EP 29 - The Parkinson Weekly Helpdesk

🎙️ We’re back with the twenty-ninth episode of Parkinson Weekly, hosted by Prof. Bas Bloem — and the second instalment of the Parkinson Weekly Helpdesk.

In this episode, Prof. Bloem answers three new listener questions covering some of the most talked-about topics in Parkinson’s care.

He explores the role of diet and the gut, offering practical advice on nutrition, constipation, and how these may impact medication effectiveness. The episode also dives into Mucuna pruriens — what it is, how it compares to standard levodopa therapy, and when it may (or may not) be appropriate.

Finally, Prof. Bloem discusses cognitive training, addressing whether brain exercises can help manage symptoms or slow cognitive decline.

As always, the Helpdesk combines evidence with real-world clinical insight — helping to cut through conflicting advice and focus on what truly matters for patients.

Have a question you’d like Bas to answer in a future episode? Email us at parkinsonweekly@gmail.com – we’d love to hear from you.

Transcript

SPEAKER_01 0:01

This is episode 29, the second Parkinson Weekly help desk. So here we are, episode 29 of Parkinson Weekly, and it's the second help desk episode. I hope you've enjoyed last week's discussion on three very good questions, and many more questions have been coming in. I've selected three new ones for this week's episode, and one of them is on the role of nutrition and the role of the gut. And what is your practical advice? This one person is asking on diet for people with Parkinson's, particularly considering the role of the gut. This person has young onset Parkinson's and wants to optimize symptoms through exercise and nutrition, but there is a lot of conflicting advice. And what should patients realistically focus on? I think again, a brilliant question and a difficult one, because I think out of all the lifestyle interventions, nutrition is the one I receive most questions about. And it's also the one where the evidence is still largely lacking. So what I'm going to talk about today is partially evidence-based practice, but also partially practice-based evidence, meaning it's based on my experience. And I will try to separate evidence from opinion to the best of my abilities. So the one thing every person with Parkinson's disease should do is ascertain regular bowel movements. We think Parkinson's may start in the gut for many folks. We call this body first Parkinson's. But even for folks where the disease does not start in the gut, ultimately the gut becomes affected. And I think constipation, slow bowel movements, are the rule rather than the exception. And why is constipation so important? Well, first of all, it's bothersome. People can have bloating feelings, frequent winds, they don't enjoy their meals anymore, they have difficulty getting rid of their stools, it can be painful, can cause hemorrhoids, all sorts of reasons why it's bothersome. And in addition, and this is research ongoing in various centers across the globe, including my own, we now know that chronic constipation may lead to secondary changes in the constitution of the gut's microbiota. We call this small intestinal bacterial overgrowth. And these wrong bacteria start to convert levadopa into dopamine already in the lumen of the gut, which means that you will lose a lot of the oral medication via the stool without it ever reaching the brain. And what is really fascinating is that there is a certain proportion of people with Parkinson's, we don't know the exact proportion, but it's five to maybe even ten percent, who really have Parkinson's confirmed after death by examining the brain under the microscope, who never respond in a satisfactory way to oral levadopa, even though this is the cornerstone of our treatment. And we feel that this is at least in part explained by the gut interfering with the absorption of levadopa, and that for some of those folks, the gut is simply a barrier that interferes with the efficacy of levadopa. Other people may experience delayed ons where the medication kicks in only after a long time. Dose failures, where it appears that some of your doses aren't working properly, and this is all gut, gut, gut to my time, to my mind. So back to this person's question: what is practical advice? Well, first of all, do anything you can to treat constipation, which means a diet high in fibers. It means two liters, half a gallon of water or other fluids per day. A practical trip is to have two empty bottles filled with water, labeled one and two, put them somewhere visible in your living room, and they have to be empty by the end of the day. Exercise, moving about a lot is helpful in reducing constipation. If needed, laxatives, if really needed, an enema, a powerful enema, to get rid of the and it's not nice what I'm saying, but this is true, the fecal plug that is obstructing the passage of properly formed stools in your gut. So from a dietary perspective, high fiber diet and lots and lots of fluids. The Mediterranean diet is associated with a lower risk of developing Parkinson's. There are two studies that carefully suggest it may be beneficial in people who already have the diagnosis, but that evidence is weaker. All of it is associations and not necessarily causality, but I think the Mediterranean diet is something definitely to consider. Eat like the Greeks, but not the souflaki and the other meats. It's mainly the vegetarian version that we feel is important. So olive oil, nuts, vegetables, fruits are important, maybe some fish. Red meat is probably not a good idea. There is some evidence from a recent Italian study to suggest that red meats and processed meats are not a good idea. So the Mediterranean diet, particularly the plants, avoiding meat is probably a good idea. There's a hefty debate on vegetables and fruits because they may contain residues of pesticides. People who have followed me closely know that I'm