Markers of disease severity are associated with malnutrition in Parkinson's disease

The missing piece of the puzzle - The key role of the dietitian in the management of Parkinson's disease

The current paradigm for the multidisciplinary management of Parkinson's Disease (PD) does not include regular nutritional assessment despite research showing that 90 % of people living with Parkinson's (PwP) lack access to basic dietetic services. Since many non-motor symptoms such as dysphagia, constipation and orthostatic hypotension and PD complications such as weight loss and sarcopenia can be improved through dietary intervention, dietitians are a critical missing piece of the PD management puzzle. This paper serves to review the role of dietitians and medical nutrition therapy in management of PD as well as a call to action for future studies to investigate improvement of nutritional status and quality of life for all PwP.

Unravelling the mechanisms of underweight in Parkinson's disease by investigating into the role of gut microbiome

Approximately half of patients with Parkinson's disease (PD) suffer from unintentional weight loss and are underweight, complicating the clinical course of PD patients. Gut microbiota alteration has been proven to be associated with PD, and recent studies have shown that gut microbiota could lead to muscle wasting, implying a possible role of gut microbiota in underweight PD. In this study, we aimed to (1) investigate the mechanism underlying underweight in PD patients with respect to gut microbiota and (2) estimate the extent to which gut microbiota may mediate PD-related underweight through mediation analysis. The data were adapted from Hill-Burns et al., in which 330 participants (199 PD, 131 controls) were enrolled in the study. Fecal samples were collected from participants for microbiome analysis. 16S rRNA gene sequence data were processed using DADA2. Mediation analysis was performed to quantify the effect of intestinal microbial alteration on the causal effect of PD on underweight and to identify the key bacteria that significantly mediated PD-related underweight. The results showed that the PD group had significantly more underweight patients (body mass index (BMI) < 18.5) after controlling for age and sex. Ten genera and four species were significantly different in relative abundance between the underweight and non-underweight individuals in the PD group. Mediation analysis showed that 42.29% and 37.91% of the effect of PD on underweight was mediated through intestinal microbial alterations at the genus and species levels, respectively. Five genera (Agathobacter, Eisenbergiella, Fusicatenibacter, Roseburia, Ruminococcaceae_UCG_013) showed significant mediation effects. In conclusion, we found that up to 42.29% of underweight PD cases are mediated by gut microbiota, with increased pro-inflammatory bacteria and decreased SCFA-producing bacteria, which indicates that the pro-inflammatory state, disturbance of metabolism, and interference of appetite regulation may be involved in the mechanism of underweight PD.

The Role of Diet in Parkinson's Disease

The aim of this review is to examine the intersection of Parkinson's disease (PD) with nutrition, to identify best nutritional practices based on current evidence, and to identify gaps in the evidence and suggest future directions. Epidemiological work has linked various dietary patterns and food groups to changes in PD risk; however, fewer studies have evaluated the role of various diets, dietary components, and supplements in the management of established PD. There is substantial interest in exploring the role of diet-related interventions in both symptomatic management and potential disease modification. In this paper, we evaluate the utility of several dietary patterns, including the Mediterranean (MeDi), Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND), Alternative Healthy Eating Index (AHEI), vegan/vegetarian, and ketogenic diet in persons with PD. Additionally, we provide an overview of the evidence relating several individual food groups and nutritional supplements to PD risk, symptoms and progression.

Impact of weight loss for depressive symptom in mid-stage patients with Parkinson's disease: a 4-year follow-up study

Introduction

Weight loss is one of the non-motor symptoms frequently seen in patients with Parkinson's disease (PwPD). Weight loss in PwPD is known to be negatively associated with motor and other non-motor symptoms and has been shown to influence the prognosis of PD. In this study, we followed weight change over a 4-year period in PwPD at a single institution and investigated the relationship between weight change and patients' motor and non-motor symptoms.

Methods

PwPD who visited our hospital from January 2018 to December 2022 were enrolled. Body weights were measured at two points in 2018 (at the start of observation, 'baseline') and 2022 (at the end of observation, 'end date'). In addition, motor symptoms, disease severity, cognitive function, and psychiatric symptoms were evaluated during the same period, and the relationship with weight loss was examined.

Results

Data of 96 PwPD were available for a 4-year follow-up. At baseline, the mean age was 65.7 ± 10.0 years, the mean disease duration was 6.8 ± 4.0 years, and the mean Hoehn and Yahr stage was 2.4 ± 0.7. Among them, 48 patients (50.0%) had a weight loss of ≥5% from baseline (weight loss group; mean loss was 6.6 ± 2.9 kg). The weight loss group was older (p = 0.031), had a lower Mini-Mental State Examination (MMSE) at baseline (p = 0.019), a significantly lower body mass index (p < 0.001), and a higher Zung Self-Rating Depression Scale (SDS) (p = 0.017) at the end date. There was a negative correlation (γ = -0.349, p < 0.001) between weight change and age, a positive correlation (γ = 0.308, p = 0.002) between weight change and MMSE at baseline, and a negative correlation (γ = -0.353, p < 0.001) between weight change and SDS at the end date. Age-adjusted correlations showed a final negative correlation (γ = -0.331, p = 0.001) between weight change and SDS. MMSE and age-adjusted correlations showed a low negative correlation (γ = -0.333, p = 0.001) between weight change and SDS at the end date.

Conclusion

Weight loss in PwPD in mid-stage was more likely with increasing age, and ≥ 5% weight loss was associated with worsening depression. Further research is needed regarding the significance of weight loss in PwPD.

The evaluation of the nutritional status in Parkinson's disease: geriatric nutritional risk index comparison with mini nutritional assessment questionnaire

OBJECTIVE

The symptoms associated with Parkinson's disease may lead to reduced food consumption and in turn, malnutrition. It is therefore important to apply a reliable nutrition screening tool to evaluate the nutritional status of individuals with Parkinson's disease. This cross-sectional study aims to compare the Mini Nutritional Assessment (MNA) questionnaire and the Geriatric Nutrition Risk Index (GNRI) in the assessment of the nutritional status of individuals with Parkinson's disease, and to evaluate the usability of the GNRI in cases of Parkinson's disease.

METHODS

The study was conducted with 89 individuals over the age of 60 who were diagnosed with Parkinson's disease. Study data were collected using a questionnaire form administered through face-to-face interviews, the MNA-Long Form (MNA-LF), and the GNRI was calculated.

