JAAHA7232_proof.pdf

2021 AAHA Nutrition and Weight Management

Guidelines for Dogs and Cats



Martha G. Cline, DVM, DACVN

†

, Kara M. Burns, MS, MEd, LVT, VTS (Nutrition), Jason B. Coe, DVM, PhD,

Robin Downing, DVM, MS (Bioethics), DAAPM, DACVSMR, CVPP, CCRP, Tiffany Durzi, DVM, CVA, CCRT, CVPP

Maryanne Murphy, DVM, PhD, DACVN, Valerie Parker, DVM, DACVIM, DACVN

ABSTRACT

The guidelines discuss the components of a systematic approach to nutritional management of dogs and cats. A nutri-

tional assessment, including a body condition score and muscle condition score, is a screening evaluation that should

ideally be performed at every examination. Individualized nutritional recommendations, based on the nutritional assess-

ment, should be designed to achieve and maintain an appropriate body weight and meet nutritional requirements. Com-

municating nutritional recommendations to clients is a challenging aspect of nutritional management because pet

owners may interpret the practice team’s guidance as advocacy for a particular pet food brand or a judgment of the cli-

ent’s ability to properly care for the pet or of the owner’s own nutritional status. The guidelines discuss approaches for

effective, nonjudgmental communication of dietary recommendations to clients and strategies to increase acceptance of

and adherence to veterinary nutrition recommendations. Other pet nutrition topics of current interest include recommen-

dations for particular pet life stages, breeds, and disease conditions; risk factors for nutritional deﬁciencies and obesity;

and considerations for home-prepared diets. (J Am Anim Hosp Assoc 2021; 57:153–174. DOI 10.5326/JAAHA-MS-7232)

AFFILIATIONS

From Red Bank Veterinary Hospital, Tinton Falls, New Jersey (M.G.C.);

Academy of Veter inary Nutrition Technicians, Lafayette, Indiana (K.M.B.);

Department of Population Medicine (J.B.C.) and Hill’s Pet Nutrition Primary

Healthcare Centre (T.D.), Ontario Veterinary College, University of Guelph,

Guelph, Ontario, Canada; The Downing Center for Animal Pain Management,

LLC, Windsor, Color ado (R.D.); Depa rtment of Small An imal Clinica l Sciences,

University of Tennessee College of Veterinary Medicine, Knoxville, Tennessee

(M.M.); and Department of Veterinary Clinical Sciences, The Ohio State

University, Columbus, Ohio (V.P.).

CONTRIBUTING REVIEWERS

Angela Rollins, DVM, PhD, DACVN, Small Animal Clinical Sciences,

University of Tennessee College of Veterinary Medicine, Knoxville,

Tennessee

Megan Shepherd, DVM, PhD, DACVN, Virginia-Maryland College of

Veterinary Medicine, Blacksburg, Virginia

Correspondence: [email protected]

† M. Cline is the chair of the AAHA Nutrition and Weight Management

Guidelines Task Force.

§ T. Durzi is the representative for the Primary Care Veterinary Educators.

These guidelines were prepared by a Task Force of experts convened

by the American Animal Hospital Association (AAHA) and were

subjected to a formal peer-review process. This document is intended

as a guideline only, not an AAHA standard of care. These guidelines

and recommendations should not be construed as dictating an

exclusive protocol, course of treatment, or procedure. Variations in

practice may be warranted based on the needs of the individual

patient, resources, and limitations unique to each individual practice

setting. Evidence-based support for speciﬁc recommendations has

been cited whenever possible and appropriate.

Other recommendations are based on practical clinical experience and a

consensus of expert opinion. Further research is needed to document

some of these recommendations. Because each case is different,

veterinarians must base their decisions on the best available scientiﬁc

evidence in conjunction with their own knowledge and experience.



These guidelines are supported by generous educational grants

from Hill’s Pet Nutrition, Inc., Purina Pro Plan Veterinary Diets, and

Royal Canin. They were subjected to a formal peer-review process.

AAFCO (Association of American Feed Control Ofﬁcials); ACVN

(American College of Veterinary Nutrition); BCS (body condition score);

BF% (body fat percentage); BW (body weight); CKD (chronic kidney

disease); DCM (dilated cardiomyopathy); DEXA (dual-energy X-ray

absorptiometry ); DHF (diet history form); HPP (high-pressure processing);

MER (maintenance energy requirement); MCS (muscle condition score);

RER (resting energy requirement); WSAVA (World Small Animal

Veterinary Association); USDA (United States Department of Agriculture)

The AAHA website (aaha.org/nutrition) contains supporting information

and resources for practice teams.

VETERINARY PRACTICE GUIDELINES

Introduction

Nutritional management is a central component of a complete

healthcare plan for canine and feline patients and is integral to a

pet’s longevity and quality of life. The positive impact of proper

nutrition on health and morbidities such as chronic kidney disease

(CKD), diabetes mellitus, and osteoarthritis is well accepted. Thus, a

nutritional assessment of canine and feline patients should be per-

formed on a regular basis throughout all pet life stages, ideally at

each exam visit. With that goal in mind, the objectives of these

guidelines are to:

 Describe how to perform an individualized, breed-speciﬁc, evidence-

guided nutritional assessment for canine and feline patients.

 Provide recommendations for diagnosis, treatment, and manage-

ment of under- or overweight pets.

 Provide a comprehensive list of nutrients of concern for speciﬁc

health conditions.

 Offer suggestions on how to effectively communicate and educate

owners about nutritional recommendations, including for weight

control.

 Provide strategies to increase adherence to pet nutrition

recommendations.

 Address several nutrition-related topics of current interest, including

raw and home-prepared diets, breed-speciﬁc nutrition, and diet-

associated dilated cardiomyopathy in dogs.

This report updates and complements previously published but

still relevant nutrition-related guidelines produced by the American

Animal Hospital Association. These include the 2010 AAHA Nutri-

tional Assessment Guidelines for Dogs and Cats and the 2014 AAHA

Weight Management Guidelines for Dogs and Cats.

1,2

These prior

guidelines address two essential components of nutritional manage-

ment: assessment and weight control. The 2021 AAHA Nutrition

and Weight Management Guidelines for Dogs and Cats include other

important topics necessary for a truly comprehensive approach to

dietary management in primary-care companion-animal practice.

These include step-by-step methods for performing a complete

nutritional assessment and preparing an individualized nutritional

plan as well as communication tips that promote optimal adherence

to the dietary recommendations.

Practitioners have minimal or no control over certain aspects of

pet health such as the patient’s genetics and home environment.

Nutrition, on the other hand, can be substantially inﬂuenced by the

veterinarian’s medical expertise and recommendations. Achieving

this positive effect requires a partners hip between the veterinarian,

the practice team, and the pet-owner client. More so than many

other pet healthcare topics, discussing nutrition with clients can

include sensitive topics such as obesity, pet food choice, feeding hab-

its, and food rewards. For that reason, these guidelines include a

detailed discussion on communicating dietary recommendations to

clients in a trust-based, nondefensive manner.

