Screening Evaluation

There are two overarching components to a complete nutritional assessment: a screening evaluation and an extended evaluation, if needed. A nutritional assessment starts with a screening evaluation followed by an extended evaluation if nutritional risk factors are identified (Figure 2). A screening evaluation should be performed on every pet at every visit. The elements of a screening nutritional assessment are not time consuming and are performed as part of a routine history and physical exam. The screening should include an evaluation of nutritional history, environment, activity level, body weight (BW), body condition score (BCS), and muscle condition score (MCS), followed by a complete physical exam. If nutritional risk factors are identified, an extended evaluation is recommended.

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A nutritional history should include not only main meal items but also treats, table food, supplements, and foods used for medication administration. The American College of Veterinary Nutrition (ACVN) and the WSAVA publish sample diet history forms (DHFs).^4,5 Longer examples are also available.⁶ To improve nutritional history accuracy, owners can be asked to complete the DHF at home. Practice team members can then verify DHF information that is incomplete or inaccurate.

BCS is a physical assessment of body fat mass.^7,8 The 9-point BCS scale is validated to correlated with body fat percentage (BF%) using dual-energy X-ray absorptiometry (DEXA).^9,10 Every incremental increase in BCS is equivalent to a 5% increase in BF% while each BCS >5/9 is equivalent to being 10% overweight (Table 2).^9–11 The authors suggest universal use of the 9-point (1–9) BCS scale with whole integers for the standardization of medical records, consistency of data collection and interpretation for research, and for consistent communication from veterinary team members to pet owners.

TABLE 2 Summary of BCS Scales and Their Relationship with BF and BW

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MCS is a physical assessment of the patient’s muscle mass, which includes visualization and palpation of the musculature over the spine, scapulae, skull, and pelvis.^12,13 The authors suggest a narrative description of MCS that includes normal muscle mass or mild, moderate, or severe muscle loss. The MCS has been signifi-cantly correlated with ultrasonographic measurements of the epaxial musculature (cats and dogs) and DEXA (cats).^14–17 The routine use of MCS is important to identify patients with muscle loss related to cachexia and sarcopenia (see terminology definitions in Table 3). Both cachexia and sarcopenia can adversely affect outcomes in veterinary patients.¹⁷ BCS and MCS are not causally related and should be assessed separately (e.g., an animal may be overweight with muscle loss). Underweight patients often have loss of both body fat and muscle mass, yet BCS and MCS should still be scored separately.

TABLE 3 Clinically Relevant Nutrition Terms

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Although typically not included in the screening evaluation, additional tools to be considered are the body fat index (BFI) and girth assessments. BFI, like BCS, is a validated scale to correlate with BF% in both the dog and cat.^18,19 A BCS is limited in its assessment of patients with a high BF% (>45%). The BFI system is a useful tool in differentiating patients with a higher level of BF%. Morphometric measurements to assess lean body mass and fat mass have been established in the dog and cat. These measurements in addition to BFI are useful for patients with a BCS ≥8/9.

Limb girth assessments, an objective measure of muscle mass and strength, are an emerging area of investigation and may prove to be valuable in specific patient populations or for specific patients. For example, this could be a tool for an orthopedic patient enrolled in a physical rehabilitation program.

A fecal score can be included in the screening assessment as a useful tool to assess stool quality and characteristics.^20,21 Various fecal scoring systems have been proposed for veterinary patients.^20,21 A fecal scoring system used repeatedly in a practice can be useful for consistent communication between the client and veterinary team members and to follow trends in fecal quality.

Screening Assessment for Hospitalized Patients

A nutritional assessment should be performed on admission and at least daily for hospitalized patients. Historical information should establish the patient’s food preferences, unexplained weight change, and recent appetite changes including anorexia, hyporexia, and dysrexia (see terminology definitions in Table 3). The physical exam should include an assessment of mentation, an examination for the presence of ascites or edema, and an assessment of available diagnostics. BW needs to be checked at least daily to assess the hydration status of the patient. Specific feeding orders including calculation of resting energy requirement, specific food(s) to be offered, feeding amount (based on a percentage of resting energy requirement [RER]), and frequency offered should be written and assessed daily.

