Multiple Factors Affect Renal Dietitians’ Use of the NKF-K/DOQI Adult Nutrition Guidelines

Dietitians' practices in dialysis units in Brazil: nutritional assessment and intervention

INTRODUCTION

The importance of dietitians in dialysis units is indisputable and mandatory in Brazil, but little is known about the practices adopted by these professionals.

OBJECTIVE

To know practices adopted in routine nutritional care, focusing on nutritional assessment tools and treatment strategies for people at risk or diagnosed with malnutrition.

METHODOLOGY

Electronic questionnaire disseminated on social media and messaging applications. It included questions that covered dietitians' demographic and occupational profile characteristics and of the dialysis unit, use and frequency of nutritional assessment tools, nutritional intervention strategies in cases of risk or diagnosis of malnutrition, prescription and access to oral supplements.

RESULTS

Twenty four percent of the Brazilian dialysis units (n = 207) responded electronically. The most used nutritional assessment tools with or without a pre-established frequency were dietary surveys (96%) and Subjective Global Assessment (83%). The strategies in cases of risk or presence of malnutrition used most frequently (almost always/always) were instructions to increase energy and protein intake from foods (97%), and increasing the frequency of visits (88%). The frequency of prescribing commercial supplements with standard and specialized formulas was quite similar. The availability of dietary supplements by the public healthcare system to patients varied between regions.

CONCLUSION

Most dietitians use various nutritional assessment tools and intervention strategies in cases of risk or malnutrition; however, the frequency of use of such tools and strategies varied substantially.

Workforce needs and estimated costs/savings for nutrition care in chronic kidney disease-stage 3 through maintenance dialysis

The role of nutrition in chronic kidney disease (CKD) is well known. However, controversies, misconceptions, and gaps in the literature exist regarding the workforce required to provide nutrition care in CKD. This paper reviews the existing literature on this topic, focusing primarily on the United States. Topics covered in this review include the qualifications and services of the registered dietitian nutritionist (RDN), to which specific patients nutrition care should be provided in CKD and on dialysis, barriers to the utilization of nutrition services, the quantity of nutrition care needed to improve patient outcomes, and the risks of provider burnout. Controversies include whether more staffing is associated with better care and the best measures of staffing. The topics are supported with estimations for the economic impact and practicality of workforce decisions.

Patients' experiences and perspectives of a mobile phone text messaging intervention to improve dietary behaviours in haemodialysis

AIM

Dietary requirements for people on haemodialysis are complex and often poorly adhered to. Mobile phone text messaging offers a simple strategy to enhance current nutritional care. KIDNEYTEXT was a 6-month pilot randomised controlled trial that evaluated the feasibility and impact of mobile phone text messages to alter participants' dietary behaviours. The aim of this study was to elicit the perspectives of people on haemodialysis regarding acceptability of mobile phone text messages targeting dietary behaviours.

METHODS

Semi-structured interviews were conducted with participants in the intervention arm of the KIDNEYTEXT study. Participants were purposively sampled and interviews were conducted in-person or over the phone. Transcripts were thematically analysed using principles of grounded theory.

RESULTS

Interviews were conducted with 25 participants. Four major themes were identified: building awareness (reinforcement of information, simple and comprehensible, guiding choices, accessible information enhancing motivation, gaining skills in management), valuing care (boosting self-esteem, in-person care bolstered by reminders), activating change (adjusting lifestyle, gaining control of electrolytes and fluid, striving to improve overall health), waning attention and motivation (lack of personalisation limiting change, maintaining the status quo, reverting back to old habits).

CONCLUSIONS

Participants perceived that the KIDNEYTEXT intervention enabled participants to build on their knowledge through the dissemination of simple and actionable content. Participants appreciated frequent reminders of how to improve their diet and felt that this increased contact motivated them to alter some dietary behaviours. Future trials should consider strategies to enhance personalisation to further motivate dietary change.

Registered Dietitian Staffing in Dialysis: Impact on Quality Ratings in Mandate and Nonmandate States

OBJECTIVE

Texas is the only state to mandate a patient to full-time equivalent (FTE) registered dietitian (RD) ratio (<125 patients:FTE RD) in dialysis. Little research exists about the relationship between patient:FTE RD ratio and quality. Our objectives were to a) examine the effect of the mandate on patient:FTE RD ratios in Texas facilities compared to similar nonmandated facilities and b) examine the association between patient:FTE RD ratio and the patient rating of staff quality or star rating of the facility.

DESIGN AND METHODS

Using data from Dialysis Facility Annual Reports, we excluded facilities with less than 125 patients and matched based on region, chain/profit status, and number of patients, pairing each Texas facility with 2 non-Texas facilities. T-tests for difference of means and chi-square tests were performed to compare facility groups characteristics and assess mandate impact. We used correlation between patient:FTE RD ratio and staff quality linearized score, and ANOVA to compare patient:FTE RD ratios between the star rating levels.

RESULTS

The patient:FTE RD ratio was higher in non-Texas than Texas facilities (111.84 ± 40.70 vs 90.80 ± 24.02, P < .01). The Pearson correlation between patient:FTE RD ratio and linearized score rating of the dialysis center staff was essentially nonexistent (r = -0.046). We found a trend of higher patient:FTE RD ratios in facilities with lower star ratings for quality and staff but no statistical significance.

CONCLUSION

The mandate effectively lowered the patient:FTE RD ratio in Texas dialysis facilities with over 125 patients, indicating that states considering such a mandate may benefit from implementing it. We found no association between patient:FTE RD staffing and quality, either objectively or via patient assessment. Further research should examine whether dialysis facilities are trending toward smaller patient sizes to circumvent staffing mandates and examine the relationship between other professions' staffing ratios and quality.

Renal Dietitians' Perceptions of the Value of Subjective Global Assessment: A Mixed Methods Study

OBJECTIVE

The objective of this study is to assess how renal registered dietitians (RDs) in Canada perceive the value of Subjective Global Assessment (SGA) to assess protein-energy wasting for clients with chronic kidney disease.

DESIGN AND METHODS

A sequential exploratory mixed method approach included 2 focus groups (n = 6 and 8) and a national survey (n = 54). Two online focus groups were conducted 1 month apart followed by an online survey. Participants included renal RDs working with Stage 5 chronic kidney disease (dialysis and non-dialysis) patients.

RESULTS

Five main themes (consistency, organizational/environment, confidence, interpretation, and education) emerged. Renal RDs support using a tool to provide a standardized process for nutrition assessment and feel SGA is an effective educational tool; however, barriers such as time, privacy, confidence in the tool, as well as ability to perform physical assessment, interpretation, and subjectivity limit the use of SGA. Renal RDs feel that it is important to examine nutrition interventions in conjunction with SGA results.

CONCLUSION

The main results of the study describing the limitations to the clinical use of the SGA tool revolve around RDs' time, confidence, ability to interpret the SGA tool, and how SGA is used by administration. The results support the need for educators and administrators to communicate the use of SGA results and provide education opportunities focusing on the use of validated, reliable, responsive tools to assess nutrition status as well as hands-on physical assessment. In some situations, an alternative validated version of SGA or screening tool may be appropriate.

Registered dietitian nutritionists and perceptions of liberalizing the hemodialysis diet

BACKGROUND/OBJECTIVES

The objective of this study was to assess the level of awareness, comfort, and likelihood of liberalizing the hemodialysis diet in practicing renal registered dietitian nutritionists (RDN).

SUBJECTS/METHODS

An original, cross-sectional survey was sent to the Academy of Nutrition and Dietetics' Renal Practice Group in May 2017, consisting primarily of renal dietitians.

RESULTS

A total of 187 renal dietitians responded to the survey designed to assess their current practices regarding the renal diet for hemodialysis patients and how comfortable they would be liberalizing the current restrictions. On average, 16.3% of dietitians are extremely likely to liberalize the restrictions on various food groups including fruits and vegetables, beans and legumes, and whole grains.

CONCLUSIONS

RDN feel confident in their ability to interpret and apply evidence-based literature into practice, and they are moderately comfortable liberalizing the renal diet. The participants were generally more comfortable liberalizing the phosphorus restriction than the potassium restriction, and the sodium restriction remains important to control interdialytic weight gain and hypertension. Future research is needed to establish efficacy of a liberalized diet as well as interventions to help RDN feel more comfortable implementing a liberalization of the renal diet.

Quantifying the Time Used for Renal Dietitian's Responsibilities: A Pilot Study

OBJECTIVE

The purpose of this study was to quantify how dialysis dietitians spend their time and whether the activities that were most frequent varied based on the ratio of patient to full-time equivalent (FTE) dietitian.

METHODS

This study is a cross-sectional, observational, time-and-motion study carried out using the Work Activity Measurement by Activity Timing software/method for time recording. This study was carried out in 14 dialysis centers in and around Cleveland, Ohio. Fourteen registered dietitian nutritionists participated in this study. The mean time/experience of these nutritionists in dietetics was 26.6 ± 8.5 years. Percent of time in direct care (e.g., patient interaction) versus indirect care (e.g., documentation and plans of care, professional communication) versus other responsibilities (e.g., administrative work, education of self or others).

RESULTS

The mean number of tasks recorded per 3-hour observation session was 38.3 ± 14.0, including 18.5 ± 7.7 indirect care tasks, 7.7 ± 6.2 direct care tasks, and 9.7 ± 5.4 other tasks. The mean number of unique patients seen per observation session was 6.9 ± 5.4; the mean direct care time per patient encounter was 6.95 ± 4.05 minutes. Indirect care took the highest proportion of observed time, 56.0 ± 22.2%, followed by direct care, 24.9 ± 18.8%. Increasing the ratio of patient to FTE had a moderate negative correlation with the percent of time spent in direct patient care (r = -0.35, P = .21), but there was no relationship between the ratio of patient to FTE and direct care time per patient (r = 0.02, P = .94).

CONCLUSION

About 25% of dietitians' time was available for direct patient care. This is much less than that reported in previous studies and may not be sufficient to improve the nutritional status. Limitations of our study include a small sample size from a single region. Further work is needed to understand the balance of responsibilities among renal dietitians and their impact on patient outcomes.

Structural Equation Modeling to Explore Patient to Staff Ratios as an Explanatory Factor for Variation in Dialysis Facility Outcomes

OBJECTIVE

Patient to staff ratios vary based on facility characteristics, and therefore have been proposed as an explanatory factor for the variation in dialysis facility outcomes. This analysis tested that hypothesis.

DESIGN AND METHODS

Observational study using Dialysis Facility Report data. Reported staff numbers from the Annual Facility Survey were converted to full time equivalents (FTE). Subsequently, ratios were created for patients per FTE registered dietitian (RD), social worker, nurse, and patient care technician. Bivariate associations and structural equation modeling (SEM) were used to explore relationships between these ratios and patient outcomes: standardized mortality ratio and standardized hospitalization rate, when also considering the impact of non-modifiable facility characteristics (region, chain, profit status). Our focus was on RD staffing; therefore we also included serum phosphorus and normalized protein catabolic ratio in the model, and also conducted a sub-analysis of the 198 facilities that exceeded the KDOQI maximum of 150 patients:FTE RD.

SUBJECTS

Dialysis centers in the US with at least 30 adult patients and no pediatric patients. 4035 facilities had complete data for the proposed variables.

MAIN OUTCOME MEASURE

Standardized mortality ratio and standardized hospitalization rate were the primary outcomes.

RESULTS

The mean and standard deviation for patients per FTE staff were 90.0 ± 34.0, 88.7 ± 32.8, 17.1 ± 20.5 and 11.9 ± 7.0 for RDs, social workers, nurses, and technicians, respectively. Facility characteristics impacted staffing in bivariate analyses and SEM. The only significant paths from staffing ratio to outcomes were for patient:FTE social worker to SMR (standardized beta = -0.09, 95% CI -0.13, -0.04) and Patients:FTE RD to SHR Days (standardized beta = 0.04, 95% CI 0.001, 0.09). In the sub-analysis, there were no significant paths from staffing to outcomes.

CONCLUSIONS

This study did not provide evidence that patient per staff ratios explain variation in dialysis facility outcomes. While there are some important bivariate relationships, these disappear in more complex models. Future research should investigate the impacts of staffing ratios on individual patients, to overcome the possible ecological fallacy.

Qualitative exploration of the experiences of renal dietitians and how they help patients with end stage kidney disease to understand the renal diet

AIM

Dietary modification is integral to the management of end stage kidney disease. However, adherence to the renal diet is poor. Few studies have explored the perspectives of renal dietitians and how they work with patients to facilitate dietary change. The objectives of this study were to explore the experiences of renal dietitians about educating patients with end stage kidney disease; and to describe the strategies perceived to help patients understand the renal diet.

METHODS

Semi-structured interviews based on Sensemaking theory were conducted with renal dietitians (n = 27) working in Australia and New Zealand from a range of metropolitan, regional and remote areas.

RESULTS

Five major themes across two categories were derived from the data. The renal dietitians in this study experienced feelings of frustration, frequently worked in practice environments with limited or inadequate resources and perceived that establishing trust and demonstrating empathy were important to sense making. Renal dietitians helped patients make sense of and understand the diet by clarifying ambiguities and conflicting information; and simplifying complexity by using simple explanations, individualised advice and practical support. These strategies were considered critical to the renal diet sense making process.

CONCLUSIONS

The experience of providing renal diet advice to adults with end stage kidney disease was emotionally and professionally challenging. Alternative approaches to patient education may help dietitians to empower patients to better understand the renal diet. Further research exploring the experiences of learning about the renal diet from the patient and carer perspective would also help to inform future alternative approaches.

Modified Nutritional Recommendations to Improve Dietary Patterns and Outcomes in Hemodialysis Patients

The renal diet has traditionally been regarded as one of the most complex medical nutrition therapies to teach, understand, and implement. Specifically, patients are instructed to limit fruits, vegetables, nuts, legumes, dairy, and whole grains because of both phosphorus and potassium concerns. Furthermore, hemodialysis patients are often encouraged to decrease fluid intake to control interdialytic weight gain. These restrictions can result in frustration, lack of autonomy, and the perception that there is nothing left to eat. It is possible that the traditional renal diet may be liberalized, with a focus on whole foods low in sodium and phosphorus additives, to afford patients greater choices and ultimately improved outcomes. Therefore, the objective of this review is to concisely assess the evidence in support of a renal diet focused primarily on reducing the intake of sodium and inorganic phosphorus. Finally, the limited evidence for restrictions on dietary potassium intake is summarized.

Development and evaluation of continuing education course in renal nutrition

BACKGROUND/OBJECTIVE

Competent renal dietitians are crucial for better patient compliance and clinical outcomes, specifically in critical settings. The aim of this study was to develop and evaluate an evidence-based course in renal dietetics for dietitians working in health care systems where dietetic specialization is absent.

SUBJECTS/METHODS

Fifteen licensed dietitians working with hemodialysis patients in Lebanon were randomly recruited to participate in the course. The latter was developed by the study's primary investigator, according to evidence-based practice guidelines, and focused on all aspects of renal nutrition. Total course duration was 28 hours spread over a 2 month period. Dietitians' knowledge in renal nutrition was tested pre- and post-training through a 23-item questionnaire; the total score was expressed in percentage (< 60% score indicated insufficient knowledge). Paired-samples t test was used for statistical analysis.

RESULTS

Overall knowledge of the dietitians significantly improved post-training and reached satisfactory levels (pre: 38.75 ± 17.20%, post: 62.08 ± 21.85%). Sub-analysis of the change in the knowledge showed significant and satisfactory improvement only in 3 topics: 1) correct body weight use in calculations, 2) energy estimation method and 3) phosphorus management. Knowledge in the fluid management significantly improved but did not achieve a satisfactory level.

CONCLUSION

The course significantly improved dietitians' knowledge in renal nutrition. If adopted as part of the continuing education of dietitians in countries that lack dietetic specializations, it may serve the first step towards improving health care practice.

Renal Dietitians' Perceptions of Roles and Responsibilities in Outpatient Dialysis Facilities

OBJECTIVE

This study was designed to determine what job responsibilities renal dietitians working in outpatient dialysis facilities consider as most important and most time-consuming. We hypothesized that more time-consuming activities would not always be considered most important.

DESIGN AND PARTICIPANTS

An online survey was sent to 3,382 renal dietitians via professional organization e-mail lists. The survey included 30 activities that renal dietitians perform, grouped into 3 categories (general responsibilities, assessments, and interventions) and based on the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative nutrition guidelines. For each category of activities, respondents were asked to rank the 10 activities from 1 (most important or time-consuming) to 10 (least important or time-consuming). For analysis, the rankings were combined into 3 groups: 1 to 3 = most; 4 to 6 = mid; and 7 to 10 = least important or time-consuming. Demographic and professional questions were also included.

RESULTS

Four hundred sixty six renal dietitians responded, and represented a broad range of experience in renal dietetics and type of dialysis facility. The mean number of patients per 40 hours full-time equivalent dietitian was 115.5 ± 38.4. There was good agreement between the respondents' ranking of importance and time consumed. Those activities identified as most important were traditional dietitian roles such as diet assessment and nutrition education. Many respondents provided write-in response of other activities they considered important and time-consuming such as communicating with family members or caregivers, enrolling and managing patients in the in-house pharmacy program, and serving as a care coordinator.

CONCLUSIONS

It appears that the renal dietitian's role of providing nutrition assessments and counseling in outpatient dialysis facilities is being expanded to include administrative and coordination responsibilities. The impact of these changes on patient outcomes is unclear; however, previous research has indicated that administrative responsibilities take away from patient care time and decrease dietitian job satisfaction.

Guideline use: a survey of dietitians working with adult kidney transplant recipients

AIM

  To establish current service provision as well as barriers and enablers to guideline implementation in the Nutritional Management of Adult Kidney Transplant Recipients (KTR).

METHODS

  Fifteen primary renal transplant centres (15/17; 88% response rate) and 21 secondary renal transplant centres (21/24; 88% response rate) responded to an online survey addressing key questions investigating their current practice in the nutritional management of adult KTR.

RESULTS

  Referral from primary to secondary sites was limited with only two sites (9%) routinely receiving referrals. Allocated funding for KTR at secondary sites was low (n = 4, 14%). Many primary sites received nil or <0.5 full-time equivalent (FTE) funding for inpatient (n = 8, 53%); and nil or ≤0.2 FTE funding for outpatient services (n = 9, 60%). In sites reporting FTE hours, the average dietitian-to-patient ratio was 1 FTE dietitian for every 383 (range 50-1280) annually transplanted patients. Major barriers identified in delivering nutrition services at primary sites included time/lack of resources and limitations with systems to identify or track transplant recipients.

CONCLUSION

  Dietitian-to-patient ratios in the management of KTR at primary sites are inconsistent and likely to be inadequate at secondary transplant sites to implement guideline recommendations, especially for weight management. Investigations into the effectiveness of innovative interventions such as groups or telehealth are warranted, which may assist practitioners to achieve guideline recommendations in an environment of limited resources.

Moving the issue of renal dietitian staffing forward

The day-to-day pragmatic work realities of dietitians who cover dialysis clinics are rarely the focus of discussion. This article highlights the points of convergence between these realities and the research literature. Focusing on the National Kidney Foundation Kidney Disease Outcomes Quality Initiative clinical practice guidelines for nutrition and the difficulties encountered with their full implementation, a seemingly pervasive problem of limited time is revealed. Given the evidence that renal dietitians can positively impact morbidity and mortality risks, when protein-energy malnutrition is primarily the byproduct of insufficient nutrient intake, it suggests that progress with enhancing the nutritional status of patients may be fundamentally contingent on increasing the time they have available, through improved staffing.

Adequacy of dialysis clinic staffing and quality of care: a review of evidence and areas of needed research

Improving the quality of care delivered to patients receiving in-center dialysis treatment remains a perpetual concern with stakeholders. Quality indicators traditionally have focused on such items as adequacy of dialysis, anemia management, patient survival, and, most recently, the percentage using arteriovenous fistulas. Largely overlooked in the quest for improvement has been adequate consideration of dialysis clinic staffing levels. Staffing is important because it has been identified as a structural measure of quality. With 326,671 (93.1%) of all dialysis patients receiving in-center treatments, this is a potentially critical issue. This article reviews evidence related to inadequacies in clinic staffing and how they may be contributing to suboptimal care and outcomes. Focusing on nephrologists, nurses, patient care technicians, dietitians, and social workers, this article suggests areas of needed research.

Identification and Treatment ofProtein-energy Malnutrition in Renal Disease

A web-based cross-country survey of renal registered dietitians (RRDs) was launched. It was used to assess whether or not their clinical practice in identifying and treating proteinenergy malnutrition (PEM) in adults with end-stage renal disease (ESRD) and dialysis was based on current nutrition practice guidelines (NPGs). The survey included questions on strategies, timelines, and markers used for the identification and treatment of PEM. Fifty-nine RRDs responded (21%). Sixty-seven percent did not base clinical practice on NPGs, while 33% indicated they followed the guidelines. Of those who followed guidelines, 76% use the National Kidney Foundation— Kidney Disease Outcomes Quality Initiative nutrition guidelines. Strategies used to identify and treat PEM were not related to duration of RRD experience in nephrology, but were significantly different between guidelines users and non-users. Guideline users commonly used key nutrition treatment strategies that included enteral/parenteral nutrition and medication therapy. The clinical practice of RRD is typically based on expert opinion/consensus, rather than on evidence-based practice guidelines (EBPG). It remains unclear if differences in RRDs’ adoption of clinical guidelines influences patient outcomes, particularly in the treatment of PEM. Up-to-date EBPG need to be developed for the identification and treatment of PEM in patients with ESRD.

