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pISSN 2005-940X / eISSN 2093-4939

REVIEW ARTICLE

Nutrition and Lifestyle Interventions for Managing

Parkinson’s Disease: A Narrative Review
Tracy Lister
Maryland University of Integrative Health, Laurel, MD, USA

ABSTRACT
The etiology of Parkinson’s disease (PD) is not fully understood, but environmental toxin overexposure, increased intestinal per-
meability, and dysbiosis related to nutrition and lifestyle habits are thought to be contributors. Considering these nutrition and
lifestyle implications, there is a lack of practice-based programs utilizing interventions for managing symptoms or slowing the
progression of the disease. The purpose of this narrative review was to identify relevant research related to nutrition and lifestyle
interventions for PD, evaluate the research utilizing the evidence analysis process of the Academy of Nutrition and Dietetics to as-
sess the quality of each research article, and group the research into categories. A grading of recommendations assessment, de-
velopment and evaluation (GRADE) of either good, fair, limited, or not assignable was allocated to each category of research, in-
cluding diet patterns, vitamin D, B-complex, omega-3 fatty acids, coenzyme Q10, probiotics, physical activity, stress, and sleep. An
intervention based on the research presented in the review may be utilized for coaching people with PD on symptom management.
Key WordsaaParkinson disease; Lifestyle; Vitamins; Coenzyme Q10; Diet; Fish oils.

Parkinson’s disease (PD) is a progressive disorder and one of with PD, supporting a role for the “gut-brain axis” with bidirec-
the most common neurodegenerative diseases.1 Epidemiologi- tional communication between the central and enteric nervous
cal studies show that the incidence of PD is 1 in 1,000 individu- systems by way of the vagus nerve.5,6 Hormones and neurotrans-
als, affecting 1% of the population 60 years of age or older, al- mitters, including dopamine, are responsible for the communi-
though the incidence may be higher due to the challenges of cation between the gut and brain, which is thought to be regu-
diagnosing the disease. The hallmark of the disease is collections lated by the gut microbiome.7 Therefore, changes in the gut may
of abnormal neuronal proteins called alpha-synuclein, which influence changes in the brain, affecting circadian rhythms, cog-
aggregate to form Lewy bodies, causing cell death and reducing nition, and behavior. Dopamine produced in the gut also pro-
dopamine production.2 These abnormalities of the brain may tects the intestinal mucosa and controls gastrointestinal motili-
cause symptoms characteristic of PD many years prior to diag- ty.8 A reduction in dopamine in the gut has been linked to a longer
nosis.3 The etiology of PD is a complex collection of factors that colonic transit time causing constipation, which occurs in 50–
is not fully understood, but environmental toxin overexposure, 80% of cases early in the disease process.2,9,10 Without the pro-
increased intestinal permeability and dysbiosis related to nutri- tection of dopamine, the gut becomes damaged, increasing in-
tion and lifestyle are thought to be contributing factors.1 Although testinal permeability and allowing undigested food particles,
the pathology is not fully understood, PD is considered an in- microorganisms, and toxins to be absorbed into the bloodstream,
flammatory disease. triggering the immune system and inflammatory processes.5,9,11,12
Dopamine is also produced in the gastrointestinal system (gut).4 Consuming a “western style” diet high in processed foods con-
Aggregated alpha-synuclein has been found in the gut of people tributes to increased intestinal permeability and dysbiosis due to
Received: January 24, 2020 Revised: March 3, 2020 Accepted: March 17, 2020
Corresponding author: Tracy Lister, DCN
Maryland University of Integrative Health, 7750 Montpelier Road, Laurel 20723, MD, USA / Tel: +1-250-954-7908 / E-mail: [Link]@gmail.
com
cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ([Link]

licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Copyright © 2020 The Korean Movement Disorder Society 97

