VNA Level II Module 6: Communicating Therapeutic Nutrition ... · Learning Objectives ... It serves as a portable energy storehouse, ... their activity level in their youth. Older

Learning Objectives

Learning Objectives After completing this module, your basic understanding should include:

• Why proper pet weight control is an important part of responsible pet ownership and health care team concern. • How to assess, with veterinary involvement, Body Condition Scoring (BCS) and relate the importance of maintaining a BCS of 3/5 throughout a pet’s lifetime. • Ways to set up an effective weight loss program. • The features and benefits of Hill’s® Prescription Diet® w/d® Canine, r/d® Canine, w/d® Feline, r/d® Feline and m/d® Feline.

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VNA Level II Module 6: Communicating Therapeutic Nutrition- Weight Management

Introduction


Effectively communicating the importance of proper pet nutrition with clients is an extremely valuable service veterinary health care team members can provide. Remember, of the three main factors affecting the health and longevity of dogs and cats, (genetics, environment and nutrition) nutrition is the area we have most direct control over. This fact is especially important when considering the detrimental, long-term ramifications of excessive weight, (Body Condition Scores, [BCS] of 4/5 and 5/5). Confidently, competently and comfortably discussing the benefits of proper weight maintenance and weight loss for pets is a key area of advocating for the pet’s best interest. This module of VNA is designed to provide you with a variety of communication points, to help in conveying your concerns about weight issues in pets. Emphasis will be placed on the proper use of Hill’s® Prescription Diet® pet foods designed to aid in the management of weight reduction and weight control.

Introduction

VNA Level II Module 6: Communicating Therapeutic

Nutrition-Weight Management

Preventing The Proliferation Of Pounds In The First

Place


Before addressing the management of weight reduction, (related to excessive caloric intake) and weight control, let’s reflect on our ability, AND obligation to influence proper weight throughout a pet’s life. All of us involved in veterinary medicine have a particular responsibility regarding the pet’s nutritional best interest. This means that we have to find ways to successfully deal with the oftentimes touchy subject of excess weight. If not us, who? Pets are dependent upon owners to make decisions on what, when, how and how much to feed. In turn, clients are dependent on veterinarians and veterinary health care team members for guidance, firm recommendations, specific pet food products, and encouragement on proper feeding protocols. Throughout this Veterinary Nutritional AdvocateSM educational experience, we have discussed the importance of your not only understanding proper pet nutrition, but also your ability to communicate your understanding. Emphasizing the importance of an optimal body condition score of 3/5 throughout a pet’s life, is an area members of the veterinary health care team can have significant impact, where everyone involved benefits!

The main functions of the kidney include excreting waste products of metabolism, regulating the body’s concentration of water and salt, maintaining a slightly alkaline body environment, reabsorbing vital body molecules, and secreting various hormones.

Figure 1. One of the simplest, yet most comfortable and effective ways to discuss a pet’s weight, is to stand next to, instead of across from, the pet owner. That way, your attention is directed towards the pet, NOT the pet owner.


Nutrition-Weight Management Preventing The Proliferation Of Pounds In The First Place


Place


Think about all the puppies and kittens that visit your veterinary practice in the course of a year. These new pets are usually brought in multiple times their first year of life. A lot of information needs to be effectively communicated during those visits. Ancillary materials also need to be provided to augment and reinforce points you and other members of your health care team deem critical to convey. As discussed in Level II, Module 2, one of the most influential ideas to continually stress is the importance of young pets growing and developing at a controlled, rather than rapid rate. While this approach has several benefits, especially for large- and giant-breed puppies, a major benefit is often one of clients realizing the necessity of proper, not excessive nutrient, (including caloric) intake. Establishing the positive “habit” of working with the veterinary health care team and being cognizant of optimal foods and feeding practices, can help set the tone for a wonderful, long-term relationship. The main beneficiary of such concern and teamwork: The pet!

Preventing The Proliferation Of Pounds In The First Place

As we have reiterated throughout VNA, what better way to have regular face-to-face dialogue with pet owners, than to have them purchasing their pet’s Hill’s® pet food products from your practice? Encourage clients to bring their pets in and weigh them during these visits.




