Applied Veterinary Clinical Nutrition E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Applied Veterinary Clinical Nutrition Well-referenced clinical resource for canine and feline nutrition, with expansions throughout and two new chapters covering birds and small mammals. Fully revised to reflect new advances and information throughout, the Second Edition of Applied Veterinary Clinical Nutrition presents current, authoritative information on all aspects of small companion animal nutrition. The book provides clinically oriented solutions for integrating nutrition into clinical practice, with introductory chapters covering the foundation and science behind the recommendations and extensive references for further reading in every chapter. With contributions from more than 25 leading veterinary nutritionists, Applied Veterinary Clinical Nutrition covers topics such as: * Integration of nutrition into clinical practice, basic nutrition, energy requirements, and pet food regulations in North America and Europe that also apply to many other regions * Using and reviewing pet food labels and product guides, feeding the healthy dog and cat, and abridged clinical nutrition topics for companion avian species & small mammals * Commercial and home-prepared diets, and nutritional management of body weight and orthopedic, skin, and gastrointestinal diseases * Nutritional management of exocrine, hepatobiliary, kidney, lower urinary tract, endocrine, cardiovascular, and oncological diseases as well as enteral and parenteral nutrition A valuable resource on the principles of small animal nutrition and feeding practices in health or disease, Applied Veterinary Clinical Nutrition is a widely trusted and practical daily reference for veterinary practitioners including specialists, residents, and students seeking expert information on feeding their canine, feline, avian, and small mammalian patients.
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
List of Contributors
Preface
Acknowledgments
1 Integration of Nutrition into Clinical Practice
Introduction
Average Revenue from Food Sales and the Potential
Strategies to Increase Product Sales
Creating or Increasing Revenue from Nutritional Advice
References
2 Basic Nutrition Overview
Energy
Essential Nutrients
Essential Nutrient Deficiency Signs and Clinically Available or Relevant Methods of Assessing Nutrient Status
Nutrient Requirements
Key Clinical Nutritional Excesses and Signs
Additional Education on Nutrition
References
3 Determining Energy Requirements
Units
Basic Concepts and Terminology
Diet Records or History
Calculating the Energy Content of a Diet
Calculating Energy Requirement from Body Weight
Calculating Energy Requirements in States of Disease
Summary
References
4 Nutritional and Energy Requirements for Performance
How Much Should Exercising Dogs Be Fed?
Energy Requirements for Performance and Work
Types of Exercise and Nutrient Requirements
The Importance of Training
Nutritional Recommendations for Dogs Undertaking Different Types of Exercise
Summary
References
5 Pet Food and Supplement Regulations: Practical Implications
US Regulation
European Union Regulation
References
6 Using Pet Food Labels and Product Guides
“Reading” a Pet Food Label
Caloric Distribution Calculation
Using Product Brochures and Guides
Summary
7 Feeding the Healthy Dog and Cat
Feeding the Healthy Dog and Cat
When and How to Feed
What to Feed
Feeding Guidelines for Different Life Stages
Summary
References
8 Commercial and Home‐Prepared Diets
Introduction
Commercial Diets
Commercial Dog and Cat Diet Formulation and Considerations
Home‐Prepared Diets
Raw Food Feeding
Summary
References
9 Nutritional Management of Body Weight
The Health Consequences of Overweightness and Obesity
Increasing Awareness of Overweightness and Obesity
Accurate Accounting of Caloric Intake
Formulation of the Weight‐Loss Plan
Assessment of the Weight‐Loss Plan
Adjustment of the Weight‐Loss Plan
Summary
References
10 Nutritional Management of Orthopedic Diseases
Bone Composition and Calciotropic Hormones
The Role of Nutrition During Skeletal Growth and Development
Nutrient Requirements for Skeletal Maintenance in Adult Animals
Implementation of Nutrition in Clinical Orthopedics
Influence of Nutrition in the Occurrence of Orthopedic Diseases
Prevention of Nutritionally Related Orthopedic Diseases
Diets to Support Treatment of Patients with Osteoarthrosis
Summary
References
11 Nutritional Management of Gastrointestinal Diseases
Key Dietary Variables
Immune Response to Dietary Antigens (Oral Tolerance)
Acute Gastrointestinal Disease
Chronic Gastrointestinal Disease
Large Intestinal Disease
Summary
References
12 Nutritional Management of Exocrine Pancreatic Diseases
Pancreatitis
Nutritional Management
Exocrine Pancreatic Insufficiency
Nutritional Management
Summary
References
13 Nutritional Management of Hepatobiliary Diseases
Metabolic Alterations in Liver Failure
Nutritional Management of Common Hepatobiliary Disorders
Summary
References
14 Nutritional Management of Skin Diseases
Evaluation of Diet in the Context of Dermatologic Disease
Nutritional Deficiencies and Excesses
Skin Diseases That Benefit from Nutritional or Dietary Management
Nutritional Supplementation for Management of Skin Disease
Therapeutic Diets for Skin Health
Summary
References
15 Nutritional Management of Kidney Disease
Chronic Kidney Disease
Acute Kidney Injury
Glomerular Disease
Fanconi Syndrome
Conclusion
Summary
References
16 Nutritional Management of Lower Urinary Tract Disease
Crystal‐Related Lower Urinary Tract Disease
Idiopathic Cystitis
Urinary Tract Infections
Summary
References
17 Nutritional Management of Endocrine Diseases
Diabetes Mellitus
Hyperlipidemia
Hypothyroidism and Hyperadrenocorticism in Dogs
Dietary Hyperthyroidism in Dogs
Feline Hyperthyroidism and Idiopathic Hypercalcemia
Summary
References
18 Nutritional Management of Cardiovascular Diseases
Feeding the Cat with Cardiac Disease
Feeding the Dog with Cardiac Disease
General Nutritional Issues for Dogs and Cats with Cardiac Disease
Summary
References
Note
19 Nutritional Management of Oncologic Diseases
Cancer‐Associated Malnutrition
Nutritional Management of Cats and Dogs with Cancer
Nutritional Fads
Summary
References
20 Enteral Nutrition and Tube Feeding
The Case for Enteral Feeding
Nutritional Support of Veterinary Patients
When to Intervene
General Contraindications
Enteral Feeding Devices
Beginning Enteral Feeding
Diet Choices
Immunomodulating Nutrients
Calculation of Energy Requirements
Complications
Transitioning Patients to Voluntary Intake
Summary
References
21 Parenteral Nutrition
History
Assessment of Nutritional Status and Patient Selection
Nomenclature
Determination of Administration Route
Catheter Selection and Placement
Parenteral Nutrition Components
Carbohydrate
Energy Requirements
Formulation Calculations
Compounding
Initiating Parenteral Nutrition
Monitoring Guidelines
Complications
Discontinuing ParenteralNutrition
Summary
References
22 Abridged Clinical Nutrition Topics for Companion Avian Species
Water
Energy
Food‐Based Enrichment
Amino Acids and Protein
Essential Fatty Acids and Lipids
Vitamins
Minerals
Other Clinical Nutrition Issues
Conclusions
References
23 Nutrition for Small Mammalian Companion Herbivores and Carnivores
General Nutrition for Small Mammalian Companion Herbivores
Nutrition‐Related Diseases of Small Mammalian Companion Herbivores
Critical Care Nutrition for Small Mammalian Companion Herbivores
General Nutrition for Small Mammalian Carnivores
Nutrition‐Related Diseases of Small Mammalian Companion Carnivores
Nutrition‐Related Diseases of Small Mammalian Carnivores
Critical Care Nutrition for Small Mammalian Companion Carnivores
References
Index
End User License Agreement
List of Tables
Chapter 2
Table 2.1 Daily long‐chain omega‐3 fatty acid doses (in mg of combined EPA ...
