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Veterinary Forum January 2008 (Vol 25, No 1)

Expert Summit on Pet Food

    Veterinary Learning Systems, publisher of Veterinary Forum, recently brought together key players in the field of pet nutrition to discuss labeling, education, regulations and the effects of last year's pet food recall. In Part One, they talk about discussing pet nutrition with owners, reading labels and what veterinary schools should be teaching.

    Kathryn E. Michel, DVM, MS, DACVN, Moderator: I've appreciated a level of discomfort, confusion and frustration on the part of practitioners who are on the front line talking with pet owners about their access to information that would help them communicate effectively about animal nutrition.

    What are some of the issues that generate the most concern or confusion?

    Dorothy P. Laflamme, DVM, PhD, DACVN: I think confusion stemming from a lack of understanding about ingredients is probably the most common concern I hear about. There are lots of different questions, but they all stem from a lack of understanding about the ingredients, where they come from and why they're used. We need to provide an understanding about ingredients and why they're used, what they are, how their safety is assessed and related issues, which could go a long way toward addressing the most common concerns about commercial pet food.

    Mary B. Tefend, MS, LVT, VTS (ECC): I agree. Working with students, I know they don't understand how to read a pet food label. For example, they fail to realize that ingredients are listed by weight. So usually in canned food, for instance, water is listed first. Students think that the greatest percentage of canned food is water and don't understand that it is the predominant ingredient by weight and, therefore, is listed first. So the second ingredient listed might be, by percentage, the main ingredient on a dry basis. Teaching veterinary students how to read a pet food label would be beneficial because they will be educating clients about pet food and nutrition.

    Lisa M. Freeman, DVM, PhD, DACVN: So many of the questions are related to veterinarians being trained about nutrition in veterinary school — how to read labels, knowing what the ingredients are, knowing how pet food is regulated. Each vet school should have a board-certified nutritionist to provide nutrition training for students.

    Julie Churchill, DVM, PhD: Ironically, veterinarians are often uncomfortable with their ability to evaluate or discriminate among products, possibly because of a lack in education. Yet, owners are quite comfortable in making nutrition decisions, but they are often based on misinformation.

    Philip Roudebush, DVM, DACVIM: This industry is one of the most dynamic that practitioners encounter, yet they fail to recognize that. In the past 3½ years, more than 1,000 pet food products have been introduced in the US market alone, along with a handful of new nutrition-related drugs. But practitioners don't realize the enormity of this industry. They need to spend some time and energy understanding it.

    When I was a student, the leading cat food in America was Puss 'n Boots, and if that's what I still thought today, I would be grossly misinformed. There is more than one new pet food product a day — day in and day out, year after year. For those of us in industry, it's difficult to keep up with it.

    Laflamme: That's an interesting observation in light of the fact that the nutritional needs of dogs and cats really haven't changed. Yet, so many new products are being introduced. Veterinarians need to start by understanding the nutritional needs of dogs and cats and the individual factors that affect those needs, so they can select appropriately from the available pet foods. It can be a real challenge.

    Sean Delaney, DVM, MS, DACVN: How do you get veterinarians involved in nutrition? Veterinarians often have a hard time charging for their time and their knowledge, whereas if they have a tangible product that they can sell to clients, they may be more likely to make money.

    Roudebush: There's a whole issue of profitability that practitioners don't understand. The reality is that even with the most expensive therapeutic food, every dog and cat can be fed for less than a dollar a day. It's a tremendous value.

    I'm a true believer that good nutrition is good medicine, and good nutrition and good medicine are good business. I don't think practitioners understand that there's nothing more profitable in their hospital than food. We hired KPMG to conduct a profitability study on pet food in 2002. The average profit is 49 cents a pound — that's profit, not gross sales. I was talking to a solo practitioner who sells 100,000 pounds of food a year. His profit, not his gross sales, is $50,000 just because he believes in nutrition — he believes in it for wellness as well as therapeutic reasons and actively makes recommendations to clients.

