People with a good nutritional status are more likely to have a robust immune system, reduced risk of cardiovascular disease (CVD), and increased longevity [1]. With the increasing global incidence of diet-related chronic diseases, interventions, including prevention, management, and treatment, using the concept of “food as medicine” have become an integral part of patient care [2]. Diets are particular food or nutrition regimens used for weight control or to address medical conditions [3]. For example, for people who strictly adhere to the Mediterranean (Medi) diet, additional health benefits have been shown, especially in those with cardiovascular disorders, and emerging evidence suggests that adherence to the Medi diet also has potential benefits for neurodegenerative diseases, including Parkinson’s disease (PD) [4,5]. Importantly, unlike medications, food is universally available, and the components of a prescribed diet can be easily substituted with local food ingredients.

Due to the rapid growth of the aging population and increasing longevity, the number of patients with PD is rising [4,6,7]. Currently, PD is the fastest-growing neurodegenerative disorder, with the affected population expected to double by 2040 to more than 17.5 million, with approximately half residing in Asia [6,8]. Therefore, we are facing a PD pandemic era [6], and research efforts will need to produce early and heightened activism to prevent the worsening of the disease [9]. As the clinical presentation of PD has many stages, including a preceding long prodromal stage in which clinical symptoms are minimal or subtle, different food interventions may be utilized for disease prevention or slowing disease progression into the full clinical syndrome [7]. Most epidemiological studies have shown that greater adherence to the Medi diet is associated with a significant improvement in health and cognitive status and a lower incidence of neurodegenerative diseases, including PD [4,10,11]. Therefore, food is now being recognized as a potential treatment for PD, with the Medi diet seemingly the most promising based on early evidence from patients in specific geographical regions, especially in European regions, but still not yet documented in Asia [4].

The Medi diet is a typical dietary pattern based on the Mediterranean food culture followed in countries bordering the Mediterranean Sea [12]. The term “Mediterranean diet” signifies both the origin of this dietary pattern and the regions where it is prevalent. The traditional Medi diet is characterized by a high intake of vegetables, legumes, fruits, nuts, cereals, and olive oil, a moderately high intake of fish, a low intake of saturated fats, dairy, meat and poultry, and a regular but moderate intake of alcohol, primarily in the form of wine and generally during meals [12,13]. Researchers consider that the beneficial preventive effects of the Medi diet are attributed to possible synergistic effects or benefits associated with the combined nutrients in the Medi diet rather than a single ingredient. However, despite these emerging health benefits, the perception of the term “Mediterranean” may lead people who live outside these regions to believe that the Medi diet is not applicable or adaptable to non-Mediterranean regions due to the unavailability of certain ingredients in their countries, such as olive oil or red wine. Moreover, many people misunderstand that the Medi diet is restricted only to people living in the Mediterranean area, which is also not accurate. Indeed, the adoption of the Medi diet outside the Mediterranean region in clinical trials (i.e., Australia) has been shown to be feasible, with clinical benefits of improving mental health in patients with depression [14].

As mentioned previously, PD is a common degenerative disease that has a preceding prodromal stage before the established clinical stages, and its incidence is rapidly increasing worldwide; therefore, it can serve as a good disease model for preventive trials [7]. Patients in the prodromal or early stages or even those at risk of the disease can be targeted for preventive interventions, such as the Medi diet, and early evidence from such interventions suggests that adherence to the Medi diet provided protective effects in healthy older adults and PD patients of varying disease stages (Figure 1). For healthy older adults, adherence to the Medi diet was associated with a lower risk of PD and a reduced risk of developing parkinsonism [11,15]. For patients at the prodromal PD stage, adherence to the Medi diet also reduced the risk of nonmotor symptoms, such as depression, constipation, urinary dysfunction, and daytime somnolence [16]. Furthermore, adherence to the Medi diet enhanced cognitive function for patients diagnosed with PD [17].

