Clinical Nutrition and GI Diseases in Cats and Dogs PDF

27/10/2024 Learning objectives...

27/10/2024 Learning objectives Conduct a nutritional assessment of a patient including taking a dietary history Understand processes in the body which are affected by diet and how this relates to gastrointestinal disease Determine dietary management of acute gastrointestinal disease Clinical Nutrition and the management of GI diseases in Cats and Dogs Dr Jon Lewis PhD MSc BSc(Hons) Veterinary Business Manager COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY. EUKANUBA COPYRIGHT IS A MARS, TRADEMARK INC. CONFIDENTIAL OF MARS, INC. – INTERNAL EXCEPT INUSE EUROPE ONLY COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 1 2 Digestive organs and their role in digestion The gut microbiome Mouth Salivary glands ➤ Microbiome refers to all the microbes in the GI tract Mastication Lubrication ➤ Bacteria (most abundant) Large bowel (colon) ➤ Viruses ➤ Fungi Fermentations by ➤ Protozoa microbiota; absorption of ➤ Archaea Oesophagus water & minerals; Transit ‘storage’ of feces Pancreas ➤ Microbiome evolves over time ➤ Recent studies indicate it may develop in utero Enzymes secretion Stomach ➤ Weaning is a key time for microbiome changes Grinding, 1st enzymes ➤ Few changes in bacteria in adulthood ➤ In senior pets’ microbiota number and diversity may decrease Liver ➤ The microbiome is considered a living organism Bile secretion ➤ Whilst research in this area is ongoing Processing of absorbed Small bowel ➤ We can’t underestimate its importance to pet health nutrients & detoxification Enzymes; digestion & absorption of nutrients and fluids COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 4 3 4 Prevalence Impact of GI diseases ➤Gastrointestinal diseases are COMMON…. ➤ They affect the QUALITY OF LIFE of cats and dogs, and can be LIFE THREATENING ➤ Weight loss, abdominal pain ➤Most common category of disease for dogs in the UK ➤ Vomiting, diarrhoea ➤ 17.8% of all first-opinion dog consultations (1) ➤ Urinary signs and neurological signs (liver disease) ➤ Pancreatitis  33% mortality within 30 days (1) ➤Fourth category of disease for cats in the UK ➤ Portosystemic shunt  medical management fails and is associated with euthanasia in ➤10% of all first-opinion cat consultations (2) 50% of cases (2) (1) O’Neil et al (2014) COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 5 (1) Fabres et al (2019) COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 6 (2) O’Neil et al (2014) (2) Watson et al (1998) 5 6 1  27/10/2024 One diet cannot fit all GI tract needs! What happens when there is an imbalance in the microbiome? ➤ Dysbosis = imbalance in the gut microbiome ➤ Leads to: ➤ Reduction in diversity of bacteria ➤ Changes in quantity of bacteria ➤ Functional changes of bacteria ➤ Occur in all parts of the GI tract OR be isolated to different parts ➤ Small intestinal dysbiosis ➤ Change in composition of function of intestinal microbiota ➤ Caused by: ➤ Increase/alteration in microbiota composition – often linked to inflammation ➤ Altered gut motility ➤ Anatomical changes ➤ Exocrine Pancreatic Insufficiency ➤ Poorly digestible diets ➤ Large intestine dysbiosis ➤ Change in composition of function of intestinal microbiota ➤ Results of alterations in Small Intestine or inflammation in the colon COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 7 COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 8 7 8 A full clinical exam… Why is nutrition important? ➤ ± diagnostic tests ➤WSAVA recommends to incorporate nutritional assessment into regular patient care as part of the standard physical examination for all small animals ➤ ”5 vital signs” ➤ Temperature ➤ Pulse ➤ Respiration ➤ Pain assessment ➤ Nutritional assessment COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 9 10 Nutrition – Why is it important? Nutritional assessment screening o WSAVA recommends to incorporate nutritional assessment into regular patient care as part of the standard physical ➤It’s a two part process: examination for all small animals ➤Screening evaluation; ➤Performed on every patient. Based on this screening, pets that are o ”5 vital signs” healthy and without risk factors need no additional assessment o Temperature o Pulse ➤Extended Evaluation; o Respiration ➤Performed when one or more nutrition-related risk factors are o Pain assessment found or suspected based on the screening evaluation o Nutritional assessment ➤ For more detail on the nutritional assessment and screening process follow the following link https://wsava.org/wp- content/uploads/2020/01/WSAVA-Nutrition-Assessment-Guidelines-2011-JSAP.pdf COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY © COPYRIGHT MARS INCORPORATED – CONFIDENTIAL – INTERNAL USE ONLY 11 12 2  27/10/2024 Nutritional assessment screening Screening Evaluation Are there ➤Physical ➤History Nutritional Risk factors present? ➤ Altered GI function e.g. vomiting diarrhoea, ➤ Body Condition Score (9-point scale) nausea, flatulence constipation ➤ Healthy at 4/5 ➤ Previous/ongoing medical conditions/disease ➤ Muscle Condition Score ➤ Currently receiving medications and/or dietary Yes, there are risk No, there aren’t ➤ Unexplained weight change supplements factors present risk factors present ➤ Dental abnormalities/disease ➤ Unconventional diet (e.g. raw homemade, ➤ Poor skin/hair vegetarian, unfamiliar) ➤ New medical conditions/disease ➤ Snacks, treats, table food >10% total calories ➤ Inadequate or inappropriate housing Patient to undergo extended No further action Nutritional required Assessment COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY. EUKANUBA COPYRIGHT IS AMARS, TRADEMARK INC. CONFIDENTIAL OF MARS, INC. – INTERNAL EXCEPT INUSE EUROPE. ONLY 13 14 Extended evaluations – animal factors Extended Evaluation – Diet factors ➤ Changes in food intake/behaviour ➤ Check the caloric density of current diet ➤ E.g., amount eaten, chewing, swallowing, nausea, vomiting, regurgitation ➤ Evaluate other sources of nutrients (e.g., treats) ➤ Condition of the integument ➤ If disease conditions exist that may be the result of tainted or spoiled food, the diet should be ➤ E.g., dry, easily plucked hair, thin, dry or scaly skin and reduced resistance to venipuncture submitted for testing ➤ Diagnostic workup ➤ Evaluate diet ➤ Minimum database/laboratory testing as appropriate ➤ commercial foods, homemade, unconventional ➤ Specific tests might include; complete blood count (checking for anaemia), urinalysis, biochemistry profile (electrolytes and albumin), faecal culture and other nutritional concentrations that may be low/high because of an unbalanced diet (e.g. taurine/ vitamin B12) ➤ Additional workup as indicated (e.g., imaging, endoscopy) ➤ Current medical conditions and medications ➤ Assess effects of the disease and any treatment plan on pet’s nutritional status (e.g., thyroid disease) ➤ Some medications (e.g., diuretics)/ procedures (e.g., significant intestinal resection) can cause a loss of malabsorption of essential nutrients COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 15 16 Diet History Evaluating a commercial diet Specific type of ➤ Current & previous diets manufacture’s food reputation ➤ Brand, flavor, texture ➤ How much (calculate calories) Storage formulat condition ion ➤ Treats Ask the ➤ “Traditional” treats Ask yourself Where is it client produced ➤ Human foods and can it Objective ➤ Chews/dental treats info to positive be visited When and Flavour experience where it was assist variety ➤ Flavored medications, supplements, toothpastes purchased? What Quality Ask the food research control measures manufacture has been conducted https://wsava.org/wp-content/uploads/2020/01/Nutritional- Assessment-Checklist.pdf Formulated by veterinary nutritionist or COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY equivalent COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 17 18 3  27/10/2024 Evaluating a homemade foods Extended evaluation and environmental factors Sources of Amount Specific the nutrients recipe Stresses in ingredients used the Activity level environment Recipe rotation/ Ask Preparation Digestibility and client Primary Multi-pet Extent of substitution Bioavailability feeder of pet household enrichment Contact who formulated the diet Feeding Animals management Other food Storage specific needs e.g. location provides/ and sources COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY frequency COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 19 20 Where do you draw the line between acute vs. chronic? Did you know that a highly digestible GI diet may help manage acute diarrhoea quicker than an Acute GI issues Chronic GI issues antibiotic? GI issues (e.g. diarrhoea, vomiting) that GI issues (e.g. diarrhoea, vomiting) that have started recently been going on for more than 2 weeks Group 1 examples examples highly digestible dry food Kitten with diarrhoea that started 2 days ago Adult cat with intermittent vomiting for the + placebo tablet past couple of months Group 2 Adult dog that started vomiting 3 days ago Adult dog with soft stool for the past month Rudinsky et. al. enrolled 59 adult dogs with highly digestible dry food noninfectious acute colitis, then divided into 3 groups  + metronidazole tablet Group 3 Diet only (1st & 3rd groups) resulted in quicker resolution and highly digestible dry food reduced reoccurrence, as compared to diet + metronidazole. with added psyllium + 2 weeks is an arbitrary cut off that separates acute from chronic placebo tablet Plus, no GI dysbiosis in the diet only groups! COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 22 J Am Vet Med Assoc. 2022 Oct 6;1-10. Randomized controlled trial demonstrates nutritional management is superior to metronidazole for treatment of acute colitis in dogs. Rudinsky et. al. 21 22 Goals of Nutritional Management: What qualities are you looking for in nutritional Digestive support for the GI patient? ➤ Prevent malnutrition & support pet recovery What is a common go-to BLAND? for a bland approach? ➤ Protect and nourish the GI tract Patients with acute GI issues would ➤ Control fermentations & regulate intestinal motility benefit from a highly digestible diet ➤ Support immune and anti-inflammatory processes PALATABLE? Patients with acute GI issues may not ➤ Restore/support a healthy microbiota have a hearty appetite LOW FAT? Some patients with acute GI issues would benefit from fat restriction chicken &rice COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 24 23 24 4  27/10/2024 Chicken & rice will not meet 100% of nutrient needs because … Let's think about how a we could go it is not complete & balanced BEYOND BLAND, with a GI diet 100% 100 Essential Nutrients per AAFCO Guidelines 75 What nutrients 50% are missing? 50 Let’s use a layered cake 25 to construct key aspects essential fatty of a GI diet 0 acids, Commercial Diet Chicken and Rice several minerals & vitamins Vitamins Minerals Fatty acids Amino acids Nutrients levels above were determined using the USDA FoodData Central database. COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 25 COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 26 25 26 Go BEYOND BLAND Go BEYOND BLAND Complete & balanced (layer 1) Highly digestible (layer 2) Feeding a complete & balanced diet is an essential base to supporting all cats & dogs More protein for the patient & less protein for microbes to ferment in the large intestine Simply meeting all essential nutrient needs is Omega-3s & Zeolite Omega-3s & Zeolite important for the gastrointestinal tract Robust fiber blend Robust fiber blend B-vitamins, like B12, are critical for intestinal health Electrolytes are critical for intestinal health AND hydration Palatable & highly digestible Palatable & highly digestible Feed the diet right! Can you think of a time that a patient’s GI health was Complete & balanced Complete & balanced sabotaged by treats? More protein (green) absorbed in the small intestine means no more than 10% of daily calories from treats less undigested protein (i.e. residue) to be fermented in the large intestine COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 27 COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 28 27 28 Go BEYOND BLAND The role of FOS in the body Robust fiber blend (layer 3) (Fructo-oligosaccharide) Without FOS  Through fermentation, FOS are a direct source of nourishment for the cells of The use of less fermentable fibers to support healthy the large intestine. stool quality and regularity  They inhibit the development of Omega-3s & ‘bad’ bacteria … like psyllium husk Zeolite pathogenic bacteria ‘good’ bacteria Soluble with a high water binding Robust fiber blend Digestive transit  They promote the growth of bacteria With FOS capacity FOS that have beneficial effects on the (i.e. can soften hard stool and firm MOS health of the digestive tract. Palatable & highly digestible up loose stool)  They improve digestion and nutrient This Photo by Unknown Author is Complete & balanced absorption. licensed under CC BY-NC Mackei. Altered Intestinal Production of Volatile Fatty Acids in Dogs Triggered by Lactulose and Psyllium Treatment. Vet Sci 9(5):206 COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 29 COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 30 Alves. The use of soluble fibre for the management of chronic idiopathic large-bowel diarrhoea in police working dogs. BMC Vet Res 17(1):100 29 30 5  27/10/2024 The role of MOS in the body Go BEYOND BLAND (mannan-oligosaccharides) Omega-3 fatty acids (layer 4) Without MOS  Effective against harmful bacteria living MARINE-BASED OMEGA-3 FATTY ACIDS, EPA & DHA in the intestinal lumen ‘bad’ bacteria Omega-3s & ‘good’ bacteria Tailored beyond essential needs Zeolite Digestive transit  They prevent the development of Helps to modulate inflammation Robust fiber blend pathogenic bacteria. With MOS FOS MOS Bioavailable to multiple tissues  They directly enhance the effectiveness Palatable & highly digestible of the body’s immune system The pathogenic bacteria are no Complete & balanced longer able to attach themselves to the intestinal The intestinal mucosa wall strengthens its immunity COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 31 COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 32 31 32 Go BEYOND BLAND 1. Feeding Management Is Key Zeolite (layer 4) For Managing GI Issues ZEOLITE (SODIUM ALUMINOSILICATE) binds free water and toxins & supports Omega-3s & Zeolite 01 Diet consistency is an important part of managing the pet with GI issues. beneficial bacteria 02 Robust fiber blend Small frequent meals may be better tolerated Zeolite than 1 or 2 larger meals. Palatable & highly digestible Complete & balanced 03 Ensure that treats should make up no more than 10% of daily calories and the rest should come Intestinal wall from a GI diet. COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 33 COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 34 Sabbioni et. al. Modulation of the Bifidobacterial Communities of the Dog Microbiota by Zeolite. Front Microbiol. 2016; 7: 1491 33 34 Summary ➤ The Gastrointestinal tract contains multiple different organs that are impacted by diet ➤ The main organs being stomach, small intestine and large intestine ➤ Two parts to conducting a nutritional THANK YOU assessment ANY QUESTIONS? ➤ Screening evaluation ➤ Extended evaluation ➤ Don’t be afraid to question everything about a diet ➤ Diet is a suitable method for Acute GI issues ➤ A GI diet is somuch more that a bland diet like Chicken and Rice COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY. EUKANUBA IS A TRADEMARK OF MARS, INC. EXCEPT IN EUROPE. 35 36 6  27/10/2024 References ➤ Alves. The use of soluble fibre for the management of chronic idiopathic large-bowel diarrhoea in police working dogs. BMC Vet Res 17(1):100 ➤ Fabres V, Dossin O, Reif C, Campos M, Freiche V, Maurey C, Pilot F, Desquilbet L, Benchekroun G. Development and validation of a novel clinical scoring system for short-term prediction of death in dogs with acute pancreatitis. J Vet Intern Med. 2019;33(2):499-507. ➤ Mackei. Altered Intestinal Production of Volatile Fatty Acids in Dogs Triggered by Lactulose and Psyllium Treatment. Vet Sci 9(5):206 ➤ O′Neill DG, Church DB, McGreevy PD, Thomson PC, and Brodbelt DC. Prevalence of Disorders Recorded in Dogs Attending Primary-Care Veterinary Practices in England. PLoS One. 2014; 9(3): e90501. ➤ O′Neill DG, Church DB, McGreevy PD, Thomson PC, and Brodbelt DC. Prevalence of disorders recorded in cats attending primary-care veterinary practices in England. Vet J. 2014;202(2):286-91. ➤ Rudinsky et al (2022). J Am Vet Med Assoc. Oct 6;1-10. Randomized controlled trial demonstrates nutritional management is superior to metronidazole for treatment of acute colitis in dogs. ➤ Rhimi, S.; Kriaa, A.; Mariaule, V.; Saidi, A.; Drut, A.; Jablaoui, A.; Akermi, N.; Maguin, E.; Hernandez, J.; Rhimi, M. The Nexus of Diet, Gut Microbiota and Inflammatory Bowel Diseases in Dogs. Metabolites 2022, 12, 1176 ➤ Sabbioni et. al. Modulation of the Bifidobacterial Communities of the Dog Microbiota by Zeolite. Front Microbiol. 2016; 7: 1491 ➤ Watson P, Herrtage M. Medical management of congenital shunts in 27 dogs – a retrospective study. JSAP. 1998;39(2):62:8. ➤ https://wsava.org/wp-content/uploads/2020/01/Nutritional-Assessment-Checklist.pdf ➤ https://wsava.org/wp-content/uploads/2020/01/WSAVA-Nutrition-Assessment-Guidelines-2011-JSAP.pdf COPYRIGHT MARS, INC. CONFIDENTIAL – INTERNAL USE ONLY 37 7