Diet & nutrition

You may find that Tremor affects your weight considerably but you should try to maintain a healthy weight as being over or underweight can affect your health in many ways.

Tremor may cause you to gain weight as you become less mobile and extra weight can strain the joints and make movement even more difficult. If this happens you may be advised to watch your diet and control the calories you consume, for example by avoiding fried foods, sweet desserts, cakes and biscuits and sugary drinks.

More commonly though people with Tremor find that they lose weight and have to try hard to maintain a high intake of calories so as to avoid excessive weight loss. Weight loss may be due to a loss of appetite or because eating or swallowing becomes more difficult, or it may be that your body simply doesn’t absorb nutrients efficiently, or you may be using extra energy in coping with your Tremor symptoms. It also seems that various medications may also have different influences on body weight. Whatever the cause you will need to consume more calories in whichever way suits you:

• you may find that it is better to reduce the size of meals but have perhaps four or five appetising meals a day with a snack between each meal
• to increase calories try incorporating a little more butter, cream, peanut butter, milkshakes, biscuits, chocolate and dessert for example, but make sure you take good care of your teeth if eating a lot of sugary food! Three or four tablespoons of milk powder can also be added to half a litre or a pint of full cream milk to make it more nutritious
• try drinking nutritious drinks specially formulated to easily increase calorie intake in between meals. These should be available at your supermarket, pharmacy or from your doctor.
• however you vary your diet to increase calories, make sure that you still consume a balance of the various food groups (see below).

Food supplements (not to be confused with vitamin and mineral supplements) are available either from pharmacies or on prescription and may be helpful for those who are unable to eat enough and become considerably underweight, perhaps because of nausea, loss of appetite or difficulty in eating. If you do lose a lot of weight and find it hard to consume the additional calories your body requires it may be helpful to discuss the possibility of food supplements with your doctor or dietician.

If you think that your weight is fluctuating, it is a good idea to weigh yourself regularly and keep a record of your weight over a period of time as this can be useful information for your doctor or a dietician if needed. 

Constipation is a common problem for those with Tremor and altering your diet may be a key factor in overcoming or reducing this symptom. Increasing your intake of fibre rich foods such as fruit and vegetables, pulses and lentils, wholewheat bread and cereals, can help but beware that too much fibre can cause constipation, so you do need to get the balance right. Increasing fluid intake can also help as fluid is absorbed by the bowel to soften stools and make them easier to pass, and exercise is beneficial as this helps to stimulate the bowels. Remember that a bowel movement is not necessary every day – emptying the bowel only three to four times as week is fine so don’t worry if you do not have a bowel movement every day.

If constipation is not relieved by altering your diet and increasing your exercise then it is best to speak with your doctor.

Getting the right balance

A balanced diet will contain a wide variety of foods from the various food groups below. Ideally you should choose an item from each food group for each meal throughout the day as you will then obtain all the nutrients required by the body to keep it healthy, although for some this may not be possible.

Current general dietary recommendations include:

• maintaining energy intake at 25-30 kilocalories per kilogram of body weight, with additional calories if dyskinesias are present
• a carbohydrate to protein proportion of at least 4-5:1
• a recommended daily protein allowance of 0.8g/kg of body weight.

Carbohydrate

These starchy and/or sugary foods provide the basic fuel or energy your body needs as they break down once digested and produce glucose. Typical carbohydrates are bread, potatoes, pasta, rice, cereals, biscuits and cakes

Proteins

These are the basic building blocks for your body and are needed for growth and repairing the body. Typical proteins are meat, dairy products, nuts, pulses, eggs and fish

Fruit and vegetables

These are a good source of fibre and are essential for healthy bowels and avoiding constipation. They also contain some carbohydrate and many vitamins and minerals

Fats and sugars

Although fats and sugars can be harmful if consumed in large quantities, they are essential for producing energy and ‘essential fatty acids’ are also needed for the efficient absorption of some key vitamins.

