AAHA Nutritional Assessment Guidelines for Dogs and Cats

Abstract

The American Animal Hospital Association recommends these nutritional assessment guidelines because good nutrition enhances pets’ quality and quantity of life, and is integral to optimal animal care. Incorporating nutritional assessment into regular animal care is critical for maintaining pets’ health, as well as their response to disease and injury. It requires little to no additional time or cost.The specific goals of this article are to provide:The positive impact of proper nutrition on health and disease is well established in all animals. Appropriate feeding throughout all life stages can help prevent diet-associated diseases, as well as to assist in the management of other diseases. For example, diets formulated for dogs and cats with chronic kidney disease have been shown to provide significant benefits.1,2,3The National Research Council (NRC) of the U.S. National Academy of Sciences is the leading provider of nutrient recommendations for dogs and cats.4 The NRC publications form the basis for Association of American Feed Control Officials (AAFCO) nutrient profiles, which are updated routinely.5 AAFCO provides a mechanism for developing and implementing uniform and equitable laws, regulations, standards and enforcement policies, and establishes nutrient profiles for cat and dog foods.Assurance of proper nutritional health, however, entails more than meeting nutrient profiles; additional factors must be considered. Figure 1 represents the “Circle of Nutrition,” symbolizing the comprehensive approach to clinical nutrition used by the American College of Veterinary Nutrition (ACVN).According to this approach, nutritional assessment considers several factors that are described in detail in this document. An iterative process, in which each factor affecting the animal’s nutritional status is assessed and reassessed as often as required, provides a thorough nutritional assessment of the small animal.6,7,8 The factors to be evaluated include the animal, the diet, feeding management and environmental factors, as described below.Animal-specific factors include the age, physiological status and activity of the pet. Problems related to animal factors are referred to as nutrient-sensitive disorders (e.g., intolerances, allergies and organ-specific diseases). Diet choice for these animals should be restricted to those formulated to meet the disease-associated nutritional limitations of the specific animal.Diet-specific factors include the safety and appropriateness of the diet fed to the animal in question. Problems related to diet factors are referred to as diet-induced disorders (e.g., nutrient imbalances, spoilage, contamination, adulteration). Animals with these disorders may be treated by feeding a diet known to be appropriate for the animal.Feeding factors include the frequency, timing, location and method of feeding, whereas environmental factors include space and quality of the pet’s surroundings. Problems related to feeding and environmental factors are referred to as feeding-related and environment-related disorders (e.g., over- or underfeeding, excessive use of treats, poor husbandry, competitive eating in dogs, and lack of appropriate environmental stimulation). These situations require effective communications to produce the appropriate behavioral changes in the client.Nutritional assessment is a two-part process.The interview portion of the evaluation should be performed by a person trained to elicit required information from the caregiver most knowledgeable about the pet(s). A detailed nutritional history should be obtained. A variety of forms are available for recording these findings.9,10Nutritional screening is part of routine history taking and physical examination of every animal. Information collected should include assessment of each of the parameters of the circle of nutrition.Certain life factors, by themselves, may not call for an extended evaluation if the animal is otherwise healthy. Low or high activity level, multiple pets in the home, gestation, lactation, or age <1 year or >7 years, all create a need for closer scrutiny. Although these factors by themselves may not trigger an extended evaluation, they should cause the veterinarian to scrutinize the pet’s situation more closely.Specific risk factors known to influence nutritional status include those listed in Table 2. When features are identified that raise one’s “index of suspicion” for a nutrition-related problem, an extended nutritional evaluation may be indicated.The value of an extended nutritional evaluation increases as the number of risk factors and their severity increase. Moreover, sufficient concern about any one parameter may be enough to warrant extended evaluation.If no concerns are raised by the screening evaluation, then the nutritional assessment is complete.Use a consistent method and scale to measure body weight (BW), body condition score (BCS) and muscle condition score (MCS) to assess current status and changes over time. Although different scoring systems may have situation-specific merits, the panel recommends that practices choose, and all doctors and staff consistently use, one system and record the total points on which it is based (i.e., the denominator).The BCS evaluates body fat [Figure 2]. Various BCS systems are used to evaluate dogs and cats (e.g., scales of 5, 6, 7 or 9).11,12,13The goal for most pets is a BCS of 2.5–3 of 5, or 4–5 of 9. (This may appear too thin to some pet owners, so client education is important.) These BCS goals are based on a limited number of studies in dogs and cats14,15,16,17 as well as those from other species. Disease risk associations with higher BCS in adult animals appear to increase above 3.5 of 5 (6 of 9). Similar risk associations for other life stages in client-owned pets have not been reported, but may occur at low BCS based on studies of laboratory-housed animals, and in humans.16,18 Additional research on dogs and cats