IMPLEMENTING A NUTRITIONAL CONSULTATION PROGRAM IN YOUR HOSPITAL Vicky L. Ograin, MBA, RVT, VTS (Nutrition) Academy of Veterinary Nutrition Technicians Introduction Proper nutritional management is one of the most important factors in the health and disease management of pets. As pet owners become more aware of the importance of nutrition in their own health, they will expect a higher standard of nutritional care for their pets. The nutritional counselor should be the preferred, expert source of the best nutritional information for pets. Nutritional counselors that understand and embrace clinical nutrition and demonstrate in-clinic behaviors consistent with that conviction will benefit their patients, their clients, their practice and the profession. What is a Nutritional Counselor? Nutritional counselors work with the veterinarian to reinforce, implement and follow up the food recommended for the pet. They accomplish this by working with the pet owner, explaining what and why the food is being recommended and to answer any questions the pet owner may have. A nutritional counselor follows up with the pet owner to assure compliance, but more importantly to be the cheerleader for the owner and the pet. Pet owners need to know someone is there for them to help with questions or concerns even after the initial visit. Nutritional Counselors Reinforce the Veterinarian s Recommendation. The consultation will start after the veterinarian (or technician) has made a food recommendation for the pet. If the veterinarian gave the recommendation he/ she will advise you what the food is and if the pet can have dry, canned or both. The veterinarian should mention if only specific treats can be fed. If the pet needs to lose weight, the veterinarian will also advise what the goal weight should be. To begin the consultation, ask two very important questions: what are you currently feeding and why? When asking what they are currently feeding, remember that this includes everything they are feeding, including pet food, treats, table food, and supplements. Have pet owners tell you everything that passes their pet s lips, be it solid or liquid food (it is common for cat owners to give milk). This will give you a lot of important information and will help guide you in your discussion to make sure transitioning to the new food is successful. After gaining an understanding of what they are feeding and why, you will know what you need to discuss to make the transition to the new food successful. Discuss with the pet owner what the new food is, and why the veterinarian is recommending it. For example, the veterinarian is recommending a renal food for your cat: it has controlled protein, phosphorous and sodium, to take the work load off your cat s kidneys, and will improve and extend the quality and length of your cat s life.
Nutritional Counselors Implement the Recommendation. The second part of the consultation is very important. This is where you will help the owner accept the recommendation by communicating everything they need to know about the new food: how much to feed and how to transition, and answer questions they may have. This ensures they accept the recommendation. The technician plays a pivotal role in helping the pet owner. Switching to a new food can be a stressful time for the pet owner, especially if the pet is switching to a therapeutic food. We are there to be the pet owners cheerleader and let them know we are there for support. How Much to Feed? It is important to discuss how much to feed. It is best if you calculate exactly what the dog or cat should be getting; do not leave it up to the pet owner to decide how much to feed. This is especially important when a pet needs to lose weight. Based on your initial questions and what the veterinarian has recommended, you will know if the pet will be getting canned, dry or both. To calculate feeding amounts first calculate resting energy requirement. There are a few calculations recommended, such as RER= (70x kg BW 0.75 ) or RER= 70 + (30xkg BW). Daily requirements are then multiplied by a factor that takes into account the age, activity, or physiological condition of the animal. 1 When calculating for weight loss, use the goal weight given to you by the veterinarian to calculate the feeding amount.2 Make sure you advise the owner that the amount you are recommending is a starting point. The amount may need to be adjusted based the how the pet responds to the feeding amount. This is especially important for weight loss. If available, use a brochure that discusses the new food. If the pet food company does not provide brochures, make your own with basic information about how the food will benefit the pet. Many pet owners are stressed and not completely taking in what you tell them at the clinic, so it is important to give them something to read at home. The pet owner can share the information with family members that were not present at the veterinary clinic during the exam and recommendation. It is important to give the pet owner full instructions on how much to feed and any additional instructions, such as how many treats, along with information on how to transition, and a measuring cup (if the pet food companies supply them), or instruction to purchase the correct 8 oz. (250 g) measuring cup. Transition It is important to recommend a transition. There are two reasons to do a transition: 1) occasionally a pet will have a GI upset when switched to a new diet, 2) a pet will accept a new food better when a transition is done to allow the pet to get use to the new texture and flavor. There is more of a chance with a hydrolyzed protein or different (high or low) fiber level food to cause a GI upset. Transition recommendation- 1)Recommend ¾ old diet ¼ new diet, 2) Do this for a few days; if no GI upset, go to the next step, 3) ½ old diet- ½ new diet, 4) Do this for a few days; if no GI upset, go to the next step, 5) ¼ old diet- ¾ new diet, 6) Do this for a few days; if no GI upset, go to the next step, 7) End with 100% of the new food.