    Churchill: In veterinary education, we've underemphasized the importance of nutrition and its role in wellness and maintaining health. We seem to have a love affair with treatment. And veterinarians do have a higher comfort level with the "therapeutic diets" or using nutrition in the role of therapy but underemphasize its importance in maintenance and wellness.

    Tefend: Unfortunately, the veterinarian can discharge a pet after making a dietary recommendation to the owner, but then there is no follow up. How can owner compliance be checked?

    Roudebush: Compliance involves much more than owner compliance, and we've had a tendency as a profession to place all blame or focus on owner compliance. The AAHA compliance study, however, showed that the largest gap is after the initial recommendation made by the veterinarian.

    It's that initial recommendation and the acceptance by the client that are important. As part of the AAHA study, veterinarians were videotaped while talking to clients. The study findings indicated that veterinarians think they've made a specific recommendation but they really haven't.

    In the study, 80% of the veterinarians said, "Oh yes, I made a recommendation," but only 10% to 15% of the owners said, "Well, yes, they made that recommendation."

    If a patient has chronic kidney disease, you make that diagnosis and there's clear evidence that a therapeutic renal food can prolong the patient's survival and quality of life, the veterinarian's recommendation should strongly urge client compliance by saying, "We need to make a dietary change because the evidence is clear that this will significantly make a difference in your pet." Then, when the technician comes into the room, she or he should reinforce that recommendation by saying, "Okay the doctor has prescribed this diet, and here's information about the recommendation." And the reinforcement should continue all the way to the receptionist.

    I think making a strong, clear recommendation up front is important.

    Michel: What can be done to make nutrition a more central part of practitioners' focus?

    Freeman: That relates back to education. Veterinarians and veterinary technicians need a better understanding of pet food ingredients because it makes it easier to answer those questions.

    The other thing that makes it a real challenge for veterinarians is that it's a topic owners feel comfortable with. Owners would not come to us and say, "We should be using this Β”-blocker instead of that Β”-blocker," but are quite comfortable saying, "I'm feeding this diet," "I want to feed a raw diet" or "This diet is better."

    Laflamme: Yet, veterinarians remain the number one cited source of information about nutrition and pet care for pet owners. There is some perception that veterinarians don't know about nutrition and this perception is partly correct because we know that nutrition training for veterinarians is highly variable across the country. Some schools have several courses in nutrition and board-certified nutritionists, and other schools provide no nutrition training.

    Some years ago, the ACVN hired the AVMA to conduct a survey, and the findings indicated that veterinarians perceived this lack of training, recognized it and wanted to get better nutrition education.

    We still have a dichotomy in which veterinarians are the number one source of nutrition answers for pet owners and, yet, what is their source of nutrition information? Veterinarians need to have the tools to address the issues, understand what the issues are and provide solutions.

    A homemade diet might be a solution for a specific patient, but what are the issues? Commercial foods might be the right selection for another patient, but what is the right diet?

    Karen Todd-Jenkins, VMD: But for veterinarians to make the recommendations and to help clients with nutrition choices, we need to know what we're looking for when comparing these diets side by side. If I were selecting an antibiotic for a dog, I would consider the organism and, for example, with Staphylococcus aureus would select an antibiotic that is effective accordingly.

    Maybe we could talk about the major things in the ingredient list that veterinarians should consider. If a diet is new and improved, is the improvement still the right choice for this pet?

    Roudebush: We still find that veterinary health care teams are uncomfortable making an active recommendation. So many times I've heard — and we saw it on the videotapes AAHA did with the compliance study — the veterinarian, technician or receptionist say, "Well, any good food will do." That's not a recommendation.

    When I started in practice more than 30 years ago, wellness foods weren't available through veterinarians, but we still had a bag of food in every room. When we made a recommendation, we were sending owners to the local grocery store. It might not be the best approach today, but it was the standard recommendation at the time. If the client asked any staff member — veterinarian, technician, receptionist — the response would be, "This food is it," and there was a sense of decisiveness to the recommendation, But today, many veterinarians seem uncomfortable doing that. Why?

