Tuesday, November 21, 2017

Arguments Against the Sale of Veterinary Prescription and Wellness Diets by Veterinarians

          









A student paper written  as a final assignment for SACS 455 Year 3 Nutrition Elective  Western College of Veterinary Medicine;  Supervisor  Meg Smart DVM, PhD, Professor  in Clinical Nutrition 

Veterinary Prescription Diet Debate
Arguments Against the Sale of Veterinary Prescription and Wellness Diets by Veterinarians

Introduction
In 400 B.C. Hippocrates stated “Let food be medicine,” and this central dogma constitutes the foundation of the practice of veterinary nutrition. According to the Veterinarian’s Oath, it is the professional and moral obligation of every practicing veterinarian to uphold the highest standards of care in order to integrate their medical knowledge with current industry standards to provide a well-rounded approach to the health and well-being of their veterinary patients, and this includes providing professional advice to clients regarding the nutrition requirements of their pets in a manner that is consistent with the principles of veterinary medical ethics. According to the Veterinarian’s Oath, it is the professional and moral obligation of every practicing veterinarian to uphold the highest standards of care. Veterinarian's must strive to integrate their medical knowledge with current industry standards in order to provide a well-rounded approach to the health and well-being of their veterinary patients. This includes providing professional advice to clients regarding the nutrition requirements of their pets in a manner that is consistent with the principles of veterinary medical ethics.
With the advent of retailing in the veterinary profession and inherent economic basis of the retail pet food market, there is some speculation that the immediate goal of providing high-quality veterinary care to our patients has taken a back seat to potential conflicts of interest associated with the use of retailing and the commercialization of the veterinary industry. The sale of “premium” pet food products for therapeutic benefit and maintenance in healthy animals is believed to constitute 10-30% of the income in many private veterinary practices and constitutes approximately 10-11% of hospital-wide profit (Jerving-Bäck and Bäck 2007), associated with an average 40% markup in price. At present, the most popular veterinary therapeutic products are Hills (Prescription Diet), Medi-cal, Purina and Iams, all of which provide not only “high quality pet nutrition” but also opportunities for financial benefit to veterinary profession in the form of feeding programs, research and educational funding and pet food merchandise, to name a few. Although the distribution of veterinary therapeutic and wellness diets through veterinary clinics has the potential to promote a more complete and balanced health care approach within the private practice setting, the constitutions underlying the use of “prescription” or “therapeutic diets” in veterinary practices are only ethical if the products provide potential benefit to the patient, if the veterinarian is not biased in their recommendation of a particular brand, and if the sale and use of these diets are not misleading to the client (Jerving-Bäck and Bäck 2007).
This article appraises relevant information regarding the potential pitfalls which may be associated with the sale and distribution of these diets due to the poor regulatory standards of pet food, the lack of superiority of veterinary therapeutic diets, the current deficit of nutritional education held by veterinarians. Veterinarians need to keep in mind that public perceptions of their nutritional recommendations are that they are “credible” and central to dietary selection.