Assessment of nutritional practice in Italian chronic kidney disease clinics: a questionnaire-based survey

BACKGROUND

The prevention of malnutrition in patients with progressive chronic kidney disease (CKD) presents a challenge to nephrologists. We evaluated nutritional practice and routines, at a national level, related to the nutritional management of nondialyzed CKD patients.

METHODS

A questionnaire-based survey (32 open and 9 multiple-choice questions) was used to assess the evaluation of nutritional status in nondialyzed CKD outpatients at baseline and during follow-up. Data were obtained for 230 Italian public nephrology centers (63% of the total number of Italian public nephrology centers).

RESULTS

There was a dedicated dietitian at only 19% of the centers. At baseline, body weight, body mass index, and serum albumin were determined in almost all centers, nutrient intakes and bioimpedance analysis in half the centers, and subjective global assessment and skinfold thickness in a small proportion of centers. During follow-up, the rate of assessments decreased by 8% for weight, 14% for nutrient intake, and 29% for subjective global assessment and skinfold thickness. Overall, the K/DOQI minimum criteria for nutritional assessment were fulfilled in only two thirds and half of the clinics at baseline and during follow-up, respectively. Multivariate analysis showed that the number of nutritional variables evaluated was significantly related to the size of the CKD clinic and the presence of a dietitian at baseline, but only with the presence of dietitian during follow-up. Daily urinary output was collected at 90% of the centers, but urea and sodium excretions were determined in only 59% and 57% of cases, respectively. The rate of assessment for urinary solutes during follow-up was higher at centers where a very low protein diet was prescribed.

CONCLUSIONS

The indications about nutritional assessment for CKD patients are poorly translated into practice patterns, especially with respect to the evaluation of nutrient intakes and additional but simple variables such as skinfold-thickness measurement and bioimpedance analysis. The presence of a dedicated dietitian appears to improve the quality of nutritional assessment in CKD.

Job Satisfaction Among Renal Dietitians

OBJECTIVE

Little is known about job satisfaction among renal dietitians. We sought to determine overall job satisfaction and specific domains of job satisfaction among renal dietitians.

DESIGN

Cross-sectional study.

SETTING

A total of 46 outpatient hemodialysis facilities in northeast Ohio.

PARTICIPANTS

A group of 40 renal dietitians.

INTERVENTION

Structured questionnaire.

MAIN OUTCOME MEASURE

Overall job satisfaction; specific domains of job satisfaction, workload, and suggestions for improving job satisfaction.

RESULTS

Of all responding dietitians, 78% expressed overall satisfaction with their job. Dietitians were least satisfied with opportunities for advancement (13%), supervisors' handling of employees (50%), the chance to be somebody in the community (53%), praise received for doing a good job (55%), and amount of work assigned (58%). Dietitians were most satisfied with the chance to do things for others (98%). A higher patient-to-renal dietitian ratio was associated with lower overall job satisfaction and a reduced likelihood that renal dietitians would recommend their career to others. The most common suggestions for improving job satisfaction consisted of reducing paperwork (named by 28% of dietitians), spending more time with patients (23%), and increasing time for creative projects (18%).

CONCLUSIONS

Although renal dietitians generally expressed overall satisfaction with their jobs, almost all were dissatisfied with opportunities for advancement, and nearly half were dissatisfied with other specific aspects of their work. We urge local and national associations of renal dietitians to collaborate with dialysis facilities, chains, and regulatory agencies to improve job satisfaction. Further research is needed to determine the impact of job satisfaction of renal dietitians on patient outcomes.

Management of osteoporosis: a national survey of Israeli dietitians' knowledge and perceptions

The aim of this study was to assess Israeli dietitians' knowledge and attitudes regarding osteoporosis. Participants were 320 dietitians responding to a mail survey. Israeli dietitians scored highly on the Facts on Osteoporosis Quiz-FOOQ. Israeli dietitians' dietary knowledge regarding calcium (recommended dietary allowance, content in food and in supplements) was fairly high; unlike knowledge regarding vitamin D. Israeli dietitians had a firm positive opinion of their role in the prevention and treatment of osteoporosis.