    If I ask my dentist what dental products to use, I'm looking for an active recommendation. That's why I went to the dentist.

    Delaney: The presumption is that there are significant differences among foods. I would argue that there are a lot of good foods, using that term, so it becomes challenging if we're discriminating among foods for healthy animals. How do you distill and filter information? Unless there's a specific known disease state or preventive strategy we're trying to employ, it is challenging for a veterinarian, even a veterinary nutritionist, to discriminate. Obviously, that scenario is different for therapeutic foods, but for most patients, that's the challenge.

    Daniel McChesney, PhD: When veterinarians are asked, "What should I feed?" many tell clients to read the label on the can, and if it indicates that the food was subjected to AAFCO feeding trials or nutritional profiles, then nutritionally it's fairly equal regardless of the brand. Do you believe that is a true and useful statement?

    Laflamme: A diet can meet nutritional profiles established by AAFCO or be subjected to animal feeding tests, both of which substantiate nutritional adequacy. There can be a significant difference in the meaning of these two claims. Anyone can put together a diet, can it or bag it and sell it to owners without the diet ever being fed to a dog or cat. That scenario would fall within the regulations of "formulated to meet the profile."

    Animal feeding tests, according to AAFCO, are certainly a greater level of assurance, but even that, in my opinion, is probably a minimum level. Those studies will identify gross nutritional deficiencies. But we're formulating diets that we anticipate to be fed for years — sometimes the lifetime of a pet — and you have to look at an AAFCO feeding trial as an important component, but only one component.

    You also have to look at the history of the company and the research it does. Veterinarians need to complete diet histories for all their patients to establish a pattern of diets that are associated with healthy pets and diets that are associated with pets that aren't doing quite so well.

    Freeman: I echo those comments. I generally recommend a food that was made by a well-known reputable company and has undergone AAFCO feeding trials, but there are limitations to those feeding trials. A nutritional adequacy statement gives a lot of information because it tells if the food is complete and balanced. We're seeing more commercial foods that are not complete and balanced, yet they appear to be if you look at the package label. In addition to whether a diet is complete and balanced, the label provides information on life staging and whether the food has undergone feeding trials or has just been formulated.

    Churchill: But even practitioners sometimes have difficulty understanding the label because the language is legalese — it's cumbersome and frequently difficult to read. It may be on the side of the package or in very small print.

    Michel: Is any other information on the label useful for discriminating among foods?

    McChesney: Feeding instructions are often on the package, but sometimes if owners follow those instructions, they would actually be providing inadequate pet nutrition.

    Freeman: I believe that critical information on the label is how many calories are in the food. In addition, providing useful units of measures, not per kilogram but per cup or per can of food, is important.

    Delaney: There is a lot of debate among industry, I think is the best way to put it, about how useful calorie listings are. However, I do think that most nutritionists would say that having some calorie information on the bag would help more than hurt.

    McChesney: A lot of products say they are reduced-calorie, reduced-fat or low-fat diets, but the claim is actually based on that particular product. For example, if product X started with 2,000 calories, a reduced-calorie diet must be less than that 2,000 calories. However, if another brand also claims to be reduced-calorie but started with 3,000 calories, the caloric intake would be substantially higher than that found in product X.

    Delaney: I had a client who said, "I can't get my dog to lose any weight on this reduced-calorie food." We checked the packaging, and the food had 500 calories per cup, reduced from 600 calories. It was reduced in comparison with the company's normal product, but for those who are not aware, most foods are around 300 to 400 calories per cup, so it became obvious why the reduced-calorie diet was not very effective.

    Leighann Daristotle, DVM, PhD: We have gone full circle because if a reduced-calorie claim is on a product, it still needs to be the veterinarian who educates the client as to the meaning of that claim. Even if the food is a complete and balanced diet — and we'll assume that most of what's on the shelf is — the client should not make a choice simply because a food has the fewest calories, as it may not be the appropriate diet for that particular pet.

