How to handle alternative diet requests (Proceedings)

American Animal Hospital Association (AAHA) and World Small Animal Veterinary Association (WSAVA)[i] have developed a Nutritional Assessment Guidelines for every patient to be done at every visit (www.everypeteverytime.com/nutrition-assessment.html) with funding from Hill's, Nestle Purina, Royal Canin and P&G. These guidelines have a list of nutrition-related risk factors by which if any one of the risk factors is recognized during the initial screening of the patient, a more thorough examination of the patient, diet and method of feeding is suggested.

One of the nutritional risk factors listed in the Nutritional Assessment Checklist is the feeding of an “unconventional diet (e.g., raw, homemade, vegetarian, unfamiliar)” …. but what is a unconventional diet?

Other than the suggesting ‘raw, homemade, vegetarian diets' are unconventional, neither AAHA nor WSAVA offer a description of a ‘conventional' or ‘unconventional' diet. The word conventional is a subjective adjective defined as: based on or in accordance with what is generally done or believed; synonyms are “normal, standard, ordinary, usual, traditional, typical and common”; of which common or typical might be appropriate.

• One could assume dry kibble is the conventional diet based on tonnage or billions of dollars spent.

• Another assumption could be that because the vast majority of dogs (and cats) in the USA receive the majority of their calories from a commercially-made, that is conventional.

• From a different point of view, however, over the last million or so years that dogs have been in close living quarters with humans, mass produced food specifically designed for dogs has only been in use for the last 150 yrs – far less than 1% of their evolutionary life.

Alternative or non-conventional dietary options available to owners

Clearly we do not have a uniform understanding of what is an “alternative” or unconventional diet. However, the increased number and variety of alternative pet food products over the last 5 yrs has been staggering.

Suggested categorization:[ii]

• Most commonly fed pet food products – dry and canned products

• Home prepared Diets – made in the home

• Pre-made “Homemade” Diets – commercially produced using recognizable local ingredients

• Pre-made products – commercially produced components (veg or meat only)

• Individual Ingredients – single item products

• Therapeutic Diets – designed for disease management or prevention

• Any Combinations of the above

Once a small niche, products such as fresh food, refrigerated, frozen, dehydrated and freeze dried pet food products are gaining in popularity.[iii] The next upcoming group of food products for pets known as toppers, appetizers, gravies, waters and gels are designed to be highly palatable but, for now, unlikely to be adequate as the sole nutrition.

Therefore, describing a nutritional risk factor as feeding an “unconventional” diet is not sufficiently discerning. An APPA National Pet Owner Survey indicated that indeed the feeding practices of pet owners is highly varied and not limited to one type of pet food.[iv] There are 10's, if not 100's, of thousands of pet food products and anyone could be modified or “improved” within 6 months. Most likely the owner will name combinations of product(s) that are unfamiliar to you - expect that to be the norm in your diet histories. There is no way a practitioner could keep up with this explosion of pet food options, so more likely clients will be naming pet foods and feeding product combinations that are “unfamiliar” to the veterinarian. The dreaded AAFCO statement now has becomes your new “BF” best friend.

A brief diet history should be completed by the owner ideally at home where they can see the exact name of all the products fed. Examples of such forms are readily available from the WSAVA www.wsava.org/nutrition-toolkit, Veterinary School Nutrition Services, Veterinary Nutrition textbooks and some Pet Food Manufacturers. It would educational for the owner to learn how to determine the nutritional adequacy statement of all (food and treats) products fed to their pet. Initially to educate and obtain this important information will require some upfront training on how to find, read and interpret the nutritional adequacy statement that is required on ALL pet food labels. Once the owner has learned how to find and interpret the nutritional adequacy statement on pet food products, this skill will continue to be useful to them as they consider new food products coming onto the market at a regular pace. AAHA Nutrition Reference Manual has a simple, easy to understand explanation of AAFCO standards, pet food labeling and nutritional adequacy statements is downloadable http://www.everypeteverytime.com/docs/en-us/Pet_Nutrition_Ref_Manual.pdf. This type of client education and medical record entry is well within the skill set of most veterinary technicians, particularly those with specialized training in nutrition.

How to assess an alternative diet – 3 simple questions

• What type of AAFCO nutritional adequacy statement is on the product?

• Is the nutritional adequacy statement appropriate for this patient?

• Has the product been recalled?

Good news: AAFCO label regulations do not distinguish between conventional and non-conventional pet foods and is required on every pet food label sold in USA except if:

• made/sold only in AK or NV, b) clearly labeled as treat, snack or supplement, c) is home made.

It is the most important preliminary piece of information on the label when assessing the diet for a particular patient. The statement will be one of only 3 options and it will answer 2a and 2b for you in one sentence:

• Nutritionally complete and balanced (or prefect, scientific, 100% nutritious) is known or shown to be nutritionally complete. Also embedded in this Complete and Balanced statement will be the 1) specie, 2) life stage and 3) method of determining nutritional adequacy of which there is:  a) “formulated to meet” or b) “feeding tests”.
• Specie - must be named (canine or feline)

• Life stage - There are only 3 life stage claims possible:
• growth-gestation-lactation

• adult or maintenance

• all life stages (growth)

• Method of determining nutritional adequacy:
• Formulated to meet

• Feeding tests

• Family member of a product that has passed using the feeding method

• For supplemental or intermittent feeding only is assumed or known to be nutritionally incomplete as sole source of nutrition for an extended time. The specific clinical sign that may appear first and when is dependent upon the first limiting nutrient and magnitude of the variance from the recommended level (toxicity or deficiency).

• Feed under the supervision or direction of a veterinarian as seen on veterinary therapeutic dietary products. Many have passed AAFCO protocol feeding trial protocols but use Vet only label.

The most common mismatch is an owner feeding an “all life stage” food to a middle aged, obese prone breed, neutered dog or indoor middle aged, neutered cat with a body condition score greater than 6/9. You  could help the owner determine such a product was inappropriate for their pet and to help them select a more appropriate product to maintain a healthier weight and improve longevity.[v]

 Once the nutritional adequacy statement has been checked on a particular product it is unlikely to change unless recalled for a diet formulation error and then it should appear on the FDA Pet Food Recall list. Naming dropping a familiar pet food or manufacturer does not preclude the formulation errors. There were more than 30 recalls in 2013 and some of the products were from familiar ‘major' pet food companies. Pet food product recalls are now required with 24hrs (FSMA 2012) and listed on the FDA Pet Food Recall List.

Pet food products that might be considered ‘alternative' should have a nutritional adequacy statement and most often it will be the intermittent/supplemental feeding only claim, a few will have complete and balanced as verified by the formulation method. Some pre-made homemade diets carry a complete and balanced claim, e.g., Raynenutrition.com while others that are similar in appearance and contain ‘wholesome fresh' ingredients too have an intermittent or supplemental only feeding claim, e.g. Freshwholefoodfordogs.com. The difference here is the addition of specific vitamins and minerals, and adjusting the nutrient concentrations for the caloric density of the product. Both of which require nutritional expertise to accomplish and is beyond the skill level of most individuals who prepare the diets in their homes and sell locally. This AAFCO nutritional adequacy information may not be on the website or literature, but is required on the label of sold product.

Pre-made products contain attention-grabbing ingredients but are not complete and balanced as a standalone diet; however, some provide mixing instructions. The product label carries an intermittent or supplemental feeding claim, but no AAFCO nutritional claim can be made for the final meal prepared at home by the owner, e.g., Balance IT® Blend products vs. Dr. Harvey's Veg-to-Bowl. The difference here is BalanceIT was designed by an ACVN certified Veterinary Nutritionist.

Likewise the individual or single ingredient products, e.g., Wellness 95% canned Salmon has a ‘for intermittent or supplemental feeding claim' but instructs the owner to use as a mixer or topper to dry kibble. No proportions are offered to ensure the owner feeds the correct amount of the unbalanced canned product to the balanced dry kibble. The suggestion should be to limit the amount of mixers or toppers to less than 10% of the daily intake.

When the AAFCO statement cannot help you: 21% of dog owner and 15% of cat owners fed human food or a homemade diet.4 Home prepared diets do not carry any nutritional adequacy statement because they are not sold as products – only as a recipe. Since the 2007 major pet food recall, the number and availability of homemade recipe has exploded. Recipes are readily available in popular press pet books, textbooks, chat room, blogs and web sites from the one-dog-wonder pet owner, neighbor, family, friends, breeders, veterinarians, and various types of nutritionists (animal, human and veterinary) but only the latter two groups would be held accountable for their recommendations based on their training. Given 95% of 200 recipes reviewed were found to be nutritionally inadequate,[vi] it is important to have some form of nutritional guarantee from the author of the recipe.

There are two major areas of concern with homemade diets:

• Is the nutrient profile appropriate (species, lifestage and BW/BCS)?

• Does the client make the recipe according to original instructions (still)?

Each of these problems has been documented to cause malnutrition in pets.[vii],[viii],[ix],[x],[xi],[xii]

Is the nutrient profile appropriate? Checking the nutritional adequacy of recipes is not a simple task and beyond the skill set of and time available to most practitioners to do correctly b/c software, formulation skills, nutritional knowledge and access to ingredients databases is required. Therefore, practitioners should be willing to:

• Assess (Y/N) the recipe for 5 key nutrient sources, and refer if needed:[xiii]
• Protein source - should contain 25 to 30% cooked meat for dogs, (one part meat to two or three parts grain) and 35 to 50% cooked meat for cats

• Carbohydrate source - optimal grain to meat ratios should be at least 2:1 to 3:1 for dog foods and 1:1 to 2:1 for cat foods. Cooked corn, rice, wheat, potato or barley are better than 85% digested by both dogs and cats

• Fat source - need only 1% to meet essential fatty acid requirement - animal source is best.