is needed to more fully evaluate the effects of body condition on disease prevention.The MCS differs from the BCS in that it evaluates muscle mass [Figure 3]. Evaluation of muscle mass includes visual examination and palpation over the temporal bones, scapulae, lumbar vertebrae and pelvic bones. Assessing muscle condition is important because muscle loss is greater in animals with most acute and chronic diseases (i.e., stressed starvation) compared to healthy animals deprived of food, when primarily fat is lost (i.e., simple starvation). Muscle loss adversely affects strength, immune function, and wound healing and is independently associated with mortality in humans.19,20A simple MCS scale is currently undergoing development and validation.21 The authors’ clinical experience suggests that early identification of subtle muscle loss, at the “mild muscle wasting” stage, is valuable for successful intervention.Clinically, BCS and MCS are not directly related. An animal can be overweight but still have significant muscle loss. This can make an MCS of mild to moderate look relatively normal if not carefully evaluated. In these cases, although some of the areas of the body may appear relatively normal or even have excessive fat stores (especially over the ribs or in the abdominal region), muscle wasting is readily felt over bony prominences. Palpation is required for accurately assessing BCS and MCS, especially in animals with medium- to long-hair coats.Extended nutritional evaluation of animal, diet, feeding and environmental factors is indicated for animals identified to be at risk for any nutrition-related problems from the screening evaluation [Table 2]. Those items suggest that nutrition may play an important role in development of or management of the animal’s underlying disease, or life stage. First, review and summarize the history, medical record and information obtained during the screening evaluation. Second, obtain additional data as appropriate, as described below. A more detailed list of potentially relevant historical factors may be found in various references.Following the nutritional assessment, interpret and analyze the information that has been gathered to devise an action plan. Consider the following:Adults in good body condition should be reassessed regularly. Decisions regarding specific frequency of visits are made appropriately on an individual basis, based on the age, species, breed, health and environment of the pet. Healthy pregnant, lactating, senior and growing animals require more frequent monitoring. Pet owners should monitor their pet at home, including:Non-hospitalized animals for which extended nutritional evaluation was indicated may require more frequent monitoring of nutritional assessment parameters. Monitoring should include the items in Table 2.Frequent monitoring of BCS and MCS is important, as many diseases are associated with suboptimal scores. Also, animals with medical conditions are more likely to receive dietary supplements and to have medications administered with food, so specific attention to and review of these issues, with an update of the dietary plan, are important at each visit to ensure that the overall nutritional plan is optimized.Daily monitoring of hospitalized animals includes the items in Table 2, also evaluating these additional items:Many hospitalized animals are discharged prior to complete resolution of their underlying disease. Document and communicate to the client the feeding method, caloric intake, diet, frequency and specific monitoring parameters, and the schedule for rechecks and re-assessment.Discuss with the client any issues that may limit adherence to dietary recommendations (e.g., feeding schedule issues, complex instructions, financial restrictions) and address appropriately (e.g., offer over-the-counter options for appropriate diets if financial restrictions will prevent the owner from consistently feeding the prescribed diet). Create a specific schedule for follow-up via telephone to elicit questions and verify compliance/adherence.Provide choices in diets that meet nutrient goals. Create a plan with the client about what to do if calorie/nutrient goals are not achieved.When abnormal parameters have returned to normal or stabilized, the animal may continue on a therapeutic diet or be transitioned to a non-therapeutic diet. If a new diet is necessary, it may be introduced gradually, as previously described.Client communication and rapport are important for achieving desired outcomes.41,42,43 Technicians should be involved in the nutrition-evaluation process when they have knowledge and skills in both nutritional concepts and in communication.Engage the client in decision making and defining expectations. Recommendations may be modified by the client’s time, lifestyle and financial limitations. Use communication techniques that include various forms based on client preferences. Use various educational approaches and tools.Demonstrating and teaching the client to evaluate the BCS and MCS are effective in engaging the client in their pet’s care. Expectations and goals should be specific, achievable and include specific follow-up to monitor progress and compliance, and to adjust recommendations.Inform clients about specific foods, and potential advantages, risks and concerns. Include recommendations on amount and frequency of diet fed, accounting for snacks, treats, table food, foods used for medication administration, and dietary supplements. Clients may enrich their pet’s nutritional experience by interacting with them at feeding, providing food toys and playing and exercising with their pet.Nutritional assessment is an important aspect of optimal animal care. This document provides guidance for appropriate, effective assessment, evaluation, action monitoring and education. With little practice, this approach can be efficiently incorporated into daily practice without additional time or expense. Stay tuned for further developments and expanding knowledge.