Best practice guidance for dietitians on the nutritional management

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In partnership with

Best practice guidance for dietitians on

the nutritional

management of Parkinson’s

Introduction

Nutritional management at different stages of Parkinson’s

Diagnosis and early disease

Dietetic assessment

Dietary intervention

Healthy eating

Weight maintenance

High fibre diet with good fluid intake

Antioxidants

Co-enzyme Q10

B Vitamins

Vitamin D

Monitoring

Advanced disease

Dietetic assessment

Dietary intervention

Oral nutrition support (ONS)

Artificial Nutrition Support (ANS)

Bone health/Osteoporosis

Orthostatic hypotension (OH)

Dietary management of OH

PPH accompanied by weight loss

Weight gain post-deep brain stimulation

Dietary protein manipulation

Monitoring

Palliative Care

Dietetic assessment

Dietary intervention

Monitoring

Summary

References

Acknowledgements

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Introduction

People living with Parkinson’s are particularly susceptible to weight loss and malnutrition.

Involuntary movements associated with Parkinson’s result in increased energy expenditure,

while disease symptoms and medication side effects can limit food intake and alter

metabolism. They may also choose to follow unconventional nutritional therapies that

consequently exacerbate malnutrition. Dietitians play a key role in helping people with

Parkinson’s to optimise their nutritional status and manage various nutrition-related

symptoms and medication side effects. To assume this role, dietitians need to have up-to-

date knowledge about the nutritional consequences of Parkinson’s, as well as strategies

for managing a variety of nutrition-related symptoms.

For an overview of Parkinson’s Disease, including symptoms and treatments, we

recommend accessing the Parkinson’s UK website

for up-to-date information, and

signposting to other learning content and programmes. In order to help establish any

learning needs you may have, it is recommended you utilise the AHP Competency

Framework for Progressive Neurological Conditions

, which also includes a section

dedicated to Parkinson’s Disease

Nutritional management at different stages of Parkinson’s

Diagnosis and early disease

Parkinson’s can be a challenging diagnosis to make in its early stages. It is a diagnosis based

on clinical observation and exclusion of other conditions

NICE recommend considering referring people with Parkinson’s Disease to a dietitian for specialist

advice

Dietetic assessment

The initial assessment could be facilitated by another healthcare professional as well as a

dietitian e.g. Parkinson’s Nurse, GP or practice nurse. Examples of assessments that could

be undertaken are: weight; height; body mass index (BMI); and/or using a validated nutrition

screening tool e.g. the Malnutrition Universal Screening Tool (MUST)

5, or the Patients

Association Nutrition Checklist

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Dietary intervention

Healthy eating

There is no specific diet required; however, people newly diagnosed with Parkinson’s

should be advised to eat a healthy and well-balanced diet. Good nutrition is essential to the

wellbeing of this client group. It is imperative to establish and maintain good eating habits

throughout the course of the condition

Written and verbal information should be provided on how to adopt the Healthy Eating

Guidelines set out by the Food Standards Agency (FSA) and are incorporated into the

Parkinson’s UK resource Diet and Parkinson’s

Weight maintenance

Being underweight, something commonly experienced by those living with Parkinson’s, as

well as being overweight can lead to adverse health effects. In overweight individuals, it is

advised that an agreed goal for ideal body weight should be established. This is especially

significant in those who have co-morbidities e.g. hypertriglyceridaemia, diabetes, CVD etc.

Unintentional weight loss is common; people with Parkinson’s are at increased risk of

malnutrition and nutritional status should be monitored routinely regularly throughout the

course of the disease

. Malnutrition in Parkinson’s is probably under-reported, and

several predictors of malnutrition have been found: older age at diagnosis, higher

levodopa equivalent daily dose/body weight, anxiety and depression and living alone

Dysphagia in also frequently seen, especially in the advanced phases of the disease,

although it can be present at any stage

Body weight should be monitored throughout the course of the disease, and steps taken to

ensure nutritional needs are met – this may include a food first approach, supplementation

including individual vitamins and oral nutrition support when deemed appropriate, as well as

consideration of artificial nutrition support where indicated (i.e. Nasogastric feeding, gastrostomy

and in very rare cases, if the enteral route is ruled out, parenteral nutrition). However, it

should always be remembered, as with many neurological conditions, this client group is

particularly unique and must be treated as individuals; it is well known that this condition

does not affect one person in the same way as the next.