• Calcium Source - a specific calcium supplement (with little or no phosphorous) is essential.

• Multivitamin and trace mineral source - cannot be met using “whole” foods such as fruits, vegetables b/c pet can simply not consume enough vegetable material to meet the stated recommendations. Synthetic supplements are required to ensure a complete diet.

• Offer known nutritionally adequate recipes; or

• Help the client obtain advice from a veterinary nutritionist.

Boarded veterinary nutritionists, like other veterinary specialists, have advanced training and can be of particular assistance with homemade diets. Checking and correcting nutritional imbalances are generally not difficult for nutritionists; hence most recipes can be completed and balanced if the owner insists on feeding a particular recipe, e.g., cases of food reaction. Practitioners can initially screen a recipe for nutritional adequacy by answering a short list of questions (above). If the recipes fails or is questionable in any area, the case should be referred to a nutritionist if they wish to continue feeding that recipe.

Diet Drift: It is important once the homemade diet has been documented as nutritionally sound, the recipe specifics should be maintained in the medical record and reviewed on a regular basis with the owner, i.e., control diet drift. Food substitutions are usually possible but consult the originator of the recipe first.

How to assess patients on an alternative (or any) diet - see WSAVA nutritional assessment checklist for more detail.

• Body Weight and trends

• Body Condition Scores

• Muscle Condition Scores

• Skin and Coat

• Eyes and Vision (lens and retina)

• Dental Scores

• Skeleton

• Laboratory Data (albumin, total protein, RBC and WBC parameters)

A disparity in veterinary pet nutrition has been underway for some time but has now become all too apparent. At a time when clients are motivated to consider alternative diets including homemade for their pets, veterinarians are not adequately versed in pet nutrition and dietary options. Increasing the pressure on this disparity are the dramatic advances in the understanding nutrition plays in health and disease. Key nutritional factors (essential nutrients and bioactive food components) have been documented as potential modulators of health and disease. Through nutrigenomics research, we are beginning to understand the ways in which food components affect gene expression and, hence, modulate health and disease. Clients have already begun requesting such information for their dogs and cats (aka family members) in this regard. To remain competitive, practitioners must consider raising their level of nutritional competency or incorporating the specialty of nutrition, through consultants, into their practice to meet this growing client demand.

References

[i]. The World Small Animal Veterinary Association (WSAVA) Nutritional Assessment Guidelines Task Force. Nutritional Assessment Guidelines. J Sm Anim Pract 2011.

[ii]. Handling Alternative Dietary Requests from Pet Owners. Par JM, Remillard RL. Vet Clinics of NA: SA Practice Vol 44(4) 2014 667-688.

[iii]. Taylor, Jessica. Market Trends: Petfood enhancers. PetFood Industry. October 2013.

[iv]. APPA National Pet Owner Survey 2011-2012. Canine p84; Feline p188.

[v]. Kealy RD, Lawler DF, Ballam JM, et al. Effects of diet restriction on life span and age-related changes in dogs.

JAVMA 220[9]:1315-1320, 2002.

[vi]. Stockman j, Fascetti,AJ, Kass PH, et al. Evaluation of recipes for home-prepared maintenance diets for dogs. JAVMA 242[11]:1500-1505, 2013.

[vii]. Streiff EL, Zwischenberger B, Butterwick RF, et al. A Comparison of the Nutritional Adequacy of Home-Prepared and Commercial Diets for Dogs. J Nutr. 132:1698S-1700S, 2002.

[viii]. Roudebush P, Cowell CS. Results of a hypoallergenic diet survey of veterinarians in North America with a nutritional evaluation of homemade diet prescriptions. Vet Derm 3:23-28, 1992.

[ix]. Niza, MMR, Vilela CL, Ferreria LMA. Feline pansteatitis revisited: hazards of unbalanced home-made diets. J Feline Med Surg 5:271-277, 2003.

[x]. Polizpoulou ZS, Kazakos G, Patsikas MN, et al. Hypervitamoinosis A in the cat: a case report and review of the literature. J Feline Med Surg 7:363-368, 2005.

[xi]. Fornel-Thibaud P, Blanchard G, Escoffier-Chateau L, et al. Unusual case of osteopenia associated with nutritional calcium and vitamin D deficiency in an adult dog. JAAHA 2007;43:52-60.

[xii]. Gray CM, Sellon RK. Freeman LM. Nutritional adequacy of two vegan diets for cats. JAVMA 225[11]:1670-1675, 2004.

[xiii]. Remillard RL, Paragon, BM, Crane SW, et al. Making Pet Foods at Home. In: Small animal Clinical Nutrition. (4thed). Hand MS, Thatcher CD, Remillard RL, Roudebush, P (Eds) MMI Associates, 2000 pp164-181. https://s3.amazonaws.com/mmi_sacn5/Chapter+10+-+Making+Pet+Foods+at+Home.pdf