The importance of clinical nutrition

© Duhayer/Royal Canin

Good quality maintenance diets adapted to the size, breed and activity levels of the dog are powerful allies in preventive health care. When an accident or disease arises during the course of its life, the diet can be adapted to support medical treatment. Clinical nutrition is a discipline which adapts the diet of the dog to its disease, to improve quality of life and increase longevity.

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What is a clinical diet?

© UMES

A clinical diet is a complete feed designed for nutritional support in therapeutic regimes. It is specially formulated to meet the specific nutritional requirements of certain diseases. It is prescribed by a vet and requires regular monitoring (at least three times a year, but more frequently with certain conditions.). The vet will check the progression of the disease and the efficacy of the dietary support and make any necessary adjustments.

Veterinary medicine, unlike human medicine, is very fortunate to have a whole range of appetising commercial feeds that can be adapted to every situation to promote optimum health and longevity for our companions.

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Can nutrition influence the skin barrier function?

Canine atopic dermatitis (CAD) can result from a defect in the skin barrier, which maintains an allergic response. This fault is perhaps caused by disrupted lipid synthesis.

In a preliminary study of dogs with CAD fed diets with high or low ratios of omega-6/omega-3 fatty acids, the non-lesional skin of dogs which responded in a positive way (more than 50% improvement) contained a lower percentage of arachidonic acid (which can lead to less inflammation) than those dogs whose improvement was less than 50%.

Variations in linoleic acid content did not influence success.

In addition, pantothenic acid, nicotinamide and a combination of inositol and choline not only improved lipid synthesis but also reduced transepidermal water loss in dogs after 9 weeks, suggesting a role in repairing skin barrier function.

© Willemse

Professor Ton Willemse,
DVM, PhD, DipECVD
Utrecht University
(Netherlands)

Clinical diets… in treatment of disease

The introduction of a clinical diet will provide optimum nutritional adjustment and support for the pet and thus play a key role during amelioration or resolution of the clinical signs. In such cases the diet is a means, sometimes the only one, of providing appropriate support to the animal.

Nutritional management of obesity

Clinical diets specifically formulated for weight loss enable the dog to safely shed excess fatty mass without going hungry.

Key points required in the clinical diet:

- Sufficient quantity of protein to limit the loss of muscle mass during weight loss.
- Proteins selected to help provide a sensation of satiety (fullness).
- Fibre to increase the volume of the feeding amount whilst decreasing the energy density and helping to create a sensation of satiety.
- Enriched mineral and vitamin content to compensate for the energy restriction.
- Kibble designed in such a way as to provide the dog with a greater volume of food for an identical calorie intake.

Indications

- Obesity
- The high fibre content can be helpful in the treatment of constipation or fibre-responsive colitis.
- The low lipid content can help in the treatment of hyperlipidemia.

Therapeutic goals

- Decrease the calorie intake (restricted fat intake, addition of dietary fibre) whilst maintaining an adequate volume of food to provide a sensation of satiety.
- Ensure the dog loses weight safely by providing an enriched nutrient content.

© Diffomédia/Royal Canin

Nutritional management of dietary allergies

Once a food allergy has been diagnosed, a “hypoallergenic diet” that is tolerated by the animal can relieve the clinical signs (intense scratching in particular). The dog remains allergic to the triggering protein(s), but its modified diet no longer triggers an allergic response, thus obviating the need for long term medical treatments. The use of these diets in dogs with chronic diarrhoea due to an allergy or dietary intolerance may also result in clinical recovery.

Key points required in the clinical diet:
- Highly digestible hydrolysed proteins (artificially digested into small peptides) with a weak antigenic action.
- Nutrients with proven efficacy in the treatment of skin conditions (group B vitamins, essential fatty acids, antioxidants, minerals, etc.).
- Omega-3 essential fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).
- A highly digestible gluten-free source of carbohydrate.
- Fermentable fibre (sugar beet pulp, fructooligosaccharides) to promote a well-balanced gastrointestinal flora.
- Protection of the gastrointestinal mucosa (zeolite, a type of clay).

Indications

- Food allergy (with cutaneous and / or gastrointestinal symptoms)
- Dietary intolerance
- Chronic diarrhoea
- Inflammatory bowel disease

Therapeutic goals

- Avoid stimulation of the immune system and thus avoid triggering the clinical signs of the food allergy.
- Strengthen the natural efficacy of the cutaneous barrier via a targeted provision of nutrients.
- Control existing inflammation with essential fatty acids.
- Protect the gastrointestinal mucosa and help to balance the gastrointestinal flora.

© Diffomédia/Royal Canin

Clinical diets…nutritional support in prevention of disease recurrence

Whether a disease was cured with medical, nutritional and / or surgical treatment, a change in diet may help to limit the risks of recurrence. The goal of the clinical diet in this case is to keep the animal healthy for as long as possible, knowing that it is predisposed to a disease from which it has already suffered.

Prevention of periodontal disease

Periodontal disease is the most common condition of the buccal cavity in the dog. Bacterial contamination and the deposition of plaque and
tartar cause halitosis and, in the most serious cases, tooth loss. Some breeds, particularly small ones, are predisposed to this.

Although daily mechanical brushing is the best means of prevention, diet is also a useful tool in the fight against dental plaque and tartar formation, the ideal solution being to combine tooth brushing with a specific dental diet.

Key points required in the clinical diet:

- Kibble shape and texture which obliges the dog to chew, and adapted to the dog's size.

- Agents which actively protect the oral cavity against tartar deposition (polyphosphates , zinc , polyphenols, etc.).

Indications

- Daily orodental hygiene.
- Following scaling to limit further development of dental plaque and tartar.

Therapeutic goals

- Obtain a gentle abrasive effect on the teeth during feeding.
- Supply active agents which when mixed with the saliva during mastication limit the deposition of dental plaque and the formation of tartar.

© Diffomédia/Royal Canin
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Which food is better for preventing tartar in dogs?

Epidemiological studies show that feeding a dry food diet can have a positive influence on oral health, decreasing the occurrence of dental deposits and periodontal disease in dogs.

Animals fed soft food may have greater dental deposits and benefit from additional oral hygiene measures such as daily tooth brushing, use of oral rinses and dental chews.

Whatever food is used there is nothing better for oral prophylaxis than correct daily tooth brushing and systematic dental checks by a veterinarian.

© Gawor

Jerzy Gawor DVM, PhD
Fellow of the Academy of Veterinary Dentistry
Klinika Weterynaryjna Arka
Kraków (Poland)

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Can dogs wear dental braces?

© UMES

Orthodontic braces can be used for dogs to correct malocclusions. Malocclusion is the malposition of the teeth resulting in poor contact between the upper and lower teeth when the jaw is closed. Since malocclusion is an inheritable condition, genetic counselling is advised. The dog may be
excluded from dog shows and breeding programs.

Malocclusion of the teeth can lead to eating problems, periodontal disease, soft tissue trauma, asymmetries and deformities of the oral cavity and face, and mandibular joint disorders.

The aim of the orthodontic treatment is to provide a functional and aesthetic occlusion.

© Stoian

Camil Stoian, veterinary surgeon
(Austria)

Prevention of urinary calculi

When a dog has had an episode of urinary crystals or calculi, managed by diet or surgical intervention , the implementation of a maintenance diet to control urolithiasis can limit the risks of further recurrence. The majority of urinary calculi present in the dog can be controlled using a diet which targets struvite and calcium oxalate calculi or a diet which targets urate and xanthine calculi.

Key points required in the clinical diet:

- Carefully selected ingredients and a precise recipe to ensure a constant urinary environment.
- A supply of nutrients that help reduce the concentration of crystalloids in the urine.

Indications

- Dissolution of struvite uroliths
- Reduction of recurrent urolithiasis
- Bacterial cystitis (which may be lead to urinary crystal and calculi formation).

Therapeutic goals

- Decrease the concentration of minerals in the urine.
- Increase urinary volume.
- Obtain a stable and controlled urinary pH.

© Diffomédia/Royal Canin

Prevention of weight gain following weight loss

Some breeds, such as the Labrador Retriever, are predisposed to obesity. Neutering also promotes weight gain. In these situations or following a successful weight loss diet, obesity can be prevented by providing a clinical diet that has been specially formulated to limit weight gain.

Key points required in the clinical diet:

- Proteins selected to help provide a feeling of satiety.
- Fibre to increase the volume of the feeding amount whilst decreasing the energy density and helping to create a feeling of satiety.

Indications

- Maintenance of optimal weight following a weight loss programme.
- Dogs predisposed to obesity.
- Neutered dogs
- The high fibre content can be helpful in the treatment of constipation or fibre-responsive colitis.
- The low lipid content can help in the treatment of hyperlipidemia.

Therapeutic goals

- Maintain ideal weight
- Offer the dog an acceptable volume of food.

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How can nutrition support dogs with liver diseases?

Nutritional support is important for liver disease associated with
portosystemic shunting and for hepatitis. Shunting of portal blood past the liver and reduced liver function may lead to hepatic encephalopathy. Congenital portosystemic shunts, primary portal vein hypoplasia and arteriovenous fistula are examples.

These dogs may be kept on dietary support life long. It is essential
to reduce the exposure to neurotoxins such as ammonia, but at the same time provide sufficient protein to avoid hypoalbuminaemia and
ascites due to poor liver function.

A diet with a slightly reduced content of highly digestible soy-based protein, and containing soluble fibre or lactulose, performs best to reduce the production and intestinal absorption of ammonia.

Low protein formulas contain too little protein for long term maintenance of such patients.

Hepatitis is often (up to 30%) caused by copper accumulation and is associated with oxidative damage. Supporting diets should contain low levels of copper and high zinc: copper ratios to reduce intestinal copper uptake. Antioxidants may help to prevent ongoing cell damage.

© Rothuizen

Professor Jan Rothuizen,
Veterinary University of Utrecht
(Netherlands)

Clinical diets… nutritional support for medical treatment

These diets are prescribed to provide nutritional support to medical treatment and to provide optimum support for organ function and the animal.

Nutritional support of cardiac disease

Salt restriction is the best known of the recommendations for dogs with heart problems, but it is not the only way to help support the pet with this disease. In addition, such restriction should be progressive. Heart
failure is a cachectic disease, i.e. it leads to weight loss (loss of fat, but also loss of lean tissue mass) which worsens with the progression of the
disease. A clinical diet for heart problems, through its composition and taste, helps maintain the animal’s lean mass, thus preserving quality of life for as long as possible.

Key points required in the clinical diet:

- A moderate to restricted salt content, depending on the severity of the disease.
- Highly palatable.
- Sufficient quantities of high quality proteins.
- Antioxidants to combat oxidative stress.
- Nutrients which promote cardiac function (taurine, L-carnitine)

Indications

- All cardiac diseases
- Arterial hypertension

Therapeutic goals

- Limit water retention through sodium restriction
- Prevent muscle wastage (the heart is a muscle too).
- Ensure the correct functioning of cardiac cells.
- Limit electrolyte imbalances (e.g. magnesium, potassium) caused by treatment.
- Maintain food intake.

Nutritional support of skin disease

The skin is an important organ with numerous essential roles (including protection against the external environment). It is constantly being
renewed (every three weeks or so) and therefore has significant nutrient requirements. Healthy skin and a shiny coat are the reflection of the dog’s health and a balanced diet. Dermatological clinical diets are an essential preventative tool in dogs with specific needs and sensitivities, but also
as part of the nutritional support of treatment for cases of dermatitis (inflammation of the skin) of various origins.

Key points required in the clinical diet:

- Nutrients with proven efficacy at the cutaneous level (group B vitamins, essential fatty acids, antioxidants, minerals, etc.).
- Omega-3 essential fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).

Key points required in the clinical diet:

- Dépilations, cicatrisation cutané
- Inflammation de la peau : dermatite atopique, allergie aux piqûres de puces, otite externe
- Infections de la peau : pyodermites

Indications

- Hair loss, skin lesions.
- Inflammation of the skin: atopic dermatitis, flea allergy dermatitis, otitis externa.
- Skin infections: pyodermatitis

Therapeutic goals

- Meet the significant nutritional requirements for maintenance and renewal of the coat.
- Strengthen the natural efficacy of the cutaneous barrier via a targeted provision of nutrients.
- Control existing inflammation with essential fatty acids.

© Diffomédia/Royal Canin

Nutritional support of diabetes mellitus

A combination of clinical diet and insulin therapy can be used to control diabetes mellitus in the dog. Clinical diets specifically formulated for
diabetic dogs improve the action of insulin and, in the majority of cases, enable a reduction in the daily dose of this essential hormone.

Key points required in the clinical diet:

- A reduction in carbohydrate intake (which limits the postprandial rise in blood glucose levels).
- Carbohydrates with a low glycaemic index (such as maize).
- Dietary fibres which slow digestion.
- Antioxidants to combat the oxidative stress associated with the disease.

© Diffomédia/Royal Canin

Indications

- Diabetes mellitus
- The high fibre content can be helpful in the treatment of constipation or fibre-responsive colitis.

Therapeutic goals

- Decrease the postprandial spike in blood glucose.
- Spread the absorption of carbohydrate over time to reduce hyperglycaemia and provide energy throughout the day.
- Decrease the amount of insulin needed.

Nutritional support of renal failure

Renal clinical diets have proven their efficacy in improving the animal’s quality of life and life expectancy. As with heart failure, renal failure causes cachexia, inducing the loss of both fatty and lean mass (muscles, organs). Renal clinical diets should have a reduced protein content without compromising the animal's appetite, and must still provide sufficient protein to meet essential requirements for body functions and maintenance of lean mass.

Key points required in the clinical diet:

- Carefully selected, very high quality proteins
- A controlled protein content to limit waste in the form of urea.
- Restricted phosphorus content (slows the progression of the disease)
- A raised intake of fish oil (rich in omega-3), which supports renal function, helping to reduce chronic glomerular inflammation and maintain the glomerular filtration rate.
- Antioxidants to strengthen immunity and delay cellular ageing.
- Gastrointestinal mucosal protectors (zeolite clay) to combat the effects of uraemic toxins (e.g. diarrhoea).
- Fermentable fibres (sugar beet pulp, fructooligosaccharides) to promote a well-balanced gastrointestinal flora and promote the use of nitrogenous waste (urea, ammonia).
- Highly appetising, easy to chew kibble.

Indications

- Chronic renal failure

Therapeutic goals

- Limit the production of toxic waste products
- Support renal function and slow the progression of the disease
- Maintain adequate food intake and the animal’s body condition and quality of life.

Nutritional support of joint disease

Arthritis is a common problem in dogs and it may even affect young animals. A clinical diet targeted at achieving and maintaining optimal body weight and formulated with joint supplements can limit the severity of the symptoms and their frequency. This dietary change can be accompanied by a reduction in medical treatment and an increase in the animal’s mobility and well being.

Key points required in the clinical diet:

- A reduced energy density to limit the risk of weight gain.
- Joint supplements (chondroitin, glucosamine)
- Omega-3 essential fatty acids: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA).
- Carefully selected, very high quality proteins
- Antioxidants to delay cellular ageing

Indications

- Support the articular mobility of the dog (arthritis, elderly animals)
- Dysplasia

Therapeutic goals

- Control existing inflammation with omega-3 fatty acids
- Protect the cartilage and stimulate the metabolism of the articular cells
- Improve and maintain the dog’s mobility.

Nutritional support of convalescence

Over the course of cachectic diseases (diseases accompanied by weight loss), such as heart failure, cancer or during convalescence, a specifically formulated clinical diet for intensive care is essential to maintain the animal’s lean body mass (muscles, bones and organs). These diets are composed of ingredients of the highest quality and are formulated to stimulate the animal’s appetite (high energy density, highly appetising).

Key points required in the clinical diet:

- High energy density
- A high intake of essential nutrients
- Highly appetising
- Antioxidants to combat oxidative stress
- A consistency that enables administration via a feeding tube, or with a syringe directly into the animal’s mouth if necessary.

Indications

- Malnutrition
- Anorexia
- Convalescence

Therapeutic goals

- Meet the animal’s nutritional requirements in a small volume
- Stimulate the appetite
- Easy to eat by licking
- Support immune functions
- Promote healing and cellular regeneration

© The Dragon/Fotolia
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The importance of clinical nutrition
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