A successful series

I’m incredibly happy to report that the “Top 10 nutrition frequently-asked questions” series at Western Veterinary Conference was a success. I had a large, full room, and lots of extra questions and interaction. Thanks to the organizers, and especially to everyone who came to participate!

Not the Las Vegas top 10 list that you’d expect

Tomorrow, I’ll be headed to Las Vegas for The Western Veterinary Conference, and I’ll get to wear one of those fancy “speaker” ribbons on my badge.

I’m presenting a series of talks for veterinarians on my top 10 frequently-asked nutrition questions, an idea from Bill Porte, a friend and veterinary mentor who wouldn’t steer me wrong.

While a top 10 list doesn’t sound particularly novel on the surface, this one actually is. Preparing these talks was part of the inspiration for my “It’s easy to believe that vets don’t know anything about nutrition…” post, and the positive response I got to it reinforces that this series is needed. The novelty is that I’m emphasizing not how to DO nutrition, but how to TALK ABOUT nutrition with pet owners.

Wish me luck, or, if you’re attending the conference, come see me!

Winnie’s customized “senior diet”

Labrador Retrievers seem to stay puppies longer than other large-breed dogs; there seems to be a component of refusal to grow up. While the (long) puppy stage is fun, it’s also exhausting; and adulthood is nice (if you’ve done things remotely right, you have an amazing companion by now); but for me, there’s no better friend than a senior Labrador Retriever. I’m just a sucker for the gray muzzle.

Many owners of senior pets feed commercial pet food marketed as “senior diets.” However, most probably don’t know that there isn’t an official nutritional definition for senior diets like there is for puppy/kitten and adult diets. Commercially-available senior diets are variations on adult maintenance diets; but the variations vary by manufacturer. There is no other unifying feature. While this isn’t necessarily problematic for most healthy senior pets, I believe that more so than almost any other group of pets, seniors need a tailored approach. There is so much potential for them to benefit from a diet that considers and addresses their unique combination of needs.

Now I’ll introduce Winnie; a 13 year-old Labrador Retriever. Her owner, also a veterinarian, had contacted me about making sure she was giving Winnie all the support that she could, and I was happy to help.

In many ways, Winnie is typical of older dogs of her breed. She had trouble getting up and around and tended to be a bit itchy; she always had. Many pet owners would say that “she’s just getting old” and shrug their shoulders. Winnie’s owner took a different approach and I’m glad.

While age is not a disease in and of itself, age is a predisposition to a number of diseases; arthritis is a good example. With that in mind, Winnie’s owner set out to make sure that she knew exactly what was (and was not) going on with Winnie.

It was already known that Winnie had significant arthritis affecting her knees and elbows, as well as her other joints to a lesser extent. She’d been receiving acupuncture treatments and hydrotherapy (exercise done in water to reduce impact on sore joints) to keep her joints comfortable and her muscles strong. She received several types of pain medication, including a non-steroidal anti-inflammatory drug, for her arthritis as needed.

Through a somewhat tedious process of trials with flea preventative medication and an elimination diet, Winnie’s owner had already determined that Winnie’s itchiness was due to environmental allergies. This is similar to a person who has watery eyes and sneezing in response to certain types of pollen or other allergens, but dogs tend to manifest this as itching and licking at their feet.

While Winnie appeared to be completely healthy otherwise, to find out if there was anything else that she needed to know about, Winnie’s owner/veterinarian submitted Winnie’s blood and urine samples for analysis. This screening labwork showed that Winnie’s kidney function was beginning to decline. This was good to know, since non-steroidal anti-inflammatory drugs used to treat arthritis pain can be harmful to a pet with inadequate kidney function. The labwork indicated that Winnie had no other problems.

Winnie seemed to be doing “okay” on her current commercial maintenance diet, but it didn’t specifically address any of her medical concerns. In addition, since it was formulated for healthy adult dogs, it would not be appropriate for Winnie’s chronic kidney disease.

Winnie’s owner knew that many diets for chronic kidney disease in dogs are low in protein (which is helpful in later stages), and that Winnie was already experiencing some loss of muscle mass due to her arthritis, so this didn’t seem like the right choice for Winnie. In addition, she wanted to provide Winnie with a home-prepared diet where she could control the ingredients and make adjustments as Winnie’s needs changed.

In order to create a special diet that provided Winnie with everything she needed, Winnie’s owner/veterinarian contacted Veterinary Nutrition Care. Dr. Farcas reviewed Winnie’s medical and diet history, and spoke at length with Winnie’s owner to make sure she understood what was important for Winnie and her owner. She explained what features of a diet could be used to help Winnie’s arthritis, environmental allergies, and manage her chronic kidney disease.

While nothing can be done to reverse the bony changes that occur within an arthritic joint, treatments (including diet) can be aimed at reducing the inflammation associated with those changes. To achieve this, Winnie’s diet would provide a fairly high dose of anti-inflammatory long-chain omega-3 polyunsaturated fatty acids (from fish oil). Winnie was already at a healthy weight, but had this not been the case, a weight loss plan would have also been needed, since carrying even a few extra pounds can make arthritis pain significantly worse.

A similar approach is taken to address environmental allergies with diet; as this is also an inflammatory process, anti-inflammatory long-chain omega-3 polyunsaturated fatty acids (from fish oil) can help. In addition, making sure that Winnie’s diet provided enough linoleic acid, an essential omega-6 fatty acid was important, since this contributes to the skin’s ability to act as a good barrier to water loss and environmental allergens. Other minerals such as zinc and copper are needed to maintain skin health, so making sure that Winnie’s diet was balanced would also benefit her skin condition.

Lastly, Winnie’s new diet would be designed to accommodate her early stage of chronic kidney disease. At this stage, patients don’t show any symptoms, so treatment is aimed at delaying progression of the disease. One important aspect of this is limiting phosphorus intake. It’s the kidneys’ job to excrete excess phosphorus, but if the kidneys aren’t functioning properly, excess phosphorus is retained and drives a process called renal secondary hyperparathyroidism, which results in worsening of kidney function. So, to keep that from happening, dietary phosphorus must be limited.

Another aspect of protecting Winnie’s remaining kidney function was already to be included in her diet; besides the anti-inflammatory effects of the long-chain polyunsaturated fatty acids from fish oil, these fatty acids can also help to manage blood pressure within the part of the kidney that acts as a filter for the blood, thus protecting it from further damage.

People often discuss protein restriction for pets with chronic kidney disease. This is important at a later stage of the disease when, in addition to worrying about delaying progression, we also want to manage symptoms of chronic kidney disease. The symptoms of poor appetite, vomiting/nausea, oral/stomach/intestinal ulceration, dry mouth, and others that are associated with chronic kidney disease are attributable to a group of compounds, collectively called uremic toxins that accumulate when the kidneys lose the ability to excrete normal by-products of protein breakdown. At this point, less protein = less by-products = less uremic toxins = pet feels better. That said, every pet has an absolute requirement for certain amounts of protein every day, and inadequate protein intake is detrimental as well. Finding a balance can be tricky, but is absolutely worth doing.

There’s no evidence to suggest that a low-sodium diet (to avoid high blood pressure) is needed for pets with chronic kidney disease, since sodium intake doesn’t appear to drive hypertension in healthy pets. However, as long as Winnie’s sodium requirement was met, there would be no harm in also making her diet low in sodium.

While I’m never happy when a patient has multiple diseases to manage, it makes life easier for everybody when the nutritional management strategies for the different diseases don’t conflict with each other. Read about Cheeka for an example of a patient with conditions requiring opposite nutritional strategies.

Winnie’s new home-prepared diet would provide her with a high dose of fish oil, be restricted in phosphorus, moderate in protein, and low in sodium. Rather than using a separate fish oil supplement, Winnie’s owner was happy to use salmon as the protein source to supply long-chain omega-3 polyunsaturated fatty acids. Salmon provides calories as both protein and fat. A small amount of a plant-based oil provided linoleic acid and some calories as fat, and the remainder of Winnie’s calories came from white rice, which is low in phosphorus. Using these 3 ingredients alone, or even with added fruits and vegetables would mean that Winnie’s diet would be deficient in several important vitamins and minerals (including calcium). For this reason, a vitamin and mineral supplement was also included to make sure that the diet was balanced to meet all of Winnie’s needs.

Once the specific amounts of each ingredient needed to provide Winnie with the right amounts of calories and nutrients were determined, a detailed recipe and preparation instructions were delivered to Winnie’s owner/veterinarian. Along with this came recommendations to monitor Winnie’s weight, response to the new diet, and to continue to monitor Winnie’s kidney function parameters.

Winnie’s owner gradually transitioned her to the new home-prepared diet. Being a good Labrador Retriever, Winnie loved the new diet. She initially lost a bit of weight, and a slight increase in the amount fed per day was all that was needed to correct that. This is not uncommon when changing to a new diet if the exact amount of food (and treats) that the pet ate previously isn’t known.

When Dr. Farcas checked in on Winnie a few months later, she was thrilled to hear that Winnie’s owner had been able to transition her completely off of her non-steroidal anti-inflammatory drug, and that Winnie was happy and more active. Her itching, while not completely resolved, was improved, and her coat was full and soft. Repeat labwork showed no progression of Winnie’s kidney disease. Happy to hear that Winnie had done so well with her new diet, but wanting to determine if the response was due solely to the diet, Dr. Farcas asked more questions; Winnie’s owner/veterinarian answered them all and assured her that nothing else had changed. She attributed the changes she was seeing in Winnie to her customized home-prepared diet and was very happy with the results.

For Winnie, her owner’s proactive approach means that she gets all the support she needs so that while she’s not acting like a puppy again, she’s happy and comfortable. Since her medical status is known and appropriately managed, her owner knows that she’s providing the best care possible to Winnie. The fact that Winnie’s owner is a veterinarian doesn’t affect very much about the story; a pet owner with any other background dedicated to proactive care could accomplish the same for their own pet with the help of an involved veterinarian and a resource like Veterinary Nutrition Care.

It’s easy to believe that veterinarians don’t know anything about nutrition; but that doesn’t make it true.

I’m a big believer that most “black and white” statements about nutrition are oversimplified, frequently to the point of being inaccurate; and that the longer, grayer story is really the better one.

While I could (and just might) write an entire series based on this introduction, today’s long-overdue post addresses a mostly-inaccurate statement that is frequently made by those offering pet nutrition advice online, and even occasionally by veterinarians. I’m referring to the myth “veterinarians don’t know anything about nutrition.”

First, some truths. All graduates of US veterinary schools, no matter when they graduated, have nutrition integrated into their curriculum, whether it was a required course labeled “Nutrition 407” or whether it was sprinkled into other aspects of medicine, it’s in there. Some nutrition knowledge is also requisite to pass examinations for veterinary graduates to practice in the US. I’ll be the first to agree that some veterinary institutions don’t provide enough nutrition training; however, even those institutions have curriculum that incorporates critical thinking, research, and the importance of continuing education. To maintain licensure to practice, veterinarians are required to complete a certain amount of continuing education each year, and there are many options available for veterinarians to either brush up on nutrition or pick up where vet school left off. It’s just a matter of making an effort to do so. There really isn’t a good excuse for a veterinarian to be ignorant when it comes to nutrition.

All that said, I just revealed my feelings about black-and-white statements about nutrition, so I’ll also say that I absolutely have met a (very) few veterinarians who appear to have completely blocked nutrition from their memory and have no interest in learning something new. They exist, but they’re exceptionally rare. I do, however, stand behind the black-and-white statement that there just isn’t a good excuse for this. What can I say? No profession is perfect.

So, if (nearly) every veterinarian practicing in the US truly has some nutrition knowledge, how can it be that this myth is so prevalent, even to the point that some veterinarians say it about themselves?