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an overgrowth of gram-negative bacteria.2,13 There is a positive in the Academy of Nutrition and Dietetics (AND) 2012 Evi-
correlation between PD symptom severity and increased intes- dence Analysis Manual.28 During September 2019, PubMed
tinal permeability due to neurotoxic lipopolysaccharides pro- and EbscoHost were searched for literature utilizing 42 search
duced by gram-negative bacteria penetrating the gut lining and words related to nutrition and lifestyle AND/OR Parkinson re-
passing into the bloodstream. The gut abnormalities often ex- sulting in 42 individual searches (Table 1). Database filters con-
tend to the esophagus and oropharyngeal cavity, which impacts sisted of human studies, English language, and primary research/
swallowing, taste, smell, salvation, and speech.14 peer publications. The exclusion criteria included animal or in
Neurotoxicity may also be caused by environmental toxin vitro studies, case studies, narrative reviews, gene therapy, risk
overexposure, including food and water.15-19 Food and water of developing PD, and pharmaceutical research. Each article
may be the largest component of toxin exposure due to consum- meeting the inclusion criteria was assessed for quality utilizing
ing unfiltered water, processed foods, sugar, sugar substitutes, the AND checklists; those graded as negative quality were also
and nonorganic vegetables and fruit treated with pesticides and excluded. The research articles were then grouped into catego-
herbicides. As toxins are fat soluble, foods high in fat have the ries, and each category was assigned a grading of recommenda-
potential to increase the risk of PD; for every 200 g/day of milk tions assessment, development and evaluation (GRADE) with
or 10 g/day of cheese consumed, the risk increases by 13–17%.20,21 a definition and conclusion statement (Figure 1). There was only
Exposure to toxins is also part of daily activities, as they may be one reviewer evaluating the quality of each individual research
found in cleaning and personal care products, manufactured article, grouping the positive and neutral quality articles into cat-
products, cooking utensils, food storage containers, and molds egories and arbitrarily assigning a GRADE to each category based
and bacteria endotoxins.22-24 Environmental causes are difficult on the quantity and quality of the research.
to confirm by human trials, but the research supports toxins
such as pesticides, herbicides, and industrial waste, including RESULTS
heavy metals, playing a large role in the development and pro-
gression of the disease.15-19,25,26 Utilizing key words AND Parkinson produced 6,045 publi-
The nutrition and lifestyle practices among healthcare profes- cations, of which 56 were considered relevant, with 41 assigned
sionals counseling people with PD appear to be limited to man- a neutral or positive quality rating; these were then grouped into
aging drug–nutrient interactions and swallowing disorders.27 the categories of diet patterns, vitamin D, omega-three fatty ac-
Those with vague symptoms, common early in the disease, are ids (n-3), B vitamins, coenzyme Q10 (CoQ10), probiotics, physi-
often not identified nor provided with nutrition and lifestyle in- cal activity (PA), sleep, and stress. Research on stress manage-
terventions to prevent the progression of symptoms.27 The pur- ment with regard to PD was lacking, with only one study utilizing
pose of this review was to locate research related to PD and nu- yoga as the intervention.
trition and lifestyle interventions and evaluate, interpret, and The collection of research related to diet patterns was as-
summarize the evidence. signed a GRADE of fair (II) due to utilizing study designs that
are less appropriate for interventions (cohort, crossover) and
MATERIALS & METHODS small sample sizes. However, designing ethical nutrition and
health research is difficult, and studies regarding diet patterns
The analysis process utilized to write the review is described and organic plant-based food items are compelling.29-31 The

Table 1. Literature search terms, categories of topics and GRADEs

Category Search terms GRADE
Celiac, gluten, coffee, curcumin, diet, anti-inflammatory, “dietary iron,” epigallocatechin, fat,
Diet pattern ketogenic, antioxidant, B-carotene, “elimination diet,” fasting, genistein, soy, lectin, Fair (II)
sulforaphanes, glutathione, resveratrol, quercetin, polyphenol, zinc, n-acetylcysteine
Vitamin D Vitamin D Fair (II)
Omega-three fatty acids Omega-three fatty acids Fair (II)
B-complex “Vitamin B,” anemia Limited (III)
Coenzyme Q10 “Coenzyme Q10” Good (I)
Probiotics Probiotic, microbiome, Bacteroides, Prevotella, constipation Limited (III)
Physical activity “Physical activity,” “tai chi” Good (1)
Sleep Sleep, melatonin, CBD oil Limited (III)
Stress Stress, hormone, sauna Not assignable (V)
CBD: cannabidiol, GRADE: grading of recommendations assessment, development and evaluation.

