In 2010 the American Animal Hospital Association (AAHA) introduced nutrition as the 5th vital assessment that should be measured, recorded, and addressed in veterinary patients at each visit. This was followed in 2011 by publication of the World Small Animal Veterinary Association Global Nutrition Council (WSAVA-GNC) nutrition toolkit for veterinarians. These tools were designed to streamline the process of incorporating nutritional assessment of the patient (via body and muscle condition scoring) and well as the diet and feeding management (as determined through a brief diet and husbandry history questionnaire) at each visit. Integrating nutrition into a busy practice can seem like a daunting task, but just as measuring temperature, pulse, respiration, and pain have become routine components of each physical examination, so can the nutrition assessment.
Nutritional Assessment: Identifying Risk Factors
Patient Factors
Non-reproductive, adult animals with normal whole body functions have a range of acceptable nutrient intakes; as long as minimum requirements are being met and toxicity is avoided they will do well irrespective of diet type. Assuming a complete and balanced diet is fed, the nutritional assessment is focused on ensuring that the animal is at an optimal weight and body condition score (BCS). Overweight and underweight animals are identified during the physical examination and any abnormalities in appetite, elimination, or behavior are called out during the patient history. Growing animals and those that are pregnant or lactating will have higher nutrient requirements than a non-reproductive adult. Animals with underlying medical conditions (either pre-existing or newly identified at the time of the visit) will have nutrient requirements that vary depending on the specific organ system that has been compromised.
Diet Factors
Animals eating complete and balanced commercial foods made by medium to large-sized pet food companies are the easiest to assess. As long as the pet food manufacturer is following legal requirements for product formulation and safety standards, and labeling foods as such, veterinarians can be assured that the diet provides adequate levels of all essential nutrients for the intended species. Diets that require more thorough investigation are those that are being made by the owners in their homes (i.e., a potentially unbalanced home-prepared diet) and those that are manufactured or marketed by smaller pet food companies. Many small to medium-sized pet product companies outsource formulation and manufacturing and may not have the knowledge or ability to monitor quality control of source ingredients or finished products. Additionally, small boutique-style pet food companies many not be able to guarantee a consistent quality and nutritional profile of ingredients or finished products. The WSAVA-GNC has also developed general questions that can be used to help veterinarians and pet owners evaluate individual pet food companies and products.
Management/Environmental Factors
Questioning pet owners about the feeding regime at home (amount and frequency of feeding) can identify if over or underfeeding is occurring. Frequency and amount of treats being offered each day can also contribute to unintended weight gain and potentially unbalance the overall diet and can also be identified during the diet history. Location of feeding, competition of resources, and lack of environmental enrichment can contribute to behavioral and elimination problems. Additionally, lack of physical activity can contribute to weight gain.
Nutritional Assessment: Integrating Into Practice
There is some flexibility to order of which nutritional assessments can be incorporated into clinical practice. It can begin with the reception team at check-in. While waiting to be seen owners can fill out a brief questionnaire regarding food intake, current diet type and amounts, any treats or additional foods that are given during the day, and whether supplements or nutraceuticals are being given. This can be a stand-alone diet history form or one that includes questions on activity, behavior, and elimination habits. The answers to these questions can then be followed-up and reviewed by either the veterinary nurse when the patient is shown into the consult/examination room or by the veterinarian at the start of the physical examination.
During the examination a BCS is assigned based on patient adiposity using either a 5-point or a 9-point scoring systems and the animal's musculature (and degree of muscle loss) can be scored on a 4-point scale. Examples of BCS and muscle condition charts are available through the WSAVA-GNC online toolkit. Incorporating a BCS and muscle condition score to the "Physical Examination" template will prompt attention to this feature at each visit.
The findings of the nutritional assessment are then used in conjunction with any clinical changes or diagnostic results, or both, to develop the feeding plan going forward. The feeding plan for an animal in a good BCS that appears normal at home and in the clinic (as based on additional examination +/- diagnostic test parameters) may be as simple as "no diet change needed," but the nutrition assessment could also detect problems with the feeding regime, such as overfeeding and an increasing BCS over time, or identify a new change, such as feeding of an unbalanced home-prepared diet, that could lead to long-term consequences and risk to health and longevity. Animals with underlying medical conditions may benefit from more directed nutritional changes, such as feeding a therapeutic diet with schedule follow-up at a designated time in the future. Specific case studies to be provided during the lecture.
References
1. WSAVA-GNC Global Nutrition Toolkit. http://www.wsava.org/guidelines/global-nutrition-guidelines.
2. Delaney SJ, Fascetti AJ, Brentson P. Integration of nutrition into clinical practice. In: Fascetti AJ, Delaney SJ, eds. Applied Veterinary Clinical Nutrition. 1st ed. West Sussex, UK: Wiley Blackwell; 2012:3–8.
3. American Animal Hospital Association (AAHA). The Path to High-Quality Care. Lakewood, CA: American Animal Hospital Association Press; 2003.