High fibre diet with good fluid intake

Constipation is one of the most common problems experienced by Parkinson’s patients.

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About 60-80% of patients with Parkinson’s complain of constipation, which usually

appears about 10 to 20 years before motor symptoms become evident

It is thought to be caused by damage to the peripheral or central nervous system

Other causes of constipation in Parkinson’s patients are lack of fibre intake, a lack of fluid

intake – often associated with dysphagia, decreased mobility and as a result of some

Parkinson’s medications.

Dietary advice on how to prevent constipation by following a high fibre/fluid intake should

be provided, and supporting written information is available in the Parkinson’s UK resource

Looking after your bladder and bowels when you have Parkinson’s

In addition to advising on a high fibre and fluid intake, ESPEN suggest people with

Parkinson’s experiencing constipation can benefit from the use of fermented milk

containing probiotics and prebiotic fibre

Antioxidants

There is no evidence to support that taking supplemental doses of antioxidants

slows the progression of the condition or enhances the effects of Parkinson’s drugs.

NICE explicitly state that Vitamin E should not be used as a neuroprotective therapy

, and

ESPEN state that supplementation of antioxidants are not recommended

For those who are concerned about their intake of antioxidants, they should be reassured

that a well-balanced diet will meet their antioxidant needs. Signposting them to the section

on Antioxidants in the Parkinsons UK ‘Diet and Parkinsons’ resource will help reinforce

your advice and guidance

Co-enzyme Q10

It was previously thought that taking supplementary co-enzyme Q10 could delay the

progression. However, evidence remains inconclusive and NICE guidance recommends

that co-enzyme Q10 should not be used as a

neuroprotective therapy, except in the context of clinical trials

. Co-enzyme Q10 can be

found naturally in offal, beef, soya oil, oily fish and small amounts in peanuts.

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B Vitamins

ESPEN states that during regular monitoring of nutrition and vitamin status, particular

attention should be focused on folic acid, vitamin B12 and vitamin D

Treatment with levodopa has shown an elevation of homocysteine. This is greater in

patients on higher doses of levodopa and is due to levodopa methylation by catechol-O-

methyltransferase (COMT). Concomitant use of COMT inhibitors may limit the raising of

plasma levels, although the regulation is closely linked to vitamin B12 and folate status.

Studies have shown that levodopa-treated Parkinson’s patients have also lower circulating

levels of folate and vitamin B12. Administration of these vitamins is effective in reducing

homocysteine levels and should be considered to prevent neuropathy and other

complications associated with hyper-homocysteinaemia

– the indication for

supplementation should be considered and discussed with the multi-disciplinary team.

Vitamin D

NICE advises people with Parkinson’s to take a Vitamin D supplement

. See NICE

guidance on Vitamin D for recommendations on vitamin D testing

, and the NICE quality

standards on Falls in Older people

and Osteoporosis

All at risk groups are currently advised to take a supplement that meets 100% of the

reference nutrient intake (RNI) for their age group. At the time of publication, the RNI is 10

micrograms/day for all the general population over 4 years old, and in population groups at

increased risk of vitamin D deficiency

Monitoring

Dietitians that specialise in progressive neurological conditions agree that people

newly diagnosed with, or in the early stages of Parkinson’s, should have a nutritional

assessment and/or their nutritional status reviewed at least on an annual basis if there are

no indications for a more frequent review (e.g. clinical changes), or at the patients’ and/or

multidisciplinary team’s request (this may be by a dietitian, or another health/care

professional) - this is supported by ESPEN

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Advanced disease

Dietetic assessment

Assessment is similar to the early stages of the condition paying particular attention to:

• unintentional weight-loss

• decreased oral intake

• swallowing difficulties

• poor dentition, dry mouth

• changes to taste and smell

• increased frequency of dyskinesias (abnormal involuntary movements)

• early satiety

• gastrointestinal problems: Nausea, vomiting, gastroparesis, reflux, diarrhoea

• constipation

• side effects of medication (see Table 1 below)

• physical difficulties impairing eating and drinking and preparing meals

• bone health

• weight-gain after deep brain stimulator (DBS) insertion

• mental health problems, including impulse control disorders (e.g. binge eating)

• frequency of ‘on’ (increased involuntary movements) and ‘off’ (increased muscle

tone) periods

• orthostatic hypotension (OH) – characterised by a sudden fall in blood

pressure that occurs when a person assumes a standing position

Name of drug

Mode of action

Side effects

Levodopa

(Co-beneldopa, co-

careldopa)

The most effective drug in the

treatment of Parkinson’s.

