ORIGINAL RESEARCH Current practice in nutrition

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Nutrition & Dietetics 2013; ••: ••–••

DOI: 10.1111/1747-0080.12077

ORIGINAL RESEARCH

Current practice in nutrition assessment for the management of Parkinson’s disease in Australia and Canada Jamie M SHEARD1,2 and Susan ASH1,2 1

Institute of Health and Biomedical Innovation, and 2School of Exercise and Nutrition Sciences, Queensland University of Technology, Kelvin Grove, Queensland, Australia

Abstract Aim: To document and compare current practice in nutrition assessment of Parkinson’s disease by dietitians in Australia and Canada in order to identify priority areas for review and development of practice guidelines and direct future research. Methods: An online survey was distributed to DAA (Dietitians Association of Australia) members and PEN (Practicebased Evidence in Nutrition) subscribers through their email newsletters. The survey captured current practice in the phases of the Nutrition Care Plan. The results of the assessment phase are presented here. Results: Eighty-four dietitians responded. Differences in practice existed in the choice of nutrition screening and assessment tools, including appropriate body mass index ranges. Nutrition impact symptoms were commonly assessed, but information about Parkinson’s disease medication interactions was not consistently assessed. Conclusions: The variation in practice related to the use of screening and assessment methods may result in the identification of different goals for subsequent interventions. Even more practice variation was evident for those items more specific to Parkinson’s disease and may be due to the lack of evidence to guide practice. Further research is required to support decisions for nutrition assessment of Parkinson’s disease.

Key words: clinical nutrition and dietetics, evidence-based practice, nutrition assessment, nutritional status, Parkinson’s disease.

Introduction Parkinson’s disease (PD) is increasing in prevalence globally as the population ages.1,2 There are a number of aspects related to PD requiring nutrition management3,4 but there is a paucity of quality evidence on which to base nutrition management of PD. The motor symptoms of PD include bradykinesia, akinesia, resting tremor, muscle rigidity and postural instability, and non-motor symptoms include depression, anxiety, dementia, loss of olfactory sense, dysphagia, slowed gastric motility (resulting in early satiety and constipation) and orthostatic hypotension. These may contribute to malnutrition. On the other hand, decreased voluntary physical activity and preference for sweet or fatty foods5,6 may J.M. Sheard, BHlthSci (Nutr & Diet) (Hons), BAppSci (HMS) (Hons), APD, PhD candidate S. Ash, PhD, AdvAPD, Professor Correspondence: J.M. Sheard, Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD 4059, Australia. Email: [email protected] Accepted July 2013

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predispose people with Parkinson’s disease (PWP) to weight gain. Symptom management typically involves the use of dopaminergic medication, commonly in the form of levodopa,7 or dopamine agonists.8 Long-term levodopa use can result in motor fluctuations and dyskinesias (involuntary movements)7,9 while dopamine agonists can result in compulsive eating.10 Deep brain stimulation surgery is also becoming more popular for symptom management, following which weight gain is commonly reported.11 Because of slowed gastric motility, absorption of levodopa at the jejuno-duodenal border can be delayed if medication is taken with meals.12 Therefore, taking levodopa medication 30–45 minutes prior to a meal may improve the therapeutic response. Competitive absorption between levodopa and amino acids in protein-containing foods may also exacerbate motor fluctuations.13 Modified protein diets have been suggested to manage this, which may result in reduced protein intake and compromised nutritional status if not managed appropriately. The symptoms and medical management, therefore, can result in either undernutrition or overnutrition while symptoms such as dysphagia and constipation require specific management. 1

J.M. Sheard and S. Ash

Nutrition assessment as part of medical nutrition therapy for PD should cover these nutrition issues for effective nutrition diagnosis and subsequent intervention planning. Investigating current nutrition-related practice will identify priority areas for review and development of practice guidelines and direct future research. The primary aim of the present study was to document and compare current practice in nutrition assessment as part of the nutritional management of PWP by dietitians in Australia and Canada and to determine the extent of practice variation between practice areas and countries.