Practice guidelines are consensus statements developed by

experts with decades of clinical experience, both evidence guided and

anecdotal. These guidelines support the veterinary medical profes-

sion’s bioethical obligation to its patients and their owners by giving

clinicians the practical means to advocate for pets who cannot repre-

sent themselves. Guidelines such as those contained in this report

enhance veterinarians’ expertise, which they can leverage on behalf

of their patients, thus honoring the principles of clinical bioethics

that are the basis of their client-patient relationships.

It is worth noting that individualized nutritional assessments

and dietary management require no specialized equipment and can

be implemented with little additional time expenditure or cost. Using

the approach described in these guidelines, practitioner s and their

healthcare teams can ensure that nutrition becomes a foundation of

good health for their canine and feline patients.

How to Perform a Complete

Nutritional Assessment

The ﬁve vital assessments of a standard physical exam for small animals

include temperature, pulse, respiration, pain, and nutritional assess-

ment.

TheWorldSmallAnimalVeterinaryAssociation(WSAVA)

recommends nutrition as the ﬁfth vital assessment to optimize the

health and wellbeing of pets. The AAHA Advisory Panel endorses this

recommendation.

The nutritional assessment is an iterative process that requires

repeated assessment over the animal’s lifetime. The factors evaluated

included animal- and diet-speciﬁc factors and feeding management

(Figure 1). Animal-speciﬁc factors refer to the age, physiological

status, and activity of the pet. Diet-speciﬁcfactorsinclude the safety

and appropriateness of the diet for the speciﬁcpatient.Feeding

management encompasses not only the frequency, timing, location,

and method of feeding but also the pet’s environment and human-

related factors. Speciﬁc problems related to each factor should be

identiﬁedandaddressedindividually(Table 1).

Screening Evaluation

There are two overarching components to a complete nutritional

assessment: a screening evaluation and an extended evaluation, if

needed. A nutritional assessment starts with a screening evaluation

followed by an extended evaluation if nutritional risk factors are

identiﬁed (Figure 2). A screening evaluation should be performed

on every pet at every visit. The elements of a screening nutritional

assessment are not time consuming and are performed as part of a

routine history and physical exam. The screening should include an

evaluation of nutritional history, environment, activity level, body

weight (BW), body condition score (BCS), and muscle condition

154 JAAHA | 57:3 May/Jun 2021

score (MCS), followed by a complete physical exam. If nutritional

risk factors are identiﬁed,anextendedevaluationisrecommended.

A nutritional history should include not only main meal items

but also treats, tabl e food, supp lemen ts, and fo ods used for

medication administration. The American College of Veterinary

Nutrition (ACVN) and the WSAVA publish sample diet history

forms (DHFs).

4,5

Longer exam ples are also available.

To improve

nutritional history accuracy, owners can be asked to complete the

DHF at home. Practice team members can then verify DHF informa-

tion that is incomplete or inaccurate.

BCS is a physical assessment of body fat mass (Table 2).

7,8

The

9-point BCS scale is validated to correlate with body fat percentage

(BF%) using dual-energy X-ray absorptiometry (DEXA).

9,10

Every

incremental increase in BCS is equivalent to a 5% increase in BF%

while each BCS $5/9 is equivalent to being 10% overweight (Table

2).

9–11

The authors suggest universal use of the 9-point (1–9) BCS

scale with whole integers for the standardization of medical records,

consistency of data collection and interpretation for research, and for

consistent communication from veterinary team members to pet

owners.

MCS is a physical assessment of the patient’smusclemass,

which includes visualization and palpation of the musculature over

the spine, scapulae, skull, and pelvis (Figure 4).

12,13

The authors sug-

gest a narrative description of MCS that includes normal muscle

mass or mild, moderate, or severe muscle loss. The MCS has been

signiﬁcantly correlated with ultrasonographic measurements of the

epaxial musculature (cats and dogs) and DEXA (cats).

14–16

The rou-

tine use of MCS is important to identify patients with muscle loss

related to cachexia and sarcopenia (see terminology deﬁnitions in

Table 3). Both cachexia and sarcopenia can adversely affect out-

comes in veterinary patients.

BCS and MCS are not causally related

andshouldbeassessedseparately(e.g.,ananimalmaybeoverweight

FIGURE 1

The Circle of Nutrition. Consider these interconnected variables

during nutritional assessment. Factors speciﬁc to the animal, the

diet, and feeding management/environment should be assessed.

(Reprinted with permission from the American College of Veteri-

nary Nutrition.)

TABLE 1

Problems and Management for Animal-Speciﬁc, Diet-Speciﬁc, and Feeding Management Factors

2021 AAHA Nutrition and Weight Management Guidelines

JAAHA.ORG 155

with muscle loss). Underweight patients often have loss of both body

fat and muscle mass, yet BCS and MCS should still be scored

separately.

Although typically not included in the screening evaluation,

additional tools to be considered are the body fat index (BFI) and

girth assessments. BFI, like BCS, is a validated scale to correlate with

BF% in both the dog and cat.

18,19

A BCS is limited in its assessment

of patients with a high BF% (.45%). The BFI system is a useful tool

in differentiating patients with a higher level of BF%. Morphometric

measurements to assess lean body mass and fat mass have been

established in the dog and cat. These measurements in addition to

BFI are useful for patients with a BCS $ 8/9.

Limb girth assessments, an objective measure of muscle mass

and strength, are an emerging area of investigation and may prove to

be valuable in speciﬁc patient populations or for speciﬁcpatients.

For example, this could be a tool for an orthopedic patient enrolled

in a physical rehabilitation program.

A fecal score can be included in the screening assessment as a

useful tool to assess stool quality and characteristics. Various fecal

scoring systems have been proposed for veteri nary patients.

20,21

fecal scoring system used repeatedly in a practice can be useful for

consistent communication between the client and veterin ary team

members and to follow trends in fecal quality.

Screening Assessment for Hospitalized Patients

A nutritional assessment should be performed on admission and at

least daily for hospitalized patients. Historical information should

establish the patient’s food preferences, unexplained weight change,

and recent appetite changes including anorexia, hyporexia, and dys-

rexia (see terminology deﬁnitions in Table 3). The physical exam

should include an assessment of mentation, an examination for the

presence of ascites or edema, and an assessment of available diag-

nostics. BW needs to be checked at least daily to assess the hydra-

tion status of the patient. Speciﬁc feeding orders including

FIGURE 2

Nutritional assessment screening evaluation.

156 JAAHA | 57:3 May/Jun 2021

calculation of resting energy requirement, speciﬁcfood(s)tobe

offered, feeding amount (based on a percentage of resting energy

requirement [RER]), and frequency offered should be written and

assessed daily.