Chapter 3
Table 3.1 Resting and maintenance energy requirements (kcal/day) of adult d...
Table 3.2 Resting and maintenance energy requirements (kcal/day) of adult c...
Chapter 4
Table 4.1 Approximate daily metabolizable energy (ME) requirements of exerc...
Table 4.2 Adequate intakes for dogs that undertake long‐distance aerobic e...
Chapter 5
Table 5.1 Steps and key considerations for assessment of veterinary food an...
Table 5.2 Classification of feed additives: categories and functional group...
Table 5.3 Analytical constituents that should be declared.
Table 5.4 Particular nutritional purposes that are currently authorized spe...
Chapter 7
Table 7.1 Idiosyncrasies of the carnivorous cat in comparison to the omnivo...
Chapter 9
Table 9.1 The nine‐point body condition scoring system for dogs.
Table 9.2 The nine‐point body condition scoring system for cats.
Table 9.3 Nutrients and dietary supplements that have been proposed as aids...
Table 9.4 Considerations for the design of a weight‐loss program.
Table 9.5 Weight‐loss program troubleshooting tips.
Chapter 10
Table 10.1 Content and ratio of calcium, phosphorus, and magnesium in dogs....
Table 10.2 Biochemical composition of cartilage.
Table 10.3 Mineral composition of rib biopsies at 11 and 21 weeks of age in...
Table 10.4 Similar plasma mineral levels with significant differences in vi...
Table 10.5 Investigations of the influence of excess or deficiencies on ske...
Table 10.6 Plasma levels of calcium, phosphorus, and the major vitamin D me...
Table 10.7 Vitamin D recommendations for growing dogs.
Table 10.8 Nutraceuticals and claimed effects on joints with osteoarthritis...
Chapter 11
Table 11.1 Dietary fiber types from plants.
Table 11.2 Analysis of some common dietary fibers.
Table 11.3 Rich sources of dietary fiber.
Table 11.4 Suitable home‐prepared diets for the short‐term management of ac...
Table 11.5 Potential mechanisms for non‐immunologic adverse food reactions....
Chapter 12
Table 12.1 Common foods to avoid in chronic canine/feline pancreatitis.
Chapter 13
Table 13.1 Metabolic alterations in hepatic failure.
Chapter 14
Table 14.1 Dermatologic signs associated with nutritional deficiencies.
Table 14.2 Daily recommended allowances for protein in adult animals.
Chapter 15
Table 15.1 List of intestinal phosphorus binding agents and typical doses r...
Table 15.2 Summary of key nutritional factors.
Chapter 20
Table 20.1 Comparisons of selected veterinary and human liquid diet product...
Table 20.2 Comparisons of commonly used critical care diets available in th...
Table 20.3 Example calculations for feeding a hospitalized canine patient....
Chapter 21
Table 21.1 Nutritional assessment guidelines.
Table 21.2 Commonly used solutions and supplements for parenteral nutrition...
Table 21.3 Parenteral nutrition monitoring guidelines.
Chapter 22
Table 22.1 Predicted BMR for passerines, non‐passerines, and parrots.
Chapter 23
Table 23.1 Nutrient comparison between different types of hay.
List of Illustrations
Chapter 3
Figure 3.1 Energy terms and sources of energy loss in animal nutrition.
Figure 3.2 A summary of the steps required to estimate the metabolizable ene...
Figure 3.3 Comparisons of maintenance energy requirements (MERs) for dogs (p...
Figure 3.4 A summary of the steps required to estimate the maintenance energ...
Figure 3.5 A summary of the steps required to determine how much to feed a d...
Chapter 4
Figure 4.1 Daily metabolizable energy requirements of dogs undertaking diffe...
Figure 4.2 Sources of energy for a greyhound during sprint exercise. High‐en...
Figure 4.3 Typical guaranteed analysis on the label of a higher‐protein, hig...
Chapter 5
Figure 5.1 Example of a label for a nutritional supplement in conformance wi...
Figure 5.2 Example of a label for a non‐nutritive supplement in the format d...
Figure 5.3 EU framework legislation chronologically ordered.
Chapter 7
Figure 7.1 Arginine.
Figure 7.2 Taurine.
Figure 7.3 Diet history form.
Chapter 8
Figure 8.1 (a) Lateral and (b) ventral‐dorsal views of a 2½‐month‐old kitten...
Figure 8.2 (a) Lateral and (b) ventral‐dorsal views of the same kitten taken...
Chapter 9
Figure 9.1 Illustration of the nine‐point body condition scoring system for ...
Figure 9.2 Illustration of the nine‐point body condition scoring system for ...
Chapter 10
Figure 10.1 Potential deleterious effects in skeletal development in large‐b...
Figure 10.2 Young dog with hyperparathyroidism due to calcium‐deficient diet...
Figure 10.3 (a) Cancellous bone of the epiphyseal area of a 6‐month old dog....
Figure 10.4 Hypophosphatemic rickets. A Great Dane of 2 months raised on foo...
