Obesity: Is there anything we can do about the epidemic? (Proceedings)

Obesity is the most common nutritional problem encountered in daily practice. Studies suggest that obesity may affect as many as 40% of dogs and 30% of cats in some practices. Obesity, like cancer and infection, is a plural noun, as the list of causes below demonstrates:

Causes

     1. Animal

          a. Breed

          b. Age

          c. Neuter status

     2. Nutritional

          a. Diet

               i. Highly palatable diets

               ii. High fat diets

          b. Feeding

               i. Early feeding practices (?)

               ii. Progressive hyperphagic obesity

               iii. Frequency of eating

               iv. Overeating

     3. Environmental factors

          a. Activity

          b. Stress

               i. Owners

               ii. Housing

               iii. Other animals

          c. Seasonal

     4. Genetic factors

          a. Autosomal recessive traits

          b. Autosomal dominant traits

          c. X-linked traits

          d. Chromosomal abnormalities

     5. Intrauterine, perinatal influences

          a. Intrauterine malnutrition

          b. Intrauterine hormonal influences

          c. Early life dietary influences

     6. Drug-related

          a. Phenothiazines

          b. TCAs (amitriptyline)

          c. Cyproheptadine

          d. Glucocorticoids

          e. Megestrol acetate

          f. Valproate

          g. Lithium

          h. Insulin

          i. Sulfonylureas

     7. Seasonal

     8. Neuroendocrine

          a. Hypothalamic syndrome

          b. Cushing's syndrome

          c. Hypothyroidism

          d. Hypogonadism

          e. Growth hormone deficiency

               i. Genetic

               ii. Acquired (?)

          f. Insulinoma and hyperinsulinism

     9. Viral - ?

     10. Idiopathic

In 2004, we published our experience with an obesity therapy program for dogs that included dietary changes, monthly weight checks, and a structured maintenance portion. We found that clients achieve an average percent weight loss of 15% and a decrease in body condition score (BCS) of an average of 2/9 during 6 months of weight reduction, and maintain the reduced weight in their pets for the following 18 months.1 To our knowledge, this is the most successful documented approach to obesity therapy. Despite this positive overall result, individual results varied widely, and nearly 50% of clients dropped out during the course of the study.

Although understanding the causes of obesity in companion animals remains a daunting challenge for veterinary nutritional scientists, veterinary hospitals that provide clients a structured obesity therapy program offer a valuable service for their clients. After the veterinarian and client identify the problem(s), the client and patient are "referred" to a trained technician, who usually has more time to focus on the complex issues raised during obesity therapy. An outline of our approach follows:

Approach

     1. History

          a. Clinical – onset - age (young, mature), rate - (slow, fast), co-morbid conditions (drug therapy?), disease risks factors (endocrinopathy, musculoskeletal)

          b. Diet – satisfactory?

          c. Feeding – ad lib? Meal? Intake? –high (>maintenance), intermediate (<maintenance>basal), low (<basal)

          d. Environmental – opportunities for activity, other animals, other humans (alternative food sources, saboteurs, allies)

     2. PE – Body Condition Score, Muscle Condition Score, fat distribution, other abnormalities (skin, other)

     3. Labs – as indicated by index of suspicion from Hx & PE (thyroid, adrenal, etc.)

     4. DDX

     5. Simple – young, healthy, high intake, positive history and environment

          a. Intermediate –older, predisposed breed, ± disease, intermediate intake, questionable history (e.g., orphan) or environment,

          b. Complicated – aged, + other disease, low intake, unstable environment

     6. Options for Management

          a. Animal

               i. Simple – healthy animal

               ii. Intermediate – begin treating other conditions before weight loss to assess/gain adherence.

               iii. Complicated – question need for weight loss

          b. Diet

               i. Simple – reduce intake of satisfactory diet

               ii. Intermediate - ± change to reduced energy density food

               iii. Complicated – change to reduced energy, increased protein content diet

          c. Feeding

               i. Simple – meal feed, try to eliminate other sources of food, replacement vs. supplementation of kcal

               ii. Intermediate – Simple + treat bags, recruit other family members as allies,

               iii. Complicated – collaborate with owner on a plan

          d. Owner/environment

               i. Simple – education, find alternative forms of interaction (obedience training, teach tricks to cats, more activity)

               ii. Intermediate – identify hidden sources of food, saboteurs

               iii. Complicated - collaborate with owner on a long-term plan

Obesity therapy program

The goal of obesity therapy is not weight loss; it is maintenance of the lost weight. We have found that a structured approach to obesity therapy is the best way to ensure successful obesity therapy outcomes for your clients. As mentioned, our program builds on collaboration between the veterinarian, the technician, and the client to assure the most efficient use of time for all. The veterinary technician leads and maintains the program after referral from the veterinarian, with each consulting with the other as appropriate for client management and patient care. An important feature of treatment is goal setting (by the client):

Goal setting - helping clients make "smartr" goals

Once clients understand the benefits of change and have agreed on a goal, the steps to achieving it don't have to be difficult. A set of clear objectives that are well defined, measurable, realistic, and time driven is a great place to start. A simple process for writing down goals called "SMARTR" goal setting can help assure that goals are clearly communicated, well defined, and agreed upon by all involved in the change. SMARTR goals are Specific, Measureable, Action Oriented, Realistic, Time-Driven/Timely, and Rewarded!

Let's say, for example, that a client has an obese, inactive cat. Based on your discussion with the client, you agree that providing the cat a SlimCat (www.slimcat.com) ball to provide environmental enrichment and help increase activity.

The following is an example of the SMARTR goal process can be used to create a personalized plan to achieve this goal:

I. Specific: Goals need to be clear, focused, concise, and well defined. Avoid general terms and be as detailed as possible.

     • A vague example: I want to feed my cat using a SlimCat ball. A SMARTR specific example: I will place half the cat's daily food in the ball, and the other half in his bowl. Until he understands what it is, I will leave the top open so food falls out easily. Once he starts to

     • use it, I will start with large opening, making them progressively smaller as he learns about using the ball

II. Measurable: We need to have a way to measure of success. SMARTR goals can use time frames, dates, dollar amounts, product names, etc. to measure success.

     • An un-measurable example: I will buy a SlimCat ball.

     • A SMARTR measurable example: I will buy a SlimCat ball today.

III. Action oriented: The goal must require the client to take action, not a reaction. Winning the Lotto jackpot may be one of the few examples of achieving your goals without giving much effort. However, your odds are more than one in 4 million. Check your goal to see if you are including a list of actions you plan to take to accomplish your goal.

     • A non-action oriented example: I'll find a store to buy SlimCat ball, soon.

     • A SMARTR action-oriented example: I will stop at the store my veterinarian recommended and buy a

     • SlimCat ball on my way home from our meeting today

IV. Realistic: Next, check to see that the goal is manageable, attainable, and believable for the client! As we know from experience, letting others set goals for us can lead to low motivation and high anxiety. Low motivation because they were imposed on us, and we are expected to comply, and anxiety because we may not understand, agree with, or be able to execute the goal in our situation. The chances for success improve when clients set goals they understand, agree with, and can do.

     • A not-so-realistic example: I will start using the ball soon.

     • A SMARTR realistic example: I will start using the ball this weekend, when I have time to watch the cat and troubleshoot any problems that might arise.

V. Time driven/timely: SMARTR goals have a starting time, a time-line and an ending time. Goals can also be broken down into smaller objectives.

     • Short-term (to be accomplished within 6 weeks)

     • Medium-term (to be accomplished within 6 months)

     • Long-term (goals to be sustained for the life of the pet)

VI. Rewarded - As important as goal setting is, we tend to value what we are rewarded for. Clients can be "rewarded" by being heard and involved in treatment plans (since they will be responsible for carrying them out), having clear ways to measure progress, praising successes and troubleshooting failures during the change process, and receiving constant reinforcement of desired behaviors.

Follow-up

One of the critical keys to a successful obesity therapy program is to follow the progress of the patient. We tell clients what our follow-up schedule is, and ask them to agree to a preferred method and time to be contacted. Our first contact with the client occurs within a week after initial recommendations are made, followed by repeat "check-ins" at 3-6 weeks, 3 months, 6 months, and 1 year. This allows us to monitor the patient's body condition score and weight progress, to make adjustments as needed, and to continue to support and motivate the client. It also helps to determine when the owner is becoming frustrated or is having problems with the plan so that encouragement or suggestions to help keep them on the plan can be offered.

Activity and Environmental Enrichment

Before making recommendations to increase a patient's activity, be sure that both the client and patient are physically capable of doing so. Activity recommendations must also consider the client's schedule so they are not asked to do anything they can't realistically accomplish.

Many pets lead sedentary lifestyles due to their owner's work schedules. We sometimes suggest that owners adjust the animal's environment to increase its activity. This can include placing bowls in places the animal has to climb or jump to for food and water. Along the same lines, baby gates or similar barriers can be placed in doorways so the animal has to work to get in and out of various rooms throughout the house. There are toys available that dispense dry dog or cat chunks when the animal moves them; these toys can simulate (or stimulate) hunting as well as slow down food intake.

If a client is too busy, or physically not able, to regularly exercise their pet, there are ways to increase the animal's activity by means of playful interactions within the home. Playing fetch by throwing a toy up (or down) the staircase is a good means of exercise, and a good way to offer a treat (instead of just handing it to the pet). Another (favorite) suggestion is to have the dog do "doggie sit-ups"; command the pet to "sit" and "lay down" 4 or 5 times in a row before giving a treat. There are also a large variety of interactive toys (e.g., laser lights or fishing poles with feathers) for dogs and cats that promote increased activity. A good way to begin a new exercise program is to set a goal to increase the pet's activity by one minute per day until a goal of 10 minutes per day is reached. Once this goal is attained, the duration can be slowly increased until the pet's activity is at the desired level.

Cats also can be trained, especially with food rewards (replacement, not supplementation!). In fact, some cats will get great exercise by chasing pieces of their daily dry ration across the floor if thrown by the owner. And believe it or not, some cats can be trained to walk with a harness and leash.

Obesity is a major nutritional problem affecting pets. The risks associated with obesity warrant the need to offer intervention, which can be achieved at veterinary clinics by instituting both an effective client education program for prevention, and a structured program that includes long term follow-up and support for obesity therapy. Veterinary technicians provide a valuable resource that can be fully utilized to institute and manage these programs, which serve to benefit the patients, clients and the veterinary clinic.

Prevention

We believe that the best way to prevent pets from developing a weight problem is to educate the client about proper feeding techniques and to teach them how to evaluate their pet's body condition before the pet's weight becomes a problem. This education should occur during their first visit to your clinic, regardless of the lifestage of the animal. The best time to provide this information however, is when the pet is still a puppy or kitten; proper intervention at the start of life can ensure a lifetime of moderate body condition. We provide "go home kits" that contain food samples, literature on proper feeding practices, a pet food measuring cup and a body condition scoring sheet, so the owner can monitor their pet's condition themselves and adjust the amount of food offered as necessary. We show clients how to assess body condition score using the rib cage, abdominal tuck, and waist parameters and have them practice in our presence to be sure they understand the procedure.

When an animal is spayed or neutered, its energy needs decrease by about 25%, so this provides another opportune time to remind the client to decrease the amount of food offered, or change the diet to one of lower caloric density. In dogs, this may be an appropriate time to change the diet from a growth food to one designed for adults, particularly if the dog has completed the majority of its growth. For cats, we recommend continuing growth foods for 12-18 months, until skeletal development has finished, to avoid the potentially increased acidifying potential of diets designed for adult cats. Many people believe that neutered pets automatically become overweight; if they follow the above guidelines, assess their pet's body condition and adjust food intake as necessary, this should not be a problem.