IT'S NOT JUST GRAIN-FREE: AN UPDATE ON DIET
It?s Not Just Grain-Free: An Update on Diet-Associated Dilated Cardiomyopathy
by Lisa M. Freeman, DVM, PhD, DACVNNovember 28, 2018
You may have read my June 4 post, ?A broken heart: Risk of heart disease in boutique or grain-free diets and exotic ingredients.? This post had more than 180,000 page views in the first week and continues to get more than 2000 page views a day. So, I?m pleased that people are interested in this important issue and trying to learn about it. But I?ve also found a tremendous amount of confusion and misinformation in the past 5 months including people who doubt that this is a real issue, some who still haven?t heard about it, and people who mistakenly think it?s just grain-free diets or that it?s only related to taurine.
As a result of the continued confusion, some of my cardiologist colleagues and I wrote an article which was published in the latest issue of the Journal of the American Veterinary Medical Association. This article provides a summary of our current understanding of diet-associated dilated cardiomyopathy (DCM), how to recognize it, and a recommended protocol for veterinarians to follow when they see dogs with DCM.
To be sure this information reaches as wide an audience as possible and to clear up confusion, I thought I?d provide some updates to address the most common misconceptions I?m hearing:
It?s not just grain-free. This does not appear to be just an issue with grain-free diets. I am calling the suspected diets, ?BEG? diets ? boutique companies, exotic ingredients, or grain-free diets. The apparent link between BEG diets and DCM may be due to ingredients used to replace grains in grain-free diets, such as lentils or chickpeas, but also may be due to other common ingredients commonly found in BEG diets, such as exotic meats, vegetables, and fruits. In addition, not all pet food manufacturers have the same level of nutritional expertise and quality control, and this variability could introduce potential issues with some products.
Most dogs being diagnosed with DCM do not have low taurine levels. Some owners continue to feed a BEG diet but supplement taurine thinking that this will reduce their risk for heart disease. In our hospital, we currently measure taurine in all dogs with DCM, but more than 90% of our patients with DCM in which taurine has been measured have normal levels (and the majority are eating BEG diets). Yet some of these dogs with DCM and normal taurine levels improve when their diets are changed. This suggests that there?s something else playing a role in most cases ? either a deficiency of a different nutrient or even a toxicity that may be associated with BEG diets. Giving taurine is unlikely to prevent DCM unless your dog has taurine deficiency. And given the lack of quality control for dietary supplements, you can introduce new risks to your dog if you give a supplement without evidence that she needs it.
Raw diets and homemade diets are not safe alternatives. Out of concern, some owners are switching from BEG diets to a raw or home-cooked diet. However, we have diagnosed DCM in dogs eating these diets too. And raw and home-cooked diets increase your dog?s risk for many other health problems. So, forego the raw or home-cooked diets and stick with a commercial pet food made by a well-established manufacturer that contains common ingredients, including grains. If your dog requires a home-prepared diet for a medical condition or you feel strongly about feeding one, I strongly recommend you consult with a Board-Certified Veterinary NutritionistTM (acvn.org). However, because home-cooked diets are not tested for safety and nutritional adequacy like good quality commercial diets, deficiencies could still develop.
Current thoughts on DCM
Currently, it appears that there may be three separate groups of dogs with DCM (although this may change as we learn more). I am listing them in the approximate frequency that we are currently seeing them in our hospital:
Diet-associated DCM with normal taurine levels. While this form of the disease was first identified in dogs of breeds not predisposed to DCM that are eating BEG diets, it appears to also occur in dogs of typical DCM breeds that are eating a BEG diet.
Primary DCM in predisposed breeds that is unrelated to diet. This is the traditional, genetically-related DCM in typical breeds, such as the Doberman Pinscher, Boxer, Irish Wolfhound, and Great Dane.
Diet-associated DCM with taurine deficiency: This is the least common form we are seeing in our hospital. This appears to happen both in breeds predisposed to DCM and breeds that are not predisposed to DCM.
We still have a great deal to learn about diet-associated DCM. However, I?m providing answers to some common questions I?ve been getting based on what is currently known:
What?s causing diet-associated DCM in dogs? For the vast majority of dogs, we do not yet know what is causing this disease. There are definitely some dogs with DCM that have low taurine levels, many of which will improve with taurine supplementation and change of diet. For dogs that have normal taurine levels, however, other nutritional deficiencies may be present. Some nutritional deficiencies can affect the heart?s normal function, so an insufficient amount of these nutrients (or reduced bioavailability) in the diet could cause heart disease. Diet-associated DCM could also be due to an ingredient in the food that is toxic to the heart. The FDA and many researchers are actively studying this issue so that it can be solved as quickly as possible.
My dog was diagnosed with DCM. What should I do? Ask your veterinarian to measure taurine levels and give heart medications as directed by your veterinarian. If your dog is eating a BEG diet or other unconventional diet (including vegetarian, vegan, or home-prepared diets), I recommend following the steps outlined in my previous post, including switching to a non-BEG diet. Three updates to my previous post are:
Taurine supplements: Consumer Lab is expected to release a report on independent quality control testing of taurine supplements in late 2018. Given the lack of quality control for dietary supplements (human and pet), having these results will be very useful to find good quality products for dogs that require taurine supplementation. Your veterinarian or veterinary cardiologist can help you determine an optimal dose for your dog.
Other dogs in the household: We are now recommending that other dogs in the household of dogs with DCM that are eating the same BEG diet be screened by their veterinarian since their hearts could also be affected (even if they are showing no symptoms).
Outcome: Not all dogs with DCM will improve and improvements in the echocardiogram, when they do occur, can take a long time (often more than 6 months).
If my dog is eating a BEG diet but has no symptoms, should I test for DCM or switch to a different diet? It?s unlikely that most dogs eating a BEG diet will develop DCM. However, given the fact that we don?t yet understand why BEG diets are affecting some dogs and because DCM is a life-threatening disease, I recommend you reconsider your dog?s diet until we know more. Contrary to popular belief, there are no health benefits of grain-free or exotic ingredient diets except in the rare case of food allergy. If your dog is a part of your family and you want to feed him the very best, be sure to base this important decision on more objective factors than marketing and the ingredient list (see our post).
Be sure to watch for early signs of heart disease ? weakness, slowing down, less able to exercise, shortness of breath, coughing, or fainting. If you notice any of these, get your dog checked out by your veterinarian who will listen for a heart murmur or abnormal heart rhythm (although not all dogs with DCM have any changes that can be heard with a stethoscope). Your veterinarian (or a veterinary cardiologist) may do additional tests, such as x-rays, blood tests, electrocardiogram, and ultrasound of the heart (echocardiogram ? the test of choice to diagnose DCM).Tell your veterinarian what you?re feeding your dog. You can help your veterinarian by bringing a list of everything your dog eats to every appointment.
If your dog has no symptoms, additional testing is really up to you. Some owners have measured plasma and whole blood taurine levels or scheduled an echocardiogram to check their dog?s heart size and function. However, given the cost of an echocardiogram, other owners have elected to have their veterinarian do a blood test called NT-proBNP, which goes up when the heart is enlarged. While a normal value doesn?t guarantee your dog has no heart disease, a high level suggests your dog?s heart should be evaluated further.
Has diet-associated DCM been seen in cats? The association between BEG diets and heart disease has only been reported in dogs so far. However, that doesn?t mean cats are immune. If your cat is diagnosed with DCM and is eating a BEG, vegetarian, vegan, or home-prepared diet, I recommend following the same protocol as described for dogs with DCM.
Lastly, if your dog has been eating a BEG diet and has been diagnosed with DCM, please don?t feel guilty. I?ve talked to owners who feel terrible because they wanted to provide the finest care for their dog by feeding them the best diet possible. They often spent a lot of money buying an expensive boutique diet and now that same diet may be associated with their dog?s heart disease. Trying to decide what is really the best food is confusing and difficult because of the many different products available, nutrition fads, and compelling marketing. My hope is that the one bright side of this serious situation is that it will shine a light on the complexities of making safe and nutritious pet food and the importance of nutritional expertise and quality control, rather than just what is new and trendy.
JM SMUCKER has recalled 9 Lives Protein Plus wet, canned cat food
Columbia River Natural Pet Food Recalls expanded
Elm Dog Food Recalled
ANF Dog Food Recalled
Heartworm Flea an Tick Prevention
There are so many choices when it comes to preventing parasites. It is our goal to provide the safest most effective products for our patients at fair and competitive prices.
Sentinel: This product is a once monthly flavored tablet primarily for the prevention of Heartworm Disease. It eliminates heartworm larvae in the early stage of infection, preventing heartworm disease. It also eliminates intestinal parasites including roundworms, hookworms, and whipworms. In addition, it helps prevent flea infestation by breaking the flea life cycle.
Heartgard: This product is a once monthly beef chewable Heartworm Preventative. It also prevents Hookworms and Roundworms.
Seresto: This product is a collar delivery system for topical Flea and Tick prevention. It provides full body coverage against fleas and ticks for 8 months by spreading through the lipid layer present only in Dog and Cat skin. Since humans lack this layer, the product is non toxic to humans. The product can not release onto human skin. The product both kills and repels fleas and ticks, while remaining only in the skin. We recommend having the collar placed by our staff, so it can function most effectively.
Bravecto: This is an oral Flea and Tick control product. Given only once every 12 weeks, it eliminates fleas and ticks, but does not repel them. It's efficacy is not altered by bathing or swimming.
Parastar: This is a liquid topical Flea and Tick control product. It is applied monthly and is effective if your dog swims or is bathed. It does not repel fleas and ticks.
Prescription Foods. We offer a wide variety of Hills Prescription food, Iams, and Purina ProPlan Veterinarian Diets. In the event you want to research what may be right for your pet please visit the following website http://www.petnutritionalliance.org/Pet_Owner_Tool_Sections\
Winter Weather Safety Tips
Protect Your Pet During Winter and Cold Weather
Follow our tips to keep your pets safe and comfortable
Pets are happiest and healthiest when kept indoors, especially during extreme cold snaps.
In many areas, winter is a season of bitter cold and numbing wetness. Make sure your four-footed family members stay safe and warm by following these simple guidelines:
Keep pets indoors and warm
The best prescription for winter's woes is to keep your dog or cat inside with you and your family. The happiest dogs are those who are taken out frequently for walks and exercise but kept inside the rest of the time.
Don't leave pets outdoors when the temperature drops. During walks, short-haired dogs may feel more comfortable wearing a sweater.
No matter what the temperature is, windchill can threaten a pet's life. Pets are sensitive to severe cold and are at risk for frostbite and hypothermia during extreme cold snaps. Exposed skin on noses, ears and paw pads can quickly freeze and suffer permanent damage.
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CANINE INFLUENZA FAQ
Canine influenza (CI), or dog flu, is a highly contagious viral infection affecting dogs and also cats. Influenza viruses belong to the family Othomyxoviridae. Canine Influenza is a Type A influenza virus and is further identified based on the composition of two specific proteins in the lipid outer layer of the capsid: hemagglutinin (HA) and neuraminidase (NA). At present, two strains of canine influenza virus have been identified in the United States: H3N8 and H3N2.
Influenza viruses are able to quickly change and give rise to new strains that can infect different species. Both strains of canine influenza identified in the U.S. can be traced to influenza strains known to infect species other than dogs. At some point, these viruses acquired the ability to infect dogs and be transmitted from dog to dog.
Canine H3N8 influenza was first identified in Florida in 2004 in racing greyhounds. It is thought this strain developed from an equine H3N8 influenza strain that jumped from horses to dogs. Since being detected in 2004, canine H3N8 influenza has been identified in dogs in most U.S. states and the District of Columbia.
Canine H3N2 influenza was first identified in the United States in March 2015 following an outbreak of respiratory illness in dogs in the Chicago area. Prior to this, reports of canine H3N2 influenza virus were restricted to South Korea, China and Thailand. It was initially identified in dogs in Asia in 2006-2007 and likely arose through the direct transfer of an avian influenza virus ? possibly from among viruses circulating in live bird markets ? to dogs.
Following the initial diagnosis in Chicago, additional cases of canine H3N2 influenza were reported in a number of states. In early 2016, a group of shelter cats in Indiana were diagnosed with H3N2 canine influenza. It is believed the virus was transmitted to them from infected dogs.
In May 2017, canine H3N2 influenza was diagnosed in dogs in Florida, Georgia, North Carolina, South Carolina, Texas, Kentucky, Tennessee, Missouri, Louisiana, and Illinois. This was the same strain of H3N2 involved in the 2015 outbreak in Chicago.
There is no evidence that either strain of canine influenza (H3N8, H3N2) can infect humans.
Canine influenza is transmitted through droplets or aerosols containing respiratory secretions from coughing, barking and sneezing. Dogs in close contact with infected dogs in places such as kennels, groomers, day care facilities and shelters are at increased risk of infection. CI can be spread indirectly through objects (e.g., kennels, food and water bowls, collars and leashes) or people that have been in contact with infected dogs. It is important to clean and disinfect objects that have been in contact with an infected dog to avoid exposing other dogs to the virus. Likewise, people who have been in contact with an infected dog should wash their hands and clean their clothing to avoid spreading the virus.
The virus can remain viable (alive and able to infect) on surfaces for up to 48 hours, on clothing for 24 hours, and on hands for 12 hours. It is important to implement biosecurity protocols and disinfection procedures to reduce the risk of disease transmission.
H3N8 has an incubation period of 1 to 5 days, with clinical signs in most cases appearing 2 to 3 days after exposure. Dogs infected with H3N2 may start showing respiratory signs between 2 and 8 days after infection. Dogs are most contagious during the incubation period and shed the virus even though they are not showing clinical signs of illness. Some dogs may show no signs of illness, but have a subclinical infection and shed the virus.
Pathology and Clinical Signs
Canine influenza virus infects and replicates inside cells in the respiratory tract from the nasal lining to the terminal airways. The inflammatory response to the infection results in rhinitis, tracheitis, bronchitis and bronchiolitis. The pathologic process results in death of the epithelial cells lining the respiratory tract, exposing the underlying basement membrane. This predisposes the respiratory tract to secondary bacterial infections that contribute to nasal discharge and coughing.
Virtually all dogs exposed to CIV become infected, with approximately 80% developing clinical signs of disease. The approximately 20% of infected dogs that do not exhibit clinical signs of disease can still shed the virus and spread the infection.
Like other mammalian influenza viruses, canine influenza virus causes an acute respiratory infection in dogs. There is no "season" for canine influenza, and infections can occur any time of the year. Canine influenza virus infection often resembles canine infectious tracheobronchitis ("kennel cough"), which is caused by one or more bacterial or viral infections, including Bordetella bronchiseptica and parainfluenza virus.
The majority of infected dogs exhibit the mild form of canine influenza. The most common clinical sign is a cough that persists for 10 to 21 days despite treatment with antibiotics and cough suppressants. Affected dogs may have a soft, moist cough or a dry cough similar to that induced by kennel cough. Nasal and/or ocular discharge, sneezing, lethargy and anorexia may also be observed. Many dogs develop a purulent nasal discharge and fever (104-105o?F). The nasal discharge is usually caused by secondary bacterial infections, including Pasteurella multocida and mycoplasma species.
Some dogs are more severely affected and exhibit clinical signs of pneumonia, such as a high-grade fever (104°F to 106°F) and increased respiratory rate and effort. Thoracic radiography (chest x-rays) may reveal consolidation of lung lobes. Although most dogs recover without incident, deaths due to H3N2 have been reported.
Cats infected with H3N2? display signs of upper respiratory disease, including nasal discharge, congestion, malaise, lip smacking and excessive salivation.
Canine influenza cannot be diagnosed solely by clinical signs (coughing, sneezing and nasal discharge) because these clinical signs also present with other canine respiratory illnesses. Tests are available to diagnose and identify stain of canine influenza virus. Tests include: virus isolation, immunoassays to detect virus antigen, PCR to detect virus nucleic acid, and serology for antibodies specific to the virus. PCR may be the most reliable test for the diagnosis of CI. Contact your diagnostic lab for recommendations regarding tests and sample collection.
Veterinary expertise is required to determine treatment options and the best course of treatment. Treatment for CI, as for most viral diseases, is largely supportive. Good husbandry and nutrition may help dogs mount an effective immune response. Most dogs recover from canine influenza within 2-3 weeks. Secondary bacterial infections, pneumonia, dehydration, or other health factors (e.g., pregnancy, pre-existing pulmonary disease, immunosuppression, tracheal collapse, etc.) may necessitate additional diagnostics and treatments including, but not limited to:
Antimicrobials for known or suspected secondary bacterial infections.
idal anti-inflammatory medications as needed to reduce fever and inflammation.
Fluids to help correct dehydration or maintain hydration.
Treatment modifications should be made as needed, based on response to treatment, other health factors, and other factors such as compliance and animal care capabilities of the owner/caretaker.
To prevent transmission of the virus, dogs infected with canine H3N2 influenza as well as other dogs in the household should be isolated for 4 weeks.
Antiviral drugs to treat influenza are approved for use in humans only. Little is known about their use, efficacy and safety in dogs. Veterinarians who use approved drugs in a manner not in accord with approved label directions (e.g., use of an antiviral drug only approved for use in humans) must follow the federal extralabel drug use regulations of the Animal Medicinal Drug Use Clarification Act (AMDUCA).
Morbidity and Mortality
Canine influenza virus is not widespread in the dog population and many dogs have never been exposed to the virus. The morbidity rate (the number of exposed animals that develop disease) estimated at 80%. The mortality (death) rate is low; less than 10%. Deaths occur mainly in dogs with the severe form of disease.
To date, no fatalities in cats infected with canine influenza have been reported.
Prevention and Control
The canine influenza virus may persist in the environment for approximately 2 days, and be viable on hands and clothing for up to 24 hours. In veterinary, boarding, and shelter facilities, the canine influenza virus appears to be easily killed by disinfectants commonly used in those facilities, such as quaternary ammonium compounds (eg, benzalkonium chloride), aldehydes, potassium peroxymonosulfate, phenols and bleach (1:30 dilution) solutions. Cleaning and disinfection protocols should be established to ensure reduce the risk of virus transmission through indirect contact with people or other fomites (e.g. cages, bowls, exam rooms, etc.).
All employees should wash their hands with soap and water:
Upon arriving at the facility
Before and after handling each dog
After coming into contact with dogs' saliva, urine, feces, or blood
After cleaning cages
Before eating meals, taking breaks, or leaving the facility
Before and after using the restroom
Isolation protocols should be rigorously applied for dogs showing clinical signs of respiratory disease. Dogs exposed to CI or exhibiting respiratory symptoms should not be brought to locations where other dogs are present such as training classes, shows or events, day care, and boarding and shelter facilities until the isolation period is completed.
Sick or exposed dogs should be isolated, preferably in an area with a separate air supply. An isolation period of 4 weeks is recommended. Wear personal protective equipment (gown and gloves at a minimum) when handling ill animals to avoid contaminating clothing. Clean and disinfect all clothing (including shoes), equipment, surfaces and hands after exposure to dogs showing signs of respiratory disease. Owners whose dogs are coughing or exhibiting other signs of respiratory disease should bringing their dogs should not participate in activities with other dogs or bring their dogs to facilities where other dogs are present to avoid exposing them to the virus.
Veterinary practices should implement biosecurity protocols to prevent transmission of CI between dogs at the practice. Dogs with clinical signs consistent with respiratory disease should not be allowed in the waiting room. Clients may need to wait in the car with their dog until clinic staff is ready to see the dog without risking exposure to other dogs. Dogs suspected of having CI should avoid the main entrance and enter and exit the facility through a different door. Areas where potentially infected dogs are examined and treated, as well as all instruments used, must be thoroughly cleaned disinfected after the dog is discharged. Staff members should wear personal protective equipment (gloves and a gown at minimum) when examining or caring for dogs suspected of having CI.
Vaccines are available for both H3N8 and H3N2 canine influenza. A bivalent vaccine offering protection against both strains is also available. Currently, there are no canine influenza vaccines approved for use in cats. Vaccination can reduce the risk of a dog contracting canine influenza. Vaccination may not all together prevent an infection, but it may reduce the severity and duration of clinical illness.
The canine influenza vaccine is a "lifestyle" vaccine, and is not recommended for every dog. In general, the vaccine is intended to protect dogs at risk for exposure to the canine influenza virus, which includes those that participate in activities with many other dogs or are housed in communal facilities, particularly where the virus is prevalent. Dogs that may benefit from canine influenza vaccination include those that receive the kennel cough (Bordetella/parainfluenza) vaccine, because the risk groups are similar. Dog owners should consult with their veterinarian to determine their dog's risk of exposure to the canine influenza virus and if vaccination is appropriate for their dog.
More Information about Canine Influenza
Canine Influenza resources (Iowa State University Center for Food Security & Public Health)
Key Facts about Canine Influenza (Centers for Disease Control and Prevention)
Canine Influenza FAQs for Pet Owners and Veterinarians (2017) (University of Florida College of Veterinary Medicine)
Sheltering Organizations: Canine Influenza FAQ (University of Florida College of Veterinary Medicine)
Canine Influenza Fact Sheet (Iowa State University)
H2N3 Canine Influenza Virus Fact Sheet of Veterinarians (University of Florida College of Veterinary Medicine)
Canine Influenza Virus (Cornell University Veterinary Diagnostic Laboratory)
2015 Canine Influenza Outbreak in Chicago Area (Cornell University Veterinary Diagnostic Laboratory)
Doginfluenza.com (Merck Animal Health)
Meyer M. UF veterinary researchers discover a new disease in dogs. Explore: Research at the University of Florida; 2006:11. Available at: http://www.research.ufl.edu/publications/explore/v11n2/story3.html. Accessed on April 22, 2015.
Crawford C. Canine influenza: Frequently asked questions from dog owners. University of Florida; 2009.
Cornell University: College of Veterinary Medicine. Emerging issues - Canine influenza: Test summary for canine influenza virus in dogs not affiliated with greyhound racetracks Animal Health Diagnostic Center.
Crawford C. Canine influenza: Frequently asked questions from veterinarians. University of Florida; 2009.
Iowa State University. Canine Influenza. Available at: www.cfsph.iastate.edu/Factsheets/pdfs/canine_influenza.pdf. Accessed on August 19, 2009.
Cornell University: College of Veterinary Medicine. Emerging issues - Canine influenza virus. Animal Health Diagnostic Center; 2006.
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