Figure 10.5 Alimentary‐induced hypercalcitoninism. Two groups of Great Danes...
Figure 10.6 Inside the medullary cavity, white confluating spots are visible...
Figure 10.7 A 4‐month‐old Great Dane with radius curvus syndrome raised on a...
Figure 10.8 Extensive new bone formation without bone resorption throughout ...
Figure 10.9 A 5‐month‐old Rottweiler with poor renal function and hydronephr...
Figure 10.10 Radiograph and pathologic specimens revealing (a) incongruity (...
Figure 10.11 Hypertrophic osteodystrophy (HOD) is characterized by a very pa...
Figure 10.12 Growth chart of German shepherd dogs based on information from ...
Figure 10.13 Origin of inflammatory mediators in the joint. LTB
4
, pro‐inflam...
Figure 10.14 Excessive food intake or fasting may influence growth hormone (...
Chapter 12
Figure 12.1 Response of cholecystokinin secretion by intestinal mucosal cell...
Figure 12.2 Cat with pancreatitis and concurrent hepatic lipidosis with an e...
Figure 12.3 When and how to start nutritional support. ASAP, as soon as poss...
Figure 12.4 Dog with exocrine pancreatic insufficiency.
Chapter 13
Figure 13.1 Fatty liver from a cat diagnosed with hepatic lipidosis showing ...
Figure 13.2 Hepatic biopsy from a cat's liver showing a diffuse vacuolar hep...
Figure 13.3 Bedlington terrier diagnosed with primary copper‐associated hepa...
Figure 13.4 Hepatic biopsy from a Labrador retriever with copper associated ...
Figure 13.5 Copper‐colored irises in an encephalopathic kitten diagnosed wit...
Figure 13.6 Abdominal ultrasound using color flow doppler interrogation in a...
Figure 13.7 Exploratory laparotomy in a cat with a single extrahepatic shunt...
Figure 13.8 Exploratory laparotomy in a dog showing a plexus of multiple ext...
Chapter 14
Figure 14.1 Type 1 zinc deficiency in a husky dog. Adherent scale, crusts, a...
Figure 14.2 Type 1 zinc deficiency in a non‐arctic breed dog. There is a wel...
Figure 14.3 Generic dog food disease in a young Labrador. There are areas of...
Figure 14.4 Erythematous pre‐auricular areas and pinnae with evidence of sel...
Figure 14.5 Algorithm evaluating for cutaneous adverse food reaction (CAFR) ...
Figure 14.6 Plasma amino acids in 36 dogs with histologically confirmed supe...
Figure 14.7 Foot‐pad lesions in a dog with superficial necrolytic dermatitis...
Figure 14.8 Adherent crusting over pressure point on the tarsus and severe h...
Chapter 16
Figure 16.1 Lateral abdominal radiograph of an 8‐year‐old, castrated male mi...
Figure 16.2 Calcium oxalate dihydrate urocystolith removed from the dog in F...
Figure 16.3 Calcium oxalate dihydrate crystals from the dog in Figure 16.1....
Figure 16.4 Lateral abdominal radiograph of a 10‐year‐old mixed‐breed intact...
Figure 16.5 Infection‐induced struvite urocystoliths removed from the dog in...
Figure 16.6 Struvite crystals, sperm, and blood cells from the dog in Figure...
Figure 16.7 Lateral double‐contrast cystogram of a 4‐year‐old castrated male...
Figure 16.8 Ammonium urate urocystoliths removed from the dog in Figure 16.7...
Figure 16.9 Ammonium urate crystals from the dog in Figure 16.7.
Figure 16.10 Lateral double‐contrast cystogram of a 3‐year‐old castrated mal...
Figure 16.11 Contrast portal radiography from the dog in Figure 16.10 demons...
Figure 16.12 Ammonium urate urocystoliths removed from the dog in Figure 16....
Figure 16.13 Xanthine crystals from a 3‐year‐old castrated male domestic sho...
Figure 16.14 Lateral abdominal radiograph of a 3‐year‐old intact male Englis...
Figure 16.15 Cystine urocystoliths removed from the dog in Figure 16.14.
Figure 16.16 Cystine crystals from the dog in Figure 16.14.
Figure 16.17 Compound urocystoliths removed from a 10‐year‐old castrated mal...
Figure 16.18 Matrix‐crystalline urethral plug expressed from the distal uret...
Chapter 18
Figure 18.1 Muscle condition score chart for cats. The muscle condition scor...
Figure 18.2 Muscle condition score chart for dogs. The muscle condition scor...
Chapter 19
Figure 19.1 A cat with gastrointestinal lymphoma and an esophagostomy tube f...
Figure 19.2 A dog with metastatic neoplastic disease. Many dogs with cancer ...
Figure 19.3 Flowchart outlining the clinical decision‐making process involve...
Chapter 20
Figure 20.1 Decision‐making process for addressing expected or ongoing anore...
Figure 20.2 Consideration of nutritional needs should be part of the managem...
Figure 20.3 To avoid premature removal, an Elizabethan collar or similar bar...
Figure 20.4 Pushing the nares dorsally and introducing the tube at a ventrom...
Figure 20.5 Esophagostomy tubes are generally well tolerated and are easily ...
Figure 20.6 A properly wrapped esophagostomy tube.
Figure 20.7 The area around the stoma for a feeding tube must be kept clean ...
Figure 20.8 A loosely tied anchor suture is attached to the friction suture ...
Figure 20.9 A gastrostomy tube is an excellent method of administering enter...
Figure 20.10 Low‐profile gastrostomy tubes may be more esthetically pleasing...
Figure 20.11 A small‐gauge tube terminating in the small intestine can be pl...
Figure 20.12 After a purse‐string suture is placed in the intestinal serosa,...
Figure 20.13 Vomition and severing of an esophagostomy tube warrant determin...
Chapter 21
Figure 21.1 Algorithm for determining the appropriate method for assisted fe...
Figure 21.2 Placement of a multilumen polyurethane catheter in a dog for cen...
Figure 21.3 Individual components for manual parenteral nutrition solution c...
Figure 21.4 Manual parenteral nutrition solution compounding within a mobile...
Figure 21.5 Clean room for automated parenteral nutrition compounding at the...
Figure 21.6 An automated compounder used for preparing parenteral nutrition ...
Figure 21.7 Automated parenteral nutrition solution compounding at the Unive...
Figure 21.8 Feline patient at the University of California, Davis Veterinary...
Figure 21.9 Canine patient at the University of California, Davis Veterinary...
Figure 21.10 Canine patient at the University of California, Davis Veterinar...
Chapter 22
Figure 22.1 Marked obesity in a budgerigar (
Melopsittacus undulatus
).
Figure 22.2 Abnormal colors (green to black change) of many contour feathers...
Figure 22.3 Metabolic bone disease in a duck. Note marked bony deformities i...
Chapter 23
Figure 23.1 An adult obese rabbit. This rabbit had been fed an inappropriate...
Figure 23.2 Syringe‐assisted feeding in a rabbit.
Figure 23.3 A lateral whole‐body view radiograph of an adult male castrated ...
Guide
Cover Page
Title Page
Copyright Page
List of Contributors
Preface
Acknowledgments
Table of Contents
Begin Reading
Index
WILEY END USER LICENSE AGREEMENT
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Applied Veterinary Clinical Nutrition
Second Edition
Edited by
Andrea J. Fascetti, VMD, PhD
Diplomate ACVIM (Nutrition and Small Animal Internal Medicine)
Board‐Certified Veterinary Nutritionist®
Professor of Nutrition, Department of Molecular Biosciences,School of Veterinary Medicine, UC Davis,Davis, CA, USA
Sean J. Delaney, BS, DVM, MS
Diplomate ACVIM (Nutrition)
Board‐Certified Veterinary Nutritionist®
Founder, Balance It®, A DBA of Davis Veterinary Medical Consulting, Inc.
Davis, CA, USA
Jennifer A. Larsen, DVM, MS, PhD
Diplomate ACVIM (Nutrition)
Board‐Certified Veterinary Nutritionist®
Professor of Clinical Nutrition, Department of Molecular Biosciences,School of Veterinary Medicine, UC Davis,Davis, CA, USA
Cecilia Villaverde, BVSc, PhD
Diplomate ACVIM (Nutrition)
Board‐Certified Veterinary Nutritionist®
Diplomate ECVCN
EBVS®, European Specialist in Veterinary and Comparative Nutrition
Consultant, Expert Pet Nutrition, Fermoy, County Cork, Ireland
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List of Contributors
Robert C. Backus, MS, DVM, PhDDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Associate Professor and Director of the Nestlé Purina Endowed Program in Small Animal NutritionCollege of Veterinary MedicineUniversity of MissouriColumbia, MO, USA
Joe Bartges, DVM, PhDDiplomate ACVIM (Small Animal Internal Medicine and Nutrition)Board‐Certified Veterinary Nutritionist®ProfessorDepartment of Small Animal Medicine & SurgeryUniversity of GeorgiaAthens, GA, USA
Paul Brentson, BA, MBAPB ConsultingApplegate, CA, USA
C.A. Tony Buffington, DVM, PhDDiplomate ACVIM (Nutrition, retired)Board‐Certified Veterinary Nutritionist®Clinical ProfessorSchool of Veterinary MedicineUniversity of California–DavisDavis, CA, USAEmeritus Professor of Veterinary Clinical SciencesThe Ohio State UniversityColumbus, OH, USA
Nick Cave PhD, MVSc, BVScDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Associate ProfessorGroup Leader – AcademicSchool of Veterinary ScienceTe Kunenga ki Pūrehuroa | Massey UniversityPalmerston North, New Zealand
Ronald J. Corbee, DVM, PhDDiplomate ECVCNEBVS®, European Specialist in Veterinary and Comparative NutritionProfessorDepartment of Clinical SciencesUniversiteit UtrechtUtrecht, Netherlands
Sean J. Delaney, BS, DVM, MSDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Founder, Balance It®, A DBA of Davis Veterinary Medical Consulting, Inc.Davis, CA, USA
David A. Dzanis, DVM, PhDDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®CEO (retired), Regulatory Discretion, Inc.Santa Clarita, CA, USA
Denise A. Elliott, BVSc (Hons), PhDDiplomate ACVIM (Nutrition and Small Animal Internal Medicine)Board‐Certified Veterinary Nutritionist®Global Vice PresidentResearch & DevelopmentRoyal CaninAimargues, Occitanie, France
Andrea J. Fascetti, VMD, PhDDiplomate ACVIM (Nutrition and Small Animal Internal Medicine)Board‐Certified Veterinary Nutritionist®Professor of NutritionDepartment of Molecular BiosciencesSchool of Veterinary MedicineUniversity of California–DavisDavis, CA, USA
Lisa M. Freeman, DVM, PhDDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Professor, Department of Clinical Sciences & Agriculture, Food and EnvironmentCummings School of Veterinary MedicineTufts UniversityNorth Grafton, MA, USA
Herman Hazewinkel, DVM, PhDDiplomate European College of Veterinary SurgeonsDiplomate ECVCNEBVS®, European Specialist in Veterinary and Comparative NutritionEmeritus Professor Companion Animal OrthopaedicsDept of Clinical Sciences and Companion AnimalsUtrecht University,Utrecht, Netherlands
Marta Hervera, BVSc, PhDDiplomate ECVCNEBVS®, European Specialist in Veterinary and Comparative NutritionCo‐founder and ConsultantExpert Pet NutritionZurich, Switzerland
Richard C. Hill, VetMB, PhDDiplomate ACVIM (Nutrition and Small Animal Internal Medicine)Board‐Certified Veterinary Nutritionist®Associate ProfessorSmall Animal Clinical SciencesUniversity of FloridaGainesville, FL, USA
Aarti Kathrani, BVetMed (Hons), PhD, FHEA, MRCVSDiplomate ACVIM (Nutrition and Small Animal Internal Medicine)Board‐Certified Veterinary Nutritionist®Senior Lecturer in Small Animal Internal MedicineDepartment of Clinical Science and ServicesRoyal Veterinary CollegeHatfield, Herts, UK
Elizabeth Koutsos, PhDPresident, EnviroFlight, LLCApex, NC, USA
Jennifer A. Larsen, DVM, MS, PhDDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Professor of Clinical NutritionDepartment of Molecular BiosciencesSchool of Veterinary MedicineUniversity of California–DavisDavis, CA, USA
Stanley L. Marks, BVSc, PhDDiplomate ACVIM (Nutrition,Small Animal Internal Medicine and Oncology)Board‐Certified Veterinary Nutritionist®Board‐Certified Veterinary Oncologist®ProfessorDepartment of Medicine & EpidemiologyUniversity of California–DavisDavis, CA, USA
Isabel MarzoAgricultural EngineerSenior Consultant in animal feed and veterinary medicinesCosta‐Marzo Consulting, SLUBarcelona, Spain
Glenna E. Mauldin, DVM, MSDiplomate ACVIM (Oncology and Nutrition)Board‐Certified Veterinary Nutritionist®Director of Clinical ResearchThrive Pet Healthcare and PetCure OncologyAustin, TX, USA
Kathryn E. Michel, BA, DVM, MS, MSEDDACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Professor of Nutrition and Associate Dean of Education, School of Veterinary Medicine, University of Pennsylvania,Philadelphia, PA, USA
Catherine A. Outerbridge, DVM, MVScDiplomate, ACVDBoard‐Certified Veterinary Nutritionist®Diplomate ACVIM (Small Animal Internal Medicine)Professor of Clinical DermatologyDepartment of Medicine and EpidemiologySchool of Veterinary MedicineUniversity of California–DavisDavis, CA, USA
Tammy J. Owens, DVM, MSDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Assistant ProfessorSmall Animal Clinical SciencesWestern College of Veterinary Medicine – University of SaskatchewanSaskatoon, SK, Canada
Sally C. Perea, DVM, MSDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Veterinary Nutritionist, Research & DevelopmentRoyal Canin, A division of Mars, Inc.Lewisburg, OH, USA
Olivia A. Petritz, DVMDiplomate ACZMAssistant ProfessorDepartment of Clinical SciencesNorth Carolina State UniversityRaleigh, NC, USA
Yann Queau, DVMDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Discover Vet Pillar Team ManagerResearch & DevelopmentRoyal CaninMontpellier, Occitanie, France
Jon J. Ramsey, PhDProfessorDepartment of Molecular BiosciencesSchool of Veterinary MedicineUniversity of California–DavisDavis, CA, USA
John E. Rush, MS, DVMDiplomate ACVIM (Cardiology)Board‐Certified Veterinary Cardiologist®Diplomate ACVECCBoard‐Certified Veterinary Specialist in Veterinary Emergency and Critical Care®Professor, Department of Clinical SciencesCummings School of Veterinary MedicineTufts UniversityNorth Grafton, MA, USA
Brian Speer, DVMDiplomate ABVP (Avian Practice)Diplomate ECZM (Avian)DirectorMedical Center for BirdsOakley, CA, USA
Jonathan Stockman, DVMDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Assistant ProfessorDepartment of Clinical Veterinary SciencesLong Island UniversityBrookville, NY, USA
Cecilia Villaverde, BVSc, PhDDiplomate ACVIM (Nutrition)Board‐Certified Veterinary Nutritionist®Diplomate ECVCNEBVS®, European Specialist in Veterinary and Comparative NutritionConsultant, Expert Pet NutritionFermoy, County Cork, Ireland
Preface
We envision this text to be a resource not only for the veterinary practitioner but also for students and residents of multiple disciplines. Many veterinary schools and universities are now teaching a course in small animal clinical nutrition, and this text will make a nice complement to such lecture material.
(From the first edition)
We have been very fortunate to have the first edition fulfill its original vision. This is largely thanks to its widespread promotion and adoption by our colleagues in industry and academia.
Like many sciences and specialties, nutrition knowledge evolves, and it became clear that an update was needed. We also saw an opportunity to enhance the text's international applicability to better support its use outside of North America and translation into multiple languages.
With this edition, we have astoundingly maintained all but one now retired contributor and added many more contributors to give additional depth as well as to add international perspective and species expertise outside of dogs and cats, including avian and small mammalian species. To quote the first edition again, “We consider our contributors to be the experts in their fields, so we are extremely fortunate that they have been willing to share their knowledge and experience through their respective chapters” and now sidebars. This sentiment remains even more true with this second edition.
We have kept the structure and approach similar in this new version. Notably, one will continue to find heavy use of citations wherever possible. These references provide additional opportunities for further reading and enrichment, especially in areas where controversy may exist or our understanding is not yet complete.
With this edition, two new co‐editors have been added from two previous contributors and colleagues, Drs. Jennifer Larsen and Cecilia Villaverde. Dr. Larsen brings an unrivaled degree of clinical experience teaching veterinary students and residents. Dr. Villaverde, as a board‐certified veterinary nutritionist in both North America and Europe with extensive teaching experience in South America, provides unparalleled international expertise. Their generosity in the midst of many other commitments made this second edition possible.
With so many necessary updates, additions, and contributors and a multiyear life‐altering pandemic, our publisher Wiley has shown an impressive and unwavering commitment to this text and by extension veterinary nutrition. We are indebted to their team's guidance and patience, especially from Erica Judisch, Merryl Le Roux, Susan Engelken, Sally Osborn, Simon Yapp, ETC.
It is the four co‐editors' collective hope that this second edition will further the practice of veterinary nutrition in small animals globally and serve you, the reader, as a ready and accessible resource to help your understanding, students, residents, clients, and/or patients.
Acknowledgments
I would like to welcome and thank Dr. Jennifer Larsen and Dr. Cecilia Villaverde for agreeing to assist in completing the second edition of the textbook with Dr. Sean Delaney and me.
I am also appreciative of all of our collaborators from around the world who worked so hard in bringing their expertise to this book. It is only through their tireless efforts that we have a second edition.
I remain truly grateful for the continuous support from my immediate family, my husband Greg, sons Noah and Ari, and our dog Holly.
Andrea J. Fascetti, VMD, PhD
Diplomate ACVIM (Nutrition and Small Animal Internal Medicine)
Board‐Certified Veterinary Nutritionist®
Professor of Nutrition
Department of Molecular Biosciences
School of Veterinary Medicine
University of California–Davis
Davis, CA, USA
In the first edition, I acknowledged my teachers/mentors, veterinary nutrition colleagues, co‐editor, family, and personal animal companions in detail. I remain very grateful to them all, especially my wife Siona, and daughters Maya and Ruby. For this second edition, I would like to concisely acknowledge my two new co‐editors, co‐workers, past students, residents, referring veterinarians and veterinary specialists, clients, customers, and patients. I am forever better for having crossed paths with these tens of thousands of beings over the last three decades. These interactions have given me the frequent and great privilege to see people at their most humane. I hope this text helps to give a little back as a way to show my sincere appreciation for this gift.
Sean J. Delaney, BS, DVM, MS
Diplomate ACVIM (Nutrition)
Board‐Certified Veterinary Nutritionist®
Founder, Balance It®, A DBA of Davis Veterinary Medical Consulting, Inc.
Davis, CA, USA
I would like first to express my thanks and appreciation to my co‐editors. I am grateful to be a part of this project, which represents the collective experience, knowledge, and wisdom of each contributor. This text resource is a valuable contribution to our discipline, and I also thank each author for sharing their efforts with us.
Jennifer A. Larsen, DVM, MS, PhD
Diplomate ACVIM (Nutrition)
Board‐Certified Veterinary Nutritionist®
Professor of Clinical Nutrition
Department of Molecular Biosciences
School of Veterinary Medicine
University of California–Davis
Davis, CA, USA
I would like to thank my co‐editors for inviting me to participate in this unique project in the area of companion animal nutrition, and all the authors for sharing their knowledge and expertise so generously.
Cecilia Villaverde, BVSc, PhD
Diplomate ACVIM (Nutrition)
Board‐Certified Veterinary Nutritionist®
Diplomate ECVCN
EBVS®, European Specialist in Veterinary and Comparative Nutrition
Consultant, Expert Pet Nutrition
Fermoy, County Cork, Ireland
1Integration of Nutrition into Clinical Practice
Sean J. Delaney, Andrea J. Fascetti, Jennifer A. Larsen, and Paul Brentson
Introduction
While some veterinarians enjoy the various complex aspects of owning and managing a clinical practice, many more take on these roles out of necessity rather than preference. In either case, this results in many clinical approaches being at least partially viewed through a “fiscal filter.” Although this filter should not be fine enough to strain out appropriate medical decisions, it certainly requires that the economics associated with certain medical practices be considered. Therefore, this introductory chapter will discuss the “business” of nutrition in clinical practice, as an understanding of these basics will enable the practitioner to afford to implement the knowledge contained in the rest of this textbook.
Average Revenue from Food Sales and the Potential
In 2017, the average food revenue was static compared to 2015 at 3.5% of total veterinary practice revenue in the United States (range 2.8–4.3%; AAHA 2019). At the same time, average total revenue earned by practices in 2017 was US$1 271 402. The therapeutic food revenue‐to‐expense ratio has remained fairly static over time at 1.3, and is consistent across practice types (with regard to number of full‐time clinicians, revenue level, years at current location, and American Animal Hospital Association [AAHA] member status). Practices with higher ratios may be managing expenses more efficiently (including consideration of costs related to inventory control) or have higher markups. Lower ratios may reflect undercharging relative to the cost of managing food inventory. Revenue from therapeutic diet sales, while relatively significant on average, can be higher, as practices that focus more on the large compliance gap with therapeutic food recommendations (this gap includes both veterinarians who do not actively recommend medically needed foods and clients who do not choose to feed them) can easily double gross profits from food sales with minimal additional effort or expenditures.
Theoretically, there is much opportunity for growth in revenues and profits if practices can successfully identify and correct barriers to care both for wellness and for chronic and acute disease management (Volk et al. 2011). In large part, the longevity and success of any given practice model will depend on the ability to remain flexible and responsive to changing client demographics, the impacts of the economic climate, and the continued growth in internet resources for both information and products. For some clients, the accessibility and cost of veterinary care and products are a challenge, and the practitioner must effectively communicate the value of services and facilitate convenience in order not just to achieve compliance, but also to maximize both medical outcomes and revenue (Box 1.1). In fact, profits could be increased more than fivefold based on the low compliance found in a study by the AAHA, which includes sales of therapeutic pet foods (AAHA 2003).
Box 1.1Dietary Recommendations to Maximize Patient Outcome and Ensure Practice Sustainability
Few recommendations hold as much weight with clients about what to feed their animal companion as a veterinarian's recommendation. Many pet food companies are aware of this and invest heavily in the veterinary community, vying for the veterinarian's awareness of their products and, ideally, for their recommendation. Unfortunately, the resulting influx of generous support is increasingly viewed by some as creating a conflict of interest for veterinarians and resulting in a bias in dietary recommendations. This perception is increased by veterinarians who have limited recommendations beyond the products, brands, and/or companies they stock. Therefore, the goal of this chapter is to assist the veterinarian in methods to ensure they can afford to provide the best medical care for their patients and clients by fully integrating nutrition into their clinical practice.
Strategies to Increase Product Sales
Recommending an Effective Therapeutic Food
The surest way to increase compliance and therapeutic pet food sales is to recommend an effective one. This sounds simple enough, but can be quite challenging in practice. To start, one must make the correct diagnosis and select a food that can produce measurable improvement in the animal companion's condition or disease management. For example, clients feeding a “weight loss” food that does not result in weight loss are likely to stop feeding the ineffectual food. Similarly, trying to sell food that an animal companion will not eat is unlikely to be successful. Therefore, establishing expectations, performing a nutritional assessment to guide more informed food recommendations, monitoring the patient response, and providing a variety of options are vital for client compliance.
Establishing Expectations
Many clients choose not to start feeding a recommended therapeutic food, or choose to stop feeding one, because they do not clearly understand what is expected from the food. Expectations are built on the client's understanding of the purpose and mechanism of the food. For example, clients who understand that higher dietary phosphorus can cause progression of chronic kidney disease, and that most dietary phosphorus comes from protein‐rich ingredients, are more likely to feed an appropriately lower protein‐ or phosphorus‐containing food. Not surprisingly, human patients have better retention of medical information when verbal information is accompanied with written information (Langdon et al. 2002). Therefore, in the veterinary setting, client handouts can be a very useful adjunct to verbal client education. Equally helpful can be reinforcement of key points by veterinary staff at checkout or discharge. Veterinary staff can play an instrumental role in drafting these materials, as they are often aware of common questions and issues that should be addressed. Staff involvement is expected to enhance their investment in effective transmission of this information to clients, and helps maintain a unified approach to communication.
Performing a Nutritional Assessment
An evaluation of the patient's medical status as well as lifestyle, life stage, weight trends, body composition, appetite, and diet history is a critical step to inform a confident food recommendation. The process of collecting this information, and assessing it in the context of the patient's clinical presentation, provides valuable data to the healthcare team. In some cases this may help achieve a diagnosis, while in other cases a specific treatment plan can be more confidently justified. For example, the clinician may need to discuss specific risk factors in the case of clients who feed raw meat to their omnivore or carnivore. Similarly, a different approach may need to be considered for a feline patient with recurrent constipation that has only ever eaten foods with high fiber content.