concerned about the role that pesticides in our environment can play in causing Parkinson's and perhaps also in hastening disease progression after your diagnosis. At the same time, fruit and vegetables are very good for everyone's health. This is just a generic advice at the population level. There's even a recent Italian study to suggest that intake of fruit and vegetables reduces the risk of Parkinson's. There are the benefits of the Mediterranean diet, which is also rich in vegetables and fruit. So weighing all the evidence. A key recommendation is to eat ample fruit and ample vegetables and not to be concerned about the theoretical risk of the residues of pesticides. Do I think the world is a better place without those residues? I absolutely do, but I think it is at this point no reason to refrain from fruit and vegetables. In fact, I recommend ample intake of both. So that is important. There is interesting work to suggest that an excessive amount of dairy products, so milk, yogurt, cheese, is associated with a higher risk of developing Parkinson's. This is an association, it's not necessarily pointing to causality. We don't fully understand the link between dairy products and the higher risk of Parkinson's. For people who already have the disease, I always say you need dairy products because of the calcium which you need for bone health. Anything that's excessive should be avoided in general in life. So excessive dairy intake is probably best avoided. Also, because the proteins in dairy products can interfere with the efficacy of oral levadopa. So when you are on oral levadopa, take it on an empty stomach as much as possible. Try to steer away from your meals in particularly proteinaceous meals, but enjoy your milk, enjoy your yogurt, enjoy your cheese if you use it moderately, and use it because you need calcium for your bones, and this is particularly important for women of a certain age when osteoporosis starts to kick in. So that's about the milk products. And then finally, there is some evidence to suggest that coffee is associated with a lower risk of Parkinson's. Again, this is an association, and it's not necessarily pointing to causality. I think there's no urgent need to take coffee. If you enjoy it, please do. It probably helps with bowel movements as well. Dark tea, black tea, is apparently also associated with a slightly lower risk. Again, no pressing need to take coffee if you don't like it. If you do like coffee, enjoy it and take a few cups of coffee per day. So those are the things that we recommend at the moment in daily practice. And I hope this answers the question of the first listener for today. So, the second question, and I promised last week that I would get back to this, is mucuna pruriens. And Mukuna pruriens is interesting because mucuna is used as a supplement. Mukuna pruriens plant is an Ayurvedic plant that contains beans that contain levodopa. And interestingly, the levodopa in the Mukuna pruriens beans is the exact same levadopa that you will get from your Cinamet or Matopar or regular Levadopa. It is the exact same thing. But when you take Cinemat, when you take Matopar, it comes with an auxiliary second drug. You may not know this, but look at the pillbox, it comes with a second auxiliary drug because you want levatopa to be converted to dopamine only in the brain and not in the bloodstream in your body. Because dopamine itself has difficulty entering the brain, but levadopa can enter the brain. So if you take levadopa with this auxiliary drug called either carbidopa or bencericide, then that helper drug blocks the conversion of levadopa into dopamine in the systemic circulation. But interestingly, levadopa can enter the brain like a Trojan horse, but the auxiliary drug cannot. So Levadopa is now left on its own in the brain. There it's converted to dopamine, which is exactly what you want, and that's when it works. And the Mercuna pruriens bean only contains Levadopa and not the helper drug. So, in a way, it's not an irrational treatment because it is the exact same Levodopa, but it does not contain the help drug, which is why it is probably less effective than the regular pharmaceutical levadopa that we prescribe from pills. We published a case report on a patient who was only taking mucuna and nothing else, and who was quite severely debilitated. I added a fraction of carbidopa to her medication regime and she improved in a spectacular way, confirming my suspicion that some of the levadopa contained by the mucuna prurien's bean is converted into dopamine already in the bloodstream. Having said that, the Journal of Parkinson's disease published a beautiful paper by Roberto Silia and his group, where they provided people in Africa where levadopa, the pharmaceutical levodopa, is not available for many folks, which I think is criminal by the way. And they decided to grow the Mukuna Purians plant in Africa and cooked or baked, I'm I think it's baked or fried the beans and fed people with Parkinson's in Africa who had no access to cinnamon or metopar, the levadopa contained within the Mukuna plant, and these people improved, sometimes even spectacularly. So clearly, Mukuna is better than nothing. I think it is suboptimal because it doesn't contain the helper drug, but it's definitely better than nothing. So if you listen to this podcast and you live in a part of the world where you have no access to Cinemat or Matopar, then Mukuna is better than nothing. And I would certainly consider this. If you live in a part of the world where you do have access to regular Cinemat or Matopar, that is my preferred option. And why? Because the powder that is containing the Mukuna Purians lividopa is under less strict medication control than the regular pharmaceutical pill. So you don't know exactly how many milligrams you're taking. That's one concern. So quality overall is less it doesn't contain the helper drug. But interestingly, if you are already