The impact of nutrition on health and disease is well established. Appropriate diet can help to maintain wellbeing and to prevent diet-related problems, whereas inadequate diet can cause substantial health issues. However, consideration of dietary intake and nutritional assessment is often neglected at the veterinary visit (Vandendriessche et al, 2017; Blees et al, 2022). The reasons for this are numerous and include a lack of perceived knowledge and competence; too tight a schedule or short appointment times with insufficient time for nutritional assessment; and a lack of confidence to discuss diet and nutrition with pet owners (Lumbis and De Scally, 2020).
Omitting the nutritional assessment in a consultation may lead to nutritional risk factors and thus, important patient information being missed. This may mislead or delay the diagnosis and proper treatment. Therefore the routine inclusion of a nutritional assessment of every pet is of vital importance.
Nutritional assessment
As with any medical intervention, there are always risks of complications and this is no different with nutritional interventions. Minimising such risks depends on regular nutritional assessment, prompt identification of patients in need of nutritional support and determination of the optimal feeding route and method. Following the evaluation of temperature, pulse, respiration and pain, nutritional assessment is the fifth vital assessment and identifies malnourished patients requiring immediate nutritional support, as well as those at risk of developing malnutrition (Freeman et al, 2011). Regardless of age, life-stage and condition, a nutritional assessment should be conducted on every pet that is presented at the veterinary practice as part of routine history taking and physical examination.
To help the veterinary healthcare team and pet owners in ensuring that small animals receive optimal nutrition, tailored to their needs, the WSAVA Global Nutrition Committee launched Nutritional Assessment Guidelines in 2011 (Freeman et al, 2011). These have since been published worldwide and translated into 12 different languages. For the veterinary healthcare team, these guidelines provide a framework to assist them in making a nutritional assessment, and in providing specific nutritional recommendations, for small animals (Figure 1).
The first stage involves making an initial, systematic ‘screening’ evaluation of the animal, as well as identification of the diet being fed and a review of feeding management and environmental factors (Figure 2). A screening evaluation may indicate that a pet is in good health and physical condition, is being housed in appropriate environmental conditions and is being fed a suitable and adequate diet with optimal feeding management. In this situation, the recommendation and plan may simply be to continue with the current regimen and to regularly reassess this. The exact frequency should be based on the species, breed, age/life stage, health status (e.g. hospitalised patients need more frequent assessment than patients on an elimination diet), and environment of each individual pet. Life-stage may influence the approach taken to conducting a nutritional assessment of a dog or cat, with specific considerations for each stage outlined by American Animal Hospital Association (AAHA) (2021a) and AAHA (2021b). Healthy pregnant, lactating, senior, and growing animals require more frequent monitoring (Freeman et al, 2011). The identification, or suspected presence, of any nutrition-related risk factors, including previous or ongoing medical conditions or disease, prompts a more in-depth ‘extended’ evaluation of each of these factors, a framework for which is published online (AAHA, 2010). Regardless of whether or not nutritional risk factors are present, it is important to make a specific dietary recommendation and nutritional plan, while also considering the preferences of the pet and owner.
This iterative process with regular reassessment of the dietary plan will help to ensure the optimisation of nutritional intake, with appropriate adjustments made where necessary to achieve and maintain optimal body condition (Freeman et al, 2011).
The Global Nutrition Toolkit
Following on from the launch of the WSAVA's Global Nutrition Guidelines in 2011, a suite of non-branded support materials and practical aids have been developed by the WSAVA Global Nutrition Committee as part of a ‘Global Nutrition Toolkit’ (WSAVA, 2022). These are freely available to access and download from the WSAVA website: https://wsava.org/global-guidelines/global-nutrition-guidelines/.
Tools including a dietary history form, nutritional assessment checklist and calorie chart for healthy dogs and cats, help to address nutrition and assist in making nutritional assessment and recommendations more efficient. Guidance for the nutritional support of clinically affected patients is also provided through feeding guides, feeding instructions and a monitoring chart for hospitalised dogs and cats, together with videos illustrating placement of common feeding tubes. The availability of body and muscle condition score charts and videos facilitates consistency in use across the veterinary healthcare team and pet owners. Guidance for successful implementation, including communication tips, helps to further advance the central role of the veterinary healthcare team as the expert source of nutrition information.
