- Email: [email protected]
Nutritional status and dietary habits in Parkinson’s disease patients in Ghana
Nutrition 29 (2013) 470–473
Contents lists available at ScienceDirect
Nutrition journal homepage: www.nutritionjrnl.com
Brief report
Nutritional status and dietary habits in Parkinson’s disease patients in Ghana Michela Barichella M.D. a, Albert Akpalu M.D. b, Momodou Cham M.D. c, Giulia Privitera a, Erica Cassani M.D. a, *, Emanuele Cereda M.D., Ph.D. a, d, Laura Iorio M.D. a, Roberto Cilia M.D. a, Alba Bonetti a, Gianni Pezzoli M.D. a a
Parkinson Institute, Istituti Clinici di Perfezionamento, Milan, Italy Korle Bu Teaching Hospital, Accra, Ghana c Comboni Hospital, Sogakofe, Ghana d Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 June 2012 Accepted 3 September 2012
Objective: Dietary treatment is important for the management of Parkinson’s disease (PD). Our objective was to describe the dietary habits and assess the nutritional status of Ghanaian patients with PD. This study is part of a larger project, for which Ghana has been selected as a pilot country. Methods: Fifty-five Ghanaian patients with PD and 12 healthy Ghanaian controls were recruited. We assessed nutritional status, investigated dietary habits, and assessed the prevalence of the nutritional complications of PD (e.g., constipation and dysphagia). Results: The mean daily caloric intake was about 1200 kcal/d in patients with PD and in controls. The typical diet was based on semisolid foods, usually vegetable soups accompanied by cereal flour or root starch or sometimes chicken or fish. The intake of milk and its derivatives was low. The prevalences of constipation and dysphagia in patients with PD were 49% and 21%, respectively. Conclusion: This study has yielded information that could be useful for the study of the management of PD and for the assessment of response to therapy. Ó 2013 Elsevier Inc. All rights reserved.
Keywords: Parkinson’s disease Nutritional status Diet Constipation Dysphagia
Introduction Dietary factors should be taken into consideration for the management of Parkinson’s disease (PD). First of all, diet may influence the response of patients with PD to treatment: large quantities of proteins, especially animal proteins, compete with levodopa for absorption from the gut and therefore may decrease the absorption of levodopa and, hence, its efficacy [1]. Second, an appropriate diet prevents malnutrition in terms of deficiency, which occurs mainly in the advanced stages of PD [2]. Third, the diet has a role in the treatment and prevention of non-motor complications of PD, such as constipation [3] and dysphagia [4]. Recently, several nutrients and foods, such as milk [5] and vitamin D [6], have been suggested to be included among the environmental risk factors for PD, although with inconsistent results. A recent article by Smith [7], showing how a high-protein
diet promotes atherogenesis in rats, supports the hypothesis that the diet can promote the onset of neurodegenerative diseases. Furthermore, epidemiologic studies investigating the epidemiology of PD in sub-Sahara countries have suggested a lower prevalence than in developed countries [8–10]. The finding of a five-fold higher prevalence of PD in African-American than in Western African populations [11] has suggested that environmental factors might be responsible for this difference [8]. In developing countries, the local diet is different from the Mediterranean diet. This environmental factor may be important in the understanding and management of PD motor and nonmotor symptoms. Considering all these preliminary remarks, we decided to assess the nutritional status and dietary habits of Ghanaian patients with PD. Ghana was identified as a suitable country for the performance of a pilot study. Materials and methods
This work was supported by the Fondazione Grigioni per il Parkinson. * Corresponding author. Tel./fax: þ39-02-5799-3322. E-mail address: [email protected] (E. Cassani). 0899-9007/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nut.2012.09.017
At the Parkinson Institute, Istituti Clinici di Perfezionamento (Milan, Italy), we have set up a research project on PD in developing countries. The project started in Ghana and will be extended to others countries in Africa. A multidisciplinary team, including two neurologists, one nurse, and one nutritionist, went