Nutritional Risk Factors

The goal of the s creening evaluation is to identify any nutritional

risk factors from the patient’s life stage, medical/dietary history, or

physical exam (Table 4). Once a nutritional risk factor(s) is identi-

ﬁed, an extended nutritional assessment is recommended. Vulnerable

life stages such as growth, gestation, lactation, and advancing age

alter the patient’s energy and nutrient requirements. Previous or

chronic medical conditions may have key nutritional factors to

address when making new recommendations. Owners may use foods

to administer medications or supplements, and dietary supplements

may be a signiﬁcant source of calories. Noncomplete or unbalanced

food calories at .10% of a patient’s daily caloric intake dilute essen-

tial nutrients and provide excess calories. Unconventional diets

should be assessed for nutritional adequacy and safety. Inadequate or

inappropriate housing can contribute to stress or barriers that may

cause changes in food intake.

ABCS,4/9 or .5/9, MCS with any degree of loss, and unex-

plained weight change from the pet’s previous assessment should

prompt an extended assessment. Dental abnormalities or disease

may impact food intake, leading to anorexia, hyporexia, or dysrexia.

Poor skin or hair coat quality may indicate nutrition-related abnor-

malities. New medical conditions or diseases may beneﬁt from spe-

ciﬁc nutritional interventions (Table 8).

Extended Evaluation

An extended nutritional assessment is an opportunity to g ather a

more comprehensive nutritional history and pursue clinical diagnos-

tics (Table 5). The speciﬁcs of an extended assessment will depend

on abnormal physical exam ﬁndings, the information obtained

through the screening nutritional history, and identiﬁcation of spe-

ciﬁc nutritional risk factors. The development of nutritional recom-

mendations provides an opportunity for the skills of the entire

veterinary team to be utilized.

How to Create Individualized Nutritional

Recommendations

Feeding Plans for Healthy, Appropriate-Weight Cats

and Dogs

For apparently healthy patients maintaining ideal weight, major diet

adjustments are likely not required unless a nutritional risk factor is

identiﬁed. When making new feeding recommendations, the follow-

ing factors should be considered:

 Give speciﬁc feeding plans, including the new diet, feeding amount,

feeding frequency, recommended daily treat-snack-table food-medi-

cation food allowance, and supplement adjustments.

 Diet adjustments over a 4- to 7-day period may reduce the occur-

rence of negative gastrointestinal responses.

FIGURE 3

Components of a comprehensive nutrition history.

TABLE 2

Summary of BCS Scales and Their Relationship with BF and BW

2021 AAHA Nutrition and Weight Management Guidelines

JAAHA.ORG 157

 Even with no physically apparent dietary issues, this is the opportu-

nity to help the owner lay a better nutritional foundation for later in

life. Teach owners how to assess BCS and MCS so they can recog-

nize an undesirable change and adjust intake as needed. Owner

assessment of these parameters should be veriﬁed by a member of

the veterinary team.

 Discuss feeding management and other environmental factors (e.g.,

free-choice feeding, food competition/social hierarchy, outdoor

access leading to additional calories from predation, feces, etc.) that

may negatively inﬂuence their ability to adhere to the feeding plan.

 Food-dispensing toys or automated feeders are useful to control

food access and amount. Feeding toys may positively affect activity

level in dogs, although the beneﬁt in cats is more related to enrich-

ment and behavior modiﬁcation.

22–25

When a cat or dog is healthy and maintains an appropriate

weight, ensure the pet is being fed a complete and balanced diet in a

suitable amount to avoid future unintended consequences. Although

maintenance of ideal BW and BCS is the indicator for how well cur-

rent intake meets energy needs, these parameters do not address the

distribution of calories from unbalanced food items. The Association

of American Feed Control Ofﬁcials (AAFCO) nutritional adequacy

statement indicates whether a commercial diet contains all the

required nutrients in the correct ratios (i.e., “complete and bal-

anced”) for long-term feeding to the speciﬁed life stage. Some foods,

including many therapeutic diets, have an “intermittent or sup-

plemental” use label indicating they do not meet the requirements of

being “complete and balanced” or that the diet has a special nutri-

tional or dietary purpose. Treats, snacks, and supplements do not

require a nu tritional adequacy statement.

If product packaging is

FIGURE 4

A general framework for communicating a nutrition-related healthcare recommendation.

TABLE 3

Clinically Relevant Nutrition Terms

158 JAAHA | 57:3 May/Jun 2021

not available, the company’s customer service line or website may

provide the information.

Assessing the overall quality of a commercial diet is challenging.

Speciﬁc questions to consider asking pet food companies and their

responses to a few of these questions have been published.

27,28

The

FDA also publishe s searchable recall and withdrawal information,

based on brand and reason for recall.

To determine if caloric intake is suitable, calculate RER and

maintenance energy requirement (MER) based on the pet’s activity

and life stage factor guidelines (Box 1).

1. Calculate current caloric intake from all food items. AAFCO

requires calorie content on dog and cat food labels, including snacks

and treats; however, this does not include chews, bones, or toys.

The

United States Department of Agriculture (USDA) FoodData Central

system provides caloric content of whole foods.

The caloric content

of supplements may be listed on the label or obtained by contacting

the manufacturer.

2. Compare MER with total caloric intake. Ensure the calories consumed

are within a reasonable level of agreement to MER and that the main

source of complete and balanced nutrition represents $90% of total

intake whereas treats and other food items make up #10%.

3. If there is a signiﬁcant difference between calculated MER and

reported intake level, review calorie intake, life stage, activity level,

and MER/RER calculation accuracy.

TABLE 4

Nutritional Screening: Risk Factors as Determined by Life Stage,

Medical/Dietary History, or Physical Exam

TABLE 5

Examples of Clinical Diagnostics for an Extended Nutritional

Assessment

2021 AAHA Nutrition and Weight Management Guidelines

JAAHA.ORG 159

4. Consider an extended nutritional assessment, especially in over-

weight or underweight pets.(see preceding section on How to Per-

form a Nutritional Assessment).

Commercial pet foods are required to contain feeding recom-

mendations. In an ideal world, the pet owner will perform RER/

MER calculations rather than relying solely on package guidelines

because AAFCO does not standardize this process. However, many

owners will feed a commercial pet food according to the label direc-

tions. In such cases, it is important for the practice team to assess the

dog’sorcat’s bodyweight, BCS, and MCS on a regular basis to ensure

that the patient is receiving optimal calories and protein.

Feeding Plans for Hospitalized Patients

For hospitalized patients, base feeding calculations on current weight

if ideal or underweight or on ideal BW if overweight or obese in

order to provide energy to current lean mass. Support anorexic or

hyporexic patients by speciﬁc feeding techniques (e.g., various forms

of food, heating meals, remove E-col lars, separate food from litter

boxes and pee pads). For animals in whom there are no contraindi-

cations, high-fat diets tend to have an increased caloric density, mini-

mizing the total food consumption volume needed to meet energy

requirements. Consider medication support, including appetite stimu-

lants, antiemetics, and prokinetics. If feeding techniques and medica-

tions do not improve total voluntary intake, assisted feeding via

enteral tubes (e.g., nasal, esophageal, gastric) is strongly recom-

mended within 72 hr of consumption of #1/3 RER including the

time before hospitalization. Because of the risk of food aversion and

aspiration, oral syringe feeding is no longer recommended. Feeding

protocols should promote the delivery of enteral nutrition over

parenteral nutrition when assisted nutrition support is needed. Paren-

teral nutrition is reserved for select cases, generally in referral facilities

with 24-hr care.

Prevention of Obesity

Prevention of overweight and obesity aid the patient’soverallquality

of life and may contribute to a lengthened life span.

32–35

It is easier

to prevent weight gain than it is to treat obesity, adding to the advan-

tages of prevention.

36,37

Obesity dis cussions can be challenging, as

there may be a perception that recommendations are a judgment of

the owner’s ability to properly care for their pet or a judgment of the

owner’s own body composition. It is best to enter these conversa-

tions with compassion and sensitivity, while also remaining a stead-

fast advocate for the pet’s wellbeing (see section on Communicating

with Clients).

BOX 1

Energy Requirement Calculations.

160 JAAHA | 57:3 May/Jun 2021

Obesity comorbidities include osteoarthritis and endocrine dis-

eases (e.g., hypothyroidism, diabetes mellitus, hyperadrenocorti-

cism).

38–41

In some cases (e.g., feline diabetes mellitus), preventing obe-

sity may help reduce the risk of developing the comorbidity, whereas

in others (e.g., hypothyroidism), the underlying condition will continue

to predispose to obesity development unless adequately managed.

In order to successfully prevent obesity, an approach including

risk factor assessment and mitigation is recommended. Obesity risk fac-

tors stem from both human-related and animal-related roots (Table 6).

A main human factor is the ability to overfeed the primary diet, and

owners ﬁnd it difﬁcult to make subsequent adjustments. Animals may

also overeat if they have access to another pet’s food bowl. Compare

reported intake against calculated requirements based on ideal BW and

make downward recommendations accordingly. Reassess and adjust

recommendations as needed at each subsequent visit.

Owners also have the ability to overfeed food items that are not

the primary diet and overestimate their pet’s activity level.

Advise

owners to maintain all additional item intake to #10% total daily

caloric intake to avoid disrupting nutrient balance of the primary

diet. To increase exercise in cats, consider the use of feather toys, cat

trees, exercise wheels, or similar devices. Fitness trackers may

increase owner motivation to increase their dog’s physical activity.

Animal factors must also be considered to effectively prevent

obesity (Table 6). Energy requirements are reduced after spaying or

neutering, necessitating intake reduction.

44–46

Certain breeds (e.g.,

Labrador retrievers, beagles, Norwegian forest cats, Persians) are pre-

disposed to weight gain and the owner should be educated regarding

obesity risk, even if their pet currently has an ideal BCS.

47,48

Increase in BW through middle age contributes to the preva-

lence of obesity.

47–49

Energy requirements are thought to decrease

through middle age in the dog, which contributes to this weight

gain,

50,51

although results are not consistent.

Metabolic rates in the

dog can also be inﬂuenced by breed and their respective life expec-

tancy.

During senior and geriatric life stages, loss of lean body

mass and overall weight loss can occur.

In cats, fat, protein, and

energy digestibility can decrease with advanced aging.

54,55

Energy

intake can be higher for senior cats to compensate for this decrease

in digestibility.

An important aspect of obesity prevention and

maintenance of ideal BCS and MCS is incorporating the entire prac-

tice team in client education. Appropriate training is essential to

ensure that the team speaks with a common voice (see section on

Leveraging the Value of Proper Nutrition in Your Practice).

Weight Reduction in the Obese Pet

In 2014, AAHA published comprehensive weight management

guidelines, including a detailed protocol for safe weight reduction.

Because weight loss is a critical aspect of nutritional management for

many pets, the 2021 Nutrition and Weight Management Guidelines

include an abbreviated overview of this topic. We encourage readers

to consult the 2014 Weight Management Guidelines for more com-

plete information on this essential aspect of nutritional management.

Once an animal has gained excess we ight, the veterinary team

must appropriately inform the owner, gauge their willingness to insti-

tute a weight loss program, and offer guidance and support for the

duration of the program. The overall design process is reviewed in the

2014 Weight Management Guidelines. Traditional methods to calcu-

late caloric needs are included. Recent data suggest mean caloric intake

for weight loss over a 12 wk period is 63 6 10.2 kcal/kg

0.75

in dogs

and 52 6 4.9 kcal/kg

0.711

in cats.

57,58

Thesameprinciplesregarding

feeding plans for healthy, appropriate-weight cats and dogs apply for

weight loss plans. The major difference is adjusting MER calculations

to account for necessary reduced calorie intake to induce weight loss

(Box 1). Base these calculations on ideal weight and adjust as needed

for the individual patient, based on current intake and lifestyle needs.

Although the correct calculations are necessary for a successful

weight management program, feeding management and activity plans

are essential parts of the package. Puzzle toys and automated feeders

continue to be invaluable resources that may be especially useful to

achieve successful weight loss via improved ease of plan implementation

by owners.

59,60

Consider collaborating with or referring to a veterinary

rehabilitation practitioner (Table 7) to design a comprehensive exercise

plan to address desired weight loss while maintaining muscle mass

basedonthepet’s current level of physical ﬁtness. Use the 2014 Weight

Management Guidelines for things to consider with an activity plan.

Long-term monitoring and maintenance are often the most difﬁ-

cult aspects of a weight loss program. Failure to achieve and maintain

weight loss is common, and owner nonadherence is a major fac-

tor.

61–63

After starting a weight loss program, reach out to the owner

within the ﬁrst couple days to determine if there are any immediate

concerns. This can be done via phone or email and may help main-

tain owner adherence and reduce the risk of subsequent dropout.

Because owners often have a strong human-animal bond with their

pets, these ﬁrst few days may pose the largest obstacle as the owner

reconciles a “new normal” that does not involve a constant show of

love and affection via provision of food items. Weight management

plansshouldaddressincreasingnon–food-related interactions (e. g.,

walks, playtime, brushing). Postappointment contact can be used to

reinforce these recommendations with owners who are struggling

with their commitment to the feeding restriction aspect of the plan.

The 2014 Weight Management Guidelines outline monitoring and

maintenance options.

Thegoalistobeanadvocateforboththepet

and the owner, while maintaining a nonjudgmental style of commu-

nication (see section on Communicating with Clients).

2021 AAHA Nutrition and Weight Management Guidelines

JAAHA.ORG 161

TABLE 6

Obesity Risk Factors

75-77

44-46

79,80

47,48

54,55

47,48,82

162 JAAHA | 57:3 May/Jun 2021

Use of Therapeutic Diets Designed to Promote

Weight Loss

Therapeutic weight loss diets are recommended for patients undergoing

signiﬁc ant calorie restriction (less than or equal to RER) for weight loss.

