Chapter 2 30 may result in less consumption of fresh foods and vegetables, which leads to a risk of malnutrition.(47) Researchers in other fields consistently reported healthier food choices among women compared to men, including increased consumption of fresh fruit and vegetables and reduced consumption of processed food and alcohol.(48,49) Encouragement by nutritionists of the consumption of healthy, solid, foods should consider these gender norms, as well as direct assessment of the ability to prepare and consume foods due to disease-related physical limitations. Again, this is an area in which a gender-sensitive care intervention for people with PD could be informed by data from other fields. However, to our knowledge, no studies have examined the effectiveness of gender-sensitive approaches to nutrition among people with PD to date. Once validated, gender-sensitive approaches may also help to better understand differences in body weight related impairments between men and women with PD. A useful example here comes from the field of cardiometabolic diseases, in which the observation of body fat distribution differences between women and men led to the identification of the hip-to-waist ratio as a better predictor of risk than BMI, especially for women.(50) Among people with PD, weight loss generally associates with higher mortality and worse quality of life.(51) While unexplained weight change is reported more commonly in women with PD (52,53), clinically significant weight loss is reported to be associated with lower 1-year survival rates in men, compared to women with PD.(54) Future studies should examine the sex-specific prognostic utility of weight loss among people with PD. Gender considerations are also relevant in the context of physical activity. Women worldwide appear to engage less frequently in physical activity compared to men.(55) Different drivers can modulate the uptake of physical activity in women and men with PD. Women appear to rely on enjoyment as the primary motivator while men describe self-efficacy as the primary driver for physical activity.(56) In different regions, genderrelated factors might also be at play. For example, in a qualitative study in Jordan, women with PD reported family commitment and support as important elements to initiate and maintain an exercise program. However, gender norms acted as barriers as unequal division of household tasks and childcare limited the time available for exercise.(57) Different motivation strategies might be needed for women and men with PD and gender norms should be made explicit to reduce barriers to exercise (Table 1). Examples could be drawn from gender-sensitive programs to increase physical activity and promote healthy weight such as WISEWOMAN in the United States and Football Fans in Training (FFIT) in the UK.(58,59)
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