Fluids 

It is very important to drink plenty of fluids, preferably eight to 10 cups daily - water, juices, tea, coffee, milk etc. Alcohol may be included in moderation and can be beneficial if it helps you to keep up your social life - your doctor will advise you if you need to avoid alcohol. If you have problems with your bladder or bedwetting it may be advisable to drink mainly in the morning and early part of the day. You may also find that carbonated or fizzy drinks make you feel bloated so may be best avoided. If dry mouth is a problem then frequent sips of water or using an oral rinse or spray can help. Sucking a sweet or chewing gum can also stimulate the production of saliva and so help alleviate dry mouth.

Vitamins and minerals

There are a variety of vitamins and minerals contained in food and by eating a variety of foods from the various groups above you should be getting all the vitamins and minerals your body needs. If you are deficient in any particular vitamin or mineral it is generally better to increase your intake of foods containing the particular nutrient rather than a supplement but for some a supplement may be the only answer, particularly if your body does not absorb nutrients well. It is best to speak to your doctor or ask to be referred to a dietician if you have any concerns.

Osteoporosis, or brittle bones, is particularly important to avoid as those with Tremor are more likely to fall, so a good intake of calcium and vitamin D should be maintained to help prevent breaks or fractures in bones.

Vitamins A, D, E and K tend to be found in milk and dairy food and are fat-soluble, which means that they remain in the body for some weeks before being used or expelled.

Vitamins B (complex) and C are mostly found in citrus fruit and green, leafy vegetables and need to be consumed daily as they are water-soluble and therefore do not remain in the body for any period of time.

Minerals are present in many foods although often only in very small, or trace, quantities. Key minerals include calcium, chloride, chromium, fluoride, iodine, iron, magnesium, manganese, phosphorous, potassium, selenium, sodium, sulphur and zinc.

Antioxidants

Certain vitamins and minerals are known as antioxidants as they can help reduce the damage caused by oxidation, a normal process occurring in all cells in the body. Oxidation produces a substance which is known to cause cell damage and can lead to disease such as Parkinson’s, Alzheimer’s, cancer and heart disease for example. It is therefore good for general health to ensure that you eat foods containing antioxidant vitamins and minerals although there is no evidence at present to suggest that these will help with Tremor. Providing you are eating a balanced and healthy diet you are unlikely to need to take antioxidant supplements but if you have any concerns do ask your doctor or dietician.

Co-Enzyme Q10

Co-enzyme Q10 has strong antioxidant properties but it is not at present recommended as a treatment for Tremor. 

Most medications can be taken at any time and do not need to be specially timed in relation to mealtimes.

It is best to avoid taking antacid/indigestion tablets at the same time as Tremor medications as they can interfere with medicine absorption.  They can however generally be safely taken at a different time to your medications.

Depending on the country you live in your doctor may be able to refer you to any of the following specialists to give advice on diet or eating problems you may experience.

A dietician can provide advice on all aspects of nutrition and diet. They will advise on maintaining a healthy diet and adjusting it to suit your needs and symptoms, bearing in mind your specific needs in relation to your medications.

A speech and language therapist will be able to help you with problems in swallowing and ways to overcome such difficulties, as well as speech difficulties.  They can also help eliminate any other possible causes of swallowing problems before any dietary changes are made.

An occupational therapist will be able to look at ways to make food preparation easier, possibly by altering the set up in your kitchen or home.  Simple changes to your kitchen and dining area can make all the difference, for example:

• adding grab rails to help you move around safely
• moving the position of equipment needed to prepare meals so that things are grouped in one part of the kitchen, so reducing the amount you need to move around
• buying a blender, microwave or small chopper for example can ease preparation and reduce the amount of time spent manually preparing food.

An occupational therapist will also be able to advise on special equipment available to make food preparation and mealtimes easier and more comfortable.

There are various practical ways in which you can help yourself follow a healthy diet - all too often the effort involved in preparing food can mean you don’t have the energy or inclination to eat properly so the following tips may be helpful in avoiding or minimising this problem.

Shopping and preparing meals

Careful planning can make shopping and preparing meals far easier and an occupational therapist will be able to give you tips to help with this aspect of your routine. Here are some tips to help you:

• keep a good range of foods in your cupboard and freezer that have a long shelf life as these are always a good back up if you are unable to shop as planned
• plan meals in advance and write a list of the ingredients before going to the shops, or ask someone to buy ingredients for you
• think about how long you can stand preparing your meal and don’t decide on a menu that will take longer to prepare than you can cope with
• if taking the trouble to cook a meal that can be frozen for other days then remember to double or treble the quantity so that you have a few quick and easy meals another time
• make use of ready prepared meals as they can be simply reheated and can save on electricity or gas as well as your own energy. Remember that frozen and tinned vegetables and fruit can be just as nutritious as fresh
• if you do not own a microwave you may consider buying a small one as meals or snacks can very simply and quickly be thoroughly cooked or reheated this way
• look out for specially adapted supermarket trolleys for those who have limited mobility.
• if getting to the shops is difficult it may be better to order you shopping online

Special food aids

Special aids for eating are available. Ask your occupational therapist for information on what is available in your country and suitable for you. Below are some suggestions that may help although not all may be available where you live:

• try using cutlery that has specially adapted handles which are angled or weighted for ease of use, or ‘rocking’ knives that can be used one handed
• try using two handled cups or beakers, or a large mug filled only halfway to reduce spillage
• use an insulated cup to keep hot drinks warm
• use specially weighted cups that help prevent tremor
• use a straw and don’t overfill cups
• use an apron or bib and an easy wipe table cloth
• try placing elbows on the table to steady your hands and arm when eating
• try raising your plate on a book or box so that it is nearer to your mouth
• use a damp cloth or special non-slip mat under a plate can stop it moving as you eat
• try using a special plate which keeps food warm or microwave a meal when it becomes cold so that it remains appetising. Some plates have angled, high rims to prevent spillage and make it easier to get food onto cutlery
• look for special devices designed to grip jars and bottles for easy opening

Eating and swallowing

Being comfortable when eating is important in ensuring that you are able to eat and swallow food.

If a meal takes a long time and becomes cold and unappetising you may prefer to eat smaller portions and four or five smaller meals rather than 3 large meals each day. It is also a good idea to time meals so that medication is working properly – eating is very difficult during ‘off’ periods so try to avoid meals when ‘off’.

If you experience a lot of difficult swallowing or opening your mouth ask to see a speech and language therapist. They will be able give tips on the consistency and texture of food to make it easier to eat, and also on ways of eating. Some tips for easier swallowing are:

• try to relax the throat muscles by yawning before and during eating
• make sure that you are comfortable and sit up straight without leaning on the table
• try tucking your chin down to your chest to make swallowing easier
• soften hard foods with sauce, gravy, or dips
• avoid soups with bits in and go for thick creamy ones rather than thin, watery soups
• take smaller mouthfuls and regular sips of water
• avoid dry, brittle foods such as toast or crackers, or if you really like to eat these moisten them with plenty of spread or dip in something like soup
• eat wholemeal bread rather than white as it is less likely to get stuck around your mouth
• instead of bread try pasta, noodles or mashed potato as carbohydrate in a meal
• ensure that any dentures are a good fit and not uncomfortable when chewing.

A semi-solid diet will make swallowing much easier and in extreme difficulty a puree diet may be recommended but you should only follow such a diet on the advice of your doctor, dietician or speech and language therapist.

Below is a sample of a daily eating plan with regular meals which include a wide and balanced range of foods from the various food groups.  

These suggestions are for guidance only and there are of course other options and alternatives available. 

Breakfast
Fruit or fruit juice; cereal (wholewheat if constipation is a problem) with milk; bread or toast with butter or margarine and jam or other spread; bacon, sausage, egg, cheese, cold meats etc

Midday meal
Meat, fish, eggs, cheese, pulses, lentils or other protein; potato, rice, pasta, noodles, bread or other carbohydrate; vegetables or salad; yoghurt, milk pudding or fruit drink

Evening meal
As midday meal

Snacks between meals
Fruit, cakes, biscuits, sandwiches, cereals.

Drinks
You should drink with meals and between them too, for example tea, coffee, fruit juice, water, milk, soup. Beware of drinking too many carbonated drinks as they may make you feel bloated and unable to eat your snack or meal.

We would like to acknowledge the use of information taken from the European Parkinson’s Disease Association website www.rewritetomorrow.eu.com