from natural sources but again they're like the supplements you don't really know what you're getting some of the time and they haven't really been studied for the most part as much as you know fda-approved medications but that being said I don't just try to dissuade my patients from trying out okay so where I recognize we're at the top of our hour and I'm hoping I can keep you for a few minutes more because we've got a couple more questions I'd like to ask and great and the first one is you know and this is something I think we see a lot Society and that's about gluten is there any relationship between gluten and Parkinson disease is it something that should be avoided what are your thoughts on that yeah so that is a common question I think my understanding of the the field is that there there obviously are certain percentage of 1% of the population will ever have true celiac disease in which case minimizing gluten this is probably a good thing however gluten is one form of protein is found in mostly whole grain that in general are good for you so I think for the vast majority of people who don't have celiac disease trying to avoid all gluten products is is you know mostly a fad experience that that may or may not be T Bone affect the the speculation that large percentages of the population are what they call gluten intolerant not I I just don't I haven't seen the data that has convinced me that that's the case there are obviously people who if you have you know GI symptoms and skin problems and other things then you know an elimination diet that includes eliminating gluten and slowly adding things back in is a reasonable choice for people but I think that anybody who says that people with Parkinson's he should unequivocally avoid all gluten I I'm not convinced that the data supports that conclusion okay thank you you know another question that comes up is for people who you know have doctors who may not be as experienced with describing some of the PD medications is there's a concern about interaction with foods so one of the questions I have from personally Parkinson's in Texas is that if some of the foods on your on your list that you're recommending or on that do not eat list because of tyramine or you know that Mayo mao inhibitors the class meanwhile there's mao-b inhibitors which people with PD take like as elective rescheduling and saline Debra no so what are your thoughts on that and what would you advise a person to do so so obviously like I said at the beginning I don't want anybody listening to me to take my advice without consulting their own physician I think clearly if you're on nonspecific Mao compounds then putting hypertension I think there's much less of a concern for people taking rive estate mean I think the risk of hypertension from tyramine reaction is is exceedingly load in that case but you know a lot of the highest tyramine containing foods like processed meats and aged cheese's I'm not really recommending you eat anyway but but certainly if you have any concerns about your medications and potential food interactions then obviously that serves the conversation with your own physician before making any significant changes okay that's really good advice thank you now we've got time for one more question and I just wanted to I think ask this again somewhat topical because of you know our discussion about the microbiome and things what are your thoughts about fecal transplants for people Parkinson's disease yeah I guess let me throw in the same time probiotics because yes please do yeah they are intermixed thank you so the it is an interesting concept so let's start with probiotics II it is there's one study at least that suggests some possible benefit for people with Parkinson's taking a probiotic supplement but most probiotics have a combination of lactobacillus and some other things but they're not really the compounds that we're talking about them may be health promoting by producing short chain fatty-acids things like that so um there to my knowledge there are no probiotics that have those compounds and many of them are anaerobic it would probably be difficult to get into a into a supplement anyway so that brings up the other possibility instead of you know taking in those bacteria orally then taking them and rectally with a with a stool transplant the in my mind it still transplants are really you know they've been proven effective in conditions that have a wildly florid overgrowth of a particular bacteria so you want to introduce other bacteria to compete with that bacteria and wipe out its proliferation if you are thinking about a chronic neurodegenerative disease or even a chronic condition like heart disease or something then in my mind if you make if you do a stool transplant it doesn't matter what bacteria you put in there unless you feed them what they eat bacteria that are that eat fiber and unprocessed carbohydrate components are potentially the good bacteria and if you don't feed them those sources of fiber they're not going to pull it right and and the the other you know the bad bacteria are going to live right anyway so I think it's a little premature to say whether or not there's a clear difference in either the bacteria that you got from your your mother at birth or or other things that that may actually be remiel well with a stool transplant but in my mind eating healthy sources of soluble and insoluble fiber that will feed the good bacteria in your gut is probably at least that a good as good an idea as considering something like probiotics or or a stool transplant because all you need is it's good healthy source of fiber and and people have shown in studies that within two weeks you can change the content of your microbiome by changing your diet so if you're not willing to change to a healthy hopefully based diet loaded with with fiber to feed those bacteria I think a stool transplant is unlikely to be beneficial yeah it sounds like it's uh planting a new lawn but unwilling to water it yeah nothing's gonna happen so yeah John doctor to do this has been a fantastic presentation the kudos keep flowing in excellent information excellent presentation registered dietitians on the call with a brother of keen she thanks you very much for this and also have another dietitian on the call and they had recommended for those who were interested in trying to find a dietitian that there's the Academy of Nutrition and Dietetics Dietetics and they have a website called eat right org find an expert so if you kind of Google eat right org you should be able to find perhaps a dietitian that way John thank you very much for excellent presentation and your time today and I'd like to thank everyone else for listening in and just to let people know that we have our next webinar on the docket coming up on Tuesday November 21st same time 1 p.m. to 2 p.m. and it's about depression and Parkinson's disease treatment options with dr. rose and Africans from Rutgers my home state I wanted to applaud everybody who attended recognize that their interest in learning more about Parkinson's disease as an important component of fighting back just like all the other lifestyle choices that we can make absolutely that dope they say goodbye thank you very much

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