Nutritional Risk Factors

The goal of the screening evaluation is to identify any nutritional risk factors from the patient’s life stage, medical/dietary history, or physical exam (Table 4). Once a nutritional risk factor(s) is identified, an extended nutritional assessment is recommended. Vulnerable life stages such as growth, gestation, lactation, and advancing age alter the patient’s energy and nutrient requirements. Previous or chronic medical conditions may have key nutritional factors to address when making new recommendations. Owners may use foods to administer medications or supplements, and dietary supplements may be a significant source of calories. Non-complete or unbalanced food calories at >10% of a patient’s daily caloric intake dilute essential nutrients and provide excess calories. Unconventional diets should be assessed for nutritional adequacy and safety. Inadequate or inappropriate housing can contribute to stress or barriers that may cause changes in food intake.

TABLE 4 Nutritional Screening: Risk Factors as Determined by Life Stage, Medical/Dietary History, or Physical Exam

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A BCS <4/9 or >5/9, MCS with any degree of loss, and unexplained weight change from the pet’s previous assessment should prompt an extended assessment. Dental abnormalities or disease may impact food intake, leading to anorexia, hyporexia, or dysrexia. Poor skin or hair coat quality may indicate nutrition-related abnormalities. New medical conditions or diseases may benefit from specific nutritional interventions (Table 8).

Extended Evaluation

An extended nutritional assessment is an opportunity to gather a more comprehensive nutritional history and pursue clinical diagnostics (Table 5). The specifics of an extended assessment will depend on abnormal physical exam findings, the information obtained through the screening nutritional history, and identification of specific nutritional risk factors. The development of nutritional recommendations provides an opportunity for the skills of the entire veterinary team to be utilized.

TABLE 5 Examples of Clinical Diagnostics for an Extended Nutritional Assessment

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Feeding Plans for Healthy, Appropriate-Weight Cats and Dogs

For apparently healthy patients maintaining ideal weight, major diet adjustments are likely not required unless a nutritional risk factor is identified. When making new feeding recommendations, the following factors should be considered:

• Give specific feeding plans, including the new diet, feeding amount, feeding frequency, recommended daily treat-snacktable food-medication food allowance, and supplement adjustments.

• Diet adjustments over a 4- to 7-day period may reduce the occurrence of negative gastrointestinal responses.

• Even with no physically apparent dietary issues, this is the opportunity to help the owner lay a better nutritional foundation for later in life. Teach owners how to assess BCS and MCS so they can recognize an undesirable change and adjust intake as needed. Owner assessment of these parameters should be verified by a member of the veterinary team.

• Discuss feeding management and other environmental factors (e.g., free-choice feeding, food competition/social hierarchy, outdoor access leading to additional calories from predation, feces, etc.) that may negatively influence their ability to adhere to the feeding plan.

• Food-dispensing toys or automated feeders are useful to control food access and amount. Feeding toys may positively affect activity level in dogs, although the benefit in cats is more related to enrichment and behavior modification.^22–25

When a cat or dog is healthy and maintains an appropriate weight, ensure the pet is being fed a complete and balanced diet in a suitable amount to avoid future unintended consequences. Although maintenance of ideal BW and BCS is the indicator for how well current intake meets energy needs, these parameters do not address the distribution of calories from unbalanced food items. The Association of American Feed Control Officials (AAFCO) nutritional adequacy statement indicates whether a commercial diet contains all the required nutrients in the correct ratios (i.e., “complete and balanced”) for long-term feeding to the specified life stage. Some foods, including many therapeutic diets, have an “intermittent or supplemental” use label indicating they do not meet the requirements of being “complete and balanced” or that the diet has a special nutritional or dietary purpose. Treats, snacks, and supplements do not require a nutritional adequacy statement.²⁶ If product packaging is not available, the company’s customer service line or website may provide the information.

Assessing the overall quality of a commercial diet is challenging. Specific questions to consider asking pet food companies and their responses to a few of these questions have been published.^27,28 The FDA also publishes searchable recall and withdrawal information, based on brand and reason for recall.²⁹

To determine if caloric intake is suitable, calculate RER and maintenance energy requirement (MER) based on the pet’s activity and life stage factor guidelines (Box 1).

