The Survey of Malnutrition Prevalence in Patients With Parkinson Disease In Tehran, Iran

Background: Parkinson disease (PD) introduced as the second most prevalent neurodegenerative disease following Alzheimer disease. A patient’s nutritional status may be compromising in PD. This study aimed to describe the outpatient nutritional status in patients with PD at a third-level hospital in Iran. Methods: The validated Persian version of the Mini-Nutritional Assessment (MNA) questionnaire was used to evaluate the nutritional status of 158 Iranian PD patients (age, 35-85 years). The exclusion criteria were as follows: chronic comorbidities affecting the nutritional status (e.g., diabetes and hypertension); adherence to special diets; and cognitive disorders. Based on the MNA questionnaire, a total score below 17 represented malnutrition, while scores 17-24 indicated a risk of malnutrition. Results: Based on the findings, 26% of the participants had low weight, 67% of whom were over 65 years. According to the MNA questionnaire, 14.3% of the participants showed malnutrition and 26.2% were at risk of malnutrition. Conclusion: Based on our findings, PD can contribute to reduced nutritional status. More than onefourth of the PD population was at risk of malnutrition, which highlights the need for more attention towards nutritional assessment. Nutritional assessment is essential for the development of nutritional interventions and early detection of PD patients who are at risk of malnutrition.

Nutritional status assessed with the Mini-Nutritional Assessment (MNA) test, which includes simple measurements and brief questions; it took nearly 10-15 minutes to complete the test. The complete version of the MNA questionnaire consists of two sections and 18 items, i.e., six screening and 12 assessment questions in section I and section II, respectively. The maximum score is 30 in the questionnaire (16 for screening questions and 14 for assessment questions). A total score of <17 was indicative of malnutrition, scores 17-23.5 signified the risk of malnutrition and scored ≥ 24 represented a normal nutritional status15. In this study, the full translated form of MNA questionnaire, which was provided by Nestlé Nutrition Institute, was applied 11-12. Subsequently, data assessed in SPSS 20 (Chicago, IL, USA).

Results
A total of 158 patients (44% male) were studied, and an average disease duration of 6.44 years identified. Overall, 72% of the patients reported tremor as an initial symptom. The subjects had a mean weight of 72.45 ± 12.5 kg, mean age of 67.42 ± 7.5 years, mean height of 164±8 cm, and mean BMI of 26.2 ± 4.46 kg/m 2 . Twenty-six percent of the population identified as having low weight, and 32% identified as overweight or obese.
Considering the MUAC, which was 13.47 ± 7.41 mm, 26% of the studied subjects had a reduced fat mass. In addition to PD, 46% and 37.4% of the population presented hypertension and diabetes, respectively. Table  1 shows the clinical and anthropometric characteristics of the subjects classified by age (under 50 years and over 50 years). Table 2 demonstrates the data from MNA test of PD patients; overall, 14.3% had malnutrition, and 26.2% were at risk of malnutrition.

Discussion
Nutritional status defined as the balance between food intake and its use by the body. 10 In this study, it observed that 26% of the population was underweight, of whom  In most cases, the progression of PD accompanied by a consequent loss of weight.14-16 In this study, 69.4% of the patients reported having lost weight in the last three months, and most subjects older than 50 years (65%) reported a decrease in food intake in the last week. All subjects have treated with levodopa, which associated with an increased risk of malnutrition risk. [6][7][8][9][10][11][12][13][14][15] In comparison with men, women usually are exposed to a higher risk of malnutrition and unintentional weight loss 17 ; this finding has confirmed in previous studies. 1,2 This study also aimed to categorize and compare malnutrition in younger and older subjects. However, further studies are necessary to determine the critical risk factors for each age group. Another strength of this study is the use of a nutritional assessment tool (Persian version of the MNA questionnaire), which applies to any age and includes recent weight changes and physical examination. This study also revealed that in this population, anthropometric indices alone could not detect malnourishment.
In conclusion, this study showed that 26.7% of patients had malnutrition. Together with the findings of other studies, this indicates that PD can contribute to a decrease in the nutritional status. Therefore, nutritional assessment is essential for early detection of patients with PD at risk of malnutrition. Also, implementation of individualized nutritional interventions and the development of strategies, which favor food intake to improve the nutritional status and general condition of patients with idiopathic PD, should be highlighted.
Nutritional evaluation, education, and even interventions should be considered in the multidisciplinary work-up of PD patients to improve their nutrition and to prevent weight loss or to worsening of nutritional status. Moreover, a follow-up examination of PD patients to track longitudinal changes in the nutritional status is of high demand to better understand the factors influencing nutrition; this could investigate in future studies.