“Complete and Balanced”: Providing a False Sense of Security on Every Bag
Educated recommendations are the foundation of veterinary practice, second only to the level of trust instilled in veterinary professionals by their clients. As such, veterinarian's need to stand behind the products they recommend, prescribe and sell within their practice. This includes supporting the label claims on those products. Many veterinary professionals and pet food owners alike are under the impression that the claim “complete and balanced” seen on most commercial veterinary products is a guarantee that pet food manufacturers have substantiated and the particular food contains everything an animal needs for optimal health.
“Animal feeding tests using AAFCO procedures substantiate that (a pet food) provides complete and balanced nutrition for the maintenance of (a pet)”      
This is a label claim included on both commercial and therapeutic diets sold by veterinarians and often instills a potentially false sense of security that the associated diet is appropriate for the day-to-day maintenance of cats and dogs. An in-depth look at the regulations and guidelines surrounding the claim of a “complete and balanced” diet reveals that this statement is inherently flawed, due to in part to the fact that we do not know what “complete and balanced” truly entails. The complexities of feline and canine nutritional requirements are not completely understood, and although this topic is a growing area of interest in the research community, the potential uncertainty makes validating claims of “complete and balanced” difficult.
In 1987, Dr. Pion and Dr. Kittleson, published a paper showing a direct link between low taurine plasma levels in commercially manufactured pet food and the development of dilated cardiomyopathy in cats. Prior to this discovery, thousands of cats had been dying every year due an 'idiopathic' form of dilated cardiomyopathy. We now know, this previously “idiopathic” syndrome was due an incomplete diet which was previously believed to be 'complete and balanced'. With growing knowledge of the complexities of feline dietary requirements as obligate carnivores, perhaps feline diabetes mellitus or hyperthyroidism, will one day be proven to be caused by a missing or over-supplemented nutrient.. There are already several recent publications listing consumption of canned cat food as a potential risk factor for hyperthyroidism (Edinboro et al, 2000; Wakeling al, 2009).
Although the exact science behind feline nutritional requirements is still developing, a quick assessment of the average nutrient content of normal prey species consumed by cats, provided by Dr. Smart at the Western College of Veterinary Medicine, suggests an approximate nutrient breakdown of 62.8% protein, 23.1% fat, 10.4% ash, and 3.7% fiber and carbohydrates combined. A common example of the nutritional inadequacies inherent in veterinary therapeutic diets is the excessive use of carbohydrates in feline therapeutic diets. Veterinarians continue to promote feeding these diets high in carbohydrates despite growing evidence attesting to the obligate carnivorous nature of our feline veterinary patients (Zoran, 2002) and the apparent detrimental effects associated with long-term feeding of these formulas including obesity and Type 2 diabetes mellitus, affectionately known as the “diabesity epidemic” (Buffington, 2008). This is in strict violation of the central veterinary dogma which states “first do no harm”.  Regardless, dry food sales dominate the current pet food market based on consumer and distributor convenience.
It is difficult to rationalize these diets in a species that is an obligate carnivore, yet these diets continue to be certified by AAFCO as 'complete and balanced'. We also know that obesity in cats is linked to insulin resistance (Biourge et al, 1997), yet Purina canned DM therapeutic food contains approximately 17% fat on a dry matter basis, which may make it difficult for some feline patients to lose weight.  Arguably there are many successful clinical trials in the treatment of feline diabetes where Purina canned DM was the diet of choice, however these trials were also funded by Purina and one would be hard pressed to find research challenging these studies where there effects of non-therapeutic canned foods were evaluated.
“Minimum Requirements?” Are our Nutritional Guidelines Rational and Reflective of the Dietary Needs of out Pets?
The nutrient requirements released by the National Research Council (NRC) are the basis for the requirements set by AAFCO. The NRC has released several updates on the nutritional requirements of cats and dogs since the first release in the mid 1980s. With continued research, an understanding of the baseline dietary requirements of cats and dogs will continue to develop and change. However, with our understanding of feline and canine dietary requirements constantly changing, it seems profoundly irresponsible to suggest that even those diets that comply verbatim with current NRC recommendations are “complete and balanced”. Although, NRC nutrient requirements are based on scientific research, the current state of research affairs in veterinary science is largely based on low-quality evidence consisting of anecdotal reports, non-randomized, non-controlled studies, and studies containing low, non-statistically viable numbers of participants. Most importantly, these studies have the potential for inherent bias due to the influence of retail pet food and pharmaceutical companies that fund a vast majority of the current research. Some data for species such as cats is even extrapolated from dogs due to a lack of empirical evidence. It is also important to keep in mind that NRC requirements are based on the minimum quantity of a nutrient required to provide the desired outcome of interest (i.e. growth) (Zicker, 2008). The NRC does not, however, appear to be concerned with limiting those nutrients which are often associated with obesity. Calcium, phosphorus, vitamins A, D, and E and copper and iron are some of the nutrients with maximum recommendations; however most nutrients do not have upper limits. It appears that we know how to keep an animal from starving to death but we are not certain how to maintain optimal health.
Dietary Adequacy as Assessed by AAFCO Feeding Trials: Is the Current Empirical Basis of Veterinary Nutrition Sufficient to Assess the Nutritional Adequacy of Pet Food Products?
Pet foods which have been certified through AAFCO are required to either:
1.      Pass AAFCO feeding trials, or
2.      Must meet or exceed the nutrient requirements recommended by AAFCO.
According to current AAFCO regulations, pet food manufacturers may substantiate nutritional claims for “complete and balanced nutrition” by one of three methods outlined by Zicker (2007). The first, “formulation method” entails formulation of novel diets to meet minimum AAFFCO nutrient profiles. The second, “feeding trial” or “protocol method” entails successful completion of an AAFCO-controlled feeding trial, which employ “minimum protocols” as outlined by the NRC. The third, “family method” indicates that product analyses may be sufficient to validate nutritional competency claims if the diet in question is closely formulated to another approved trial.  Feeding trials are considered the gold standard and diets sold within veterinary clinics are usually certified this way. However, a given diet can also be labeled as having passed AAFCO feeding trials, if its nutrient content is similar to another diet that has previously meet AAFCO standards as per the “family method” (Dzanis, 2004).