Methods Members of the Dietitians Association of Australia (DAA) (n = 4500) and subscribers of the Canadian Practice-based Evidence in Nutrition (PEN) service (n = 3400, excluding DAA members) were approached by their respective email newsletters to complete an online survey. Email invitations were also sent to the disability and residential aged care DAA interest groups. No exclusion criteria were applied to the recruitment process. Informed consent was obtained as per protocol approved by the Queensland University of Technology Human Research Ethics Committee. Survey. The survey was developed using Key Survey, and the questions were presented within the four phases of the Nutrition Care Plan: nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition evaluation/ monitoring.14 DAA members had 10 weeks, and PEN subscribers four weeks, to respond. There were 39 questions with a mix of multiple-choice and open-ended questions. Information about demographics, practice setting, level of confidence in practice with PWP, commonly asked patient/client questions and information needs was obtained. The ‘clinical’ practice setting represented the acute care setting. Nutrition assessment questions (n = 12) covered malnutrition, anthropometric methods, nutritionrelated symptoms, medications, biochemical measures, macro- and micronutrient intake, and use of nutrition supplements. The questions about the nutrition diagnosis (n = 1), nutrition intervention (n = 11) and nutrition monitoring (n = 3) phases are covered elsewhere (Jamie M. Sheard et al., unpublished results, 2013). Respondents were able to provide more than one response to the majority of questions. Statistical analyses. Open-ended responses and those provided in the ‘Other’ response choice were categorised according to the researcher’s judgment. If the response was considered to be similar to an existing answer, it was included in the frequency for that answer rather than in the ‘Other’ category. Results are presented as frequencies, and percentages may not total 100% for those questions where multiple responses were allowed. χ2 tests and Fisher’s exact tests (cell count less than 5) were conducted to determine differences in responses between practice categories and country of practice. Statistical analysis was completed using SPSS Version 19 2

(SPSS Inc., Chicago, IL, USA). Statistical significance was set at P < 0.05.

Results There were 84 responses to the survey (1% response rate of total members/subscribers). The respondent from Singapore, a member of DAA, was included with the Australian respondents. The majority of respondents worked in Australia (79.8%, n = 67/84), had worked in dietetics for more than five years (59.5%, n = 50/84) and spent less than 25% of their working time with PWP (88.1%, n = 74/84) (Table 1). Twenty-eight (33.3%) reported working in more than one area of practice. Significantly more of the Canadian dietitians reported working in the aged care setting (χ2 = 7.42, P = 0.012) (Table 1). ‘Other’ practice area responses included management, corporate, rehabilitation and mental health. Referrals originated from other allied health professionals (63.1%, n = 53/84), other medical professionals (geriatricians and nursing staff) (39.3%, n = 33/84), general practitioners (GPs) (32.1%, n = 27/84), neurologists (17.8%, n = 15/84), self-referrals (11.9%, n = 10/84) and community programs (4.8%, n = 4/84). ‘Other’ responses included referrals from routine screening in hospital (3.6%, n = 3/84) and routine assessment in aged care facilities (9.5%, n = 8/84). Referrals from GPs were reported significantly less by clinical dietitians (23.7% vs 52.0%, χ2 = 6.44, P = 0.020) and significantly more by community (64.7% vs 23.9%, χ2 = 10.36, P = 0.002) and private practice (73.3% vs 23.2%, Fisher’s exact test, P = 0.000) dietitians. Canadian dietitians reported significantly more referrals from ‘Other’ sources (50.0% vs 14.7%, Fisher’s exact test, P = 0.005). The majority of the respondents (79.8%, n = 67/84) had medium to high level of confidence working with PWP. Confidence did not differ significantly based on years of experience or % of working time spent with PWP. Nearly all respondents (98.8%, n = 83/84) reported a need for evidence-based guidelines for nutrition-related management of PD. Self-initiated literature reviews and textbooks were the most commonly reported resources used to guide the nutrition management of PD (Table 1). PEN was used significantly more by Canadian dietitians (χ2 = 30.98, P = 0.000). The majority of respondents (82.1%, n = 69/84) reported routine nutrition screening using a validated screening tool (76.2%, n = 64/84) (Table 2). ‘Other’ responses included a facility/department-generated screening tool (4.8%, n = 4/84), clinical judgment (1.2%, n = 1/84) and nutrition assessment only (1.2%, n = 1/84). The Malnutrition Screening Tool (MST)15 was the most highly used screening tool overall (44.0%, n = 37/84) (Table 2) and across the majority of the practice settings (Figure 1). There were significant differences between countries in the use of the MST (χ2 = 15.56, P = 0.000), the Nutritional Risk Screening tool16 (χ2 = 5.78, P = 0.045) and the use of other screening tools (X2 = 9.50, P = 0.011) (Table 2). © 2013 Dietitians Association of Australia

Nutrition assessment of Parkinson’s disease

Table 1 Practice characteristics of the dietitians (n = 84) who responded to the online survey regarding nutrition management practices for Parkinson’s disease as a total sample and also by country Participant characteristics Country of practice Australia Canada Other: Singapore Years of experience as a dietitian (years) 5 Area of dietetic practice Clinical (acute care) Community nutrition and public health Private practice/consultancy Food service and management Food industry Research Aged care Other Time spent with PD patients/clients (%) 0–25 >25 Confidence in the nutritional management of people with PD 1–2 (low level) 3 (medium level) 4–5 (high level) Resources currently used NICE clinical guidelines for management of Parkinson’s disease BDA consensus on the nutritional management of Parkinson’s disease PEN knowledge pathway Internal organisational practice guidelines/protocols Self-initiated literature review Textbooks Other

Total sample n (%)

Australia n (%)

Canada n (%)

67 (79.8) 16 (19.0) 1 (1.2)

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— — —

8 (9.5) 26 (31.0) 50 (59.5)

8 (11.8) 20 (29.4) 40 (58.8)

0 (0) 6 (37.5) 10 (62.5)

59 (70.2) 17 (20.2) 15 (17.9) 5 (6.0) 1 (1.2) 4 (4.8) 24 (28.6)* 5 (6.0)

48 (70.6) 16 (23.5) 12 (17.6) 4 (5.9) 1 (1.5) 4 (5.9) 15 (22.1) 4 (5.9)

11 (68.8) 1 (6.3) 3 (18.8) 1 (6.3) 0 (0) 0 (0) 9 (56.3) 1 (6.3)

74 (88.1) 10 (11.9)

62 (91.2) 6 (8.8)

12 (75.0) 4 (25.0)

17 (20.2) 43 (51.2) 24 (28.6)

13 (19.1) 34 (50.0) 21 (30.9)

4 (25.0) 9 (56.3) 3 (18.8)

15 (17.9) 10 (11.9) 19 (22.6)* 27 (32.1) 45 (53.6) 39 (46.4) 6 (7.1)

14 (20.6) 10 (14.7) 7 (10.3) 25 (36.8) 34 (50.0) 33 (48.5) 6 (8.8)

1 (6.3) 0 (0) 12 (75.0) 2 (12.5) 11 (68.8) 6 (37.5) 0 (0)

* Significant differences between country of practice, P < 0.05. BDA, British Dietetic Association; NICE, National Institute for Health and Clinical Excellence; PD, Parkinson’s disease; PEN, Practice-based Evidence in Nutrition.

The Malnutrition Universal Screening Tool17 was used significantly more often by community-based respondents (29.4% vs 7.5%, χ2 = 6.23, P = 0.013) (Figure 1). Respondents in aged care were significantly less likely to use the MST (16.7% vs 55.0%, χ2 = 10.22, P = 0.002), and they were more likely to report not screening for nutritional risk (33.3% vs 11.7%, χ2 = 4.60, P = 0.053). The majority of respondents (85.7%, n = 72/84) reported routine nutrition assessment and the use of a validated assessment tool (73.8%, n = 62/84) (Table 2). ‘Other’ responses included a facility/department/individualgenerated assessment tool (3.6%, n = 3/84), clinical judgment (3.6%, n = 3/84) and screening only (1.2%, n = 1/84). The Subjective Global Assessment (SGA)18 was the most highly used assessment tool overall (44.0%, n = 37/84) (Table 2) and across the majority of the practice settings (Figure 2). There were significant differences between countries in the use of the SGA (χ2 = 7.98, P = 0.005) and © 2013 Dietitians Association of Australia

the use of ‘Other’ assessment tools (χ2 = 10.83, P = 0.005) (Table 2). Respondents in aged care were significantly less likely to use the SGA (16.7% vs 55.0%, χ2 = 10.22, P = 0.002) and more likely to use the Mini-Nutritional Assessment (MNA) (45.8% vs 21.7%, X2 = 4.91, P = 0.035) (Figure 2). Because of the disability related to PD, information about the method of measuring weight and height for wheelchairor bed-bound patients/clients was collected. Weight was most often obtained by hoist or wheelchair scales (67.9%, n = 57/84). Six (7.1%) reported the use of other measures (mid-arm or calf circumference). ‘Other’ choices to document weight in these patients/clients included patient/carer/ spouse self-report (8.3%, n = 7/84), estimated based on recent weight changes (6.0%, n = 5/84), medical records (4.8%, n = 4/84), and do not obtain a weight (4.8%, n = 4/84). To obtain height, 33.3% (n = 28/84) reported the use of ulna length followed by records (drivers license, medical 3

J.M. Sheard and S. Ash

Table 2 Reported practice in the nutrition assessment phase of the NCP by 84 dietitians in Australia and Canada reported as a total sample and also by country as frequency (%)

Method of nutrition screening MST15 MUST17 SNAQ32 MNA-SF33 NRS-200216 Do not screen Other Method of nutrition assessment SGA18 PG-SGA34 MNA35 Do not assess Other Nutrition impact symptoms Poor appetite Dysphagia Constipation Dentition Nausea/vomiting Mental health Diarrhoea Early satiety Dry mouth Taste changes Pain Lack of smell Do not assess Other Macro- and micronutrients Energy Protein Fat Carbohydrates Fibre Alcohol Calcium Iron Vitamin D Vitamin B6 Vitamin B12 Do not assess nutrients Other nutrients Timing of medications with food/meals Use of vitamin/mineral/herbal supplements Collaboration with other health professionals Speech therapists Occupational therapists General practitioners Neurologists Other Work alone

Total sample n (%)

Australia n (%)

Canada n (%)

37 (44.0)* 10 (11.9) 2 (2.4) 25 (29.8) 5 (6.0)* 15 (17.9) 6 (7.1)*

37 (54.4) 10 (14.7) 2 (2.9) 18 (26.5) 2 (2.9) 12 (17.6) 2 (2.9)

0 (0) 0 (0) 0 (0) 7 (43.8) 3 (18.8) 3 (18.8) 4 (25.0)

37 (44.0)* 12 (14.3) 24 (28.6) 12 (14.3) 8 (9.5)*

35 (51.5) 12 (17.6) 18 (26.4) 9 (13.2) 3 (4.4)

2 (12.5) 0 (0) 6 (37.5) 3 (18.8) 5 (31.3)

83 (98.8) 82 (97.6) 79 (94.0) 70 (83.3) 64 (76.2) 57 (67.9) 55 (65.5) 54 (64.3) 51 (60.7) 51 (60.7) 39 (46.4) 30 (35.7) 0 (0) 20 (23.8)

67 (98.5) 66 (97.1) 63 (92.6) 57 (83.8) 54 (79.4) 44 (64.7) 43 (63.2) 44 (64.7) 40 (58.8) 40 (58.8) 31 (45.6) 24 (35.3) 0 (0) 16 (23.5)

16 (100) 16 (100) 16 (100) 13 (81.3) 10 (62.5) 13 (81.3) 12 (75.0) 10 (62.5) 11 (68.8) 11 (68.8) 8 (50.0) 6 (37.5) 0 (0) 4 (25.0)

82 (97.6) 80 (95.2) 30 (35.7) 34 (40.5) 66 (78.6) 29 (34.5) 52 (61.9) 40 (47.6) 37 (44.0) 6 (7.1) 23 (27.4) 2 (2.4) 5 (6.0) 59 (70.2)* 66 (78.6)

67 (98.5) 66 (97.1) 24 (35.3) 29 (42.6) 52 (76.5) 25 (36.8) 40 (58.8) 32 (47.1) 28 (41.2) 6 (8.8) 19 (27.9) 1 (1.5) 4 (5.9) 52 (76.5) 52 (76.5)

15 (93.8) 14 (87.5) 6 (37.5) 5 (31.3) 14 (87.5) 4 (25.0) 12 (75.0) 8 (50.0) 9 (56.3) 0 (0) 4 (25.0) 1 (6.3) 1 (6.3) 7 (43.8) 14 (87.5)

72 (85.7) 50 (59.5) 42 (50.0) 28 (38.3) 28 (33.3) 3 (3.6)

57 (83.8) 41 (60.3) 31 (46.3) 22 (32.4) 23 (33.8) 3 (4.4)

15 (93.8) 9 (56.3) 11 (68.8) 6 (37.5) 5 (31.3) 0 (0)

* Significant differences between country of practice, P < 0.05. MNA, Mini-Nutritional Assessment; MNA-SF, Mini-Nutritional Assessment Short Form; MST, Malnutrition Screening Tool; MUST, Malnutrition Universal Screening Tool; NCP, Nutrition Care Plan; NRS-2002, Nutritional Risk Screening; PG-SGA, Patient-Generated Subjective Global Assessment; SGA, Subjective Global Assessment; SNAQ, Short Nutritional Assessment Questionnaire.

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Figure 2 Nutrition Assessment Tool use by area of practice expressed as a percentage of respondents in each area (MNA, Mini-Nutritional Assessment; PG-SGA, Patient-Generated Subjective Global Assessment; SGA, Subjective Global Assessment). *Significant differences when compared with the rest of the practice areas, P < 0.05. records, etc.) (23.8%, n = 20/84), knee height (21.4%, n = 18/84), demi-span (13.1%, n = 11/84), n/a (all mobile; do not use height) (13.1%, n = 11/84) and self-report (6.0%, n = 5/84). © 2013 Dietitians Association of Australia

Age-specific body mass index (BMI) categories were used by 26.2% (n = 22/84). The most commonly healthy weight categories used for older adults were 22–27 kg/m2 (63.6%, n = 14/22), 23–29 kg/m2 (9.1%, n = 2/22) and one each for 5

J.M. Sheard and S. Ash

22–25 kg/m2 and Master tables.19 Categories used among younger adults included 20–25 kg/m2 (45.5%, n = 10/22) and 18.5–25 kg/m2 (36.4%, n = 8/22). When age was not taken into consideration, the most common BMI categories were 22–27 kg/m2 (32.2%, n = 19/59), 20–25 kg/m2 (11.9%, n = 7/59) and 18.5–25 kg/m2 (10.1%, n = 6/59). Nine other BMI categories were used by 15.5% (n = 9/59) of the respondents. Three (3.6%) reported not using BMI. All respondents assessed nutrition impact symptoms (Table 2). Of these, early satiety, constipation and nausea/ vomiting were significantly less likely to be assessed in the aged care setting (χ2 = 7.49, P = 0.011; χ2 = 6.89, P = 0.022; χ2 = 8.98, P = 0.005). Private practice was the only area in which respondents reported not assessing macro- or micronutrients (13.3%, χ2 = 9.42, P = 0.030) (Table 2). Information about timing of PD medications with meals and the use of vitamin and mineral supplements was also commonly collected (Table 2). Dietitians from Canada were significantly less likely to assess the timing of PD medications with meals (χ2 = 6.63, P = 0.015).