1. Calculate current caloric intake from all food items. AAFCO requires calorie content on dog and cat food labels, including snacks and treats; however, this does not include chews, bones, or toys.³⁰The United States Department of Agriculture (USDA) FoodData Central system provides caloric content of whole foods.³¹The caloric content of supplements may be listed on the label or obtained by contacting the manufacturer.

2. Compare MER with total caloric intake. Ensure the calories consumed are within a reasonable level of agreement to MER and that the main source of complete and balanced nutrition represents ≥90% of total intake whereas treats and other food items make up ≤10%.

3. If there is a significant difference between calculated MER and reported intake level, review calorie intake, life stage, activity level, and MER/RER calculation accuracy.

4. Consider an extended nutritional assessment, especially in overweight or underweight pets (see preceding section on How to Perform a Nutritional Assessment).

Commercial pet foods are required to contain feeding recommendations. In an ideal world, the pet owner will perform RER/MER calculations rather than relying solely on package guidelines because AAFCO does not standardize this process. However, many owners will feed a commercial pet food according to the label directions. In such cases, it is important for the practice team to assess the dog’s or cat’s bodyweight, BCS, and MCS on a regular basis to ensure that the patient is receiving optimal calories and protein.

Feeding Plans for Hospitalized Patients

For hospitalized patients, base feeding calculations on current weight if ideal or underweight or on ideal BW if overweight or obese in order to provide energy to current lean mass. Support anorexic or hyporexic patients by specific feeding techniques (e.g., various forms of food, heating meals, remove E-collars, separate food from litter boxes and pee pads). For animals in whom there are no contraindications, high-fat diets tend to have an increased caloric density, minimizing the total food consumption volume needed to meet energy requirements. Consider medication support, including appetite stimulants, antiemetics, and prokinetics. If feeding techniques and medications do not improve total voluntary intake, assisted feeding via enteral tubes (e.g., nasal, esophageal, gastric) is strongly recommended within 72 hr of consumption of ≤1/3 RER including the time before hospitalization. Because of the risk of food aversion and aspiration, oral syringe feeding is no longer recommended. Feeding protocols should promote the delivery of enteral nutrition over parenteral nutrition when assisted nutrition support is needed. Parenteral nutrition is reserved for select cases, generally in referral facilities with 24-hr care.

Prevention of Obesity

Prevention of overweight and obesity aid the patient’s overall quality of life and may contribute to a lengthened life span.^{19,21,32–34} It is easier to prevent weight gain than it is to treat obesity, adding to the advantages of prevention.^35,36 Obesity discussions can be challenging, as there may be a perception that recommendations are a judgment of the owner’s ability to properly care for their pet or a judgment of the owner’s own body composition. It is best to enter these conversations with compassion and sensitivity, while also remaining a steadfast advocate for the pet’s wellbeing (see section on Communicating with Clients).

Obesity comorbidities include osteoarthritis and endocrine diseases (e.g., hypothyroidism, diabetes mellitus, hyperadrenocorticism).^37–40 In some cases (e.g., feline diabetes mellitus), preventing obesity may help reduce the risk of developing the comorbidity, whereas in others (e.g., hypothyroidism), the underlying condition will continue to predispose to obesity development unless adequately managed.

In order to successfully prevent obesity, an approach including risk factor assessment and mitigation is recommended. Obesity risk factors stem from both human-related and animal-related roots (Table 6). A main human factor is the ability to overfeed the primary diet, and owners find it difficult to make subsequent adjustments. Animals may also overeat if they have access to another pet’s food bowl. Compare reported intake against calculated requirements based on ideal BW and make downward recommendations accordingly. Reassess and adjust recommendations as needed at each subsequent visit.

