1 5186042966900211988
1 5186042966900211988
1 5186042966900211988
Edited by
Martha G. Cline
Maryanne Murphy
CRC Press
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We would like to dedicate this book to our spouses, B.J. and Cormac, for their
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We would also like to dedicate this book to Colm, Clara, Ryder, Lennert, Jaxen,
and Yona.
Contents
Preface ix
Editors xi
Contributors xiii
Index 209
vii
Preface
Veterinary medicine is facing a critical epidemic. Overweight and obese dogs and
cats have a decreased quality of life, shortened life span, increased risk of other
disease, and an overall increased cost of veterinary care. Veterinary professionals,
from nurses to boarded specialists, should become fluent in the language of this
epidemic.
General practice veterinarians and veterinary nurses are the target audience
for this textbook . We began our careers after residency in a large private practice
where specialists practiced veterinary medicine alongside general practitioners.
Although many excellent resources regarding pet obesity exist, we saw a need to
develop a comprehensive text to equip veterinary professionals on the first line.
We also hope that those with a keen interest in veterinary nutrition will find this
text an extensive resource of recent literature.
We would like to acknowledge the contributions of our authors. They manage
pet obesity in clinical practice. They contribute to our body of knowledge
surrounding pet obesity through research and publication. They educate future
and current veterinary professionals on all aspects of obesity in veterinary
medicine. The diverse experience and knowledge of these experts make this a
beneficial resource for any veterinary professional.
Martha G. Cline
Maryanne Murphy
ix
Editors
Dr. Martha G. Cline received her BS in biology from Lipscomb University in 2005
and her DVM from the University of Tennessee College of Veterinary Medicine in
2010. She subsequently completed a small animal rotating internship at Oradell
Animal Hospital in New Jersey followed by a small animal clinical nutrition
residency at the University of Tennessee. Dr. Cline became a Diplomate of the
American College of Veterinary Nutrition in 2013 and then joined the staff at
Red Bank Veterinary Hospital in Tinton Falls, NJ where she continues to practice
clinical nutrition full time. Dr. Cline is the current President (2017–2019) of the
American Academy of Veterinary Nutrition and has served on its Executive Board
since 2013.
Dr. Maryanne Murphy received her dual BS in animal sciences and biological
sciences from Rutgers University in 2004 and her DVM from Iowa State
University in 2008, following which she completed a rotating general medicine
and surgery internship at Fifth Avenue Veterinary Specialists in New York City
and a clinical nutrition residency at the University of Tennessee. Dr. Murphy
became a Diplomate of the American College of Veterinary Nutrition in 2013
and earned her PhD in Comparative and Experimental Medicine from the
University of Tennessee in 2014. The focus of Dr. Murphy’s dissertation research
was energy metabolism and satiety in lean and obese dogs. She joined the staff
of Red Bank Veterinary Hospital in Tinton Falls, NJ as a clinical nutritionist and
then transitioned back to academia at the University of Tennessee in 2016 where
she is a Clinical Assistant Professor of Nutrition. Dr. Murphy is currently Vice
President of the American College of Veterinary Nutrition (ACVN).
xi
Contributors
xiii
xiv Contributors
Maryanne Murphy, DVM, PhD, DACVN Justin Shmalberg, DVM, DACVN, DACVSMR
Department of Small Animal Clinical Department of Comparative,
Sciences Diagnostic, and Population
College of Veterinary Medicine Medicine
University of Tennessee College of Veterinary Medicine
Knoxville, Tennessee University of Florida
Elizabeth Orcutt, DVM, MS, DACVIM Gainesville, Florida
Red Bank Veterinary Hospital Moran Tal, BSc, DVM, DVSc
Tinton Falls, New Jersey Department of Clinical Studies
Valerie J. Parker, DVM, DACVIM, DACVN Ontario Veterinary College
Department of Veterinary Clinical University of Guelph
Sciences Guelph, Ontario, Canada
College of Veterinary Medicine Adronie Verbrugghe, DVM, PhD, DECVCN
The Ohio State University Department of Clinical Studies
Columbus, Ohio Ontario Veterinary College
Angela Witzel Rollins, DVM, PhD, DACVN University of Guelph
Department of Small Animal Clinical Guelph, Ontario, Canada
Sciences Claudia Wong, DVM
College of Veterinary Medicine Department of Clinical Studies
University of Tennessee Ontario Veterinary College
Knoxville, Tennessee University of Guelph
Megan Shepherd, DVM, PhD, DACVN Guelph, Ontario, Canada
Department of Large Animal Clinical
Sciences
Virginia-Maryland College of
Veterinary Medicine
Blacksburg, Virginia
1
Epidemiology of small
animal obesity
ADRONIE VERBRUGGHE
1.1 Definition 1
1.2 Prevalence and time trends 1
1.3 Risk factors 2
1.3.1 Animal-specific factors 2
1.3.1.1 Genetics and breed 2
1.3.1.2 Age 2
1.3.1.3 Gender and neutering 7
1.3.2 Human-specific factors 8
1.3.2.1 Diet type and feeding method 8
1.3.2.2 Physical activity 9
1.3.2.3 Owner attitudes and household characteristics 9
1.4 Conclusion 10
References 10
1.1 DEFINITION
Obesity results from a chronic positive energy balance, when caloric intake
exceeds caloric needs, leading to excess body weight as body fat accumulates
(1–3). Overweight pets are 10%–20% above ideal body weight; obese pets are
more than 20% above ideal (4). Body composition studies note 25%–35% body fat
is considered overweight and >35% obese (5,6). These obesity definitions should
also include a component of disease, as excess body fat modifies bodily functions
and contributes to disease processes (1–3).
59.4% (Table 1.1) (7–20). In cats, the prevalence rate ranges from 11.5% to 63.0%
(Table 1.2) (10,21–32).
The presented data, however, has many limitations. The available studies spread
a large time span and may not reflect the situation today. Moreover, studies have
been conducted in a limited number of veterinary practices or were performed
in very specific pet populations, using a variety of techniques to estimate body
condition leading to various definitions of overweight/obesity. Also the person
assessing the pet’s body condition varies among studies.
Differences between countries and time trends are therefore difficult to
investigate. A relatively constant distribution of body condition was noted in a
cat population over a 4-year timespan (22,23). Also cat households surveyed in
the same city in 1993 and 2007 did not show a difference of obesity prevalence
(26,31).
1.3.1.2 AGE
The obesity prevalence increases with age (8,11–13,18,22,31), due to decreasing
energy requirements especially as physical activity declines and age-related
body composition changes cause the basal metabolic rate to drop (37,38). Harper
described a 20% decrease in dogs, yet observed constant energy requirements
throughout adult life in cats (37). Bermingham et al. could however not confirm
a decline of energy requirements in aging dogs (39), yet did find an age-related
reduction of energy expenditure in cats (40). Epidemiological studies report the
highest prevalence of obesity in the middle-aged years for both dogs (12,14,18) and
Table 1.1 Prevalence of obesity in various canine populations in various countries over 55-year time period (from 1960 to 2015)
Sample
Authors Year Country Population size Evaluation method Prevalence rate
Krook et al. (7) 1960 Sweden Canine necropsies 10,993 Pathologist Obese: 11.2%
Presence of pathologic adiposity
Mason (8) 1970 UK One veterinary practice 1000 Attending veterinarian Obese: 28.0%
3-point scale: thin, normal or obese, fat
covering thorax
Edney and 1986 UK 11 veterinary practices, 8268 Attending veterinarians Obese/gross:
Smith (9) ranging from veterinary 5-point scale: thin, lean, optimum, 24.3%
schools to private obese, gross
practices
Lund et al. (10) 1999 USA 52 veterinary practices 86,772 Attending veterinarians BCS ≥4/5: 28.3%
5-point scale: fat covering ribs and tail
base and abdominal contour.
Robertson (11) 2003 Australia 2326 households, 657 Owners Overweight/
telephone survey 3-point scale: underweight, correct obese: 25.2%
weight, overweight/obese
McGreevy 2005 Australia 209 veterinary practices 2661 Attending veterinarians: BCS ≥4/5: 1.1%
et al. (12) 5-point scale: Hill’s weight guide chart
for dogs and cats showing silhouettes
Colliard et al. 2006 France Vaccination service of 616 Attending veterinarian BCS ≥4/5: 38.8%
(13) veterinary school 5-point scale, adapted from Laflamme (5)
(Continued)
1.3 Risk factors 3
Table 1.1 (Continued) Prevalence of obesity in various canine populations in various countries over 55-year time period (from 1960 to 2015)
Sample
Authors Year Country Population size Evaluation method Prevalence rate
Lund (14) 2006 USA 52 veterinary practices
21,754 Attending veterinarians BCS ≥4/5: 34.1%
5-point scale: fat covering ribs and tail
base and abdominal contour
Courcier et al. 2010 UK One charitable and 4 696 Attending veterinarians or student S.H.A.P.E.TM
(15) private first-opinion veterinarians ≥5/7: 59.4%
veterinary practices Morphometric technique adapted from a
7-point scale S.H.A.P.E.TM score (74)
Sallander et al. 2010 Sweden Owners of pure-bred, 461 Owners Obese/very obese:
(16) dogs registered with 5-point scale: very lean, lean, normal, 16.0%
4 Epidemiology of small animal obesity
Sample
Authors Year Country Population size Evaluation method Prevalence rate
Sloth (21) 1992 Denmark One veterinary practice 233 Attending veterinarian Overweight/
4-point scale: underweight, normal obese: 40.0%
weight, overweight, obese weight
Scarlett et al. (22) 1994 USA 31 veterinary practices 2091 Attending veterinarians Heavy/obese:
6-point scale: cachectic, lean, 25.0%
optimal-lean, optimal, heavy, and
obese using silhouettes
Donoghue and 1998 USA 27 veterinary practices, 1654 Attending veterinarians Heavy/obese:
Scarlett (23) information from 6-point scale (22) 24.5%
previously studied cats
(22)
Lund et al. (10) 1999 USA 52 veterinary practices 42,774 Attending veterinarians BCS ≥4/5: 27.5%
5-point scale: fat covering ribs and
tail base and abdominal contour,
adapted from Scarlett et al. (22)
Robertson (24) 1999 Australia 2195 households, tele- 644 Owner Overweight/
phone survey 3-point scale: underweight, correct obese: 18.9%
weight, overweight (obese)
Russell et al. (25) 2000 UK Households, door-to-door 136 Experienced assessor Overweight/
visit 17-point scale adapted from obese: 52%
Laflamme (6)
(Continued)
1.3 Risk factors 5
Table 1.2 (Continued) Prevalence of obesity in the feline population in various countries, and time trends over 23 years (from 1992 to 2015)
Sample
Authors Year Country Population size Evaluation method Prevalence rate
Allan et al. (26) 2000 New Zealand 492 households, door-to- 182 Experienced assessor Overweight/
door survey 3-point scale: normal weight, obese: 25.8%
overweight, obese, assessing
inguinal, abdominal and subcuta-
neous fat
Lund et al. (27) 2005 USA 52 veterinary practices 8159 Attending veterinarians BCS ≥4/5: 35.1%
5-point scale: fat covering ribs and
abdominal contour
Colliard et al. (28) 2009 France Vaccination service at 385 Attending veterinarian BCS ≥4/5: 26.8%
6 Epidemiology of small animal obesity
3%
Small
animal
obesity
97%
Figure 1.1 Risk factors of small animal obesity, including animal-specific and
human-specific factors. Percentages according to Bland et al. (33).
cats (22,24,27,28,30). The obesity frequency declines after about 10 years of age
(12,22), as overweight animals may have a shorter lifespan because of detrimental
health effects (41).
postneutering in queens (49,50) and bitches (51). Also resting energy expenditure
is 30% lower after gonadectomy in cats of both genders (52,53). At last, neutering
also leads to a reduction in spontaneous activity, because of decreased roaming
and sexual behavior, especially among males (54,55).
that children may give too many treats or overfill the food bowl; yet living with
one child was reported to lower the obesity risk in cats (28). Also households with
only one dog (11) or only one or two cats (22,24) showed a higher risk, while the
presence of dogs reduced the risk of cats to become obese (26).
Owners underestimating their pet’s body condition (8,13,15,26,28,29,31,60,65,66)
is another reason to overfeed and has been identified to be a major factor in feline
obesity (26,28,29,31). For example, owners who consider their normal weight
cats to be underweight may be encouraged to feed more (28) and if owners don’t
perceive their pet to be overweight, owners will not be motivated to reduce the
pet’s energy intake (31). Likewise, if informed by their veterinarian that their dog
is overweight, owners may be either reluctant to accept this judgment or may not
think this is an important concern (65).
1.4 CONCLUSION
Numerous risk factors including animal-specific factors and human-specific
factors are involved in pet obesity, making for a disease that is often hard to tackle.
Risk factors should be identified by a thorough nutritional assessment in every pet
at every veterinary health exam to prevent weight gain or to achieve weight loss.
Animal-specific factors can be targeted in individualized calculations of daily
energy requirements. However, of utmost importance is owner education and
elimination of human-specific factors, such as dietary factors, physical activity,
owner attitudes, and household characteristics, which contribute the most to the
obesity epidemic.
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1. German AJ. The growing problem of obesity in dogs and cats.
The Journal of Nutrition 2006;136(7 Suppl):1940S–1946S.
2. Laflamme DP. Understanding and managing obesity in dogs and
cats. Veterinary Clinics of North America: Small Animal Practice
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4. Burkholder WJ. Use of body condition scores in clinical assessment of the
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5. Laflamme D. Development and validation of a body condition score
system for dogs. Canine Practice 1997;22(4):10–15.
6. Laflamme D. Development and validation of a body condition score
system for cats: A clinical tool. Feline Practice 1997;25(5–6):13–18.
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obesity, and pyometra in the dog. American Journal of Veterinary
Research 1960;21:120–127.
References 11
24. Robertson ID. The influence of diet and other factors on owner-perceived
obesity in privately owned cats from metropolitan Perth, Western
Australia. Preventive Veterinary Medicine 1999;40(2):75–85.
25. Russell K, Sabin R, Holt S, Bradley R, Harper EJ. Influence of feeding
regimen on body condition in the cat. The Journal of Small Animal
Practice 2000;41(1):12–17.
26. Allan FJ, Pfeiffer DU, Jones BR, Esslemont DHB, Wiseman MS.
A cross-sectional study of risk factors for obesity in cats in New Zealand.
Preventive Veterinary Medicine 2000;46(3):183–196.
27. Lund EM, Armstrong PJ, Kirk CA, Klausner JS. Prevalence and risk
factors for obesity in adult cats from private US veterinary practices.
International Journal of Applied Research in Veterinary Medicine
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28. Colliard L, Paragon BM, Lemuet B, Bénet JJ, Blanchard G. Prevalence
and risk factors of obesity in an urban population of healthy cats.
Journal of Feline Medicine and Surgery 2009;11(2):135–140.
29. Courcier EA, O’Higgins R, Mellor DJ, Yam PS. Prevalence and risk factors
for feline obesity in a first opinion practice in Glasgow, Scotland. Journal
of Feline Medicine and Surgery 2010;12(10):746–753.
30. Courcier EA, Mellor DJ, Pendlebury E, Evans C, Yam PS. An investigation
into the epidemiology of feline obesity in Great Britain: Results of a
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17
18 Pathophysiology of obesity
why has obesity reached epidemic proportions in both humans and companion
animals? Studies evaluating twins and family associations find genetics account
for approximately 65% of the variance in obesity and body mass index (BMI) in
people (1–6). It also appears that most of the remaining variance in BMI results
from differences in individuals rather than shared environmental effects (1). In
dogs, certain breeds (see Chapter 1) have higher rates of obesity than others (7).
While genetics certainly play a role regarding individual variation of adiposity,
the dramatic increase in obesity rates over the past 50 years cannot be fully
attributed to genetic changes alone. The prevalence of obesity in U.S. adults has
more than doubled since the early 1960s, increasing from 13.4% to 35.7% (8,9).
While most experts agree our modern societal changes in food availability and
sedentary behaviors have combined with a susceptible genetic background to
create the perfect scenario for weight gain, several theories to further clarify this
relationship exist.
Arcuate nucleus of
the Hypothalamus
AgRP and
POMC/CART
NPY
Orexigenic –
increased appetite
Anorexigenic – Secondary
reduced appetite neuron
Central and
peripheral
tissues
Figure 2.1 Central appetite control occurs within the arcuate nucleus of
the hypothalamus. Neurons expressing proopiomelanocortin (POMC) and
cocaine- and amphetamine-regulated transcript (CART) neuropeptides reduce
appetite and increase energy expenditure and are termed anorexigenic.
Neurons expressing agouti-related protein (AgRP) and neuropeptide Y (NPY)
increase appetite while decreasing energy expenditure and are termed
orexigenic.
●● Basal metabolism
●● Thermogenesis
●● Physical activity
●● Anabolic development—growth, pregnancy, lactation
has been established (100,101). The majority of investigations of the obese gut
microbiota have been carried out in humans and rodents. Generally, the gut
microbiota of obese individuals is characterized by a reduced diversity (102–106).
The taxa-level alterations, such as the abundance of Firmicutes phylum members
in the gut or feces of obese versus lean individuals of the same species, varies
between studies. For the dog, signatures of obese versus lean lack consistency
across the few studies published (107,108). The variation across studies could be
due to variation across study cohorts, such as client-owned versus colony dogs
or the effect of environment on gut microbes (109). Furthermore, the variation
could also be explained by the lack of consensus in methods for evaluating the
complex gut, or often fecal, microbiota (110). Employing gut microbes in disease
management is challenging because the membership of the gut microbiota
does not directly reflect function as there are conserved functions across broad
bacterial taxonomic groups. Proposed mechanisms by which gut microbes
may influence obesity include altered digestion and dietary energy extraction,
enhanced lipogenesis and fat storage, and appetite regulation (100,105,111–114);
these mechanisms have not yet been studied in the dog or cat.
2.4 CONCLUSION
Although it is easy to describe obesity as the result of energy intake exceeding
energy expenditure, it is clear that such a relationship is complex and affected by
a myriad of factors. The genetic makeup and environment of our patients play
enormous roles in the development of excess adipose tissue. For example, the
middle-aged, hypothyroid Labrador retriever will likely have to consume fewer
calories per kilogram to maintain a lean body weight compared to a young-
adult Weimaraner. We also now realize that obesity has systemic effects on the
entire body, and the pro-inflammatory state produced by excess adipose tissue
contributes to chronic illnesses such as cancer and diabetes mellitus. By better
understanding the causes and consequences of obesity, veterinarians will be
better able communicate with pet owners and devise effective weight loss plans.
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3.1 Introduction 40
3.2 Obesity and life span 40
3.3 Obesity paradox 40
3.4 Endocrine disease 42
3.4.1 Diabetes mellitus 42
3.4.2 Canine diabetes mellitus 42
3.4.3 Feline diabetes mellitus 43
3.4.4 Hyperadrenocorticism 44
3.4.5 Hypothyroidism 44
3.4.6 Hyperlipidemia 44
3.5 Cardiovascular and respiratory disease 45
3.5.1 Congestive heart failure and cardiovascular disease 45
3.5.2 Hypertension 46
3.5.3 Collapsing trachea 46
3.6 Renal and urinary disease 46
3.6.1 Renal disease 46
3.6.2 Urinary disease 47
3.7 Orthopedic and neurologic disease 48
3.7.1 Orthopedic disease 48
3.7.2 Neurologic disease 49
3.8 Neoplasia 49
3.9 Anesthetic considerations 50
3.9.1 Obesity-induced alterations in physiology 50
3.9.1.1 Respiratory pathophysiology 50
3.9.1.2 Cardiovascular pathophysiology 51
3.9.1.3 Other organ dysfunction 52
39
40 Pathophysiology of obesity
3.1 INTRODUCTION
The associations between body weight and many comorbidities have been
studied. This chapter will review some of these relationships in dogs and cats as
well as provide recommendations for management. In addition, perianesthetic
management of obese patients will be considered.
of the obesity paradox in people have shown a linear relationship between body
weight and survival (8,9), although some have demonstrated a U- or J-shaped
curve, with people having the highest body weight also having decreased survival
(10,11).
In veterinary medicine, the obesity paradox has been investigated in dogs and
cats with cancer (12), heart failure (13,14), and chronic kidney disease (CKD)
(15,16). Dogs with heart failure that gained body weight had longer survival times
compared to those that lost or maintained body weight (13). In CKD dogs, those
with a thin BCS (≤3/9) had significantly shorter survival than dogs with a BCS ≥4
(15). Additionally, cats with a body weight of <4.2 kg at the time of CKD diagnosis
had a significantly shorter survival time compared to cats ≥4.2 kg (16).
In cats with cancer, both body weight and BCS were significantly associated
with survival (12). In cats with heart failure, cats with low body weight had shorter
survival times compared to cats with moderate body weights. However, cats with
the highest body weights also had reduced survival times, suggesting a U-shaped
relationship between body weight and survival (4). Similar findings were found
in cats with CKD; a J-shaped survival curve was documented (Figure 3.1) (16).
