Understanding the nutritional needs of patients
A Q&A with veterinary nutritional expert Dr. Rebecca Remillard
DVM: When considering nutrition for pets, what are the keys to postsurgical recovery?
Remillard: The general rule we use is that animals have to be provided nutritional support within three days. Veterinarians know this general principle, but that does not mean they always follow through on it. Depending on the medical issue, veterinarians may have to wait more than three days to begin feeding, such as with animals hit by a car or animals with chronic vomiting.
DVM: Sick animal care has to present challenges for the general practitioner. Could you offer some advice? How do you get a sick animal to eat if it is refusing?
Remillard: I would recommend striving to meet the pet's caloric requirements using tube or parenteral feeding methods if the animal refuses to eat on its own. The animal needs energy and protein to heal.
DVM: Could you describe some of the more unusual cases you treat?
Remillard: There are certainly difficult cases, as well as ones that require some imagination. Additionally, there are many diseases. Basically, if, for some reason, you cannot get an animal to eat or you cannot get to the small bowel, you need to start thinking about providing the animal energy (calories). For example, in the case of a dog hit by a car, the animal may have a lung contusion and difficulty breathing, and it is probably an anesthetic risk. You will need to wait for the lungs to heal. In these cases, the animals usually do not eat. You may want to consider using a parenteral IV.
DVM: What are common problems you see with regard to nutritional management?
Remillard: In cases of pets that are vomiting or that have diarrhea or pancreatitis, veterinarians generally wait too long to feed their patients. They may wait until the animal stops vomiting, which can take five to 10 days in some cases. Often you can lose optimal recovery time by waiting.
DVM: What about current trends in nutrition?
Remillard: In the nutrition field, we are working to address obesity — with some success. There is a general move toward more preventive medicine, weight control, as well as development of foods that are specifically designed to be anti-inflammatory, which can reduce pain medication dosages.
On the horizon, now that the genome has been deciphered in dogs and cats, we are learning that nutrients directly affect the genome. This has the potential to open up a new world where foods with specific nutrients, such as omega-3 fatty acids, can target (+/-) gene expression.
Look for manufacturers to be incorporating those nutrients into the foods they design, based on how they want to influence genetics.
DVM: What is causing the obesity epidemic, and how serious is it?
Remillard: The epidemic is multifactorial, but the bottom line is more pets are obese today. People are overfeeding and under-exercising their pets. Also, consider that the average practice visit with the veterinarian is 20 to 30 minutes, once or twice a year. That is not a lot of time to cover all the necessary information with the client. Sometimes weight control does not get on the agenda. But veterinarians have to get comfortable talking about it. It is an epidemic among kids, adults and pets.
For the veterinarians' part, they need to have more confidence that obesity is actually a disease. Many do not regard it as a disease. If I told 100 practitioners that we have the cure for a disease that affects 30 percent of their patients, they would be excited to hear about this cure. Every third patient is overweight or obese. Obesity is damaging in many ways and costs money to manage. The cure is cost-effective. Obesity contributes to orthopedic diseases, as in the case of a client paying several thousands of dollars to fix a knee, which may have been avoided through weight loss.
DVM: Are veterinarians open to collaborating with nutritionists?
Remillard: I don't think practitioners see calling on specialists in nutrition the same as they view other consults, but they should. Some veterinarians may feel as though they should know everything about pet nutrition and diets, even though the AVMA has said it is a specialty unto itself. Therefore, veterinarians should treat nutrition as a specialty and defer to a nutritionist when needed.
Veterinarians can certainly have a nutritionist as an adjunct to their practice with online or phone availability. As with any other specialist, you can have the nutritionist as an option for your clients. Veterinarians do not have qualms about calling a traveling veterinary ultrasonographer or surgeon. The same method works for nutritionists.
DVM: Where is the sticking point in getting veterinarians on board?
Remillard: I'm not sure. Veterinarians are very quick to admit their lack of understanding or expertise in the area of nutrition, but they have not yet made the leap to seek out a specialist in nutrition. We are seeing more clients seeking out nutritionists and bringing their referring veterinarian along with them.
The veterinarians who find that using the services of a nutritionist is simple and efficient continue using nutritional services. Some nutritionists will deal directly with the client, whereas some nutritionists will work only directly with a local veterinarian. But there is now access through online, fax or phone. Appointment visits are available with me directly at Angell for local pet owners.
We're seeing more veterinarians coming for consults from across the United States and Canada.
DVM: What does a typical consult entail?
Remillard: The ultimate consult works best if the veterinarian is involved. Veterinarians formulate the diagnosis or the rule-out list. The nutritionist can then turn to the client with a series of questions concerning his or her expectations: Do you prefer commercial food? A homemade diet? Canned or dry?
The ideal nutrition consult truly marries both sides — the veterinarian's expertise with owners' expectations. A veterinarian does not have the time really to deal with the specifics about what the pet "likes" to eat. But the nutritionist can talk with the client about different meat and grain options or fiber types. The nutritionist is responsible for understanding available ingredients for the client and the nutrition profile needed for the patient.
A veterinary practitioner is often limited to the foods they sell in their practices. A nutritionist rarely has those limits. So the nutritionist should be able to list the best food options for the pet. The veterinarian may look at such a task as daunting; however, the nutritionist sees the wide selection as a positive, providing a variety of available pet food options. The veterinarian doesn't have time to work through all the pet food options.
Additionally, nutritionists can present advice on supplements to their client. Again, the nutritionist is rarely tied to a specific supplement product line and can freely discuss the pros and cons of supplements. Some clients have chosen to spend their entire appointment time talking about supplements. A nutritionist can be an independent consultant.
Basically, the nutritionist sets clients up with a dietary plan to follow until there are other changes in the disease. Clients are rarely brand-loyal to pet foods. Most switch according to the coupon in hand or to the latest product seen on TV. So it is relatively easy to convince clients of a better food choice. Many are open to trying homemade versus commercial as well.
DVM: What messages would you like to send home with veterinarians?
Remillard: If veterinarians feel weak in nutrition, it's understandable and justifiable. The amount of time spent on nutrition in the veterinary curriculum hasn't changed in 20 years. Only a handful of schools have a nutritionist on staff.
Because it may be a weak area for the veterinarian, it should be an area in which veterinarians seek out a specialist. You need not hire or retain a nutritionist but can establish a relationship with one and provide access for your clients. If you feel less than confident in this area, look for a way to provide nutritional expertise as an adjunct to your practice.
Veterinarians should start by contacting the AVMA or the American College of Veterinary Nutrition. There are a variety of ways to locate nutritionists, so you should be able to find one who can work with you and your clients.
Editor's Note: Rebecca Remillard, PhD, DVM, MS, DACVN, is a board-certified nutritionist at MSPCA-Angell nonprofit humane society in Boston. Part of her responsibilities includes addressing the metabolic requirements of patients with numerous medical conditions through clinic visits, case consults and clinical research. Her role as director of clinical research enables her to observe whether studies are structured to meet scientific methods and whether the studies provide necessary data to help further the veterinary profession. Dr. Remillard also oversees the continuing education program for MSPCA-Angell.
Ms. Skernivitz is a freelance writer in Cleveland, Ohio.