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Grade I: Good—The evidence consists of results from studies of strong design for answering the question addressed. The results are both clinically
important and consistent with minor exceptions at most. The results are free of serious doubts about generalizability, bias, and flaws in research
design. Studies with negative results have sufficiently large sample sizes to have adequate statistical power.
Grade II: Fair—The evidence consists of results from studies of strong design answering the question addressed, but there is uncertainty attached
to the conclusion because of inconsistencies among the results from different studies or because of doubts about generalizability, bias, research
design flaws, or adequacy of sample size. Alternatively, the evidence consists solely of results from weaker designs for the questions addressed,
but the results have been confirmed in separate studies and are consistent with minor exceptions at most.
Grade III: Limited—The evidence consists of results from a limited number of studies of weak design for answering the questions addressed.
Evidence from studies of strong design is either unavailable because no studies of strong design have been done or because the studies that
have been done are inconclusive due to lack of generalizability, bias, design flaws, or inadequate sample sizes.
Grade IV: Expert Opinion Only—The support of the conclusion consists solely of the statement of informed medical commentators based on
their clinical experience, unsubstantiated by the results of any research studies.
Grade V: Not Assignable*— There is no evidence available that directly supports or refutes the conclusion.

Figure 1. Grade definitions: strength of evidence for a conclusion statement. Adapted from Academy of Nutrition and Dietetics.28

Mediterranean-DASH Diet Intervention for Neurodegenera- levels of 22.5 ± 9.7 ng/mL reported improved PD symptoms
tive Delay (MIND) diet, studied to reduce neurodegenerative when serum levels reached 41.7 ± 12.6 ng/mL.37
changes, was associated with a 13% reduction in the risk of de- There are only two trials with the same small sample utilizing
veloping PD or the progression of symptoms. It is a Mediterra- 1,000 mg of n-3s from flaxseed oil for 12 weeks. These studies
nean-type plant-based anti-inflammatory diet consisting of veg- reported a reduction in inflammatory markers and increased
etables, fruits, legumes, whole grains, nuts, small wild fish, and antioxidative capacity and glutathione production, reducing
small amounts of farm raised poultry and red meats low in sat- PD symptoms.38,39
urated fats.31 Considering that PD is related to toxic burden, a There are a limited number of studies utilizing individual B
plant-based diet, which is high in vegetables and some fruits, vitamins and deficiency states in PD. Thiamine (B1) deficiency
should consist mostly of organic foods. Lu et al.30 conducted a has been linked with neuroinflammation and neurodegenera-
study to determine the contribution of pesticide intake from tion, suggesting a role in the progression of PD.40 An observa-
vegetables and fruits in American children at a private school. tional study found that 100 mg of B1 administered intramuscu-
The pesticides malathion dicarboxylic acid and malathion tri- larly twice weekly improved PD symptoms within 3 months.40
choloro-2 pyridinol were detected in the children’s urine on days Coimbra et al.41 conducted a study to determine the riboflavin
they were fed their usual diet but not the days they were fed an (B2) status among participants with PD and found that people
organic diet. with PD had lower serum B2 levels compared to controls. Af-
Organic plant-based diets tend to be lower in protein due to ter supplementation with 30 mg of B2 every eight hours, partic-
limiting or excluding animal foods; therefore, supplementing ipants reported improved sleep, reasoning, and motivation and
with a protein powder may be necessary to meet protein require- reduced depression within two weeks and improved motor func-
ments. Supplementing with 20 g of organic whey protein pow- tion by 44–71% in three months. A deficiency in B vitamins is
der daily has been shown to improve motor function, reduce associated with neuroinflammation and oxidative stress, for
homocysteine related to inflammation, and increase glutathi- which homocysteine is a biomarker.42 Ozer et al.43 found a neg-
one synthesis necessary for detoxification in those with PD.32 ative correlation between homocysteine and visual-spatial tasks,
Higher protein diets such as a ketogenic or gluten-free diet have learning, serum vitamin B12, and serum folate.
been proposed as interventions for PD, as studies show improve- People with PD tend to be at greater odds of a CoQ10 defi-
ments in motor function due to better glycemic control and re- ciency, an antioxidant that is important for the detoxification
duced toxicity associated with food intolerances.33,34 system, which may be partially responsible for their toxic bur-
Several nutrition supplements related to PD have been inves- den.44 Several high-quality studies have shown that supplemen-
tigated, but there was a lack of high-quality studies utilizing vi- tation with 100–1,200 mg of CoQ10 daily, particularly larger
tamin D. Vitamin D supplementation research provides con- dosages, reduces inflammatory markers and improves motor
flicting results regarding PD, which may be related to the dose symptoms.45-49
provided and the length of the studies. A prospective cohort in There is very little research regarding interventions to support
China found that 43% of participants with PD had lower serum a healthy microbiome in PD. A study with participants with PD
levels than controls, which trended towards a positive correla- utilizing fermented milk rich in probiotics combined with a pre-
tion with disease duration.35 Hiller et al.36 reported significant biotic fiber reduced incomplete evacuation of stool and increased
improvements in balance when participants with PD were sup- the frequency from 3 to 4.5 bowel movements weekly.50 A trial
plemented with 10,000 IU vitamin D daily. Another trial sup- conducted with probiotic supplements containing 8 × 109 CFU
plementing 1,200 IU daily for 12 months in those with serum reduced inflammatory markers, but changes in PD symptoms

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were not tracked.51 Abnormalities in the microbiota may extend als, fiber, and antioxidants, including flavonoids, which are
to the esophagus and oropharyngeal cavity, which may be relat- found in plant-based foods, particularly berries. Gao et al.72 in
ed to a higher number of alpha-synuclein mutations found in their cohort study reported reduced risk and progression of PD
the oral cavity of subjects with PD.14 It has been speculated that with the consumption of flavonoids as these antioxidants cross
these abnormalities may be responsible for PD nonmotor symp- the blood brain barrier, reduce inflammation, influence neural
toms, including changes in swallowing, taste, smell, salivation, signaling, and improve the survival of dopamine neurons. Cur-
and speech. cumin/turmeric should be included as a spice in cooking due to
There was a wealth of publications related to PA. Many stud- its antioxidant abilities that protect cells, restore cell morpho-
ies utilized the American College of Sports Medicine (ACSM) logical changes, increase cell survival, and reduce cell death by
guidelines, suggesting that people engage in 150 minutes of mod- influencing gene expression.73,74
erate-intensity PA weekly or 75 minutes of high-intensity train- Food sensitivities and intolerances often go undetected, which
ing or a combination of both.52 Several studies with PA utilizing may contribute to toxic burden, inflammation, and gut damage
the ACSM guidelines found that higher intensity exercise im- leading to excessive immune responses. There appears to be a
proves motor function, balance, cognition, depression, sleep, and connection between PD and celiac disease, suggesting the pos-
quality of life.53-58 Two studies showed an improvement in in- sibility of nonceliac gluten intolerance, which may cause cerebel-
flammatory markers, and Landers et al.59 reported improved lar ataxia and neuropathy.34,75 A systematic review conducted
motor and nonmotor skills and neuroplasticity.60 Corcos et al.61 in 2018 suggested that gluten sensitivity should be considered
reported that progressive weightlifting improved motor skills for movement disorders owing to the connection with neuro-
more than a nonprogressive program. logical dysfunction.76 Therefore, an elimination diet should be
Other forms of exercise, such as yoga, tai chi (TC), and dance, tried for people with PD to identify any possible food sensitivi-
have led to improvements in motor and nonmotor function. ties or intolerances that are contributing to symptoms. Once
Yoga has been shown to improve sleep, depression, cognition, food sensitivities have been identified, a modified Mediterra-
balance, motor skills, and quality of life.62-64 TC improves not nean-type diet should be prescribed for long-term usage.
only motor skills but also flexibility, internal awareness, orien- Avoiding processed foods, sugar and sugar substitutes will re-
tation, and proprioception.65-67 Hackney and Earhart68 reported duce inflammation and toxic burden and improve blood glucose
that tango had a larger impact on motor skills than TC, which in most individuals, which is essential for supporting neurologi-
may be related to the impact of music and rhythm and the in- cal health.33 Excess carbohydrate intake may also interfere with
creased cognitive demands of memorizing steps and motor muscle protein synthesis, reducing muscle strength and function.77
planning. Obtaining adequate protein sources may be challenging due
There was a lack of published research related directly to PD to locating organic meats and poultry and wild fish. Supple-
and sleep and stress. Inadequate or ineffective sleep impacts menting with 20 g of whey protein spread throughout the day
the brain and motor skills, which may be related to replenish- preserves muscle mass and reduces oxidative stress and inflam-
ing dopamine levels.69,70 Research specifically related to PD and mation.32 Whey protein is a good source of cysteine that is
stress was limited to one small study with 10 participants with needed for glutathione production to support detoxification
PD reporting a reduction in psychological stress and increased and reduce homocysteine. As glutathione appears to be ineffec-
wellbeing.71 tive as a supplement, food sources are required to increase its
biosynthesis to reduce inflammation and oxidative damage to
DISCUSSION neurons.32
Diet and gut health also play an important role in supporting
The evidence suggests that nutrition and lifestyle interven- detoxification and managing constipation.78 Regular bowel
tions may reduce PD symptoms and possibly delay disease pro- movements prevent toxins from deconjugating and being freed
gression. Prescribing specific diet patterns and nutritional sup- within the lumen and reabsorbed in the presence of increased
plements has the potential to reduce inflammation and toxin intestinal permeability.78,79 Fiber binds toxins and influences
exposure, support detoxification, heal the gut, and calm the im- tight junction proteins that support gut wall integrity to prevent
mune system to reduce PD symptoms and promote health and increased intestinal permeability and toxin reabsorption.78-80
wellbeing. Substances that alter the microbiome and damage the gut in-
The research supports prescribing a Mediterranean-type diet clude medications, a low-fiber diet high in processed foods, in-
pattern to reduce inflammation by focusing on whole foods that fectious agents and food intolerances.81,82 Gut dysbiosis is a re-
are low in toxins.31 The diet pattern is high in vitamins, miner- sult of consuming foods that are poorly tolerated or highly