The mechanism by which overweight and obesity exert a protective effect
in these varied diseases is not completely understood, but several theories are
10
8
7
6
5
4
3
Hazard ratio
1 2 3 4 5 6 7 8 9 10
Weight (kg)
Figure 3.1 Hazard ratio based on body weight at the time of diagnosis of
chronic kidney disease of 569 cats. Dotted lines indicate the 95% confidence
interval. Cats with the lowest and highest body weights at the time of
diagnosis of CKD have shorter survival times than cats with more moderate
body weights (P < 0.0001). (Adapted from Freeman LM et al., Journal of
Veterinary Internal Medicine 2016;30:1661–1666.)
42 Pathophysiology of obesity
presenting in a state of obesity should have a dietary plan to help with controlled
weight management in conjunction with appropriate medical management.
3.4.4 Hyperadrenocorticism
Hyperadrenocorticism (HAC) is a common endocrinopathy affecting middle
aged to older dogs. The development of visceral obesity and abdominal distension
is a classic clinical sign of HAC. Visceral adiposity and HAC may be associated
with changes in adipokine and hormone production. Overweight dogs with
pituitary-dependent hyperadrenocorticism (PDH) had higher concentrations
of leptin and insulin compared to overweight dogs without PDH (38). Leptin
concentrations were linearly associated with serum cortisol concentrations in
this same study. It has been suggested in people (39) that hyperleptinemia has
inflammatory, thrombotic, and oxidative effects that may play a role in the
progression and occurrence of complications related to HAC; however, further
studies are needed to evaluate this relationship in the dog. Following treatment
with trilostane, concentrations of insulin and leptin were reduced but still higher
when compared to controls, which may be the result of intermittent periods of
hypercortisolism and higher visceral fat content when compared to controls (38).
Changes in adiponectin are inconsistent between studies with one study reporting
decreased concentrations in dogs with PDH and another reporting no difference
when compared to controls with a similar BCS (38,40). The latter study reported
this lack of significance may be due to the small study population.
Treatment of HAC with trilostane resulted in significant decreases in body
weight and BCS in overweight dogs (38). Changes to diet or purposeful weight
management were not reported in this study. Weight reduction in addition to
medical management of HAC to reduce visceral adiposity and potentially improve
control of disease has not been investigated. Hyperlipidemia is often associated
with HAC in addition to visceral adiposity, therefore diet change to aid in the
management of this disease is reasonable.
3.4.5 Hypothyroidism
Thyroid hormone is necessary for all normal metabolic functions throughout
the body, therefore hypothyroidism affects the metabolic function of almost all
organ systems. Clinical signs seen with metabolic derangements associated with
hypothyroidism include lethargy, exercise intolerance, and weight gain without
increased appetite or food intake. Energy expenditure in hypothyroid dogs was
noted to be 15% less compared with normal dogs that returned to normal after
treatment (41). Achieving weight loss in hypothyroid dogs first should focus on
restoration of euthyroidism to improve energy expenditure. If desired weight loss
is not achieved with normalization of thyroid hormone alone, further nutritional
management is recommended.
3.4.6 Hyperlipidemia
Hyperlipidemia in the dog and cat refers to the increase of plasma or serum
cholesterol and/or triglycerides. Causes of fasting hyperlipidemia can either
be a primary disorder of lipid metabolism or secondary to other disease
3.5 Cardiovascular and respiratory disease 45
between body weight and survival with reduced survival times in cats with the
lowest and highest body weight (14).
Obesity is not associated with the development of coronary artery disease
in the dog or cat as it is in people (52). Dogs and cats lack significant activity
of the enzyme cholesterol ester transfer protein (CETP) responsible for the
transfer to cholesterol esters from high-density lipoproteins (HDL) to very low-
density lipoproteins (VLDL), and low-density lipoproteins (LDL). This results in
the transfer of cholesterol esters to the liver by HDL molecules rather than the
peripheral tissues.
3.5.2 Hypertension
The association between canine obesity and hypertension is debatable. Although
a few studies have documented that obesity may induce hypertension (53,54), this
finding is not universal. In one study where there was no association between
BCS and hypertension, the authors suggested that it is possible that obese dogs
are more likely to have comorbidities that may induce hypertension (e.g., cardiac
disease, endocrinopathies) (55). Most authors have concluded that the effect, if
present is typically minor and does not usually require specific antihypertensive
therapy (56,57). No association in cats has been documented between obesity and
hypertension (49).
those with an ideal or high BCS (61). Cats with a body weight >4.2 kg at diagnosis
had a significantly longer survival time than cats with a body weight <4.2 kg at
diagnosis (16).
In dogs, despite evidence that having a BCS ≥4/9 may offer some longevity
benefit (15), obesity has been shown to induce adverse renal effects. Experimentally
induced obesity in dogs increased arterial blood pressure and activation of the
renin–angiotensin system. It caused glomerular hyperfiltration and histologic
changes consistent with glomerular injury (62). It has yet to be determined if
obesity is a significant risk factor in dogs and cats for development of naturally
occurring renal disease.
One study evaluated the impact of weight loss in 37 obese dogs on indicators
of renal function (63). After weight loss, urea and urine specific gravity were
increased. Urine protein:creatinine (UPC) ratio, urine albumin:creatinine
(UAC) ratio, and creatinine were decreased after weight loss. Three novel
biomarkers of renal function (homocysteine, cystatin C, and clusterin) all
decreased with weight loss. The authors concluded that canine obesity could
result in subclinical alterations in renal function, which can improve with
weight loss (63). In contrast, another study found no association between UPC
and BCS in dogs (BCS 4–5/9 versus BCS >6/9) (64). This study was unable to
differentiate between overweight and obese BCS due to the limited sample size.
If an overweight/obese animal has significant proteinuria, it may be warranted
to consider use of a lower protein low calorie diet to achieve weight loss while
not exacerbating proteinuria.
3.8 NEOPLASIA
Neoplasia is a broad disease group, with diverse findings regarding body
composition and its relationship to disease prevalence and outcome. In a large
prospective population-based study that followed 196 Leonbergers from birth to
death, prevalence of primary bone tumors was assessed. Of the 196 dogs, 9 died
from primary bone cancer. Those dogs were heavier during the growth period
and early adult life, suggesting a possible influence of body composition on
development of bone tumors (92). In a study of 325 dogs with splenic masses, the
diagnosis of hemangiosarcoma was significantly less in dogs weighing ≤27.8 kg
versus those weighing >27.8 kg (93). Overweight or obesity in dogs has been
associated with a higher risk of development of mammary carcinoma, possibly
due to tumor–adipocytes interactions and hormonal receptor-related tumor
growth (94,95). Decreased adiponectin expression and increased macrophage
numbers in overweight or obese dogs with mammary tumors were significantly
correlated with factors related to a poor prognosis, such as high histologic grade
and lymphatic invasion (94). When body composition is more closely assessed,
there is a large range of BCS identified in dogs with cancer, likely dependent on the
underlying neoplasm as well as comorbid diseases. In one study of 1777 dogs with
cancer, the mean BCS was 5.3/9 (96). In another study, significantly more dogs
were classified as being overweight (BCS ≥7/9%, 29%) versus underweight (BCS
≤3/9%, 4%) (97). Muscle loss (i.e., cachexia) was much more commonly observed
in cats with various neoplasms than specifically a lower BCS (12).
In a study of cats with cancer, having a body weight >5 kg and/or BCS of ≥5/9
was significantly associated with better survival (12). In dogs diagnosed either
with lymphoma or osteosarcoma, having a lower BCS at diagnosis was associated
with a shorter survival time. Weight gain during treatment was associated with
increased survival (98).
Before implementation of a purposeful weight loss plan in a cat or dog with
obesity and neoplasia, a complete individual patient assessment should be
performed, including cancer stage, clinical signs, and prognosis. One primary goal
of weight loss in patients with neoplasia should be to improve quality of life. For
50 Pathophysiology of obesity
example, in an obese dog that has undergone limb amputation for a primary bone
tumor, weight loss may be imperative to improve the patient’s mobility. In animals
with neoplasms that are more prone to induce cachexia (e.g., gastrointestinal
lymphoma), purposeful weight loss is likely only of benefit if the animal has
comorbidities affected by overweight or obesity (e.g., significant respiratory
compromise or osteoarthritis). Otherwise, it seems prudent to allow those animals
to maintain a bit of excess weight, due to the obesity paradox phenomenon.
dogs and cats) increases expiratory flow limitations in obese humans. Airway
hyperreactivity has been documented in obese beagles and may be governed by
the systemic inflammatory state created by obesity; however, this finding was not
replicated in obese cats (106,108).
Reduced respiratory compliance and lung volumes cause inequalities in
distribution of ventilation and perfusion that can affect respiratory gas exchange.
Hypoxemia at rest can be documented in obese humans, but a small study
of 12 subjects did not confirm this finding in conscious obese dogs (108). In
a clinical study of heavily sedated obese dogs, hypoxemia requiring oxygen
supplementation was documented. The partial pressure of arterial oxygen (PaO2)
was improved and required oxygen supplementation decreased after weight loss,
especially with decreased thoracic fat deposits as evidenced by dual-energy x-ray
absorptiometry (109).
In order to maintain minute ventilation and avoid hypercapnia, respiratory
rates are increased in obese humans and dogs (105,108,109). However, due to
chronic reduction in respiratory compliance combined with increased airway
resistance, ventilatory responses to carbon dioxide concentrations decline and
obesity hypoventilation syndrome can develop. Supplementation of oxygen in
the perioperative period can decrease ventilatory drive even further, and the
anesthetist should be prepared to manually or mechanically support ventilation.
Hypercapnia was not documented in 12 obese conscious dogs but the syndrome
has not been specifically studied in companion animals (105).
Preoxygenation, recommended for all patients, is especially important for
obese animals, as they may desaturate quickly upon induction of anesthesia.
End-tidal expiratory carbon dioxide is a noninvasive and easily applied method
for monitoring adequacy of ventilation during anesthesia. Manual or mechanical
ventilation may be required in obese patients. Upper airway dysfunction may
become especially relevant in the postanesthetic period. Obese patients should be
monitored closely during recovery, and consideration should be given for oxygen
supplementation during this time.
3.9.1.2 CARDIOVASCULAR PATHOPHYSIOLOGY
Experimentally induced obesity in dogs causes a sustained increase in
sympathetic activity, increased resting heart rate, and decreased heart rate
variability, eventually leading to systemic hypertension (110). Heart rate during
rest and exercise are higher in obese dogs (BCS ≥8/9) compared to lean (BCS
5/9) or merely overweight subjects (BCS 6–7/9) (105). Obesity has not been
identified as a risk factor for systemic hypertension in a clinical population of
dogs; however, a 5-point BCS was used in this study and an exact description
of how the subjects were scored was not described (55). A separate study
documented higher systolic arterial blood pressures (SAP) as measured by a
Doppler device in obese (BCS ≥7/9) versus lean (BCS ≤6/9) dogs (111). The
Mean ± SD for SAP for obese dogs was 153 ± 19 mm Hg, whereas it was
133 ± 20 mm Hg for lean dogs. Although these values were not significantly
different, more obese dogs were classified as having moderate risk of end organ
damage than lean dogs.
52 Pathophysiology of obesity
(115). Most anesthetics and sedatives are lipophilic and may therefore experience a
greater volume of distribution in obese patients. Tissue blood flow is also altered by
obesity, with increases in blood volume and cardiac output due to higher metabolic
demands of excess adipose tissue. In addition, cardiac dysfunction may alter tissue
blood flow and drug distribution. These changes may result in an increased volume
of distribution. Albumin binding of drugs appears to be unchanged in obesity, but
uncertainty about alpha-1 acid glycoprotein binding of basic drugs exists (116).
Various recommendations have been made for alterations in bolus dosing of
sedatives and anesthetics in obese human patients, including using ideal body
weight for hydrophilic drugs, total body weight for lipophilic drugs, and an
adjusted body weight (typically ideal body weight plus 20%–40%) for drugs that
distribute to both adipose and lean tissue (117). Unfortunately, very little data
supports these suggestions, as most pharmacokinetic studies are conducted in
nonobese humans. Ideally, recommendations would be based on species-specific
pharmacokinetic studies carried out in obese subjects. To date, only one study
in dogs has investigated alterations in anesthetic drug requirements due to
increased fat mass. This was a clinical study in which pharmacokinetic data were
not collected. Based on total body weight, a lower dose of propofol (1.8 ± 0.4 mg/
kg) was required in overweight and obese dogs versus normal weight controls
(2.2 ± 0.5 mg/kg) following premedication with medetomidine and butorphanol
(118). Lacking more rigorous evidence, the best approach is to carefully titrate
initial bolus doses of injectable sedatives, analgesics, and anesthetics to effect.
3.10 CONCLUSION
Obesity can have a negative impact on life span, but the presence of excess body
weight may actually improve survival times with cancer, heart failure, and
CKD. Many endocrine, cardiovascular, respiratory, renal, urinary, orthopedic,
neurologic, and neoplastic diseases will benefit from weight loss in overweight
or obese cats and dogs, but consideration must be given to the level of weight
loss required when the specific disease is associated with the obesity paradox.
Patients with excess body weight also deserve additional considerations when
undergoing anesthesia due to obesity-induced changes in organ system function,
pharmacotherapeutic issues, and logistical challenges.
54 Pathophysiology of obesity
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References 61
4.1 Introduction 64
4.2 Carcass analysis of body composition 64
4.3 Imaging modalities to assess body composition 66
4.3.1 Dual energy x-ray absorptiometry (DEXA) 66
4.3.2 Computer tomography (CT) 68
4.3.3 Magnetic resonance imaging (MRI) 68
4.4 Nonimaging-based modalities to assess body composition 70
4.4.1 Deuterium oxide dilution technique 70
4.4.2 Bioimpedance 70
4.5 Estimating body composition in a clinical setting 71
4.5.1 Body weight 71
4.5.2 Morphometric measurements 71
4.5.2.1 Body mass index (BMI) 71
4.5.2.2 Novel morphometric equations 72
4.5.3 Morphologic estimates 73
4.5.3.1 Body condition scoring 73
4.5.3.2 Canine and feline body fat index (BFI) 74
4.6 Clinical recommendations for general practice 75
4.7 Conclusion 75
References 75
63
64 Evaluation of body composition to diagnose obesity
4.1 INTRODUCTION
A failure to recognize an overweight/obese status is likely a main contributing
factor to obesity being the main nutritional disorder in dogs and cats. Owners are
often unable to correctly assess the degree of obesity in their pet, and especially
in overweight and obese pets, they tend to underestimate the body condition
score (BCS) (1–5). This highlights the veterinarian’s role in identifying pets as
overweight/obese to initiate appropriate preventative and treatment interventions.
However, in both large referral and smaller private veterinary clinics there is
generally a failure in recording the patient’s BCS and even if recorded, actions
in relation to a BCS below or above normal are often lacking (6–9). In response
to this, the World Small Animal Veterinary Association (WSAVA) introduced
“nutritional assessment” as the fifth vital sign in 2011 (10). For all pets visiting
a veterinarian, the clinician should always perform a nutritional assessment
including body condition scoring as well as measure body temperature, pulse
rate, respiration rate, and conduct pain assessment. Additionally, the American
Animal Hospital Association (AAHA) weight management guidelines from
2014 advises veterinarians to “monitor weight trends and proactively address
weight gain early at any BCS above the ideal” both during growth, post
gonadectomy, and at following yearly examinations (11). Currently, there are
several methods available for evaluating body composition in pets; some are
more objective but expensive and require specialized equipment, whereas
some are less expensive and easier to implement in a clinical practice setting.
To appropriately use the different tools, it is important to understand their
strengths and limitations, and be aware of the accuracy (the ability to provide
correct measurements reflecting the true or absolute value) and precision
(the ability to provide reliable and consistent measurements) relating to each
method. In the following we will describe and discuss the most commonly used
or best evaluated methodologies for ante- and postmortem evaluation of body
composition in dogs and cats.
affect results. These issues can, however, be addressed by estimating water loss
by weighing the animal before and after freezing, and by fasting, evisceration,
or emptying the gut prior to analysis (13). Because this methodology can only be
applied following euthanasia of the animal, it is mainly useful in research settings
and in validating other methods and not in veterinary practice.
Most other techniques for evaluating body composition are based on
indirect methods that use the model of the body being at least two chemically
distinct compartments, often including the fat and the fat-free mass (FFM)
(14). However, the measured compartments differ in methodologies used, as
illustrated in Table 4.1 (15).
Table 4.1 Body composition terms and their relation to common body
composition measurement methods used for dogs and cats
Essential fat
Extracellular water
Total body
water
Intracellular water
Lean soft Fat free
tissue mass mass/lean
body mass
Glycogen
Soft tissue mineral
Bone mineral
through the body. By using different algorithms, the DEXA scanner can
quantitate the different types of tissues for each pixel resulting in estimates
of total mass, bone mineral content, fat, and lean soft tissue mass (15,17,22).
The radiation burden during a DEXA scan is low (17). The physical concept
of DEXA and body composition has been described in detail in the review of
Pietrobelli et al. (20).
DEXA systems are produced by a limited number of manufacturers, and
although based on the same physical principles, they differ regarding the
generation of the high- and low-energy x-ray beams, the x-ray detectors, the
imaging geometry, the calibration methodology, and software algorithms (22).
The systems come with different software packages including analysis for small
animals, and pediatric and adult humans. Interdevice differences are therefore
inevitable and comparison of results for estimates of bone mineral content and
body composition should be performed with caution (23–25).
Validation of DEXA has been conducted by comparison to carcass chemical
analysis in several species (12,26–34). DEXA estimates of total mass and
scale measurements have consistently shown high correlation (12,28–33,35).
Investigation of canine body composition has revealed no significant difference
between percentage body fat or percentage fat-free mass as estimated by DEXA and
from chemical analysis (26). However, a significant difference has been observed
in bone mineral content between DEXA measurement and ash percentage (26).
Within the study of Speakman et al., strong correlation between estimates of
total body mass (r2 = 1.00), fat-free mass (r2 = 0.998), and fat mass (r2 = 0.964)
was found in both cats and dogs. Mean error for fat-free mass component was
2.64% and 2.04% for fat tissue. However, fat-free mass differences ranged from
−2.64% underestimation to 13.22% overestimation, while for fat mass it varied
from −20.7% underestimation to 31.5% overestimation, presumably related to
the muscular hydration status (12). Studies using pigs and piglets within the
weight range of cats and dogs have also shown high correlation between DEXA
measurements and chemical analysis, though substantial differences in absolute
fat mass have been observed (27–29,31–33). These differences have been suggested
to reflect differences between the different instrument manufacturers and
analyzing software (24,32), but also incomplete homogenization of the carcasses
for chemical analysis has been considered (27). Newer instruments, refinement
of software, and specific calibration factors have improved the accuracy further
(29,36,37). Validation studies in feline, canine, and porcine species have found that
the DEXA technique provides good precision in measuring body compartments
(26–28,32,38–40). However, consistently the determination of fat mass has the
poorest coefficient of variation (CV) reported, approaching 6% as shown in cats
in one study (38).
DEXA is often considered the second best after carcass analysis for body
composition analysis of cats and dogs. It has been used for determining intra-
and interbreed variation in body composition in a variety of dog breeds (12,26),
for estimation of body composition and weight changes in cats and dogs (40–44),
and for validation of other methods for assessment of body composition such as
bioimpedance, body fat index systems, and body condition scores (45–52).
68 Evaluation of body composition to diagnose obesity
by MRI has been conducted in cats (59) and whole-body fat–water MRI
(FWMRI) have been successfully applied in dogs before and after weight gain
in combination with semiautomatic image analysis (60). FWMRI estimates of
total mass were in accordance with scale weight (r2 = 0.867), and following
weight gain, significant increases in visceral, subcutaneous, and total adipose
tissue were shown. FWMRI was a precise method for measurement of total
adipose tissue, visceral tissue, lean tissue, and cortical bone with CV in the
range of 0.2%–3.1% (60).
Using a newer technique called quantitative magnetic resonance (QMR),
body composition measurements have been validated against D2O and DEXA
in dogs and cats showing that QMR is a promising tool for body composition
measurements, though significant underestimation of total body weight, lean
body mass, and fat mass was found in dogs when compared to D2O (61). In cats
a significant underestimation was only found for fat mass when compared to
D2O (62). Apart from being spared from ionizing radiation, the QMR method
can be performed in unsedated animals. By implementing appropriate correction
equations, QMR is promising as a tool for providing accurate assessment of body
composition (61,62).
Imaging modalities provide noninvasive measurements that are objective
and reproducible. Specialized equipment such as DEXA scanners, CT, and MRI
scanners, are limited to use at larger veterinary centers and university hospitals.
In addition, general anesthesia or sedation is often necessary, and some modalities
involve a radiation burden on both animal and staff (Figure 4.2).