RESULTS

The mean GNRI scores were significantly lower in the participants with malnutrition (106.5 ± 19.4) than in the participants at risk of malnutrition (121.0 ± 10.3) and the participants with no malnutrition (125.3 ± 9.6) according to the MNA-LF (p < 0.001). Although there was a positive correlation between the MNA-LF and the GNRI scores, this correlation was not significant (p = 0.095).

CONCLUSIONS

This is the first study to research the nutritional status of individuals with Parkinson's disease using the GNRI. The malnutrition rate detected by GNRI was found to be lower than MNA in Parkinson's patients receiving outpatient treatment. Similar studies are recommended to determine the usability of GNRI on inpatients.

To restrict or not to restrict? Practical considerations for optimizing dietary protein interactions on levodopa absorption in Parkinson's disease

Administration of levodopa for Parkinson's disease (PD) has remained the most effective therapy for symptom management despite being in use for over 50 years. Advancing disease and age, changing tolerability and gastrointestinal (GI) dysfunction may result in change in dietary habits and body weight, as well as unpredictable motor fluctuations and dyskinesias. Dietary proteins which convert into amino acids after digestion are implicated as major factors that inhibit levodopa absorption. For people living with PD (PwP) who experience motor fluctuations, low protein diets (LPD) and protein redistribution diets (PRD) may be effective and are often recommended as a non-pharmacologic approach for improving levodopa bioavailability. However, there is a lack of consensus on a standard definition of these diets and appropriate treatment algorithms for usage. This may be due to the paucity of high-level evidence of LPD and PRD in PwP and whether all or specific subgroups of patients would benefit from these strategies. Managing diet and protein intake with proper education and monitoring may reduce complications associated with these diets such as dyskinesias and unintentional weight loss. Additionally, alterations to medications and GI function may alter levodopa pharmacokinetics. In this narrative review we focus on 1) mechanisms of dietary protein and levodopa absorption in the intestine and blood brain barrier, 2) dietetic approaches to manage protein and levodopa interactions and 3) practical issues for treating PwP as well as future directions to be considered.

Prevalence of Malnutrition in Patients with Parkinson's Disease: A Systematic Review

OBJECTIVES

This systematic review analyzed the prevalence of malnutrition in patients with Parkinson's Disease.

STUDY DESIGN

a systematic review.

METHOD

Four databases-Cochrane, PubMed, Embase and Web of Science-were searched from October 2021 to June 2022 by two independent researchers. The inclusion criteria were as follows: patients above 18 years old with confirmed Parkinson's Disease, performed screening nutritional assessment, cohort studies, case-control studies, and cross-sectional studies. Patients without Parkinson's Disease and with other parkinsonian syndromes were excluded.

RESULTS

49 studies were included in this systematic review. Patients ranged in age from 20 to 96 years. There were 5613 subjects included. According to Mini Nutritional Assessment, 23.9% (n = 634) participants were at risk of malnutrition and 11.1% (n = 294) were malnourished. According to BMI score, most patients were either obese or overweight.

CONCLUSIONS

the prevalence of malnutrition or risk of malnutrition in the study group was significant. Therefore, more specific and detailed studies on the prevalence of malnutrition in patients with Parkinson's Disease are needed.

Association between irritable bowel syndrome and Parkinson's disease: A systematic review and meta-analysis

BACKGROUND

Growing evidence suggests that irritable bowel syndrome (IBS) and Parkinson's disease (PD) share similar pathological mechanisms and risk factors.

METHODS

We performed a systematic review and meta-analysis of the evidence for a relationship between IBS and PD. Risk estimates from individual studies were pooled using random-effects models.

RESULTS

Six articles involving 58,645 patients with PD were included in our meta-analysis. The overall risk for PD in IBS patients was significantly higher than that in the general population (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.29-1.75; p < .001). Subgroup analysis revealed no significant differences in risk between men (OR = 1.47, 95% CI: 1.3-1.67; p < .001) and women (OR = 1.51, 95% CI: 1.29-1.75; p < .001); however, older (≥65 years) IBS patients (OR = 1.44, 95% CI: 1.3-1.59; p < .001) may be at higher risk for PD than younger (40-64 years) patients (OR = 1.32, 95% CI: 1.05-1.64; p = .017).

CONCLUSION

Overall, the PD risk was higher in IBS patients than others, indicating that the intestinal disorder may serve as a warning sign for PD.

Levodopa-induced dyskinesia: a historical review of Parkinson's disease, dopamine, and modern advancements in research and treatment

Over the past two decades, animal models of Parkinson's disease (PD) have helped to determine the plausible underlying mechanism of levo-dihydroxyphenylalanine (L-DOPA)-induced dyskinesia following L-DOPA treatment. However, our understanding of the mechanisms related to this phenomenon remains incomplete. The purpose of this manuscript is to provide a comprehensive review of treatment protocols used for assessing the occurrence of L-DOPA-induced dyskinesia, L-DOPA absorption, distribution, drug/food interaction, and discuss current strategies and future directions. This review offers a historical perspective using L-DOPA in animal models of PD and the occurrence of L-DOPA-induced dyskinesia.

Prevalence and associated factors of malnutrition in patients with Parkinson's disease using CONUT and GNRI

OBJECTIVE

Parkinson's disease (PD) is a common neurodegenerative disease, but its nutritional problems have not received enough attention. This study aims to identify the prevalence and associated factors of malnutrition in PD patients using two simple nutritional tools.

METHODS

We conducted a large-scale cross-sectional study with 1478 PD patients and equal healthy controls (HC). The controlling nutritional status score (CONUT) and geriatric nutritional risk index (GNRI) were used for malnutrition stratification.

RESULTS

By CONUT or GNRI, the prevalence of malnutrition in PD patients was higher than that in HC (40.7% vs. 25.3% and 11.1% vs. 2.1%, respectively). The binary logistic regression model showed that malnutrition in PD was associated with male sex (OR = 0.600, P < 0.001), older age (OR = 1.015, P = 0.003), lower body mass index (BMI) (OR = 0.942, P < 0.001), higher levodopa equivalent daily doses (LEDD) (OR = 1.001, P < 0.001), worse motor symptoms (OR = 1.012, P = 0.004), more serious perceptual problems/hallucinations (OR = 1.067, P = 0.019) by CONUT. In comparison, older age (OR = 1.045, P < 0.001), lower blood lymphocyte count (OR = 0.607, P = 0.006), lower serum total cholesterol levels (OR = 0.991, P < 0.001), dyskinesia (OR = 2.231, P = 0.002), worse motor symptoms (OR = 1.016, P = 0.015), more severe depression (OR = 1.028, P = 0.008) and perceptual problems/hallucinations (OR = 1.061, P = 0.033) were associated with malnutrition in PD by GNRI.