Although employing standard protocols to ensure the nutritional adequacy of pet food products is necessary to create a level of quality control in the industry, veterinarians must be aware of the current standards employed in feeding trials to permit a scrupulous assessment of diets they recommend or prescribe to their patients. In addition to apparent inconsistencies in AAFCO accreditation, AAFCO feeding trials  contain only eight animals, two of which can be dropped from the study for “non-nutritional reasons or poor food intake,” without the requirement to define or report the underlying etiology of the illness as long as it is not obviously associated with inadequate nutrition. The feeding trials for maintenance diets are conducted for 6 months, after which, the diet is considered adequate to meet the nutritional needs for the entire life of the animal. While it is true that a six month feeding trial may reveal acute deficiencies, we have no way of knowing what a chronic low level deficiency will do to overall health. There are reports that some pet food companies extend the length of these feeding trials but there is no way to tell this by looking at the bag sitting in a veterinarian's clinic and these companies are under no obligation to do these extended trials.
The animals enrolled in the trial must not lose more than 15% of their body weight over the six month trial period (Dzanis, 2004), equivalent to a 20 lb loss in an average 130lb human being. Perhaps thanks to this criterion, weight loss due to inadequate dietary calories is not the concern for our pets today and instead obesity prevails. In a recent epidemiological study of 696 dogs, 60% were overweight or obese and only 5% were underweight (Courcier et al, 2010). With this being such a problem, it would seem that setting a maximum for weight gain during a trial would be appropriate but this criteria remains absent. Since AAFCO standards apply to all commercially available pet food products, veterinarians must take the potential shortcomings of this level of pet food regulation and quality control under consideration when recommending any commercially-available pet food product, and should ensure adequate monitoring protocols to avoid the advent of health problems that may be related to nutritional inadequacies in commercial pet food products. It is also important to keep in mind that veterinary therapeutic diets are held to the same standards of quality control as commercial products despite a pre-conceived notion of nutritional superiority.
“Prescription Diet”: Are Current Industry Standards and Regulations Sufficient to Allow for Adequate Monitoring of Prescription Diets as Drugs?
Veterinary therapeutic diets are defined as those diets that are intended for use under supervision of a veterinarian, due to anticipated therapeutic benefits and potential for harm when fed as a daily diet for the life of the animal. Despite the pre-conceived notion instilled in veterinary clients that these diets are nutritionally superior, with established efficacy in preventing or alleviating the associated disease condition, the only nutrient criteria applicable to pet foods is those associated with AFFCO profiles and feeding trials (Roudebush et al. 2000; Dzanis, 2009). As such, the prescribing veterinarian must make a critical assessment of the diet themselves and decide if it meets the individual needs of the patient. According to a position statement from the AVMA regarding the use of “therapeutic diets” in veterinary medicine:
The AVMA recognizes that the Food and Drug Administration (FDA) uses enforcement discretion in the oversight of certain pet food claims. Even though many of these foods could legally be considered drugs, certain claims are not FDA approved; consequently, efficacy for these products cannot be assured. Therefore:
The AVMA encourages the pet food industry to act responsibly by only making health or therapeutic claims that are supported by quality scientific evidence.
Veterinarians should assess relevant product information through principles of evidence-based medicine prior to using or recommending wellness or therapeutic pet foods.”
In Canada, regulation of pet food is under the jurisdiction of the Canadian Food Inspection Agency, Health Canada and the Competition Bureau of Industry Canada. Specifically, Health Canada is responsible for legislation regarding health claims on advertising on pet food. Although the Food and Drug Administration requires adequate empirical scientific substantiation of health claims outlined by pet food companies, current Canadian standards are much more lenient (Hodgkins and Smart, 2008). Under sections 5.4 (“Special Dietary Use”) and section 6.3 (“Health Claim”) sections of the Guide for Labelling and Advertising of Pet Foods outlined by the Competition Bureau:
a) Adequate and proper tests must confirm the benefit of the nutritional link to the health claim.
b) Current data confirming the health claim must be kept on file with the company and must be made available to government officials upon written or verbal request.
c) Health claims must comply with existing Canadian law with respect to drug claims. For example, the words "diagnose", "cure", "mitigate", "treat" or "prevent disease" must not be used.”
“If a product is intended to be used under the direction or supervision of a veterinarian, then the following claim must be used on the product label:
"Use only as directed by your veterinarian."”
In response to a recent debate over the regulatory authority of the FDA with regards to the use of therapeutic veterinary diets, CVM director Dr. Dunham outlined the current opinion that administration of therapeutic diets requires a valid prescription from a licensed veterinarian to protect the consumer from potential detrimental effects of the diet (Fiala and Spero, 2011). As the intended use of these formulations is the treatment of existing medical conditions, prescription diets are viewed as “drugs” under the Federal Food, Drug and Cosmetic Act, although this distinction is rather vague and does not directly follow the constitutions for other drugs and associated products with regards to taxation, regulation, etc.  (Fiala and Spero, 2011). This is in contrast to current general misconceptions in the veterinary field which often associate the “therapeutic” nature of these diets as being correlated with status rather than a requisition to utilize the same degree of responsibility as prescription or therapeutic drugs. As outlined above in current regulations for health claims, in most cases, therapeutic diet claims outlined by the manufacturer’s label have not been substantiated by the FDA, or corresponding Canadian governmental agency and the extent of therapeutic efficacy documented by manufacturing companies for individual products is highly variable (Fiala and Spero, 2011; Dzanis, 2009). Aside from the Veterinary Oral Health Council (VOHC) independent organizations for assessment of therapeutic diet claims do not exist, as such the degree of quality control and empirical assessment of therapeutic efficacy of these diets is questionable, and the baseline nutritional adequacy is also questionable (Dzanis, 2009).