Place


The best way to deal with the problem of excessive weight in pets is to prevent it in the first place! Maintaining the proper weight of dogs and cats is not only prudent health-wise, it is also easier on the pet owners and the health care team. Don’t abdicate your responsibility in this critical area. Each pet’s weight should be discussed with the client AS WELL AS entered into the medical record on each visit. Praising family members for keeping their pet at a BCS of 3/5 is great positive reinforcement. That being stated, if there is a need to address a pet’s weight as being over-optimal, be sure your health care team approaches client discussions in a unified, consistent fashion. Even though it is ideal to prevent excessive weight gain in pets in the first place, working with pet owners in helping them reduce their pet’s weight is extremely rewarding.

Preventing The Proliferation Of Pounds In The First Place

If you have been working closely with a client and monitoring her puppy or kitten’s weight, and the pet owner and family have followed your advice, then the pet’s weight at about one year of age, (~18 months for giant breed dogs) should be close to optimum (BCS 3/5). Unless otherwise indicated, this is the weight the pet should be maintained at throughout its adult life.



Why Pets Need Some Fat


Fat is an important body tissue. It serves as a portable energy storehouse, allowing pets to eat intermittently and still have continuous energy for normal activities. Fat also cushions vital tissues and organs, insulates against temperature extremes and can be a reservoir for the fat-soluble vitamins (A, D, E and K) and fatty acids. Pets at ideal body weight and condition have between 15 to 25% body fat, which correlates to a BCS of 3/5. Recall from Level I of the Veterinary Nutritional AdvocateSM that proteins, fats, and carbohydrates in pet food supply energy and body building blocks. Energy not needed immediately is primarily converted to body fat. To accomplish this task efficiently, fat cells can increase their diameter by 20-fold and their volume by several thousand-fold. A pound of fat stores 3,500 kilocalories for later use, and contains millions of cells and up to a mile of blood vessels. So, while pets need some fat, the statement: “More is not better, balanced is better” is extremely appropriate regarding this nutrient.

Why Pets Need Some Fat

More, (excess) is NOT better as it relates to fat in a pet’s diet. As with all nutrients, “balanced is better!”



Causes Of Weight Gain


Think of calories eaten vs. calories used as a balance beam or scale. For pets at ideal body weight and composition, the number of daily food-ingested calories closely matches the amount of calories, (energy) expended by the body for various functions, so the beam remains balanced. Because excess energy is stored as fat, pets that eat more calories than they expend unbalance the beam and, over time, become overweight or obese. Some common causes of weight gain include:

• Overeating: Pets ingesting calories in excess of body needs will gain weight. • Feeding method: Pets that are fed free choice are more prone to becoming obese. • Genetics and metabolism: Recall from Level I that pets of the same size may have markedly different energy needs. • Lack of activity: Physically active pets expend more energy than sedentary pets. Conversely, inactive pets require fewer calories for weight maintenance. • Age: Relatively speaking, older pets are often less active compared to their activity level in their youth. Older pets usually also have reduced muscle mass. Muscle burns, (expends) more calories than fat, so older pets may be at a greater risk for progressive weight gain. • Spaying/neutering: These are responsible procedures, but lower metabolism and caloric needs. • Breed: Some breeds such as Labrador retrievers, Cairn terriers, cocker spaniels and mixed-breed cats are prone to weight gain. • Disease: Some medical conditions predispose pets to weight gain, but these are far less common than other causes of obesity.

Causes Of Weight Gain



Some Definitions


The authors of the chapter on Obesity, (William J. Burkholder and Philip W. Toll) in Small Animal Clinical Nutrition, 4th Edition, subdivide overweight dogs and cats into three categories, (see Table 1) with terminology, roughly corresponding percent total body fat and Body Condition Scores:

Some Definitions



Table 1. Relationship between % over optimal body weight, the descriptive term, total body fat % and body condition score (BCS).

These designations will be used throughout this Module.

Over Optimal Body Weight Terminology Total Body Fat % Body Condition Score

1% - 9% “above optimal” 15% - 25% 3/5

10% - 19% “overweight” 26% - 35% 4/5

20% + “obese” > 35% 5/5

Source: Small Animal Clinical Nutrition, 4th Edition.