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processed, leading to an overgrowth of gram-negative bacteria Research suggests that people with PD are deficient in CoQ10,
and their inflammatory byproducts. It has been well established glutathione and vitamins C and D.35,44,88,90 Coenzyme Q10 at
that an altered microbiota is prevalent in PD.2,13,81 dosages of 300–1,200 mg daily may have a positive impact on
PA is an important aspect of managing PD and should in- motor neuron symptoms, finger dexterity, visual color acuity,
clude a variety of activities. Most types of PA are beneficial, but and inflammation. Glutathione is not beneficial as a supplement,
the key is motivation; therefore, the activity chosen should be but its endogenous production relies on nutrients provided by
enjoyed.58 Even though all forms of PA appear to improve PD, a Mediterranean-type diet high in cruciferous and allium veg-
each type of activity has its own unique benefits. An exercise etables, citrus, and berries and possibly supplemental n-acetyl
program that is guided by a professional to increase exertion cysteine.91 A small study administering large dosages of oral n-
over time is more effective at improving motor skills and bal- acetyl cysteine (1,200 to 8,000 mg/day) to five participants with
ance compared to nonprogressive programs.53-61 Interval train- PD reported an increase in serum glutathione without adverse
ing with high spurts of activity followed by lower exertion ac- effects at a dose of 1,200 mg daily.92
tivities has the best outcomes, including neuroplasticity, which People with PD are at risk of vitamin D deficiency, but there
includes improving cognition and mental health.53,54 An exer- is conflict in the research regarding the daily dose.35,36,93 The
cise routine of stretching, strength training and aerobic activity impact of adequate vitamin D for good health is well established;
improves depression and quality of life, which might be related therefore, serum levels should be tested and treated as need-
to increasing brain-derived neurotrophic factor and decreasing ed.94 To treat deficiencies, calculating a dose based on 40 IU for
inflammation.57,59,60 Strength training combined with an ade- every 12 ng/mL for serum levels below 50 ng/mL may be the
quate intake of dietary protein is important not only for manag- best approach.95
ing PD symptoms but also for reducing age-related sarcopenia Although there is no research related to PD and vitamin C
associated with frailty.32,83 supplementation, vitamin C is a powerful antioxidant that
Yoga, dance, and TC may be more enjoyable than regimented quenches reactive oxygen species developed during detoxifica-
PA programs for some individuals and more appropriate for the tion. Ide et al.89 found an inverse relationship between serum
elderly or those with limited motor function.62,64-67,84,85 Yoga is vitamin C and the most severe stages of PD. As vitamin C sup-
beneficial for improving motor function, overall physical fitness, ports detoxification, food sources would be included in the
flexibility, strength, sleep, and stress.62,64,71 Dancing provides not daily diet pattern.
only a social experience but also improves intellectual function, Deficiencies in B vitamins are more prevalent with PD than
flexibility, balance, strength, functional movements (including in the healthy population.40,96 Deficiencies in B1 are linked with
finger and hand dexterity), motor planning and memory in peo- neuroinflammation and neurodegeneration and B12, B6, and
ple with PD.84 TC improves quality of life and depression.67 folate to elevated homocysteine. Correcting B1 deficiency may
Sleep is important for PD management as it improves motor improve motor function, fatigue and cognition.96 Motor symp-
function possibly by restoring dopamine levels.70,86 Ineffective toms, sleep, motivation, and depression improve with the cor-
sleep also has a negative impact on brain and motor skills, wors- rection of B2 deficiency.41 Correcting B6, B12 and folate defi-
ening symptoms and quality of life. Although the effects of sleep ciencies has a positive effect on homocysteine, which tends to
on PD are not well studied, the research does support a positive be high in those taking levodopa.97 In clinical practice, biomark-
effect of sleep on other neurological diseases and motor skill im- ers of B vitamins have several limitations for assessing nutrition
provements even in healthy individuals.69,87 status; therefore, a thorough nutrition-focused physical exami-
There are no high-quality studies linking stress and PD, but it nation should be conducted to identify micronutrient deficien-
is well known that stress has a direct connection to developing cies that should then be treated as needed.98,99
chronic diseases, particularly those of the brain.88 Chronic stress Omega-three fatty acids reduce inflammation and may im-
affects neuropeptide signaling, causing anxiety, depression, and prove PD motor skills. Flaxseed is a source of n-3s, but the con-
inflammation related to disease. The dopaminergic nuclei are version of alpha-linolenic acid to eicosapentaenoic acid (EPA)
also inhibited by chronic stress, which may be related to the de- and docosahexaenoic acid (DHA) is very small; therefore, fish
pressive symptoms common in PD. Depression may affect glu- sources that are rich in EPA and DHA are recommended.100 As
tamate, which activates receptors and alters the hippocampal fish are contaminated with methylmercury and polychlorinat-
excitatory synapse, which affects cognition, another common ed biphenyl, prescribed n-3 supplements should be purified.
feature of PD. Stress reduction should be addressed in the man- The suggested dose is 1 g increasing to 4 g daily as tolerated.38,39
agement of PD, as it has the potential to reduce symptoms and Consuming probiotic supplements and prebiotics as food
improve overall health and quality of life. sources reduces inflammation and oxidative stress to heal the