CONCLUSIONS

Our study indicated that malnutrition is more prevalent in PD patients than HC. Multidimensional risk factors for malnutrition in PD should be taken seriously.

Gastrointestinal disorders in hyperkinetic movement disorders and ataxia

BACKGROUND

Gastrointestinal (GI) disorders have been thoroughly investigated in hypokinetic disorders such as Parkinson's disease, but much less is known about GI disorders in hyperkinetic movement disorders and ataxia. The aim of this review is to draw attention to the GI disorders that are associated with these movement disorders.

METHODS

References for this systematic review were identified by searches of PubMed through May 2020. Only publications in English were reviewed.

RESULTS

Data from 249 articles were critically reviewed, compared, and integrated. The most frequently reported GI symptoms overall in hyperkinetic movement disorders and ataxia are dysphagia, sialorrhea, weight changes, esophago-gastritis, gastroparesis, constipation, diarrhea, and malabsorption. We report in detail on the frequency, characteristics, pathophysiology, and management of GI symptoms in essential tremor, restless legs syndrome, chorea, and spinocerebellar ataxias. The limited available data on GI disorders in dystonias, paroxysmal movement disorders, tardive dyskinesias, myoclonus, and non-SCA ataxias are also summarized.

CONCLUSION

The purpose of our systematic review is to draw attention that, although primarily motor disorders, hyperkinetic movement disorders and ataxia can involve the GI system. Raising awareness about the GI symptom burden in hyperkinetic movement disorders and ataxia could contribute to a new research interest in that field, as well as improved patient care.

Prevalence of freezing of gait in Parkinson's disease: a systematic review and meta-analysis

BACKGROUND

Freezing of gait (FOG) is considered one of the most disturbing and least understood symptoms in Parkinson's disease (PD). The reported prevalence rates of FOG in PD vary widely, ranging from 5 to 85.9%.

OBJECTIVE

We conducted a systematic review and meta-analysis to provide a reliable estimate of the average point prevalence of FOG in PD, and we further investigated the study characteristics that might have influenced the estimate.

METHODS

We searched different databases to identify studies that report the prevalence of FOG in PD or include relevant raw data for further calculation. The last inclusion date was February 20, 2020. The modified Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool was used for the quality assessment, and articles that met the predefined criteria were included in the quantitative analysis.

RESULTS

Sixty-six studies were selected from 3392 references. A weighted prevalence of 50.6% in 9072 PD patients experienced FOG based on the special questionnaires (the FOG-Q and NFOG-Q), which was about twice as high as that assessed by the specific items of the clinical rating scales (UPDRS item2.14 and MDS-UPDRS item3.11) (23.2%) or simple clinical questions (25.4%). The weighted prevalence was 37.9% for early stage (≤ 5 years) and 64.6% for advanced stage (≥ 9 years). Moreover, a higher prevalence was calculated from the population-based studies than that in multicenter and single-center studies (47.3% vs. 33.5% and 37.1%, respectively).

CONCLUSION

The result from this systematic review confirms that FOG is very common in PD and its prevalence is usually underestimated in hospital settings. Importantly, a more accurate assessment of FOG in future clinical researches would involve the use of special FOG scale rather than a single item on a scale or a general clinical inquiry.

Malnutrition and related factors in Filipino patients with Parkinson's disease: results from a pilot study

Aim: Emerging evidence demonstrates a bidirectional relationship between nutritional status and Parkinson's disease (PD). Our aim was to determine the local prevalence of malnutrition and associated factors among Filipino PD patients. Materials & methods: We assessed the nutritional status of 95 PD patients using the body mass index (BMI) and Subjective Global Assessment (SGA) and identified malnutrition-associated factors. Results & conclusion: In our sample, the mean BMI was 24.5 ± 4.2 kg/m². Consistent with published estimates, five (5.3%) patients were classified as underweight and 57 (60%) patients were classified as overweight/obese. A total of 30 (31.6%) patients had abnormal nutritional status based on SGA. Weight-adjusted levodopa equivalent daily dose was a significant factor (p = 0.032) for BMI, while dysphagia and higher weight-adjusted levodopa equivalent daily dose were found to be predictive of abnormal nutritional status using SGA (adjusted odds ratio of 8.85 [95% CI: 1.59-49.17; p = 0.015] and 1.10 [95% CI: 1.02-1.20; p = 0.021], respectively).

Prevalence and Risk Factors for Malnutrition in Patients With Parkinson's Disease

Objectives: This study aimed to investigate the relationship between nutritional status and Parkinson's disease (PD) features.

Methods: The cohort was composed of 556 Parkinson's patients who were admitted to the hospital. Patients were categorized as normal nutrition or at risk of malnutrition/already malnourished. Questionnaires, physical examinations, and biochemical tests were conducted. The relationship between nutrition status and PD was analyzed using t-tests, χ²-tests, and logistic regression models.

Results: The prevalence of malnutrition [defined as a Mini Nutritional Assessment (MNA) score <17] was 39.2%, and 30.3% of patients were at risk of malnutrition (17 ≤ MNA score ≤ 23.5). There was no difference in gender and age between the different nutrition groups (P < 0.05). Patients at risk of malnutrition and those who were malnourished had a longer course of disease, more severe motor symptoms, a higher stage of PD according to the Hoehn and Yahr (H-Y) classification, a lower body mass index (BMI) index, a lower cognitive score, higher levels of depression and anxiety, and more serious non-motor symptoms (P < 0.05) than patients with normal nutrition. There were differences in adenosine deaminase, albumin, phosphorus, chlorine, total protein, and uric acid between the two groups (P < 0.05). High Unified PD Rating Scale (UPDRS-III) scores, high H-Y stages, and dyskinesia were risk factors for malnutrition in PD patients, while high levels of total protein, uric acid, and chlorine were protective factors that led to good nutrition (P < 0.05).

