Parkinson's disease and body mass index: too much or too little?

Doença de Parkinson e índice de massa corporal: excesso ou falta de peso?

EDITORIAL

Parkinson's disease and body mass index: too much or too little?

Doença de Parkinson e índice de massa corporal: excesso ou falta de peso?

Hélio A. G. Teive

MD, PhD; Head of the Movement Disorders Unit and Neurology Service; Hospital das Clínicas, Federal University of Paraná, Curitiba PR, Brazil

^{Correspondence}

Parkinson's disease (PD) is the second most common degenerative disease, being characterized by the presence of motor and non-motor symptoms. The former include bradykinesia, rigidity, tremor and postural instability; the latter include depression, sleep disorders, hyposmia, constipation, cognitive dysfunction, dementia and body mass index (BMI) abnormalities¹. The relationship between BMI and PD is very controversial. In 2010, Hawkes et al. defined a timeline for PD based on the Braak pathological staging (from stage 1 to 6) and suggested that different brain stem structures are involved in the prodromal phase (estimated to be 20 years)^2. In stage 2, in which there is involvement of the coeruleus/subcoeruleus complex (CSC), the magnocellular portions of the reticular formation and the dorsal raphe nuclei, authors suggested that sleep disorder (REM sleep behavior disorder), depression and obesity are present². A dysfunction in the CSC could cause obesity as a result of abnormalities in orexin signaling. Hu et al. studied the relationship between BMI and the risk of PD in a Finnish cohort in 2010³. They found that the risk of PD was twice as high in men with BMI over 30 than in those with BMI under 23, and that there was a 70% higher risk among women³. Palacios et al. published an interesting study in 2012 in which they investigated obesity, diabetes and risk of PD in 656 patients⁴. They concluded there is no relationship between obesity, measures of central obesity and diabetes and the risk of developing PD⁴. However, some studies suggest that patients with advanced PD present with malnutrition and lower BMI in relation to controls for several reasons, including the presence of dysphagia, dyskinesia, depression and cognitive problems^3-5. Cassani et al. studied serum adiponectin levels in advanced-stage PD patients with body weight loss and found significantly higher levels of this protein in PD patients than in controls⁶.

van der Marck et al. published a meta-analysis of BMI in PD in 2012⁷. This pooled data from seven studies and demonstrated that PD patients had a significantly lower BMI than controls, and that patients at Hoehn-Yahr stage 3 had lower BMI in comparison to patients at stage 2⁷. Fiszer et al. studied leptin and ghrelin concentrations (produced respectively in the adipose tissue and mainly in the stomach) in PD patients with weight loss⁸. The findings in this interesting study, in which plasma leptin levels were reduced and IGF-1 levels were elevated, confirm that altered plasma leptin concentrations are common in PD patients. Altered plasma concentrations of orexigenic and anorexigenic peptides (ghrelin and leptin, respectively) lead to alterations in the hypothalamic-pituitary axis⁸. However, PD patients who undergo neurosurgery for a deep brain stimulation (DBS) implant in the subthalamic nucleus can exhibit significant weight gain, underscoring the complex interaction between the hypothalamic-pituitary axis and the basal ganglia^3,5,7,9. Markali et al. studied the role of ghrelin, neuropeptide Y and leptin in PD patients who had weight gain after DBS implant surgery⁹. They concluded that the introduction of a DBS implant in the subthalamic nucleus temporarily deregulated the hypothalamic secretion of neuropeptide Y and ghrelin, and that weight gain was therefore the result of increased production of ghrelin and leptin⁹.

In the current issue of Arquivos de Neuro-Psiquiatria, Morales-Briceño et al. published a very interesting study about overweight PD patients¹⁰. The authors carried out a cross-sectional study with 177 healthy controls and 177 PD patients. Analyzing BMI, they found that overweight and normal weight were more prevalent in the PD group than among controls. They concluded that overweight/obesity are common among Mexican patients with PD while underweight is almost negligible¹⁰. However, it should be noted that the PD patients in their study had a relatively short disease duration (6.3 +/- 5 years) and that the mean Hoehn-Yahr stage was 2.3 (+/- 0.9). None of the patients had DBS in the subthalamic nuclei. In the study, 65.9% of the PD patients were on dopamine agonists (83.8% on pramipexole). Although these agonists have been associated with overweight due to impulse control disorders, such as compulsive eating, the authors did not evaluate such disorders in their study¹⁰.

Another important aspect of the study by Morales-Briceño et al. is that 90.9% of the patients had mild or moderate disease, and only 9.1% had severe disease, which potentially explains the lower frequency of underweight in this study¹⁰. In conclusion, the relationship between BMI and PD is still controversial, and obesity, normal weight and underweight can be present in different stages of the disease.

5 Strowd RE, Cartwright MS, Passmore LV, Ellis TL, Tatter SB, Siddiqui MS. Weight change following deep brain stimulation for movement disorders. J Neurol 2010;257:1293-1297.

Received 08 October 2012

Received in final form 09 October 2012

Accepted 16 October 2012

Conflict of interest: There is no conflict of interest to declare.

• 1. Chaudhuri KR, Healy DG, Schapira AH, National Institute for Clinical Excellence. Non-motor symptoms of Parkinson's disease: diagnosis and management. Lancet Neurol 2006;5:235-245.
• 2. Hawkes CH, Del Tredici K, Braak H. A timeline for Parkinson's disease. Parkinsonism Relat Disord 2010;16:79-84.
• 3. Hu G, Jousilahti P, Nissinen A, Antikainen R, Kivipelto M, Tuomilehto J. Body mass index and the risk of Parkinson disease. Neurology 2006;67:1955-1959.
• 4. Palacios N, Gao X, McCullough ML, et al. Obesity, diabetes, and risk of Parkinson's disease. Mov Disord 2011;26:2253-2259.
• 6. Cassani E, Cancello R, Cavanna F, et al. Serum adiponectin levels in advanced-stage Parkinson's disease patients. Parkinsons Dis 2011;2011:624764 (Epub 2011, Jun 16).
• 7. van der Marck MA, Dicke HC, Uc EY, et al. Body mass index in Parkinson's disease: a meta-analysis. Parkinsonism Relat Disord 2012;18:263-267.
• 8. Fiszer U, Michalowska M, Baranowska B, et al. Leptin and ghrelin concentrations and weight loss in Parkinson's disease. Acta Neurol Scand 2010;121:230-236.
• 9. Markaki E, Ellul J, Kefalopoulou Z, et al. The role of ghrelin, neuropeptide Y and leptin peptides in weight gain after deep brain stimulation for Parkinson's disease. Stereotact Funct Neurosurg 2012;90:104-112.
• 10. Morales-Briceño H, Cervantes-Arriaga A, Rodríguez-Violante M, Calleja-Castillo J, Corona T. Overweight is more prevalent in patients with Parkinson's disease. Arq Neuropsiquiatr 2012:70:843-846.

Publication Dates

• Publication in this collection
  14 Nov 2012
• Date of issue
  Nov 2012