Market Need: Are Veterinary Diets Superior Relative to Commercial Competitors?
It is often assumed that the “premium” therapeutic diets sold in veterinary clinics are not only superior in formulation, but also in the quality of ingredients and manufacturing. This is used to justify the price inflation and the need for a prescription from a veterinarian.  As previously discussed, stringent regulation and demonstrated efficacy of these diets for therapeutic benefit in veterinary patients is variable. Although many of the therapeutic claims may be based in empirical research for nutritional requirements, currently available diets may not adequately satisfy scientific recommendations.  For example, it has become common knowledge in the veterinary community that low-protein, low-phosphorus, high potassium diets are fundamental to slowing the progression of renal disease in cats in stage 1 or stage 2 renal failure. Current recommendations, based on substantial research regarding dietary management of renal failure in cats, indicate that dietary protein should not exceed 30% in these patients and levels of phosphorus, sodium and potassium should be tightly regulated (Hand and Novotony, 2000). A table of prescription diets specifically formulated to prevent or slow the progression of renal disease in feline patients is outlined in Table 1 below, and illustrates the fact that many prescription diets formulated for a specific disease condition may not be nutritionally balanced to satisfy current nutritional recommendations. As such, critical appraisal of the nutritional labels and relative nutrient constituents in any therapeutic diet should be evaluated prior to prescribing such patients to a client.
Renal Diets in Cats
Diet
Protein
Phosphorus
Sodium
Potassium
Recommended Levels
30
0.4-0.6
<0.35
0.8-1.2
Veterinary Formulas (Wet)
Hill’s Prescription Diet Feline g/d
35.1
0.54
0.74
0.29
Hill’s Prescription Diet Feline k/d
29.5
0.39
1.05
0.32
Medi-Cal Feline Reduced Protein
35.3
0.59
0.27
N/A
Purina Feline NF-Formula
31.1
0.52
0.16
0.96
Veterinary Formulas (Dry)
Hill’s Prescription Diet Feline g/d
33.4
0.55
0.34
0.75
Hill’s Prescription Diet Feline k/d
28.2
0.46
0.25
0.76
Iams Multi-Stage Renal
30.4
0.54
0.49
0.71
Purina Feline NF-Formula
30.8
0.41
0.20
0.88
Table 1. Veterinary Therapeutic Renal Diets in Cats. Adapted from Hand and Novotony, 2000.
Many veterinarians and consumers have also come to believe that many of the therapeutic diets available on the market today have been uniquely formulated to satisfy the nutritional requirements for patients with a given disease condition, and that low-cost commercial alternatives are not readily available. This belief often results in exclusivity in the sale and distribution of veterinary therapeutic diets to patients with disease conditions that are highly dependent on dietary control such as feline and canine diabetes mellitus. Several studies have shown that a decrease in the carbohydrate load of the diet may reduce insulin resistance or reduce the tendency for hyperglycemia in out veterinary patients, and aid in establishing adequate dietary and medical control of this disease (Bennet et al. 2006; Hand and Novotony, 2000; Kirk, 2006). Critical appraisal of available veterinary therapeutic diets relative to “low quality” commercial pet food diets reveals the potential for the use of low-cost commercial diets in lieu of more expensive therapeutic diets in these patients (see Table 2 and Table 3 below).  Particularly in cases where finance is a primary concern, veterinarians need to be able to critically appraise both commercial and therapeutic diets for potential efficacy for a given disease condition based on current nutritional requirements and make appropriate and honest recommendations to their clients.
Commercial Diabetic Diets for Dogs
Products
Protein
Fat
Crude Fiber
Carbohydrate
Recommended Levels
15-25
<20
8-17
50-55
Dry Canine Foods (Veterinary)
Hills Prescription Diet Canine w/d
18.9
8.7
16.9
51
Iams Eukanuba Glucose-Control
29.0
8.0
2.9
52.4
Purina CNM DCO-Formula
25.3
12.4
7.6
47.8
Select Care Canine Hilfactor Formula
25.1
10.6
14.3
42.5
Waltham/Pedigree Canine High Fiber Diet
21.9
8.2
4.9
57.2
Moist Canine Foods (Veterinary)
Hills Prescription Diet Canine w/d
18.2
13.0
12.2
52.3
Select Care Canine Hilfactor Formula
24.8
9.1
15.0
47.0
Waltham/Pedigree Canine High Fiber Diet
29.8
8.0
10.3
45.0
Moist Canine Foods (Commercial)
Alpo Prime Cuts Savory Beef
18.4
6.25
10.22
52.84
Table 2. Diabetic Canine Diets. Adapted from Hand and Novotony, 2000.