TABLE 6 Obesity Risk Factors

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TABLE 6 Continued

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Owners also have the ability to overfeed food items that are not the primary diet and overestimate their pet’s activity level.⁴¹ Advise owners to maintain all additional item intake to ≤10% total daily caloric intake to avoid disrupting nutrient balance of the primary diet. To increase exercise in cats, consider the use of feather toys, cat trees, exercise wheels, or similar devices. Fitness trackers may increase owner motivation to increase their dog’s physical activity.⁴²

Animal factors must also be considered to effectively prevent obesity (Table 6). Energy requirements are reduced after spaying or neutering, necessitating intake reduction.^43–45 Certain breeds (e.g., Labrador retrievers, beagles, Norwegian forest cats, Persians) are predisposed to weight gain and the owner should be educated regarding obesity risk, even if their pet currently has an ideal BCS.^46,47

Increase in BW through middle age contributes to the prevalence of obesity.^46–48 Energy requirements are thought to decrease through middle age in the dog, which contributes to this weight gain,^49,50 although results are not consistent.⁵¹ Metabolic rates in the dog can also be influenced by breed and their respective life expectancy.⁵² During senior and geriatric life stages, loss of lean body mass and overall weight loss can occur.⁵³ In cats, fat, protein, and energy digestibility can decrease with advanced aging.^54,55 Energy intake can be higher for senior cats to compensate for this decrease in digestibility.⁵⁶ An important aspect of obesity prevention and maintenance of ideal BCS and MCS is incorporating the entire practice team in client education. Appropriate training is essential to ensure that the team speaks with a common voice (see section on Leveraging the Value of Proper Nutrition in Your Practice).

Weight Reduction in the Obese Pet

In 2014, AAHA published comprehensive weight management guidelines, including a detailed protocol for safe weight reduction.² Because weight loss is a critical aspect of nutritional management for many pets, the 2021 Nutrition and Weight Management Guidelines include an abbreviated overview of this topic. We encourage readers to consult the 2014 Weight Management Guidelines for more complete information on this essential aspect of nutritional management.

Once an animal has gained excess weight, the veterinary team must appropriately inform the owner, gauge their willingness to institute a weight loss program, and offer guidance and support for the duration of the program. The overall design process is reviewed in the 2014 Weight Management Guidelines. Traditional methods to calculate caloric needs are included. Recent data suggest mean caloric intake for weight loss over a 12 wk period is 63 ± 10.2 kcal/kg^0.75 in dogs and 52 ± 4.9 kcal/kg^0.711 in cats.^57,58 The same principles regarding feeding plans for healthy, appropriate-weight cats and dogs apply for weight loss plans. The major difference is adjusting MER calculations to account for necessary reduced calorie intake to induce weight loss (Box 1). Base these calculations on ideal weight and adjust as needed for the individual patient, based on current intake and lifestyle needs.

Although the correct calculations are necessary for a successful weight management program, feeding management and activity plans are essential parts of the package. Puzzle toys and automated feeders continue to be invaluable resources that may be especially useful to achieve successful weight loss via improved ease of plan implementation by owners.^59,60 Consider collaborating with or referring to a veterinary rehabilitation practitioner (Table 7) to design a comprehensive exercise plan to address desired weight loss while maintaining muscle mass based on the pet’s current level of physical fitness. Use the 2014 Weight Management Guidelines for things to consider with an activity plan.

TABLE 7 Additional Resources

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TABLE 8 Nutrients of Concern for Diseases and Select Specific Conditions

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TABLE 8 Continued

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Long-term monitoring and maintenance are often the most difficult aspects of a weight loss program. Failure to achieve and maintain weight loss is common, and owner nonadherence is a major factor.^61–63 After starting a weight loss program, reach out to the owner within the first couple days to determine if there are any immediate concerns. This can be done via phone or email and may help maintain owner adherence and reduce the risk of subsequent dropout.⁶⁴ Because owners often have a strong human-animal bond with their pets, these first few days may pose the largest obstacle as the owner reconciles a “new normal” that does not involve a constant show of love and affection via provision of food items. Weight management plans should address increasing non–food-related interactions (e.g., walks, playtime, brushing). Post-appointment contact can be used to reinforce these recommendations with owners who are struggling with their commitment to the feeding restriction aspect of the plan. The 2014 Weight Management Guidelines outline monitoring and maintenance options.² The goal is to be an advocate for both the pet and the owner, while maintaining a nonjudgmental style of communication (see section on Communicating with Clients).