While a study on veterinarians’ self-reported level of nutrition knowledge, comparing it to their educational records, and correlating these with how they approach nutrition in practice would be an amazing tool for improving nutrition care within US veterinary practices, and the best way to answer this question, it doesn’t exist, to my knowledge. What I do have to offer, is my assessment of the situation, based on my own veterinary and residency training, my time spent teaching at veterinary universities, and several years of speaking with veterinarians and pet owners about their experiences. This is not a substitute for a more evidence-based approach, but it’s what we have.

The way I view veterinarians’ nutrition deficiencies focuses not on knowledge, but on communication.

First, we have to go back 20-30 years to consider that things have changed relatively recently when it comes to nutrition. There were drastically fewer options for pet owners to choose from when it came to pet food, and pet food marketing was fairly simplistic. The body of knowledge about pet nutrition and diet formulation was much smaller, and internet access wasn’t a factor in people’s decision-making. Because of this, there was a tendency for pet owners to ask veterinarians for nutrition advice when it was needed, and to take that advice at face value. Easy.

Now, all of those factors have changed. Pet owners think about nutrition much more than they did in the past, largely due to the ease with which information is available now. There has been an explosion in the number of pet food options available, and along with this, some very smart marketing that has even managed to look like unbiased information has entered the pet food market. In addition, science has progressed so that we now know much more about pet nutrition, and pet food and the internet has brought the general public a ton of information (some useful, some useless, much confusing). With all of these changes, people’s expectations of their veterinarian, when it comes to nutrition, have changed.

Pet owners are no longer asking for advice (even if they phrase it as such). They’re asking for a dialog. Rather than the basic instruction that would have been acceptable in the past, pet owners now want to know that their veterinarian recognizes their concerns and the energy that they’ve devoted to learning about the subject. They want the vet to be willing and able to engage in a conversation about it and they want to play an active role in determining the course of action.

Like most aspects of both veterinary medicine and life in general, having this conversation takes practice. Incidentally, it’s not something that gets talked about a lot, but one of the most important things that veterinary students in their clinical year, and new graduates, do is refine their explanations of common diseases and medical concepts. It takes time to figure out the most effective and efficient way to convey the most important information; and it’s different for everybody.

So, 20-30 years ago, veterinarians never had to be good at talking with pet owners about nutrition, because no one was asking if a grain-free diet would help their pet with diarrhea. No one was asking if a raw-meat-based diet would improve a skin problem, and no one was trying to balance a home-prepared diet using whole food ingredients. Again, black-and-white statements here- I don’t mean literally anyone, I just mean few enough people to justify not having to learn to have these conversations.

While nutrition is absolutely present in the veterinary curriculum in the US, talking about nutrition: not so much, with the exception of teaching by a few of my very proactive colleagues. It’s been up to vets to learn it on their own. By far, the vast majority of veterinarians that I talk to who’ll say that they “don’t know anything about nutrition” are actually able to make perfectly reasonable nutritional recommendations in most instances, but where they fall down is in answering the pet owner’s question about why they made the recommendation. They haven’t had the practice. It’s not a knowledge issue, it’s a communication issue.

While the pet owner may be asking “is diet x good for my pet?” it’s not a yes-or-no question anymore. Veterinarians don’t usually recognize that exactly what and how a pet is fed can potentially say a lot about the pet owner, and the pet owner may have invested much energy in the subject and determined that diet x is the way to go. Some pet food marketing has given many pet owners some false ideas about what is and is not important in pet food, and when a veterinarian outright disagrees with the results of a pet owner’s research, it’s natural for that pet owner to be offended. As a generally peaceful bunch, most veterinarians don’t enjoy being put in these situations, so it’s easy to see how “I don’t know” may be the easier (though incorrect) answer. Another scenario where “I don’t know” may incorrectly come up is in response to claims such as “feeding abc diet will cure your pet’s medical condition.” Veterinarians are trained in critical evaluation of information, so if there isn’t any valid evidence-based information on which the veterinarian can advise otherwise, “I don’t know” is the alternative to the full explanation of the importance of evidence-based medicine.