Sometimes a transition should be longer, especially for cats. Use the same recommendation, but instead of a few days, recommend doing each step for a week or more. Nutritional Counselors Follow up After the consultation is finished and the owner has gone home, it is important to follow up with the pet owner to make sure everything is going well. The nutritional counselor should call in 2-3 days, 2 weeks, and 2 months to see how the pet is doing. The first follow up is the most important; call in 2-3 days. This will be during the transition and this is when most people will give up on the new food. It is an opportunity to be the owner s support and cheerleader and help with any issues that have come up. It is also an opportunity for the pet owner to ask any questions that have come up since they went home, especially from family members. Check in at 2 weeks to see how the pet is doing; by now the pet may be on the new food or still transitioning, so it is a good time to check in and see how everything is going. At 2 months, check to see how the pet is doing. By now the pet should be on the new food, and you are calling to offer any support they may need. Call as you think necessary after the 2 month check in. If pet needs to lose weight, call monthly until the pet reaches its goal weight. Encourage weighing every 2-4 weeks until the pet reaches its goal weight, then every 6 months. Let s do a few consultations Feisty Our first case is Feisty-- she is a DSH, 15 years old, female (spayed), and she currently weighs 6 pounds (2.7 kg). The owner has reported she is not eating as well, has vomited a few times and appears to have lost weight. The veterinarian did a physical exam and ordered some lab work. The veterinarian found she has lost 2 pounds from her ideal weight of 8 pounds (3.6kg); she now weighs 6 pounds (2.7 kg). The lab work showed mild kidney disease, and the decision was made to try diet as the sole therapy for now. The veterinarian recommends a food change to a renal therapeutic food; he recommends canned and dry. The nutritional counselor comes in to speak to the pet owner. She asks what the owner is currently feeding Feisty and why. Feisty currently eats an over the counter dry food. She feed the food because the pet owner read on the internet that the brand is good food for her cats. She has never really fed canned food; she does not feed any treats, people food or give supplements. She free feeds, so is not sure how much Feisty is eating. The nutritional counselor explains why the veterinarian is recommending the k/d for Feisty: The veterinarian is recommending renal food for your cat; it has controlled protein, phosphorous and sodium to reduce the work load of your cat s kidneys, and to extend your cat s quality and length of life. The veterinarian is recommending canned and dry. Kidney patients can benefit from the water content in the canned food, because cats with kidney disease may not drink enough free water. We want to know if and how much Feisty is eating, so an exact feeding amount will be recommended. Feeding amount
The nutritional counselor calculates the feeding amounts for Feisty. She weighs 6 pounds (2.7 kg), but should weigh 8 pounds (3.6kg). The food amount is calculated for her ideal weight of 8 pounds (3.6 kg). Using the chart (table 1), take the RER (resting energy requirement) x life stage= kcals needed per day: 8 pounds (3.6 kg) = 184 kcals x 1.2 = 221 total kilocalories per day. The renal food, canned 5.5oz can contains 183 kcals per can; if ½ can per day is fed, 92 kcals come from ½ can and the remaining kcals come from dry renal food. The renal food has dry 8 oz. cup contains 492 kcals, so she would need 129 kcals or ¼ cup a day, for a total of 221 kilocalories per day. She recommends dividing the amount into two meals. Transition The nutritional counselor discusses transition; she uses a transition brochure that she received from the pet food company and a brochure about the new food to help with the discussion. Feisty has never had canned food before; cats are known to have texture issues, so a long transition is recommended (over 1 month) to allow Feisty to get used to the new food. If she is accepting the canned food, the owner can speed up the transition. The pet owner is also given a measuring cup, so she can accurately measure the dry food. When asking if the pet owner has any questions, Feisty's owner mentions she has two other cats at home and she feeds everyone the same food. She is concerned about Feisty and is willing to try, but is worried how she will accomplish this and how to make sure Feisty gets her food without the other two cats eating it. The nutritional counselor understands