Use of Therapeutic Diets Designed to Promote Weight Loss

Therapeutic weight loss diets are recommended for patients undergoing significant calorie restriction (less than or equal to RER) for weight loss. These diets are fortified in nutrients to avoid potential nutrient deficiencies associated with caloric restriction. High-protein diets can spare lean mass with calorie restriction during weight loss.^65,66 Protein and added fiber can promote a satiety effect.^37,67 Added fiber to a therapeutic diet will also reduce caloric density. High-moisture diets for cats may increase satiety and help promote weight loss.⁶⁸

Use of Therapeutic Diets Not Related to Weight Loss

When the nutritional assessment indicates a patient may benefit from consuming a purpose-formulated therapeutic diet, the clinician needs to focus on specific nutrients of concern (Table 8). When a patient has a single disease condition and no additional nuanced feeding or diet requirements, it may be adequate to simply choose a therapeutic diet designed for the disease. In diseases in which diagnostics and staging affect nutrients of concern (e.g., CKD) or when patients have multiple disease conditions and/or additional feeding or diet requirements, consider all nutrients of concern before selecting a diet. Otherwise, it is easy to overlook a nutrient of concern and inhibit or negate the treatment plan for the patient’s condition. For example, if a dog receiving a low-fat diet to manage chronic pancreatitis is diagnosed with CKD, a dietary change to address the CKD may result in recurrent pancreatitis symptoms if both disease conditions are not considered.

Gathering a Comprehensive Nutrition History

The nutrition history is the foundation of a nutrition recommendation in which an intricate relationship exists between conducting a nutrition history and making a relevant nutrition recommendation. A comprehensive nutrition history requires exploring all animal-, diet-, environment-, and human-related factors associated with a dog’s or cat’s nutrition.

To gather a comprehensive nutrition history, whether using a diet-history form or during an in-person interaction, veterinary professionals should begin with open-ended questions or statements that allow clients to share information unhindered by the practice’s own goals or agenda. For example, phrases starting with “Tell me . . .”, “Describe . . .”, or “Walk me through . . .” allow clients to share information that the veterinary professional may not have otherwise considered. Using open-ended inquiry during the initial screening evaluation increases efficiency while also allowing for greater detection of nutritional risk factors that can signal the need for an extended nutrition evaluation. Veterinary personnel should move from these broad exploratory lines of open-ended inquiry to more focused lines of open-ended inquiry before using closed-ended inquiry to gather specific details, that is, questions often answered with one-word responses (Table 9).

TABLE 9 Examples of Open-Ended and Close-Ended Inquiry

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When gathering information on diet-related factors, research suggests that veterinary personnel should be cautious about starting with simple what-prefaced questions (e.g., “What kind of food is your pet on?”).^71,72 Although a what-prefaced question is commonly used by practice team members, when analyzing clients’ responses, the question has been found to obtain limited diet information and to encourage defensive responses from clients.⁷³ In addition, treats that a dog or cat may consume have been identified as a specific component of the diet-related history that clients are less likely to disclose,^74,75 warranting more focused questioning or use of different wording (e.g., snacks, rewards, extra foods) to avoid the threat directly associated with the word “treat.”

Communicating a Nutrition Recommendation to the Client

A common obstacle that often undermines a veterinary professional’s nutrition recommendation, when sufficient nutrition history is not gathered, is that the recommendation does not align with the client’s own goals or beliefs. As part of the nutritional history, when asking what the pet is being fed, we should also explore the client’s rationale for feeding a specific food or brand. Exploring the client’s rationale for feeding a specific food or brand gives the practice team an understanding of the pet owner’s dietary viewpoints and will help avoid misunderstandings about the practice’s pet nutrition recommendations. In developing a nutrition recommendation, equal consideration must be given to animal-, diet-, environment-, and human-related factors. Similar to the nutritional assessment, developing a nutrition recommendation is an iterative rather than linear process in which returning to the nutrition history at any point may be required to gather additional information to better align a nutrition recommendation with the goals and beliefs of the client (Figure 4).

