Reflections on nutritional assessment: The Veterinary Nurse workshop 2014
Rachel H Lumbis
Saturday, March 1, 2014
Making nutritional recommendationsFollowing small group introductions (Figure 1), the workshop began with a review of nutritional assessment and discussion surrounding the importance of nutrition and deleterious effects of malnutrition. Appropriate food choices and feeding practices positively affect recovery and hospital outcome (Mohr et al, 2003; Brunetto et al, 2010; Liu et al, 2012) and are proven to extend life expectancy in dogs (Kealy et al, 2002). Nutritional assessment and intervention should therefore be considered an essential part of patient care and not simply an afterthought. Delegates were encouraged to reflect on their experiences of providing a nutritional recommendation and review the techniques that facilitated or impeded understanding and interpretation by pet owners. Reference to findings of the AAHA (2003) Compliance Study provided a valuable reminder that, while 90% of pet owners would like to receive a nutritional recommendation, only 15% perceive actually receiving one. Furthermore, despite recognition of clinical nutrition as a foundation of treatment, only 7% of pets that would benefit from a therapeutic diet reportedly received one. Such findings highlighted the importance of clear communication and steered the debate to consider the ways to increase client compliance following a nutritional recommendation (Figure 2).Figure 1.The workshop began with an introduction to nutrition and each other!Figure 2.The small group format of the workshop facilitated in-depth reflection and discussions of nutritional practice amongst delegates.
Nutrition is fundamental to wellbeing, longevity and disease prevention and is one of the most important considerations in the maintenance of health. Veterinary nurses play an instrumental role in both educating pet owners about nutrition as well as implementing the majority of nutritional support therapies to hospitalised animals. As a RVN with a specialist interest in small animal nutrition, combined with my role as a member of the WSAVA Global Nutrition Committee, it was with delight that I accepted the invitation from the Mark Allen Group to deliver this workshop, kindly sponsored by Royal Canin. Amongst many objectives, one of the key aims of the seminar was to highlight the importance of nutritional assessment and the recognition of nutrition as the fifth vital sign. It also offered a valuable opportunity to raise awareness of the current issues surrounding nutrition of healthy and clinical affected companion animals.
Marianne Lomberg, Veterinary Marketing Manager for Royal Canin, provided an introduction to the event and gave a stark reminder of the critical role of nutrition, both in optimising the health and wellbeing of companion animals and also in the management of disease, particularly in light of the current obesity epidemic.
Making nutritional recommendations
Following small group introductions (Figure 1), the workshop began with a review of nutritional assessment and discussion surrounding the importance of nutrition and deleterious effects of malnutrition. Appropriate food choices and feeding practices positively affect recovery and hospital outcome (Mohr et al, 2003; Brunetto et al, 2010; Liu et al, 2012) and are proven to extend life expectancy in dogs (Kealy et al, 2002). Nutritional assessment and intervention should therefore be considered an essential part of patient care and not simply an afterthought. Delegates were encouraged to reflect on their experiences of providing a nutritional recommendation and review the techniques that facilitated or impeded understanding and interpretation by pet owners. Reference to findings of the AAHA (2003) Compliance Study provided a valuable reminder that, while 90% of pet owners would like to receive a nutritional recommendation, only 15% perceive actually receiving one. Furthermore, despite recognition of clinical nutrition as a foundation of treatment, only 7% of pets that would benefit from a therapeutic diet reportedly received one. Such findings highlighted the importance of clear communication and steered the debate to consider the ways to increase client compliance following a nutritional recommendation (Figure 2).
WSAVA Nutritional Assessment Guidelines
The positive impact of proper nutrition on health and disease is well established in all animals. Following on from creation of the AAHA Nutritional Assessment Guidelines in 2010 (Baldwin et al., 2010), the WSAVA V5 committee (now known as the Global Nutrition Committee (GNC)) established a global initiative to recognise nutrition as the fifth vital sign (after temperature, pulse, respiration and pain). The WSAVA Global Nutrition Guidelines, first published in 2011 (Freeman et al, 2011), have been designed to help the veterinary healthcare team and pet owners ensure that dogs and cats receive optimal nutrition, tailored to their needs. These have since been published worldwide and translated into ten different languages. Use of the guidelines for dogs and cats provides a framework for veterinary staff, to assist them in making a nutritional assessment and specific nutritional recommendations for every patient on every visit.
In recognition of the need for clinical governance, evidence-based and reflective practice, together with the production and validation of contemporary and objective methods of assessing body condition, the WSAVA guidelines have become the accepted standardisation of nutritional assessment in small animals. Following development of the guidelines, the GNC developed a variety of nutrition tools to help facilitate nutritional assessment and efficient nutritional recommendations by the veterinary healthcare team. In addition, a range of educational materials for pet owners has also been created, providing guidance on topics such as selecting a pet food and identifying accurate nutrition-related information on the internet. One of the WSAVA tools, a short video, was played to demonstrate how to perform a body condition score; this together with the rest of the toolkit can be accessed at http://www.wsava.org/nutrition-toolkit. Delegates took the opportunity to reflect on their experience of using other methods of nutritional assessment and tools such as Royal Canin's new body condition scoring system (Figure 3).
Formulating a nutritional plan
Following a practical application of the guidelines, an overview of how to develop a nutritional plan for hospitalised animals was provided against a current evidence base. Calculation of daily energy requirements was demonstrated for sick and healthy dogs and cats using the formulae for resting energy requirement (RER) and maintenance energy requirement (MER). Traditionally, there was a practice involving multiplying the RER by an illness factor of between 1.0 and 2.0 to account for increases in metabolism associated with different conditions and injuries. The subjective nature of such factors, combined with their potential for overfeeding has led to the discontinuation of this practice. Current recommendations for hospitalised dogs and cats involve use of the RER as a baseline, modifying food intake according to changes in bodyweight and body condition score (Hand et al, 2010). In addition to considering the patient's clinical status and primary disease process, another important part of formulating individual nutritional goals involves communicating with the owners and ascertaining the patient's normal dietary habits at home.
Following the formulation of a feeding plan, it is essential to ensure that this prescribed nutrition is actually delivered. A study by Remillard et al (2001) to estimate the number of canine patients receiving their daily RER revealed poor feeding practice with delivery of over 95% of RER achieved for only 27% of the 821 day study period. Reasons attributed to this disparity included poorly written feeding instructions (22%), orders to have food withheld (34%) and patient refusal to eat (44%). A later study investigating the percentage of prescribed enteral nutrition delivered to hospitalised small animal patients, found that the amount of food delivered over 24 hours constituted a median percentage of 90% of the patient's daily kilocalorie requirement (Michel and Higgins, 2006). In contrast, nausea or vomiting and conflict with other treatments were the most common recorded reasons for incomplete feeds. Such results highlight the importance of patient planning, inter-professional collaboration between personnel and provision of explicit instruction. Against these, delegates were encouraged to reflect on, and share, their own experience of the delivery of prescribed nutrition before learning the reported factors that contribute to the successful delivery of prescribed enteral nutrition and recommendations.
Practical considerations when feeding
Encouraging animals to consume their daily energy requirement while in a diseased, and/or stressed, state can be particularly challenging. While there are a number of feeding strategies, the choice over which one to use should be based on its ability to meet the feeding goals of the patient in light of its condition and nutritional status. Reflection on the varying methods of assisted feeding and practical considerations to be taken into account when attempting to feed an anorexic or hyporexic animal ensued. These included variety, elimination of barriers (both physical and those less perceptible), environment, palatability and choice of food server as well as different enteral feeding methods. The opportunity to examine and compare the use of different feeding tubes prompted much debate (Figure 4). Regardless of the method of feeding, it is essential to accurately quantify and record a patient's food intake; a feeding chart, available as part of the WSAVA GNC toolkit, was presented as an example of a resource, freely available online, to help facilitate this process in the clinical setting.
Factors affecting the decision-making process in identifying the most appropriate method of feeding for a clinical scenario were explored, together with the identification, management and prevention of potential complications. Delegates also considered how they would manage and communicate with pet owners in a range of clinical situations, such as achieving weight loss in overweight pets and the feeding of unconventional diets, including Biologically Appropriate Raw Food (BARF) and home cooked meals. When monitoring and evaluating different nutritional interventions, it is important for veterinary nurses to adopt a uniform and cyclical approach, as promoted in the WSAVA nutritional assessment guidelines. Such a procedure enables continued assessment and evaluation of the patient's nutritional needs in addition to identifying dietary objectives based on individual requirements and should be completed as part of a holistic approach to patient care and treatment.
Exploring the way forward…
The workshop concluded by revisiting a key role of the RVN in instigating, monitoring and evaluating nutritional intervention and highlighting the importance of considering patients' nutritional requirements and feeding goals, anticipating individual needs and implementing support ASAP. Incorporating nutritional assessment and recommendations as the fifth vital sign in the standard physical examination requires little to no additional time or cost and can facilitate a partnership between the owner and veterinary practice, resulting in healthier pets. Access and utilisation of the WSAVA nutritional assessment guidelines and toolkit is anticipated to help assist in this process, for every patient on every visit.
Thank you to the Mark Allen Group, Royal Canin and all the delegates who attended this workshop for making it such an enjoyable day.