the owner s concern and assures her that the counselor will help her transition all the cats to meal feeding, instead of free feeding. The other two cats can stay on their current food, but will be switched over to meal feeding. The counselor recommends giving the cats their food for 15 minutes at a time and picking it up, so they get used to eating a meal. Cats must eat and cannot go without eating, so the initial recommendation is to give them many opportunities to eat during the day, so she knows they are eating. She can also try separating the cats during meal time, so each cat gets the right food. The nutritional counselor tells Feisty s owner to expect a call in a few days to see how everything is going and to see if she or her family have any additional questions. The counselor gives her card and lets the owner know if she has questions at any time to feel free to call. Follow up Two days Two days after the consultation, the nutritional counselor calls Feisty s owner. She is struggling a little with the transition. She is very happy that Feisty seems to like the dry k/d, but she did not eat the canned yesterday at all, and today Feisty took one lick and that was it. The owner is concerned Feisty does not like the canned food. The counselor encourages the owner to keep with it, reminding her Feisty has never eaten canned food and to take a lick is a great sign. The owner is encouraged to keep with it; in time Feisty will be eating the canned food. Two weeks
At two weeks after starting the k/d, the nutritional counselor called Feisty s owner and was happy to hear the report. Feisty and the other two cats had transitioned to meal feeding and it was going well. The canned food was rough in the beginning, but Feisty was now eating the canned food better and better, and in fact was starting to get excited when it was time to get her canned food. Feisty still was not completely transitioned onto the k/d, but was feeling better and the owner felt she would complete the transition and Feisty would be eating the k/d well. Also Feisty would be coming in 2 weeks for a re-check with the veterinarian. Feisty came in for her 1 month re-check. She is doing well and has gained a few ounces, which is great for a kidney patient. Two months The nutritional counselor called at two months to see how Feisty was doing. Her owner is very happy; Feisty is now only eating the k/d dry and canned, and she really likes the canned and is excited to get it. Her energy seems to be back; she is playing with the other cats and her toys. She is even happy about the recommendation to meal feed. Although it seemed challenging in the beginning, the cats have taken to it well and the other two cats have even lost a little weight since they are not able to eat all the food they want, and are instead receiving the correct amount of food. The pet owner has also started giving the other two cats canned food; she see how much Feisty likes it. In case the other cats ever need to go on canned food, she has already done the transition now, instead of when they are not feeling well. The nutritional counselor makes sure Feisty s owner knows she can call anytime with questions, and the counselor will see her at the clinic or call every 3 months to see how Feisty is doing. Kidney disease is a lifelong disease, and it is good to give support to owners as they go through the stages of the disease. Let s do a second consult Sparky Our second case is Sparky; he is at the clinic today for a routine checkup. Sparky is a shih tzu- Japanese chin mix, he is 3 years old and is a male (neutered). The veterinarian discusses nutrition on every visit, and makes a food recommendation if needed. Sparky is healthy, but is a little overweight; he currently weighs 15 pounds (6.8 kg) and should weigh 13 pounds (5.9kg). The veterinarian recommends a weight loss food in dry and canned and a treat that can be given with the weight loss food. He tells the owner the nutritional counselor will be in to discuss Sparky s diet. The nutritional counselor starts by asking what the pet owner is feeding Sparky and why. She is feeding an over the counter food, dry and canned and the treats that go with it, because it is what the family has always fed. She feeds the amount on the bag, but admits she gives a lot of treats. The nutritional counselor discusses the weight loss food and the need for Sparky to lose weight. Discuss the food being recommended and treats The nutritional counselor explains all the potential diseases and conditions that are worsened by Sparky being overweight, such as arthritis. She gives her a brochure with information about obesity and a transition brochure, as well as a measuring cup.