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Another potential barrier to a veterinary professional’s nutrition recommendation is the client’s suspicion of veterinary practices being businesses that make healthcare recommendations.⁷⁶ This skepticism can be fueled when a nutrition recommendation involves a commercial pet food. In this case, it is important to recognize that there are two decisions for clients and, therefore, two separate recommendations to be made. The first recommendation is the nutrition-related healthcare recommendation (a nutrition change to manage the health of the animal preventively or to address a nutrition-related health concern). The second recommendation, when required, is a product-specific commercial diet to support the nutrition-related healthcare decision. Separating these recommendations teases apart the question of motivation (business versus healthcare) behind an overall nutrition recommendation. Here is a step-by-step approach to making a nutrition recommendation to a client:

1. Initiating a Nutrition-Related Healthcare Recommendation

The first step to a nutrition-related healthcare recommendation is initiating the conversation with the client. This should involve some form of forewarning to gauge the client’s receptivity to the conversation. Asking permission is one way of respectfully assessing a client’s response to a topic (e.g., “Alex, I would like to spend some time discussing Harley’s [diet, weight, snacks]. Would you be open to this?"). Often, clients accept the invitation and you can move directly into the nutrition conversation. Other times, the client may show apprehension, providing an opportunity to open up the conversation to develop a greater understanding of your client’s apprehension. On occasion, a client will explicitly decline this request, and nothing is lost because the client would likely not have been responsive to moving forward otherwise. By asking permission, you show respect, protect your relationship, and provide an opportunity to engage with your client’s perspective, all of which contribute to greater trust when pursuing a future conversation.

2. Explore with the Owner All Nutrition- and Non–Nutrition-Related Options

Once a client is on board, you can explore all nutrition- and non–nutrition-related healthcare options. Research indicates that 90% of pet owners want to be made aware of all healthcare options, regardless of cost.⁷⁷ In contrast, a focus group study found that many veterinarians identified with presenting clients with only the option the veterinarian believed to be best.⁷⁸ Providing all the healthcare options actively involves clients in the decision-making process and acknowledges their autonomy. It also allows for developing greater alignment with the goals and expectations of the client. As options are presented to a client, it is not uncommon to need to return periodically to gathering more nutrition history to better align your recommendation.

3. Educate the Client About the Benefits (and Risks) of Each Nutrition Option

Critical to making any nutrition-related healthcare recommendation, whether preventive or to address a specific disease, is educating the client about the benefits of each option (or lack thereof) to the health and wellbeing of the pet (e.g., longer life, improved quality of life, reduced onset of chronic disease, resolution or management of a specific condition).⁷⁹ Research suggests that veterinarians often focus on features (e.g., a product, the time, or a service),⁸⁰ without explaining why an option may or may not provide value to the dog’s or cat’s overall health and wellbeing.

4. Make a Clear Nutrition-Related Recommendation

Research in veterinary medicine examining clients’ adherence to healthcare recommendations found that clients who were provided with a clear recommendation were seven times more likely to adhere than clients receiving an ambiguous recommendation.⁸¹ Once a client is made aware of the available options and engaged in the decision-making process, it is the veterinarian’s role to use their knowledge to make a clear recommendation that takes into consideration the nutritional assessment as well as the client’s goals.

5. Check in with the Client to Gain Feedback and Modify the Recommendation

Following a recommendation, it is important to check in with the client to see how the information was received before proceeding. This approach allows the practice team member to return to gather more nutrition history as needed or further tailor their recommendation to better align with the goals of the client. Once the client has arrived at a healthcare decision, if the decision requires a change of diet involving a commercial pet food, it is at this point the veterinary professional should move into a similar decision-making process regarding a complete and balanced commercial pet food (i.e., gather information, initiate the conversation, present options, discuss the value of each option, make a clear recommendation, check in with the client).

6. Plan Appropriate Follow-Up with the Client Once a Dietary Change Has Been Implemented

Plan for a member of the veterinary team to follow up with the client within a couple of days after a change to a dog’s or cat’s nutrition has been made. This is a great time to answer any additional questions, troubleshoot obstacles, or revisit the nutrition recommendation.

Managing Challenging Nutrition Conversations

It is important to acknowledge the plethora of potentially sensitive topics that exist in relation to pet nutrition. An observational study analyzing veterinarians’ conversations with pet owners about pet nutrition identified evidence (reflected in verbal and nonverbal cues) that patient weight, the timing of transition from one life-stage diet to another, treats, wet versus dry foods, quality of the main commercial food, and use of human foods were subjects about which clients, veterinarians, or both demonstrated sensitivity.⁷⁵ Other challenging nutrition conversations veterinary professionals may encounter include discussing a client’s unconventional food choices, preference for or disapproval of certain ingredients (e.g., grain, by-products), or use of various nutraceuticals or supplements. Navigating these conversations requires being attentive and responsive to clients’ verbal and nonverbal cues that signal sensitivity to a line of discussion. Many of these challenging conversations are driven by a veterinarian’s or the practice team’s beliefs, goals, ideas, or perceptions that do not align with the client’s own viewpoints. In response to these challenges, it is important to be aware of our own ideas, beliefs, and judgments. Acknowledging the client’s beliefs, goals, ideas, or perceptions, which does not mean agreeing with them, often provides an opportunity to further explore and understand the client’s perspective. This understanding can be used to identify common ground, which can be used to bring differences in perspective into greater alignment.

Diet-Associated Dilated Cardiomyopathy

Dietary information is an evolving science. Although the Advisory Panel has provided current information on nutritional topics of interest, practitioners should make note of new developments that postdate these guidelines. For example, there has been increased reporting of diet-associated dilated cardiomyopathy (DCM) in dogs in the last few years.^75,83,89 Previously identified risk factors include lamb and rice diets, low-protein diets, and high-fiber diets.⁷⁹ Certain breeds are predisposed (e.g., golden retrievers, Newfoundlands, Irish wolfhounds).^90–92 Recently, more atypical dog breeds have been diagnosed with DCM. Some dogs have been documented to have taurine deficiency and subsequent DCM, whereas many of the dogs have had normal blood taurine concentrations.⁷⁵ Some common dietary features in these cases included feeding a diet high in lentils or peas or feeding a grain-free diet.^93,94

Research is currently being conducted to determine what is contributing to diet-associated DCM in dogs. A few theories include:

1. Inclusion of ingredients that may negatively affect bioavailability of amino acids and other essential nutrients.

2. Low caloric intake relative to calculated energy needs, contributing to a relative decrease of nutrient ingestion.

3. A possible nutritional excess or toxicity.

4. A nonnutritional toxicity.

5. Additionally, as previously identified, there likely are some breed-related factors at play.

The only way to definitively diagnose DCM is via an echo-cardiogram, but this is an expensive test that may not be readily available to all dog owners. If a dog is exhibiting clinical signs of heart disease (e.g., new heart murmur, cardiac arrhythmia, exercise intolerance), thoracic radiographs should be performed. If there is suspicion for DCM or evidence of congestive heart failure, then an echocardiogram should be performed.

Many dog owners want guidance on what they should (or should not) be feeding their pets. Given currently available evidence, the most conservative approach is to avoid feeding grain-free diets or diets high in legumes. Because this is an evolving issue, pet owners should carefully consider the pros and cons of feeding a specific type of diet with their veterinarians. It is also incumbent upon veterinary professionals to stay current in this area of research.

Microbiome, Prebiotics, Postbiotics

The importance of a healthy gut microbiome has recently received more attention in the veterinary community. There are many ways in which the gut microbiome influences organ systems beyond the gastrointestinal tract.¹⁰⁷ There are several ways to qualify and quantify an animal’s microbiome. Although the microbiome is routinely evaluated in research settings, its clinical application is currently limited.¹⁰⁷ Pet owners and veterinary professionals should be wary of companies advertising to test a pet’s microbiome, especially if supplements are then recommended.

An animal’s microbiome can be affected by diet, antibiotics, probiotics, prebiotics, or fecal microbiome transplant. In many cases, soft stool or diarrhea can be effectively managed with a diet change, by modifying specific ingredients, dietary fat, or fiber intake.¹⁰¹ Using indiscriminate antibiotics for acute diarrhea is not recommended.¹⁰⁸ Caution should be exercised when choosing a probiotic because there is variable quality control and efficacy among supplements.^109,110