Discussion This is the first survey to report the way in which dietitians assess nutrition-related issues in PWP. The results reflect the responses of dietitians of varying levels of experience and practicing in a number of settings in Australia and Canada and indicate that variation in practice does exist. This variation is particularly evident in the use of nutrition screening and assessment tools, which differed based on work area and country of practice. The use of the MST in Australia may be explained by the fact that it was developed in Australia and is included in the Waterlow Pressure Ulcer/ Injury Risk Assessment tool in acute care facilities. The MNA-Short Form and full MNA do not require specialised training, can be completed by other health professionals and therefore may be the best option in settings where others complete screening, such as in aged care. This may explain the wide use in Canada where the majority of respondents worked in aged care. While the choice of screening and assessment tools should be specific to the setting and to the population,20 none of the available tools have been validated for use in PD. Therefore, the current use of these tools may reflect what is perceived to be the best tool for the setting. There was greater reported variation in the use of BMI categories to identify underweight and overweight. Thirteen different BMI categories were reported along with the use of average weight and height values for adults aged 65–94 in 1960.19 About a quarter of dietitians also reported using different categories depending on the age of the PWP (/= 65 years). Unfortunately, the survey did not ascertain on which evidence the choice of these categories was based or whether they were based on personal preference or experience. PD is accompanied by disability that can result in loss of mobility, and further variation was reported in the documenting of height and weight in PWP who were chair or bed bound potentially further confounding the use of BMI. 6

The use of different screening and assessment tools/ methods, height and weight measurements, and BMI categories across settings may present challenges in standardising the delivery and monitoring of nutrition-related care. Different methods to identify those in need of nutrition intervention may result in different interventions and inconsistent care by different dietitians for the same patient. This population could benefit from the use of a validated assessment tool that identifies nutrition risk independent of anthropometry. Current work underway to standardise the definition and assessment of nutrition risk21 may assist with guidance for standardised practice globally and across practice settings. Country differences also existed in practice related to the assessment of medication and meal timing. With more advanced disease and increasing and more frequent medication doses, the practice of separating meals and medication could become more important to help with achieving optimal therapeutic benefit. The physical act of eating could also benefit from the patient being in an optimally medicated state. While three-fourths of Australian dietitians assessed this timing, less than one-half of Canadian dietitians did. The majority of Canadian dietitians reported working in aged care settings where control of medications and meals are outside of the patient’s control. However, advocating for a change in those settings could potentially improve symptom control and subsequently dietary intake. Assessment of nutrition risk in PD should include documentation of the presence of nutrition impact symptoms, many of which occur more commonly than in other conditions. Previous research has identified that poor appetite, dysphagia, constipation and depressive symptoms play important roles in nutritional risk in PWP.22,23 The current results support these findings with the symptoms of poor appetite, dysphagia and constipation the most commonly assessed by the responding dietitians. Mental health, however, was not as frequently assessed perhaps because dietitians are not confident working with clients with mental health issues.24 The remainder of the nutrition impact symptoms was assessed at lower rates despite their high prevalence in PD, particularly early satiety25 and loss of olfaction.26 A number of micronutrients have been identified as being important in PWP, including calcium,27 vitamin D28 and vitamin B12.29,30 However, these were not consistently assessed by the surveyed dietitians. The risk of osteoporosis and falls is higher in PWP,31 highlighting the importance of adequate calcium intake and vitamin D status. Vitamin B12 may be reduced due to interactions with medications29,30 and by avoidance of protein-containing foods. This may result in symptoms similar to those of PD and treatment for worsening of PD symptoms rather than a vitamin deficiency. Nearly 100% of the dietitians reported the need for evidence-based guidelines to guide practice despite a medium to high level of confidence in the nutrition management of PD. This might be explained by the fact that over half reported relying on self-initiated literature reviews. Given that patients with PD represented a relatively small portion of total client time, reviewing and assessing literature © 2013 Dietitians Association of Australia