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gut and correct the balance of microbes. As there is limited in- Parkinsons Dis 2017;7:359-367.
11. Salat-Foix D, Tran K, Ranawaya R, Meddings J, Suchowersky O. Increased
formation regarding specific strains for PD, supplementation
intestinal permeability and Parkinson disease patients: chicken or egg?
with 8 × 109 CFU live bacteria with a variety of species is a gen- Can J Neurol Sci 2012;39:185-188.
eral recommendation based on the available research. 12. Umemura A, Oeda T, Yamamoto K, Tomita S, Kohsaka M, Park K, et al.
Baseline plasma C-reactive protein concentrations and motor prognosis
A systematic search of the literature has provided research re-
in Parkinson disease. PLoS One 2015;10:e0136722.
garding diet patterns, supplements, and PA, with limited research 13. De Filippis F, Pellegrini N, Laghi L, Gobbetti M, Ercolini D. Unusual sub-
on probiotics, vitamin C, individual B vitamins and the impact genus associations of faecal Prevotella and Bacteroides with specific di-
etary patterns. Microbiome 2016;4:57.
of sleep and stress on PD. Another limitation of the literature re-
14. Mihaila D, Donegan J, Barns S, LaRocca D, Du Q, Zheng D, et al. The
view is that a single author evaluated the literature and assigned oral microbiome of early stage Parkinson’s disease and its relationship
a GRADE to categories of research. Regardless of the limitations, with functional measures of motor and non-motor function. PLoS One
2019; 14:e0218252.
the research suggests that providing nutrition and lifestyle in-
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16. Narayan S, Liew Z, Paul K, Lee PC, Sinsheimer JS, Bronstein JM, et al.
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timated residential exposure to agricultural chemicals and premature
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Conflicts of Interest 18. Gorell JM, Johnson CC, Rybicki BA, Peterson EL, Kortsha GX, Brown
The author has no financial conflicts of interest. GG, et al. Occupational exposure to manganese, copper, lead, iron, mer-
cury and zinc and the risk of Parkinson’s disease. Neurotoxicology 1999;
Acknowledgments 20:239-247.
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