It is a larger neutral amino

acid – tyrosine derivative –

and is absorbed in the small

intestine. Once absorbed it

crosses the blood-brain

barrier where it is converted to

Prolonged use can result in

nausea, vomiting and

hypotension. Associated with

hyper-homocysteinaemia.

A decarboxylase inhibitor,

Benserazide, is combined

with levodopa to minimise

these side effects.

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dopamine.

Weight loss.

Dopamine

agonists

(pramipexole,

ropinirole)

These are a class of drugs

that provide antiparkinsonian

effects while avoiding some of

the problems associated with

levodopa.

Acute side effects of these

drugs include nausea,

vomiting, postural

hypotension and psychiatric

problems. Increased risk of

developing impulse control

disorders.

They tend to occur with the

initiation of treatment and as

intolerance develops over

several days to weeks.

MAO-B inhibitors

(rasagiline, selegiline,

safinamide)

This is used in the early

stages of Parkinson’s to delay

the use of levodopa. It

provides reduced motor

fluctuations and increased ‘on’

time.

It has amphetamine and

metamphetamine

metabolites which can cause

insomnia, therefore could

induce daytime sleeping.

Anticholinergics

(procyclidine,

trihexyphenidyl)

This is typically used in

younger Parkinson’s patients

(<60 years) in whom resting

tremor is the dominant clinical

feature and cognitive function

is preserved.

Side effects may include dry

mouth, constipation and

nausea

Amantidine

This is an antiviral agent that

is believed to increase

dopamine release by

blocking dopamine re-

Side effects include

confusion, hallucinations,

insomnia, nightmares and dry

mouth.

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uptake

by stimulating receptors and

possibly by anticholinergic

effects.

Table 1: Medication side effects: the following medications are commonly used in the

management of Parkinson’s

Antiemetics are usually used in conjunction with these medications to ease the

symptoms of nausea and vomiting.

Dietary intervention

Oral nutrition support (ONS)

ONS should be provided when the patient can no longer maintain their body weight

through oral diet/intake alone

A food first approach should be explored first, with suggestions such as food fortification,

high energy/protein advice, and regular small energy-dense meals.

The use of oral nutrition support products, including sip feeds, should be considered for

those who are unable to maintain an adequate intake with food alone, or are unable to

adhere to food fortification due to, for example, anxiety at meal times, early satiety or lack

of sufficient help to prepare the fortified meals and snacks.

Imaginative use of these products will help reduce taste fatigue and increase adherence

to recommendations.

Particular attention should be paid to those on a texture modified diet (TMD), especially

puree diets. Puree diets are known to provide varying nutritional adequacy and can be

unpalatable, if not prepared imaginatively. Some fortification techniques and suggestions

may need to be amended. All patients on texture modified diets should have their intake

assessed by a dietitian for nutritional adequacy

It is recommended that the dietitian and speech and language therapist work closely to

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ensure the patient receives appropriate and optimal nutrition and hydration, and

consideration should be given to the use of pre-thickened ONS.

People with Parkinson's should be advised not to take over-the-counter dietary

supplements without first consulting their pharmacist or other healthcare professional

Artificial Nutrition Support (ANS)

In Parkinson’s it often helps to anticipate artificial feeding, or the placement of a feeding

tube to support hydration, at an early stage through discussions with the patient and/or

carer, supported by the multidisciplinary team

Swallowing difficulties need to be addressed promptly to prevent weight loss and

malnutrition. About 95% of Parkinson’s patients experience swallowing difficulties at

some stage of the condition

Silent aspiration can occur, and many people with Parkinson’s may be unaware they

have a problem. When assessing and monitoring, always look out for red flags that

indicate silent aspiration could be happening.