As societies inevitably develop ways to merge the available foods derived from geographical, trade, or cultural preferences into representative dietary patterns or cuisines [18], it is becoming evident that there has been a gradual adoption of the Medi diet concept into Asian cuisines to create a perception of it as a ‘healthy’ diet [19]. Some Asian countries, such as China, India, South Korea, and Japan, have used a similar concept and adapted their local cuisine to reflect a traditional Medi diet. For instance, the Chinese diet shares similarities in ingredients with the Medi diet, which is high in vegetable and fruit consumption and low in fat and meat consumption [20]. The Medi diet score has also been applied to the Chinese diet, demonstrating the comparability of the Chinese diet and implying that it could be expected to have similar health benefits as documented for the traditional Medi diet [20]. This adoption concept has also been applied in India and South Korea [21,22]. The Indo-Medi diet differs slightly from the traditional Medi diet because it contains more whole grains, mustard seed or soybean oil, and a variety of healthy spices, such as coriander, cumin, turmeric, cloves, and cardamom, and it has been demonstrated to protect against the progression of coronary artery disease [21,23]. Similar to India, modification of Medi diet components and adaptation to the Koreanstyle Medi diet (KORMED) has been achieved by adding flavorful ingredients familiar to Koreans (such as fermented soybeans and garlic) to olive oil as an alternative to seasonings [22]. Whole grain rice was used instead of whole grain bread, pasta, and cereal, and seafood was served with olive oil as a means of cooking, with cooking methods of steaming or boiling recommended [22]. With this adoption concept, the KORMED has been shown to be a feasible option and has helped patients maintain this style of diet during their daily lives. A study also showed the positive effects of the KORMED on functional physical changes, cognitive scores, and depression scores among elderly Koreans with a high risk of dementia [22]. Another good example of adaptation of the Medi diet idea to local cuisine is seen in Japan. Japanese food shares several similarities with the Medi diet, as both are plant-based diets that use foods such as rice, vegetables, grains, legumes, and fruit, with fish also regularly consumed in both Japan and Mediterranean countries [24]. Japanese food is famous for promoting health and may be a factor that contributes to Japanese people’s healthy life and longevity, similar to that enjoyed by those on the Medi diet [21]. However, although Japanese food showed an association with a decreased risk of PD [25], it involves a lower consumption of total fats, and the difference in the ratio of n-6 PUFAs/n-3 PUFAs may enhance the risk of CVDs and type 2 diabetes mellitus in Japan [21,26]. Therefore, a Japanese-adapted MD score (jMD score) was developed, which demonstrated the comparability of the Japanese diet to the three categories of Medi diet adherence (low, moderate, and high), with a higher jMD score associated with a lower prevalence of overweight/obesity in Japan [27]. Figure 2A shows the spread of the concept of the Medi diet in various Asian cuisines.

Thai food is famous worldwide, and Thai people are proud of their food, believing it to have good flavor and be good for their health [28]. People in Thailand tend to eat locally available food, with spiciness and sweetness being prominent characteristics [28]. Similar to the Indo-Medi diet, Thai food contains healthy local herbs, and spices with specific medicinal properties are key to the popularity of Thai food and may help treat certain PD symptoms [21]. For example, turmeric and basil have ascribed benefits against gastrointestinal symptoms (i.e., dyspepsia and bloating), commonly experienced by PD patients [29]. There are also similarities between Thai food and the Medi diet in terms of ingredients and cooking methods (Table 1, Figure 2B). Some components of the Medi diet can be substituted with locally available ingredients in Thailand. Thailand has an abundance of fruits and vegetables; therefore, local and seasonal fruits and vegetables can be substituted for Mediterranean fruits and vegetables. Thailand is also near the sea, and fish and shellfish are locally available. Chicken and duck are considered healthy Thai foods and are preferred over red meat, such as pork or beef. Nuts such as peanuts and cashews are popular and can substitute nuts in the Medi diet, such as almonds, pistachios, and walnuts. Thai food also utilizes many cooking methods, such as boiling, stewing, steaming, grilling, salad preparation, stir-frying, and deep-frying, similar to those used in Mediterranean cuisine [30].

However, in contrast, vegetable oil and lard are used in Thai cooking as opposed to the olive oil used in the Medi diet [28]. Additionally, in the past, not many Thai people preferred wine over other alcoholic beverages. However, due to Thailand’s tropical climate, which is suitable for cultivating grapes for winemaking, Thai wine is becoming recognized, and local Thai wineries, such as GrandMonte Vineyard and Siam Winery, are becoming popular with Thai people [31]. Therefore, changing food concepts and adopting the Medi diet style to fit Thai-style cuisine and preferences (Thai-style Medi diet) for Thai people to become more familiar with this type of food is feasible and convincing. We propose that our Thai-style Medi diet might prevent PD and improve other symptoms, as the Medi diet does, due to the similarity in ingredients and cooking methods. Therefore, this diet adoption is expected to influence Thai people with possible immediate/symptomatic effects and protective effects, such as improving appetite, enhancing swallowing, preventing choking, and decreasing bloating and constipation. However, implementing the Thai-style Medi diet nationwide in Thai cuisine requires a stepwise approach, recommended as follows: 1) food selection by advertising a selection of local ingredients that can be substituted for Mediterranean ingredients; 2) as pesticides are one of the environmental risks for PD [32], all selected local ingredients should be organic products and free of pesticides; 3) the development of a Thai-Medi diet adherence score to identify compatibility and level of adherence to the diet (Supplementary Table 1 in the online-only Data Supplement); 4) the provision of cooking lessons and menus to teach how to prepare and cook a Thai-style Medi diet, which has similar taste and flavor as original Thai cuisines, to make people familiar with the taste of the diet and maintain it in the long term; and 5) further support from various stakeholders to implement this initiative, such as increasing awareness of its health benefits, launching a health promotion campaign with the slogan “We are what we eat,” and providing a selection of Thai-Medi diet foods at a lower cost to encourage people to adhere to these types of foods in the long term.