Thesedietsarefortiﬁed in nutrients to avoid potential nutrient deﬁ-

ciencies associated with caloric restriction. High-protein diets can spare

lean mass with calorie restriction during weight loss.

65,66

Protein and

added ﬁber can promote a satiety effect.

67,68

Added ﬁber to a therapeu-

tic diet will also reduce caloric density. High-moi sture diets for cats

may increase satiety and help promote weight loss.

Use of Therapeutic Diets Not Related to Weight Loss

When the nutritional assessment indicates a patient may beneﬁt

from consuming a purpose-formulated therapeutic diet, the clinician

needs to focus on speciﬁc nutrients of concern (Table 8). When a

patient has a single disease condition and no additional nuanced

feeding or diet requirements, it may be adequate to simply choose a

therapeutic diet designed for the disease. In diseases in which diag-

nostics and staging affect nutrients of concern (e.g., CKD) or when

patients have multiple disease conditions and/or additional feeding

or diet requirements, consider all nutrients of concern before select-

ing a diet. Otherwise, it is easy to overlook a nutrient of concern and

inhibit or negate the treatment plan for the patient’s condition. For

example, if a dog receiving a low-fat diet to manage chronic pancrea-

titis is diagnosed with CKD , a dietary change to address the CKD

may result in recurrent pancreatitis symptoms if both disease condi-

tions are not considered.

Communicating with Clients

Communicating about a dog’sorcat’s nutrition can be a complex

topic for veterinary personnel and pet owners to navigate. Nutrition

conversations start with the recognition that there are three aspects

of communication to be considered.

First is the content, the medi-

cal or scientiﬁc knowledge that informs a complete and balanced

nutrition recommendation, which is outlined in the majority of these

guidelines. Second is the process, the approach used to engage a cli-

ent in discussion about their dog’sorcat’s nutrition, which is pre-

sented throughout this section. Third is the perceptual aspect of

communication—how the client thinks and feels about pet nutri-

tion—which represents the assumptions, beliefs, goals, and thought

process a person brings to a nutrition conversation. Although we

often focus on the content of communication, it is the process and,

even more often, the perceptions of staff and clients that dictate

whether a nutrition conversation is successful.

What we bring to a nutrition conversation in terms of our own

ideas, knowledge, and prior experiences is a critical starting poi nt.

This involves recognizing and managing our own biases and percep-

tions associated with pet nutrition in order to enter the conversation

with an open mind. When a client’sbeliefs,goals,ideas,orpercep-

tions are not aligned with our viewpoint, the client is likely to reject

our viewpoint in favor of their own, regardless of the content we

communicate.

Nutrition conversations require a curiosity that

allows us to be attentive and responsive to understanding our client’s

TABLE 7

Additional Resources

2021 AAHA Nutrition and Weight Management Guidelines

JAAHA.ORG 163

TABLE 8

Nutrients of Concern for Diseases and Select Speciﬁc Conditions

Synergistic eects of nutrients when

combined.

Maintain optimal body and muscle

condition.

164 JAAHA | 57:3 May/Jun 2021

TABLE 8

Continued.

2021 AAHA Nutrition and Weight Management Guidelines

JAAHA.ORG 165

viewpoint. As a result, successfully communicating a nutrition rec-

ommendation to a client is heavily dependent upon understanding

the client’sperspective.Thisisgainedthroughconductingacompre-

hensive nutritional history (Figure 3).

Gathering a Comprehensive Nutrition History

The nutrition history is the foundation of a nutrition recommenda-

tion in which an intricate relationship exists between conducting a

nutrition history and making a relevant nutrition recommendation.

A comprehensive nutrition history requires exploring all animal-,

diet-, environment-, and human-related factors associated with a

dog’sorcat’s nutrition.

To gather a comprehensive nutrition history, whether using a

diet-history form or during an in-person interaction, veterinary profes-

sionals should begin with open-ended questions or statements that

allow clients to share information unhindered by the practice’sown

goals or agenda. For example, phrases starting with “Tell me …”,

“Describe …”,or“Walk me through …” allow clients to share infor-

mation that the veterinary professional may not have otherwise consid-

ered. Using open-ended inquiry during the initial screening evaluation

increases efﬁciency while also allowing for greater detection of nutri-

tional risk factors that can signal the need for an extended nutrition

evaluation. Veterinary personnel should move from these broad explor-

atory lines of open-ended inquiry to more focused lines of open-ended

inquiry before using closed-ended inquiry to gather speciﬁcdetails,that

is, questions often answered with one-word responses (Table 9).

When gathering information on diet-related factors, research sug-

gests that veterinary personnel should be cautious about starting with

simple what-prefaced questions (e.g., “What kind of food is your pet

on?”).

72,73

Although a what-prefacedquestioniscommonlyusedby

practice team members, when analyzing clients’ responses, the question

has been found to obtain limited diet information and to encourage

defensive responses from clients.

In addition, treats that a dog or cat

may consume have been identiﬁed as a speciﬁc component of the diet-

related history that clients are less likely to disclose,

72,73

warranting more

focused questioning or use of different wording (e.g., snacks, rewa rds,

extra foods) to avoid the threat directly associated with the word “treat.”

Communicating a Nutrition Recommendation to

the Client

A common obstacle that often undermines a veterinary professional’s

nutrition recommendation, when sufﬁcient nutrition history is not

gathered, is that the recommendation does not align with the client’s

own goals or beliefs. As part of the nutritiona l history, when asking

what the pet is being fed, we should also explore the client’srationale

for feeding a speciﬁc food or brand. Exploring the client’srationale

for feeding a speciﬁc food or brand gives the practice team an under-

standing of the pet owner’s dietary viewpoints and will help avoid

misunderstandings about the practice’s pet nutrition recommenda-

tions. In developing a nutrition recommendation, equal consideration

must be given to animal-, diet-, environment-, and human-related

factors. Similar to the nutritional assessment, developing a nutrition

recommendation is an iterative rather than linear process in which

returning to the nutrition history at any point may be required to

gather additional information to better align a nutrition recommen-

dation with the goals and beliefs of the client (Figure 4).

Another potential barrier to a veterinary professional’snutrition

recommendation is the client’s suspicion of veterinary practices being

businesses that make healthcare recommendations.

This skepticism

canbefueledwhenanutritionrecommendationinvolvesacommer-

cial pet food. In this case, it is important to recognize that there are

two decisions for clients and, therefore, two separate recommenda-

tions to be made. The ﬁrst recommendation is the nutrition-related

healthcare recommendation (a nutrition change to manage the health

of the animal preventively or to address a nutrition-related health

concern). The second recommendation, when required, is a product-

speciﬁc commercial diet to support th e nutrition-relat ed healthcare

decision. Separating these recommendations teases apart the question

of motivation (business versus healthcare) behind an overall nutrition

recommendation. Here is a step-by-step approach to making a nutri-

tion recommendation to a client:

1. Initiating a Nutrition-Related Healthcare Recommendation

The ﬁrst s tep to a nutrition-related healthcare recommendation is

initiating the conversation with the client. This should involve some

form of forewarning to gauge the client’s receptivity to the conversa-

tion. Asking permission is one way of respectfully assessing a client’s

response to a topic (e.g., “Alex, I would like to spend some time dis-

cussing Harley’s [diet, weight, snacks]. Would you be open to this?").

