Promoting the big three: Dentistry, obesity and senior care (Proceedings)

Perform this simple exercise during your next staff training session: Ask each team member to list the top ten conditions and/or diagnoses your hospital sees on a daily basis. List the common things you see such as ear infections (yeast otitis externa), large bowel diarrhea (colitis) and itching dogs and cats (allergic dermatitis). Don't dig up that Addisonian case that you saw exactly one of last year. Focus on the routine, common and everyday cases you see.

The list may surprise you. Not only will you see that it is a small list and that many cases can be grouped together under some common headings, but that the list is manageable by all team members. Once we distill the essence of what we commonly encounter in our everyday practices, we can better train and prepare our team to deal with these common cases. By identifying what we see and do, we can ensure that our team members are recommending and providing the highest standards of care for our pet patients.

Clients primarily visit the veterinarian with an ill pet for two reasons: they can't fix it themselves or the pet is in pain. Crude, I know, but true. And tied to that visit is the most important fact: they care. If they didn't care, who cares if it's "broken" or hurting? After we understand the core motivation for our sick-pet visits, we can tailor our message to address these primary concerns of "fixing the problem" and alleviating pain. These are the results our clients are turning to us for. And the greater the care and relationship factors, the more demanding the client will be that we solve their pet's problems in a timely and compassionate manner. Don't be threatened – celebrate the relationship and honor their wishes. After all, this is what is driving the elevating of standards of veterinary medical care. Fix it, take away the pain and show that you care. These are the tenets are success.

So what do we see frequently? Let's take a look at some of the more common conditions, how to communicate with our clients about these diseases and what can we do to "fix them."

Periodontal disease

Periodontal disease is the number one condition in all pets over three years of age according to the American Veterinary Dental Society. The AVDS reports that approximately 80 percent of dogs and 70 percent of cats show signs of oral disease by age three.

Periodontal disease refers to the condition in which bacteria attack the soft gum tissue and damage the underlying support structures of the teeth. Periodontal disease is the final stage in a process that begins with the development of plaque on a pet's teeth. Plaque is a substance that forms when bacteria multiply on the teeth and gums. Plaque mixes with saliva and becomes the hardened substances known as tartar and calculus. Bacteria, plaque, tartar, and calculus irritate the gums, which become tender, red, and swollen. This stage of dental disease is called gingivitis. Eventually inflamed gums separate from the teeth, creating pockets that can trap more bacteria. These pockets deepen and bacteria may attack the roots of the teeth and the bony tissue of the jaw, causing teeth to loosen, the gums to bleed, mouth odor, and pain when your pet eats. This is periodontal disease.

Bacteria from the teeth and gums can enter the bloodstream and may travel to major organs and begin infection there. Among organs that are most often affected are the lungs, heart, kidneys, and liver. Parts of the nervous system may be affected as well. Although these infections are usually treatable when caught at an early stage, they can cause serious damage to these organs and, if not caught in time, may lead to death.

Key client communication points

Oral infections contribute to:

• Heart valve infections – endocardiosis – this why the American Dental Association (ADA) requests that all patients with heart disease undergo prophylactic antibiotic treatment prior to any dental procedure

• Kidney infections – pyelonephritis

• Decreased immune function

• Bad breath

• Tartar/Gingivitis/Calculus

• Oral pain when tooth mobility develops or gum recession below the crown occurs

Staging periodontal disease

• Stage I - Initial gum disease and periodontitis - minimal plaque; reddened gums.

• Stage II - Early gum disease and periodontitis - greater plaque and calculus accumulation; swollen gums; some bleeding from the gums.

• Stage III - Established gum disease and periodontitis - moderate calculus accumulation; severely swollen gums; gingival pockets. Immediate danger of irreversible tooth damage.

• Stage IV - Advanced gum disease and periodontitis - large accumulation of dental deposits; gum recession; loose teeth; bone loss. Often involves mandatory tooth extraction(s).

Consequences of untreated periodontal disease

• Severe gingivitis and bleeding from gums – Often painful

• Loss of appetite and ability to eat normal foods

• Halitosis or "bad breath"

• Tooth loss and broken teeth – Painful

• Tooth root abscesses and infections – Very Painful

• Heart valve infections – Endocardiosis

• Increased incidence of kidney and liver infections

• Nasal infections and increased nasal discharge and sneezing

• Loss of mandibular and maxillary bone resulting in physiologic fractures

• More severe infections when biting or chewing, including biting or chewing at skin (severe pyoderma)

• Reduced life expectancy due to poor diet and constant struggle with infection

• Diminished overall quality of life due to constant pain and discomfort

Home dental care

The gold standard for improving and maintaining proper oral health begins with daily brushing. The problem is simple: 1) who has time to brush their pet's teeth every day or 2) is willing to do this or 3) has a compliant pet that will easily allow brushing? These real challenges don't mean we shouldn't recommend daily dental care; it means we shouldn't chastise or clients if they fail to do so. During each second or third puppy or kitten appointment, we demonstrate how to brush their pet's teeth and actively promote the practice. We stress the role oral health plays in longevity, quality of life and disease prevention.

I have a rule in my life that transcends into my practice: I don't expect others to do more than I do myself. I've found than an honest, transparent approach to this issue yields better results. I readily admit to my clients that I don't brush my pet's teeth regularly. In fact, I brush my pet's teeth rarely. As a result of my inability to brush my pet's teeth regularly, I have their teeth cleaned every six to twelve months.

In addition to regular teeth cleanings, I also feed my pets a diet that has been demonstrated to reduce tartar and calculus buildup. I also use a water treatment to maintain fresh breath and promote good oral health.

In short, we encourage clients to perform whatever level of pet dental care they feel is practical for their lifestyle. We don't admonish clients for failing to brush their pets teeth. The "pay me now or pay me later" philosophy is stressed explaining that their pets will require a dental cleaning and polishing every one to two years if they fail to provide regular teeth brushing.

Dental scaling and polishing

Dental prophylaxis is a term we commonly use to describe a dental scaling and polishing. To ensure maximum safety and to provide the highest level of care, we perform the following services with all of our dental prophys:

1. All pets receive a physical examination prior to anesthesia.

2. All patients have pre-surgical blood tests (complete blood cell count (CBC), chemistries and electrolytes) to ensure proper kidney and liver function, hydration status, and presence of infection. This helps us to evaluate a patient's overall health status. Remember, we can not 'see' liver and kidney function on a physical examination.

3. All pets receive intravenous fluids by the use of an IV infusion pump. This aids in a faster recovery from anesthesia and provides an instant means for administering emergency drugs in a crisis.

4. We use only the safest anesthetics. Remember that there are no safe anesthetics – there are only safe anesthetists. However, we must always caution all clients that there always exists the possibility of an anesthetic complication, despite all precautions. We primarily use propofol injectable anesthetic. This is the same drug used on President George W. Bush when he underwent colonoscopy in 2002. In fact, the risk of death is statistically lower than the chance of being killed in an automobile accident.

5. We monitor all patients with the latest in monitoring equipment. All patients are supervised by a staff member from the moment of induction until they are fully awake – they are never alone during the procedure. Pulse oximetry (Sp02), end-tidal C02, ECG, body temperature, heart and respiration rates are continuously monitored on all patients undergoing anesthesia.

When to talk about it

I typically begin the oral examination after examining the ears, eyes and nares. I ask the client to get out of their chair and come close to their pet to show them any problem areas. I want them to see and smell any periodontal disease present. If the teeth look great, I take this opportunity to congratulate them on their efforts. By actively engaging and interacting with clients, you're more likely to impress upon them the seriousness of the condition. If a client remains distanced and uninvolved, it is much easier for them to ignore our recommendations for dentistry. It is imperative to make the connection between oral health and systemic diseases such as endocarditis. Too many clients view dentistry as merely a cosmetic procedure and see no value in keeping their dog's teeth "Hollywood-white." It is our professional obligation to make sure clients understand the relationship between the mouth and general health and well-being. If you note loose teeth, discuss pain. If you see gingivitis, remark about gum recession, tooth root exposure and the potential to adversely affect adjacent teeth. It is important to keep in mind that few clients thoroughly examine their pet's oral cavity at home. Take this opportunity to lift the lip and educate your clients on the dangers of periodontal disease.

An important note: I recommend you point out and briefly touch on an abnormal finding during the course of the examination, regardless of the issue. I recommend you reserve the more detailed discussion for the time after your examination when you review pertinent findings with the client in a seated position. Additionally, you can also have a trained staff member give more detailed information on conditions such as periodontal disease after you exit the appointment.

Senior care

Over the past ten years, I've written about and given innumerable presentations on "senior care." My conclusion after all these years: too often we make it too complicated. Let's face it, senior care is simply focusing the conversation and examination on the more common conditions an older pet is likely to develop. Periodontal disease, obesity, hypertension, heart, kidney, liver and thyroid disease and cancer are some of the most common conditions we should be searching for in any pet over seven years of age. These diseases are most commonly diagnosed by a thorough medical history, careful physical examination and comprehensive blood and urine tests. Pretty basic, yet it is estimated that fewer than 10% of all senior pets receive this simple care. Why? The answer to that question has frustrated me for over ten years. The reason: it's us. Veterinarians simply aren't either taking the time to talk with clients about the common senior diseases or don't feel comfortable asking clients to pay for the diagnostic testing in an apparently healthy patient.

Why do veterinarians feel this way? I think there are many reason, but I'd like to share two of the most common causes I've observed in veterinary clinics all over the world: 1) fear of rejection and 2) fear of fee.

Why not? 1) Fear of rejection

The fact is that not every client will accept everything we recommend, regardless of how medically necessary it is. This may be heartworm preventive, spaying or neutering, dentistry or even basic diagnostic tests to determine the cause of a pet's illness. Get used to it. You're not going to hit a home run every time you bat. So then we break down into two types of individuals: those that continue to play the game and those that walk away. In the game of veterinary medicine, I firmly believe it is our professional obligation to swing as hard as we can at every opportunity. Period. I don't care if I've discussed it a hundred times with a client and they've rejected me every time, this is my job. I will do my job respectfully, compassionately and intelligently using every trick in my bag to try and persuade a client to provide the best care for their pet. If the client accepts my proposal, wonderful! If not, I don't take it personally and I move on to the next client. The problem is, most people get sick of rejection. Hit someone with enough "no's" and pretty soon they begin to doubt themselves or their abilities. As an ego defense, we stop exposing ourselves by asking. This is the cause for our profession's paltry dentistry, senior blood and urine tests and weight reduction compliance rates. Somewhere along the way we simply stopped asking because we got sick of being rejected.

Why not? 2) Fear of fee

A close second and potentially intertwined reason for not recommending senior blood and urine tests is a veterinarian's fear of the cost of these services. How can we justify a client spending $100, $150 or more for diagnostic tests on an "obviously" healthy appearing eight-year old dog? The answer is easy: because we can't detect many diseases any other way until they become fulminate (read the dog or cat is now obviously ill). The challenge is becoming comfortable celebrating a completely normal blood and urine test panel and capturing the value of those services.

Talking about senior care

Senior care starts with obtaining a thorough medical history. Diet, lifestyle, risk factors such as contact with other dogs or cats, and the presence of excess weight or periodontal disease are basic cornerstones to begin the discussion. The most efficient method for obtaining this information is a staff-administered questionnaire. Create a questionnaire that addresses the ten or fifteen major topics you want to focus on with your senior patients. Review the previous examination and record the previous weight and periodontal disease stage. This information should be closely tracked and shared with the client. The most impactful information is often the demonstration of a worsening condition. Begin the conversation by stating the obvious: that the pet has now entered another phase of life and certain conditions or diseases are more likely to develop. Stress the importance of early disease recognition and intervention as opposed to waiting until a disease is grossly evident and reversal or improvement will be much more challenging. It is much easier (and cheaper) to maintain an automobile in good working order instead of waiting until the engine fails and replacing it. Besides, we can't easily replace many "engines" in veterinary practice.

The role of nutrition and exercise cannot be under stressed in senior pets. Nutritional supplements to combat oxidation stress and free radical damage should be considered for all older pets. Clients are extremely receptive to natural, non-prescription medication recommendations to maintain a healthy pet. Do the research and decide for yourself the role of aerobic activity and nutrition in your senior care program.

The senior pet physical examination

The foundation of the senior care experience is a thorough physical examination. You should carefully examine and articulate your findings all of the observable body systems. As part of your examination, be sure to educate the client on what changes to look for that could signal a problem. For example, when examining the lymph nodes, explain where to palpate and that any hard "knots" or swellings should be brought to your immediate attention. Without going into great detail, mention that the lymph system can be a source of many diseases and that the pet owner should routinely feel these areas for any changes. My goal is to create client that have a high degree of awareness of abnormalities in their pet's health. From start to finish, most thorough physical examinations will take our doctors nine to twelve minutes. Approach each senior exam as if you're not going to see that patient for another five to seven years and you'll offer the attention the pet needs and deserves.

Blood and urine tests

In addition to a detailed physical examination, we must examine the parts of the body we can't see, hear or feel. This is the true value of blood and urine tests. Further, these tests give us the only objective data we have on the patient's health status. Liver and kidney function, blood glucose levels, thyroid function, bone marrow health and platelets are just a few of the compelling reasons that each senior pet should have basic blood and urine tests every year. It is also important to note that a year is a long time relative to a dog or cat's life expectancy. A year can be 5 to 10% of a pet's entire lifetime. Think about this: we typically recommend annual blood and urine tests at seven years of age. That means we're only performing a maximum seven to ten "routine" senior blood and urine test panels during most pet's entire lifetime.

At Seaside Animal Care, our Senior Care program includes a physical examination and written copy of the report, any vaccinations based on lifestyle needs, intestinal parasite examination, a twelve-chemistry panel, total thyroid hormone (TT4), electrolytes and five-part differential CBC in addition to an automated urinalysis and urine specific gravity for our patients over seven years of age. We have laminated copies of the various options and their associated costs to help our staff educate clients. We don't offer a discount on these services but bundle the charges together to make presentation to the client easier and more understandable. If a client rejects the staff member's recommendations, the doctor will follow up with further discussion on the importance of blood and urine tests in the senior pet. If the client still refuses, we don't belabor the point, get defensive or negatively judge the client. We move on to the next patient and will review the recommendations next year. If we observe consistent rejections and relatively decreased compliance from a specific staff member (this is accomplished through tracking each staff member's total number of senior care packages each month), we provide additional one-on-one training with that individual. A success rate of 25 to 30% has been consistent among our experienced staff members for many years.

Follow up

We send out twice yearly email newsletters to all patients over seven years of age. These newsletters detail common senior disease, related clinical signs, and new products or services tailored for older pets. This has proven to be a highly economical and powerful communication tool. With the cost of postage continuing to escalate, electronic communication has become a core of our client outreach program.

Pet obesity

We see it every day: fat cats, fat dogs, fatter cats and fatter dogs. The pet obesity epidemic is here and is evidenced by the growing number of portly pets seen in veterinary clinics nationwide. What started out as a trickle has swollen to a rushing river of weight-related disorders such as osteoarthritis, type 2 diabetes, heart disease, hypertension and more. It is vital that today's veterinarians learn to recognize weight related health issues and implement intervention strategies to help our clients better care for their pets and prevent obesity. Further, the discussion of pet obesity may help improve our client's health and well-being by getting them to think about their own weight in the non-threatening context of their pet's condition. By learning how to discuss obesity with our clients and understanding the ramifications even a few "extra" pounds have on a pet's wellness, we will help our pets live longer, more fulfilling lives and, in the process, we may help our clients do the same.

How big is obesity?

