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VeTeamAdvisor

F O R T H E C O M M I T T E D V E T E R I N A R Y S T A F F E R

Ve Te a m A d v i s o r i s a v e t e r i n a r y s t a f f t o o l d e s i g n e d t o b e r e m o v e d f r o m C l i n i c i a n ’s B r i e f ®

March 2007

Starting a Weight Loss ProgramPart II: A Stepwise Approach

In the first part of this series, wediscussed how to approach clientsabout starting a weight managementprogram for their pets and whyoffering such a program to clients isimportant. In this second half, we willoutline how to successfully manageyour patients’ weight through apractical, stepwise approach.

Your team has had their staff meeting and everyone is on board and ready to institute the hospital’s new weightmanagement program. You’ve targeted several patients to

begin the program and the owners are eagerto begin. So where do you start? By taking asystematic approach, you and your team caneffectively create a customized plan that willget your patients on their way to a healthierweight.

Ruling Out Underlying DiseaseBefore starting a patient on a

weight loss plan, a complete physicalexamination, complete blood count, andbiochemistry screen should be performedto rule out any underlying or predisposingdiseases. Hypothyroidism in particular mustbe identified as, unless medically treated, it is unlikely weight loss can be achieved. At the same time, establishing a patient’soverall health will help preventmisinterpreting weight loss due tounderlying disease versus that resultingfrom a successful weight loss plan.

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1. I don’t know how to reach clients who don’t even recognize that theirpets are overweight - they just don’t see it as a problem!

2. I don’t want to upset the clients and make them feel guilty.3. Clients just don’t want to spend money on good pet food. They’d rather

buy whatever is on sale at the grocery store. They think it is all the same.4. They don’t follow our advice and they claim that they never overfeed

their pets.5. It is a sensitive subject to bring up when the client is overweight, too.6. I’m overweight, how can I even bring up weight loss with a client?7. What can I say to clients who complain that they’ve tried pet diets before

and they don’t work?8. I don’t know what to do when clients say they can’t say no when their pet

begs them for food.9. The clients say they can’t manage feeding one pet differently from the

others because they all eat one another’s food.10. Clients won’t give the diet food a chance. If their pets don’t take to it right

away, they cave in and go back to the regular food.

VeTe a m Ad v i s o r ’s

Top10Excusesthe Veterinary Team Gives forNot Starting Pets on a WeightManagement Program:

STEP1

Starting a Weight Loss ProgramPart II continued from page 1

2. . . . . N AV C c l in ic ian’s br ief . march . 2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .veteam advisor

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RER = 70 ×× (BWkg)3/4

MER = RER ×× Factor* (see table below)

Canine Factors Life Stage/Neuter Status Feline Factors

1.8 Intact, normal weight 1.41.6 Neutered, normal weight 1.21.4 Obese Prone (but currently normal weight) 1.01.0 Weight Loss 0.8

ENERGY REQUIREMENT EQUATION

the appropriate amount of food to feed toachieve the desired rate of weight loss, andthat the patient may even gain weight until theappropriate amount is determined.

Selecting a Food andProviding TreatRecommendations

Although it is tempting to feed the foods andtreats that are already being used, it is generallynot recommended unless the foods aredesigned for weight loss and the treats are lowin energy density. Foods that are fed duringweight loss should have a low energy densityand increased levels of essential nutrients(protein, vitamins, and minerals). Foods thatmeet these criteria are limited to veterinarytherapeutic foods designed for weight loss, anda limited number of over-the-counter weightloss foods (most over-the-counter “lite” or“reduced calorie” foods are designed forweight stability, not active weight loss).

Providing treat recommendations is veryimportant to the success of a weight loss plan.Guidelines for feeding treats in limitedamounts will help prevent cheating and willincrease client awareness of specific treats’contribution to the total daily caloric intake.Treats should be limited to no more than 10%of the pet’s total daily caloric intake, thuslimiting the risk of creating a nutrientdeficiency, as most treats are not complete,balanced foods. The daily calories allotted fortreats should be subtracted from the totalcalorie amount determined in Step 3. Specificdaily amounts of commonly fed treats, as wellas low-calorie treat options (eg, baby carrots

and air-popped popcorn) should be providedto the client, allowing them to see the variablecalorie levels in different treat types.

