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VeTeamMarch 2007 Advisor F O R T H E C O M M I T T E D V E T E R I N A R Y S T A F F E R Starting a Weight Loss Program Part II: A Stepwise Approach In the first part of this series, we discussed how

1 VeTeamMarch 2007 Advisor F O R T H E C O M M I T T E D V E T E R I N A R Y S T A F F E R Starting a Weight Loss Program Part II: A Stepwise Approach In the first part of this series, we discussed how to approach clients about starting a weight management program for their pets and why offering such a program to clients is important. In this second half, we will outline how to successfully manage your patients weight through a practical, stepwise approach. Your team has had their staff meeting and everyone is on board and ready to institute the hospital s new weight management program. You ve targeted several patients to begin the program and the owners are eager to begin. So where do you start? By taking a systematic approach, you and your team can effectively create a customized plan that will get your patients on their way to a healthier weight. 1 Ruling Out Underlying Disease Before starting a patient on a weight loss plan, a complete physical examination, complete blood count, and biochemistry screen should be performed to rule out any underlying or predisposing diseases. Hypothyroidism in particular must be identified as, unless medically treated, it is unlikely weight loss can be achieved. At the same time, establishing a patient s overall health will help prevent misinterpreting weight loss due to underlying disease versus that resulting from a successful weight loss plan. continues on page 2 VeTeam Advisor s Top 10 Excuses the Veterinary Team Gives for Not Starting Pets on a Weight Management Program: 1. I don t know how to reach clients who don t even recognize that their pets are overweight - they just don t see it as a problem! 2. I don t want to upset the clients and make them feel guilty. 3. Clients just don t want to spend money on good pet food. They d rather buy whatever is on sale at the grocery store. They think it is all the same. 4. They don t follow our advice and they claim that they never overfeed their pets. 5. It is a sensitive subject to bring up when the client is overweight, too. 6. I m overweight, how can I even bring up weight loss with a client? 7. What can I say to clients who complain that they ve tried pet diets before and they don t work? 8. I don t know what to do when clients say they can t say no when their pet begs them for food. 9. The clients say they can t manage feeding one pet differently from the others because they all eat one another s food. 10. Clients won t give the diet food a chance. If their pets don t take to it right away, they cave in and go back to the regular food. VeTeam Advisor is a veterinary staff tool designed to be removed from Clinician s Brief

2 Starting a Weight Loss Program Part II continued from page 1 2 Establish the Patient s Specific Energy Requirement Determining a pet s specific energy requirement is crucial to establishing a successful weight loss plan. An animal s maintenance energy requirement (MER) is defined by the amount of calories required to maintain its body weight. Energy requirement equations are also available; however, these equations do not account for the wide variation (+/- 50%) in energy requirement for healthy pets. 1 If the pet s weight is stable, the MER can be determined by calculating its current caloric intake. The most accurate diet history is created by having the client bring in a typical day s worth of food and treats to a scheduled weight loss appointment. One of the veterinary team members can then weigh out each item and calculate the total amount of calories fed daily by using product guides, manufacturer toll free numbers or Web sites, as well as databases available to the public for free at (pet foods, treats, and human foods) or (human foods). Alternatively, a diet history form can be used, but it must be impressed upon the client the need for both completeness and specificity for it to be of value. If the pet s diet is highly variable, or if the client is unable to provide an accurate diet history, the pet s MER can be calculated by using equations for an average adult dog or cat (see Energy Requirement Equation). 3 Determine the Initial Amount of Caloric Restriction If the patient-specific MER for weight stability has been determined by calculating the pet s current caloric intake, then it is recommended that 80% of this amount of calories be fed when initiating a weight loss plan. If the pet s MER has been calculated by using the less specific energy requirement equation, then the resting energy requirement (RER) is used for determining a dog s recommended caloric intake for weight loss, while in the cat, 80% of the RER is used. If using this approach, the client should be warned that it may take longer to determine ENERGY REQUIREMENT EQUATION RER = 70 (BW kg ) 3 / 4 MER = RER Factor* (see table below) Canine Factors Life Stage/Neuter Status Feline Factors 1.8 Intact, normal weight Neutered, normal weight Obese Prone (but currently normal weight) Weight Loss 0.8 * These factors are starting points only. Adjustments may be necessary as the calculated MER can vary as much as 50% from an animal's true requirement the appropriate amount of food to feed to achieve the desired rate of weight loss, and that the patient may even gain weight until the appropriate amount is determined. 4 Selecting a Food and Providing Treat Recommendations Although it is tempting to feed the foods and treats that are already being used, it is generally not recommended unless the foods are designed for weight loss and the treats are low in energy density. Foods that are fed during weight loss should have a low energy density and increased levels of essential nutrients (protein, vitamins, and minerals). Foods that meet these criteria are limited to veterinary therapeutic foods designed for weight loss, and a limited number of over-the-counter weight loss foods (most over-the-counter lite or reduced calorie foods are designed for weight stability, not active weight loss). Providing treat recommendations is very important to the success of a weight loss plan. Guidelines for feeding treats in limited amounts will help prevent cheating and will increase client awareness of specific treats contribution to the total daily caloric intake. Treats should be limited to no more than 10% of the pet s total daily caloric intake, thus limiting the risk of creating a nutrient deficiency, as most treats are not complete, balanced foods. The daily calories allotted for treats should be subtracted from the total calorie amount determined in Step 3. Specific daily amounts of commonly fed treats, as well as low-calorie treat options (eg, baby carrots and air-popped popcorn) should be provided to the client, allowing them to see the variable calorie levels in different treat types. 5 Selecting the Rate of Weight Loss It is generally recommended that patients not lose more than 1% to 2% of their body weight per week. Weight loss rates that are greater lead to greater hunger, which can make compliance more challenging for the client as the patient is more apt to beg. Weight loss rates that are slower can be acceptable when comorbidities exist that are not worsened by the patient s obesity. Client Instructions Client instructions should be given in 6 both a verbal and a written form, and should include the following pieces of information: Clear instructions on the exact amount and frequency to feed, including the amount and frequency for any treats Instructions on when the client is to come back to reweigh the pet A clear explanation that initially weight loss plans need to be adjusted frequently (every 2 weeks) based on reweighs and that the pet may lose weight at the wrong rate or may even gain weight initially Recommendations on the types and amounts of exercise or play that would be appropriate for their pet (see Exercise Recommendations, page 4) The phone number to call if they encounter any difficulties or need assistance continues on page NAVC clinician s brief. march veteam advisor

3 Team Member Tasks VETERINARIAN PRACTICE MANAGER As with most programs, obstacles will be faced when trying to implement a weight loss program. By dividing tasks and keeping one another motivated, however, team members can make weight loss programs successful and satisfying for everyone. With the other doctors in the practice, decide on a body condition system (BCS) to use and determine when you will recommend a dietary intervention (eg, a BCS of > 6 on a 9-point scale). Utilize your technicians to complete a diet history prior to the appointment and to review specific recommendations with the clients at the end of the office visit. Provide clients with a list of both their regular treats and low-calorie treat options with the exact amounts that may be fed daily (clients will often choose the low-calorie treat options when they see how much more of these they can feed). If the client becomes frustrated at slow or unsuccessful weight loss, refocus them on small steps (biweekly weight loss goals) and warn them from the beginning that multiple adjustments may be required to fine-tune the plan. Have guidelines in place on how to instruct clients to adjust the amount fed if the appropriate rate of weight loss is not achieved. Work with your team to set a goal for the number of pets you want to start on weight management plans. Typically 40% of pets in a practice are overweight or obese and only a small percentage are on a weight reduction plan, which means that even a small 1.5-doctor practice could easily have 1,000 pets that would benefit from a diet and exercise plan. If you set a goal of enrolling even half of the overweight pets you see in your practice, that would be at least 500 pets per year in a small practice, or about two a day that the team would need to enroll to meet its patient care goal. Brainstorm ways to achieve the goal with your team. Provide regular feedback on how well the team is doing to help everyone stay motivated and focused on pet weight loss; report weekly the number of pets put on diets and compare it to your weekly goal and talk about individual pets progress. TECHNICIAN Be sure to record the BCS score in the medical record for each pet and confirm that the doctor has recommended a weight reduction plan for eligible pets. Create a diet history form that highlights the need for exact brand names and specific measurements. Provide clients with a free 8 oz measuring cup (available from many pet food companies) so that they can accurately measure food at home. Clients may also weigh some food on a gram scale. Have premade client handouts to make it easier to give clients both verbal and written instructions. Make support calls to clients at home to help them trouble-shoot problems that might interfere with the pets weight loss plans, especially when they are first starting their pets on a reduction diet. Create a technician-supervised weekly support group where multiple clients can come in to reweigh pets and share their experiences with one another. RECEPTIONIST Schedule specific weight loss appointments and preschedule weigh-ins. Create a call-back schedule and log for the team. Put reminders in the system to help clients remember their pets weigh-in appointments. Have clients bring in fully labeled samples of a day s worth of food so that they can be accurately measured when the diet history is taken. Make sure that pet owners go home with a diet tip sheet to help them to overcome common problems and to give them ideas for how to be successful when they first put their pets on reduction diets. Work with the practice manager and technicians to determine the best way to invite and remind clients about participating in the weekly pet weight loss support program. Take before and after photos of the pets as they lose weight so that the clients can see the difference and stay motivated. With the clients permission, display photographs of the pets that have successfully lost weight to make poster child pets for weight loss and motivate even more clients. ALL TEAM MEMBERS Be certain all team members are educated on foods designed for weight loss. Track your progress in putting pets on a weight management program against your goal so that you can see you are making a difference. Help one another overcome client objections. Share ideas and tips that you have learned work well. Celebrate success at set milestones. For instance, when the first 50 pets are enrolled in the weight loss program, and again when the first 100 pets are enrolled and so on, to reinforce success and keep enthusiasm high. veteam advisor...navc clinician s brief. march

Starting a Weight Loss Program Part II continued from page 2 7 Adjusting Weight Loss Plans Based on Actual Response It should be expected that, initially, weight loss plans will need to be adjusted

If weight loss is too rapid, the patient should be examined and checked again to be certain no underlying disease is leading to weight loss (ie, diseases that lead to energy loss, such as diabetes

4 Starting a Weight Loss Program Part II continued from page 2 7 Adjusting Weight Loss Plans Based on Actual Response It should be expected that, initially, weight loss plans will need to be adjusted based on frequent (every 2 weeks) reweighs to achieve the desired rate of loss. If the patient is losing weight within the desired range per week (typically 1% to 2%), then no adjustment is needed. If weight loss is too rapid, the patient should be examined and checked again to be certain no underlying disease is leading to weight loss (ie, diseases that lead to energy loss, such as diabetes mellitus or protein-losing illnesses, malabsorption, and/or a decreased appetite). If the pet is healthy, at least 10% to 20% more volume of every food and treat should be fed. If the rate of loss is very rapid ( > 2.5% of body weight per week), it might be worthwhile to stop the weight loss plan briefly and ensure that the animal is eating well and is capable of weight stability. EXERCISE RECOMMENDATIONS The following suggestions for exercising pets can be made to clients. Exercise should be given in gradually increasing amounts until at least 30 minutes per day is devoted to some type of physical activity. For dogs: Leash walking Playing ball Swimming (especially for patients with orthopedic disease) For cats: Leash walking (up to 10% of cats are reportedly leash trained) Play activity that mimics predatory behavior For a Calorie Burn Chart to see how different exercises can help burn calories go to If the patient is losing weight too slowly or is gaining weight, then compliance with the feeding plan should be confirmed and the development of an underlying disease ruled out (ie, diseases that lead to polyphagia, such as Cushing s, third space fluid accumulation, and/or a slowed metabolism, as in hypothyroidism). If the client is being continues on page 8 PET TREAT SHEET Low-Calorie Treats Commercial Treats Eukanuba canine Restricted Calorie Rewards Hill s Prescription Diet Canine Treats Purina Veterinary Diets Canine Lite Biscuits Royal Canin Veterinary Diet feline Treats Royal Canin Veterinary Diet canine Treats Human Foods Air-popped popcorn Raw baby carrots Plain rice cake, unsalted Raw snap green beans Calorie Content 13 kcal per treat 13 kcal per 5-gram treat 27 kcal per biscuit 1.4 kcal per treat 14 kcal per treat 31 kcal per cup 4 kcal per baby carrot 35 kcal per rice cake 34 kcal per cup This table may be downloaded and printed for use in your clinic at NAVC clinician s brief. march veteam advisor

IN-CLINIC RECORD DIET DIARY Pet s Name: Day One: Current body weight: kg Calculated Maintenance Energy Requirement (MER): kcal/day Plan: Daily caloric intake: kcal/day What to feed: Pet food:

last visit: kg Rate of weight loss since last visit: % / week Plan: Daily caloric intake: kcal/day What to feed: Pet food: (amount, type, frequency) Treats: (amount, type, frequency) Date: Exercise

6 IN-CLINIC RECORD DIET DIARY Pet s Name: Day One: Current body weight: kg Calculated Maintenance Energy Requirement (MER): kcal/day Plan: Daily caloric intake: kcal/day What to feed: Pet food: (amount, type, frequency) Treats: (amount, type, frequency) Exercise recommendations: Date: Place photo here Before photo Next reweigh: (date) Week Two: Current body weight: kg Weight gain/loss since last visit: kg Rate of weight loss since last visit: % / week Plan: Daily caloric intake: kcal/day What to feed: Pet food: (amount, type, frequency) Treats: (amount, type, frequency) Date: Exercise recommendations: Next reweigh: (date) Week Four: Current body weight: kg Weight gain/loss since last visit: kg Rate of weight loss since last visit: % / week Plan: Daily caloric intake: kcal/day What to feed: Pet food: (amount, type, frequency) Treats: (amount, type, frequency) Date: Exercise recommendations: Next reweigh: (date) This form may be downloaded and printed for use in your clinic at NAVC clinician s brief. march veteam advisor

WHAT S NEW IN Weight Management PRODUCT: PURPOSE: Slentrol (Pfizer) To provide another tool to the veterinary team for dealing with canine obesity AVAILABILITY: FDA approved.

8 WHAT S NEW IN Weight Management PRODUCT: PURPOSE: Slentrol (Pfizer) To provide another tool to the veterinary team for dealing with canine obesity AVAILABILITY: FDA approved. Should become available for dispensing in the spring of 2007 COMPARATIVE COST: Cost to owner will be about $1 to $2 per day, depending on the size of the dog. Multiple variables make it difficult to compare the cost of the drug to the long-term cost of obesity. EASE OF USE: Easy. Once-daily liquid oral dose has a neutral flavor, allowing it to be added to treats or food without changing the flavor. Can also be dispensed directly into the dog s mouth. HOW IT WORKS: Slentrol belongs to a new class of drugs known as microsomal triglyceride transfer protein (MTP) inhibitors. As a result of MTP inhibition, the absorption of fats from the intestine is delayed. While the mechanism for producing weight loss is not yet completely understood, the drug does cause a decrease in appetite with subsequent decreased food consumption and weight loss. PLUSES: Slentrol is easy to use, safe, and appears to work. A field study of client-owned dogs showed an average weight loss of 11% body weight in 4 months. At this rate, results are slow enough to be safe, but fast enough for owners to see a difference. MINUSES: Some owners may find the cost to be an issue. Cannot be used in cats. Possible side effects: vomiting (25% of study dogs vomited at least once during the 4-month trial versus 20% of the placebo group), soft stool, anorexia. Vomiting, the most common side effect, was found to be self-limiting; the medication could be continued and no veterinary intervention was necessary. Potential for human abuse: Slentrol is not labeled for humans, but this may not deter some people. Veterinarians and owners need to be aware that this drug is not for humans. COMMENTS: The mainstay of any weight loss program, diet and exercise, still holds for dogs on Slentrol. This medication is not a magic bullet. It is meant to be temporary and can help getting a dog started with weight loss, but diet and exercise are necessary to maintain a healthy weight. Starting a Weight Loss Program Part II continued from page 4 compliant and the patient is healthy, then 10% to 20% less volume of every food and treat should be fed. Referral to a boarded veterinary nutritionist ( is recommended if it appears that the patient requires less than 50% of the RER at its current weight to achieve weight loss. 8 Transitioning to Weight Stability once Weight Loss has been Achieved After the long road to success, the last step of keeping weight off must not be neglected. At this stage, the client may wean the pet onto an adult maintenance diet. Although not required, it is recommended that a low-calorie diet designed for weight stability in obese-prone pets be selected. The amount of energy required to maintain body weight is generally equivalent to 110% of the calories fed during the active weight loss period. The clients should start by feeding this amount, then follow up with a reweigh in 2 weeks. If the pet has maintained its body weight, then no further adjustments are required. If the pet has gained or lost weight, then further adjustments of 5% to 10% of the calories should be made and follow-ups continued until weight stability is achieved. Reference 1. Small Animal Clinical Nutrition III. Lewis LD, Morris ML, Hand MS Topeka, KS: Mark Morris Associates, 1987; pp Contributors: Sally C. Perea, DVM, MS, DACVN; consultant, DVM Consulting, PC; associate veterinarian and assistant clinical professor, University of California, Davis Sean J. Delaney, DVM, MS, DACVN; founding consultant, DVM Consulting, PC; associate veterinarian and assistant clinical professor, University of California, Davis; vice president, American Academy of Veterinary Nutrition Karyn Gavzer, MBA, CVPM, president of KG Marketing & Training, Inc Managing Editor: Jennifer L. Schori, VMD 2007 Educational Concepts LLC 8...NAVC clinician s brief. march veteam advisor

Obesity Prevention & Management. Valerie J. Parker, DVM, DACVIM, DACVN

Obesity Prevention & Management Valerie J. Parker, DVM, DACVIM, DACVN The Problem Approximately 59% of dogs and cats are overweight. This is the most commonly diagnosed nutritional disorder in veterinary