Nutrition assessment of Parkinson’s disease

may not be an efficient use of resources. Furthermore, about one-third of respondents reported the use of internally developed guidelines. These could collectively contribute to a shared evidence resource such as the PEN resource developed by Dietitians Canada. Only a quarter of respondents reported the use of available guidelines. The NICE (National Institute for Health and Clinical Excellence) guidelines provide only limited nutrition-related information while few dietitians may have been aware of the British Dietetic Association guidelines. Lack of exposure to these and PEN at the time of the survey may have limited their use. Furthermore, there are currently limited practice questions available in PEN, and they do not reflect the complex and varied nutritional issues requiring management in PD. However, consistency in practice across countries may be assisted by the move towards the use of PEN as a basis for evidence-based practice for both Canadian and Australian dietitians with the development of further practice questions. Further challenges exist relating to referrals from other health professionals. Responding dietitians reported receiving the majority of their referrals from other allied health professionals with only 20 and 30% from neurologists and GPs. Differences could be seen between practice areas, which is not surprising given that different referral pathways exist for each setting. However, a number of PWP requiring nutrition assistance may be missed, particularly in the community, if referrals are generated primarily from other allied health professionals. Monitoring of PD symptoms and treatment regime occurs on a regular basis and it is those health professionals who should be screening for nutrition-related issues and providing appropriate referrals. One limitation of the study is the low proportion of both Australian dietitians, whose response rate to surveys issued through DAA is generally 6% ( J Rodwell, personal communication, 2009), and Canadian respondents, the majority of who were in aged care. Comparisons between countries and particularly between practice areas across countries were therefore limited. However, it is unknown how many dietitians who were approached have contact with PWP within their practice, which presents challenges in determining an accurate response rate among those dietitians. Furthermore, the survey questions related directly to the participating dietitians’ practice but did not capture whether other health professionals may be responsible for some aspects of nutrition-related care, such as nutrition screening. This may explain the low rates of nutrition screening reported by some dietitians. The reason for referrals was also not obtained, which may have highlighted the nutritionrelated issues considered important by other health professionals. In addition, depending on the method of macro- or micronutrient intake assessment (qualitatively or quantitatively), some dietitians may not have responded that they assess specific nutrients if they did not quantitatively determine intake for each. Understanding current practice can highlight those areas for which further evaluation and generation of evidence is © 2013 Dietitians Association of Australia

required to support nutrition-related assessment. The present study highlights the level of variation in practice in the nutrition assessment of PWP. The use of different assessment methods may influence the goals of subsequent interventions, and the confusion about the most appropriate BMI range is a concern. For those items that are more specific to PD, such as managing medication or the need to monitor specific micronutrients, there was more variation in practice, potentially due to the lack of experience and limited working exposure with PD. About half of the responding dietitians reported relying on literature reviews to support their practice with PWP and could therefore benefit from the development of evidencebased guidelines. Further research should be conducted to provide evidence for the most appropriate tools in this population. Current guidelines should include information about all aspects of nutrition assessment of relevance in PD.

Authorship J.M. Sheard: conceived the study, designed the questionnaire, collected data, analysed the data, wrote the manuscript. S. Ash: conceived the study, reviewed the questionnaire, provided input in the data analysis, critically reviewed the manuscript, approved the final manuscript.

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