Our center, the Chulalongkorn Centre of Excellence for Parkinson’s Disease and Related Disorders (ChulaPD, www.chulapd.org), is a national tertiary center for Parkinson’s disease that is affiliated with the Thai Red Cross society with a mission to provide specialist care to those who are affected by PD and other movement disorders as well as advance research and education within the country. As the PD population rapidly grows within Asia, including Thailand, we realize that it would not be feasible to wait for patients to visit the center when they are very symptomatic from their advanced conditions (passive strategy). Rather, we should actively engage in identifying new cases, especially those in the prodromal or early stages, for preventive interventions with an ‘Eat, Move, Sleep’ concept. To achieve this task at a national level, a digital platform is being validated on certain sets of biomarkers that include voice, tremors, gait, finger dexterity, and handwriting. Implementing the Thai-style Medi diet is part of an ‘eat right’ intervention, in which local Thai cuisines have been evaluated and examined by a multidisciplinary team that comprises health care professionals, dietitians, and nutritionists with extensive experience in the care of PD; these professionals will be working with a group of Thai chefs and PD patients and caregivers to develop a Thai-style Medi diet that has a comparable nutritional value to the Medi diet and, at the same time, has the familiar taste and flavors of traditional Thai food.

Therefore, this viewpoint shows how the Thai-style Medi diet could be implemented as part of the preventive interventions of national PD screening in Thailand, with the stepwise approach that has been proposed with local ingredients used to maintain the unique taste of Thai food. Although more evidence of its benefits among Thai patients with PD needs to be gathered, as Thailand can be used as an example in Asia, the benefits of applying this concept to other countries in Asia should also be explored. We can all learn from each other, and we hope that this is the starting point for future collaborations within the region. Increasing awareness of this approach and its potential benefits, launching support campaigns, collaborating with the food industry, and providing a selection of this adapted Medi diet at a lower cost across Asia are likely to encourage patients and those at risk for PD to adhere to these types of foods in the long term and enhance health benefits across the region. Food is what we eat every day, and adapted Thai food contains herbs and spices that have medicinal properties; therefore, such healthy eating interventions are becoming a core part of lifestyle interventions.

Supplementary Materials

Notes

Ethics Statement

The ethical approval is not required for this manuscript. Informed patient consent was not necessary or acquired for this work.

Conflicts of Interest

The authors have no financial conflicts of interest.

Funding Statement

This study is supported by the Senior Research Scholar Grant (RTA6280016) of the Thailand Science Research and Innovation (TSRI) and Center of Excellence grant of Chulalongkorn University (GCE 6100930004-1).

Author Contributions

Conceptualization: Onanong Phokaewvarangkul, Roongroj Bhidayasiri. Data curation: Onanong Phokaewvarangkul. Formal analysis: Onanong Phokaewvarangkul. Funding acquisition: Roongroj Bhidayasiri. Methodology: Onanong Phokaewvarangkul, Roongroj Bhidayasiri. Project administration: Onanong Phokaewvarangkul, Roongroj Bhidayasiri. Resources: Roongroj Bhidayasiri. Supervision: Roongroj Bhidayasiri. Validation: Roongroj Bhidayasiri. Visualization: Onanong Phokaewvarangkul, Roongroj Bhidayasiri. Writing—original draft: Onanong Phokaewvarangkul. Writing—review & editing: Roongroj Bhidayasiri, Nitinan Kantachadvanich, Vijittra Buranasrikul, Appasone Phoumindr, Saisamorn Phumphid, Priya Jagota.

Figure 1.

Role of the food intervention in early and advanced stages of Parkinson’s disease. This figure demonstrates that implementing specific food interventions can play a crucial role in managing PD symptoms at various stages. The regular diet is the baseline for patients with early PD and represents the standard dietary intake without specific modifications. It includes a balanced diet of proteins, carbohydrates, fats, and essential nutrients. In contrast, the LPD and PRD can be particularly helpful in advanced stages to optimise levodopa medication response.Additionally, the texture modification can ensure adequate nutrition and prevent complications associated with dysphagia in advanced PD patients. Understanding the role of these diets can help healthcare professionals tailor nutritional interventions based on the stage of the disease and individual patient needs. However, modifications to Mediterranean diet styles may be considered to PD patients. H&Y, Hoehn and Yahr stages; MC, motor complications; RBD, rapid eye movement sleep behavioral disorders; GI, gastrointestinal; LPD, low protein diet; PRD, protein redistribution diet; PD, Parkinson’s disease.

Figure 2.

Adaptation of Mediterranean cuisine outside Mediterranean region and Mediterranean and Thai diet pyramids. A: Spread of the concept of the Medi diet to various Asian cuisines. The concept of Medi diet have been recently influenced in Asian countries including China, Japan, South Korea, India, and Thailand. B: Comparison of food ingredient elements in the Medi and Thai diet pyramids. This figure compares the food ingredient elements in the Medi diet and Thai diet pyramids. The two diet pyramids represent traditional dietary patterns observed in their respective regions and reflect the cultural diversity and regional availability of ingredients, each offering potential health benefits in their unique ways. This figure was created with BioRender.com.

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References

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• Old problems, new solutions: harnessing technology and innovation in Parkinson’s disease—evidence and experiences from Thailand
  Roongroj Bhidayasiri
  Journal of Neural Transmission.2024;[Epub]     CrossRef

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