Some Definitions


A BCS of 3/5 takes into consideration slight fluctuations in body weight, but for the most part, the pet’s weight is maintained as close to “optimal” body weight as possible, and definitely not over 9% of what has been determined to be ideal. It may be difficult to define an exact “optimal” body weight for a mixed breed, and even in purebred pets, especially dogs. There may be “accepted” variations, based on such things as body type and lineage. For example, the American Kennel Club lists an “average” weight for a female Golden retriever at 55-65 pounds, and for a male, 65-75 pounds. So, even for a purebred dog or cat, your insights in defining the best weight for each particular pet is important. BCS is a helpful tool for the health care team to utilize and will be discussed in more detail below. An “overweight” pet is one that is, on average, about 15% over optimal body weight, correlating to roughly 30% body fat and a BCS of 4/5. An “obese” pet is 20% or more over optimal body weight, with over 35% body fat and a BCS of 5/5

Some Definitions

Figure 2. Example of a dog with a BCS of 5/5.

Body Condition Scoring is a helpful tool in identifying what category, (1-5) a pet falls into. Ideally, assess a pet several times a year at your practice. A great time to weigh a pet and perform a quick BCS evaluation is when the pet owner comes to your practice, (with the pet) repurchasing the appropriate Hill’s® product.



Health Risks Of Obesity


Many diseases and conditions are associated with being overweight or obese. Fat deposits on the chest wall and within the chest and abdomen can make breathing more difficult, (dyspnea). Fatty deposits around the heart exacerbate this problem. Furthermore, the heart must work harder to push blood through the extra blood vessels in excess body fat. These factors combine to make anesthesia and surgery more challenging for the health care team and surgeon, and stressful for obese pets. Table 2 lists some additional problems related to obesity, (BCS 5/5).


A study published in the veterinary literature in 2002 showed that Labrador retrievers fed 25% less food lived significantly longer and had a delayed onset of chronic diseases than littermates.

Figure 3. Lateral abdominal radiographs of a normal cat (BCS 3/5, left) and an obese cat (BCS 5/5, right). Note the enlarged abdomen and ventral fat deposition in the obese cat. Source: Small Animal Clinical Nutrition, 4th Edition.








Table 2. Diseases associated with or exacerbated by obesity.

Metabolic alterations Functional alterations

Hyperlipidemia Joint stress/musculoskeletal pain Insulin resistance Dyspnea Glucose intolerance Hypertension Hepatic lipidosis (cats) Dystocia Anesthetic complications Exercise intolerance Heat intolerance Decreased immune function

Endocrinopathies Other diseases

Hyperadrenocorticism Degenerative joint and orthopedic disease Hypothyroidism Cardiovascular disease Diabetes mellitus Transitional cell carcinoma (bladder) Insulinoma Pituitary chromophobe adenoma Hypopituitarism Hypothalamic lesions Source: Small Animal Clinical Nutrition, 4th Edition.

Detecting Overweight/Obese Pets



Some pets are, on average, more muscular or have larger frames than similar type dogs or cats that weigh less. Still others may have metabolic or medical conditions that cause, for example body fluid to accumulate. Most overweight/obese pets however, have simply ingested more calories than they have expended, the result being extra body fat deposition. Recall, a pet with a BCS of 3/5 has about 15%-25% body fat, whereas an overweight pet, (BCS 4/5) has ~26% to 35% of their body weight as fat. Obesity is defined as an excess of body fat of ~35% or more, (BCS 5/5).

Figure 4. Some dogs and cats require less energy, (calories) than others to maintain their body weight. Therefore, feeding dogs of initially equal body weights the same amount of calories can lead to obesity. This is true in cats also. It is important to use pet food label feeding guides AS A STARTING POINT, monitoring and adjusting the food amount accordingly. Source: Small Animal Clinical Nutrition, 4th Edition.






Body condition can be subjectively assessed by a process called Body Condition Scoring, (BCS). In general, this process assesses a patient's fat stores and, to a lesser extent, muscle mass. Fat cover is evaluated over the ribs, down the topline, around the tailhead and ventrally along the abdomen.

Figure 5. Canine Body Condition Scoring.



BCS 1: Very Thin BCS 2: Underweight BCS 3: Ideal

BCS 4: Overweight BCS 5: Obese




Figure 6. Feline Body Condition Scoring.