M. Barichella et al. / Nutrition 29 (2013) 470–473 Table 1 Food-frequency questionnaire 1. a b c d e 2. a b c d e 3. a b c d e 4. a b c d e 5. a b c d e 6. a b c d e 7. a b c d e 8. a b c d e 9. a b c d e 10. a b c d e 11. a b c d e
471
Table 1 (continued)
How many times a day do you eat? 1 2 3 When I have time and food is available I don’t know How many times a week do you eat fufu? >5 2 or 3 1 0 I don’t know ? How many times a week do you eat banku >5 2 or 3 1 0 I don’t know How many times a week do you ear omo tuo or kelewele? >5 2 or 3 1 0 I don’t know How many times a week do you eat red red? >5 2 or 3 1 0 I don’t know How many times a week do you eat vegetables (onions, tomatoes, okro, or eggplant)? >5 2 or 3 1 0 I don’t know How many times a week do you eat fruit? >5 2 or 3 1 0 I don’t know How many times a week do you drink milk? >5 2 or 3 1 0 I don’t know How many bowls of water do you drink a day? 1 3 5 >8 I don’t know How many times a week do you drink beer? >5 2 or 3 1 0 I don’t know How many times a week do you drink palm wine? >5 2 or 3 1 0 I don’t know (continued)
there several times in 2011 (four visits, each lasting about 1 wk). During the stay in Ghana, at Accra and Sogakofe, the team examined many patients referred by local physicians because of suspected PD. All the subjects underwent a complete neurologic examination and the diagnosis of PD was confirmed in 55 patients
12. a b c d e 13. a b c
How many times a week do you drink apa teshi or bumkutuku? >5 2 or 3 1 0 I don’t know Do you favor food with spices (cumin, cinnamon, chili pepper, ginger)? Yes No I don’t know
according to UK Brain Bank criteria [12]. The duration of disease was 6.3 4.7 y (mean standard deviation). These patients were given levodopa and underwent an in-depth assessment of nutritional status. A control group of 12 African patients, matched by age and sex, was also identified. Patients with PD and the controls were assessed by the nutritionist. Anthropometric data (body weight in kilograms, height in meters, and body mass index as the ratio of body weight to height squared) were collected. A food-frequency questionnaire (Table 1) was administered to assess the qualitative intake of nutrients and the quantitative intake of food expressed in kilocalories. The questionnaire was drafted by the nutritionist, after having established the composition of the main typical dishes by consulting the Wikipedia Web site [13] and collecting information from the local population. A food history was also collected by 2–4 h recall. The 2–4h recall is designed to assess the quantitative intake of nutrients and kilocalories. It has been used by other investigators in nutritional studies performed in Ghana [14]. The Swallowing Disturbance Questionnaire [15], validated for PD, was used to assess the presence of dysphagia. The scale has 14 items, each with a score ranging from 0 to 3, except one question with a score ranging from 0.5 to 2.5. The total score ranges from 0.5 to 44.5. The scientific evidence has suggested it can be used for the diagnosis of dysphagia needing treatment (cutoff score 11). The Rome III criteria (Constipation module) were used to assess the presence of chronic constipation, and these criteria have been used in PD [3]. According to these criteria, patients are considered to have functional constipation if they score at least 2 points on the questionnaire. The daily energy expenditure was measured in six subjects using an armband [16], which monitored energy expenditure during usual daily activities for 24 h. Patients were asked to pursue their usual daily activities while they wore the armband for 24 h. A food history was also collected by 24-h recall. All questionnaires were administered in English with the collaboration of an interpreter. Informed consent was obtained from all the patients. The ethics committee approved this study. The data were collected anonymously and entered into a database protected by a password. The statistical analysis of data was carried out using JMP 3.2.6 (SAS Institute, Cary, NC, USA). P < 0.05 was the limit for statistical significance. Means were compared using the Mann–Whitney test for non-parametric data.