Often, clients accept the invitation and you can move directly into

the nutrition conversation. Other times, the client may show appre-

hension, providing an opportunity to open up the conversation to

develop a g reater understanding of your client’s apprehension. O n

occasion, a client will explicitly decline this request, and nothing is

lost because the client would likely not have been responsive to mov-

ing forward otherwise. By asking permission, you show respect, pro-

tect your relationship, and provide an opportunity to engage with

your client’s perspective, all of which contribute to greater trust

when pursuing a future conversation.

2. Explore with the Owner All Nutrition- and Non–Nutrition-

Related Options

Once a client is on board, you can explore all nutrition- and

non–nutrition-related healthcare options. Research indicates that

166 JAAHA | 57:3 May/Jun 2021

90% of pet owners want to be made aware of all healthcare options,

regardless of cost.

In contrast, a focus group study found that

many veterinarians identiﬁed with presenting clients with only the

option the veterinarian believed to be best.

88,89

Providing all the

healthcare options actively involves clients in the decision-making

process and acknowledges their autonomy. It also allows for develop-

ing greater alignment with the goals and expectations of the client.

As options are presented to a client, it is not uncommon to need to

return periodically to gathering more nutrition history to better align

your recommendation.

3. Educate the Client About the Benefits (and Risks) of Each

Nutrition Option

Critical to making any nutrition-related healthcare recommendation,

whetherpreventiveortoaddressaspeciﬁc disease, is educating the

client about the beneﬁts of each option (or lack thereof) to the health

and wellbeing of the pet (e.g., longer life, improved quality of life,

reduced onset of chronic disease, resolution or management of a spe-

ciﬁccondition).

Research suggests that veterinarians often focus on

features (e.g., a product, the time, or a service),

without explaining

whyanoptionmayormaynotprovidevaluetothedog’sorcat’s

overall health and wellbeing.

4. Make a Clear Nutrition-Related Recommendation

Research in veterinary medicine examining clients’ adherence to

healthcare recommendations found that clients who were provided

with a clear recommendation were seven times more likely to adhere

than clients receiving an ambiguous recommendation.

Once a cli-

ent is made aware of the available options and engaged in the

decision-making process, it is the veterinarian’sroletousetheir

knowledge to make a clear recommendation that takes into consider-

ation the nutritional assessment as well as the client’s goals.

5. Check in with the Client to Gain Feedback and Modify the

Recommendation

Following a recommendation, it is important to check in with the cli-

ent to see how the information was received before proceeding. This

approach allows the practice team member to return to gather more

nutrition history as needed or further tailor their recommendation to

better align with the goals of the client. Once the client has arrived at

a healthcare decision, if the decision requires a change of diet involv-

ing a commercial pet food, it is at this point the veterinary profes-

sional should move into a similar decision-making process regarding

a complete and balanced commercial pet food (i.e., gather informa-

tion, initiate the conversation, present options, discuss the value of

each option, make a clear recommendation, check in with the client).

TABLE 9

Examples of Open-Ended and Close-Ended Inquiry

2021 AAHA Nutrition and Weight Management Guidelines

JAAHA.ORG 167

6. Plan Appropriate Follow-Up with the Client Once a Dietary

Change Has Been Implemented

Plan for a member of the veterinary team to follow up with the

client within a couple of days after a change to a dog’sorcat’s

nutrition has been made. This is a great time to answer any addi-

tional questions, troubleshoot obstacles, or revisit the nutrition

recommendation.

Managing Challenging Nutrition Conversations

It is important to acknowledge the plethora of potentially sensitive

topics that exist in relation to pet nutrition. An observational study

analyzing veterinarians’ conversations with pet owners about pet

nutrition identiﬁed evidence (reﬂected in verbal and nonverbal cues)

that patient weight, the timing of transition from one life-stage diet

to another, treats, wet versus dry foods, quality of the main commer-

cial food, and use of human foods were subjects about which clients,

veterinarians, or both demonstrated sensitivity.

Other challenging

nutrition conversations veterinary professionals may encounter

include discussing a client’s unconventional food choices, preference

for or disapproval of certain ingredients (e.g., grain, by-products), or

use of various nutraceuticals or supplements. Navigating these con-

versations requires being attentive and responsive to clients’ verbal

and nonverbal cues that signal sensitivity to a line of discussion.

Many of these challenging conversation s are driven by a veterinar-

ian’s or the practice team’sbeliefs,goals,ideas,orperceptionsthatdo

not align with the client’s own viewpoints. In response to these chal-

lenges, it is important to be aware of our own ideas, beliefs, and

judgments. Acknowledging the client’sbeliefs,goals,ideas,orpercep-

tions, which does not mean agreeing with them, often provides an

opportunity to further explore and understand the client’sperspec-

tive. This understanding can be used to identify common ground,

which can be used to bring differences in perspective into greater

alignment.

Intrateam Nutrition Communication

Engaging clients in conversation about pet nutrition is a perfect

veterinary-team sport, in which information is passed from one team

member to another as the entire team moves toward a common

goal. All team members who interact with clients should be equipped

with the skills needed to perform a comprehensive nutrition history

and to engage clients in a conversation about their pet’s nutrition.

This offers the practice team the opportunity to gather nutrition

information and share this information with other members of the

veterinary team who are positio ned to d evelop a nutrit ion recom-

mendation. Involving your broader team in nutrition conversations

increases team engagement, boosts self-efﬁcacy, enhances efﬁciency,

and emphasizes to clients that the entire practice team is there and

available to support them.

How to Navigate the Emotional Connections

Between Pet Food Recommendations

and People

Aperson’s personal food choices are complex and inﬂuenced by

biological, economical, physical, social, psychological,

and environmen-

tal determinants.

Furthermore, attitudes, beliefs, and knowledge about

food also affect food choice. People may anthropomorphize their own

nutrition ideas to their pets.

Across a range of studies, common factors

that inﬂuence pet food purchasing decisions include the ingredients,

quality, cost, company reputation, veterinary recommendation, and ease

of purchasing.

94,96,97

Pet owners and members of the veterinary team

share a common interest in the health and therapeutic beneﬁts of nutri-

tion. It is advantageous for the veterinary team to understand a client’s

perspective before making nutritional recommendations.

Emotions such as hesitation, frustration, anxiety, and suspicion of

the pet owner may dominate conversations about pet nutrition. Social

media, marketing messag es, and pet food recalls may reinforc e these

emotions and support feelings of distrust. Clients may be suspicious

that nutrition recommendations by the veterinary team are primarily

inﬂuenced by ﬁnancial incentive rather than health beneﬁts for their

pet. Some clients may feel uncomfortable or intimidated discussing a

topic in which they perceive a conﬂict may exist, particularly with

unconventional diet strategies. With regard to the veterinary team,

frustration may exist when clients bring up preconceived notions about

nutrition and the sources from which they have gained these ideas.

