Close this window to return to IVIS www.ivis.org Proceedings of the European Veterinary Conference Voorjaarsdagen Amsterdam, the Netherlands Apr. 5-7, 2012 Next Meeting: Apr. 18 20, 2013 - Amsterdam, the Netherlands Reprinted in IVIS with the permission of the Conference Organizers http://www.ivis.org
the 5th Vital Assessment The WSAVA has developed a global initiative to standardize five vital signs as part of the standard physical examination for all small animals. These are temperature, pulse, respiration, pain, and nutritional assessment. Although the name (5th Vital Assessment) is not quite adapted to the Dutch/European diagnostic approach, nutritional status is an important aspect of health and disease. The positive impact of proper nutrition on health and disease is well established in all animals. Appropriate feeding throughout all life stages can help prevent diet-associated diseases, as well as to assist in the management of other diseases. For example, foods formulated for dogs and cats with chronic kidney disease have been shown to provide significant benefits. The nutritional guidelines are introduced to have a more uniform diagnostic approach regarding nutrition and nutritional status. Furthermore it emphasizes the importance of nutrition in health and disease, which should be monitored for every pet at every consultation. This will help to place the role of recommending small animal nutrition back into the hands of the experts: veterinarians! The factors that need to be assessed are the animal, the diet, feeding management and environmental factors. The guidelines further specify these factors as: nutrient sensitive disorders, diet induced disorders, feedingrelated disorders and environment-related disorders. The nutrition assessment consists of a screening evaluation for every patient and an extended evaluation when one or more nutrient-related risk factors are found or suspected based upon the screening evaluation. Most of the screening evaluation is often already done when taking the history of your patient. The presence of a medical condition, sudden weight change, or muscle wasting, may warrant for an extended nutritional evaluation. Unconventional diets, feeding of supplements, feeding lots of table food or snacks, and obesity also warrant for an extended nutritional evaluation. Body Condition Score and Muscle Condition Score should be performed on every patient at every visit. This aids in detecting gradual changes in body condition and muscle condition over time. An extended evaluation will be demonstrated on cases and consists of a more thorough evaluation of nutrient sensitive disorders, diet induced disorders, feedingrelated disorders and environment-related disorders. After the evaluation an action plan needs to be made, involving all the aforementioned aspects, and communicated with the client followed by good monitoring. The total approach can be efficiently implemented into daily practice without additional time or expense and will be rewarding by optimizing animal health and wellbeing, as well as more dedicated clients and staff, due to better recommendations. What s in that petfood? There are a lot of misconceptions about the ingredients and the production of petfood. The aim of this lecture is to give you more insights in how to read a petfood label, what the ingredients are and what are the most important differences between kibbles, canned food, and commercially available complete raw meat diets. As veterinarians are regarded the experts on nutrition, some common questions about petfood will be discussed as well as the evaluation of home made diets. A lot of information about pet food is obtained from the industry, and most often our nurses are regarded as the experts in nutrition within our practices. Pet owners often see veterinarians as the experts on 54
health, nutrition and wellbeing of their pets. We must keep this leading position and seek for more information on nutrition, which is available from the literature. Evidence-based clinical nutrition improves the health and wellbeing of pets and makes veterinarians more critical to commercial talks by the industry. Pet owners are confronted with a lot of different types of diets and seek for advice to make their choices. Some follow the advice given by breeders or pet shop owners, while others ask their veterinarian for advice. At every visit we have the opportunity to discuss the pet s diet with the owner and assess whether the diet is appropriate or not. By measuring body weight, body condition score and muscle condition score we are able to monitor if the right amounts of food are given. For puppies and kittens a growth curve can be made. Some pet owners are only interested in the costs per bag of food, others want to feed only natural ingredients, and others prefer a holistic diet. Furthermore, an increasing number of pet owners are feeding unconventional diets based on bones and raw food (BARF) or commercially available balanced raw meat diets. It is important for veterinarians to understand the benefits as well as the concerns regarding these diets and to be able to inform clients about these concerns. Different nutrient profiles are needed for these animals when they suffer from a nutrient-sensitive or diet-induced disease. Common misconceptions about benefits and concerns of dry food, canned food and raw meat diets will be discussed. European specialists in animal nutrition can help veterinarians by evaluating unconventional diets and to prescribe a dietary plan based on the needs of the patients, which is compatible with the ideas and beliefs of the pet owner. Allergens in pet food Department of Clinical Sciences of Companion Animals Adverse reactions to food is a generic term for multiple disorders. The reactions can result in gastrointestinal signs like vomiting and diarrhea, which are food responsive within 2-3 weeks. Itchy skin reactions are also common, which are food responsive within 6-8 weeks. Dermatologists estimate that adverse reactions to food account for 1-6% of all dermatoses and 10-49% of allergic responses in dogs and cats. The response to food allergens can be immediate (i.e. after a single exposure) or after prolonged exposure to one brand, type or form of food. Pathogenesis Ingested items are the greatest antigenic load confronting the immune system. Fortunately, normal food items are tolerated by the immune system. In hypersensitivity there is a loss of tolerance to normal food items due to incomplete digestion of food, loss of barrier function of the gut or loss of suppressor activity of immune cells. Beef, dairy products and wheat are the most important allergens in dogs, whereas beef, dairy products and fish are the most commonly reported allergens in cats. CHAPTER 2 Clinical Nutrition History All ingested items may be the source of adverse food reactions so a thorough dietary history should be obtained including food, supplements, snacks, treats, chew toys, medication, human food (leftovers), food for other animals in the household, plants, feces, etc. Clinical signs Adverse reactions to food can occur at any age and in any breed. 55
Pruritis is non-seasonal and localized to feet, face, axillae, inguinal region and ears. Other dermatological signs are eosinophilic plaques, eosinophilic granulomas and indolent ulcers in cats as well as angioedema, erythema multiforme and urticarial vasculitis in dogs. Gastrointestinal signs are vomiting, diarrhea (both small bowel and large bowel), abdominal pain, weight loss and flatulence. Gluten-hypersensitivity is a special condition in Irish Setters and German Shepherds. Adverse reactions to food may also play a role in inflammatory bowel disease as well as irritable bowel syndrome. Up to 50% of the animals with dermatological signs also demonstrate gastrointestinal clinical signs. About 30% of dogs and cats with adverse reactions to food have concurrent atopic dermatitis and/or fleaallergy. Diagnosis can be confirmed by an eliminationchallenge trial. Other tests are unreliable. Home cooked diets with a novel protein source (based on dietary history) and a single carbohydrate source are the golden standard for an elimination diet. Commercially available hypoallergenic diets are either hydrolyzed protein or novel protein diets and have an effect of 70% compared to home cooked diets as elimination diets. I prefer not to have a lot of other modifications of the diet for a diagnostic trial (e.g. increased omega-3 fatty acid content in combination with hydrolyzed protein), however, they can be very effective as maintenance diets for animals with adverse reactions to food. Dietary treatment, by using commercially available novel protein or hydrolyzed protein diets, is often effective. Sometimes the elimination diet is the only diet that does not provoke recurrence of clinical signs. It has then to be balanced by a nutritionist by following a step-by-step approach. Omega-3 fatty acids EPA and DHA (0.35-1.8% on dry matter basis) are thought to decrease inflammatory reactions associated with adverse reactions to food. High digestibility is beneficial for animals demonstrating gastrointestinal signs. For animals with adverse reactions to food and other medical conditions that require dietary management, a special diet can be formulated by a board certified nutritionist. Ask clients to keep a diary with the food and/or supplements given to the animal before, during, and after the elimination trial. The response to the diet should also be monitored in this diary. Treat concurrent or complicating conditions adequately. This may be needed while in the elimination trial. To be sure that the elimination trial is effective the elimination trial must be extended for 3 weeks after the end of treatment. A partly successful trial indicates a concurrent allergic condition (atopic dermatitis, flea-allergy) and requires further diagnostic work up. Canine urolithiasis: which diet is appropriate? Urolithiasis is a common disorder of the urinary tract in dogs. It may be a first indication for underlying systemic disorders such as a portosystemic shunt. Detection of uroliths is therefore the first step into the diagnostic process. Determination of urolith composition is of high importance for further diagnostics, treatment and prevention. Urolith formation is initiated by the formation of a crystal nidus. This requires supersaturation of the urine with lithogenic compounds as well as other factors (e.g. ph, presence of crystallization inhibitors and/or promotors, a preformed organic matrix). The presence of foreign materials (e.g. catheters, suture material) may also enhance nucleus formation. After formation of the nidus, the crystals will grow. This depends on: being present in the urinary tract, degree and duration of supersaturation, physical characteristics of the nidus. Epitaxy may occur (i.e. growth of a crystal on the nidus which has a different mineral composition). 56
History Owners often notice hematuria, pollakiuria, dysuria and sometimes incontinence. If an obstruction and/or concomitant bacterial infection are present restlessness, lethargy and vomiting may be noted. A dietary history is important to identify risk factors such as vitamin-mineral supplements, use of unconventional diets. Also medication and previous illnesses may predispose the patient to various types of uroliths. Clinical signs Apart from the signs that the owner has noticed abdominal pain may be noted. Especially in patients with nephroliths, no clinical signs may be present. Uroliths may be palpable in the urethra by rectal examination. Inability to advance a catheter through the urethra may indicate the presence of uroliths, however, this could also be caused by strictures, or space occupying lesions that occlude the urethral lumen. Pain and enlargement of the kidney may be noted. Urinalysis may reveal signs of inflammation and/or infection. Urinary ph may be increased due to infection, but can also be increased after a meal. Culture with antimicrobial susceptibility testing is always recommended. Crystalluria may be present and is indicative for supersaturation. It can also be an in vitro effect with no clinical importance. To prevent these errors a urine specimen should be evaluated when it is still fresh and warm. Only quantitative analysis of uroliths reveals their true composition; however crystals may provide a tentative diagnosis. Radiographs may reveal the site, number, density and shape of radiodense uroliths. Ultrasound reveals the same information for both radiodense and radiolucent uroliths. Small uroliths may only be detected by double-contrast radiography. Blood biochemistry may reveal the presence of liver failure and hypercalcemia. Uroliths must be retrieved, either by spontaneous voiding, urohydropropulsion, catheter-assisted or by surgery and send in for quantitative analysis. Removal of the uroliths by aforementioned methods. of concurrent infection and/or diseases. Dietary treatment should be adapted to the mineral type. As long as the mineral type is not clear, promote water intake by prescribing a canned diet that is designed for treatment of multiple urolith types. After urolith removal the patient should be monitored to detect possible recurrence at an early stage. In general, plain radiographs are recommended every 6 months and urinalysis every 3 months. The aim is to keep the urine specific gravity below 1.020. Diets in feline lower urinary tract disease Feline lower urinary tract disease (FLUTD) is a generic term and includes feline idiopathic cystitis (FIC), urolithiasis, urethral plugs and urinary tract infection. FLUTD has a prevalence of 2-5%. It is one of the most common reasons for seeking veterinary care; it accompanies behavioral problems and is one of the main reasons for cat owners to relinquish their cats to animal shelters. History Owners often notice hematuria, pollakiuria, dysuria and sometimes incontinence. If an obstruction and/or concomitant bacterial infection are present restlessness, lethargy and vomiting may be noted. A dietary history is important to identify risk factors such as dry food, drinking behavior, vitamin-mineral supplements, use of unconventional diets and treats. Also medication may predispose the patient to urolithiasis. Clinical signs Apart from the observations of the owner it is worthwhile to watch the cat during urination. Palpation of the bladder may indicate the presence of urocystoliths. The urethra must be palpated rectally and may reveal the presence of urethral abnormalities. The kidneys should be evaluated by palpation. Clinical Nutrition CHAPTER 2 57
Urinalysis may reveal signs of inflammation and/or infection. Urinary ph may be increased due to infection, but can also be increased after a meal or after a stressful event (i.e. visiting the veterinarian!). Culture with antimicrobial susceptibility testing is always recommended. Crystalluria may be present and is indicative for supersaturation. It can also be an in vitro effect with no clinical importance. To prevent these errors a urine specimen should be evaluated when it is still fresh and warm. Only quantitative analysis of uroliths reveals their true composition; however crystals may provide a tentative diagnosis. Radiographs may reveal the site, number, density and shape of uroliths. Ultrasound reveals the same information as well as changes in bladder wall thickness and abnormalities. Small uroliths may only be detected by double-contrast radiography. Blood biochemistry may reveal the presence of hypercalcemia or evidence for the presence of a portosystemic shunt. Uroliths must be retrieved, either by spontaneous voiding, urohydropropulsion, catheterassisted or by surgery and send in for quantitative analysis. Removal of the uroliths by aforementioned methods. of concurrent infection and/or diseases. Dietary treatment should be adapted to the mineral type. As long as the mineral type is not clear, promote water intake by prescribing a canned diet that is designed for treatment of multiple urolith types. Increasing water intake is also of importance for the other causes of FLUTD. Omega-3 fatty acids EPA and DHA (0.35-1.0% dry matter basis) are considered to have anti-inflammatory effects that may be beneficial for cats with FIC. Ingredients that contain a high oxalate content should be avoided (spinach, carrots, liver, sardines) in cats with Ca-oxalate uroliths. Pyridoxine (vitamin B6) deficiency increases urinary oxalate concentration and should be supplemented to home made diets for cats with Ca-oxalate uroliths. After urolith removal the patient should be monitored to detect possible recurrence at an early stage. In general, plain radiographs are recommended every 6 months and urinalysis every 3 months. The aim is to keep the urine specific gravity below 1.020. 58 Dietary management of obesity Obesity is a common disease in dogs and cats with a prevalence of 40-50%. A lot of research has been done to determine risk factors and to link obesity as well as weight loss to other clinical diseases such as osteoarthritis in dogs and diabetes in cats. History and clinical signs A lot of owners do not recognize obesity in their pets or consider it as healthy or happy. A long study done by Kealy et al. (1992-2002) revealed that overweight/ obesity decreases life span and quality of life by increased need for pain medication due to osteoarthritis and elbow dysplasia. In cats obesity is highly correlated to type 2 diabetes as well as hepatic lipidosis. Often the concurrent diseases are the reason for consultation, as is also demonstrated at the Dutch pet obesity clinic. Decreased activity, exercise intolerance, lameness are common observations. A dietary history must be obtained and include all food, snacks, treats, flavored medication, access to other food etc. It is helpful to ask the owner to keep a diary and weigh out all the items that the animal eats. Obesity is defined as having a body condition score over 5 on a 9-point scale. The body weight is excessive by 10% for each point on the 9-point scale. Some animals even exceed the 9-points on the 9-point scale. For those animals the ideal body weight must be estimated by different methods like bioelectrical impedance, labeled water method or dual-energy-xray-absorptiometry (DEXA). Eat less, exercise more. It demands a lifestyle change. This is true in humans and also in dogs and cats. It is extremely important that everyone in the family and everyone involved in taking care of the pet are willing to cooperate; otherwise it will not be a success. The
amount of food to be given should be calculated based on the resting energy requirement (RER) for optimal body weight using the equation: 70xBW^0.75 in kcal metabolizable energy per day. Dogs should be fed at 1.0xRER and cats at 0.8xRER. The aim for weight loss is 1-3% per week in dogs and 0.5-2% per week in cats. The amount of exercise should be increased gradually and more short periods are more effective then fewer long periods. The amount of food must be weighed out every day to be accurate. Measuring cups are inaccurate. Most pet food companies will provide software programs to help you guide the pet owners and keep the motivated by beautiful graphs. is the key to successful weight management. Reaching target weight should be celebrated, but keeping the animal on its target weight is far more important. Keep weighing the animal every 1-2 weeks after reaching target weight while adjusting the amount of food. If the animal s weight is stable for 2 consecutive weighinns, the periods can gradually be extended to a maximum of once per 3 months. Clinical Nutrition CHAPTER 2 Prevention Prevention is better then cure, and this is especially true for obesity. Keep growth charts of puppies and kittens and make sure that the clients are not overfeeding their animals. Especially after spay/ neutering the change of being overweight increases and warrants good client education. 59