Selecting theRate of Weight LossIt is generally recommended that

patients not lose more than 1% to 2% of theirbody weight per week. Weight loss rates thatare greater lead to greater hunger, which canmake compliance more challenging for theclient as the patient is more apt to beg. Weightloss rates that are slower can be acceptablewhen comorbidities exist that are notworsened by the patient’s obesity.

Client InstructionsClient instructions should be given inboth a verbal and a written form, and

should include the following pieces of information:

■ Clear instructions on the exact amount andfrequency to feed, including the amountand frequency for any treats

■ Instructions on when the client is to comeback to reweigh the pet

■ A clear explanation that initially weight lossplans need to be adjusted frequently (every2 weeks) based on reweighs and that thepet may lose weight at the wrong rate ormay even gain weight initially

■ Recommendations on the types andamounts of exercise or play that would beappropriate for their pet (see ExerciseRecommendations, page 4)

■ The phone number to call if they encounterany difficulties or need assistance

Establish the Patient’sSpecific EnergyRequirement

Determining a pet’s specific energy require-ment is crucial to establishing a successfulweight loss plan. An animal’s maintenanceenergy requirement (MER) is defined by theamount of calories required to maintain its bodyweight. Energy requirement equations are alsoavailable; however, these equations do notaccount for the wide variation (+/- 50%) inenergy requirement for healthy pets.1

If the pet’s weight is stable, the MER can bedetermined by calculating its current caloricintake. The most accurate diet history iscreated by having the client bring in a typicalday’s worth of food and treats to a scheduledweight loss appointment. One of the veterinaryteam members can then weigh out each itemand calculate the total amount of calories feddaily by using product guides, manufacturertoll free numbers or Web sites, as well asdatabases available to the public for free atwww.balanceit.com (pet foods, treats, andhuman foods) or www.nal.usda.gov (humanfoods). Alternatively, a diet history form canbe used, but it must be impressed upon theclient the need for both completeness andspecificity for it to be of value.

If the pet’s diet is highly variable, or if theclient is unable to provide an accurate diethistory, the pet’s MER can be calculated byusing equations for an average adult dog orcat (see Energy Requirement Equation).

Determine the InitialAmount of CaloricRestriction

If the patient-specific MER for weightstability has been determined by calculatingthe pet’s current caloric intake, then it isrecommended that 80% of this amount ofcalories be fed when initiating a weight lossplan. If the pet’s MER has been calculated byusing the less specific energy requirementequation, then the resting energy requirement(RER) is used for determining a dog’srecommended caloric intake for weight loss,while in the cat, 80% of the RER is used. Ifusing this approach, the client should bewarned that it may take longer to determine

STEP2

STEP3

STEP4

STEP5

STEP6

* These factors are starting points only. Adjustments may be necessary as the calculated MER can vary as much as 50%from an animal's true requirement

veteam advisor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . N AV C c l in ic ian’s br ief . march . 2007. . . . . 3

VETERINARIAN■ With the other doctors in the practice, decide on a body condition system (BCS) to use and determine when you will recommend a

dietary intervention (eg, a BCS of > 6 on a 9-point scale).■ Utilize your technicians to complete a diet history prior to the appointment and to review specific recommendations with the clients at

the end of the office visit.■ Provide clients with a list of both their regular treats and low-calorie treat options with the exact amounts that may be fed daily

(clients will often choose the low-calorie treat options when they see how much more of these they can feed).■ If the client becomes frustrated at slow or unsuccessful weight loss, refocus them on small steps (biweekly weight loss goals) and

warn them from the beginning that multiple adjustments may be required to fine-tune the plan.■ Have guidelines in place on how to instruct clients to adjust the amount fed if the appropriate rate of weight loss is not achieved.

PRACTICE MANAGER

RECEPTIONIST

■ Work with your team to set a goal for the number of pets you want to start on weight management plans. Typically 40% of pets in a practice are overweight or obese and only a small percentage are on a weight reduction plan, which means that even a small 1.5-doctor practice could easily have 1,000 pets that would benefit from a diet and exercise plan.

■ If you set a goal of enrolling even half of the overweight pets you see in your practice, that would be at least 500 pets per year in asmall practice, or about two a day that the team would need to enroll to meet its patient care goal.

■ Brainstorm ways to achieve the goal with your team.■ Provide regular feedback on how well the team is doing to help everyone stay motivated and focused on pet weight loss; report

weekly the number of pets put on diets and compare it to your weekly goal and talk about individual pets’ progress.