4.4 N
ONIMAGING-BASED MODALITIES TO ASSESS
BODY COMPOSITION
4.4.1 Deuterium oxide dilution technique
The deuterium oxide (D2O) dilution technique is based on the fact that body
water is predominantly associated with nonfat tissue; thus, total body water
measurement provides an indirect measure of fat-free mass (13). Deuterium
oxide is a stable, nontoxic tracer that is freely exchangeable with water. Following
intravenous administration of a known quantity of D2O, it will, given time,
distribute uniformly throughout the different body water pools. When equilibrium
is reached, total body water can be assessed by measuring the degree of dilution
of the tracer in a blood sample (13,63). Based on the assumption that fat-free
mass contains 73.2% water, body fat percentage (BF%) can be calculated using the
following formula: BF% = 100 – percent total body water/0.732 (13,46,63). It has
been proposed that a possible loss of isotopes through pulmonary respiration and
urine is inevitable and could affect the results. However, in a study in dogs, urinary
loss was determined to be insignificant (13,63). Compared with carcass analysis,
D2O overestimated amount of body water by 21.8%, which was evaluated as
relatively high, and several equations could not be validated due to nonparametric
data. However, correlation based on proposed equations was good; percent body
water (r2 = 0.96), percent body fat (r2 = 0.96), percent nitrogen (r2 = 0.77), and
percent ash (r2 = 0.64) (13). Studies in dogs have revealed an overestimation of
body fat by DEXA scans in comparison to D2O around 13%–15.8%. Though
having lack of absolute agreement, the two methods showed a good correlation
(r2 = 0.78) (35,46). Taking the possible systematic underestimation of BF% into
account, most studies have shown an excellent relative agreement between the
D2O dilution technique, carcass analyses, and DEXA in both dogs and cats
(35,46,61–63). Time for isotope equilibration, however, affects results and should
be standardized (13,64).
The D2O dilution technique is a safe and noninvasive method for providing
quantitative measures for body composition in dogs and cats. It is, however,
expensive, requires hospitalization until equilibrium is reached, and therefore is
primarily used for research.
4.4.2 Bioimpedance
Bioimpedance (BIA) measures the resistance to an electrical signal through the
water contained in muscle and fat tissues. High muscle and low fat mass result
in a higher body water content that facilitates the flow of an electrical current
through the body. With more fat present, the resistance increases and the electrical
flow declines (65,66). The methodology is described as a safe, noninvasive, and
easy-to-use bedside test (65). However, it relies on the assumption that subjects
have similar body geometry as well as a constant composition of fat-free mass.
Hydration status and changes relating to altered body configuration such as
obesity may therefore significantly impact results (65,66). For estimating fat-free
4.5 Estimating body composition in a clinical setting 71
been proposed by Royal Canin (91), but these have to the authors knowledge not
yet been validated.
It should be noted that all BCS systems have been developed and validated on
populations including no or very few animals with a BCS <4/9 and relatively low
numbers with BCS above 8/9, and studies have only included animals with a fat
mass of up to 45% for BCS 9/9 or 5/5 (46,47,49,71,73,78,89).
Recently, the 5-point BCS system was evaluated in relation to the
development of a canine and feline body fat index (BFI) where it was found to
be inferior to the proposed systems (51,52). By definition, all animals assigned
a BCS 5/5 were assessed to have 40% BF with the BCS system used. The poor
performance of the BCS in this study, therefore, more likely reflects the fact
that 65% of the dogs and 71% of the cats in the selected populations had a BF%
>40%, for all of which BF% would naturally be underestimated according to
the definitions used.
The accuracy of body condition scoring relies significantly on investigator
training. Veterinarians or trained scorers provide a more accurate BCS compared
with untrained scorers or owners, where the latter often underestimate their
pet’s BCS (2,4,5,73). In one study, implementing a 5-point BCS system for owner
evaluation of their pet’s body condition did not improve agreement with a trained
investigator (3). Further studies are needed for evaluating how to best educate
owners in identifying and monitoring weight changes in their pets.
The BCS systems are easy to use in a clinical setting; are illustrative and
repeatable; and provide valuable tools for assessing if a pet is normal weight,
underweight, or overweight. Further, they complement body weight measures in
planning and monitoring individual weight loss programs (92). However, cats and
dogs with a BCS of 9 may display a wide range of body fat percentages, making it
challenging to accurately determine ideal body weight for these patients.
4.7 CONCLUSION
To prevent and treat obesity in pets, easy and reliable systems for assessment of
body composition are pivotal. If advanced methods such as D2O, DEXA, CT,
or MRI are unavailable, the 5- or 9-point body condition scoring systems have
repeatedly shown acceptable performances in identifying obesity in dogs and cats.
However, overlapping scores and discrepancies between BCS and mean body fat
percentage limits the systems’ applicability in obesity research. Further, the newly
developed BFI should probably be preferred for estimating optimal BW in grossly
obese subjects.
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5
Nutritional management
of obesity
Patients with excess body weight require dedicated time to address diet history, and
nutritional and exercise recommendations in addition to the patient evaluation.
This process starts with an accurate diagnosis of obesity and subsequent
estimation of target body weight (TBW) or ideal body weight (IBW). Current
caloric intake and estimated energy requirements for weight loss are compared
prior to making a diet selection and weight loss program recommendations.
Consistent reevaluation, including after TBW has been achieved, gives cats and
dogs the best chance at long-term success.
83
84 Nutritional management of obesity
It is important to note that BCS and BFI account for body fat and not lean body
mass. As animals age, they may develop sarcopenia, the loss of muscle mass that
occurs with age unrelated to an underlying inflammatory or pathologic condition
(14). In older dogs, sarcopenia may be most evident along the epaxial musculature as
opposed to temporal and quadriceps muscle measurements (15). Muscle condition
score (MCS) is recommended as part of a complete nutritional assessment by the
World Small Animal Veterinary Association (WSAVA) and includes palpation and
visualization of the temporal bones, scapula, ribs, lumbar vertebrae, and pelvic
bones (Figure 5.3) (16). Although this system is not validated to lean body mass,
especially in relation to obesity, it can be used to subjectively assess muscle loss with
good repeatability, particularly when performed by the same assessor over time (17).
Because the percentage of lean body mass impacts BF%, in animals with a degree of
age-related muscle atrophy, an ideal BF% of 25 may be acceptable.
1 3 5 7 9
UNDER IDEAL IDEAL OVER IDEAL
1 Ribs, lumbar vertebrae, pelvic bones and all bony 4 Ribs easily palpable, with 6 Ribs palpable with slight excess fat covering. Waist is discernible
prominences evident from a distance. No discernible minimal fat covering. Waist viewed from above but is not prominent. Abdominal tuck
body fat. Obvious loss of muscle mass. easily noted, viewed from apparent.
2 Ribs, lumbar vertebrae and pelvic bones easily visible. above. Abdominal tuck 7 Ribs palpable with difficulty; heavy fat cover. Noticeable fat
No palpable fat. Some evidence of other bony prominences. evident. deposits over lumbar area and base of tail. Waist absent or
Minimal loss of muscle mass. 5 Ribs palpable without excess barely visible. Abdominal tuck may be present.
3 Ribs easily palpated and may be visible with no palpable fat covering. Waist observed 8 Ribs not palpable under very heavy fat cover, or palpable only
fat. Tops of lumbar vertebrae visible. Pelvic bones becoming behind ribs when viewed from with significant pressure. Heavy fat deposits over lumbar area
prominent. Obvious waist and abdominal tuck. above. Abdomen tucked up and base of tail. Waist absent. No abdominal tuck. Obvious
when viewed from side. abdominal distention may be present.
9 Massive fat deposits over thorax, spine and
German A, et al. Comparison of a bioimpedance monitor with dual-energy x-ray absorptiometry for noninvasive
estimation of percentage body fat in dogs. AJVR 2010;71:393-398. base of tail. Waist and abdominal tuck absent.
Jeusette I, et al. Effect of breed on body composition and comparison between various methods to estimate body Fat deposits on neck and limbs.
composition in dogs. Res Vet Sci 2010;88:227-232.
Kealy RD, et al. Effects of diet restriction on life span and age-related changes in dogs. JAVMA 2002;220:1315-1320. Obvious abdominal distention.
Laflamme DP. Development and validation of a body condition score system for dogs. Canine Pract 1997;22:10-15.
Figure 5.1 (a, b) Canine and feline body condition scoring system (9-point scale). (Global Nutrition Committee Toolkit courtesy of the
World Small Animal Veterinary Association.) (Continued)
(b)
1 3 5 7 9
UNDER IDEAL IDEAL OVER IDEAL
1 Ribs visible on shorthaired cats. No palpable fat. 4 Ribs palpable with minimal 6 Ribs palpable with slight excess fat covering.
Severe abdominal tuck. Lumbar vertebrae and wings fat covering. Noticeable waist Waist and abdominal fat pad distinguishable but not obvious.
of ilia easily palpated. behind ribs. Slight abdominal Abdominal tuck absent.
2 Ribs easily visible on shorthaired cats. Lumbar vertebrae tuck. Abdominal fat pad absent. 7 Ribs not easily palpated with moderate fat covering.
obvious. Pronounced abdominal tuck. No palpable fat. 5 Well-proportioned. Waist poorly discernible. Obvious rounding of abdomen.
Observe waist behind ribs. Moderate abdominal fat pad.
3 Ribs easily palpable with minimal fat covering.
Lumbar vertebrae obvious. Obvious waist behind ribs. Ribs palpable with slight fat 8 Ribs not palpable with excess fat covering. Waist absent.
Minimal abdominal fat. covering. Abdominal fat Obvious rounding of abdomen with prominent abdominal fat pad.
pad minimal. Fat deposits present over lumbar area.
9 Ribs not palpable under heavy fat cover.
Heavy fat deposits over lumbar area, face and limbs.
Distention of abdomen with no waist. Extensive
abdominal fat deposits.
Bjornvad CR, et al. Evaluation of a nine-point body condition scoring system in physically inactive pet cats. AJVR 2011;72:433-437.
Laflamme DP. Development and validation of a body condition score system for cats: A clinical tool. Feline Pract 1997;25:13-18.
influence the success of a weight management program (20). If the veterinary staff
members are unable to obtain a complete diet history, the program can still be
instituted based on estimated energy requirements for weight loss.
For animals with an accurate diet history and known caloric consumption,
some practitioners may elect to decrease the animal’s current caloric intake by
20% to avoid sudden and drastic reductions in caloric intake. In these cases,
the rate of weight loss may be slow or unsuccessful if the pet was gaining
weight prior to this reduction. While this method may be more conservative,
challenges with owner adherence and frustration due to lack of success should
be considered. Successful weight loss at subsequent visits is an excellent
motivator for owner adherence, and subjective owner descriptions of food-
seeking behavior have been shown to decrease in dogs on the more typical
caloric restriction weight loss program (22). Cats, however, have been shown to
both increase and decrease food-seeking behavior when consuming a restricted
energy level (23,26,27).
Regardless of the method used to determine IBW/TBW and calculate energy
requirements, these are initial estimates that may change over time. Follow-up
is necessary to tailor the pet’s weight loss program based on their individual
metabolic requirements and to reassess their body condition to determine when
TBW is achieved.
Low Risk Moderate Risk High Risk Serious Risk Severe Risk Extreme Risk
20
16-25% Body Fat
30
26-35% Body Fat
40
36-45% Body Fat
50
46-55% Body Fat
60
56-65% Body Fat
70
66-75% Body Fat
your dog Shape From Above Moderate fat cover. Shape From Above Very thick fat cover. fat cover. fat cover.
increased risk? Well proportioned Shape From Above Loss of lumbar waist, Shape From Above Shape From Above Shape From Above
lumbar waist. Detectable broadened back. Markedly Extremely Extremely broadened
Shape From lumbar waist. Shape From broadened back. broadened back. back, bulging
e right weight loss nutrition mid-section.
the Side Shape From the Side Shape From the Side Shape From
n help reduce the risks
Abdominal tuck the Side Flat to bulging Marked abdominal the Side Shape From the Side
sociated with high body present. Slight abdominal tuck. abdomen. bulge. Severe abdominal Very severe
percentage. bulge. abdominal bulge.
Shape From Behind Shape From Behind Shape From Behind Shape From Behind
Clear muscle definition, Losing muscle Rounded to square Square appearance. Shape From Behind Shape From Behind
body fat increases,
smooth contour. definition, appearance. Tail Base Bones Square appearance. Irregular or upside
does the risk for:
Tail Base Bones rounded appearance. Tail Base Bones Not prominent. Tail Base Bones down pear shape.
Shortened life expectancy Slightly prominent. Tail Base Bones Not prominent. Extremely difficult Not prominent. Tail Base Bones
Diabetes mellitus Easily felt. Slightly to not Very difficult to feel. to feel. Impossible to feel. Unidentifiable.
Tail Base Fat prominent. Tail Base Fat Tail Base Fat Tail Base Fat Tail Base Fat
Reduced mobility
Thin fat cover. Can be felt. Thick fat cover. Very thick fat cover. Extremely thick Extremely thick
Arthritis
Tail Base Fat May have a small Fat dimple or fat cover. fat cover.
Increased physical injury Moderate fat dimple. fold present. Large fat dimple or Large fat folds or pads.
Respiratory disease fat cover. fat fold.
Kidney disease
Cancer
Figure 5.2 (a, b) Canine and feline body fat index. (Reprinted with permission of Hill’s Pet Nutrition, Inc.) (Continued)
(b)
Low Risk Moderate Risk High Risk Serious Risk Severe Risk Extreme Risk
20 30 40 50 60 70
16-25% Body Fat 26-35% Body Fat 36-45% Body Fat 46-55% Body Fat 56-65% Body Fat 66-75% Body Fat
Face Face Face Face Face Face
Minimal fat cover. Slight fat cover. Slight to moderate fat cover. Moderate fat cover. Thick fat cover. Very thick fat cover.
Prominent bony structures. Defined bony structures. Defined to slight Slight to minimal Minimal to no No bony structures.
Head & Neck Head & Neck bony structures. bony structures. bony structures. Head & Neck
Prominent distinction between Clear distinction between Head & Neck Head & Neck Head & Neck No distinction between
our cat head & shoulder. head & shoulder. Clear to slight distinction Minimal distinction between Poor to no distinction head & shoulder.
Loose scruff. Loose scruff. between head & shoulder. head & shoulder. between head & shoulder. Tight scruff.
increased risk? No scruff fat. Slight scruff fat. Loose to snug scruff. Loose to snug scruff. Snug to tight scruff. Very thick scruff fat.
Sternum Sternum Slight to moderate scruff fat. Moderate scruff fat. Very thick scruff fat. Sternum
Prominent. Defined, slightly prominent. Sternum Sternum Sternum Not prominent.
right weight loss nutrition can Very easy to palpate. Easy to palpate. Minimally prominent. Poorly defined. Not prominent. Impossible to palpate.
Minimal pectoral fat. Slight to moderate Palpable. Difficult to palpate. Extremely difficult Extreme pectoral fat.
reduce the risks associated pectoral fat. Moderate pectoral fat. Thick pectoral fat. to palpate.
Scapula Scapula
high body fat percentage. Prominent. Scapula Scapula Scapula Extremely thick pectoral fat. Not prominent.
Very easy to palpate. Defined, slightly prominent. Slightly prominent. Minimally to not prominent. Scapula Impossible to palpate.
Ribs Easy / very easy to palpate. Easy to palpate. Palpable. Not prominent. Ribs
body fat increases, Difficult to palpate.
Prominent. Ribs Ribs Ribs Not prominent.
oes the risk for: Very easy to palpate. Not prominent. Not prominent. Not prominent. Ribs Impossible to palpate.
Abdomen Easy to palpate. Palpable. Difficult to palpate. Not prominent. Abdomen
hortened life expectancy Loose abdominal skin. Extremely difficult to
Abdomen Abdomen Abdomen Extremely heavy fat pad; indistinct
Easy to palpate Loose abdominal skin Obvious skin fold with Heavy fat pad. impossible to palpate. from abdominal fat. Impossible to
iabetes mellitus
abdominal contents. with minimal fat. moderate fat. Difficult to palpate Abdomen palpate abdominal contents.
educed mobility Tail Base Easy to palpate Easy to palpate abdominal contents. Very heavy fat pad; indistinct Tail Base
Prominent bony structure. abdominal contents. abdominal contents. Tail Base from abdominal fat. Bony structure not prominent.
rthritis Impossible to palpate
Easy to palpate. Tail Base Tail Base Poorly defined Extremely difficult to palpate.
Minimal fat cover. Slightly to minimally Minimally prominent bony structure. abdominal contents. Extremely thick fat cover.
creased physical injury
Shape From the Side prominent bony structure. bony structure. Difficult to palpate. Tail Base Shape From the Side
espiratory disease Moderate to slight Palpable. Palpable. Moderate to thick fat cover. Bony structure Very severe abdominal bulge.
abdominal tuck. Slight fat cover. Slight to moderate fat cover. Shape From the Side not prominent.
epatic lipidosis Very difficult to palpate. Shape From Above
Shape From Above Shape From the Side Shape From the Side Moderate abdominal bulge. Extremely broadened back.
idney disease No abdominal tuck. Slight abdominal bulge. Very thick fat cover.
Marked hourglass. Shape From Above
Shape From Above Shape From Above Broadened back. Shape From the Side
ancer Severe abdominal bulge.
Slight hourglass / Lumbar waist.
ladder stones lumbar waist. Shape From Above
Severely broadened back.
5.3 Implementation of a treatment program 91
Equation 5.1:
Current body weight (kg or lb) × (100% − Current body fat %)
IBW (kg or lb) =
100% − Ideal body fat %
Equation 5.2:
Current body weight (kg or lb) × (100% − % Excess body weight )
IBW (kg or lb) =
100
Equation 5.3:
Dogs:
In addition to a high protein content, many therapeutic weight loss diets utilize
a high fiber (HF) level to reduce caloric content and impart a satiety effect. A
HF diet (92.5 g/1000 kcal total dietary fiber [TDF]) was associated with reduced
caloric intake versus a lower fiber diet (39.1 g/1000 kcal TDF) in dogs. This effect
was due to the reduced caloric density of the high versus low fiber diet (3138 kcal/
kg vs. 3615 kcal/kg ME) rather than a change in volume intake (34). This effect
was repeated when low and medium fiber diets were investigated, while reduced
volume of food intake was also seen with diets high in crude fiber when fed an
extra daily meal (35). When dogs were on an energy-restricted active weight loss
5.3 Implementation of a treatment program 93
program, there was no change in voluntary intake of an extra daily meal with TDF
levels from 12.9 to 99.1 g/1000 kcal (36). Lean client-owned dogs have also been
reported to receive more crude fiber than obese dogs, regardless of treats (37). Cats
increase food intake to maintain similar total energy consumption when eating
diets of varying fiber content (22–56 g/1000 kcal TDF), but cats eating HF diets
consume a larger volume of food when offered an extra meal with a palatable,
energy-dense diet (38). Other studies have shown decreased energy intake when
cats are fed diets supplemented with kaolin or varying levels of cellulose, but
diminished diet palatability may have been the main cause for these cats (39–41).
In dogs, a high protein–high fiber diet (HPHF; 103 g/1000 kcal protein,
60 g/1000 kcal crude fiber, 97 g/1000 kcal total dietary fiber, 2900 kcal/kg ME) was
compared to a moderate protein–high fiber diet (MPHF; 86 g/1000 kcal protein,
87 g/1000 kcal crude fiber, 132 g/1000 kcal total dietary fiber, 2660 kcal/kg ME) and
high protein–moderate fiber diet (HPMF; 104 g/1000 kcal protein, 35 g/1000 kcal
crude fiber, 56 g/1000 kcal total dietary fiber, 3275 kcal/kg ME). HPHF dogs
consumed less calories compared to HPMF and MPHF dogs (42). When fed an
HPHF diet, overweight or obese dogs on an active weight loss program lost a greater
percentage of weight (31.8% vs. 20.0%) at a faster rate (1.0%/week vs. 0.7%/week)
than matched HPMF dogs. HPHF dogs also had a greater change in body fat mass
loss compared with HPMF (58% vs. 37%) (43). When obese cats were fed canned or
dry diets with 115–139 g/1000 kcal protein and 28–81 g/1000 kcal TDF as part of a
controlled weight loss trial, body weight and BCS decreased similarly over time for
all diets, but owners were least satisfied with and felt their cats were hungrier when
fed only a dry diet with 115 g/1000 kcal protein and 81 g/1000 kcal TDF (26).
Rather than increasing the dietary fiber level, some weight loss feeding
recommendations, especially for cats, utilize low carbohydrate (LC) diets. LC
diets aim to put the body into a glycogenolytic state in which glycogen stores are
depleted and the body moves toward lipolysis and β-oxidation as an alternative
energy source. Increased acetyl-CoA production results in increased hepatic
ketone body (acetone, acetoacetic acid, β-hydroxybutyric acid) production,
providing an alternative energy source for most tissues and reserving glucose for
glucose-dependent tissues such as brain and erythrocytes. The shift away from
glucose results in decreased fasting and postprandial glucose and circulating
insulin. These types of diets may have a metabolic advantage over HF diets,
particularly in cats with obesity and insulin resistance that may result in diabetes
mellitus (44), although weight loss regardless of diet selection is most important
in controlling or achieving remission of diabetes mellitus in the cat (45).