BCS 1: Very Thin BCS 2: Underweight BCS 3: Ideal

BCS 4: Overweight BCS 5: Obese




Here’s how to use body condition (BCS) scoring: For dogs and cats always determine the amount of fat covering the ribs. Feel the areas between ribs to get the most information. Palpate the tailbase in dogs (area in front and to the sides of where the tail attaches to the body) and the areas over the backbone and hipbones in cats for more information. Then, review the profile of the abdomen from the side and top. Dogs and cats, when viewed from the side should have a concave waist (also called tuck). Dogs should have an hourglass figure when viewed from the top. Assess the amount of fat in the abdominal fat pad (also called apron) along the bottom of a cat’s stomach. The ribs of overweight, (BCS 4/5) and obese, (BCS 5/5) cats and dogs, are difficult to feel because they are covered with fat. Overweight dogs have a smooth-to-thickened tailbase and it’s difficult to palpate bones. The back of obese dogs may be markedly wider than usual and the spine may appear in a depression. Overweight dogs and cats have little or no abdominal waist. Cats with body scores of 4/5 and 5/5 have moderate to marked fat deposits along the abdominal wall.

Body condition scoring should be incorporated into the physical examination of each patient each time it is seen, AND recorded, (documented) in the pet’s record, along with comments on discussions with the pet owner.

Body Condition Scoring is one of the most obvious and visible evaluations you can demonstrate on a pet in front of the client. All members of the veterinary health care team should periodically practice evaluating BCS on a variety of pets, under the supervision of a veterinarian. Discuss your observations.






Anthropometry is the science that deals with body measurements, such as height, weight, and proportions. It is used to assess body fat and protein stores. For example, in people, triceps skinfold and arm circumference are measured and recorded. Zoometrics is an equivalent animal term. Body weight is the most common technique used in small animal practice. As mentioned above, weight over time coupled with body scoring techniques (palpation) is very useful for estimating fat and protein stores in pets. You may apply what you’ve learned about body scoring and zoometrics in weight-loss programs for pets. For example, you might use a tape measure to measure the circumference of a dog’s abdomen immediately in front of its back legs, in the flank area. Because dogs on an effective weight-loss program will lose lumbar (back) fat as they lose weight the circumference should decrease. Like decreasing body weight, a decreasing abdominal circumference measurement helps convince clients they are doing a good job with a weight-loss program for their pet.

Figure 7. Measuring abdominal (pelvic) circumference. Source: Small Animal Clinical Nutrition, 4th Edition.






Using Patient Records to Spot Weight Trends Because pets have different skeletal sizes, body weight by itself has limited usefulness as an indicator of obesity. However, trends in body weight can be very significant. A dog that weighed 20 pounds at one year of age and weighs 25 pounds at 10 years of age, is likely overweight or obese. Pets, like people, tend to lose muscle mass as they age. So, it is possible that this five-pound weight gain for a dog that isn't active may be a three-pound muscle loss and an eight-pound fat gain! As an estimate, pets should weigh no more when they are older than they did when they were full-grown young adults (usually 12 months of age for cats and most dogs; giant breed dogs should weigh no more than they did at 18 months of age) in ideal body condition. Always review the medical record to determine whether a pet's weight has crept up over the years. An effective way to easily find and record a pet's weight in its record, on each visit, is to develop a simple chart as depicted in Figure 8



Date Age Weight Food Discussion/ Recommendations

Addressing The Extra Pounds



A pet that is overweight or obese, (as the result of excess caloric intake over time) has a condition that is very treatable, IF there is total commitment by all involved. On the surface, weight loss is simple: the pet must eat fewer calories than it expends. But, getting family members to adhere to your practice’s weight reduction plan for their pet may not always be easy, but it is an important issue to advocate on behalf of the pet.