Results We examined a group of 55 patients (37 men and 18 women) with PD living in Accra (greater Accra region) or Sogakofe (Volta region). We compared the group of patients with PD with a group of 12 healthy volunteers (six men and six women); all subjects lived in Accra. The anthropometric and nutritional characteristics of the two groups are presented in Table 2. The search on local dietary habits disclosed that the typical diet of Ghanaians is based on one-dish meals, usually vegetable soups accompanied by dumplings containing a large proportion of cereal flour (rice, maize, millet) or root starch (cassava, cocoyam, yam) or sometimes also fried, grilled, or stewed chicken or fish. Large amounts of spices and palm oil are added. Also, bananas and plantains are common ingredients. The most popular local dishes are fufu (pounded cassava, rice, (pounded maize or rice with bananas, plantain, or cocoyam), banku served with stewed meat or fish soup), omo tuo (rice balls with a spicy sauce), red red (bean soup with plantain puree), and kelewele (dessert made of fried plantains flavored with ginger).
472
M. Barichella et al. / Nutrition 29 (2013) 470–473
Table 2 Anthropometric and nutritional characteristics of patients with PD and controls
Age (y) Weight (kg) Height (m) BMI (kg/m2) Daily energy intake (kcal) Calories derived from protein versus entire daily energy intake (%) Calories derived from fat versus whole daily energy intake (%) Calories derived from carbohydrates versus entire daily energy intake (%) Daily energy expenditure measured with armband (kcal)y Daily alcohol consumption (g) Daily spice consumption (percentage of subjects who use them) Daily water intake (mL) Number of meals a day Number of subjects reporting constipation (Rome III criteria score 2) Subjects with dysphagia for solids (SDQ score >11) Weekly consumption of milk and its derivatives (g) Daily fiber intake (g)
PD
Controls
(n ¼ 55, 37 men, 18 women)
(n ¼ 12, 6 men, 6 women)
65.8 10.5 63.1 12.6 1.66 0.09 22.3 4.9 1200 459 17.5 3.5 21.9 4.7 60 8 1326 193 NS 100 1141 469 2.7 0.4 27 (49%) 12 (21.8%) 455 426 z20
61.1 73.1 1.68 25.9 1200 16.9 22.5 60.5
Significance*
7.8 15.3 0.08 5.3 232 2.0 1.5 2.6
NS 0.03 NS 0.02 NS NS NS NS
NS 100 1377 559 2.6 0.5 2 (16.6%) 0 (0%) 644 581 z20
NS NS NS NS <0.01 <0.01 NS NS
BMI, body mass index; PD, Parkinson’s disease; SDQ, Swallowing Disturbance Questionnaire Values are presented as mean SD. * P < 0.05. y Only in six patients (five men and one woman) with PD with the following features: mean age 65.6 7.6 y, mean body weight 59.1 11.6 kg, and mean BMI 23 1.9 kg/m2.
The weekly consumption of milk and its derivatives is very low in Ghana (about 500–600 g/wk per person in patients with PD and controls). Cheeses and yogurt are not part of their usual diet; they drink milk only occasionally and add powdered milk to coffee and tea. As far as milk derivatives are concerned, Ghanaians sometimes eat a prepacked ice cream and yogurt (mostly in cities). Discussion The daily calorie intake of patients with PD in Ghana is much lower (1000–1200 kcal/d) than the daily calorie intake recommended for subjects of the same age in Italy (about 1800–1900 kcal/d) [17]. However, the anthropometric data did not indicate that they were underweight. There are several possible explanations for this phenomenon: 1) their daily calorie expenditure is very low owing to their low mobility from PD (their modest daily calorie expenditure was documented by the measurements made with armband); 2) the high environmental temperature does not required a high energy expenditure for thermogenesis; and 3) a routine modest calorie intake since childhood may induce the body to adapt, slowing down its basal metabolism. The mean daily energy expenditure was measured with an armband in six subjects (five men and one woman) with the following features: mean age 65.6 7.6 y, mean body weight 59.1 11.6 kg, and mean body mass index 23 1.9 kg/m2. The mean daily calorie intake estimated with the questionnaire was about 1200 kcal; the mean daily energy expenditure estimated with the armband was 1326 kcal. As expected, the anthropometric data for patients with PD in Ghana indicated that the patients’ body weight and body mass index were significantly lower than those of healthy controls at equal levels of daily calorie intake. In the literature, there is evidence of a considerable loss of body weight in patients with PD in the advanced phases of the disease [2]. The prevalence of constipation and dysphagia was significantly higher than in the controls but lower than the prevalence of these complications described in the literature (60% and 30– 80%, respectively) [3,15]. We speculate that these findings may
be due to the dietary habits of Ghanaians. Regarding constipation, they consume a large amount of fruits and vegetables every day (about 15–20 g of fiber a day per person), thus guaranteeing a regular intake of suitably large amounts of water (1 L/d). Regarding dysphagia, Ghanaians eat thick, creamy, semisolid food, such as thick soups, cereal puree, and pounded flour. Consuming food of this consistency is useful for the management of dysphagia [18]. Regarding the consumption of milk and derivatives, it is much lower (less than half) than, for instance, the mean consumption in Italy (about 1400 g/wk) [19]. Their main source of calcium appears to be water (mean consumption 1100–1200 mL/d by the patients and controls). This is of interest, because recent studies, albeit with inconsistent results, have identified milk consumption among the possible environmental risk factors for PD [5,6]. The daily intake of proteins in Ghanaian patients with PD is about 0.8 g/kg of body weight. This intake positively influences the response of patients with PD to treatment: large quantities of proteins compete with levodopa for absorption and therefore may decrease the absorption of levodopa and, hence, its efficacy. The daily intake of 0.8 g of protein per kilogram of body weight is recommended for patients with PD in levodopa therapy [1]. Conclusions Observation of the dietary habits of Ghanaians has yielded interesting information that could be useful for the clinical management of PD and for assessment of response to levodopa therapy. We therefore believe it would be useful to extend the assessment to a larger population in Ghana and in other developing countries in Africa.
Acknowledgments The authors express their gratitude to Dr. Jennifer Hartwig for writing assistance and to the Fondazione Grigioni per il Parkinson for financial support.
M. Barichella et al. / Nutrition 29 (2013) 470–473
References [1] Cereda E, Barichella M, Pedrolli C, Pezzoli G. Low protein and protein redistribution diets for Parkinson’s disease patients with motor fluctuations: a systematic review. Mov Disord 2010;25:2021–4. [2] Bachmann CG, Trenkwalder C. Body weight in patients with Parkinson’s disease. Mov Disord 2006;21:1824–30. [3] Kaye J, Kimber A, Storey L, Trend P. Excess burden of constipation in Parkinson’s disease: a pilot study. Mov Disord 2006;21:1270–2. [4] Miller N, Allcock L, Hildreth AJ, Jones D, Noble E, Burn DJ. Swallowing problems in Parkinson disease: frequency and clinical correlates. J Neurol Neurosurg Psychiatry 2009;80:1047–9. [5] Miyake Y, Tanaka K, Fukushima W, Tsuboi Y, Yamada T, Oeda T, et al. Lack of association of dairy food, calcium, and vitamin D intake with the risk of Parkinson’s disease: a case–control study in Japan. Parkinsonism Relat Disord 2011;17:112–6. [6] Knekt P, Kilkkinen A, Rissanen H, Marniemi J, Sääksjärvi K, Heliövaara M. Serum vitamin D and the risk of Parkinson disease. Arch Neurol 2010;67:808–11. [7] Smith SR. A look at the low-carbohydrate diet. N Engl J Med 2009;361:2286–8. [8] McInerney-Leo A, Gwinn-Hardy K, Nussbaum RL. Prevalence of Parkinson’s disease in populations of African ancestry: a review. J Natl Med Assoc 2004;96:974–9. [9] Okubadejo NU, Bower JH, Rocca WA, Maraganore DM. Parkinson’s disease in Africa: a systematic review of epidemiologic and genetic studies. Mov Disord 2006;21:2150–6.
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[10] Dotchin C, Msuya O, Kissima J, Massawe J, Mhina A, Moshy A, et al. The prevalence of Parkinson’s disease in rural Tanzania. Mov Disord 2008;23: 1567–72. [11] Schoenberg BS, Osuntokun BO, Adeuja AOG, Bademosi O, Nottidge V, Anderson DW, et al. Comparison of the prevalence of Parkinson’s disease in black populations in the rural United States and in rural Nigeria: door-todoor community studies. Neurology 1988;38:645–6. [12] Hughes AJ, Ben-Shlomo Y, Daniel SE, Lees AJ. What features improves the accuracy of clinical diagnosis in Parkinson’s disease: a clinicopathologic study. Neurology 2001;57:S34–8. [13] Available at: http://en.wikipedia.org/wiki/Ghanaian_cuisine. [14] Nti CA. Household dietary practices and family nutritional status in rural Ghana. Nutr Res Pract 2008;2:35–40. [15] Manor Y, Giladi N, Cohen A, Fliss DM, Cohen JT. Validation of a Swallowing Disturbance Questionnaire for detecting dysphagia in patients with Parkinson disease. Mov Disord 2007;22:1917–21. [16] Cereda E, Pezzoli G, Barichella M. Role of electronic armband in motor function monitoring in patients with Parkinson’s disease. Nutrition 2010;26:240–2. [17] Available at: http://www.sinu.it/larn/tab_rias.asp. [18] Barichella M, Cereda E, Pezzoli G. Major nutritional issues in the management of Parkinson’s disease. Mov Disord 2010;24:1881–92. [19] Leclercq C, Arcella D, Piccinelli R, Sette S, Le Donne C, Turrini A. The Italian National Food Consumption Survey INRAN-SCAI 2005-06: main results in terms of food consumption. Public Health Nutr 2009;12: 2504–32.
Contents lists available at ScienceDirect
Nutrition journal homepage: www.nutritionjrnl.com
Brief report
Nutritional status and dietary habits in Parkinson’s disease patients in Ghana Michela Barichella M.D. a, Albert Akpalu M.D. b, Momodou Cham M.D. c, Giulia Privitera a, Erica Cassani M.D. a, *, Emanuele Cereda M.D., Ph.D. a, d, Laura Iorio M.D. a, Roberto Cilia M.D. a, Alba Bonetti a, Gianni Pezzoli M.D. a a
Parkinson Institute, Istituti Clinici di Perfezionamento, Milan, Italy Korle Bu Teaching Hospital, Accra, Ghana c Comboni Hospital, Sogakofe, Ghana d Nutrition and Dietetics Service, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 4 June 2012 Accepted 3 September 2012
Objective: Dietary treatment is important for the management of Parkinson’s disease (PD). Our objective was to describe the dietary habits and assess the nutritional status of Ghanaian patients with PD. This study is part of a larger project, for which Ghana has been selected as a pilot country. Methods: Fifty-five Ghanaian patients with PD and 12 healthy Ghanaian controls were recruited. We assessed nutritional status, investigated dietary habits, and assessed the prevalence of the nutritional complications of PD (e.g., constipation and dysphagia). Results: The mean daily caloric intake was about 1200 kcal/d in patients with PD and in controls. The typical diet was based on semisolid foods, usually vegetable soups accompanied by cereal flour or root starch or sometimes chicken or fish. The intake of milk and its derivatives was low. The prevalences of constipation and dysphagia in patients with PD were 49% and 21%, respectively. Conclusion: This study has yielded information that could be useful for the study of the management of PD and for the assessment of response to therapy. Ó 2013 Elsevier Inc. All rights reserved.
Keywords: Parkinson’s disease Nutritional status Diet Constipation Dysphagia
Introduction Dietary factors should be taken into consideration for the management of Parkinson’s disease (PD). First of all, diet may influence the response of patients with PD to treatment: large quantities of proteins, especially animal proteins, compete with levodopa for absorption from the gut and therefore may decrease the absorption of levodopa and, hence, its efficacy [1]. Second, an appropriate diet prevents malnutrition in terms of deficiency, which occurs mainly in the advanced stages of PD [2]. Third, the diet has a role in the treatment and prevention of non-motor complications of PD, such as constipation [3] and dysphagia [4]. Recently, several nutrients and foods, such as milk [5] and vitamin D [6], have been suggested to be included among the environmental risk factors for PD, although with inconsistent results. A recent article by Smith [7], showing how a high-protein
diet promotes atherogenesis in rats, supports the hypothesis that the diet can promote the onset of neurodegenerative diseases. Furthermore, epidemiologic studies investigating the epidemiology of PD in sub-Sahara countries have suggested a lower prevalence than in developed countries [8–10]. The finding of a five-fold higher prevalence of PD in African-American than in Western African populations [11] has suggested that environmental factors might be responsible for this difference [8]. In developing countries, the local diet is different from the Mediterranean diet. This environmental factor may be important in the understanding and management of PD motor and nonmotor symptoms. Considering all these preliminary remarks, we decided to assess the nutritional status and dietary habits of Ghanaian patients with PD. Ghana was identified as a suitable country for the performance of a pilot study. Materials and methods
This work was supported by the Fondazione Grigioni per il Parkinson. * Corresponding author. Tel./fax: þ39-02-5799-3322. E-mail address: [email protected] (E. Cassani). 0899-9007/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nut.2012.09.017
At the Parkinson Institute, Istituti Clinici di Perfezionamento (Milan, Italy), we have set up a research project on PD in developing countries. The project started in Ghana and will be extended to others countries in Africa. A multidisciplinary team, including two neurologists, one nurse, and one nutritionist, went
M. Barichella et al. / Nutrition 29 (2013) 470–473 Table 1 Food-frequency questionnaire 1. a b c d e 2. a b c d e 3. a b c d e 4. a b c d e 5. a b c d e 6. a b c d e 7. a b c d e 8. a b c d e 9. a b c d e 10. a b c d e 11. a b c d e
471
Table 1 (continued)
How many times a day do you eat? 1 2 3 When I have time and food is available I don’t know How many times a week do you eat fufu? >5 2 or 3 1 0 I don’t know ? How many times a week do you eat banku >5 2 or 3 1 0 I don’t know How many times a week do you ear omo tuo or kelewele? >5 2 or 3 1 0 I don’t know How many times a week do you eat red red? >5 2 or 3 1 0 I don’t know How many times a week do you eat vegetables (onions, tomatoes, okro, or eggplant)? >5 2 or 3 1 0 I don’t know How many times a week do you eat fruit? >5 2 or 3 1 0 I don’t know How many times a week do you drink milk? >5 2 or 3 1 0 I don’t know How many bowls of water do you drink a day? 1 3 5 >8 I don’t know How many times a week do you drink beer? >5 2 or 3 1 0 I don’t know How many times a week do you drink palm wine? >5 2 or 3 1 0 I don’t know (continued)
there several times in 2011 (four visits, each lasting about 1 wk). During the stay in Ghana, at Accra and Sogakofe, the team examined many patients referred by local physicians because of suspected PD. All the subjects underwent a complete neurologic examination and the diagnosis of PD was confirmed in 55 patients
12. a b c d e 13. a b c
How many times a week do you drink apa teshi or bumkutuku? >5 2 or 3 1 0 I don’t know Do you favor food with spices (cumin, cinnamon, chili pepper, ginger)? Yes No I don’t know
according to UK Brain Bank criteria [12]. The duration of disease was 6.3 4.7 y (mean standard deviation). These patients were given levodopa and underwent an in-depth assessment of nutritional status. A control group of 12 African patients, matched by age and sex, was also identified. Patients with PD and the controls were assessed by the nutritionist. Anthropometric data (body weight in kilograms, height in meters, and body mass index as the ratio of body weight to height squared) were collected. A food-frequency questionnaire (Table 1) was administered to assess the qualitative intake of nutrients and the quantitative intake of food expressed in kilocalories. The questionnaire was drafted by the nutritionist, after having established the composition of the main typical dishes by consulting the Wikipedia Web site [13] and collecting information from the local population. A food history was also collected by 2–4 h recall. The 2–4h recall is designed to assess the quantitative intake of nutrients and kilocalories. It has been used by other investigators in nutritional studies performed in Ghana [14]. The Swallowing Disturbance Questionnaire [15], validated for PD, was used to assess the presence of dysphagia. The scale has 14 items, each with a score ranging from 0 to 3, except one question with a score ranging from 0.5 to 2.5. The total score ranges from 0.5 to 44.5. The scientific evidence has suggested it can be used for the diagnosis of dysphagia needing treatment (cutoff score 11). The Rome III criteria (Constipation module) were used to assess the presence of chronic constipation, and these criteria have been used in PD [3]. According to these criteria, patients are considered to have functional constipation if they score at least 2 points on the questionnaire. The daily energy expenditure was measured in six subjects using an armband [16], which monitored energy expenditure during usual daily activities for 24 h. Patients were asked to pursue their usual daily activities while they wore the armband for 24 h. A food history was also collected by 24-h recall. All questionnaires were administered in English with the collaboration of an interpreter. Informed consent was obtained from all the patients. The ethics committee approved this study. The data were collected anonymously and entered into a database protected by a password. The statistical analysis of data was carried out using JMP 3.2.6 (SAS Institute, Cary, NC, USA). P < 0.05 was the limit for statistical significance. Means were compared using the Mann–Whitney test for non-parametric data.
Results We examined a group of 55 patients (37 men and 18 women) with PD living in Accra (greater Accra region) or Sogakofe (Volta region). We compared the group of patients with PD with a group of 12 healthy volunteers (six men and six women); all subjects lived in Accra. The anthropometric and nutritional characteristics of the two groups are presented in Table 2. The search on local dietary habits disclosed that the typical diet of Ghanaians is based on one-dish meals, usually vegetable soups accompanied by dumplings containing a large proportion of cereal flour (rice, maize, millet) or root starch (cassava, cocoyam, yam) or sometimes also fried, grilled, or stewed chicken or fish. Large amounts of spices and palm oil are added. Also, bananas and plantains are common ingredients. The most popular local dishes are fufu (pounded cassava, rice, (pounded maize or rice with bananas, plantain, or cocoyam), banku served with stewed meat or fish soup), omo tuo (rice balls with a spicy sauce), red red (bean soup with plantain puree), and kelewele (dessert made of fried plantains flavored with ginger).
472
M. Barichella et al. / Nutrition 29 (2013) 470–473
Table 2 Anthropometric and nutritional characteristics of patients with PD and controls
Age (y) Weight (kg) Height (m) BMI (kg/m2) Daily energy intake (kcal) Calories derived from protein versus entire daily energy intake (%) Calories derived from fat versus whole daily energy intake (%) Calories derived from carbohydrates versus entire daily energy intake (%) Daily energy expenditure measured with armband (kcal)y Daily alcohol consumption (g) Daily spice consumption (percentage of subjects who use them) Daily water intake (mL) Number of meals a day Number of subjects reporting constipation (Rome III criteria score 2) Subjects with dysphagia for solids (SDQ score >11) Weekly consumption of milk and its derivatives (g) Daily fiber intake (g)
PD
Controls
(n ¼ 55, 37 men, 18 women)
(n ¼ 12, 6 men, 6 women)
65.8 10.5 63.1 12.6 1.66 0.09 22.3 4.9 1200 459 17.5 3.5 21.9 4.7 60 8 1326 193 NS 100 1141 469 2.7 0.4 27 (49%) 12 (21.8%) 455 426 z20
61.1 73.1 1.68 25.9 1200 16.9 22.5 60.5
Significance*
7.8 15.3 0.08 5.3 232 2.0 1.5 2.6
NS 0.03 NS 0.02 NS NS NS NS
NS 100 1377 559 2.6 0.5 2 (16.6%) 0 (0%) 644 581 z20
NS NS NS NS <0.01 <0.01 NS NS
BMI, body mass index; PD, Parkinson’s disease; SDQ, Swallowing Disturbance Questionnaire Values are presented as mean SD. * P < 0.05. y Only in six patients (five men and one woman) with PD with the following features: mean age 65.6 7.6 y, mean body weight 59.1 11.6 kg, and mean BMI 23 1.9 kg/m2.
The weekly consumption of milk and its derivatives is very low in Ghana (about 500–600 g/wk per person in patients with PD and controls). Cheeses and yogurt are not part of their usual diet; they drink milk only occasionally and add powdered milk to coffee and tea. As far as milk derivatives are concerned, Ghanaians sometimes eat a prepacked ice cream and yogurt (mostly in cities). Discussion The daily calorie intake of patients with PD in Ghana is much lower (1000–1200 kcal/d) than the daily calorie intake recommended for subjects of the same age in Italy (about 1800–1900 kcal/d) [17]. However, the anthropometric data did not indicate that they were underweight. There are several possible explanations for this phenomenon: 1) their daily calorie expenditure is very low owing to their low mobility from PD (their modest daily calorie expenditure was documented by the measurements made with armband); 2) the high environmental temperature does not required a high energy expenditure for thermogenesis; and 3) a routine modest calorie intake since childhood may induce the body to adapt, slowing down its basal metabolism. The mean daily energy expenditure was measured with an armband in six subjects (five men and one woman) with the following features: mean age 65.6 7.6 y, mean body weight 59.1 11.6 kg, and mean body mass index 23 1.9 kg/m2. The mean daily calorie intake estimated with the questionnaire was about 1200 kcal; the mean daily energy expenditure estimated with the armband was 1326 kcal. As expected, the anthropometric data for patients with PD in Ghana indicated that the patients’ body weight and body mass index were significantly lower than those of healthy controls at equal levels of daily calorie intake. In the literature, there is evidence of a considerable loss of body weight in patients with PD in the advanced phases of the disease [2]. The prevalence of constipation and dysphagia was significantly higher than in the controls but lower than the prevalence of these complications described in the literature (60% and 30– 80%, respectively) [3,15]. We speculate that these findings may
be due to the dietary habits of Ghanaians. Regarding constipation, they consume a large amount of fruits and vegetables every day (about 15–20 g of fiber a day per person), thus guaranteeing a regular intake of suitably large amounts of water (1 L/d). Regarding dysphagia, Ghanaians eat thick, creamy, semisolid food, such as thick soups, cereal puree, and pounded flour. Consuming food of this consistency is useful for the management of dysphagia [18]. Regarding the consumption of milk and derivatives, it is much lower (less than half) than, for instance, the mean consumption in Italy (about 1400 g/wk) [19]. Their main source of calcium appears to be water (mean consumption 1100–1200 mL/d by the patients and controls). This is of interest, because recent studies, albeit with inconsistent results, have identified milk consumption among the possible environmental risk factors for PD [5,6]. The daily intake of proteins in Ghanaian patients with PD is about 0.8 g/kg of body weight. This intake positively influences the response of patients with PD to treatment: large quantities of proteins compete with levodopa for absorption and therefore may decrease the absorption of levodopa and, hence, its efficacy. The daily intake of 0.8 g of protein per kilogram of body weight is recommended for patients with PD in levodopa therapy [1]. Conclusions Observation of the dietary habits of Ghanaians has yielded interesting information that could be useful for the clinical management of PD and for assessment of response to levodopa therapy. We therefore believe it would be useful to extend the assessment to a larger population in Ghana and in other developing countries in Africa.
Acknowledgments The authors express their gratitude to Dr. Jennifer Hartwig for writing assistance and to the Fondazione Grigioni per il Parkinson for financial support.
M. Barichella et al. / Nutrition 29 (2013) 470–473
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