under ormatopar, so you already have your helper drug, which is built in your regular drug, that same auxiliary drug can help the mucuna derived from the mucuna, the levitopa from the mucuna. So I do have patients in my practice who take regular Cinemat or regular carbido, a regular matopar, and they combine it with the mucuna. And that is a more rational treatment, still with the caveat that the numbers of milligrams contained by the mucuna powder are less adequately controlled. So that is something to consider. The specific question by this person was: is it harmful to delay starting levadopa? And I think the answer is yes. Being on mucuna only, if you have an alternative in the form of regular drugs, is not something I would recommend. See the case report that we published on the lady on Mukuna monotherapy. Levadopa is an effective treatment that will allow you to regain mobility, improve quality of life, that will allow you in turn to exercise more, be more optimistic, be more positive, etc. And I think people who postpone treatments just for the sake of postponing are doing something wrong. We should treat Parkinson's as aggressively as we can when Parkinson's is a treatable condition, which is in an early disease phase. So don't withhold Levadopa just for the sake of withholding it. If you are very keen on trying Mukuna, I would recommend combining it with Cinemat or Matopar. It is possible, theoretically, and I've done it in a number of people, to get single carbidopa from your pharmacist. They need to specifically manufacture this. But in a way, that's counterintuitive because you take this natural occurring compound, which has this romantic idea of you know Ayurvedic plant, but then you still need to combine it with a chemical drug. So combine it with Matopar or Cinemat. I would avoid in general mucuna monotherapy. It's a possibility to combine it. And if you have no access to any treatment whatsoever, mucuna definitely is better than nothing, thanks to the beautiful trial published by Roberto Silia in Journal of Parkinson's Disease. And finally, the third question is, and just showing how lovely the questions are and the spectrum of the questions that we're receiving here at Parkinson Weekly is about cognitive training in Parkinson's disease. Can activities like cognitive puzzles or brain training games help delay cognitive decline in Parkinson's? I thought this was a lovely and interesting question because there's a lot of research on physical exercise, which we now know is a symptomatic treatment. And we think physical exercise, the aerobic workout, panting, cranking up your heart rate, is probably the closest to delivering the promise of ever becoming a disease-modifying treatment. We know from a number of studies, for example, Elke Kalbe, a wonderful neuroscientist from Germany, has done beautiful work on cognitive training, and we've also participated in trials with colleagues from France, in showing that cognitive exercises help with symptomatic relief of cognitive impairment. To date, even for physical exercise, let alone for other interventions, there is no definitive proof that any treatment can slow down progression of Parkinson's. So even though I personally feel intuitively that perhaps regular cognitive training could slow down cognitive decline, the use it or lose it concept, the honest answer is that is not based on scientific evidence. There's a good rationale, but it's never been proven. I do feel that challenging your brain with cognitive exercises is helpful. I would definitely recommend it in my clinical practice. I would recommend it because it probably gives you symptomatic relief, it gives you self-control, it's a self-management strategy, it may alleviate stress, it may give you greater confidence. I don't think there's any real evidence to suggest it slows down cognitive decline, although it could, but that needs to be tested in proper studies, and those are horribly difficult to design. Does it matter what type of cognitive training? I don't think that's ever been tested. I would recommend to do something you like, that you enjoy, that you adhere to. I know from the field of cognitive decline and Alzheimer's disease that bridge the cards game was a good way of preventing Alzheimer's, although confounding by indication was probably playing a role there. It's an example of one type of cognitive exercise that you can consider. I don't think there's any particular cognitive training that is definitely better than any other one. Maybe mix it, try different types of cognitive challenges, build in the social component, do your cognitive training, your card games with friends, with family, your spouse. We know that social interactions is another dimension of a healthy lifestyle that is still largely neglected. So use it or lose it, challenge your brain, do it in different ways, do it for symptomatic relief. You can cautiously hope it may slow down cognitive decline, but again, not based on scientific evidence, and it needs to be taken to the test. So that was question number three for today's episode 29. I promise, if the questions keep coming in at this speed, that we will do this much more often. I must say that it gives me great pleasure to share these answers because I know that not only the person who answered or who raised the question receives the answer, but I hope it's beneficial to all of you. Feel free to send us feedback about this new concept through the Parkinsonweekly at gmail.com email account. We look forward to receiving your feedback. If there's anything I can do to improve my services to you as a Parkinson community, then please let me know. I'm happy to hear. I'm happy to help out. I'm here to help out. I enjoy doing it. So I hope you enjoyed this episode 29 of Parkinson Weekly, and we will definitely speak to each other again at the latest next week.

SPEAKER_00 21:21

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