    Laflamme: Veterinarians should develop an inventory or list of foods that are sold in their area because there are a lot of good national foods, but there are also some good regional foods.

    By completing dietary histories on all patients and then considering additional pertinent information from the pet food manufacturers, veterinarians can identify a number of different foods that they feel confident recommending in different price categories to meet the financial capabilities of all their clients. Most owners want the best value. They want good-quality nutrition, but they also want it at an affordable price and a convenient location.

    Tefend: If every school had a nutritionist and from the very beginning taught nutrition concepts, then when students entered their clinic year, they would better understand the differences among pet food products.

    Michel: Beyond understanding nutrition concepts and value, is there any other information that veterinarians should be getting from the package label?

    Tefend: Another tool on the label would be a better guaranteed analysis. There's a maximum and a minimum indicated, but the label doesn't say how much nutrient is actually in a can. The exact amounts aren't listed.

    Delaney: I would provide the proximate analysis, meaning the protein levels and then, by difference, the carbohydrate level. Being able to calculate and compare that information can be useful. For example, if an animal is prone to hyperlipidemia, with this information you could identify whether a food is high in fat.

    Arming veterinarians with the ability to convert proximate analysis to an energy basis would be a good filtering tool. Even if veterinarians recommend a specific brand, within that brand there could be considerable variation in the nutrient profile. My favorite example is Fancy Feast — the fat level among different flavors can range from 25% up to 55%. That's a huge difference from a physiologic point of view.

    Todd-Jenkins: That's a good point. How much fat is too little or too much, and how much protein is too much or too little? Veterinarians need some type of quick reference guide: If the label specified milligrams of fat or grams of protein, that information could help veterinarians make a decision in selecting a diet. Or is that approach too oversimplified?

    Laflamme: It's a great concept, but it wouldn't be a simple grid.

    Daristotle: There are too many variables, such as life stage and lifestyle, even the form of the food, health of the pet and its activity level.

    Delaney: We give our veterinary students a range: This is the typical maintenance level, this is very high or very low in carbohydrates, while this is very high or very low in protein.

    Michel: So do we have a consensus about the nutrition adequacy statement? Veterinarians and clients should be looking for statements that mention AAFCO feeding trials.

    Laflamme: The key words are "animal feeding trials." Veterinarians should recommend that clients look for those key words.

    Freeman: In addition, owners should check whether the diet is complete and balanced for the appropriate life stage. Veterinarians also need factual information about ingredients. There's so much misinformation about ingredients on the list. For example, lamb listed as the first ingredient is sometimes perceived as better than a by-product, which has become a frightening term to some people. Yet, some labeling might list the first ingredients as beef heart, beef liver or beef lung without the word by-product.

    Delaney: And it seems that the industry has made many attempts to get rid of that term, even by renaming it protein co-products. What is amusing to me are people who are strong advocates of raw food diets and foes of by-products saying, "I have this great source of beef liver or beef heart."

    Daristotle: Consumers may not understand that most of the macro-ingredients in commercial pet foods are indeed by-products of the human food industry, not because they are bad for anyone but because of food preferences.

    Roudebush: My grandfather and father grew up on farms, and when an animal was slaughtered, all of it was used. There were no by-products. We have gotten away from that practice.

    People who are entering veterinary medicine today have less of that background. Then, so much of it is cultural in the United States, where people are less accustomed to having contact with where our food comes from and how it is used. When I was in Paris, a little street near the hotel had a butcher shop with a whole wild boar sitting on a big wooden block, along with the kidneys and everything else we would call by-products.

    When I am asked about by-products during a seminar, I respond, "Who in this room has eaten a hot dog?" Typically, everybody raises a hand. I then say, "Who has ever had Jell-O?" Again, the hands go up. That's the way I would approach clients about not only by-products but also many of the ingredients in pet foods.

    See next month's issue for a continuation of this discussion on ingredients, as well as a lively dialogue about regulations and pet food safety.

    NEXT: FORUM Fast Stat (January 2008)

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