Conclusions: Our results showed that dyskinesia, disease severity, total protein levels, uric acid levels, and chlorine levels were associated with nutritional status among Chinese PD patients. The findings of this study indicate the significance of the early detection and prevention of malnutrition to improve the quality of life of PD patients.

Nutritional Status Associated with Molecular Biomarkers, Physiological Indices, and Clinical Severity in Parkinson's Disease Patients

This study is intended to explore the associations between nutritional status and molecular biomarkers and the clinical severity of Parkinson's disease (PD), as well as to examine the differences in related factors between PD patients with normal nutrition and those with at risk for malnutrition. A cross-sectional assessment of 82 consecutive outpatients with PD was conducted using the mini nutritional assessment (MNA), Unified Parkinson's Disease Rating Scale (UPDRS), and the Hoehn and Yahr scale to determine the nutritional status, the clinical severity of PD, and the stage of the disease. Recordings of blood samples collected after 12 h of overnight fasting were also assessed in terms of serum levels of glycated hemoglobin (HbA1c), blood urea nitrogen (BUN), creatinine, cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), hemoglobin (Hgb), folate, and vitamin B12. All participants were divided into normal nutrition and malnutrition risk groups via the MNA scores to compare the above-mentioned parameters. The results showed that the total MNA score was significantly correlated with some parts of the UPDRS scale (e.g., Sections 1 and 2) and the levels of HbAlc in PD patients and those with risk for malnutrition, with significantly lower weight and body mass index (BMI), and with lower levels of Hgb and HDL. Higher levels of cholesterol were observed in the malnutrition risk group as compared with the normal nutrition group. The findings suggest that the clinical severity of PD is associated with nutritional status. Body weight, BMI, and the levels of Hgb, cholesterol, and HDL could be, at least partially, important biological markers to monitor malnutrition and the progression of the disease.

Progressive and accelerated weight and body fat loss in Parkinson's disease: A three-year prospective longitudinal study

INTRODUCTION

Although weight loss is common in Parkinson's disease (PD), longitudinal studies assessing weight and body composition changes are limited.

METHODS

In this three-year longitudinal study, 125 subjects (77 PD patients and 48 spousal/sibling controls) underwent clinical, biochemical and body composition assessments using dual-energy X-ray absorptiometry.

RESULTS

Patients were older than controls (65.6 ± 8.9 vs. 62.6 ± 7.1, P = 0.049), with no significant differences in gender, comorbidities, dietary intake and physical activity. Clinically significant weight loss (≥5% from baseline weight) was recorded in 41.6% of patients, with a doubling of cases (6.5 to 13.0%) classified as underweight at study end. Over three years, patients demonstrated greater reductions in BMI (mean -1.2 kg/m², 95%CI-2.0 to -0.4), whole-body fat percentage (-2.5% points, 95%CI-3.9 to -1.0), fat mass index (FMI) (-0.9 kg/m², 95%CI-1.4 to -0.4), visceral fat mass (-0.1 kg, 95%CI-0.2 to 0.0), and subcutaneous fat mass (-1.9 kg, 95%CI-3.4 to -0.5) than in controls, with significant group-by-time interactions after adjusting for age and gender. Notably, 31.2% and 53.3% of patients had FMI<3rd (severe fat deficit) and <10th centiles, respectively. Muscle mass indices decreased over time in both groups, without significant group-by-time interactions. Multiple linear regression models showed that loss of body weight and fat mass in patients were associated with age, dyskinesia, psychosis and constipation.

CONCLUSIONS

We found progressive loss of weight in PD patients, with greater loss of both visceral and subcutaneous fat, but not muscle, compared to controls. Several associated factors (motor and non-motor disease features) were identified for these changes, providing insights on possible mechanisms and therapeutic targets.

The Prevalence and Determinants of Neuropsychiatric Symptoms in Late-Stage Parkinsonism

Background

Late-stage parkinsonism and Parkinson's disease (PD) are insufficiently studied population. Although neuropsychiatric symptoms (eg, psychosis, depression, anxiety, behavioral problems) are frequently present, their prevalence and clinical predictors remain unknown.

Objective

To determine the prevalence and predictors of neuropsychiatric symptoms in late-stage PD.

Methods

We conducted a multinational study of patients with PD with ≥7 years disease duration and either a Hoehn and Yahr stage ≥4 or a Schwab and England score ≤ 50% in the on stage. Neuropsychiatric symptoms were assessed through interviews with carers using the Neuropsychiatric Inventory, with a frequency × severity score ≥ 4, indicating clinically relevant symptoms. The determinants analyzed were demographic characteristics, medication, and motor and nonmotor symptoms. Univariate and multivariate logistic analyses were performed on predictors of clinically relevant neuropsychiatric symptoms.

Results

A total of 625 patients were recruited in whom the Neuropsychiatric Inventory could be completed. In 92.2% (576/625) of the patients, at least 1 neuropsychiatric symptom was present, and 75.5% (472/625) had ≥1 clinically relevant symptom. The most common clinically relevant symptoms were apathy (n = 242; 38.9%), depression (n = 213; 34.5%), and anxiety (n = 148; 23.8%). The multivariate analysis revealed unique sets of predictors for each symptom, particularly the presence of other neuropsychiatric features, cognitive impairment, daytime sleepiness.

Conclusion

Neuropsychiatric symptoms are common in late-stage PD. The strongest predictors are the presence of other neuropsychiatric symptoms. Clinicians involved in the care for patients with late-stage PD should be aware of these symptoms in this specific disease group and proactively explore other psychiatric comorbidities once a neuropsychiatric symptom is recognized.

Association between malnutrition, clinical parameters and health-related quality of life in elderly hospitalized patients with Parkinson's disease: A cross-sectional study

Objective

This study aimed to explore the association between malnutrition, clinical parameters, and health-related quality of life in elderly hospitalized patients with Parkinson’s disease (PD).

Methods

Cross-sectional study of 92 hospitalized elderly patients with PD (mean age 73.6 ± 6.7 years) without dementia. The Mini Nutritional Assessment (MNA) was used to evaluate nutritional status. Motor impairment and non-motor symptoms burden (Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale [MDS-UPDRS], Non-Motor Symptoms Questionnaire, and Hoehn & Yahr staging), depression (Becks Depression Inventory-II), and health-related quality of life (PD quality of life Questionnaire-39) were assessed.

Results

Every second patient was malnourished or at risk of malnutrition. In the multivariable analysis, male gender, longer disease duration, higher Hoehn & Yahr and depression were associated with total MNA score. Besides non-motor symptoms and motor impairment, malnutrition was an independent predictor of poor health-related quality of life. In the multivariate analysis, malnutrition had a statistically significant effect on emotional well-being, mobility, social support, stigmatization, and cognition. The strongest association was found between malnutrition and emotional well-being.

Conclusion

Elderly male persons with longer PD duration and higher disease stages are more likely to be malnourished or at risk for malnutrition. Malnutrition was mainly associated with poor emotional well-being, suggesting that treatment of depression and anxiety beside diet and physical activity can help improving nutrition status in these subjects. The MNA should not be used independent of other measures of cognition and depression in people with advanced PD.

Altered Body Composition and Increased Resting Metabolic Rate Associated with the Postural Instability/Gait Difficulty Parkinson's Disease Subtype

Background

Weight loss in Parkinson's disease (PD) patients is a common but poorly understood manifestation. Several studies have reported that weight changes could be related to motor symptoms, drug side effects, dysphagia, depression, and/or dementia. Weight loss in PD is not a benign phenomenon and it has several clinical and prognostic implications with increased morbidity and mortality. Thus, it is crucial to determine nutritional changes in PD patients in order to prevent malnutrition and improve their quality of life.

Objective

To compare body composition and resting metabolic rates between PD patients and controls.

Methods

A total of 64 PD patients and 52 controls were studied. The Hoehn-Yahr scale was used to determine the disease stage, clinical and epidemiological data were recorded from verbal questionnaire, Inbody S10® was used to collect corporal parameters, and FitMate system was used to assess the resting metabolic rate.

Results

No significant differences were found between both experimental groups in age, gender, height, cholesterol levels, and the presence of hypertension, diabetes, and hypo/hyperthyroidism. However, the PD group showed lower body fat mass, whole-body fat percentage, and greater resting metabolic rate compared to controls (p < 0.05), with no significant differences in musculoskeletal mass. Parkinson's disease postural instability/gait difficulty (PD-PIGD) subtype showed lower body fat parameters, increased fat-free mass, and higher resting metabolic rates.

Conclusions

These results suggest that PD patients present an increased resting metabolic rate associated with the postural instability/gait difficulty PD subtype, allowing a selective decrease of body fat mass and not musculoskeletal mass. Of note, several disease-related factors may contribute to this weight loss in PD patients, being a complex and multifactorial consequence. Our findings could likely be one of the many contributing factors. However, present findings may further add to our understanding of the phenomenon of weight loss in patients with PD.

Untangling the relationship between fat distribution, nutritional status and Parkinson's disease severity

Background

Parkinson’s disease (PD) is responsible for significant changes in body composition.

Aims

We aimed to test the association between PD severity and fat distribution patterns, and to investigate the potential modifier effect of nutritional status in this association.

Methods

We enrolled 195 PD subjects consecutively admitted to a university geriatric day hospital. All participants underwent comprehensive clinical evaluation, including assessment of total and regional body composition (dual-energy X-ray absorptiometry, DXA), body mass index, nutritional status (Mini-Nutritional Assessment, MNA), motor disease severity (UPDRS III), comorbidities, and pharmacotherapy.

Results

The fully adjusted linear regression model showed a negative association between UPDRS III and total body fat in kg and percentage (respectively, B − 0.79; 95% CI − 1.54 to − 0.05 and B − 0.55; 95% CI − 1.04 to − 0.05), percentage android fat (B − 1.07; 95% CI − 1.75 to − 0.39), trunk–leg fat ratio (B − 0.02; 95% CI − 0.04 to − 0.01), trunk–limb fat ratio (B − 0.01; 95% CI − 0.06 to − 0.01) and android–gynoid fat ratio (B − 0.01; 95% CI − 0.03 to − 0.01). After stratification by MNA score, all the parameters of android-like fat distribution resulted negatively associated (p < 0.001 for all) with UPDRS III, but only among subjects with a MNA < 23.5 (risk of malnutrition or malnutrition).

Conclusion

We found a negative association between severity of motor impairment and total fat mass in PD, more specific with respect to an android pattern of fat distribution. This association seems to be driven by nutritional status, and is significant only among patients at risk of malnutrition or with overt malnutrition.

Estado nutricional de idosos com doença de Parkinson e seus fatores associados: uma revisão integrativa

Resumo Objetivo Identificar os fatores associados ao Estado Nutricional de idosos com doença de Parkinson (DP) por meio de uma revisão integrativa da literatura. Método Foram utilizadas as bases de dados LILACS, MEDLINE, BDENF, Scielo e Pubmed, sem filtros para ano de publicação e desenho do estudo. Foram incluídos os estudos disponibilizados em português, inglês ou espanhol com população idosa (idade ≥60 anos). Foram excluídos estudos que não tratavam da temática, publicações não disponíveis na íntegra e que não atenderam à pergunta norteadora. Extraíram-se informações referentes aos objetivos, desenho de estudo, amostra investigada, instrumentos para a avaliação nutricional e principais resultados, além dos fatores associados. A qualidade metodológica dos estudos foi avaliada pelos instrumentos Critical Appraisal Skill Programme e Agency for Health care and Research and Quality. Para sumarização dos fatores associados foi considerado o percentual de estudos cuja análise intergrupo, associação ou correlação foi significativa para o desfecho esperado. Resultados A análise final resultou em 8 artigos. Os fatores associados ao Estado Nutricional entre as variáveis clínicas relacionadas à DP foram duração e gravidade da doença, sintomas motores e função cognitiva. Com relação às variáveis clínico-nutricionais apresentaram associação à gordura corporal, parâmetros bioquímicos, atividade física, doméstica e mobilidade, ingestão de energia e hábitos alimentares. Conclusão A perda de peso na DP é uma consequência complexa e multifatorial, sendo primordial diagnosticar precocemente mudanças nutricionais nesses pacientes. A realização de mais estudos nessa população é necessária, visando compreender melhor esse processo de perda de peso nos pacientes idosos com DP.