A number of non-branded educational materials have also been designed specifically for pet owners. These assist in making appropriate pet diet-related decisions, help to clarify common dietary myths and misconceptions and educate about different diets and pet food ingredients. They also help to promote pet owner provision of a full and accurate dietary history.
Incorporating nutritional assessment and recommendations
Incorporating nutritional assessment and recommendations into patient care is critical to the optimisation of animal health and enhancement of pets’ quality of life. It also strengthens relationships, helping to develop a partnership and build trust between pet owner and the veterinary healthcare team, resulting in better care and healthier pets.
Reported factors contributing to the successful implementation of nutritional assessment and provision of dietary recommendations and protocols include:
- Creating awareness among the veterinary healthcare team and pet owners about the importance of nutritional assessment, planning and intervention
- Making a team commitment to acknowledge nutrition as the fifth vital assessment and follow the WSAVA Nutritional Assessment Guidelines
- Collaborating to develop a customised written protocol to ensure every pet receives a nutritional assessment and specific dietary recommendation
- Ensuring appropriate team training so that all staff are sufficiently knowledgeable, competent and confident to follow practice protocols
- Promoting pet owner education as a key responsibility for all members of the veterinary healthcare team
- Effectively communicating prescribed feeding orders to all those involved in patient care and treatment. This should include specific information such as frequency of feeding, amount offered, amount eaten and any food used for the delivery of medications
- Ensuring accurate record keeping, including the completion of a nutrition monitoring chart
- Identifying, training, and utilising a member of staff to act as nutrition ‘champion’, helping to promote the inclusion of nutrition as a standard component of patient care and to reinforce good nutritional practice throughout the veterinary clinic (Creevy et al, 2019).
Such factors highlight the importance of interprofessional collaboration between personnel, patient planning, and the provision of explicit instruction. As acknowledged by AAHA (2009), the provision of high-quality patient care can be achieved when every member of the pet's healthcare team, including the owner, shares a common understanding and agreement about all aspects of the recommended care.
Establishing good client rapport and making use of appropriate communication is crucial to achieving desired outcomes (Cornell et al, 2007; Creevy et al, 2019; Quimby et al, 2021). Clearly documented, specific dietary recommendations should be communicated to the pet owner. These include the feeding method (e.g. voluntary oral feeding, coax feeding or via a feeding tube), caloric intake, diet and frequency, and the schedule for rechecks and reassessment. Combining verbal provision with other formats such as handwritten or electronic instruction helps to reiterate the message and enhance compliance (Wayner, 2012; Wilson, 2014).
In accordance with Freeman et al (2011) and Wareham et al (2019), dietary compliance can be further maximised through:
- An understanding of the factors affecting whether a client will comply with the specified recommendations
- The identification of any issues that may limit pet owner adherence and involving them in the decision-making process
- The maintenance of regular communication with pet owners
- Good teamwork, with appropriate delegation and the utilisation of all members of the veterinary healthcare team to provide feeding advice and pet owner support in executing nutritional recommendations (Freeman et al, 2011; Wareham et al, 2019).
It is essential to encourage the active involvement of all pet owners in the nutritional assessment of their pet(s) at home, with Freeman et al (2011) recommending the frequent assessment of specific monitoring parameters, including:
- Food intake and appetite
- Body condition score and bodyweight
- Gastrointestinal signs (e.g. faecal consistency and volume; any vomiting)
- Overall appearance and activity.
Patient scenario
A 7-year-old spayed female Cairn Terrier, Ava, was presented at the clinic for veterinary examination because of intermittent large-bowel diarrhoea for 3 weeks. In addition, the owner was worried about Ava's ‘bloated’ appearance. Ava had been diagnosed with acute pancreatitis approximately 2 months earlier. At that point, the veterinarian had highlighted that diet would be an important part of the treatment and a commercial low-fat dry food was advocated yet, for unapparent reasons, an extended nutritional assessment was not performed. Several weeks later, a routine follow-up phone call by the reception team revealed that just under half of the original bag of food remained because of a lack of dietary compliance, therefore a repeat order was unnecessary. Enquiries into Ava's health revealed gastrointestinal symptoms, further prompting the recommendation for a veterinary examination and nutritional assessment.
The physical examination was unremarkable although Ava had gained 1.5 kg since the last visit, weighing now 9.7 kg, and was slightly overweight (body condition score (BCS) 6/9, normal muscle mass). Rectal examination revealed soft faeces with some mucus. Possible nutrition-related risk factors of weight gain and intermittent diarrhoea were identified, warranting the completion of an extended nutritional assessment.
First, Ava's diet was discussed in more detail. Following the earlier veterinary recommendation, the owner had purchased a bag of low-fat diet. However, Ava refused to eat the kibble so the owner had been adding minced beef to improve the diet's palatability. Unsurprisingly, Ava ate the minced beef and left most of the kibble. When scrutinised, the diet now consisted almost completely of minced beef (fat 17% dry matter), with only about 15% of the daily caloric intake coming from the low-fat kibble.
Before the diet change, Ava had been an ideal weight of 8.2 kg. Her daily activity level was low (walking on the lead for around 1 hour per day), and based on age and physiological state, her daily energy requirement was estimated to be 95 kcal ME/kg0.75 (European Pet Food Industry Federation (FEDIAF), 2021). Ava was consuming approximately 170 kcal per day more than recommended for her weight and activity level, most of which was coming from fat and protein. Although carbohydrates (sugars, starch, and fibres) are not considered essential nutrients for dogs, they are a valuable source of energy and nutrients. Dietary fibres fermented by the gut microbiota provide energy to bacteria and large intestinal cells, thus normalising intestinal motility, promoting gut health, and helping to regulate faecal consistency.
When discussing the diet with the owner, it was revealed that Ava had never liked kibble and had been fed mostly canned dog food or home-made risotto. Consequently, the feeding recommendation was modified to feed the commercial low-fat diet as a canned, rather than dry, formula. The owner was urged to contact the veterinary health care team immediately if there were problems with palatability. The importance of maintaining dietary consistency was also emphasised.
Following the veterinarian's dietary recommendation, a veterinary nurse calculated Ava's caloric needs and a daily feeding amount to meet the daily need of an 8.2 kg dog with low activity level. The owner was also advised how to assess Ava's body condition and other important monitoring parameters. This was included with full details of the dietary recommendation and re-visit appointments in a written feeding instruction for the owner. The owner was instructed to bring Ava to the clinic for a check-up, but because of financial restrictions and a lack of transport, the owner opted for a follow-up phone consultation instead. This was carried out 1 week later by the veterinary nurse who enquired about Ava, reiterated the veterinarian's dietary recommendation and provided support to the owner in ensuring full compliance. The owner reported that Ava was eating the canned diet well and her faecal quality had improved. A check-up was then scheduled for 6 weeks later with a veterinary nurse. At this point she weighed 8.7 kg and had an ideal BCS of 5/9 with good muscle mass. No signs of intermittent large bowel diarrhoea had been exhibited since the diet change.
KEY POINTS
- Correct nutrition is a key factor in optimising animal health and wellbeing, and in enhancing quality of life.
- The veterinary healthcare team should be the trusted and primary source of sound nutritional advice and recommendations.
- A nutritional assessment and specific dietary recommendation is the fifth vital assessment and an essential part of patient care for every pet, at every visit.
- Nutritional support should be considered as part of a holistic approach to patient care and must be documented within patients’ records and as part of a comprehensive nursing care plan.
- Effective interprofessional communication and collaboration leads to a positive team environment founded on respect, trust and mutual support and can maximise the effectiveness of nutritional recommendations.
Enhancing nutritional care and support through interprofessional practice
Interprofessional practice may be defined as two or more professions working together, understanding each other's roles, ensuring clear communication on patient care and agreeing on objectives to be met by the team (Kinnison et al, 2011). In veterinary practice, this interface between veterinarians, veterinary nurses, paraprofessional team members and support staff is critical and influences patient care and outcomes, client satisfaction and the incidence of medical errors (Kinnison et al, 2014).
Multifaceted clinical knowledge is required to enhance the quality of nutritional management, optimise nutritional support according to the health and nutritional status of each individual animal and to avoid potential complications. Conducting a screening evaluation, as described in the WSAVA Nutritional Assessment Guidelines, as the fifth vital assessment in the standard physical examination requires little or no additional time or cost. However, as outlined in the given patient scenario, a consistent and detailed, interprofessional approach, involving all members of the veterinary healthcare team, is fundamental.
Clear definition of responsibilities with appropriate delegation can help to ensure that all aspects of nutritional care, from initial assessment and screening through to feeding plan development, delivery of prompt and targeted nutrition and provision of accurate monitoring, is carried out. Historically, veterinarians have been positioned at the top of a hierarchical workplace structure and have taken responsibility for all actions in the veterinary practice (Kinnison et al, 2014). While great geographic variation exists, there is increasing professional diversity, and patient care no longer tends to rest solely with one veterinarian. In many countries, veterinary teams frequently consist of multiple veterinarians, veterinary nurses, other paraprofessionals, receptionists and administrators, all of whom contribute to the completion of patient- and client-oriented tasks (Kinnison and May, 2016). Relieving veterinarians of the pressures of jobs that can be completed by suitably qualified colleagues, enables completion of the work that only they are qualified to carry out. This has direct impact on the care received by pets and their owners and demonstrates the expertise of the veterinary healthcare team (Abood and Verton-Shaw, 2021).
Nutritional interventions by veterinary practitioners is not being translated into their training (Becvarova et al. 2016) or practice (Vandendriessche et al, 2017; Lumbis and de Scally, 2020; Blees et al, 2022) and, consequently, they often lack the necessary knowledge, skills and confidence to educate clients effectively (Bergler et al, 2016; Bruckner and Handl, 2020). Alongside veterinarians, veterinary nurses are frequently identified as a source of nutrition advice and recommendations to pet owners (Bruckner and Handl 2021; Lumbis and de Scally 2020; Blees et al, 2022), and can have a positive impact on owners’ understanding of nutritional recommendations (Freeman et al, 2011; Johnson and Linder, 2013) and dietary compliance (Hancock and Schubert, 2007). In the UK, registered veterinary nurses (RVNs) are regulated professionals who are responsible for adhering to a Code of Professional Conduct (Royal College of Veterinary Surgeons (RCVS), 2022) and are subject to a disciplinary system. If a task is appropriately delegated to a RVN, they become professionally responsible and accountable for its completion. This is different to many other countries where the veterinarian retains full responsibility for the delegatee's acts or omissions and overall outcome. However, appropriate delegation of work according to relevant skills, competence and expertise, rather than hierarchical status, can help to promote more efficient and cost-effective patient care. It also contributes to greater job satisfaction, respect, appreciation and recognition. Robust professional communication and accurate record keeping is needed to enhance and support delegation, thus promoting a united veterinary healthcare team and high quality patient, and client, care. This is essential for the provision of nutritional support and all other aspects of veterinary care and treatment.
Conclusions
Nutrition is fundamental to wellbeing, longevity and disease prevention and plays a critical role in optimising health, enhancing quality of life and managing disease. Incorporating nutritional assessment and recommendations as the fifth vital assessment in the standard physical examination requires little to no additional time or cost and can facilitate a partnership between pet owner and veterinary practice. Utilisation of the WSAVA Nutritional Assessment Guidelines and toolkit facilitates this process, helping to efficiently address nutrition.
Once dietary intervention is deemed necessary, collaboration is essential to determine the most appropriate method and route of delivery, the patient's nutrient and energy requirements, and feeding goals, and to ensure appropriate monitoring. Appropriate delegation and the utilisation of all members of the veterinary healthcare team is needed to provide feeding advice and pet owner support in executing nutritional recommendations.