Monitoring Patient Response
Although therapeutic foods can be quite effective, not all foods work for every patient. A food's failure may be simply due to a patient being unwilling to eat the food. Therefore, monitoring both acceptance and response to a newly recommended food is crucial to improving compliance. Initially, the greatest risk to compliance is food refusal. Often this can be managed with appropriate recommendations for transitioning to the new food, as well as planned and periodic follow‐up in the form of an email, phone call, or in‐person office visit to address any issues that arise. Follow‐up is equally important to reinforce the importance of the dietary recommendation. Recommendations that have no follow‐up are more likely to be perceived as not being as crucial or important. Finally, checking on progress provides an opportunity to discuss and select an alternative but still appropriate food if the first recommendation is not successful. At times there can be a reluctance to perform follow‐up since it often is “nonbillable” time; however, follow‐up can be tiered or bundled, and veterinary support staff can be leveraged to assist. Many outbound calls can be conducted by veterinary staff, with elevation to veterinarians as needed. This “triaging” of sorts can increase efficiency, and often is welcomed by staff members who feel both entrusted and empowered.
Providing a Variety of Options
Since no food will work in every situation, it is important to have additional options for the client. A ready and specific alternative recommendation should reduce the likelihood that the client may choose a food by themselves, resulting in the potential for an inappropriate food to be selected and the possible loss of a medically justified sale. The tendency to stock only one “house brand” – while convenient from an inventory management perspective – decreases the ability to readily offer alternatives and can lead to a perception that there is only one option, or, worse yet, that the recommendation is made solely on the basis that the particular brand is all the veterinarian sells. Certainly, carrying every therapeutic food available (which now number in the hundreds for small animals) is not feasible in most practice settings. A selection of those foods most often used for the management of diseases seen frequently at the practice, along with a willingness to special order or even identify direct delivery options for clients, is probably the best approach.
Additionally, stocking more smaller bags can help increase the variety of foods offered without substantially increasing the “carrying cost of inventory.” Small bags also can be useful for a trial, and if successful, a standing order for that patient in larger sizes can be created. Such standing orders then help to increase the number of inventory turns, thereby improving cash management. This “small bag” approach might also assist with reducing the labor involved in stocking larger bags as well as increasing the storage capacity of a facility. Some foods are also available in sample packs or starter kits, which are more cost effective and lower the commitment for clients who may be skeptical of acceptance or efficacy. In addition, most therapeutic food manufacturers will accept return not just of foods under a “satisfaction guarantee,” but also of inventory that has expired. For those manufacturers where that is not the case, carrying smaller package sizes and fewer of them can minimize “perishable shrink” by reducing the cost of any expired bag that cannot be returned.
The greatest value of carrying and recommending a variety of products for the same condition can be increasing options to account for co‐morbidities or other individualized needs. In addition, clinical experience with more products increases the likelihood of making the best initial recommendation, as well as increasing options for alternative products in case the initial recommendation proves unsuccessful.
Recommending Therapeutic Treats
A growing category within veterinary product offerings is therapeutic treats. These treats often pair with a “matching” therapeutic food to give the client a nutritionally appropriate treat option. Treats generally do not offer anything novel to the nutritional management of the condition or disease, but rather assist with compliance by encouraging the patient's interest in the new dietary approach while preventing the use of potentially inappropriate treats. The same process as outlined earlier should be used when recommending an effective therapeutic food.
Recommending Nutraceuticals and Dietary Supplements
For more discussion on this subject, see Chapter 5.
From a financial perspective, stocking certain dietary supplements should be considered. Although the margin on such products can vary greatly, they generally take up much less shelf space than food and treats. Typically, products that are only sold through veterinarians should be considered, unless carrying nonexclusive products adds overall value for the client due to convenience. Caution should be used when recommending or offering products for sale at a premium if comparable human supplements of equal or even greater quality or potency are available for a similar or lower price. If such products are available from other retailers, whether “brick and mortar” or online, it is in the best interest of solid client relations to refer clients to that retailer, while being sure to give a specific product and retailer recommendation for clarity and convenience. If a product is widely available only online, then clients are generally willing to purchase such products directly from the veterinarian, who may be able to compete on the basis of reduced delivery time and cost.
Creating or Increasing Revenue from Nutritional Advice
Veterinarians' time is limited for both their own continuing education and client education. Therefore, there is an “opportunity cost” associated with spending time on nutrition. If a veterinarian earns more income from learning about and performing surgery, for example, than learning about and advising on nutrition, there is a financial incentive to focus on surgery and a disincentive to focus on nutrition. Certainly the generalist cannot pick and choose only the aspects of veterinary medicine that are most profitable, but recognizing the potential for fiscal disparity provides context for a discussion on nutritional advice revenue.
The value of a veterinarian's nutritional advice can also be diluted by the perception that they lack the expertise to make nutritional recommendations. There is no shortage of such claims, especially from online sources, which are often used to dismiss or minimize expert opinion in order to promote alternative ideas or products. The perception of veterinary ignorance about nutrition can be increased by the appearance of bias for a particular brand or company's food in one's recommendation(s), as already discussed, or by a variety of compounding factors. Another factor is the belief that nutrition is not a real science or that it is not learned in veterinary school. These assertions are untrue, of course, since nutrition is such a key aspect of the management of many companion animal diseases. Thus, nutritional concepts are inherent in the veterinary curriculum, whether as distinct courses or rotations, or integrated into many other disciplines. In addition, continuing education and other resources related to nutrition are widely available to practicing veterinarians. Unfortunately, clients are not always aware that veterinarians who recommend a particular therapeutic food may choose to do so because such recommendations are based on scientifically proven strategies or have, in fact, actually been tested for the condition or disease in question. Certainly many therapeutic veterinary foods are in need of additional clinical study (Roudebush et al. 2004); however, they are largely based on very sound science.
Clients may also believe that nutrition is simple, after all, as they likely have successfully fed themselves for most of their lives. However, many people neglect to consider that many human foods are fortified with essential nutrients to address common gaps in intake, and that poor nutritional status in various human populations is not uncommon. Additionally, in circumstances where adequate intake is crucial, a carefully balanced diet (similar to pet food) is provided, such as in the intensive care unit, for baby formula, and when humans go into space or are involved in military operations. Finally, the field of nutrition is also beset by self‐proclaimed “nutritionists” who have little, if any, medical or nutritional training, yet they still promote the idea that only they are experts in this discipline. Combined with the barrage of sometimes misleading and aggressive marketing used to promote a huge and growing number of pet food products, these factors have led to a level of discomfort for many on the subject, rather than the expertise or mastery they may feel on other veterinary medical topics. Thus, a climate exists where veterinarians acquiesce in the nutritional management of their patient, or at least fail to take a very active role unless intervention is absolutely necessary, such as in cases of hepatic lipidosis or food allergy. Therefore, the following recommendations are intended to encourage practitioners to take an active role in the management of all their patients' diets.
Nutritional Advice for Healthy Patients
The number one obligation of the veterinarian when advising clients about an appropriate diet for a healthy animal companion is to ensure that it maintains an ideal body condition (see Chapter 9 on the nutritional management of body weight). Keeping dogs lean is the only proven intervention to increase both the quantity and quality of life (Kealy et al. 2002). Although yet to be proven in cats or many other companion animal species, caloric restriction has repeatedly been shown to extend lifespan in mammals (Sohal and Weindruch 1996; Barja 2004). Therefore, avoidance of overweight and obesity should be a goal for the feeding of every patient.
In addition to weight management, an appropriate food should have an appropriate nutritional adequacy statement for the patient. This means that the food is appropriate for the patient's species, age, and reproductive status if the patient is a reproducing female. As would be expected, many foods meet these criteria, and further discrimination should be based on both client and patient preference. For a client, convenience, cost, and personal nutritional philosophy may be important in deciding which foods they select. For patients, ingredients and their associated impact on palatability, along with texture (i.e. dry, wet, semi‐moist) and macronutrient distribution (e.g. protein, fat, and carbohydrate percentages), play key roles in the foods they consume when given a choice. Recognizing that no one food can meet all of these preferences and needs underscores why so many brands and varieties exist and what needs to be considered when advising clients about food options.
It can often be useful to have the client select a few foods they like and review these products with them during wellness visits. This method helps to narrow down the very wide field of foods to consider, and typically provides an opportune time to exhibit some expertise, as well as an openness to discuss nutrition. If the client has no preconceived notions, then recommendations should favor companies that manufacture their own food and employ nutritionists. Such companies are more likely to have the technical expertise to address any issues that might arise, as well as the knowledge to make nutritionally sound and safe products.
From a fiscal perspective, such a review of potential foods or nutritional recommendations should not result in a unique charge for the client, but rather should be captured in the office visit fee. This assumes that any requested review does not require additional research and analysis outside the office visit. In cases where this becomes necessary, time should be charged either on an agreed flat rate or on a per‐unit of time basis up to some pre‐established maximum. Clients who do not wish to pay for the veterinarian's time should be advised that the evaluation is accordingly limited. Some veterinarians find it difficult to charge for researching an issue, but if the research is specific to a patient, most clients will accept that it is appropriate when the point is raised with confidence and the resolve that one's professional time is of value. In addition, consultation with a variety of specialists is increasingly available to other clinicians, and asking for input from a board certified veterinary nutritionist® can be a valuable tool as well (Box 1.2). It should be noted that a veterinarian's review frequently involves dietary supplements, and the variety and number of novel and often unconventional supplements greatly exceed those of pet foods, which are, in practice, more closely regulated.
Box 1.2What Is a Board Certified Veterinary Nutritionist®?
A board certified veterinary nutritionist® is a licensed veterinarian who has undergone additional education and training in the field of veterinary nutrition. This typically involves additional graduate coursework and/or graduate degrees in nutrition, along with residency training at the secondary or tertiary referral level under the supervision of a board certified veterinary nutritionist®. In addition to clinical residency training and publication of animal nutrition‐related research in peer‐reviewed scientific journals, candidates for certification also complete formalized clinical case benchmark exercises to demonstrate mastery of the discipline. To complete certification, candidates must also pass a rigorous, multipart general examination that covers advanced physiology, pharmacology, and disease‐related topics. Candidates must also pass a more focused, intensive specialty examination that covers advanced metabolism and biochemistry as well as basic, applied, and clinical nutrition. Candidates who successfully achieve all of the requirements can refer to themselves as board certified veterinary nutritionists® or “diplomates.” There are currently two veterinary nutrition specialty colleges in the world, the American College of Veterinary Internal Medicine (nutrition is one of the six specialties of ACVIM, which is also the basis for most of the summary of requirements above) and the European College of Veterinary Comparative Nutrition (ECVCN). Members of the ACVIM Nutrition Specialty can be found in North America, the Caribbean, the United Kingdom, Europe, and Australasia, while most ECVCN diplomates are found in Europe. The majority of diplomates are employed in academia, industry, private practice, or the government. Attending veterinarians and specialists in other disciplines typically refer cases to diplomates of the ACVIM Nutrition Specialty or ECVCN in academia or at large referral hospitals.
At times, veterinarians have difficulty distinguishing the continuing self‐study required as a veterinary medical professional and the work involved in researching unique supplements or foods. The best way to distinguish this in one's own mind is that the veterinarian is not charging for the knowledge of how to interpret and find information, but rather for the act of applying their critical thinking and scientific knowledge to the patient's and/or client's specific products and/or needs. An analogy might be that one does not charge for the time it takes to learn a surgical procedure, but rather charges for using the resulting skills and knowledge to perform the surgery on particular patients.
Nutritional Advice for Unhealthy Patients
Most, if not all, diseases and conditions can be affected by diet. In some cases, this may simply be related to the adverse effects of inadequate caloric intake associated with illness‐related hyporexia or anorexia. For many other diseases, there are specific nutritional management interventions that are the subject of most of the rest of this textbook. For these sick patients, both improved outcomes and revenue generation are more likely to occur through the use of veterinary therapeutic foods, treats, and/or parenteral solutions, or through procedures such as feeding tube placement, compared to specific nutritional guidance and/or advice involved in their selection. However, it should be noted that consultation with a board certified veterinary nutritionist® on specific cases will generate justified fees for such advice, and the primary veterinarian will need in turn to communicate this to the client. It is recommended that when a board certified veterinary nutritionist®