Assessment of 7 trace elements in serum of patients with nontuberculous mycobacterial lung disease

Nontuberculous mycobacterial (NTM) lung diseases are an emerging cause of pulmonary infection, becoming more common in the clinical setting as incidence of NTM lung diseases steadily increases worldwide. Trace elements are essential micronutrients and are known to play many important roles in infectious diseases. We investigated the concentrations of trace elements in patients with NTM lung disease and compared these values to patients with pulmonary tuberculosis and healthy controls. A case-control study was conducted to evaluate the serum trace element concentrations in 95 patients with NTM lung disease, 97 patients with pulmonary tuberculosis, and 99 healthy control subjects. The serum concentrations of 7 trace elements (cobalt, copper, chromium, manganese, molybdenum, selenium, and zinc) were measured using inductively coupled plasma-mass spectrometry. We also analyzed demographic data, clinical outcomes, and other biochemical parameters. The median serum concentrations of copper and molybdenum were higher in patients with NTM lung disease (109 vs. 91 μg/dL, p < 0.001 and 1.70 vs. 0.96 μg/L, p < 0.001). In contrast, the median serum concentrations of selenium and zinc were significantly lower in patients with NTM lung disease than in healthy controls (105 vs. 115 μg/L, p < 0.001 and 94 vs. 102 μg/dL, p < 0.001). Compared to patients with pulmonary tuberculosis, the serum concentrations of molybdenum and zinc were higher in patients with NTM lung disease, while cobalt and copper concentrations were lower (p < 0.001). Correlations among trace element concentrations were observed (copper and zinc, r = -0.367; cobalt and molybdenum, r = -0.360; selenium and zinc, r = 0.335; and manganese and zinc, r = 0.327, respectively). None of the 7 trace elements were associated with treatment outcomes. Patients with NTM lung disease showed different serum trace element concentrations. Our study indicates that altered trace element status is associated with mycobacterial disease. Further study investigating the clinical significance of individual trace elements and their association with nutritional status in patients with NTM lung disease would be required.

Exercise as a therapeutic intervention for motor and non-motor symptoms in Parkinson's disease: Evidence from rodent models

Parkinson's disease (PD) is characterised by degeneration of dopaminergic neurons of the nigrostriatal pathway, which leads to the cardinal motor symptoms of the disease - tremor, rigidity and postural instability. A number of non-motor symptoms are also associated with PD, including cognitive impairment, mood disturbances and dysfunction of gastrointestinal and autonomic systems. Current therapies provide symptomatic relief but do not halt the disease process, so there is an urgent need for preventative strategies. Lifestyle interventions such as aerobic exercise have shown potential to lower the risk of developing PD and to alleviate both motor and non-motor symptoms. However, there is a lack of large-scale randomised clinical trials that have employed exercise in PD patients. This review will focus on the evidence from studies on rodent models of PD, for employing exercise as an intervention for both motor and non-motor symptoms.

Does nutritional status affect Parkinson's Disease features and quality of life?

Objectives

The aim of this study was to determine the relationship between nutritional status and Parkinson's Disease (PD) features in association with depression, anxiety and quality of life in people with PD.

Materials and methods

This study was conducted on 96 patients with idiopathic PD to whom the following scales were applied: Unified Parkinson’s Disease Rating Scale (UPDRS), 39-item PD questionnaire (PDQ-39), Hospital Anxiety and Depression Score (HADS), Mini Nutritional Assessment (MNA). The scales and measurements were applied to patients at their first assessment. Patients with malnutrition or at risk of malnutrition were assessed by the dietitian and nutrition nurse. These patients received nutritional support through personalized diet recommendations and appropriate enteral nutritional products, considering factors such as age, comorbidity, socioeconomic and cultural conditions. At the end of 6 weeks, the scales and measurements applied during the first visit were again applied to the patients.

Results

A significant and inverse correlation was determined between mental (Spearman r:-0.510, p<0.001), activities of daily living (Spearman r:-0.520, p<0.001), motor (Spearman r:-0.480, p<0.001), complications (Spearman r:-0.346, p<0.001) UPDRS subdivisions and total scores (Spearman r:-0.644, p<0.001) and total MNA score. A significant and inverse correlation was found between all PDQ-39 subdomains and total MNA score (p<0.05). The highest inverse correlations were found in mobility (Spearman r:-0.690, p<0.001) and stigma (Spearman r:-0.570, p<0.001). Both depression (Spearman r:-0.631, p<0.001) and anxiety (Spearman r:-0.333, p<0.001) scores were determined to be inversely correlated with total MNA score. At the 6-week control visit, significantly lower scores were found in all subdivisions and in the total UPDRS score, PDQ-39 score and in the patients' anxiety and depression scores (p<0.05). MNA scores were found to be significantly higher in the assessment performed after 6 weeks of support for patients who had abnormal nutritional status at inception (p<0.001).

Conclusion

PD motor and nonmotor functions, disease duration and severity are related to nutritional status. Quality of life was also shown to be affected by changes in the nutritional status. These results show that nutritional status assessment should be a standard approach in the PD treatment and follow-up processes.

Disease Specific Aspects of Malnutrition in Neurogeriatric Patients

Malnutrition in elderly patients is a common condition. Nevertheless, there is evidence on specific risk factors and problems of malnutrition in geriatric patients with neurological diseases. In this review, we summarize recent knowledge on malnutrition in different neurological diseases with a focus on elderly patients. This overview also provides strategies for a more specific and profound assessment of neurogeriatric patients to improve identification and treatment of malnutrition. Early and consequent treatment of malnutrition can lead to a decreased progression of the neurological disease and to a better quality of life in geriatric patients.

Weight Loss and Malnutrition in Patients with Parkinson's Disease: Current Knowledge and Future Prospects

Parkinson's Disease (PD) is currently considered a systemic neurodegenerative disease manifested with not only motor but also non-motor symptoms. In particular, weight loss and malnutrition, a set of frequently neglected non-motor symptoms, are indeed negatively associated with the life quality of PD patients. Moreover, comorbidity of weight loss and malnutrition may impact disease progression, giving rise to dyskinesia, cognitive decline and orthostatic hypotension, and even resulting in disability and mortality. Nevertheless, the underlying mechanism of weight loss and malnutrition in PD remains obscure and possibly involving multitudinous, exogenous or endogenous, factors. What is more, there still does not exist any weight loss and malnutrition appraision standards and management strategies. Given this, here in this review, we elaborate the weight loss and malnutrition study status in PD and summarize potential determinants and mechanisms as well. In conclusion, we present current knowledge and future prospects of weight loss and malnutrition in the context of PD, aiming to appeal clinicians and researchers to pay a closer attention to this phenomena and enable better management and therapeutic strategies in future clinical practice.