The veterinary team should focus on discussing nutrition in an

open, honest, and approachable manner, in which the client feels

comfortable and respected. Team members should identify the under-

lying emotional reaction to these conversations, recognize the impact

of nonverb al cues, and listen to the clien t’sconcerns.

It is important

to understand that validating a client’s concern is different from

agreeing with the client. The goal is not to reinforce false information

but to validate concerns and come to a shared understanding.

The veterinary team must agree that there are different but

appropriate strategies to optimally feed pets. If the concerns about

unconventional diets are ignored, clients may turn to less reliable

sources for nutritional information.

100

Although the beneﬁts of con-

ventional diets include nutritional adequacy and convenience, some

clients may be concerned or skeptical about processed foods.

101

Pet

food manufacturers should provide transparency and details about

the contents, research, and beneﬁts of their diet. The veterinary team

can help build a trusting relationship by alerting clients about pet

food recalls and public health outbreaks if this is to happen.

168 JAAHA | 57:3 May/Jun 2021

Other Timely Nutrition Topics of Interest

Diet-Associated Dilated Cardiomyopathy

Dietary information is an evolving science. Although the Advisory

Panel has provided current information on nutritional topics of

interest, practitioners should make note of new developments that

postdate these guidelines. For example, there has been increased

reporting of diet-associated dilated cardiomyopathy (DCM) in dogs

in the last few years.

102–104

Previously identiﬁed risk factors include

lamb and rice diets, low-protein diets, and high-ﬁber diets.

105

Certain

breeds are predisposed (e.g., golden retrievers, Newfoundlands, Irish

wolfhounds).

102,106,107

Recently, more atypical dog breeds have been

diagnosed with DCM. Some dogs have been documented to have

taurine deﬁciency and subsequent DCM, whereas many of the dogs

have had normal blood taurine concentrations.

102

Some common

dietary features in these cases included feeding a diet high in lentils

or peas or feeding a grain-free diet.

104,105

Research is currently being conducted to determine what is

contributing to diet-associated DCM in dogs. A few theories include:

1. Inclusion of ingredients that may negatively affect bioavailability of

amino acids and other essential nutrients.

2. Low caloric intake relative to calculated energy needs, contributing

to a relative decrease of nutrient ingestion.

3. A possible nutritional excess or toxicity.

4. A nonnutritional toxicity.

5. Additionally, as previously identiﬁed, there likely are some breed-

related factors at play.

The only way to deﬁnitively diagnose DCM is via an echocar-

diogram, but this is an expensive test that may not be readily avail-

able to all dog owners. If a dog is exhibiting clinical signs of heart

disease (e.g., new heart murmur, cardiac arrhythmia, exercise intoler-

ance), thoracic radiographs should be performed. If there is suspicion

for DCM or evidence of congestive heart failure, then an echocardio-

gram should be performed.

Many dog owners want guidance on what they should (or

should not) be feeding their pets. Given currently available evidence,

the most conservative approach is to avoid feeding grain-free diets or

diets high in legumes. Because this is an evolving issue, pet owners

should carefully consider the pros and cons of feeding a speciﬁc type

of diet with their veterinarians. It is also incumbent upon veterinary

professionals to stay current in this area of research.

Home-Prepared Diets

Home-prepared diets may include cooked or raw foods. Multiple

veterinary studies of recipes found in books and on websites have

shown that the majority of these recipes, even those written by veter-

inarians, do not provide complete and balanced nutrition.

108–110

For

pet owners who prefer to feed home-prepared diets, a consult with a

board-certiﬁed veterinary nutritionist is recommended. More infor-

mation about requesting nutrition consults can be found online at

the ACVN website (acvn.org/nutrition-consults/).

Once a recipe has been formulated and provided to the pet

owner, it is imperative that the owner follow the recipe exactly as

written to ensure that it provides complete and balanced nutrition.

This is especially important regarding speciﬁc vitamin, mineral, and

amino acid supplements to ensure that all micronutrient require-

ments are met. It is common for owners to gradually amend recipes

over time,

111

so practitioners should be conﬁrming at appointments

that owners are still following speciﬁc instructions. Supplements can

also change over time, so home-prepared diet recipes should be

updated annually with a board-certiﬁed veterinary nutritionist.

Raw Protein Diet

AAHA does not advocate or endorse feeding pets any raw or dehy-

drated nonsterilized foods, including treats that are of animal ori-

gin.

112

Feeding a raw diet increases the risk of bacterial and protozoal

pathogen transmission to the pets consuming the diet as well as to

people and other animals. Several studies have documented the pres-

enceofpathogensinrawdietsforpetsandinthefecesofdogsand

cats eating the raw diets.

113,114

Importantly, dogs and cats can shed

Salmonella without exhibiting any clinical signs of disease.

115,116

Some pet food companies use high-pressure processing (HPP)

to reduce bacterial numbers in their products. The efﬁcacy of HPP

to reduce bacterial numbers dep ends on several facto rs, including

bacterial species, number of HPP cycles performed, pH, pressure

achieved, processing time, and temperature.

117

A pet food label claim

of HPP does not equate to “sterile” food.

Age-Specific and Breed-Specific Diets

Puppies and kittens should be fed diets appropriate for growth until

they reach skeletal maturity. For cats and small and medium-size

dogs, this typically means fee ding a diet for growth until approxi-

mately 1 yr of age. For some large- and giant-breed dogs, skeletal

maturity may not be achieved unt il closer to 15–16 mo, and it is

important to support a giant-breed puppy’s growth accordingly, aim-

ing to maintain a lean BCS and avoiding excessive calcium

intake.

118,119

Energy requirements can vary as pets age, but there are no spe-

ciﬁc nutritional requirements set by AAFCO for mature, senior, or

geriatric pets. Thus, pet owners and veterinarians should not feel

compelled to automatically change a pet’sdietonceitreachesacer-

tain age. If an older dog or cat is doing well with its complete and

balanced adult maintenance diet, it is perfectly appropriate to con-

tinue feeding that diet until a medical condition prompts otherwise.

2021 AAHA Nutrition and Weight Management Guidelines

JAAHA.ORG 169

This becomes especially true when considering that there is no

consensus among different pet food manufacturers about what should

constitute a “senior” pet food. Signiﬁcant variability has been docu-

mented among pet foods marketed for senior dogs.

120,121

Although

certain companies have their own standards, this is not true across

the board. Thus, practitioners should use caution with the recommen-

dation to feed any senior or mature diet to a cat with CKD who will

not readily accept a veterinary therapeutic renal diet. This may result

in unintentionally feeding excessive phosphorus to the patient.

Some pet food companies market breed-speciﬁcdiets.These

diets may be designed to accommodate certain breed predispositions

(e.g., a lower-calorie food for an overweight-prone dog breed) or the

kibble may be shaped in a way to help prehension. Ultimately, nutri-

tional recommendations should be made based on the individual pet

and the speciﬁcnutrientproﬁle of the diet.

Microbiome, Prebiotics, Postbiotics

The importance of a healthy gut microbiome has recently received

more attention in the veterinary community. There are many ways

in which the gut microbiome inﬂuences organ systems beyond the

gastrointestinal tract.

122

There are several ways to qualify and quan-

tify an animal’s microbiome. Although the microbiome is routinely

evaluated in research settings, its clinical application is currently lim-

ited.

122

Pet owners and veterinary professionals should be wary of

companies advertising to test a pet’s microbiome, especially if supple-

ments are then recommended.

An animal’s microbiome can be affected by diet, antibiotics,

probiotics, prebiotics, or fecal microbiome transplant. In many cases,

soft stool or diarrhea can be effectively managed with a diet change,

by modifying speciﬁc ingredients, dietary fat, or ﬁber intake.

123

Using

indiscriminate antibiotics for acute diarrhea is not recommended.

124

Caution should be exercised when choosing a probiotic because there

is variable quality control and efﬁcacy among supplements.

125,126

Opportunities and Resources to Leverage

the Value of Proper Nutrition in

Your Practice

Proper nutrition is one of the most important factors in the manage-

ment of health and disease in pets. Veterinary healthcare teams that

understand and embrace clinical nutrition and demonstrate in-clinic

behaviors consistent with that conviction will beneﬁt not only

patients and clients but also their practice and the profession.

Pet owners have access to vast information resources and are

subsequently becoming more e ducated and bringing detailed ques-

tions to the healthcare team. This provides an excellent opportunity

for the veterinary team to properly educate the client. Integrating

nutritional assessments into a practice requires commitment and

engagement of the entire veterinary team. This dedication and par-

ticipation in developing a strong nutrition program will promote

success, optimal pet health, the client-pet relationship, and a long-

term client relationship with the practice. There are many beneﬁts to

implementing a team approach to the practice mission and the veter-

inary team. The veterinary technician is poised to lead the initiative

to provide nutritional care for all patients. Group effort increases efﬁ-

ciency by distributing workload and delivering an integrated cohesive

message about the importance of nutrition and the value of preven-

tive care. When roles are delegated, everyone contributes to success

and individual motivation increases to accomplish results.

A Team Approach

Providing optimal nutritional management to patients requires the

entire practice team with whom the client interacts. Using the entire

team increases morale, utilization, and revenue for the hospital. The

client service team should facilitate the completion of a diet history

form before the appointment. Veterinary technicians should ass ess

the patient’s BCS, BW, and MCS and take a history from the pet

owner including a nutritional history. This information should be

relayed to the veterinarian, who uses it along with further question-

ing, diagnostics, and the exam to make a nutritional recommenda-

tion. To ensure client adherence, the recommendation is supported

and further explained to the client by the veterinary technician or

assistant. This explanation is an educational process involving how

the nutritional recommendation impacts the disease process and in

turn the health and wellbeing of a patient, and it allows for questions

from the client.

Once a nutrient proﬁle, portion, and feeding schedule have

been prescribed, the next steps toward success are follow-through by

the veterinary healthcare team and accountability. An easy-to-imple-

ment program leverages the veterinary team to partner with the cli-

ent to position the pet toward optimal health.

In executing this approach, the client makes an appointment

(before leaving the practice) for a weigh-in and a body composition–

muscle composition assessment. A member of the practice team follows

up with the client by phone or email within the ﬁrst couple of days.

The client then returns for the subsequent visit, the pet is weighed, and

the BCS-MCS is assessed and recorded in the medical record. The feed-

ing plan is reviewed and veriﬁed with the client. The target weight is

reviewed, and the goal is adjusted if needed. Questions from the client

are encouraged and answered. Finally, dietary portioning is adjusted if

needed and the next assessment appointment is scheduled.

There are multiple ways to ﬁne-tune an accountability program

to enhance its value to the client, to the veterinary healthcare team,

170 JAAHA | 57:3 May/Jun 2021

to the patient, and ultimately to the practice. Some nuances to con-

sider include:

 Pair each patient with a speciﬁc team member. This creates continuity

for the client, patient, and practice. It allows that team member to note

the trend of the pet’sprogresstowardoptimalbodycomposition.The

continuity of contact builds trust with the client, potentially reduces

fear for the patient, and further bonds the client to the practice. This

helps to set the practice apart in a crowded marketplace and enhances

the role of the team member, allowing that person to contribute to the

success of the practice and the practice’snutritionalgoals.

 Set boundaries or “rules” for this assessment and accountability pro-

gram. For instance, a formal appointment should be on the clinic’s

schedule and the value to the patient of checking in regularly

explained to the client. Consider an appropriate interval for these

visits. Four to 8 wk apart is reasonable. These assessments should

stand independent of the pet’s wellness or preventive care

appointments.

 Consider creating a small incentive or “thank you” for the client.

This acknowledges the client’s investment in helping their pet to be

as healthy as possible.

 Recognize that clients who involve their pets in a weight management

program enter the practice more frequently. This provides multiple

opportunities for the client to mention or a veterinary team member

to recognize medical issues that require attention. Any of these artic-

ulated concerns can lead to scheduling a formal appointment, allow-

ing the practice team to catch and deal with a medical issue early

before it progresses and expands into something more serious.

Summary

Nutrition is the foundation of pet health and wellbeing and should

be a central component of every canine and feline patient’shealth-

care plan. An objective nutritional assessment is the initial step in a

systematic approach to nutritional management. When performed at

each exam visit, the assessment considers such evolving factors as the

patient’s age, health status, and lifestyle-related risk factors. Based on

the assessment, patient-speciﬁc nutrition recommendations can be

made. Besides health maintenance, these recommendations often

have speciﬁc therapeutic goals such as weight loss or dietary support

of chronic or acute disease conditions.

Client attitudes toward pet nutrition, informed by commercial or

nonscientiﬁc information, are often based on individual biases and sub-

jective but strongly held beliefs. For this reason, effective client commu-

nication is an important factor in achieving adherence with dietary rec-

ommendations. Nutrition conversations with clients should focus on

messaging content as well as the communication process, with the goal

of ensuring that the client has a positive perception of the practitioner’s

nutritional recommendations. A key element of productive discussions

on pet nutrition is to understand the client’s viewpoint on topics such

as pet food choice, dietary rewards, and weight control.

Integrating nutritional management as a vital part of the practi-

ce’s culture requires the commitment and engagement of the entire

veterinary team. A uniﬁed approach to implementing an effective

nutrition program will promote optimal pet health, therapeutic suc-

cess, a strong veterinarian-client-pet relationship, and a long-term

client association with the practice.

The authors gratefully acknowledge the contribution of Mark

Dana of Kanara Consulting Group, LLC, in the preparation of

the guidelines manuscript.

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