Commercial Diabetic Diets for Cats
Products
Protein
Fat
Crude Fiber
Carbohydrate
Recommended Levels
28-45%
<20%
8-17%
20-40%
Dry Feline Foods (Veterinary)
Hill’s Prescription Diet Feline w/d
38.8
9.3
7.9
37.9
Purina CNM OM-Formula
38.4
8.5
8.0
37.6
Moist Canine Foods (Veterinary)
Hill’s Prescription Diet Feline w/d
41.3
16.7
10.7
24.6
Purina CNM DM-Formula
56.9
23.8
3.6
8.1
Commercial Non-Diabetic Diets
Royal Canin Oral Care 30 (Dry)
33%
16%
8.3%
36%
Science Diet Mature Adult Active Longevity Gourmet Turkey Entrée Minced
34.5%
20.1%
4.8%
34.5%
Friskies Indoor Delights Dry
34.1%
10.2%
5.7%
43.1%
Fancy Feast Filet Mignon Dry
35.6%
17.8%
5.0%
35%
Table 3. Diabetic Feline Diets. Adapted from Hand and Novotony, 2000.

It is difficult to definitively determine whether therapeutic diets have an inherent therapeutic benefit to warrant their elevated pricing. The notion of superior efficacy and ingredient quality draws the assumption that the basic dietary constituents and ingredients of these diets would be of superior quality to commercial brands. However, wide-spread recalls associated with the melamine toxicity episode of 2007, laid the groundwork for an index of suspicion that pet food formulations of all pre-conceived “qualities” contained similar ingredients. Although determination of the origin of ingredients for many of the large-scale pet food companies is difficult, analysis of product labeling and comparison of ingredients lists suggests that many of the veterinary therapeutic diets not only contain similar ingredients, but also have similar formulations to lower-end commercial products. 

Comparison of Ingreditent Composition and Quality for 3 Commercial Products
Medi-Cal Feline Preventative Dry
Adult Fit 32 Feline Dry
Techni-Cal Adult Formula Dry
Chicken Meal, Rice, Corn Gluten Meal, Corn, Chicken Fat, Dried Egg Powder, Natural Flavour, Dried Brewer’s Yeast, Tomato Pomace (Source of Lycopene)
Dried Tomato (Source of Lycopene), Calcium Sulphate, Dried Beet Pulp, Flax Meal, Fish Oil, Potassium Chloride, DL-Methionine, Sodium Bisulphate, Taurine, Fructo- Oligosaccharides, Vitamins (DL-Alpha-Tocopherol [Source of Vitamin E], Inositol, Niacin, L-Ascorbyl-2-Polyphosphate [Source of Vitamin C], D-Calcium Pantothenate, Biotin, Pyridoxine Hydrochloride [Vitamin B6], Riboflavin [Vitamin B2], Thiamine Mononitrate [Vitamin B1], Vitamin A Acetate, Folic Acid, Vitamin B12 Supplement and Vitamin D3 Supplement), Choline Chloride, L-Lysine, Marigold Extract (Source of Lutein), Trace Minerals (Zinc Proteinate, Zinc Oxide, Ferrous Sulphate, Manganese Proteinate, Copper Proteinate, Copper Sulphate, Manganous Oxide, Calcium Iodate and Sodium Selenite), Brewer’s Yeast Extract (Source of Mannan-Oligosaccharides), L-Carnitine, Beta-Carotene and L-Glutamine. Naturally Preserved with Mixed Tocopherols, Rosemary Extract and Citric Acid.
Chicken meal, brown rice, corn, corn gluten meal, chicken fat, natural flavors, pea fiber, dried brewers yeast, dried beet pulp, rice hulls,
soybean oil, dried egg powder, anchovy oil (source of EPA and DHA omega 3 fatty acids), calcium sulfate, potassium chloride, salt, DL-methionine, brewers yeast extract (source of mannan-oligosaccharides), choline chloride, L-lysine, taurine, sodium tripolyphosphate, vitamins [DL-alpha tocopherol (source of vitamin E), L-ascorbyl-2-polyphosphate (source of vitamin C), niacin, biotin, riboflavin (vitamin B2), D-calcium pantothenate, vitamin A acetate, pyridoxine hydrochloride (vitamin B6), thiamine mononitrate (vitamin B1), folic acid, vitamin B12 supplement, vitamin D3supplement], trace minerals [zinc oxide, zinc proteinate, ferrous sulfate, manganese proteinate, copper proteinate, copper sulfate, manganous oxide, calcium iodate, sodium selenite]. Preserved with natural mixed tocopherols (source of vitamin E) and citric acid, rosemary extract.
Chicken Meal, Rice, Ground Corn, Corn Gluten Meal, Chicken Fat, Beet Pulp, Salmon Oil, Pea Fibre, Natural Flavour, Calcium Sulphate, Potassium Chloride, Brewers Yeast, DL-Methionine, SodiumTripolyphosphate, Choline Chloride, L-Lysine, Taurine, Yucca Schidigera Extract, Vitamins [Vitamin E, Niacin, Inositol, Ascorbic Acid, Thiamine, D-Panthothenate, Riboflavin, Pyridoxin, Beta-Carotene, Vitamin A, Vitamin K, Folic Acid, d-Biotin, Vitamin D3, Vitamin B12], Trace Minerals [Zinc Oxide, Zinc Proteinate, Ferrous Sulphate, Iron Proteinate, Manganous Oxide, Manganese Proteinate, Copper Sulphate, Copper Proteinate, Calcium Iodate, Sodium Selenite], Preserved With Natural Tocopherols, Rosemary Extract and Citric Acid.

Table 4. Compairson of Three Quaity "Grades" of Pet Food.

Dry Dog Food Analysis (Based on Ingredient Quality at www.dogfoodanalysis.com)
Comercial Dry Dog Food Products
1 Star
2 Star
3 Star
4 Star
5 Star
6 Star
·     PC Nutrition Extra Meaty Lamb and Rice
·     Pedigree Large Breed
·     Pro Plan Large Breed
·     Purina One Adult Beef and Rice Formula
·     Iams Healthy Naturals
·     Cesar Small Breed Adult
·     Caribou Creek Gold
·     Eukaneuba Adult Maintenance
·     Royal Canin Mini Adult 27
·     Addiction Wild Kangaroo and Apples
·     Almo Nature Holistic Croquettes Large Breed Diet
·     American Natural Premium Original
·     Azmira Lamb Meal and Barley Dog Food
·     Acana Large Breed
·     Avoderm Natural Lamb Meal and Brown Rice Adult Dog Food
·     Blue Buffalo Chicken and Brown Rice for Adults
·     By Nature Active Formula
·     Acana Grasslands
·     Artemis Fresh Mix Adult
·     Before Grain Salmon
·     Blue Wilderness Chicken
·     Canidae Beef and Fish
·     Fromm Four Star Duck and Sweet Potato
·     Artemis Maximal Dog
·     Blue Wilderness Salmon
·     Go Natural Grain Free Endurance
·     Innova Evo Herring and Salmon
·     Instrinct Duck Meal and Turkey Meal Formula
Table 5. Examples of Various Commercial Dog Food Products and Associated Quality Scores. Assessment of ingredient quality available at Dog Food Analysis (www.dogfoodanalysis.com).
Veterinary Diets (Dry) Analysis
Purina Veterinary Diets
Iams Veterinary
Royal Canin Veterinary
Hill’s Prescription Diet
DCO
1 Star
Low-Residue
1 Star
Calorie Control
2 Star
B/D
1 Star
DH
2 Star
Joint Health
1 Star
Dental
2 Star
C/D
1 Star
DRM
1 Star
Renal
1 Star
Development
1 Star
D/D (Duck)
1 Star
EN
1 Star
Response FP
2 Star
Diabetic
2 Star
D/D (Salmon)
2 Star
HA
1 Star
Response KO
1 Star
Hepatic
2 Star
D/D (Egg)
2 Star
JM
1 Star
Weight Control
1 Star
Hypoallergenic
2 Star
G/D
1 Star
LA
1 Star
Restricted Calorie
1 Star
Low Fat
2 Star
H/D
1 Star
NF
1 Star


Mature
1 Star
I/D
1 Star
OM
1 Star


Renal (LP/MP)
2 Star
J/D
2 Star




Skin Support
2 Star
K/D
1 Star




Urinary SO
2 Star
L/D
1 Star




Vegetarian
1 Star
R/D
1 Star






T/D
1 Star






U/D
1 Star






W/D
1 Star






Z/D
1 Star






Z/D Ultra
1 Star
Table 6. Quality Assessment of Various Veterinary Therapeutic Diets and Associated Scores. Assessment of ingredient quality available at Dog Food Analysis (www.dogfoodanalysis.com).

Is the Current Level of Veterinary Nutrition Education Sufficient to Make Recommendations Regarding Pet Food Products?
Without question, the current state of regulation and standardization in both therapeutic and commercial pet food diets leaves several important questions unanswered. As such, the impetus for the task of critical appraisal and assessment of potential efficacy, quality, risks and benefits of commercial and prescription diets falls on the veterinarian. An important question that we must ask ourselves with regards to the sale of veterinary therapeutic diets is:  do we as veterinarians receive enough nutritional training and education to give clients unbiased advice on the best clinical and preventative diets to feed their pets? As veterinarians, we are regarded as experts in small animal nutrition, and clients look to us for advice and guidance.  Through our appointments and sale of these products in our clinics we are telling clients that we recommend these products for their pets, but do we actually have enough training and knowledge to support these claims and stand behind these products?
In order to better analyze the preparedness of veterinarians with regards to companion animal nutrition it seems logical to investigate how much emphasis veterinary institutions place on nutrition in general, and in particular the opportunities available to become educated in small animal nutrition. A survey of North American and overseas veterinary schools conducted by Dr. Meg Smart in 2010 revealed that a curricular focus on small animal nutrition is still currently lacking at most institutions. Twenty-four out of twenty-eight American veterinary schools responded to the survey, all of the Canadian school and five out seven major overseas schools also responded to the survey. The results demonstrated that only three schools require nutrition as a prerequisite, meaning that for many students, veterinary school is their first introduction to the principles of nutrition.  Only seventeen out of thirty three schools surveyed have a basic nutrition course (varying from 1 to 3 credits), and these courses include large and small animal nutrition. Two schools cover nutrition as part of another course. Several schools do not offer any core nutrition classes, but only offer nutrition as an upper year elective. With regards to more specific education, sixteen schools offer companion animal nutrition electives that are taught in-house by faculty from their respective colleges, ten schools offer an elective taught by the Mark Morris Foundation (funded by Hill’s Pet Nutrition), and four schools offer in-house consultations. Out of all the surveyed veterinary schools, only eight schools offer final year rotations in companion animal nutrition.
A survey of practicing veterinarians conducted by the Veterinary Information Network in 2007 regarding companion animal nutrition found that although most clinicians stated that nutrition was included in their veterinary curriculums as a core course, 63% of surveyed veterinarians said that their core nutrition courses spent less than 20 percent of the time on small animal nutrition. When you take into account that most core nutrition classes are only 1 to 3 credits at most institutions, less than 20% only leaves several hours for a small animal nutrition focus. Furthermore, only 15% of those surveyed responded that greater than 50% of their nutrition courses were devoted to small animal nutrition, which is surprising when you take into account that greater than 75% of those surveyed said that they were practicing primarily small animal medicine.
Fitting in all of the necessary courses required to ensure that students are well-prepared for boards and clinics is a difficult task for school administrators. Curriculums are well packed with medicine, surgery, husbandry, physiology, histology and anatomy; this often leaves little time of for any focus on small animal nutrition in the veterinary curriculum.  Consequently, it is the pet food companies that frequently help fill in the gaps at many veterinary institutions. For the most part veterinary schools are pleased to support the pet food companies and their role in small animal nutrition. Pet food companies offer free extracurricular lectures and labs in small animal nutrition out of school hours, and therefore do not compete with school curriculums, budget or require faculty to teach these lectures. The companies offer many incentives to veterinary students such as free or discounted pet foods, paid student coordinator positions. Discounted pet foods are often made available to teaching hospitals and profits sometimes go to the benefit of the school. The major pet food companies provide financial and educational support to students in the form of scholarships, specialized equipment and funding teaching hospital improvements (i.e. WCVM  Nestle-Purina Dental Suite). In addition, pet food companies fund faculty research projects and nutrition professorships in some schools.
The education and support provided by pet food companies is not necessarily completely negative, as it offers students exposure to the veterinary therapeutic diets available, introduces us to research being conducted in their facilities and access to trained nutritionists, however when the majority of education is being provided by a major pet food company and little information is available regarding non-veterinary diets, smaller companies or homemade/raw diets, how are students and veterinarians expected to provide clients with an unbiased opinion for a diet that is optimal their pet.  Small animal nutrition is a complicated and often overwhelming field; consequently if core nutrition classes, electives and rotations taught by highly-trained and university funded faculty are lacking, future veterinarians are likely to fall back on the brand names of foods that saturated their veterinary education; lacking the ability and time to critically analyze these diets.  This is the case today in many veterinary clinics; clinicians have grown up with these companies and therefore trust these veterinary products and rarely question the ingredient lists, formula designs, research or actual benefits of feeding the diets long-term.
Conclusions
Without controversy, adequate nutrition is fundamental to ensuring the health and well-being of our veterinary patients, and as such, veterinarians will continue to play a crucial role in the pet food industry. To definitively state that integration of nutrition into a complete veterinary preventative and treatment regimen is in itself contrary to the fundamental premise of the mandate of the veterinary profession. However, several underlying concerns with the current state of veterinary clinical nutrition and the role of the veterinarian necessitates a more stringent consideration of the ethical and professional responsibilities of veterinarians in facilitating acquisition of an appropriate diet to meet the needs of an individual patient. This includes the limited educational exposure to small animal clinic nutrition in the current veterinary curriculum, the propensity for impaired or inadequate critical appraisal of available therapeutic and wellness diets, susceptibility of concrete and finite evaluation of available diets to the commercialization of the pet food industry, and the fundamental inadequacies and fallacies afforded by the current state of regulation and standardization of the pet food industry.
It is pertinent that any nutritional recommendations made by an attending veterinarian receive the same standard of consideration and intellectual scrutiny as that which would be afforded to decisions regarding medical and surgical management of existing diseases in veterinary patients. Such profound critical diligence with regards to diet can only be afforded by progressive revision to the current standards that predominate labelling and health claim practices currently instilled in the Canadian pet food industry. Until growth of the pet food industry permits unyielding confidence in the sale and distribution of therapeutic and wellness diets by veterinary medicine, veterinary practitioners should use a heightened level of discretion and stringent duty of care when making dietary decisions that promote the life-long health of their veterinary patients. Both the potential benefits and limitations of any diet prescribed by a veterinarian should be conveyed truthfully to the client. As well, the  outcome and progression of health of any patient receiving a therapeutic or commercial diet under advisement of the attending veterinarian should be carefully monitored, in order to detect potential dietary inadequacies. In doing this, keep in mind that we may find future nutritional correlations to disease conditions previously thought to be idiopathic.




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