While I don’t believe that “I don’t know” is the right answer in either of these scenarios, when veterinarians are managing hospitalized patients and returning phone calls from worried pet owners in between running a hospital, surgeries, appointments that are never long enough, walk-in patients, and emergencies, with a little bit of perspective, it’s easy to understand how saying “I don’t know” and not having a 40-minute conversation about nutrition may be the answer that keeps the day on track.

I’ll try not to sound like a marriage counselor here, but if the problem is communication, then the solution is to understand the other person’s perspective and taking steps to accommodate it.

My calls to action:

Veterinarians: Ask owners of pets requiring nutritional care or clients with concerns about feeding their pet to schedule an appointment to discuss nutrition. Consider that criticism of your client’s current feeding choices is indirectly criticism of your client and their lifestyle. Focus on providing background in evidence-based medicine and the medical basis for your recommendations. Point out the level of evidence that informs each idea being discussed. Find a gentle (but honest) way to suggest making changes, and keep the focus on the fact that you both want to provide the best care possible to the pet. Contact a veterinary nutritionist if needed. Use this opportunity to develop your approach to talking about nutrition. You’ll say “umm” a lot and feel like it’s your first week in practice for a while, but it will become second-nature. Your client will leave with the impression that you care, that you listened, and that you do know something about nutrition.

Pet owners: It’s tricky to navigate pet nutrition advice. There’s a lot of it, and it ranges from excellent to terrible. Often terrible is cleverly disguised as excellent. There are resources for dog and cat owners that can help, but your vet is really the best person to help sort it out. However, understand that while “is diet x good for my pet?” sounds like a simple question, it isn’t. Not if you want an intelligent answer. The answer actually involves your pet’s medical needs (the easy part because your veterinarian already has a handle on this); your pet’s current and possibly previous diets, and his/her response to them; and the logistics of feeding and lifestyle in your home. If you are honestly interested in your veterinarian’s opinion of your pet’s diet (you should be), it’s only fair that you give them an opportunity to give you a good answer. Asking about nutrition as a “by the way” as your vet is leaving for her next appointment isn’t fair. You probably won’t be satisfied with the answer, and your veterinarian won’t get the chance to provide your pet with the best possible care. Just as you’d schedule an appointment with your vet if you had questions about your pet’s itchy skin, go ahead and schedule one for your questions about diet.

It’s not the easy way out (surprise), but between veterinarians’ expanding knowledge base in nutrition, more practice with talking about it, and a bit of perspective, the myth that veterinarians don’t know anything about nutrition can hopefully be put to rest.

Hello. Welcome to Veterinary Nutrition Care’s blog.

Everyone wants to ensure that their pet receives the very best care, but when it comes to exactly what and how much to feed, that can be difficult.

Good information on what pets need is difficult to find, and it’s hard to determine if a specific diet meets those needs. Feeding a pet can be confusing!

Veterinary Nutrition Care is here to help.

Hello.

My name is Dr. Amy Farcas. I’m a board-certified specialist in veterinary nutrition; owner of, and veterinary nutritionist for, Veterinary Nutrition Care.

Veterinary Nutrition Care is a new business, providing consulting services to pet owners and veterinarians in the San Francisco Bay area.

My mission statement “Improve pet care by providing tailored nutrition plans for pets, strengthen the human-animal bond through thoughtful pet nutrition counseling for people, and support veterinarians in their mission to provide best care for pets and their families” pretty much sums up what I’m all about. Please feel free to read more about Veterinary Nutrition Care’s philosophy, services, and approach.

​Veterinary Nutrition Care’s blog will highlight common questions and concerns about pet nutrition, as well as current events relevant to how pets are fed. The goal is to bring some evidence-based nutrition to the confusing world of “pet nutrition information available online.” I will also share, with permission, some of my patients’ stories, progress, and outcomes so readers can see some examples of what I do, and why I do it.

I’ll use blog comments as a source for the site’s FAQ page, as well as inspiration for future blog posts. I’d be happy to know what you like and want to see more of, what you want to know more about, and what you don’t find interesting at all- I’ll try to keep those posts to a minimum, but I won’t promise a home run every time.

Thank you for stopping by. I hope to see you again soon.