Predictors of weight loss in early treated Parkinson's disease from the NET-PD LS-1 cohort

Weight loss is a common symptom of Parkinson's disease and is associated with impaired quality of life. Predictors of weight loss have not been studied in large clinical cohorts. We previously observed an association between change in body mass index and change in Unified Parkinson's Disease Rating Scale (UPDRS) motor and total scores. In this study, we performed a secondary analysis of longitudinal data (1-6 years) from 1619 participants in the NINDS Exploratory Trials in PD Long-term Study-1 (NET-PD LS1) to explore predictors of weight loss in a large prospective clinical trial cohort of early treated Parkinson's disease. The NET-PD LS1 study was a double-blind randomized placebo controlled clinical trial of creatine monohydrate 10 gm/day in early treated PD (within 5 years of diagnosis and within 2 years of starting dopaminergic medications). Linear mixed models were used to estimate the effect of baseline clinical covariates on weight change over time. On average, participants lost only 0.6 kg per year. Higher age, baseline weight, female gender, higher baseline UPDRS scores, greater postural instability, difficulty eating and drinking, lower cognitive scores and baseline levodopa use (compared to dopamine agonists) were all associated with weight loss. Surprisingly baseline difficulty swallowing, dyskinesia, depression, intestinal hypomotility (constipation) and self-reported nausea/vomiting/anorexia were not significantly associated with weight loss in this cohort of early treated Parkinson's disease patients. On average, participants with Parkinson's disease experience little weight loss during the first 1-6 years after starting dopaminergic replacement therapy, however levodopa use and postural instability were both predictors of early weight loss. Trial Registration clinicaltrials.gov identifier# NCT00449865.

Clinical value of nutritional status in neurodegenerative diseases: What is its impact and how it affects disease progression and management?

Neurodegenerative diseases constitute a major problem of public health that is associated with an increased risk of mortality and poor quality of life. Malnutrition is considered as a major problem that worsens the prognosis of patients suffering from neurodegenerative diseases. In this aspect, the present review is aimed to critically collect and summarize all the available existing clinical data regarding the clinical impact of nutritional assessment in neurodegenerative diseases, highlighting on the crucial role of nutritional status in disease progression and management. According to the currently available clinical data, the nutritional status of patients seems to play a very important role in the development and progression of neurodegenerative diseases. A correct nutritional evaluation of neurodegenerative disease patients and a right nutrition intervention is essential in monitoring their disease.

Oropharyngeal dysphagia in older persons - from pathophysiology to adequate intervention: a review and summary of an international expert meeting

Oropharyngeal dysphagia (OD) is a highly prevalent and growing condition in the older population. Although OD may cause very severe complications, it is often not detected, explored, and treated. Older patients are frequently unaware of their swallowing dysfunction which is one of the reasons why the consequences of OD, ie, aspiration, dehydration, and malnutrition, are regularly not attributed to dysphagia. Older patients are particularly vulnerable to dysphagia because multiple age-related changes increase the risk of dysphagia. Physicians in charge of older patients should be aware that malnutrition, dehydration, and pneumonia are frequently caused by (unrecognized) dysphagia. The diagnosis is particularly difficult in the case of silent aspiration. In addition to numerous screening tools, videofluoroscopy was the traditional gold standard of diagnosing OD. Recently, the fiberoptic endoscopic evaluation of swallowing is increasingly utilized because it has several advantages. Besides making a diagnosis, fiberoptic endoscopic evaluation of swallowing is applied to evaluate the effectiveness of therapeutic maneuvers and texture modification of food and liquids. In addition to swallowing training and nutritional interventions, newer rehabilitation approaches of stimulation techniques are showing promise and may significantly impact future treatment strategies.

Olfactory Function, Eating Ability, and Visceral Obesity Associated with MMSE Three Years after Parkinson's Disease Diagnosis

OBJECTIVES

This study examines whether risk factors for poor nutrition are associated with global cognitive function three years after confirmed Parkinson's disease (PD) diagnosis.

DESIGN

The follow-up investigations for this prospective community-based study were conducted three years after PD diagnosis.

SETTING

The study participants lived in Västerbotten County, a region in northern Sweden with 142,000 inhabitants.

PARTICIPANTS

This study population consisted of 118 PD outpatients from the study of Newly Diagnosed PD in Umeå (NYPUM).

MEASUREMENTS

Global cognition was assessed with the Mini Mental State Examination (MMSE) at baseline and at follow-up. Anthropometry, nutrition (Mini Nutritional Assessment, MNA, 3-day food registration, 3-FDR), olfactory function (Brief Smell Identification Test, B-SIT), and swallowing, cutting food, and salivation (single questions from the Unified Parkinson's Disease Rating Scale, UPDRS) were used as markers for nutritional status.

RESULTS

The MMSE score decreased over three years (-1.06±3.38, p=0.001). Olfactory function at baseline was associated to MMSE at three years (B=0.365, p=0.004). Changes in waist/hip ratio (B=113.29, p=0.017), swallowing (B=1.18, P=0.033), and cutting food (B=-1.80, p=0.000) were associated with MMSE at follow-up.

CONCLUSION

This study indicates that olfactory function, cutting food, swallowing, and visceral obesity are associated with MMSE three years after PD diagnosis.

Improved nutritional status is related to improved quality of life in Parkinson's disease

Background

Quality of life is poorer in Parkinson’s disease than in other conditions and in the general population without Parkinson’s disease. Malnutrition also results in poorer quality of life. This study aimed at determining the relationship between quality of life and nutritional status.

Methods

Community-dwelling people with Parkinson’s disease >18 years old were recruited. The Patient-Generated Subjective Global Assessment (PG-SGA) assessed nutritional status. The Parkinson’s Disease Questionnaire 39 (PDQ-39) measured quality of life. Phase I was cross-sectional. The malnourished in Phase I were eligible for a nutrition intervention phase, randomised into 2 groups: standard care (SC) with provision of nutrition education materials only and intervention (INT) with individualised dietetic advice and regular weekly follow-up. Data were collected at baseline, 6 weeks, and 12 weeks.

Results

Phase I consisted of 120 people who completed the PDQ-39. Phase II consisted of 9 in the SC group and 10 in the INT group. In Phase I, quality of life was poorer in the malnourished, particularly for mobility and activities of daily living domains. There was a significant correlation between PG-SGA and PDQ-39 scores (Phase I, r_s = 0.445, p = .000; Phase II, r_s = .426, p = .002). In Phase II, no significant difference in the PDQ-39 total or sub-scores was observed between the INT and SC groups; however, there was significant improvement in the emotional well-being domain for the entire group, X²(2) = 8.84, p = .012.

Conclusions

Malnourished people with Parkinson’s disease had poorer quality of life than the well-nourished, and improvements in nutritional status resulted in quality of life improvements. Attention to nutritional status is an important component of quality of life and therefore the total care of people with Parkinson’s disease.

Trial registration

ACTRN12610000819022

Body weight and food intake in Parkinson's disease. A review of the association to non-motor symptoms

Research on eating behaviours has extensively highlighted that cognitive systems interact with the metabolic system in driving food intake and in influencing body weight regulation. Parkinson's disease is a good model for studying these complex interactions since alterations in both body weight and cognitive domains have been frequently reported among these patients. Interestingly, even if different non-motor symptoms may characterize the course of the disease, their contribution to weight and food preference has been poorly investigated. This review describes body weight alterations and eating habits in patients with Parkinson's disease, including those who underwent deep brain stimulation surgery. In particular, the review considers the link between non-motor symptoms, affecting sensory perception, cognition, mood and motivation, and food intake and weight alterations. The take home message is twofold. First, we recommend a comprehensive approach in order to develop effective strategies in the management of patients' weight. Second, we also suggest that investigating this issue in patients with Parkinson's disease may provide some useful information about the mechanisms underlying food and weight regulation in healthy subjects.

Mechanisms of body weight fluctuations in Parkinson's disease

Typical body weight changes are known to occur in Parkinson’s disease (PD). Weight loss has been reported in early stages as well as in advanced disease and malnutrition may worsen the clinical state of the patient. On the other hand, an increasing number of patients show weight gain under dopamine replacement therapy or after surgery. These weight changes are multifactorial and involve changes in energy expenditure, perturbation of homeostatic control, and eating behavior modulated by dopaminergic treatment. Comprehension of the different mechanisms contributing to body weight is a prerequisite for the management of body weight and nutritional state of an individual PD patient. This review summarizes the present knowledge and highlights the necessity of evaluation of body weight and related factors, as eating behavior, energy intake, and expenditure in PD.

Renal function associates with energy intake in elderly community-dwelling men

Energy intake and renal function decrease with age. In patients with chronic kidney disease (CKD), spontaneous food intake decreases in parallel with the loss of renal function. The objective of the present study was to evaluate a possible relationship between renal dysfunction and energy intake in elderly community-dwelling men. A cross-sectional study including 1087 men aged 70 years from the Uppsala Longitudinal Study of Adult Men (ULSAM) community-based cohort was carried out. Dietary intake was assessed using 7 d food records, and glomerular filtration rate was estimated from serum cystatin C concentrations. Energy intake was normalised by ideal body weight, and macronutrient intake was energy-adjusted. The median normalised daily energy intake was 105 (interquartile range 88–124) kJ, and directly correlated with estimated glomerular filtration rate (eGFR) as determined by univariate analysis. Across the decreasing quartiles of eGFR, a significant trend of decreasing normalised energy intake was observed (P =0·01). A multivariable regression model including lifestyle factors and co-morbidities was used for predicting total energy intake. In this model, regular physical activity (standardised β = 0·160; P =0·008), smoking (standardised β = − 0·081; P =0·008), hypertension (standardised β = − 0·097; P =0·002), hyperlipidaemia (standardised β = − 0·064; P =0·037) and eGFR (per sd increase, standardised β = 0·064; P =0·04) were found to be independent predictors of energy intake. Individuals with manifest CKD (eGFR < 60 ml/min per 1·73 m2) were more likely to have lower energy intake than those without. In conclusion, there was a direct and independent correlation between renal function and energy intake in a population-based cohort of elderly men. We speculate on a possible link between renal dysfunction and malnutrition in the elderly.

Motor, psychiatric and fatigue features associated with nutritional status and its effects on quality of life in Parkinson's disease patients

Objectives

Parkinson’s disease (PD) patients are more likely to develop impaired nutritional status because of the symptoms, medications and complications of the disease. However, little is known about the determinants and consequences of malnutrition in PD. This study aimed to investigate the association of motor, psychiatric and fatigue features with nutritional status as well as the effects of malnutrition on different aspects of quality of life (QoL) in PD patients.

Methods

One hundred and fifty patients with idiopathic PD (IPD) were recruited in this study. A demographic checklist, the Unified Parkinson’s Disease Rating Scale (UPDRS), the Hospital Anxiety and Depression Scale (HADS) and the Fatigue Severity Scale (FSS) were completed through face-to-face interviews and clinical examinations. The health-related QoL (HRQoL) was also evaluated by means of the Parkinson’s Disease Questionnaire (PDQ-39). For evaluation of nutritional status, the Mini Nutritional Assessment (MNA) questionnaire was applied together with anthropometric measurements.

Results

Thirty seven (25.3%) patients were at risk of malnutrition and another 3 (2.1%) were malnourished. The total score of the UPDRS scale (r = −0.613, P<0.001) and PD duration (r = −0.284, P = 0.002) had a significant inverse correlation with the total MNA score. The median score of the Hoehn and Yahr stage was significantly higher in PD patients with abnormal nutritional status [2.5 vs. 2.0; P<0.001]. More severe anxiety [8.8 vs. 5.9; P = 0.002], depression [9.0 vs. 3.6; P<0.001] and fatigue [5.4 vs. 4.2; P<0.001] were observed in PD patients with abnormal nutritional status. Except for stigma, all other domains of the PDQ-39 were significantly correlated with the total score of the MNA.

Conclusion

Our study demonstrates that disease duration, severity of motor and psychiatric symptoms (depression, anxiety) and fatigue are associated with nutritional status in PD. Different aspects of the HRQoL were affected by patients’ nutritional status especially the emotional well-being and mobility domains.