Weight-loss programs have the best opportunity for “success” when the pet’s family agrees to most, if not all of the following:

• Recognizing that the pet needs to lose weight to help avoid potential problems. • Committing to the weight-loss program designed by the veterinarian and veterinary health care team. • Agreeing on an established optimal body weight for the pet. • Feeding ONLY the right food in the right amounts. For example, Hill’s® Prescription Diet® r/d® Canine pet food products for dogs and Prescription Diet® r/d® Feline or Prescription Diet® m/d® Feline for cats respectively. • Feeding the daily food allowance in several smaller meals rather than one or two large meals. Pets that eat several small meals daily expend more energy. • Feeding pets enrolled in weight-management program separately from other household pets. • Safe exercise/play programs for the pet. Exercise helps expend calories and maintains muscle mass, which burns even more energy. • Having the pet reevaluated regularly as recommended by the veterinarian. • Placing the pet on the appropriate long-term weight maintenance dog or cat food, for example, Hill’s® Prescription Diet® w/d® Canine or w/d® Feline respectively.






Figure 9 shows an example of a Weight Reduction Monitoring Form. It will be important to provide this type of written guidance for pet owners, as well as continual encouragement and effective, frequent communication.

Figure 9. Example of a weight reduction monitoring form. Source: Small Animal Clinical Nutrition, 4th Edition.

Do not allow cats to consume less than 80% of the feeding amounts listed in the r/d® Feline section of the Hill’s® Key To Clinical Nutrition.






Prescription Diet® r/d® Canine and r/d® Feline Key Product Characteristics include: • Added L-carnitine • Low calories • Low fat • High fiber These products help reduce body weight and caloric intake by providing a food with very low calories. Insoluble fiber increases gastrointestinal bulk and reduces hunger while lowering fat and calories. Added L-carnitine helps dogs and cats burn fat while maintaining lean muscle mass. This helps achieve optimum weight for effective weight loss.






Prescription Diet® m/d® Feline Key Product characteristics include:

• Low carbohydrate, high protein formula (clinically proven to alter a cat’s metabolism resulting in effective weight loss). • Highest levels of L-carnitine (helps burn fat while maintaining lean muscle mass). • Appropriate fiber levels (helps cats feel full while losing weight). • Reduces stool volume (compared to competitive product)

The science behind Prescription Diet® m/d® Feline: Cats utilize soluble carbohydrates in the form of glucose as their first available energy source. When the intake of soluble carbohydrate is sufficiently restricted, metabolism changes from using carbodydrates, (glucose) to burning, (utilizing) dietary protein and fat, (lipid) as the primary energy sources. With fat as the major energy source, it delivers energy via ketones, just as carbodyrates deliver energy via glucose. This change in metabolism results in weight loss and glucose and lipid control.






Prescription Diet® w/d® Canine and w/d® Feline are excellent choices for obesity prevention for dogs and cats respectively.

Ketosis (metabolic control) is elevated ketone levels in the blood and tissues casued by fasting, exercise or high fat/low carbohydrate intake. This is a positive aspect of a product like Prescription Diet® m/d® Feline.



Weight Loss Options


Weight Loss Options

Pets eating a higher fiber food will produce more stool volume. The increased bulk of the fiber helps the pet feel fuller, which is a positive attribute to effectively communicate to the client.

Hill’s® now offers two proven choices for feline weight control, (Prescription Diet® r/d® Feline and m/d® Feline pet food products) backed by Evidence-Based Clinical NutritionSM Studies/ Veterinarians now have two nutritional options in addressing feline weight reduction: • Calorie Restriction with r/d® Feline • Alter Metabolism with m/d® Feline Finding the right solution means every overweight feline patient has the opportunity for improved quality of life. In addition, weight reduction often makes health risks, such as diabetes, more manageable. All Hill’s® Prescription Diet® products have this guarantee: Hill’s guarantees Prescription Diet brand pet food for quality, consistency and taste. If you are not completely satisfied with any purchase of Prescription Diet brand pet food for these reasons, simply return the unused portion to your veterinarian for a full refund or replacement.



Weight Loss Options


Weight Loss Options

When discussing “cups” of dry food to feed, be sure the client understands you are talking about an 8 fluid ounce measuring cup. Ideally, have an example for the client to see, and possibly have. Otherwise, pet owners may use any number of different types of containers and give the pet more or less than what is considered appropriate, compromising the success of the weight loss program.