■ Be sure to record the BCS score in the medical record for each pet and confirm that the doctor has recommended a weight reductionplan for eligible pets.

■ Create a diet history form that highlights the need for exact brand names and specific measurements. Provide clients with a free 8 ozmeasuring cup (available from many pet food companies) so that they can accurately measure food at home. Clients may also weighsome food on a gram scale.

■ Have premade client handouts to make it easier to give clients both verbal and written instructions.■ Make support calls to clients at home to help them trouble-shoot problems that might interfere with the pets’ weight loss plans,

especially when they are first starting their pets on a reduction diet.■ Create a technician-supervised weekly support group where multiple clients can come in to reweigh pets and share their experiences

with one another.

Team Member Tasks

TECHNICIAN

■ Be certain all team members are educated on foods designed for weight loss.■ Track your progress in putting pets on a weight management program against your goal so that you can see you are making a

difference. ■ Help one another overcome client objections. Share ideas and tips that you have learned work well.■ Celebrate success at set milestones. For instance, when the first 50 pets are enrolled in the weight loss program, and again when the

first 100 pets are enrolled and so on, to reinforce success and keep enthusiasm high.

ALL TEAM MEMBERS

As with most programs, obstacles will be faced when tryingto implement a weight loss program. By dividing tasks andkeeping one another motivated, however, team members canmake weight loss programs successful and satisfying foreveryone.

■ Schedule specific weight loss appointments and preschedule weigh-ins.■ Create a call-back schedule and log for the team. Put reminders in the system to help clients remember their pets’ weigh-in appointments.■ Have clients bring in fully labeled samples of a day’s worth of food so that they can be accurately measured when the diet history is taken.■ Make sure that pet owners go home with a “diet tip sheet” to help them to overcome common problems and to give them ideas for

how to be successful when they first put their pets on reduction diets.■ Work with the practice manager and technicians to determine the best way to invite and remind clients about participating in the

weekly pet weight loss support program.■ Take “before” and “after” photos of the pets as they lose weight so that the clients can see the difference and stay motivated. With

the clients’ permission, display photographs of the pets that have successfully lost weight to make “poster child” pets for weight lossand motivate even more clients.



If the patient is losing weight too slowly oris gaining weight, then compliance with thefeeding plan should be confirmed and thedevelopment of an underlying disease ruled

out (ie, diseases that lead to polyphagia, suchas Cushing’s, third space fluid accumulation,and/or a slowed metabolism, as inhypothyroidism). If the client is being

The following suggestions for exercising pets can be made to clients. Exercise should be givenin gradually increasing amounts until at least 30 minutes per day is devoted to some type ofphysical activity.

For dogs:■ Leash walking■ Playing ball■ Swimming (especially for patients with

orthopedic disease)

For cats:■ Leash walking (up to 10% of cats are

reportedly leash trained)■ Play activity that mimics predatory behavior

For a Calorie Burn Chart to see how different exercises can help burn calories go towww.petfit.com

EXERCISE RECOMMENDATIONSAdjusting Weight LossPlans Based on ActualResponse

It should be expected that, initially, weightloss plans will need to be adjusted based onfrequent (every 2 weeks) reweighs to achievethe desired rate of loss. If the patient is losingweight within the desired range per week(typically 1% to 2%), then no adjustment isneeded.

If weight loss is too rapid, the patient shouldbe examined and checked again to be certainno underlying disease is leading to weight loss(ie, diseases that lead to energy loss, such asdiabetes mellitus or protein-losing illnesses,malabsorption, and/or a decreased appetite).If the pet is healthy, at least 10% to 20% morevolume of every food and treat should be fed.If the rate of loss is very rapid ( > 2.5% ofbody weight per week), it might be worthwhileto stop the weight loss plan briefly and ensurethat the animal is eating well and is capable ofweight stability.