Every veterinarian and health care professional knows the story by heart: we eat and feed our pets too much food; we all get fat; we become sick and arthritic and develop other weight-associated conditions and then undergo expensive medical treatments. According to the Centers for Disease Control (CDC), over two-thirds of Americans are now overweight (Body Mass Index or BMI over 25) and over one-third are clinically obese (BMI greater than 30). About 15 percent of all US schoolchildren are obese and 30 percent are overweight. The United States was ranked as the ninth "fattest country" out of 194 in a 2007 World Health Organization (WHO) study (by comparison, Japan was ranked 163). Estimates for US pets are similar: approximately 40 to 55 percent are classified as overweight and one-third to one-half of those are obese. WHO now ranks obesity as "the 10th most important health problem today." The American Medical Association (AMA) estimates "that 300,000 preventable deaths occur each year in the United States due to diet and physical inactivity, both of which contribute to obesity – only tobacco causes more preventable deaths in this country." The CDC calculates that obesity-related problems cost our economy over $75 billion each year.

This is largely a modern problem. According to the CDC and WHO, obesity rates in the US rose approximately 112 percent from 1970 to 2000. When I graduated from veterinary medical school in 1992, pet obesity wasn't even discussed in the classroom. With such a seemingly simple solution for the majority of pets and people – eat less and exercise more – you would think we would be reversing the trend by now. Unfortunately, WHO estimates that the number of overweight adults will grow by 40 percent over the next ten years. We certainly aren't seeing a decrease in the number of plump pets visiting us.

But what about pets? On October 17, 2007, the Association of Pet Obesity Prevention (APOP) conducted a nationwide survey of dog and cat weights. A total of 98 clinics and private organizations from across the country participated in the study. Data was compiled on a total of 704 dogs and 283 cats. The dogs and cats were determined to be overweight or obese based on body condition scoring (BCS scale 1 to 5) by a licensed veterinarian. Questionnaires were simultaneously conducted regarding pet owners' opinions and attitudes concerning their pet's weight. 44.6% of dogs and 52.7% of cats were found to be overweight or obese (BCS 4 to 5). 10.2% of dogs and 19.1% of cats were determined to be obese (BCS 5).

This means almost one out of two pets seen at veterinary clinics are either overweight or obese. This is alarming. This means that the average practice sees ten to twenty affected pets each day. More alarmingly is that fact that many of these patients will go on to develop diseases that could be prevented or at least delayed if weight loss measures were taken. It is our duty as healthcare professionals to identify and discuss this potentially devastating condition with each client whose pet is affected.

Obesity is arguably the largest health crisis we have ever seen in veterinary medicine in terms of numbers of affected patients. It's time to take this topic more seriously and start doing something about it.

The dangers of obesity

So what do we know about the association of being overweight or obese and certain diseases? Plenty – at least from human studies and limited studies performed exclusively on dogs and cats. The corollary between being overweight or obese and disease incidence has been clear for many decades in human medicine. It is only in the past twenty or thirty years that the pet obesity rates have risen to a level to attract attention and interest. What we are discovering is that the conditions closely associated with obesity in humans are paralleled in dogs and cats.

• Osteoarthritis is known to be caused or exacerbated by the prolonged increased loading forces on joint surfaces. Obesity causes osteoarthritis by increasing the mechanical stress on the cartilage. In fact, next to aging, obesity is the most powerful risk factor for osteoarthritis of the knees. The early development of osteoarthritis of the knees among weight lifters is believed to be in part due to their high body weight. Interestingly, recent studies have not found an increased risk of osteoarthritis in long-distance runners.

• Type 2 diabetes has been shown to be linked to increased body mass index (BMI) in people. This is thought to be caused by increased abdominal fat causing insulin resistance. A recent Harvard Medical School study published in the October 15, 2004 issue of Science found that obesity causes stress in a system of cellular membranes called endoplasmic reticulum (ER), which in turn causes the endoplasmic reticulum to suppress the signals of insulin receptors, which then leads to insulin resistance. In addition to suppressing normal responses to insulin, ER stress also triggers inflammation in cells. The authors reported that they suspected this pathway played a central role in the development of cardiovascular disease because inflammation is increasingly being implicated in heart disease.

• Obesity alone can lead to heart failure. In a study published in the August 1, 2002 issue of the New England Journal of Medicine, the authors demonstrated how obesity itself (and not just the associated medical conditions) can lead to heart failure. Furthermore, the study shows that even being overweight, not patients considered obese, can substantially increase the risk of heart failure. The authors reported that it has long been known that obesity can cause left ventricular hypertrophy (LVH). Longstanding LVH can eventually lead to heart failure. Further, obesity is associated with metabolic syndrome X, a metabolic disorder that can cause severe lipid abnormalities. It is possible that the LVH and/or metabolic syndrome (neither of which were accounted for in this study) may explain some or all of the excess in heart failure observed in overweight patients. According to a 2007 Johns Hopkins Study looking at siblings with a familial history of heart disease, being overweight or obese significantly increased the risk of heart disease. Obesity was found to have the greatest impact on risk of heart disease in siblings who had multiple risk factors that gave them a high Framingham Risk Score (FRS) score. In the group with a high FRS score, obese siblings had twice the amount of coronary heart disease as those who were overweight, 40 percent for obese and 20 percent for overweight siblings and double the rate in siblings with normal-weight siblings. When compared to siblings with low FRS scores and normal weight, obese siblings with high FRS scores had 15 times more premature heart disease.

• The link between being overweight or obese and hypertension is clear, but the exact pathophysiology has yet to be definitively determined. Both hormonal and nervous system mechanisms may be at work, and several hormone systems have found to be affected in obesity (particularly the renin-angiotensin-aldosterone system, a network of factors that control blood volume and hence blood pressure). Obesity also interferes with kidney function, which may have an impact on regulating blood pressure. The physical mass of fat tissue may also impair normal kidney function.

• The corollary between obesity and certain cancers is gaining much attention in the research domain. An important factor appears to be the release of hormones or other signaling molecules by adipose cells. These compounds can affect the growth and proliferation of cells, and promote uncontrolled growth of cells to create a cancer. One example is breast cancer. The risk of developing breast cancer is increased in post-menopausal obese women. Potentially important factors include secretion of the female hormone estrogen by adipose cells, which stimulates the growth of breast cells. There is some evidence that signaling molecules such as leptin and other adipocytokines may also act on these cells creating a cellular environment conducive for cancer cells to develop. Insulin resistance and the inflammatory mediators caused by obesity may also contribute to the development of certain cancers.

The main shift in thinking regarding the role of obesity and disease causation has been the recognition that adipose tissue is highly active. Once we viewed fat as inert, a "lump" of tissue that, while it may be unsightly, basically caused little harm. We now know that fat tissue secretes numerous hormones and signaling compounds and has tremendous impact on our physiological systems and overall health. That fat pad hanging down on your overweight feline patient is actually a biological time bomb. Will you attempt to defuse it?

Talking about obesity with your clients

The first step toward improving the lives and well-being of the pets we're entrusted to care for and to end this epidemic is to start talking about it. We know that being overweight and obese is bad for pets; why aren't we talking about it?

In a 2004 study published in Obesity Research, 52.6% of obese patients that did not undergo bariatric surgery reported that their primary care physician "never" or only "once in a while" discussed their morbid obesity with them. In other words, unless the obese patient was going to have surgery, their doctor rarely mentioned their weight. One of the key reasons why physicians fail to counsel their patients about obesity may lie in their perceived distrust in the success of available treatments. They see lots of weight loss options and lots of overweight people; the math simply doesn't add up. When confronted with the decision to discuss something you don't really believe works, you're unlikely to discuss it.

It's no different in veterinary medicine. We see lots of overweight and obese pets and lots of diet foods and diet treatments and yet the number of fat pets keeps growing. Subsequently we stop talking about it. Nobody likes to bet on a losing horse – especially one that we believe loses with patient after patient, day after day.

Our clients depend on us for recommendations to improve the quality of life as well as life expectancy of their pets. However, due to busy schedules and lack of training in weight-related disorders, nutrition and weight loss, it is often difficult for veterinarians to communicate this information and promote change. For our profession to truly help our patients, we must take the time to learn about these issues and make the time to talk about them with our clients.

If we're going to talk about pet obesity, we must believe it's important – really important. Veterinarians who understand that achieving and maintaining ideal weight will improve their patient's quality of life and life expectancy are more enthusiastic about the topic. We must study the association between obesity and conditions such as type 2 diabetes, osteoarthritis, hypertension, heart disease, cancer and more. We must become familiar with the impact that a pet's weight-associated morbidity has on the pet-family bond and how this can negatively influence the level of care a pet receives as they age. We must search for simple lifestyle changes that can make huge improvements in a pet's well-being. We must feel comfortable looking a client in the eye and confidently discussing strategies for losing weight in a non-threatening manner. Once you believe in something, others sense that passion and are more inclined to listen and believe in you.

Another potential source of bias against counseling clients about their pet's weight issue is the doctor's perception that the client doesn't care or want to hear about it. If a doctor enters the room and thinks that the client isn't motivated to change their pet's weight, they're probably not going to start talking about obesity. Unfortunately, we're often wrong. In the same manner that we pre-judge clients and their willingness to pay for medical care, we often incorrectly assume that clients don't want to learn about pet weight loss. The issue becomes even more challenging if we don't truly believe in the benefits of weight loss and the value of spending our precious time discussing it. If we assume that everyone will be willing to pay for our services and is interested in improving their pet's quality of life, regardless of the challenges, we will better serve them.

Because of the social stigma associated with being overweight and obese, many doctors simply find it more comfortable to avoid the topic altogether. Further, a few high profile media cases involving patients suing physicians for offending them while discussing their weight has heightened fears and decreased the number of doctors being proactive about weight issues. The American Medical Association (AMA) commented on this dilemma in November 2003: "(I)f your patient's weight is a health issue, you should not hesitate to approach the topic."

Regardless of the client's weight, our responsibility is to the pet. With this in mind, we must feel comfortable separating our client's obesity from the discussion of their pet. Normally the client is already aware that their pet is overweight or obese yet may not fully understand its impact on their pet's health. Instead of stating the obvious, "Did you know Fluffy is obese?" try saying, "I'm concerned about Fluffy's weight because I'm worried it may be causing health problems for her. Do you think her weight is causing health problems?" This is especially important when the patient has weight-associated conditions such as osteoarthritis, type 2 diabetes, heart disease and hypertension.

If you get a noncommittal or disinterested response, don't start detailing how diet and exercise can help Fluffy achieve an ideal weight. Instead, focus on the long term health risks associated with Fluffy's excess weight. "I know how much you care about Fluffy and that's why I want to help you avoid some serious disease such as diabetes, heart disease and arthritis." Center the conversation on the prevention of debilitating and often costly diseases as opposed to the latest diet fad or tool.

Waging the war against pet obesity will not be easily won. There is no "magic cure" or "silver bullet". Even with today's amazing pharmacological advances, the foundation for long-term success lies with changing pet owner's attitude toward pet weight issues and adopting a healthier lifestyle for their pets. The fantastic opportunity that we have as veterinarians is that we may, by extension, positively impact the health and well-being of our human clients. It is time to make a stand and stop ignoring one of the leading causes of morbidity and mortality in our pet patients. Educate yourself, develop a communication strategy and uphold the oath we took when we entered our profession with each and every patient.

Key client communication points

• 44.6% of US dogs and 52.7% of cats are overweight or obese (2008 APOP)

• 10.2% of US dogs and 19.1% of cats are obese (2008 APOP)

• Increased weight greatly increase the risk of crippling osteoarthritis, debilitating heart disease, life-threatening type 2 diabetes mellitus, high blood pressure (the "silent" killer) and many forms of cancer

• Diet is more important than exercise when it comes to losing weight in pets or people

• Maintaining ideal body weight is second only to genetics in determining life expectancy

• Weight reduction should be performed only under direct veterinary supervision