Low fat diets are not specifically employed in canine or feline weight loss
protocols. With the exception of LC diets, many canine and feline therapeutic
diets do tend to utilize a lower fat content, however, as a means to achieve a
reduced caloric density rather than due to a specific benefit of fat reduction.
(a)
Figure 5.3 (a, b) Canine and feline muscle condition scoring system. (Global Nutrition Committee
Toolkit provided courtesy of the World Small Animal Veterinary Association.) (Continued)
5.3 Implementation of a treatment program 95
(b)
be complicated by the small volume of food. For example, a cat with an IBW of
5 kg may need to consume 190 kcal per day for weight loss, which may be less than
1/3 standard 8-ounce measuring cup (approximately 45 grams kibble) of currently
available therapeutic dry LC diets. Canned diets may increase satiety and weight
loss in cats through higher moisture content. Energy intake and body weight were
significantly decreased in cats consuming a canned diet compared to the same diet
but with a lower moisture content (freeze-drying), suggesting that higher moisture
foods may be of benefit versus dry foods during weight loss in cats (46).
Successful weight management can be achieved by both LC and HF diets,
although there are limited studies comparing the success of weight management
in cats consuming LC versus HF diets. Body condition and energy intake, not
nutrient composition, influenced body weight during weight loss in one study (47).
Another study evaluating owner-perceived satiety in cats undergoing weight loss
1200
Exponential Linear
1000
Resting energy requirements (kilocalories)
800
600
400
200
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Body weight (kilograms)
Figure 5.4 Exponential versus linear equation for calculation of resting energy
requirements (RER).
98 Nutritional management of obesity
Calculation 1 (dogs):
Protein RA
Required dietary protein content = ×1000
Daily caloric intake
Calculation 2 (cats):
Protein RA
Required dietary protein content = ×1000
Daily caloric intake
Calculation 3 (cats):
Protein RA
Required dietary protein content = ×1000
Daily caloric intake
Example: 5 yr FS Beagle, estimated ideal weight 8.2 kg (18 lb), feeding
339 kcal/day
●● Calculation 1:
15.9 g protein
8.2 kg 0.75 × 3.28 = ×1000 = 46.9 g/1000 kcal protein
339 kcal
Example: 8 yr FS American domestic shorthair, estimated ideal weight
3.7 kg (8.14 lb), feeding 149 kcal/day
●● Calculation 2:
11.9 g protein
3.7 kg 0.67 × 4.96 = ×1000 = 80 g/1000 kcal protein
149 kcal
●● Calculation 3:
20.8 g protein
3.7 kg 0.75 × 7.8 = ×1000 = 140 g/1000 kcal protein
149 kcal
was unable to find a difference between LC versus HF diets, although the sample
size of this study was limited (48). If dry food is preferred, the authors typically
recommend a high protein, low caloric density food (through added fiber and/or
reduced fat), as LC diets tend to have higher fat levels, therefore a higher calorie
density.
likely to portion out a larger amount of kibble when using large bowls and large
scoops as compared to small bowls and small scoops (50). It is possible owners
using measuring cups, and certainly those using unmarked generic scoops, may
be unintentionally providing a higher volume of food than intended, which will
lead to inaccurate consumption reporting. Weighing food on a kitchen scale in
grams is particularly useful in cats or small dogs in which there may be significant
caloric differences as measuring cup volume changes. Calorie information
as kcal/kg should be available on the individual product label or through the
manufacturer. Switching to a smaller food bowl may also help some pet owners
avoid the perception they are feeding smaller portions of food (50).
initial body weight per week. Rates of weight loss also declined from an average of
1.3% per week to 0.8% per week over the same time frame (22). In a similar study,
cats lost 0.8 ± 0.50% of initial body weight per week and declined from 1.2% per
week to 0.7% per week (23).
Once the IBW or TBW is achieved, caloric intake can be adjusted to maintain the
current body weight. Dogs have a maintenance energy requirement of 52–104 kcal/
kg0.75 following weight loss, typically only approximately 10% more than that
required during weight loss (51). Although similar data has not been published in
cats, a caloric increase of no more than 10% is recommended for weight maintenance
in both cats and dogs. Additional follow-up (usually one to three rechecks) is needed
after maintenance feeding adjustments to ensure ideal/target weight is maintained.
If given free choice access to food after successfully losing weight, dogs regain weight
(52). Dogs will also achieve the same level of obesity faster and with less calories than
they needed to originally become obese (53).
Dogs switched to a standard maintenance diet consume more calories and
regain more weight, suggesting long-term feeding of purpose formulated weight
management diets can significantly limit regain (54). Forty-nine percent of
previously obese dogs and 46% of previously obese cats that achieved ideal or
target body weight gained more than 5% of body weight back (54,55). Cats that
rebound are more likely to regain over 50% of their original weight loss when
compared to dogs. While these data may be discouraging, it is important to keep
in mind that the majority (51%–54%) of dogs and cats maintain or continue to
lose weight after a successful weight loss program.
5.5 CONCLUSIONS
Although obstacles encountered during a weight loss plan can be discouraging,
it is important to remind owners it can be done as long as they are willing to
put in the necessary time and dedication required to maintain long-term weight
success. Long-term continuation of a weight management diet with a low caloric
density, specific treat allowance, and exercise are recommended to avoid relapse
of weight gain.
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obesity in adult cats from private US veterinary practices. The International
Journal of Applied Research in Veterinary Medicine 2005;3:88–96.
2. Lund EM, Armstrong PJ, Kirk CA, Klausner JS. Prevalence and risk
factors for obesity in adult dogs from private US veterinary practices.
The International Journal of Applied Research in Veterinary Medicine
2006;4:177–186.
3. Rohlf VI, Toukhsati S, Coleman GJ, Bennett PC. Dog obesity: Can dog
caregivers’ (owners’) feeding and exercise intentions and behaviors be
predicted from attitudes? Journal of Applied Animal Welfare Science
2010;13:213–236.
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33. Laflamme DP, Hannah SS. Increased dietary protein promotes fat loss and
reduces loss of lean body mass during weight loss in cats. The International
Journal of Applied Research in Veterinary Medicine 2005;5:2–68.
34. Jackson JR, Laflamme DP, Owens SF. Effects of dietary fiber content on
satiety in dogs. Veterinary Clinical Nutrition 1997;4:130–134.
35. Jewell DE, Toll PW. Effects of fiber on food intake in dogs. Veterinary
Clinical Nutrition 1996;3:115–118.
36. Butterwick RF, Markwell PJ. Effect of amount and type of dietary fiber
on food intake in energy-restricted dogs. American Journal of Veterinary
Research 1997;58:272–276.
37. Heuberger R, Wakshlag J. The relationship of feeding patterns and obesity
in dogs. Journal of Animal Physiology and Animal Nutrition 2011;95:98–105.
38. Loureiro BA, Sakomura NK, Vasconcellos RS et al. Insoluble fibres, satiety
and food intake in cats fed kibble diets. Journal of Animal Physiology and
Animal Nutrition 2017;10:824–834.
39. Kanarek RB. Availability and caloric density of the diet as determinants of
meal patterns in cats. Physiology & Behavior 1975;15:611–618.
40. Prola L, Dobenecker B, Kienzle E. Interaction between dietary cellulose
content and food intake in cats. Journal of Nutrition 2006;13:1988S–1990S.
41. Hirsch E, Dubose C, Jacobs HL. Dietary control of food intake in cats.
Physiology & Behavior 1978;20:287–295.
42. Weber M, Bissot T, Servet E, Sergheraert R, Biourge V, German AJ.
A high-protein, high-fiber diet designed for weight loss improves satiety
in dogs. Journal of Veterinary Internal Medicine 2007;21:1203–1208.
43. German AJ, Holden SL, Bissot T, Morris PJ, Biourge V. A high protein
high fibre diet improves weight loss in obese dogs. Veterinary Journal
2010;18:294–297.
44. Bennett N, Greco DS, Peterson ME, Kirk C, Mathes M, Fettman MJ.
Comparison of a low carbohydrate-low fiber diet and a moderate
carbohydrate-high fiber diet in the management of feline diabetes
mellitus. Journal of Feline Medicine and Surgery 2006;8:73–84.
45. Hoenig M, Thomaseth K, Waldron M, Ferguson DC. Insulin sensitivity, fat
distribution, and adipocytokine response to different diets in lean and
obese cats before and after weight loss. American Journal of Physiology:
Regulatory, Integrative and Comparative Physiology 2007;29:R227–R234.
46. Wei A, Fascetti AJ, Villaverde C, Wong RK, Ramsey JJ. Effect of water
content in a canned food on voluntary food intake and body weight in
cats. American Journal of Veterinary Research 2011;72:918–923.
47. Michel KE, Bader A, Shofer FS, Barbera C, Oakley DA, Giger U. Impact
of time-limited feeding and dietary carbohydrate content on weight
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48. Cline M, Witzel A, Moyers T, Kirk C. Comparison of high fiber and low
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6
Behavioral management
of obesity
6.1 INTRODUCTION
Obesity is a complex nutritional disorder that often requires comprehensive
management beyond a standard diet and exercise program and includes
incorporation of an understanding of human–animal interaction to be successful.
Effective client communication can assist the veterinary team in appreciating
each family’s unique relationship with the pets in the household and keep the
human–animal bond intact. Thus, obesity treatment can be multimodal and
107
108 Behavioral management of obesity
Figure 6.1 Incorporation of a body condition scoring chart with a weight scale
in a veterinary hospital to encourage conversation about ideal body condition.
5 show dogs was overweight (12), and similar findings have been described in show
cats as well (13). Owner perception can also affect behavior of pet owners and their
adherence to weight management plans. For example, when considering feeding
behaviors, studies have shown that the size of the food bowl and food scoop affects
the amount of food owners feed their dogs (14). Furthermore, even veterinary
staff’s accuracy on feeding amounts varied from an 18% underestimate to an 80%
110 Behavioral management of obesity
program due to their pet defecating in the house and decide weight management is
too difficult. Needs of other pets in the household may also need to be considered
for similar logistics to ensure adherence. By understanding clients’ backgrounds
and perspectives, weight management and in particular behavioral change can
be approached by the veterinarian in a way that clients will accept and engage in
for optimal success.
Figure 6.2 One example of an automatic food dispenser that can be set to
provide timed, measured feeding portions to pets (5-Meal Automatic Pet Feeder
by PetSafe[R]).
life that may be adversely affected by obesity to create the need for urgency in
behavior change. A validated quality-of-life questionnaire can be used with pet
owners to objectively measure these effects and how they change over time with
weight management (22). When initiating and implementing weight management
plans, a discussion that focuses on common goals shared by the veterinarian and
the owner, namely, the well-being and comfort of the pet, can help to ease owners
into the conversation and address the root of obesogenic behaviors.
pet owners in a way that reinforces owners’ relationship with their pets and does
not threaten that beneficial bond.
Interestingly, strong feelings of attachment may affect what behaviors pet
owners are willing to change, influencing treatment in both positive and negative
ways. For example, owners who are highly bonded to their pets may be more
willing to devote financial resources and time to obtaining veterinary care and
seeking weight management plans. However, high levels of attachment may also
be associated with emotional dependency and obesogenic behaviors, such as
some owners in clinical experience who provide an excess of food (and calories)
to show love and affection to their pet. An owner who has a strong emotional
relationship with an animal may be less inclined to change feeding behaviors,
such as providing high calorie treats, because those behaviors represent a part of
that relationship. For example, when engaging pet owners in a dietary history, it
may be helpful to ask them to describe their daily routine with their pet, which
would provide open-ended answers. Further questioning such as, “Which of those
activities do you feel strongly about including in our weight loss plan?” will elicit
behaviors that pet owners feel are critical to their bond with their pet and may
sabotage weight loss plans if not incorporated in some way.
In the authors’ experience, these questions can often reveal nonnegotiables
that can be incorporated to increase adherence to weight management plans.
For example, if an owner says that every night the pet needs to have a chew treat
while the owner watches TV, a less calorically dense substitute for that treat can
be made in order to preserve that aspect of their relationship while adhering
to a weight management plan. This way, the owner still gets to engage in the
desired behavior (providing a special food item and spending time with their
pet), but the treat itself or the calories in the treat can be altered without adversely
affecting their relationship. In another scenario, an owner who notes that it may
be emotionally challenging to initiate exercise with a pet that does not seem
to enjoy physical activity can be redirected to pair feeding time with exercise
in a way that the pet and the pet owner can both derive pleasure. For example,
instead of putting food into a bowl, pieces of a dry kibble could be distributed
throughout the house or used in a game of fetch for cats or dogs. In cases such
as these, an understanding of the emotional attachment between the owner and
pet can help veterinarians and owners devise ways to address challenges and still
be successful in weight loss.
attachment to their pets and have less perceived social support from peers than
healthy-weight pet owners (29). If overweight owners are indeed looking to
their pets for social support instead of their human contemporaries, engaging
pet owners in behaviors that could benefit themselves as well as their pet can
be particularly helpful and increase chances for success. Regardless of weight
status, however, all pet owners could improve their relationship with their pets
through healthy behaviors such as exercise instead of through provision of
extra calories in treats, which is how some owners express their love. Figure 6.3
highlights an opportunity for pets and owners to engage in physical activity
such as walking or swimming together.
Future research into integrative treatment programs is warranted to target
human and animal health. Family-oriented obesity treatment programs in
which overweight families and their pets can become healthy together could
have immense potential for significantly affecting health and wellness in
veterinary and human medicine. Until further research is conducted on the most
effective methodology for this type of a program, veterinarians should focus on
preserving beneficial healthy human–animal relationships. This is best done by
understanding the bonds between owners and pets, fostering healthy behaviors
already present, and creating healthy alternatives and substitutes for behaviors
that predispose both people and their pets to obesity without sacrificing beneficial
human–animal relationships and bonds.
Figure 6.3 Dogs and pet owners can enjoy physical activity together such as
walking and swimming together.
References 117
6.7 CONCLUSION
Many risk factors, combined with the complexity humans can have in their
relationships with pets, can create an environment conducive to pet obesity.
On the positive side, integrating the many medical and social science aspects
of obesity can improve success in weight management. Although treatment of
obesity can be intensive and require comprehensive management, there are many
novel aspects of obesity treatment, even many yet to be investigated, that can lead
to a rewarding and enjoyable owner, pet, and veterinarian experience. Weight
management plans that take a comprehensive approach include understanding
and integration of the complex relationship owners have with their pets, which
extend beyond standard nutritional management and improve success.
REFERENCES
1. McGreevy PD, Thomson PC, Pride C, Fawcett A, Grassi T,
Jones B. Prevalence of obesity in dogs examined by Australian
veterinary practices and the risk factors involved. Veterinary Record
2005;156:695–702.
2. Lund EM, Armstrong PJ, Kirk CA, Klausner JS. Prevalence and risk factors
for obesity in adult dogs from private US veterinary practices. International
Journal of Applied Research in Veterinary Medicine 2006;4:177–186.
3. Courcier EA, Thomson RM, Mellor DJ, Yam PS. An epidemiological study
of environmental factors associated with canine obesity. Journal of Small
Animal Practice 2010;51:362–367.
4. Scarlett JM, Donoghue S, Saidla J, Wills J. Overweight cats: Prevalence
and risk factors. International Journal of Obesity and Related Metabolic
Disorders 1994;18:S22–S28.
5. Lund EM, Armstrong PJ, Kirk CA, Klausner JS. Prevalence and risk
factors for obesity in adult cats from private US veterinary practices.
International Journal of Applied Research in Veterinary Medicine
2005;3:88–96.
6. Colliard L, Paragon B-M, Lemuet B, Bénet J-J, Blanchard G. Prevalence
and risk factors of obesity in an urban population of healthy cats. Journal
of Feline Medicine and Surgery 2009;11:35–40.
7. Courcier EA, O’Higgins R, Mellor DJ, Yam PS. Prevalence and risk factors
for feline obesity in a first opinion practice in Glasgow, Scotland. Journal
of Feline Medicine and Surgery 2010;12:746–753.
8. Cave NJ, Allan FJ, Schokkenbroek SL, Metekohy CA, Pfeiffer DU.
A cross-sectional study to compare changes in the prevalence and
risk factors for feline obesity between 1993 and 2007 in New Zealand
Preventative. Veterinary Medicine 2012;107:121–133.
9. Rohlf VI, Toukhsati S, Coleman GJ, Bennett PC. Dog obesity: Can dog
caregivers’ (owners’) feeding and exercise intentions and behaviors be
predicted from attitudes? Journal of Applied Animal Welfare Science
2010;13:213–236.
118 Behavioral management of obesity
25. Kurdek LA. Pet dogs as attachment figures for adult owners. Journal of
Family Psychology 2009;23:439–446.
26. Stanley IH, Yeates Conwell BA, Bowen C, Van Orden KA. Pet ownership
may attenuate loneliness among older adult primary care patients who
live alone. Aging and Mental Health 2014;18:394–399.
27. Barker SB, Dawson KS. The effects of animal-assisted therapy on
anxiety ratings of hospitalized psychiatric patients. Psychiatric Services
1998;49:797–801.
28. Kushner RF, Blatner DJ, Jewell DE, Rudloff K. The PPET study: People
and pets exercising together. Obesity (Silver Spring) 2006;14:1762–1770.
29. Stephens MB, Wilson CC, Goodie JL, Netting FE, Olsen CH, Byers
CG. Health perceptions and levels of attachment: Owners and pets
exercising together. Journal of the American Board of Family Medicine
2012;25:923–926.
7
Role of exercise in the
management of obesity
JUSTIN SHMALBERG
7.1 INTRODUCTION
The role of exercise in the management of canine and feline obesity is poorly
understood. Inactivity predisposes to the development of canine obesity based on
multiple epidemiological studies examining risk factors (1,2). Many veterinarians
provide anecdotal recommendations to owners that increasing their overweight or
obese pet’s exercise will facilitate weight loss. However, the addition of controlled
exercise protocols to accepted caloric control measures has not been critically
evaluated in the scientific literature. Available evidence in humans suggests that
physical activity may have therapeutic benefits during weight loss, but these are
often related to cardiovascular health and other secondary changes rather than an
effect on caloric intake or the success of a weight loss protocol (3–6). Dogs and cats
may derive similar benefits, especially if obese animals have comorbidities such
as osteoarthritis, exercise intolerance, and muscle wasting. The impact of exercise
on caloric expenditure is related to the distance traveled in normal dogs (7), and
if the same is true for overweight animals, there may be a maximum tolerance
for exercise in such dogs and cats, which limits the contribution of exercise to
energy expenditure.
121
122 Role of exercise in the management of obesity
cytokine response from muscle, which may counteract some adipokines (16–18).
However, dogs display higher basal levels of fat oxidation than humans (7,19,20).
The two species demonstrate important differences in adipokine levels during
obesity, given that a decrease in total and high molecular weight adiponectin was
not observed in dogs following weight loss unlike the observations in human
subjects (21). The exercise physiology of cats is poorly described, which further
complicates comparisons to the human literature.
The cardiovascular effects of obesity may be mitigated by exercise in humans,
whereas the actual effects of activity on measured weight loss are minimal (6).
Studies suggest that long-distance exercise (>20 miles weekly) in humans produces
body weight losses of less than 0.4% monthly, and that such recommendations are
associated with poor compliance (6,22). More modest exercise recommendations
appear to reduce the risk of rebound weight gain and to facilitate long-term
weight maintenance in people. Such effects were noted at 3 hours of exercise
or more weekly, but this is near the baseline activity level documented in some
obese dogs (2,6). The monthly rates of weight loss with the addition of exercise
to dietary approaches in humans appear greatest at 18 months as compared to
those calculated after only 12 months or after 36 months and beyond of follow-up,
suggesting that maximal benefit may be significantly delayed and peak at a
certain point (23). The heterogeneity of individual responses to exercise and the
significant amounts required to achieve a clinical effect are responsible for the
clinical recommendation that overweight individuals expect only small amounts
of total weight loss from such interventions (<2% starting body weight). However,
the combination of moderate-intensity aerobic exercise and diet as opposed to
diet alone improves cardiovascular fitness and ameliorates some of the adverse
health consequences of obesity such as reduced cardiac function, increased blood
pressure, insulin resistance and diabetes mellitus, and dyslipidemia (3–5). Such
benefits may be realized in dogs and cats, but species differences influence the
applicability of these findings, and further research is required. For example,
obesity in cats and humans, but not in dogs, is associated with non-insulin-
dependent diabetes mellitus. However, the role of exercise in reducing diabetic
morbidity and mortality in cats has not been explored.
in which dogs were fitted with additive weights and run on treadmills failed to
document an increased severity of arthritis as compared to control animals (27).
This may suggest that the hormonal impacts of obesity cause arthritis, or that in
animals genetically predisposed to arthritis, increased articular loading worsens
the condition only after it develops. Alternatively, obesity may reduce activity,
which could be associated with a decline in the mechanical forces that contribute
to the health and nutrition of chondrocytes (28). Regular low-impact exercise
has been recommended for the management of arthritis in humans and in dogs
(29,30), and weight reduction improved weight-bearing in osteoarthritic animals
and reduced markers of systemic inflammation (21,31). The performance and
efficacy of various exercise protocols in cats has not received significant attention
from the scientific literature.
patients, and owners were encouraged to exercise treated dogs at home, whereas
owners of diet-only dogs were not given such advice. Energy intake was not
different between groups during the study. Mean weight loss in exercised dogs was
1.16% weekly for 12 weeks, and 1.08% weekly for dietary management exclusively,
which was not statistically significant. An improvement in resting heart rate was
observed in both groups but was not different between groups, despite increased
accelerometry counts in treated dogs and decreased counts in diet-only dogs.
The primary significant finding, and possible benefit to exercise therapy, was an
increase in lean body mass with exercise (+4.6%) versus a decrease in sedentary
dogs (−2.5%).
Possibly advantageous changes in the relevant transcriptome were identified
in enrolled dogs in a related study (38). The difference in weight loss, if
statistically relevant, would amount to 330 grams over the study period; applying
Wishnofsky’s rule (39), this would be an endogenous energy consumption of
2500 kcal, or about 182 kcal/kg0.75, as a result of 36 hours of exercise covering an
estimated distance of 19.7 km. The resulting value suggests, if ascribed solely to
the treadmill exercise performed in the clinic, a distance-based energy cost of
9.2 kcal/kg0.75/km. Treated dogs displayed an increase in weekly accelerometry
counts of 0.85 million weekly compared to baseline, for an energy per count value
of 245 kcal per million counts. Interestingly, diet-only dogs had a 7.6% decrease
at 12 weeks in accelerometry counts as compared to baseline, which is roughly
consistent with another study of diet only that documented an 11.3% decrease at
the same time point (40).
The energy expenditure of various types of activity is known for normal,
fit dogs (Figure 7.1) (7,41,42). Sitting and standing require 30% and 46% more
energy, respectively, than lying down, and therefore sustained modest changes
in a dog’s activity could influence daily calorie expenditure (43). Walking dogs
require about 1.2 kcal/kg0.75/km, and therefore a medium-sized dog may only
increase its energy expenditure by 1% over the course of 30 minutes of walking as
commonly suggested (44). The energy required for running dogs is approximately
1.1 kcal/kg/km; dogs with longer legs use less energy to cover a fixed distance as
compared to those with shorter legs (7,45), but most obese dogs are too poorly
conditioned to run. Underwater treadmill activity in elbow-height water requires
1.9 kcal/kg0.75/km (44). A 30-minute session of underwater treadmill administered
to a medium-sized dog would increase daily energy expenditure by only 1.5% (42).
No data are available on which to evaluate the recommendation that animals
swim to improve weight loss success.
An enrichment program in cats which employed effort-driven feeding
dispensers, new toys and climbing structures, and food-incentivized exercises,
produced an unquantified increase in activity when paired with a therapeutic
diet, resulting in a statistically significant, but clinically insignificant, reduction
in body weight as compared to controls (46). Extension of the photoperiod
provided to cats to 16 hours of light per day increased activity counts by 20%,
but only increased energy intake 5% (47). Conflicting studies are available on
whether increased feeding frequency or dietary moisture increases activity in
cats (48,49).
126 Role of exercise in the management of obesity
1000
975
Daily energy expenditure (kcal)
950
925
900
875
850
825
800
MER Lateral Sternal Sit Stand Walk UWTM Trot UWTM UWTM
Walk Trot Run
Various Activities (30 min duration)
*MER = maintenance energy requirement, UWTM = underwater treadmill
7.7 CONCLUSION
Exercise in the absence of significant caloric restriction is unlikely to result in
significant weight loss. The role of exercise in the management of obesity should
therefore focus on the benefits of exercise for other purposes, such as increasing
endurance, improving the rehabilitation or management of comorbidities,
or enhancing cardiovascular fitness. The use of veterinary-assisted exercise
modalities for weight loss, such as underwater treadmill therapy, may not produce
sufficient additive benefits to justify the expense and effort unless done on a
routine basis. Methods of increasing feline activity are poorly described, as are
the therapeutic implications of exercise on obesity in cats. Additional studies are
required on the energy consumption of obese animals during different activities
as are prospective controlled trials of such interventions.
REFERENCES
1. Courcier EA, Thomson RM, Mellor DJ, Yam PS. An epidemiological study
of environmental factors associated with canine obesity. Journal of Small
Animal Practice 2010;51(7):362–367.
2. Robertson ID. The association of exercise, diet and other factors with
owner-perceived obesity in privately owned dogs from metropolitan
Perth, WA. Preventive Veterinary Medicine 2003;58(1):75–83.
3. De Feo P. Is high-intensity exercise better than moderate-intensity
exercise for weight loss? Nutrition, Metabolism and Cardiovascular
Diseases 2013;23(11):1037–1042.
128 Role of exercise in the management of obesity
4. Lee DC, Sui X, Blair SN. Does physical activity ameliorate the health
hazards of obesity? British Journal of Sports Medicine 2009;43(1):49–51.
5. Swift DL, Johannsen NM, Lavie CJ, Earnest CP, Church TS. The role of
exercise and physical activity in weight loss and maintenance. Progress in
Cardiovascular Diseases 2014;56(4):441–447.
6. Wadden TA, Webb VL, Moran CH, Bailer BA. Lifestyle modification
for obesity: New developments in diet, physical activity, and behavior
therapy. Circulation 2012;125(9):1157–1170.
7. National Research Council Ad Hoc Committee on Dog and Cat Nutrition.
Nutrient Requirements of Dogs and Cats. Washington DC: National
Academies Press; 2006.
8. Mao J, Xia Z, Chen J, Yu J. Prevalence and risk factors for canine obesity
surveyed in veterinary practices in Beijing, China. Preventive Veterinary
Medicine 2013;112(3):438–442.
9. Warren BS, Wakshlag JJ, Maley M, Farrell TJ, Struble AM, Panasevich MR,
Wells MT. Use of pedometers to measure the relationship of dog walking
to body condition score in obese and non-obese dogs. British Journal of
Nutrition 2011;106(S1):S85–S89.
10. Roudebush P, Schoenherr WD, Delaney SJ. An evidence-based review of
the use of therapeutic foods, owner education, exercise, and drugs for
the management of obese and overweight pets. Journal of the American
Veterinary Medical Association 2008;233(5):717–725.
11. Lund EM, Armstrong PJ, Kirk CA, Klausner JS. Prevalence and risk factors
for obesity in adult dogs from private US veterinary practices. International
Journal of Applied Research in Veterinary Medicine 2006;4(2):177.
12. Degeling C, Burton L, McCormack GR. An investigation of the association
between socio-demographic factors, dog-exercise requirements, and the
amount of walking dogs receive. Canadian Journal of Veterinary Research
2012;76(3):235.
13. Westgarth C, Christian HE, Christley RM. Factors associated with daily
walking of dogs. BMC Veterinary Research 2015;11:116. doi:10.1186/
s12917-015-0434-5.
14. Kienzle E, Bergler R, Mandernach A. A comparison of the
feeding behavior and the human-animal relationship in owners of
normal and obese dogs. Journal of Nutrition 1998;128(12 Suppl):
2779S–2782S.
15. Rohlf VI, Toukhsati S, Coleman GJ, Bennett PC. Dog obesity: Can dog
caregivers’ (owners’) feeding and exercise intentions and behaviors be
predicted from attitudes? Journal of Applied Animal Welfare Science
2010;13(3):213–236.
16. Blaak EE, Wim HMS. Substrate oxidation, obesity and exercise
training. Best Practice & Research Clinical Endocrinology & Metabolism
2002;16(4):667–678.
17. Borsheim E, Bahr R. Effect of exercise intensity, duration and mode on post-
exercise oxygen consumption. Sports Medicine 2003;33(14):1037–1060.
References 129
18. Pedersen BK, Febbraio MA. Muscles, exercise and obesity: Skeletal
muscle as a secretory organ. Nature Reviews Endocrinology
2012;8(8):457–465.
19. Havel RJ, Naimark A, Borchgrevink CF. Turnover rate and oxidation of
free fatty acids of blood plasma in man during exercise: Studies during
continuous infusion of palmitate-1–C14. Journal of Clinical Investigation
1963;42(7):1054.
20. Issekutz B, Miller HI, Paul P, Rodahl K. Source of fat oxidation in
exercising dogs. American Journal of Physiology 1964;207(3):583–589.
21. Wakshlag JJ, Struble AM, Levine CB, Bushey JJ, Laflamme DP, Long GM.
The effects of weight loss on adipokines and markers of inflammation in
dogs. British Journal of Nutrition 2011;106(Suppl 1):S11–S14. doi:10.1017/
S0007114511000560.
22. Slentz CA, Duscha BD, Johnson JL, Ketchum K, Aiken LB, Samsa GP,
Houmard JA, Bales CW, Kraus WE. Effects of the amount of exercise
on body weight, body composition, and measures of central obesity:
STRRIDE—A randomized controlled study. Archives of Internal Medicine
2004;164(1):31–39.
23. Avenell A, Brown TJ, McGee MA, Campbell MK, Grant AM, Broom
J, Jung RT, Smith WCS. What interventions should we add to weight
reducing diets in adults with obesity? A systematic review of randomized
controlled trials of adding drug therapy, exercise, behaviour therapy or
combinations of these interventions. Journal of Human Nutrition and
Dietetics 2004;17(4):293–316.
24. Leland MH, Edwards TC, Montant J-P. Abnormal cardiovascular
responses to exercise during the development of obesity in dogs.
American Journal of Hypertension 1994;7(4 Pt 1):374–378.
25. Bach JF, Rozanski EA, Bedenice D, Chan DL, Freeman LM, Lofgren JL,
Oura TJ, Hoffman AM. Association of expiratory airway dysfunction with
marked obesity in healthy adult dogs. American Journal of Veterinary
Research 2007;68(6):670–675. doi:10.2460/ajvr.68.6.670.
26. Smith GK, Lawler DF, Biery DN, Powers MY, Shofer F, Gregor TP,
Karbe GT, McDonald-Lynch MB, Evans RH, Kealy RD. Chronology
of hip dysplasia development in a cohort of 48 Labrador
retrievers followed for life. Veterinary Surgery 2012;41(1):20–33.
doi:10.1111/j.1532–950X.2011.00935.x.
27. Newton PM, Mow VC, Gardner TR, Buckwalter JA, Albright JP. The effect
of lifelong exercise on canine articular cartilage. The American Journal of
Sports Medicine 1997;25(3):282–287.
28. Griffin TM, Guilak F. The role of mechanical loading in the onset and
progression of osteoarthritis. Exercise and Sports Sciences Reviews
2005;33(4):195–200.
29. Bennell KL, Hinman RS. A review of the clinical evidence for exercise in
osteoarthritis of the hip and knee. Journal of Science and Medicine in
Sport 2011;14(1):4–9. doi:10.1016/j.jsams.2010.08.002.
130 Role of exercise in the management of obesity
43. Scott KC, Shmalberg J, Williams JM, Morris PJ, Hill RC. Energy intake of
pet dogs compared to energy expenditure at rest, sitting, and standing.
The WALTHAM International Nutritional Sciences Symposium 2013.
Portland, Oregon; 2013.
44. Shmalberg J, Scott KC, Williams JM, Hill RC. Energy expenditure of
dogs exercising on an underwater treadmill compared to that on a dry
treadmill. 13th Annual AAVN Clinical Nutrition and Research Symposium.
Seattle, Washington; 2013.
45. Hill RC, Scott KC, Williams JM, Morris PJ, Shmalberg J. Energy required
for trotting is inversely proportional to leg length in small dogs. 13th
Annual AAVN Clinical Nutrition and Research Symposium, Seattle,
Washington; 2013.
46. Clarke DL, Wrigglesworth D, Holmes K, Hackett R, Michel K. Using
environmental and feeding enrichment to facilitate feline weight loss.
Journal of Animal Physiology and Animal Nutrition 2005;89(11–12):427.
47. Kappen KL, Garner LM, Kerr KR, Swanson KS. Effects of photoperiod
on food intake, activity and metabolic rate in adult neutered male cats.
Journal of Animal Physiology and Animal Nutrition 2014;98(5):958–967.
48. de Godoy MRC, Ochi K, de Oliveira Mateus LF, de Justino ACC, Swanson
KS. Feeding frequency, but not dietary water content, affects voluntary
physical activity in young lean adult female cats. Journal of Animal
Science 2015;93(5):2597–2601.
49. Deng P, Iwazaki E, Suchy SA, Pallotto MR, Swanson KS. Effects of feeding
frequency and dietary water content on voluntary physical activity in
healthy adult cats. Journal of Animal Science 2014;92(3):1271–1277.
50. Kushner RF, Blatner DJ, Jewell DE, Rudloff K. The PPET study: People
and pets exercising together. Obesity (Silver Spring) 2006;14(10):1762–
1770. doi:10.1038/oby.2006.203.
8
Establishing a weight
management program in
clinical practice
8.1 INTRODUCTION
Veterinarians and veterinary nurses in general or community practice are encouraged
to create comprehensive programs to provide clients with weight loss services for
133
134 Establishing a weight management program in clinical practice
their pets. Consultation for weight loss not only includes the initial examination and
feeding program development, but also months of follow-up during both the weight
loss and weight maintenance phases. Support after weight loss for these pets is vital
to help them maintain a healthy body condition and avoid the pitfalls of potential
weight regain. Here, the owner must be taught to change their relationship with their
pet permanently, so as to maintain control of food intake and activity levels (1,2).
Several steps can be taken to improve success with the initial weight loss consultation
as well as the long-term follow-up to improve long-term outcomes (3–6).
(a)
(b)
●● Treats with caloric content clearly defined, and instructions on how much
to feed
●● Toys and puzzle feeders
●● Other relevant items that might be available including waste bags, food
bowls, etc.
concerns; however, cat sessions are better conducted without the pets present.
Such sessions may provide camaraderie among owners struggling with the
same problems, such as dealing with begging behavior or food seeking and tips
on increasing play activity. If possible, it is helpful to have owners whose dogs
have already completed the weight loss phase (and are now maintaining weight)
in addition to those on the weight loss program. This enables sharing of good
practice among clients and also reinforces the need for owners to continue with
programs even after the weight loss phase has ended.
If face-to-face meetings are not possible or there is insufficient interest from
owners, an alternative would be to consider the use of running an online forum or
listserv, which is moderated by a member of the weight management team. These can
be very successful but do take time to administer, which should be considered from
a staffing and cost point of view. Finally, the practice could facilitate opportunities
for clients to interact among one another, for example, via a walking group for
committed dog owners. These can be easy to establish since the impetus to establish
and maintain them comes from the owner rather than the practice.
initially, since this can be a time when frequent counseling and alterations are
needed. If the initial food allocation is correct, all obese animals should lose at least
some weight at this stage. This initial recheck is a way of confirming the success of
the program with the owner and reassuring them it has been worthwhile. For pets
reliably losing weight, in-clinic weight rechecks may be alternated with at-home
weight sessions in which the owner weighs their pet on a home scale and contacts
the clinic with scheduled weight updates. In the authors’ experience, this method
is more likely to be associated with poor long-term adherence to the weight loss
program and should be used sparingly and only with pets in later stages of their
weight loss program. Additionally, weighing large dogs on a home scale intended
for people may be cumbersome. In-clinic weight checks on a regular basis using
the same scale remain the preferred method to ensure consistent weight loss
success. Owners should also be provided with free access to a clinic scale to check
the weight of their pet at any time during office hours.
Weight recheck appointments should be scheduled prior to the owner leaving
the building. Prescheduling appointments greatly improves long-term follow-up
and compliance (16). All appointments should ideally be confirmed 24 hours
in advance and may be arranged for a shorter time period than that used for
other appointments. Consider recording these as veterinary nurse appointments.
Clinic nurses should be trained to review total calorie intake, determine current
weight and BCS, and calculate rate of weight loss. If weight loss is outside the
recommended range (see Chapter 5), lack of owner compliance is suspected, or
the patient has reached their ideal body weight and condition, follow-up with the
veterinarian is recommended.
There are many approaches to monitoring progress via body weight, BCS, body
shape (using a tape measure), and photography. Body weight measurements alone
can be used to determine the efficacy of a weight loss program and should be the
principle outcome measure used for decision making (17). In contrast, changes in
BCS occur slowly (typically requiring 5%–15% body weight loss per BCS unit on
a 9-point scale) (18) and are better assessed periodically rather than at every visit.
Tape measure assessments can be imprecise (19), not least if undertaken by different
people, and are best used to complement other measures to demonstrate change.
For most obese dogs and cats, the weight loss phase is likely to last at least 6
months, with the duration of some lasting beyond a year (20). The vast majority will
require alterations to the program during this time if progress stalls (e.g., lack of
weight loss or gain in weight between checks). Usually, it is necessary to reduce food
allocation, usually by a small amount (e.g., a maximum of 5%–10% of the allocation).
If dry food and gram scales are used, these small implements can be delivered with
great accuracy; it can be more challenging to make accurate adjustments when
using wet food or measuring food with a cup (21,22). In cases where weight loss
progresses too quickly (e.g., >3%/week for more than two visits), a small increase in
food intake can be considered; however, in the authors’ experience, such occasions
are rare. Progress with weight loss is usually good in the first 3–6 months, but
inevitably becomes more challenging thereafter. Later on, slower rates of weight loss
are acceptable (e.g., ∼0.3%–0.5%/week) provided that the owner remains motivated
and is happy to stick to the program (see Box 8.1 for incentive ideas).
8.3 Follow-up and recheck appointments 139
REFERENCES
1. Webb TL. Why pet owners overfeed: A self-regulation perspective. In:
Companion Animal Nutrition Summit: The Future of Weight Management.
Barcelona, Spain: Nestle Purina; 2015, pp. 89–94.
2. Murphy M. Obesity treatment: Environment and behavior modification. The
Veterinary Clinics of North America: Small Animal Practice 2016;46:883–898.
3. Marshall WG, Hazewinkel HAW, Mullen D et al. The effect of weight
loss on lameness in obese dogs with osteoarthritis. Veterinary Research
Communications 2010;34:241–253.
4. Bissot T, Servet E, Vidal S et al. Novel dietary strategies can improve the
outcome of weight loss programmes in obese client-owned cats. Journal of
Feline Medicine and Surgery 2010;12:104–112.
Kenneth J. Lambrecht
GENESIS
The development of Bug’s Cat Gym started following publication of data
showing ideal weight dogs live almost 2 years longer than their over-
weight counterparts (1). When moving to a new location, the owner of a
Midwestern veterinary facility applied this information to the development
and design of the new space with a focus on ideal weight and nutrition.
The portion dedicated to cats was also designed to meet the requirements
to become designated a gold level Cat Friendly Practice per the American
Association of Feline Practitioners.
Figure 8.2 Reception cat walks. Two cat walks connected by tunnels
were placed above the hospital reception area. (Used with permission
from the West Towne Veterinary Center, Madison, Wisconsin.)
8.5 Getting the word out 143
Figure 8.3 Bug’s Cat Gym. Full gym and boarding area for cats on the
second story of the building. (Used with permission from the West
Towne Veterinary Center, Madison, Wisconsin.)
Figure 8.5 Bug’s Private Gym. (Used with permission from the West
Towne Veterinary Center, Madison, Wisconsin.)
8.5 Getting the word out 145
Figure 8.6 More climbing perches and elevated cat walkways were
added, allowing cats to be above the action for the full circumference of
the room. (Used with permission from the West Towne Veterinary Center,
Madison, Wisconsin.)
REFERENCES
1. Kealy RD, Lawler DF, Ballam JM et al. Effects of diet restriction on life span
and age-related changes in dogs. Journal of the American Veterinary Medical
Association 2002;220(9):1315–1320.
2. One Fast Cat. Cat Exercise Wheel. Available from: http://onefastcat.com.
Accessed March 1, 2016.
encourage interaction with their pets via activity rather than feeding. Some of
these organizations may be interested in cosponsoring an event geared toward
obese or overweight pets just starting out.
There may also be opportunities within the community to work together with
human weight loss clinics, dietitians, or gym facilities with expertise in weight
loss programs for people. Consider offering veterinary support to these facilities,
focusing on overweight people who also have overweight pets.
These staff members are encouraged to refer to the visits as weight loss or
maintenance program visits in order to reduce any client confusion regarding
their expected scope.
148 Establishing a weight management program in clinical practice
8.7 CONCLUSION
Each veterinary clinic establishing a weight management program should first
create resources to help the client and pet achieve weight loss and eventual
ideal weight maintenance as efficiently as possible. An initial information
questionnaire (DAHHF), treat allowance sheets, weekly food diary, and
clearly illustrated ideal weight and BCS goals will help the veterinary staff and
owner communicate about feeding recommendations. Before and after pet
pictures, weight loss starter kits, and certificates of weight loss completion can
help incentivize owners and maintain commitment to program compliance.
Compliance is also fostered via consistent recheck appointments and open
access to clinic scales for owners to check their pet’s progress between
scheduled weight assessments. Clear feeding instructions to aid ideal weight
maintenance and continued weight rechecks at least every 6 months should
be sustained long term. Marketing materials and hospital events related to
weight loss can serve as program advertisement to the community, as can
collaboration with other veterinary or human medical professionals. Finally,
financial costs involved with establishing a weight management program
should be assessed via a cost-benefit analysis to ensure the program is realistic
and sustainable from both the client and clinic perspective.
Appendix 8.1: Diet, activity, and household history form 149
The remaining questions are to be completed for the pet who will be attending
the clinic
Appendix 8.1: Diet, activity, and household history form 153
154 Establishing a weight management program in clinical practice
Appendix 8.1: Diet, activity, and household history form 155
156 Establishing a weight management program in clinical practice
REFERENCES
1. Murphy M. Obesity treatment: Environment and behavior modification.
Veterinary Clinics of North America: Small Animal Practice
2016;46:883–898.
2. Linder D, Mueller M. Pet obesity management: Beyond nutrition.
Veterinary Clinics of North America: Small Animal Practice 2014;44:
789–806, vii.
3. German AJ, Holden SL, Gernon LJ et al. Do feeding practices of obese
dogs, before weight loss, affect the success of weight management?
British Journal of Nutrition 2011;106 (Suppl 1):S97–S100.
4. German AJ, Holden SL, Wiseman-Orr ML et al. Quality of life is reduced
in obese dogs but improves after successful weight loss. Veterinary
Journal 2012;192:428–434.
5. German AJ, Holden SL, Morris PJ et al. Long-term follow-up after weight
management in obese dogs: The role of diet in preventing regain.
Veterinary Journal 2012;192:65–70.
160 Establishing a weight management program in clinical practice
20. German AJ, Titcomb JM, Holden SL et al. Cohort study of the success of
controlled weight loss programs for obese dogs. Journal of Veterinary
Internal Medicine 2015;29:1547–1555.
21. German AJ, Holden SL, Mason SL et al. Imprecision when using
measuring cups to weigh out extruded dry kibbled food. Journal of
Animal Physiology and Animal Nutrition 2011;95:368–373.
22. Murphy M, Lusby AL, Bartges JW et al. Size of food bowl and scoop
affects amount of food owners feed their dogs. Journal of Animal
Physiology and Animal Nutrition 2012;96:237–241.
23. Jerome GJ, Alavi R, Daumit GL et al. Willingness to pay for continued
delivery of a lifestyle-based weight loss program: The Hopkins POWER
trial. Obesity 2015;23:282–285.
24. Hess J, Gerstner E. Loss leader pricing and rain check policy. Marketing
Science 1987;6:358–374.
9
Case Examples
163
164 Case Examples
with meals to stimulate his interest in food, and commercial treats for which no
caloric information was available. Smoked beef marrow bone (∼198 kcal/96 g of
1 bone) and raw vegetables were also given throughout the day. Overall, more
than 37.5% (>300 kcal/day) of his daily caloric intake originated from treats and
unbalanced table food.
His body condition score (BCS) (2) was assessed as 9/9 (approximately 50%
body fat, estimated according to clinician’s experience), but the muscle condition
score (MCS) (3) could not be assessed due to too much fat coverage. His initial
body weight (BW) was 15.8 kg, while his estimated ideal BW was calculated to be
9.88 kg ([15.8 kg × 50% lean mass]/80% lean mass) (2,4).
As the patient presented with a BCS larger than 5/9, an extended nutritional
evaluation was indicated (1). Animal factors contributing to obesity in this patient
include dachshund breed, neutered male, and middle age. Dietary factors include
a high energy density diet, feeding excessive treats and human foods, and poor
measurement of meals. Last, the patient also had a low activity level, especially
because of the recent recovery period.
9.1.3 Plan
A veterinary therapeutic diet formulated for weight loss,∗ dry and canned
formulas (nutrient compositions for dry and canned food, respectively: ME
360 kcal/100 g and 56 kcal/100 g; 94.4 and 121.8 g/1000 kcal protein; 27.8 and
35.8 g/1000 kcal fat; 7.5 and 17.9 g/1000 kcal crude fiber; 83.3 and 62.7 g/1000 kcal
L-carnitine) were selected out of several options. The daily energy intake
was calculated based on an ideal body weight of 9.88 kg to be 390 kcal/day
using a maintenance energy requirement (MER) factor of 1.0 for weight loss
(MER = 70 × [9.88]0.75 × 1.0 = 390 kcal/day) (4).
The dog was fed three meals per day to increase satiety and reduce begging
behavior. His owners were encouraged to feed him using feeding toys (puzzles
and kong †) for enrichment and to increase activity. For treats, low-calorie,
veterinary therapeutic dog biscuits‡ (ME 15 kcal/treat) and raw vegetables were
recommended, not exceeding 10% of daily energy intake, to maintain a balanced
nutrient profile (5). All other treats and human foods were strictly prohibited.
The owners were instructed to weigh each meal using a kitchen gram scale to
ensure accurate feeding amounts. To ensure a slow and consistent weight loss of
1%–2% per week (6), where 2% is the recommended maximum amount of safe
weight loss (4), biweekly weigh-ins were recommended, always using the same
scale at the family veterinarian’s practice. According to the literature, if the weight
change is lower than 0.5%, a reduction range of 5%–20% of daily energy intake is
recommended (4,7), therefore, the food amount was adjusted as required based
on weight loss.
* Royal Canin Veterinary Diets, Canine Calorie Control (dry and canned), Ontario, Canada.
† The Kong Company, Golden, Colorado.
Figure 9.1 Weight loss trends (blue) plotted against ideal body weight
(purple), an average weekly weight loss of 1% of the initial body weight (red),
and average temperatures (green). Caloric intake over time is presented at
the top of the graph (orange). *January 17, 2014: Start of weight loss plan (T0);
**March 26, 2014, and August 22, 2014 (Tm): Recheck appointment.
166 Case Examples
At the next recheck appointment (7 months after T0), the dog lost an additional
0.4 kg (Figure 9.1), and was assessed to be at ideal BCS and MCS at 9.6 kg. A long-
term weight maintenance plan was calculated (time point will be referred to as
Tm), using the same two diets, with an increase of the daily energy intake by 5%
to 378 kcal/day (4). Monthly weight updates were advised.
A month and a half later, the dog had lost 0.5 kg over two weight updates, so
his weight maintenance plan was revised accordingly to a daily energy intake of
400 kcal/day, a 6% increase.
Four months after Tm, the patient had gained 0.5 kg, and due to continuation
of weight gain, his daily energy intake was adjusted back to 378 kcal/day for the
remainder of the winter, given his lower activity level. At the time of this report,
a year after the start of the weight loss plan, the dog is maintaining his BW at this
energy intake.
9.1.5 Discussion
As described in Chapter 1, risk factors for obesity include animal-specific factors
and human-specific factors such as dietary factors, physical activity, owner
attitudes, and household characteristics. In the case presented, nutritional
assessment revealed presence of many of those predisposing factors. The dog was a
male, neutered dachshund (predisposed breed) (8,9), who was initially fed an over-
the-counter high fat diet, with an inappropriate measuring container (imprecise
and inaccurate when weighing out the daily portion size) (10). Moreover owners
rewarded the dog with unbalanced foods whenever he presented with a begging
behavior or when assumed to lack interest in food. Due to back pain the dog was
also inactive, which reduced the dog’s energy expenditure. Removing some of
these predisposing factors is crucial to initiate weight loss.
When designing a weight loss plan, energy restriction, that is, reducing the daily
energy intake, is most important to create a negative energy balance (4,11). To achieve
this, a veterinary therapeutic diet formulated for weight loss should be selected, as
energy restriction of maintenance diets may provide inadequate amounts of essential
nutrients such as protein, essential amino acids, essential fatty acids, minerals,
and vitamins. Key nutritional factors for weight loss include but are not limited to
reduced energy density, hence reduced fat (4,12); increased total dietary fiber (TDF)
content (4,13), which also dilutes energy density and contributes to satiety by slowing
gastrointestinal transit time (14); and increased protein (>60 g/1000 kcal for 80%
restriction of resting energy requirements) (4,15), which is important for lean body
mass maintenance during weight loss (15) and for its significant thermic effect (16).
A veterinary therapeutic diet formulated for weight loss was selected, considering
key nutritional factors for weight loss as mentioned earlier. Moreover, the diet was
also suitable for long-term weight management, as it was considered complete and
balanced for adult maintenance based on the recommendations of the Association
of American Feed Control Officials (17).
Using food toys for feeding and exercise helps the owners feel actively and
positively engaged in the weight loss process. Moreover, promoting daily exercise,
especially when the weather is amenable (Figure 9.1) not only enhances weight loss
Case 1 167
and maintains muscle mass but also strengthens the dog–human relationship (18).
Changes in rate of weight loss/gain also demonstrate the importance of regular
weight updates, communication with clients, and tailoring the weight loss plan
to the patient’s individual needs.
REFERENCES
1. Freeman L, Becvarova I, Cave N et al. WSAVA nutritional assessment
guidelines. Journal of Small Animal Practice 2011;52(7):385–396.
2. Laflamme DP. Development and validation of a body condition score
system for dogs. Canine Practice 1997;22(4):10–15.
3. Baldwin K, Bartges J, Buffington T et al. AAHA nutritional assessment
guidelines for dogs and cats. Journal of the American Animal Hospital
Association 2010;46(4):285–296.
4. Brooks D, Churchill J, Fein K et al. 2014 AAHA weight management
guidelines for dogs and cats. Journal of the American Animal Hospital
Association 2014;50(1):1–11.
5. Yaissle JE, Holloway C, Buffington CA. Evaluation of owner education
as a component of obesity treatment programs for dogs. Journal of the
American Veterinary Medicine Association 2004;224(12):1932–1935.
6. Laflamme DP, Kuhlman G. The effect of weight loss regimen on
subsequent weight maintenance in dogs. Nutrition Research
1995;15(7):1019–1028.
7. Fragua V, Barroeta AC, Manzanilla EG, Codony R, Villaverde C. Evaluation
of the use of esterified fatty acid oils enriched in medium-chain fatty
acids in weight loss diets for dogs. Journal of Animal Physiology and
Animal Nutrition 2015;99:48–59.
8. Lund EM, Armstrong PJ, Kirk CA, Klausner JS. Prevalence and risk
factors for obesity in adult dogs from private US veterinary practices.
International Journal of Applied Research in Veterinary Medicine
2006;4(2):177.
168 Case Examples
9. Edney AT, Smith PM. Study of obesity in dogs visiting veterinary practices
in the United Kingdom. Veterinary Record 1986;118(14):391–396.
10. German AJ, Holden SL, Mason SL et al. Imprecision when using
measuring cups to weigh out extruded dry kibbled food. Journal of
Animal Physiology and Animal Nutrition 2011;95(3):368–373.
11. German AJ. The growing problem of obesity in dogs and cats. Journal of
Nutrition 2006;136(7 Suppl):1940S–1946S.
12. Borne AT, Wolfsheimer KJ, Truett AA et al. Differential metabolic effects
of energy restriction in dogs using diets varying in fat and fiber content.
Obesity Research 1996;4(4):337–345.
13. Jackson JR, Laflamme DP, Owens SF. Effects of dietary fiber content on
satiety in dogs. Veterinary Clinical Nutrition 1997;4:130–134.
14. Jewell D, Toll P. Effects of fiber on food intake in dogs. Veterinary Clinical
Nutrition 1996;3:115–118.
15. Hannah SS, Laflamme DP. Increased dietary protein spares lean body
mass during weight loss in dogs (ABSTRACT). Journal of Veterinary
Internal Medicine 1998;12:224.
16. Hoenig M, Waldron M, Ferguson D. Effect of a high-and low-
carbohydrate diet on respiratory exchange ratio and heat production
in lean and obese cats before and after weight loss. Compendium on
Continuing Education for the Practising Veterinarian: North American
Edition 2006;28(4):71.
17. Association of American Feed Control Officials (AAFCO). 2014 Official
Publication AAFCO; 2014.
18. Westgarth C, Christian HE, Christley RM. Factors associated with daily
walking of dogs. BMC Veterinary Research 2015;11:116.
Case 2 169
MEGAN SHEPHERD
* Exclusive Chicken & Rice Formula Senior Dog Food (374 kcal/cup; kcal/kg information
unavailable).
† Pedigree Dentastix Fresh Treats (42 kcal/treat; kcal/kg information unavailable).
‡ Oscar Mayer.
§ Hill’s Prescription Diet r/d Canine (dry: 242 kcal/cup, 2968 kcal/kg as fed; canned:
The owners reported that they did not transition the Spaniel onto the therapeutic
weight loss diet.
9.2.3 Plan
The nutritionist set an initial dietary goal to transition the Spaniel onto healthier
foods. The nutritionist anticipated that it would take time to get the Spaniel fully
transitioned onto healthier foods due to the variety of human foods currently
fed. The nutritionist discussed with the owners how it may take up to 4 weeks
to get the Spaniel transitioned onto the “ideal” weight loss diet. The nutritionist
discussed several therapeutic weight loss diet options, but encouraged the owners
to reconsider the original therapeutic weight loss diet, provided it is reintroduced
slowly. The owners chose to retry the therapeutic weight loss diet previously fed.
The nutritionist recommended a slow transition onto the therapeutic weight
loss diet. It was suggested to take away 1/8–1/4 cup of the dry senior dog food at the
Spaniel’s breakfast and dinner and replace it with 1/8–1/4 cup of the therapeutic
weight loss diet (either dry or canned). Initially and temporarily using flavorful
ingredients like tuna juice, canned chicken juice, 1–2 teaspoons of ground beef
grease (postcooking), 1 tablespoon of cheese (melted to better stick to the food)
or 1 tablespoon parmesan cheese may help with the transition. Alternately, the
owners could spread a small amount of the therapeutic weight loss diet canned
onto a piece of lunch meat, then slowly spread on more therapeutic weight loss
diet canned and reduce the amount of lunch meat.
Once, the Spaniel was transitioned onto the therapeutic weight loss diet, the
owners were instructed to follow specific volume guidelines. For the therapeutic
weight loss diet, the owners had a choice of either 3.75 cups of the dry kibble,
Case 2 171
3.5 cans, or 1.5 cups dry kibble plus 2 cans. The owners were instructed to choose
one of the three options per day. The total daily amount of food was to be divided
into the three meal times (breakfast, lunch, dinner) per day. Alternately, the
owners could divide the food into two meals (breakfast and dinner), then use the
recommended treat options during lunch.
Specific treat options were recommended (Table 9.1). Treat allowance was
limited to 10% of total daily calories or 100 kcal per day. The owners were
informed that the amount recommended for each item met the 10% daily
maximum. Therefore, if more than one treat was to be fed per day, the owners
were instructed to reduce the amount of each treat respectively. For example, if
the owners wanted to feed four treat options (i.e., medication administration,
kenneling, and two other between meal times), they were to feed a quarter of the
recommended amount for that day.
The nutritionist recommended that the owners encourage voluntary activity.
Food toys were discussed as a tool to encourage voluntary movement. Several food
toy options were offered∗ and their use with the dry therapeutic weight loss diet
briefly described. The nutritionist encouraged future reconsideration for physical
* KONG Food Toys, Buster Food Cube, Aikiou Activity Food Center, Kyjen Dog Puzzles,
Ethical Pet Seek-A-Treat Shuffle Bone Dog Puzzle, StarMark Bob-A-Lot Interactive Pet Toy.
172 Case Examples
9.2.4 Follow-up
At the 4-week phone recheck, the owners reported that the Spaniel was fully
transitioned to the therapeutic weight loss diet within the first 4 weeks and that
they were seeing a change in the Spaniel’s body shape. The owners were pleased
with the results thus far. At the 4-month phone recheck, the owners reported that
the Spaniel weighed 96 pounds per the scale at the Spaniel’s veterinarian’s office.
The Spaniel was eating the therapeutic weight loss diet (3¾ cup; 908 kcal/day)
and a small, unmeasured piece of baked chicken when the first owner prepared
his lunch. The owners reported that they had cut back on all other treats but
were unable to provide specific quantities. The Spaniel was reported to be moving
around better and to now have a waist. The owners were pleased with the progress.
At the 5-month phone recheck, the owners reported that the Spaniel was still
eating the therapeutic weight loss diet and continued to move around more. The
owners did not have an updated weight at the time, but reported that friends
are noticing the Spaniel’s weight loss. The owners reported that the Spaniel had
recently increased water intake and had experienced dorsal hair loss and had
scheduled an appointment with the Spaniel’s veterinarian for evaluation of these
recent changes. Overall, the owners were still pleased with the Spaniel’s progress.
The Spaniel’s weight loss is an open case. The initial 16-pound lost over the
first 4 months was in the target range of 4–8 pounds per month. The nutritionist
was very proud of the owners for dramatically altering the Spaniel’s management.
This case highlights the importance of thorough investigation of diet history and
management, and creating a plan that minimizes stress and work for the owners
while achieving the weight loss goal.
9.2.5 Discussion
The Spaniel achieved her obese body condition due to an imbalance in energy
intake and expenditure, specifically due to excess energy intake. Weight loss will
benefit the Spaniel in numerous ways. The Spaniel initially presented to the VTH
surgery service for evaluation of lameness. Resolution of obesity will resolve the
unnecessary stress on the musculoskeletal system. The owners reported that the
Spaniel had improved ambulation within the first 4 months and before ideal body
weight was achieved.
The Spaniel’s owners successfully implemented a weight loss plan that included
careful attention to the current diet and feeding management (i.e., owner lifestyle).
Careful consideration of feeding management and daily schedule helps to frame
Case 2 173
a weight loss plan to minimize stress on the owner. It is the author’s experience
that improper diet transition can have negative consequences on acceptance of
new food, particularly when transitioning away from human food. As an open
case, the complete weight loss trajectory is unknown. In the author’s experience,
some obese patients will plateau in their weight loss. When weight loss plateaus,
diet compliance should be evaluated and recommendations should be adjusted.
Furthermore, the author’s approach to calculating ideal body weight, which
influences target daily energy requirements for weight loss, is one approach.
Another way to estimate ideal body weight is to subtract the estimated extra 40%
body weight from current body weight. At the end of the day, the initial plan
is a place to start and the success of the initial plan will be determined through
consistent monitoring and reformulation of the diet plan as needed.
REFERENCE
1. Brooks D, Churchill J, Fein K et al. 2014 AAHA weight management
guidelines for dogs and cats. Journal of the American Animal Hospital
Association 2014;50(1):1–11.
174 Case Examples
LYDIA LOVE
* Royal Canin Veterinary Diet Gastrointestinal Fiber Response, Royal Canin U.S.A, Inc.
Case 3 175
9.3.3 Plan
General anesthesia for a subtotal colectomy was planned. Anesthetic concerns are
grouped into patient- and procedure-oriented issues, and for this patient primarily
included hypoventilation and hypoxemia, subclinical cardiac dysfunction, correct
dosing of sedatives and anesthetics, and management of pain.
The respiratory system of the obese patient is less compliant than normal
weight subjects, due to increased fat mass, restrictive breathing patterns, and
increased pulmonary blood volume. Inspiratory and expiratory flow limitations
may occur and can be accompanied by hypoventilation. Obese patients breathe at
low lung volumes and have a decreased functional residual capacity (FRC) relative
to those of normal weight. The increased fat mass and small tidal volumes lead
to airway closure, subsequent atelectasis, and gas exchange inequalities. Dose-
dependent respiratory depression caused by general anesthetics and positioning
in dorsal recumbency exacerbate hypoventilation, causing respiratory acidosis
and possibly leading to desaturation in the perioperative period. Preoxygenation
prior to induction was planned for this obese patient to denitrogenate the FRC
and increase oxygen storage in the lungs, extending the time to desaturation (1).
During general anesthesia, ventilation was assessed by monitoring end-expiratory
carbon dioxide concentrations. Controlled ventilation (manual or mechanical)
was used to maintain normal carbon dioxide concentrations, and pulse oximetry
was closely followed. Close objective monitoring of oxygenation continued into
the recovery period.
Although not as well-described in dogs and cats as it is in humans, the obese
patient may display subclinical diastolic cardiac dysfunction, necessitating
close monitoring of cardiovascular function during anesthesia and attention
to perianesthetic fluid load. Drugs that can cause tachyarrhythmias (especially
dissociative anesthetics and anticholinergics) are avoided, as faster heart rates
may limit cardiac filling when diastolic dysfunction is present. Intravenous
crystalloid infusion is calculated at surgical rates but based on ideal body weight.
Total fluid load is kept under 10–15 mL/kg in the immediate perioperative time
period, barring major intraoperative blood loss.
Dose reductions of sedatives and anesthetics are calculated due to obesity-
associated changes in pharmacokinetic parameters. As total body weight
increases due to increasing fat weight, lean body weight also increases but not
in parallel. Most anesthetics and sedatives are moderately to highly lipophilic,
which promotes their movement across the blood–brain barrier to their site of
action. Therefore, dosing on total body weight (TBW) in the obese patient may
lead to a relative overdose. However, ideal body weight (IBW)–based calculations
may underdose the patient and a universal dosing scalar has not been established
in obese cats and dogs. Drug calculations for this patient were based on adjusted
body weight (ABW) (IBW + 0.4 [TBW – IBW]) to account for increased lean body
weight (2). However, all anesthetics drugs were titrated to effect while monitoring
for cardiorespiratory side effects.
A subtotal colectomy is an invasive abdominal procedure that requires dorsal
recumbency for a moderate length of time (typically less than 2 hours). In
176 Case Examples
Figure 9.3 The obese patient in the anesthesia recovery unit with a nasal line
in place to supplement inspired oxygen and decrease the risk of hypoxemia
due to residual hypoventilation and atelectasis.
9.3.5 Discussion
Increasing body mass index in humans is associated with longer anesthetic times,
longer surgical times, increased risk of respiratory and renal complications,
increased risk of infection, longer hospital stays, and increased cost in the
perioperative time period (5,6). It is likely that many of these issues are relevant to
obese, small animal anesthetic patients as well and the increased use of resources
should be anticipated.
The risks of anesthesia are mitigated by anticipating possible complications,
constructing strategies to circumvent those complications, monitoring for
development of expected and unexpected complications, and being prepared
to respond to perianesthetic issues as they arise. In obese patients the primary
concerns surround respiratory function and dose reductions of anesthetic and
sedative agents.
Preoxygenation is advised in all patients prior to induction of anesthesia to
avoid desaturation. Because obese patients have increased metabolic demands
coupled with a much smaller FRC, desaturation can occur rapidly at induction.
The patient of this report was preoxygenated for 5 minutes and then rapidly
intubated and ventilated by hand. During the maintenance phase, the patient
was placed on a mechanical ventilator. There is no consensus on perianesthetic
ventilation strategies in obese human patients and no published information
regarding this topic in cats and dogs. Tidal volumes are probably best based on
IBW to avoid baro- or volutrauma. An alveolar recruitment maneuver with the
addition of PEEP reduces atelectasis and improves compliance and gas exchange
in obese human patients during anesthesia (7). A PEEP valve was utilized
during anesthesia in the patient of this case report, but an alveolar recruitment
maneuver was not performed as no episodes of hypoxemia were noted. After
discontinuing mechanical ventilation, but while still being supplemented with
100% oxygen, hypoventilation was documented. To avoid desaturation due to
continued hypoventilation and ventilation–perfusion mismatch caused by
residual atelectasis, a nasal oxygen line was placed and the patient was monitored
objectively with continuous pulse oximetry throughout recovery.
Finally, initial drug doses were calculated for this patient based on an ABW. Not
enough information is available even for humans to make firm recommendations
about drug dosing in obesity and very few pharmacokinetic–pharmacodynamic
studies have been conducted in obese subjects of any species. Ideally, species- and
drug-specific guidelines would exist, but lacking those, using ideal body weight
plus a percentage of excess weight may account for the nonlinear increase in lean
body weight that occurs as TBW increases. More generally, anesthetic agents are
best titrated carefully to effect while monitoring for cardiorespiratory side effects.
REFERENCES
1. McNally EM, Robertson SA, Pablo LS. Comparison of time to
desaturation between preoxygenated and nonpreoxygenated dogs
following sedation with acepromazine maleate and morphine and
induction of anesthesia with propofol. American Journal of Veterinary
Research 2009 November;70(11):1333–1338.
Case 3 179
9.4.3 Plan
A weight loss plan was calculated based on the 2014 American Animal Hospital
Association (AAHA) weight management guidelines for dogs and cats (2). BCS
9/9 was estimated to equal 45% body fat. Based on this, ideal BW was calculated.
Calculation of ideal BW:
10.8 kg × (100% – 45%)/0.8 = 7.4 kg
Nutrient As fed ME
Protein (%) 34 42
Fat (%) 9 24
Carbohydrate (%) 28 34
Metabolizable energy (ME) (kcal/kg) 3090
National Research Council (NRC) recommended allowance of protein for cats (4):
The owner was informed to feed only the recommended diet and if she wanted
to give snacks to save some of the allocated ration for this.
Figure 9.4 Cat being scanned in a dual energy x-ray absorptiometry scanner.
(Photo by K.M. Hoelmkjaer.)
The cat liked the prescribed weight loss diet and it was decided to continue
feeding this diet:
Calculation of amount to feed:
9.4.5 Discussion
Based on the actual body fat percentage (BF%), it was discovered that during
the last 14 days, the cat had been fed what equaled its RER for its ideal BW and
had not been restricted to a level where weight loss could be anticipated. After
adjustment to a BF% of 60%, the cat started to lose weight at the rate of 1% per
week. The BCS system is good for determining if an animal is underweight,
lean, or obese, but care should be taken when estimating the degree of fatness
(BF%) based on a BCS. BF% relating to a BCS may depend on age, breed, and
lifestyle, and may therefore differ between individuals both in cats and dogs
(1,5,6). This case underscores the particular problem of assessing the BF% of
an animal whose fatness exceeds the BCS scale (score 9/9 equals 45% body
fat) and it highlights the limitations of using the 9-point body condition score
for extremely overweight animals. To increase the accuracy in determining
energy restriction for a particular individual, there are different complementary
methods that should be added whenever possible. If DEXA scanning is not an
option, the examination of animals with a BCS of 7–9/9 should be supplemented
with the feline Body Fat Index (BFI) scoring system (7). The feline BFI was
designed to determine higher BF%s than the BCS with a limit at 65% body fat
(BFI 70). It is a relatively new method and has only been validated once, thus
its usefulness in improving BF% estimates is not certain, but it could serve as a
valuable complementary method for obese patients. In addition, if at all possible,
calculating the energy allocation given to the cat before initiation of a weight
loss plan could support the estimation of RER and required energy restriction.
In the beginning of a weight loss plan, frequent rechecks are necessary, as they
enable you to detect if weight loss is not achieved on current recommendations
and it stimulates owner compliance. Some cats may become very stressed by
the frequent visits to the veterinarian. For those, it is possible to manage some
rechecks long distance, that is, the owner weighs the cat at home followed by a
telephone consultation. Also, take into account that lack of results could have
many explanations including incorrect estimation of ideal BW, lack of owner
compliance, and access to food elsewhere, or a combination of these. Thus, be
sure to thoroughly investigate causes for lacking results.
REFERENCES
1. Laflamme D. Development and validation of a body condition score
system for cats: A clinical tool. Feline Practice 1997;25(5/6):13–18.
2. Brooks D, Churchill J, Fein K et al. 2014 AAHA weight management
guidelines for dogs and cats. Journal of the American Animal Hospital
Association 2014;50(1):1–11.
3. Armstrong PJ, Blanchard G. Hepatic lipidosis in cats. Veterinary Clinics
Small Animals 2009;39:599–616.
4. National Research Council of the National Academies. Nutrient
requirements and dietary nutrient concentrations. In: Nutrient
Requirements of Dogs and Cats. Washington, DC: National Academies
Press; 2006, pp. 354–370.
5. Bjornvad CR, Nielsen DH, Armstrong PJ et al. Evaluation of a nine-point
body condition scoring system in physically inactive pet cats. American
Journal of Veterinary Research 2011;72(4):433–437.
6. Jeusette I, Greco D, Aquino F et al. Effect of breed on body composition
and comparison between various methods to estimate body composition
in dogs. Research in Veterinary Science 2010;88(2):227–232.
7. Witzel AL, Kirk CA, Henry GA, Toll PW, Brejda JJ, Paetau-Robinson I. Use
of a morphometric method and body fat index system for estimation of
body composition in overweight and obese cats. Journal of the American
Veterinary Medical Association 2014;244(11):1285–1290.
Case 5 185
cup, 4118 kcal/kg, protein 50% ME, fat 37% ME, carbohydrate 13% ME).
‡ Purina ProPlan Veterinary Diets DM Dietetic Management ® Feline Formula canned
(191 kcal/can, 1227 kcal/kg, protein 38.8% ME, fat 58% ME, carbohydrate 3.3% ME).
§ GNC Ultra Mega Hip and Joint Health treats (5.4 kcal per treat).
186 Case Examples
9.5.3 Plan
A weight loss plan was recommended to address the patient’s obesity and to
improve insulin sensitivity. Based on her initial BW and estimated body fat of
50%, it was estimated that her ideal BW was approximately 5.4 kg.
Due to the patient’s advanced age and evidence to suggest that female cats have
a higher body fat percentage at a body condition score of 5/9 (3), an ideal body fat
percentage of 25% was selected for this patient. A body fat percentage of 20%–24%
has been recommended to correlate with a BCS of 5/9 in both dogs and cats (2).
Resting energy requirement (RER) for her ideal body weight was calculated
at 250 kcal/day:
In order to safely attain her weight loss goal at a rate of 0.5%–2% BW per week
(2), her maintenance energy requirement (MER) was calculated using a life stage
factor of 0.8.
Calculation of MER = Life stage factor × RER
0.8×248 = 198 kcal/day
The client was instructed to feed the previously recommended diet in one of
two combinations approximating her caloric requirements (see Table 9.2), with the
prescribed insulin administered 30 minutes following each meal. The treat marketed
for joint health was also incorporated into the diet plan, with 1 given every 12 hours.
The owner was instructed to monitor daily for glucosuria and watch for signs
of hypoglycemia due to the potential for improved insulin sensitivity with weight
loss. It was recommended to follow-up in 2 weeks to ensure a safe and effective rate
of weight loss. It was also recommended to reassess diabetic control in 2 weeks
with a serum fructosamine measurement as the patient’s temperament did not
allow for a blood glucose curve in hospital or at home.
Table 9.2 The owner’s were given two feeding options: (1) ½ can every 12
hours or (2) 1/3 can and 8 grams of dry every 12 hours
9.5.5 Discussion
Diabetes mellitus (DM) in cats occurs commonly due to peripheral insulin
resistance as a result of excess adiposity and beta cell dysfunction (4). Cats can have
insulin resistance at just 10% over their lean body weight (5). Obese cats are up to
3.9 times as likely to have DM than cats with an ideal BCS (6). Every 1 kg increase
in body weight has been associated with a 30% decrease in insulin sensitivity,
which was normalized with weight loss (7). Weight loss should be a primary goal
in overweight/obese cats with DM to help achieve and maintain diabetic remission
in conjunction with appropriate medical management. The timing of weight
management should be delayed in an overtly ill cat until stabilized.
A survey of veterinarians in the Southeastern United States revealed that
97% (87/90) of vets always or usually recommended dietary management at the
time of DM diagnosis and 93% of respondents recommended diets marked as
low carbohydrate (LC) (8). The number of veterinarians recommending weight
loss was not determined in this study. A diet with a carbohydrate content of
approximately 35 g/1000 kcal or less (9,13) may be advantageous for cats with DM.
Cats fed a LC–low fiber diet appeared to be better regulated and had a significantly
higher remission rate of 68% compared to cats fed a moderate carbohydrate–
high fiber diet with a remission rate of 41% (10). It is notable that postprandial
hyperglycemia, which causes further beta-cell toxicity and exacerbates DM, is
increased in magnitude and duration in some overweight cats (11). Therefore,
correction of obesity is important to achieve and maintain diabetic remission,
as seen in the described patient. Switching to a LC diet alone without addressing
the patient’s excess body weight did not result in remission of this patient’s DM.
The authors typically recommend a canned, LC therapeutic weight loss diet
for cats with DM due to the higher moisture content, lower calorie density, and
ease of portion control when compared to dry LC diets. A dry food may be
188 Case Examples
preferred by some patients and cat owners. A low calorie density, high protein
(≥115 g/1000 kcal) weight loss diet may be recommended in these cases to improve
owner and patient compliance with higher feeding volumes when compared to
LC, high calorie density dry diets. These dry diets may be lower in fat and/or have
supplemental fiber to reduce calorie density. Diets containing high amounts of
protein (≥115 g/1000 kcal) are recommended to support lean body mass during a
weight loss plan for a diabetic patient. Specific feeding amounts during weight loss
should be recommended and ad libitum feeding of dry food is not recommended.
The authors recommend weighing dry food on a kitchen gram scale for improved
accuracy when feeding (12). This can be calculated using the caloric information
(kcal/kg) provided on the pet food label.
REFERENCES
1. Laflamme D. Development and validation of a body condition score
system for cats: A clinical tool. Feline Practice 1997;25:13–17.
2. Brooks D, Churchill J, Fein K, Linder D, Michel KE, Tudor K, Ward E,
Witzel A. 2014 AAHA weight management guidelines for dogs and cats.
Journal of the American Animal Hospital Association 2014;50:1–11.
3. Bjornvad CR, Nielsen DH, Armstrong PJ, McEvoy F, Hoelmkjaer KM,
Jensen KS, Pedersen GF, Kristensen AT. Evaluation of a nine-point body
condition scoring system in physically inactive pet cats. American Journal
of Veterinary Research 2011;72:433–437.
4. Rand JS, Fleeman LM, Farrow HA, Appleton DJ, Lederer R. Canine
and feline diabetes mellitus: Nature or nurture? Journal of Nutrition
2004;134:2072S–2080S.
Case 5 189
9.6.3 Plan
Jacob was initially placed on exercise restriction for 8 weeks after the surgical
procedure. During this time, his weight management plan consisted solely of dietary
management. The family was switched to a therapeutic weight loss food given Jacob’s
need for caloric restriction and lack of exercise. Initial calorie intake was set at resting
energy requirements for ideal weight (1) of 34 kg (this was calculated with the
formula: 70 × [Body weight in kg]0.75 = 70 × 340.75 = approximately 1000 kcal/day).
A daily feeding schedule was discussed for Jacob that included 1000 kcal total
with 900 kcal in a therapeutic weight loss food and 10% of the total 1000 kcal
(100 kcal) reserved for Jacob’s favorite treats.
diet, he ate his food quickly and enthusiastically, but then went back to being
restless until the next meal. On further discussion, the owner also felt guilty over
not allowing Jacob to go on walks or play in the pond near their house. He did
not want his dog to resent him or their time together. The owner felt that the
meals were the only enjoyable part of his dog’s daily routine and hated that it was
over so quickly, so he wanted to provide more meals and treats until Jacob could
exercise more.
It was discussed with the owner that the exercise restriction was necessary for
proper recovery and that adding food or treats would add weight and make Jacob
feel even worse, as overweight pets have more pain and emotional disturbance
(2). Options were discussed as highlighted in the American Animal Hospital
Association (AAHA) 2014 weight management guidelines troubleshooting tips
for behavioral management (1), including using food-dispensing toys and food
puzzles that would prolong mealtime. The owner really liked the idea of making
mealtime into a game that would extend Jacob’s enjoyment and allow the owner
to experience quality time with the pet as well. For one meal a day, the owner
used pieces of the kibble to teach Jacob new tricks that prolonged feeding. For
example, the owner taught him to stay while he placed one piece of kibble on each
of his paws and to wait before eating each, as seen in Figure 9.5. This resolved the
Figure 9.5 For one meal a day, the owner used pieces of the kibble to teach
Jacob new tricks that prolonged feeding. In this photo, the owner taught him
to stay while he placed one piece of kibble on each of his paws and to wait
before eating each.
192 Case Examples
owner’s concern, and at their 8-week recheck, Jacob was 35 kg (77 lb), and the
family was continuing to follow the agreed-on plan.
9.6.5 Discussion
Seeing Jacob show enthusiasm and enjoy their time together was an important
aspect of the relationship between the owner and Jacob. For both the owner and
Jacob to benefit from positive interaction, Jacob’s food motivation was encouraged
as a time to explore creative ways to interact incorporating mental stimulation
and game playing into mealtime. Instead of allowing Jacob to eat all his food
quickly, the owner engaged the dog in positive training that allowed them to
strengthen their bond without negatively affecting the weight management plan.
The owner was able to see Jacob enjoy learning new tricks and excitedly finding
parts of his meal as he spent time with the owner.
REFERENCES
1. Brooks D, Churchill J, Fein K, Linder D, Michel KE, Tudor K, Ward E,
Witzel A. 2014 AAHA weight management guidelines for dogs and cats.
Journal of the American Animal Hospital Association 2014;50:1–11.
2. German AJ, Holden SL, Wiseman-Orr ML, Reid J, Nolan AM,
Biourge V, Morris PJ, Scott EM. Quality of life is reduced in obese
dogs but improves after successful weight loss. Veterinary Journal
2012;19:428–434.
Case 7 193
JUSTIN SHMALBERG
* Nature’s Variety Instinct Rabbit Meal Formula, 482 kcal/cup, 3988 kcal/kg.
194 Case Examples
estimated daily caloric intake of 1928 kcal. Dried duck treats∗ were offered, with
an average reported consumption of three treats daily (57 kcal). No supplemental
foods were reported. The patient’s previous exposure history included a number
of commercial foods, and the patient’s diet was switched every 2–3 months to
evaluate response. A survey of the products revealed that the patient had also
consumed beef, bison, lamb, venison, whitefish, egg, tuna, and an equally broad
assortment of vegetables and grains. The referring veterinarian selected the rabbit
diet as a novel protein diet trial on the basis of its inclusion on a list provided
following IgE testing and because the promotional materials indicated that the
diet “may provide relief from most food allergy symptoms.” However, the diet
contained salmon, pork products, and vegetable proteins in addition to rabbit
meal, and it was therefore not an appropriate diet trial.
The patient’s obesity was best explained by chronic caloric intake in excess
of his requirements due to inactivity and a reduction in lean body mass
secondary to castration (1). Pathologic conditions that alter metabolic rate and
predispose to obesity, such as hypothyroidism, were considered as potential
risk factors. However, the age of the dog at the onset of obesity made such
differential diagnoses unlikely, and the provision of energy-dense diets in excess
of predicted caloric requirements during periods of concurrent glucocorticoid
administration appeared most compatible with the history and clinical signs.
The patient had no significant exercise and therefore no expected caloric
expenditure beyond that of other sedentary pet dogs. The patient’s weight was
stable the 3 months prior to presentation, and it was estimated to be about 50%
greater than his ideal weight of 42 kg using body conditioning scoring (each
point over 5/9 consistent with an estimated 13% excess over ideal body weight)
(2). The patient’s caloric intake (121 * ideal BWkg0.75 ) therefore approximated that
of laboratory dogs of similar age, a value that is generally 30% higher than
that of pet dogs (1). Significant variation has been reported in most reports
of maintenance energy requirements (MER) in the dog, but it was clear that a
significant reduction in intake would be necessary for weight loss (3).
9.7.3 Plan
The patient’s resting energy requirement (RER , 70 * ideal BWkg0.75 ) of about
1150 kcal was established as an initial target to achieve weight loss of 1% per
week as commonly suggested (4), recognizing that large breed dogs and dogs
with greater adiposity will require a greater caloric restriction relative to MER
to achieve such a rate than will smaller or less overweight dogs. It was further
thought that RER would be sufficient because the weight stable intake was high
compared to that established for pet dogs.
The client was instructed that a home-cooked diet would be the best option
for an elimination trial. Unbalanced home-cooked diets have been historically
recommended during the initial food test for simplicity and to avoid confounding
supplement ingredients (5,6). In this patient, such an approach would have
produced severe deficiencies due to the planned caloric restriction. Consequently,
a diet composed of alligator tail meat and quinoa was formulated to meet the
recommended allowances (RA) for an adult dog at the patient’s estimated ideal
body weight (Table 9.3). A basic nutrient profile for alligator tail was located,
and amino acid composition was obtained from unpublished data. Mineral and
vitamin analyses were unavailable. All added supplements were evaluated for
potential antigens; the only possible source was carmine (a natural colorant) in
the multivitamin, but no previous patient exposure was identified. The formulated
diet met or exceeded the patient’s RA for most nutrients (Table 9.4), and for those
nutrients less than the RA, no data was available for alligator meat and deficiencies
were considered unlikely.
Dietary intake using the formulated recipe approximated 1280 kcal/day,
slightly more that the established target. However, this amount was still over a
one-third reduction from previous intake, and it was to be adjusted at the first
recheck. Analysis of the prepared diet by a commercial laboratory was offered,
but declined by the client. Recheck examinations were recommended at 3–5
week intervals, but the final monitoring was dependent on concurrent visits
with the dermatologist given the distance the owner traveled. Blood work was
not a required component of this patient’s dietary follow-up, as the patient was
young and the diet was designed for short-term feeding of a maximum of 4 to
6 weeks after resolution of the skin infections and before oral challenge. The
overall nutritional prognosis was uncertain since food hypersensitivity cannot
be definitively diagnosed until rechallenge with the previous diet or individual
proteins (5) and because response to fatty acid supplementation in patients with
other forms of allergic skin disease is unpredictable (7).
Home-cooked diet
Nutrient Units 42 kg dog Intake/day % RA Intake/Mcal
Energy kcal 2145 1280 60 1000
Crude protein g 53.6 102 191 79.8
Fat g 29.6 59.5 201 46.5
Linoleic acid g 6.0 22 372 18
ALA g 0.2 5.0 2132 3.9
EPA and DHA g 0.2 1.8 780 1.4
Calcium g 2.1 2.1 97 1.6
Phosphorus g 1.6 2.0 124 1.6
Vitamin A RE 813 3000 369 2340
Cholecalciferol µg 7.3 10 137 7.8
Vitamin E mg 16 60 372 47
Thiamin mg 1.2 15 1274 12
Riboflavin mg 2.8 16 559 12
Pyridoxine mg 0.8 25.3 3149 19.8
Niacin mg 9.1 29.4 323 23.0
Pantothenic acid mg 8.0 26.6 330 20.8
Cobalamin µg 18.8 25.0 133 19.5
Exercise modification was challenging, as the sedentary habits of the dog and
owner made long-distance exercise impractical. The dog’s lameness on examination
was mild and nonspecific so no diagnostics were recommended, although the
impact of obesity on the development and severity of musculoskeletal pathology
was considered (8). Limited exercise was hypothesized to have mild effects on
daily energy expenditure. The client was instructed to walk the dog, increasing
the time over the course of a month to a target of 30 minutes twice daily. The
caloric impact of such exercise was estimated to be about 30 kcal daily above
maintenance, based on a walking speed of 1.6 km/hr and an energy expenditure
of 1.2 kcal/kg0.75/km (9). Underwater treadmill therapy was discussed, which may
provide advantages in maintaining lean body mass (10), but which would only
increase expenditure by 18 kcal daily more than walking on land and would be
associated with additional cost (9). The owner consented to the at-home exercise
protocol.
9.7.4 Follow-up
The patient lost an average of 1.6% of starting body weight per week during the
first 3 weeks on the diet without observed loss of muscle mass (Table 9.5). All
flavored oral medications were discontinued during that time. The patient’s
pruritus was reportedly improving, skin cytology was negative for cocci, and
Case 7 197
Table 9.5 Weight history and body condition scores during the monitoring period
Week 0 3 11 14 19 23 29 35
Weight (kg) 62.7 59.6 54.8 52.8 50.4 47.9 44.9 42.3
% Loss/weeka — 1.6 1.0 1.2 0.9 1.2 1.0 1.0
BCS 9 9 8 8 7 7 6 5
a The percent loss per week is calculated as the weekly average using the weight from
the previous recheck. The average rate of loss from the starting weight is 0.93% weekly.
9.7.5 Discussion
Various dietary strategies are available for the management of obesity. Generally,
weight loss diets are formulated with elevated nutrient density to ensure adequacy
during caloric restriction, as was the case here (4). Energy density is often reduced
through the inclusion of fiber and the restriction of dietary fat. Limits on dietary
fat in weight loss diets have been proposed to decrease energy density and to
augment thermal energy loss, but the diet employed here was not modified in
either nutrient due to the use of specific limited ingredients and in order to include
elevated polyunsaturated fats. Dietary protein, however, does have a clear effect
on improving weight loss. Elevated protein (>26% metabolizable energy [ME] or
>75 g/Mcal) like that found in the prescribed home-prepared diet preserves lean
body mass (12), and may result in increased energy expenditure and palatability
(3,25). The use of exercise for weight loss appears inadequate without caloric
restriction, but differences, albeit small, have been demonstrated in weight loss
studies employing restriction and exercise (see Chapter 7).
The patient’s juvenile-onset nonseasonal pruritus complicated management of
obesity and appeared consistent with food hypersensitivity at presentation, thus
necessitating further consideration before implementation of a weight loss plan.
Food hypersensitivity is a type of adverse food reaction that has an unknown
immunologic origin and no clear breed, sex, or age predilection (5). Both IgE-
mediated immediate hypersensitivity and delayed hypersensitivity have been
proposed as potential causes in dogs (5). Secretory antibodies, such as IgA, and
T-cell suppression, mediated by mesenteric lymph nodes and gut associated
lymphoid tissue (GALT), normally prevent aberrant response to dietary antigens
(13). However, such mechanisms may fail due to mucosal barrier compromise,
inadequate development of oral tolerance after birth, changes in microbial
flora, or concurrent diseases (5,13). Interestingly, affected dogs predominantly
display cutaneous signs, making the condition clinically indistinguishable from
aeroallergen-induced atopic dermatitis. However, recent work has demonstrated
altered dermal (14), but not duodenal (15), T-cell phenotypes in dogs with cutaneous
food hypersensitivity. Such studies have not yet yielded useful diagnostic tests,
and serum IgE levels, which were previously obtained in this patient, are both
unreliable and are also elevated in dogs with atopic dermatitis (16,17). Thus,
diagnosis requires a novel protein diet trial following a careful diet history (5).
No commercially available therapeutic limited ingredient diets were suitable
for a novel protein trial in this patient given his extensive exposure history. Over-
the-counter diets were not specifically evaluated, as some products have been
shown to contain unlabeled dietary antigens (18), and it was improbable that
such diets would be suitable for weight loss. Hydrolyzed diets were considered.
However, food hypersensitivity can occur with low molecular weight hydrolysates
if the complete protein is allergenic in a particular patient (19). Such diets are also
low in protein (16.5%–18% ME, or 47–52 g/Mcal), presumably due to processing
costs and to guard against the unlikely event there is a dose-dependent response
to a dietary allergen (5). As a result, no available diets provided the necessary
features of a novel high-protein diet formulated for weight loss.
Case 7 199
1. The target rate of weight loss for most dogs is between 0.5% and 2%
weekly, and rates of weight loss in the first few weeks may be higher.
2. The management of obesity with other nutritionally responsive
conditions may require customization of an animal’s diet plan.
3. Home-prepared diets can be used for weight loss with careful
planning and inclusion of some of the dietary factors known to
increase the probability of weight loss success such as high protein
content. Consultation with a board certified veterinary nutritionist is
recommended.
REFERENCES
1. National Research Council (NRC) Ad Hoc Committee on Dog and Cat.
Nutrient Requirements of Dogs and Cats. Washington DC: National
Academies Press; 2006.
2. German AJ, Holden SL, Bissot T et al. Use of starting condition score to
estimate changes in body weight and composition during weight loss in
obese dogs. Research in Veterinary Science 2009;87(2):249–254.
3. Diez M, Nguyen P, Jeusette I et al. Weight loss in obese dogs: Evaluation
of a high protein, low-carbohydrate diet. The Journal of Nutrition
2002;132(6):1685S–1687S.
4. Brooks D, Churchill J, Fein K et al. 2014 AAHA weight management
guidelines for dogs and cats. Journal of the American Animal Hospital
Association 2014;50:1–11.
200 Case Examples
19. Cave NJ. Hydrolyzed protein diets for dogs and cats. Veterinary Clinics of
North America: Small Animal Practice 2006;36(6):1251–1268.
20. Nesbitt GH, Freeman LM, Hannah SS. Effect of n-3 fatty acid
ratio and dose on clinical manifestations, plasma fatty acids and
inflammatory mediators in dogs with pruritus. Veterinary Dermatology
2003;14(2):67–74.
21. Sala-Vila A, Miles EA, Calder PC. Fatty acid composition abnormalities
in atopic disease: Evidence explored and role in the disease process
examined. Clinical & Experimental Allergy 2008;38(9):1432–1450.
22. Bauer JE. Therapeutic use of fish oils in companion animals. Journal of
the American Veterinary Medical Association 2011;239(11):1441–1451.
23. Lenox CE. Timely topics in nutrition: An overview of fatty acids in
companion animal medicine. Journal of the American Veterinary Medical
Association 2015;246(11):1198–1202.
24. Laflamme DP, Kuhlman G. The effect of weight loss regimen on
subsequent weight maintenance in dogs. Nutrition Research 1995;15(7):
1019–1028.
25. Toll PW, Yamka RM, Schoenherr WD et al. Obesity. In Hand MS, Thatcher
CD, Remillard RL et al. (eds.) Small Animal Clinical Nutrition. Topeka,
Kansas: Mark Morris Institute, 2010;502–542.
202 Case Examples
ASHLEY COX
9.8.4 Plan
Based upon an estimated 52.5% body fat, and following the 2014 AAHA weight
management guidelines for dogs and cats, Sugar’s estimated ideal body weight
(BW) was calculated (1).
Case 8 203
(a)
(b)
Figure 9.6 (a) Before (week 0) and (b) after (week 52) side profile photos.
Resting energy requirement (RER) was estimated to be 420 kcal per day (1).
Calculation of resting energy requirement (RER):
It was recommended to feed 360 kcal from a therapeutic weight loss diet with
an additional 40 kcal from treats and supplements, totaling 400 kcal per day.
At the time of the initial appointment, owners have the option to purchase a
“weight loss package” to include the initial appointment and 12 monthly weight
rechecks with the veterinary nurse at a discounted package price or paying for
each individual nurse recheck appointment. Sugar’s owner purchased the weight
loss package and scheduled for a 4-week nurse recheck appointment. Before being
discharged the owner was encouraged to participate within the private Facebook∗
page for all weight loss program participants and join monthly support meetings
offered at the clinic. Sugar was provided with a “jump-start” package to inspire
adherence throughout the weight loss venture.
9.8.5 Follow-up
Due to preemptively scheduling her recheck date and a reminder phone call from a
client service representative, Sugar returned for her first weight recheck in 6 weeks.
Her body weight at this time was 16.7 kg (36.7 lb) with a weight loss of 1.7 kg (3.7 lb)
or 9.2% of her body weight. She was reported to be eating the new diet well and her
caloric intake was reviewed to ensure adherence to the weight loss program. She
was still receiving green beans as treats, about 2/3 cup daily with 1 tablespoon of
canned pumpkin (31.6 kcal from treats) and half of a joint health supplement soft
chew (12 kcal from supplements). The daily meals and treats totaled an estimated
404 calories per day with 89% from the diet and 11% from treats and supplements.
Although calories from treats marginally exceeded the recommended 10%, Sugar
was losing at a rate of 1.5% of her body weight per week (Box 9.1) and the feeding
plan was maintained. Sugar returned approximately every 4 weeks for 7 months
with an appropriate rate of weight loss.
Sugar ′ s total rate of weight loss = [(18.4 kgs − 16.7 kgs)/18.4 kgs]
×100 = 9.2%
At her 7-month recheck, Sugar’s body weight plateaued. A review of her caloric
intake revealed that the owner had not altered any of the dietary components
from the amounts last reported. It was recommended to start weighing the dry
food in grams on a kitchen scale to improve precision when feeding (2). Treat
dispensing toys and automatic feeders were discussed with the owner as options
to remove the association of the owner to meal feedings. Following the switch
to gram measurements, feeding at 80% of RER (decrease of 68 kcal) within a
treat dispensing toy, and attending monthly support meetings and nurse recheck
appointments, Sugar was able to reach her ideal weight of 10.4 kg (23 lb) one
year from her initial weight loss appointment (Figure 9.7). Repeat photos were
taken as described earlier and added to her medical chart (Figure 9.6b). These
photos were then printed onto a certificate and given to Sugar’s owner, along with
a new collar. Overall, Sugar lost 7.9 kg (17.4 lb) during her weight loss program. To
encourage weight maintenance, her caloric intake was increased by 5% (17 calorie
increase, 353 calories per day) using her current therapeutic weight loss diet. A
weight recheck was scheduled for one month to continue to monitor her weight
maintenance phase and to adjust her caloric intake, if needed.
9.8.6 Discussion
Veterinary nurses can be an integral part of successful weight loss programs
in client-owned pets. Being able to review and collect an accurate diet history,
including the main diet, treats, foods used for medication administration, and
supplements, will establish a strong foundation for the veterinarian to make
206 Case Examples
weight, the veterinarian and veterinary nurse should recheck and finalize the
long-term weight maintenance plan. Overall, weight loss appointments require
dedication and commitment from everyone involved. Veterinary nurses are an
excellent resource when working with veterinarians to successfully lead and
support owners and their pets through all the challenging aspects of weight loss.
REFERENCES
1. Brooks D, Churchill J, Fein K et al. 2014 AAHA weight management
guidelines for dogs and cats. Journal of the American Animal Hospital
Association 2014;50:1–11.
2. German AJ, Holden SL, Mason SL et al. Imprecision when using
measuring cups to weigh out extruded dry kibbled food. Journal of
Animal Physiology and Animal Nutrition 2011;95:368–373. https://www.
ncbi.nlm.nih.gov/pubmed/21039926
Index
A Anesthetic considerations, 50
obesity-induced alterations in
AAFCO, see Association of American
physiology, 50–52
Feed Control Officials
pharmacological differences in
AAHA, see American Animal Hospital
obesity, 52–53
Association
Animal-specific factors, 2; see also
Abdominal distension, 44
Human-specific factors
ABW, see Adjusted body weight
age, 2, 7–8
Addressing emotional behaviors, 113–114
gender and neutering, 7–8
Adipocytes, 20–21, 23, 25
genetics and breed, 2
Adipokines, 23, 42
Anorexigenic neurons, 19–21
Adiponectin, 23
Anthropomorphic behaviors, 112
Adipose tissue, 23–25
Anti-inflammatory hormone
endocrine functions of, 23–24
adiponectin, 25
hormones, 42
Antibiotics, 27
mass, 65
Appetite regulation, 19–22, 26
Adipostat, 21
Arterial blood pressure, 47
Adjusted body weight (ABW), 175
Association of American Feed Control
Ad libitum, 8, 180, 188
Officials (AAFCO), 85
Age, 2, 7–8
Agouti-related protein (AgRP), 19–20
Airway resistance, 123
B
AKC, see American Kennel Club
American Animal Hospital Association Bacteria, 19
(AAHA), 64, 180, 191 Balancing energy expenditure and
American Kennel Club (AKC), 40 intake, 17
Anabolism, 22 evolutionary theories of obesity, 18–19
Anesthetic concerns in obese small mechanisms of energy expenditure
animal patient and metabolic control, 22–23
patient assessment, 174 regulation of appetite and food intake,
patient history, 174 19–22
plan, 175–176 Basal metabolic rate (BMR), 2, 22
preoxygenation, 177–178 Basal metabolism, 22–23
short-and long-term follow-up, 176–177 Basset hounds, 2
209
210 Index
Diastolic dysfunction, 52 E
Diet(ary)
ECS, see Extracellular solids
diet-induced obese rats, 48
Effective weight management plans,
factors, 2
113–114
fat, 8
Elevated protein, 198
food, 110
Emotional dependency, 114
low-fiber, 43
Endocrine disease, 42
protein, 198
canine DM, 42–43
recommendations, 43
DM, 42
strategies, 26
feline DM, 43
type, 8–9
HAC, 44
Diet, activity, and household history
hyperlipidemia, 44–45
form (DAHHF), 85, 134–135,
hypothyroidism, 44
149–155, 202
Endocrine functions of adipose tissue,
Dietary carbohydrate, 19
23–24
intake, 43
Energy
Diet selection, 89
density, 93–98
diet form and energy density,
energy-containing nutrients, 21
93–98
energy requirements for weight
macronutrients, 89–93
management, 85
Diplomate of the American College
expenditure, 17–18, 22–23
of Veterinary Sports
intake, 17–18
Medicine and Rehabilitation
Enrichment program in cats, 125
(DACVSMR), 145
Enterococcus, 26–27
DJD, see Degenerative joint disease
Environmental factors, 19
DM, see Diabetes mellitus
Epidemiologic study, 108
Dog
Epidemiology of small animal obesity
breeds, 2
prevalence and time trends, 1–2, 3–6
comorbidities, exercise, and obesity
risk factors, 2, 7–10
in, 123–124
Essential nutrients, 166
Domestic shorthair cat (DSH cat),
Evolutionary theories of obesity, 18–19
180
Excess body weight, 1
degree of obesity estimation for
Exercise, 9, 121
weight loss planning in,
in cats, 123–124
180–183
in dogs, 123–124
diabetes mellitus remission following
exercise in canine and feline obesity
weight loss in, 185–188
protocols, 124–126
Drifty genes, 18
in human obesity management,
Drug
122–123
absorption, 52
during novel protein diet trial,
distribution, 52–53
193–199
metabolism and elimination, 53
and obesity risk, 122
DSH cat, see Domestic shorthair cat
practical recommendations,
Dual energy x-ray absorptiometry
126–127
(DEXA), 66–67, 69, 181
Extracellular solids (ECS), 65
Dyslipidemia, 45
Index 213
F G
Family-oriented obesity treatment GALT, see Gut associated lymphoid tissue
programs, 116 Gastrointestinal tract (GI tract), 64–65
Family dynamics in behavioral microbial population, see Gut
management of obesity, microbiota
114–115 Gender, 7–8
Fat, 8; see also Obesity Genetic factors, 2
storage, 26 Genetics, 18
Fat-free mass (FFM), 65 GI tract, see Gastrointestinal tract
Fat–water MRI (FWMRI), 69 Glomerular hyperfiltration, 47
FBMI, see Feline body mass index Glucagon-like peptide-1 (GLP-1), 21
Fédération européenne de l’industrie Glucose metabolism, 24
des aliments pour animaux Golden retrievers, 2
familiers (FEDIAF), 85 Gut associated lymphoid tissue
Feeding (GALT), 198
frequency, 8 Gut microbiota
method, 8–9 dietary strategies, 26
Feeding behaviors, 110–111 nondietary strategies, 26–27
Feline and obesity, 25–26
body fat index, 74 in obesity management, 26
DM, 43 Gut microflora, 19
obesity epidemic, 19
Feline body mass index (FBMI), 72
H
Feline idiopathic cystitis (FIC), 47
Feline lower urinary tract disease Habitat, 9
(FLUTD), 47 HAC, see Hyperadrenocorticism
FFA, see Free fatty acids HDL, see High-density lipoproteins
FFM, see Fat-free mass Hedonic (pleasure) control of appetite,
FIC, see Feline idiopathic cystitis 21–22
Financial constraints, 146 HF, see High fiber
Financial implications, 146–148 High-density lipoproteins (HDL), 46
Firmicutes phylum members, 26 High fiber (HF), 92
FLUTD, see Feline lower urinary tract diet, 43
disease High protein–high fiber diet (HPHF), 93
Food Homocysteine, 47
food-seeking behaviors, 21 Household characteristics, 9–10
hypersensitivity, 198 HPHF, see High protein–high fiber diet
intake, 19–22 Human
Fostering healthy behaviors, 116 cancers, 25
FRC, see Functional residual companionship, 9
capacity exercise in human obesity
Free fatty acids (FFA), 24 management, 122–123
Functional residual capacity obesity, 111
(FRC), 50 Human–animal relationships, 107–108,
FWMRI, see Fat–water MRI 114–115
214 Index
Q
T
Quantitative magnetic resonance
(QMR), 69 Target body weight (TBW), 83
Target weight maintenance process, 139
TBW, see Target body weight; Total body
R
weight
Reactive oxygen species (ROS), 25 TDF, see Total dietary fiber
Recommended allowances (RA), 195–196 TEF, see Thermic effect of food
Reduced exercise, 122 Therapeutic weight
Regression analysis, 40 loss during novel protein diet trial,
Regulation of appetite and food 193–199
intake, 19 management diet, 89
central regulation of appetite, 19–22 Thermic effect of food (TEF), 22–23
hedonic (pleasure) control of appetite, Thermogenesis, 22–23
21–22 affects basal metabolism, 22–23
peripheral regulation of appetite, “Thermogenic” theory, 18
20–21 Thyroid gland, 22–23
Renal disease, 46–47 Thyroid hormones, 22–23, 44
Renin–angiotensin system, 25 Thyroxine (T4), 181
RER, see Resting energy requirement Time trends, 1–2
Respiratory disease, 45–46 prevalence of obesity in canine
Respiratory pathophysiology, 50–51 populations, 3–4
Resting energy requirement (RER), 22, prevalence of obesity in feline
88, 96, 170, 180, 186, 194, 202 population, 5–6
exponential vs. linear equation, 97 Tissue blood flow, 53
Risk factors, 108 TMS, see Trimethoprim–sulfadiazine
animal-specific factors, 2, 7–8 TNF-α, see Tumor necrosis factor-α
human-specific factors, 8–10 Total body weight (TBW), 175
small animal obesity, 2 Total dietary fiber (TDF), 92–93, 166
ROS, see Reactive oxygen species Transfaunation, 27
218 Index