Dysphagia occurs in the later stages of Parkinson’s compared to atypical

parkinsonian syndromes e.g. progressive supranuclear palsy (PSP) or multiple system

atrophy (MSA)

Significant problems with swallowing require expert assessment from a speech and

language therapist and guidance regarding appropriate food texture modification. Since

texture modified diets e.g. puree, may be nutritionally diluted and not energy

dense enough to prevent weight loss, additional supplementary enteral nutrition support

may be indicated.

Tube feeding may be given alongside oral intake, or as the main source of nutrition.

Short-term feeding via nasogastric tube is likely appropriate to manage an acute event

impacting swallow or nutritional intake. For longer term, a gastrostomy (for example a PEG

or RIG) should be considered

Gastrostomies are being used increasingly in the treatment of patients with neurogenic

dysphagia to prevent or reverse nutritional deficits

and this can improve fitness

and quality of life for those patients unable to take sufficient supplements orally.

Reassurance should be given that gastrostomies can be placed before food intake has

fallen or weight loss has occurred, in order to support optimal hydration.

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Bone health/Osteoporosis

People with Parkinson’s have been found to have a lower bone mineral density (BMD)

and increased risk of osteoporotic fracture

. The reasons are multi-factorial and include

low mobility, decreased muscle strength, low body weight, deficiency in Vitamin D, B12,

folic acid and hyperhomocysteinaemia

. As discussed earlier (page 4), Vitamin D

supplementation is recommended for a large proportion of the general population – if a

person is not already on a Vitamin D supplement when they are diagnosed, then they

should be re-assessed as their risk level will be greater.

If BMD is lower, then in line with usual treatment for osteoporosis, calcium

requirements are likely to be increased, and greater than the 700mg/day reference

nutrient intake for the general population over 19yrs old. A supplement may be

required to meet requirements, and this should be discussed with the MDT.

Orthostatic hypotension (OH)

OH (also known as postural hypotension) is a sudden fall in blood pressure that occurs

when a person assumes a standing position.

The prevalence of symptomatic orthostatic hypotension (OH) may be as high as 60% in

people living with Parkinson’s

This could be caused by: a) dopaminergic drugs which induce or worsen orthostatic

hypotension and/or b) primary autonomic failure with an involvement of the peripheral

autonomic system caused by Parkinson’s.

OH sufferers may also experience post-prandial hypotension (PPH), resulting in blurred

vision and dizziness after meals. These symptoms can occur any time from ingestion to

90 minutes post meal. Studies from long-term care facilities have shown that 24-36%

were diagnosed with PPH

24,25

. It has been suggested that the nutrient composition of

meals affect the magnitude of the decrease in postprandial hypotension.

The intestines require a large amount of blood for digestion. When blood flows to the

intestines after a meal, the heart rate increases and blood vessels in other parts of the

body constrict to help maintain blood pressure. However, with this patient group, such

mechanisms may be inadequate. Blood flows normally to the intestines, but the heart

rate does not increase adequately and blood vessels do not constrict enough to

maintain blood pressure. As a result, blood pressure falls.

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Symptoms include:

• feeling dizzy and light-headed

• changes in vision such as blurring, greying or blacking vision

• feeling vague or muddled

• losing consciousness with or without warning – a ‘blackout’ or ‘faint’ as a result of

hypotension

• pain across the back of shoulders or neck – ‘coat hanger’ pain

• pain in lower back or buttocks

• angina-type pain in the chest

• weakness

• fatigue

The symptoms are typically worse when standing and improve on lying down.

Dietary management of OH

The main aim of the dietary management is to assist in the alleviation of the symptoms of

hypotension, by focusing on the factors that affect blood pressure.

The goals of treatment are improving functional capacity and quality of life, and

preventing injury, rather than achieving a target blood pressure

. Dietary changes aim to

alleviate the symptoms of postural and postprandial hypotension and assist with fatigue

management.

The skills of the dietitian are required when advising on ways to manipulate the diet, to

ensure the nutritional adequacy of the diet is not compromised. It should also be ensured

that restrictive diets are not followed, which would lead to further risk of malnutrition in an

already nutritionally vulnerable group of patients.

Advice for people with OH:

• Avoid large meals

- aim for smaller, evenly distributed meals

• Reduce carbohydrate intake, especially simple sugars

28,29

. It has been

hypothesised that carbohydrates induce hypotension in autonomic failure through

the vasodilating properties of insulin

• Increase intake of salt

• Increase fluid intake

• Decrease or omit alcohol intake

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PPH accompanied by weight loss

As the OH progresses, many patients experience weight loss, the reason being

multifactorial. Patients may restrict intake as they associate meals or a certain food with

post-prandial symptoms, or as a consequence of dysphagia.

Deciding upon which oral supplement to use can become a challenge if you are trying

to get your patient to avoid/decrease glucose intake. Some patients can tolerate

energy-dense oral sip feeds without experiencing symptoms, especially if sipped slowly.

However, for those that do experience PPH symptoms, a lipid-based solution such as

Calogen/Procal shots, can be useful. The provision of innovative recipes and

suggestions on how to incorporate these supplements into meals will be helpful to the

person living with PPH.

It is important to liaise with the MDT regarding treatments, as it may be preferred to

manage OH/PPH pharmacologically, allowing nutritional intake to be maximised

If the patient’s autonomic failure is so severe, dietary intervention may not offer any

benefit.

Weight gain post-chronic bilateral subthalamic or deep brain stimulation (CDBS)

Deep Brain Stimulation (DBS) is a procedure in which stimulating electrodes are placed

stereo-tactically into the deep structures of the brain. DBS in selected patients has

provided significant therapeutic benefits. Successful DBS allows a decrease in medication

or makes a medication regimen more tolerable. There are gains in movement and control.

Consequently, the intervention is used for patients who cannot be adequately controlled

with medications or whose medications have severe side effects. Only a very small sub-

group of people (~1-10%) diagnosed with Parkinson’s are eligible for DBS

It has been shown that weight gain can occur in 87% of patient’s post DBS surgery.

Around 38% of these patients were found to be overweight (BMI>26–29.9) six-months

post-operatively. This is thought to be due to improvement in motor fluctuations, rather

than an increase in oral intake

Dietary intervention (using ideal body weight to calculate energy requirements) at time

of surgery has been advocated by researchers in Portugal

to enhance the benefit of

the surgery and prevent metabolic disorders. It is thought that excessive weight gain

could exacerbate motor function impairment in Parkinson’s.

It is suggested that clinicians actively monitor weight changes in these patients

Discussion of, and encouraging adoption of the Healthy Eating Guidelines as set out

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by the Food Standards Agency (FSA) and incorporated into the Diet and Parkinson’s

resources

available from Parkinson’s UK can be a useful to prevent rapid weight gain in

those who are undergoing or have undergone DBS surgery.

Dietary protein manipulation

Levodopa is the standard, and often initial, therapy for patients with this condition;

however, with continued treatment and as the condition progresses, up to 80% of patients

experience ‘wearing off’ symptoms, dyskinesias and other motor complications.

It was believed in the late 1980s and early 1990s that dietary protein manipulation would

help control motor fluctuations

36,37,38,39,40,41

. Levodopa (L-dopa) disappears from the blood

very quickly, usually about 60–90 minutes after administering the drug.

Protein can delay gastric emptying and competes with the absorption of L-dopa, and the

manipulation of dietary protein may reduce fluctuations in some patients.

Current recommendations

are to advise people with Parkinson's disease on levodopa

who experience motor fluctuations, to;

• avoid a reduction in their total daily protein consumption, and

• discuss a diet in which most of the protein is eaten in the final main meal of the day

(a protein redistribution diet)

There is no evidence to support low protein diets

Do not offer creatine supplements to people with Parkinson's disease

Dietary management of any gastro-intestinal symptoms, e.g. delayed gastric emptying,

constipation, may also be beneficial, as these can impair L-dopa efficacy

People with Parkinson’s treated with continuous duodenal duodopa should follow similar

recommendations, and should be advised to distribute food intake throughout the day and

to divide the protein intake

In cases of continuous enteral tube feeding (low-infusion-rate), there are no restrictions

but it is advisable to concentrate feeding during the night hours if possible, in order to limit

interactions

Finally, in tube-fed patients still treated with oral formulations of levodopa-containing

medications it is suggested the pausing of feeding for at least 1 h before and 30-40 min

after drug administration

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Monitoring

Every four to six weeks if there have been any changes to medications or treatment

plan, with particular focus on the swallowing recommendations.

Every three months if the patient’s condition is stable.

For oral nutrition support, regular review of ONS prescriptions every three months

is advisable, to ensure the appropriateness of the intervention. Samples of ONS can be

trialed before any changes are requested to the GP prescription.

Some centres offer one-day holistic reviews to re-assess mobility, swallow, speech and

nutritional status; if you do not have access to these, it is important to liaise with other

members of the MDT to ensure you are keeping in line with the patient’s overall

management plan.

Palliative Care

Palliative care is about helping to keep quality of life through managing symptoms,

relieving pain and managing any other distressing aspects of advanced Parkinson's. The

management of Parkinson’s remains largely palliative, despite huge advances in the

medical field. As Parkinson's progresses, many people will need some element of care

and support alongside their treatment. Palliative care isn't just for 'end of life'. It relies on

healthcare professionals making people with Parkinson’s aware of, and directing them

towards, services and support at an early stage.

NICE recommend that consideration is given to referring people at any stage of

Parkinson's disease to the palliative care team to give them and their family members or

carers (as appropriate) the opportunity to discuss palliative care and care at the end of

life

There is no set time for how long the palliative phase lasts. It can potentially be a long

time, and Parkinson's can still change and develop further within this time

It has been documented that a patient can spend on average 2.2 years in the palliative

care stage

. During this stage there may be a need to withdraw dopaminergic

medications due to lack of drug efficiency. Decreased mobility and being bed-bound can

result in the risk of pressure ulcer development.

Decisions may need to be made about the nutritional management and treatment in the

future to give the person with Parkinson’s an opportunity to state their preferences in

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case they lose capacity for making decisions in the future

Dietetic assessment

Assessment will be similar to the early stage taking into special consideration:

• suitability of active +/- aggressive nutrition support

• prognosis

• palliative care team advice

• multidisciplinary team opinion

• patient's wishes

• any advanced care planning

Dietary intervention

Artificial nutrition support may be withdrawn if it is causing discomfort or distress, or not

deemed to be in patient’s best interest. You may be asked to reduce the volume of enteral

feeds to prevent fluid overload.

Oral nutrition should always be offered but not forced upon those who decline it

or when there is risk of aspiration or choking. If a patient chooses to maintain an oral

intake despite being advised it is unsafe, it should be ensured that the patient is fully

informed of the consequence of their decision, and they should be continued to be

supported.

Monitoring

Monthly reviews may be more appropriate or as agreed with/at the request of the MDT

or palliative care team.

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Summary

The risk of malnutrition and body weight must be routinely monitored from diagnosis, and

as the condition progresses

10,45,46

. Worsening motor symptoms e.g. dyskinesias should

also be monitored to prevent or reverse weight loss in people living with Parkinson’s

10,47

As highlighted throughout this document the nutritional management of a person living with

Parkinson’s may change and evolve throughout the progression of the condition.

Dietitians have the skills to help people living with Parkinson’s to optimise their

nutritional status and manage nutrition-related symptoms at all stages of the condition

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References

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Acknowledgements

This resource was initiated by Parkinson’s UK supported by the British Dietetics

Association (BDA), and was originally published in 2015, authored by Karen Green, Senior

Specialist Dietitian, (Neurosciences), at The National Hospital for Neurology &

Neurosurgery.

The document was reviewed and updated in January 2021 by:

Karen Robinson, Consultant Dietitian, RD, MSc Adv HCP, Chair of the Neurosciences

Specialist Group of the BDA, incorporating feedback and comments from the following

members of the Neurosciences Specialist Group of the BDA:

- Rebecca Picton, Neuroscience Dietitian, University Hospitals Southampton NHS

Foundation Trust.

- Sophie Harries RD BSc

- Anna Bruce, RD