For more information on the benefits of a successful weight loss program, visit www.PetFit.com. Without your help, many pet owners may lack the discipline to feed the appropriate foods in the appropriate amounts, and to implement an exercise/play program for as long as it takes for a pet to achieve its ideal body weight. In general, overweight pets can safely lose between 0.5 and 2.0% of body weight per week. You can help pet owners by conveying the health hazards of obesity and the importance of a weight-management program. Here are two hypothetical examples of anticipated weight loss time frames, (feeding guidelines mentioned for Hill’s® products based on information provided in the Hill’s® Key To Clinical Nutrition): Dietary supplementation with calcium carbonate, dicalcium phosphate, bone meal, or vitamin D may result in excesses.



Weight Loss Options


Weight Loss Options



A 25 pound, 6 year old spayed female dog that weighed 20 pounds at one year of age. • Five pounds over “optimal” weight, (25-20). BCS 5/5. • Current food: A national grocery store brand of dog food, (provides ~570 calories/day) PLUS a variety of table food and snacks.

Note: This is a great example of why it is important for the veterinary health care team to be involved in the pet’s nutrition, and ideally have the dog on a Hill’s® pet food product from your practice!

• Discussions with the dog’s family members on exercise, health issues of obesity and the importance of keeping their dog on the weight reduction program.

• New food: Prescription Diet® r/d® Canine dry dog food. Amount to feed based on the desired target weight rather than current weight. Suggested starting point range for a 20 pound, (the determined “optimal” weight) dog is between 1 1/3 and 2 cups. Let’s start with 1 2/3 cups/day. An eight fluid ounce measuring cup = ~220. 1 2/3 x 220 calories/cup = ~365 calories/day. This is ~ 205 calories/day less than previously fed, (570-365) not including the extra calories from the table food and snacks.

• Calorie loss, considering the dog food products only. Additional calorie loss will occur by stopping the feeding of the people food, (which is difficult to determine calories from): 205 calories/day x 7 days = ~1,435 calories/week, which is ~four tenths of a pound, or about 2% of body weight.

• For this dog to lose five pounds, it should take about three months, (five pounds = 17,500 calories, [3,500 x 5] divided by 1,435 calorie reduction per week) provided the veterinary health care team communicates and reinforces the importance of weight loss!

Weight Loss Options


Weight Loss Options



A 13 pound, 5 year old neutered male cat that weighed 10 pounds at one year of age. • Three pounds over “optimal” weight, (13-10). BCS 5/5.

• Current food: A national grocery store brand of cat food, (provides ~ 247 calories/day) PLUS various meat leftovers.

Note: This is a great example of why it is important for the veterinary health care team to be involved in the pet’s nutrition, and ideally have the cat on a Hill’s® pet food product from your practice!

• Discussions with the cat’s family members on exercise/play activities, the health issues related to obesity and the importance of keeping their cat on the weight reduction program.

• New food: Prescription Diet® r/d® Feline dry cat food. Amount to feed based on the desired target weight rather than current weight. Suggested starting point range for a 10 pound, (the determined “optimal” weight) cat is between ½ and ¾ cups. Let’s start in the midrange which is 5/8 cup, (an eight fluid ounce measuring cup) = ~263 calories/cup x 5/8 = ~164 calories/day. This is ~83 calories/day less than previously fed, (247-164) not including the extra calories for the table food.

• Calorie loss: 83 calories/day x 7 days = ~581 calories/week, which is about 1.6% of body weight.

• For this cat to lose three pounds, it should take about 4.5 months, (three pounds x 3,500 calories/pound = 10,500 calories divided by 581 calories per week, provided the veterinary health care team communicates and reinforces the importance of weight loss!

Summary / Are you ready?

Summary Excessive weight gain in dogs and cats is a major health concern, with about one out of every four pets visiting a veterinary practice being overweight or obese. Effective communication early on, about obesity prevention should be stressed. Weight reduction, appropriate nutrition and implementation of successful weight management programs is a great area for the veterinary health care team to excel in. Being an advocate for the pet’s best interest regarding proper weight is of significant value to you personally, the pet owner, the practice, and of course, the pet. Hill’s is there to assist you in your efforts in helping to enrich and lengthen the special relationships between people and their pets!

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VNA Level II Module 6: Communicating Therapeutic Nutrition ... · Learning Objectives ... It serves as a portable energy storehouse, ... their activity level in their youth. Older