STEP7

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This table may be downloaded and printed for use in your clinic at www.cliniciansbrief.com

PET TREAT SHEET

Low-Calorie Treats Calorie Content

Commercial TreatsEukanuba canine Restricted Calorie Rewards 13 kcal per treatHill’s Prescription Diet Canine Treats 13 kcal per 5-gram treatPurina Veterinary Diets Canine Lite Biscuits 27 kcal per biscuitRoyal Canin Veterinary Diet feline Treats 1.4 kcal per treatRoyal Canin Veterinary Diet canine Treats 14 kcal per treat

Human FoodsAir-popped popcorn 31 kcal per cupRaw baby carrots 4 kcal per baby carrotPlain rice cake, unsalted 35 kcal per rice cakeRaw snap green beans 34 kcal per cup

This form may be downloaded and printed for use in your clinic at www.cliniciansbrief.com


Pet’s Name: _________________________________________________________

Day One: Date: ____________________________

Current body weight: _____________kg

Calculated Maintenance Energy Requirement (MER): ___________kcal/day

Plan:

Daily caloric intake: __________kcal/day

What to feed:

Pet food: _____________________________________________ (amount, type, frequency)

Treats: _____________________________________________ (amount, type, frequency)

Exercise recommendations: _________________________________________________

Next reweigh: _____________________ (date)

Week Two: Date: ____________________________


Weight gain/loss since last visit: ___________kg

Rate of weight loss since last visit: ______________ % / week

Plan:


What to feed:



Week Four: Date: ____________________________


Weight gain/loss since last visit: ___________kg

Rate of weight loss since last visit: ______________ % / week

Plan:


What to feed:



Before photo

Place photo here

Exercise recommendations:

________________________________

________________________________

________________________________

Next reweigh:

_____________________________(date)

Exercise recommendations:

________________________________

________________________________

________________________________

Next reweigh:

_____________________________(date)

IN-CLINIC RECORDDIET DIARY

PRODUCT: Slentrol (Pfizer)

PURPOSE: To provide another tool to the veterinary team for dealing with canine obesity

AVAILABILITY: FDA approved. Should become available for dispensing in the spring of 2007

COMPARATIVE COST: Cost to owner will be about $1 to $2 per day, depending on the size of the dog. Multiple variables make it difficult to comparethe cost of the drug to the long-term cost of obesity.

EASE OF USE: Easy. Once-daily liquid oral dose has a neutral flavor, allowing it to be added to treats or food without changing the flavor. Can also be dispensed directly into the dog’s mouth.

HOW IT WORKS: Slentrol belongs to a new class of drugs known as microsomal triglyceride transfer protein (MTP) inhibitors. As a result of MTP inhibition, the absorption of fats from the intestine is delayed. While the mechanism for producing weight loss is not yet completely understood, the drug does cause a decrease in appetite with subsequent decreased food consumption andweight loss.

PLUSES: Slentrol is easy to use, safe, and appears to work. A field study of client-owned dogs showed an average weight loss of 11%body weight in 4 months. At this rate, results are slow enough to be safe, but fast enough for owners to see a difference.

MINUSES: Some owners may find the cost to be an issue. Cannot be used in cats. Possible side effects: vomiting (25% of study dogsvomited at least once during the 4-month trial versus 20% of the placebo group), soft stool, anorexia. Vomiting, the mostcommon side effect, was found to be self-limiting; the medication could be continued and no veterinary intervention wasnecessary. Potential for human abuse: Slentrol is not labeled for humans, but this may not deter some people. Veterinariansand owners need to be aware that this drug is not for humans.

COMMENTS: The mainstay of any weight loss program, diet and exercise, still holds for dogs on Slentrol. This medication is not a magicbullet. It is meant to be temporary and can help getting a dog started with weight loss, but diet and exercise are necessary to maintain a healthy weight.

Weight Management

compliant and the patient is healthy, then 10%to 20% less volume of every food and treatshould be fed. Referral to a boardedveterinary nutritionist (www.acvn.org) isrecommended if it appears that the patientrequires less than 50% of the RER at itscurrent weight to achieve weight loss.

Transitioning to WeightStability once Weight Losshas been Achieved

After the long road to success, the last step ofkeeping weight off must not be neglected. At thisstage, the client may wean the pet onto an adultmaintenance diet. Although not required, it isrecommended that a low-calorie diet designed

Contributors:Sally C. Perea, DVM, MS, DACVN; consultant,DVM Consulting, PC; associate veterinarianand assistant clinical professor, University ofCalifornia, Davis

Sean J. Delaney, DVM, MS, DACVN; foundingconsultant, DVM Consulting, PC; associateveterinarian and assistant clinical professor,University of California, