What to do when a client wants to feed a raw or other unconventional diet (Proceedings)

The history of medicine has never been a particularly attractive subject in medical education and one reason for this is that it is so unbelievably deplorable … bleeding, purging, cupping and the administration of infusions of every known plant, solutions of every known metal, every conceivable diet including total fasting, most of them based on the weirdest imaginings about the cause of disease, concocted out of nothing but thin air—this was the heritage of medicine until a little over a century ago. —Lewis Thomas, American physician, 1913–1993

During the last 150 years or so, spectacular advances have been made in the science of medicine. The discoveries of the principles of adequate sanitation and nutrition, and of antibiotics, vaccines, and other drugs have demonstrated the value of the scientific approach to health problems. As a result, most health care professional education now focuses on the scientific aspects of treatment of disease. However, disease has both scientific and emotional aspects that can influence outcome. In addition to physiologic abnormalities, disease-induced fear and anxiety can affect the course of disease progression and resolution. The patient's confidence in the skills of the caregiver also plays an important emotional role in disease outcome. Throughout much of human history, the art of calming patients and instilling confidence in the efficacy of the caregiver were the primary tools of the clinician. Few active drugs other than poppy sap and willow bark were available; the most common historical disease treatments, regardless of the malady, were bloodletting or the application of dung. The scientific approach to the physiologic aspects of disease is a relatively recent historical development. Given its success, it is small wonder that the scientific approach to medicine has been embraced with such fervor.

The emotional aspects of disease have not disappeared, however. We still feel fear and anxiety in the presence of disease, and medical science still has much to learn. For example, we have not yet gained the power over the emotional aspects of disease that we have over its scientific aspects, although in clinical investigations, we acknowledge this aspect by using placebos in randomized controlled clinical trials. Clinicians also recognize differences in practitioner's "charismatic" as well as their clinical skills.

Nutrition also has both scientific and emotional aspects. A relatively constant input of nutrients is required to construct and sustain us throughout life; our understanding of the mechanisms by which this occurs comprises much of the science of nutrition. The emotional aspects of food are no less significant. All cultures and belief systems incorporate foods into their rituals, many foods are preferentially eaten in certain contexts, and many people eat "comfort foods" when confronted with stressful circumstances.

We can use this knowledge of the existence and importance of the scientific and emotional aspects of disease, nutrition, and medicine to enlighten our understanding of fears associated with food recalls, and interest in alternative diets. Many issues of the pet food recall of 2007 have been discussed and documented. One that has received less attention, however, is that the nutritional adequacy of the diets was never documented, or indeed seriously questioned. Frightening as the situation was for owners and many of us as caregivers, it really was a toxicological (food safety) issue with nutritional implications rather than a nutritional adequacy issue.

Interest in unconventional diets (e.g., "BARF" diets) also has social and emotional aspects as well as scientific aspects, both of which may be over-emphasized. For example, is the assertion that "all pet foods are toxic" any different from the assertion that, "all BARF diets are dangerous"? Both seem to me to be but different, equally emotional and unscientific, reactions to rather vague information.

"What to I say to a client that wants to feed a "raw diet"?

     1. Sure, go ahead!

     2. NO!!!!! It'll kill your dog, and maybe you too!

     3. What do you mean by a "raw diet"? Our goal here at (insert your hospital name) is to meet each of our client's needs without putting their pet's nutritional welfare at risk. We do this by listening to your concerns, and trying to help you find a diet that appears to be as complete, balanced and safe as possible. There are many nutritional support services that provide computer-based analyses for a fee (we often recommend www.balanceit.com or www.petdiets.com). As long as none of the ingredients of a satisfactory diet are contaminated, it should be safe for adult animals for months to years. We also advise careful adherence to raw food handling procedures recommended by the USDA http://www.fsis.usda.gov/Be_FoodSafe/BFS_Messages/index.asp, and to schedule more frequent check-ups to provide more careful observation of the pet.

The arguments in favor of feeding raw food diets to pets include the fact that dogs and cats evolved as carnivores eating raw foods, and the assertion that consumption of these diets result in improved coat and skin, improved "energy levels", and reduced incidence of disease (see www.barfworld.com). Other "facts" of evolution, including the short life expectancy and likely incidence of infectious disease, and the absence of evidence of any consistent benefits of raw food diets dilute the persuasive power of these arguments. Reports of adverse effects of feeding these diets also have appeared in the veterinary literature. Unfortunately, to our knowledge, no evidence-based evaluation of raw food diets has occurred. This permits those that are for or against this method of feeding to continue to engage in largely emotional arguments, without an effort to understand what the appeal is of preparing raw food for pets, something happily abandoned by most pet owners generations ago. This question has been investigated in human medicine to attempt to understand the appeal of alternative therapies. Some believe that medicine has lost its holistic perspective, leaving some to seek help from caregivers who spend the time to get to know their clients and listen to their concerns. Such veterinarians also may treat the whole situation rather than only the symptoms the patient is presented with, a feature that seems to be valued by some clients. Thus, the interest in raw foods may not truly reflect dissatisfaction with commercial diets, but rather represent an increased satisfaction with the 'cultural' aspects of preparing food for their pet, who they may see as 'one of the family", as opposed to pouring dry chunks into a bowl.

"What is the scientific basis for ancestral diets and breed specific diets?"

Historically, natural diets referred to rodents/mammals that fell prey to wolves and coyotes. Today, a "natural" diet more commonly refers to a mixture of such ingredients as raw meats with or without bones, vegetables and fruits. Some people believe that the act of ripping meat off bones and chewing bones is more healthful for their pets. Early literature reported that the natural diets of wild canids and felids had a plaque – retardant effect, and that these animals were not afflicted with periodontal or other diseases. Unfortunately there currently are no published data comparing the oral health of domestic dogs or cats consuming a natural diet with those consuming commercially available foods.1 Moreover recent reports suggest the contrary. One study followed 67 English Foxhounds, 1-9 years of age that were routinely fed raw carcasses consisting of the bony skeleton, muscle, and associated tissues. Oral examination revealed that all dogs had varying signs of periodontal disease, as well as a high prevalence of tooth fractures.2 Although the value of "ancestral diets' has been asserted by some, one must recall that the ancestral lifespan for dogs and cats was likely only 2-3 years; some pets live ten times that long currently, so one wonders about the relevance of the original diets. No evidence is available to test these claims.

With regard to breed-specific diets, here too there is little evidence of efficacy based on controlled trials. Moreover, some of the diets have a variety of changes; nutrient content (for which strength of evidence varies widely), amounts, novel processing methods to create pellets that aid prehension, etc. Some of these differences may be more important than others. As long as the diets are satisfactory and made by reputable manufacturers, they should be as good as any other food for the pet; only time, and controlled trials, will determine if they are any better.

That a therapeutic response can occur in patients exposed to an inactive substance implies that some other feature(s) of the interactions between patients and caregivers must occur. In adult humans, this interaction may be direct,3-6 whereas in veterinary patients and young humans, it may be a consequence of interactions between the caregiver and the parent or owner, respectively. These interactions seem to involve:

     • The context in which care is given

     • The "ceremonial rituals" of patient care

     • Effective communication

     • Shared decision making

Although many of these "soft" (subtle?) aspects of care might be dismissed as "placebo" "complementary" or "alternative", they actually appear to be incorporated in Western medicine guidelines. For example, the National Academy of Science Institute of Medicine's core needs for healthcare mandate treatments that are:

     • Safe: avoiding injuries to patients from the care that is intended to help them.

     • Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.

     • Patient-centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

     • Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.

     • Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.

     • Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

The principles also seem to be embedded in the Accreditation Council on Graduate Medical Education's (ACGME) core criteria for residency training, which mandates graduate competence in six areas:

     1. Patient care,

     2. Medical knowledge,

     3. Professionalism,

     4. Interpersonal and communication skills,

     5. Systems-based practice, and

     6. Practice-based learning and improvement.

The overlap of "Eastern" and "Western" ideas suggests that we could enjoy an immediate 50% improvement in outcomes (the magnitude of the placebo response rate as a % of the "treatment" response rate across many clinical trials in humans) just by practicing what we preach to our residents! By carefully considering all new treatments in the light of both the scientific and emotional aspects that comprise clinical medicine, one may be able to provide the best possible overall care for our patients.

References

Colyer F. Dental disease in animals. British Dental Journal 1947;82:31-35.

Robinson JGA, Gorrel C. The oral status of a pack of Foxhounds fed a "natural" diet. World Veterinary Dental Congress 1997;35-37.

Barry CA. The role of evidence in alternative medicine: contrasting biomedical and anthropological approaches. Soc Sci Med 2006;62:2646-2657.

Houle C, Harwood E, Watkins A, et al. What women want from their physicians: a qualitative analysis. J Womens Health (Larchmt) 2007;16:543-550.

Brody H, Brody D. The Placebo Response: How You Can Release the Body's Inner Pharmacy for Better Health: Cliff Street Books, 2001.

Brody H. The placebo response - Recent research and implications for family medicine. Journal of Family Practice 2000;49:649-654.

Di Blasi Z, Harkness E, Ernst E, et al. Influence of context effects on health outcomes: a systematic review. Lancet 2001;357:757-762.

Walach H, Jonas WB. Placebo research: the evidence base for harnessing self-healing capacities. J Altern Complement Med 2004;10 Suppl 1:S103-112.

Salmon P. Conflict, collusion or collaboration in consultations about medically unexplained symptoms: the need for a curriculum of medical explanation. Patient Educ Couns 2007;67:246-254.

Joosten EA, DeFuentes-Merillas L, de Weert GH, et al. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom 2008;77:219-226.

Berg AL, Sandahl C, Clinton D. The relationship of treatment preferences and experiences to outcome in generalized anxiety disorder (GAD). Psychol Psychother 2008.

IOM. Crossing the Quality chasm: A New Health System for the 21st Century books.nap.edu/html/quality_chasm/reportbrief.pdf, 2001.

ACGME. Program Director Guide to the Common Program Requirements; http://www.acgme.org/acWebsite/navPages/nav_commonpr.asp 2008.