Discuss how much to feed Using the chart (table 1), calculate the feeding amount using the goal weight. Calculate RER (resting energy requirement) x life stage= kcals needed per day. Sparky currently weighs 15 pounds (6.8 kg) and the goal weight is 13 pounds (5.9 kg). RER for an ideal weight of 13 pounds (5.9 kg) = 295 kcals x 1 ((weight loss lifestage multiplier) = 295 total calories per day. The weight loss food canned 13 oz. can contains 257 kcals. If ½ can is fed per day, 129 kcals are provided from wet food. The weight loss dry 8 oz. cup contains 242 kcals. If 136 kcals=.56 cup a day dry is fed, then 30 kcals can come from treats. The treats= 10 kcals each, 30 kcals =3 treats a day. So ½ canned, 0.56 cup of dry and 3 weight loss treats equals the total of 295 calories per day. Transition The counselor recommends a transition over a week s time to prevent a GI upset. How quickly should a dog lose weight? Sparky needs to lose 2 pounds. A small dog should lose about ¼ to 1/3 lbs. per week or 1-2% per week, so it should take one to two months for Sparky to lose the excess weight. Treats Sparky s owner is very concerned she is not going to be able to give treats. Giving Sparky treats is a quality of life issue for her and she feels she will not be able to not give treats anymore. The nutritional counselor explains she will be able to give 3 weight loss treats a day and she can use the recommended dry food as treats instead of putting it in his food bowl. Exercise Tips for Dogs and Cats Exercise is important and will help with weight loss. Some exercise ideas for dogs include taking the dog on a walk, playing ball or fetching toys, putting food in a food ball and tossing kibble to the dog instead of putting in the food bowl. For cats, feed small amounts in many bowls, place bowls in different locations, move bowls often to encourage movement, play with toys, rotate toys, play with a laser pointer or fishing rod-type toy, and throw kibble to the cat, instead of putting it in a food bowl. Follow up Two days The nutritional counselor calls Sparky s owner in two days. Sparky is doing well; he really likes the new food so far. She is glad we sent home a brochure. She had a hard time convincing her husband that Sparky needed to lose weight and the brochure helped to convince him of the importance of weight loss. Both owners are on board and feel that will make it easier to accomplish Sparky s weight loss goal. Two weeks Sparky is now completely transitioned to the new food, and his owners say he likes the food and seems to have more energy. They take him for walks and he loves to play ball. Sparky s owner never thought a little dog would like to play ball, but she is enjoying the play time with Sparky. They will return in a few weeks for a weighing.
Sparky returned in a month and has lost 1/2 pound. Apparently her husband was giving too many treats; but the counselor encourages Sparky s owner by assuring her that 1/2 pound is still a great accomplishment. Always celebrate the success and learn from the failure when dealing with weight loss. They discuss feeding amounts and suggest putting some kibble aside from his daily amount, so her husband could give those as treats. A dog does not have to receive all of its food in a bowl, so using the kibble as treats is a great idea. Two months At two months, Sparky had lost another pound and was nearing on his goal weight. Sparky s owner is very happy--sparky has become an energetic little dog and loves going on walks and playing ball. Her husband is even getting involved taking him for walks and not overfeeding. The nutritional counselor will call monthly until the dog reaches his goal weight. By three months, he has reached his goal weight and is transitioned to a controlled amount of a light food to maintain his new weight. His food will be evaluated every time he comes in for a visit and will be re-evaluated if needed. Summary Every pet deserves and should receive a nutritional recommendation on every visit. Nutrition is one area of veterinary medicine that affects every pet that comes into the hospital. Working as a nutritional counselor is very rewarding and is an asset to the practice as well as the pet owner and most importantly the pet. You can be instrumental in guiding a pet owner by answering questions and determining feeding amounts. Follow up is imperative for the success of a new food. Technicians can play an integral role in helping pet owners successfully switch to a new food. References/ Suggested Reading 1. Ramsey JJ, Determining Energy Requirements. In: Fascetti AJ & Delaney SJ, Blackwell, West Sussex, UK, 2012: 23-45 2. Toll PW, Yamka RM et al. Obesity. In: Hand, Thatcher, Remillard, et al, Small Animal Clinical Nutrition, 5th edition, Mark Morris Institute, Topeka, Kansas, 2010: 525-526
Table 1 Calculating Daily Energy Requirements (DER) 1. Find weight on the chart 2. Determine RER 3. RER x lifestage energy requirement = DER kcal/daily requirements Pounds KG RER (kcal per day) 1 0.5 39 2 0.9 65 Canine Lifestage Daily Energy Requirements 3 1.4 88 Lifestage DER 4 1.8 110 Puppy (up to 4 mos) 3 x RER 5 2.3 130 Puppy (4mos & older) 2 x RER 6 2.7 149 Intact adult 1.8 x RER 7 3.2 167 Neutered adult 1.6 x RER 8 3.6 184 Obese prone 1.4 x RER 9 4.1 201 Weight loss 1.0 x RER 10 4.5 218 11 5.0 234 12 5.5 250 13 5.9 265 Working Adult Canine Energy Requirements 14 6.4 280 Workload DER 15 6.8 295 Light 2x RER 16 7.3 310 Moderate 3x RER 17 7.7 324 Heavy 4-8 x RER 18 8.2 339 19 8.6 353 20 9.1 366 25 11.4 433 Feline Lifestage Daily Energy Requirements 30 13.6 497 Lifestage DER 35 15.9 558 Kitten 2.5 x RER 40 18.2 616 Intact Adult 1.4 x RER 45 20.5 673 Neutered adult 1.2 x RER 50 22.7 729 Obese prone 1.0 x RER 55 25.0 783 Weight loss 0.8 x RER 60 27.3 835 65 29.5 887 70 31.8 938 75 34.1 988 80 36.4 1037 85 38.6 1085 90 40.9 1132 95 43.2 1179 100 45.5 1225
Diet History Form Pet owner s name: Address: Home phone #: Work phone #: Cell phone #: Best time to call: Pet s name: Dog: Cat: Pet s breed: Age: Indoors: Outdoors: Indoors/Outdoors: Male: Female: Spayed/ neutered: Yes: No: Body condition score (BCS 1-5 or 1-9): Body fat index (BFI 20-70): Current weight: Ideal weight: What is your pet currently eating? Current diet (note everything the pet is eating): Treats/ People food: Why feeding current diet: Current feeding amounts: Dry: Size of measuring cup: Canned: Size of canned food: Treats/ People food (how much for each treat/ human food): What else: Supplements: How many meals per day: How active is your pet: Describe weekly exercise: Feeding Instructions Pet owner s name: Address:
Home phone #: Work phone #: Cell phone #: Best time to call: Pet s name: Dog: Cat: Pet s breed: Age: Indoors: Outdoors: Indoors/Outdoors: Male: Female: Spayed/ neutered: yes: no: Body Condition Score (BCS 1-5 or 1-9): Body Fat Index (BFI 20-70): Current weight: Ideal weight: Recommendation: Recommended food: Dry: yes: no: Canned: yes: no: Treats: yes: no: Recommended treat (if yes): Other recommendations: Calculate feeding amount: Calculate RER (kcal/day): RER= (70x kg BW 0.75 ) or RER= 70 + (30xkg BW) RER (kcal/day) x lifestage factor= Daily energy (calories) requirements (DER) Total calories needs for the day: RER x lifestage factor = DER Treats: Treats should be no more than 10% of total daily calories Treats= Total calories x.10 = Treat calories DER - (minus) treat calories = new calorie amount of food How much to feed: Dry food calories per cup: Canned food calories per can: Size of can: Calories per treat: Amount to feed (8 oz. cups) of dry: Amount to feed of canned: Amount to feed of treats or acceptable treats: Nutritional Counselor: Phone #: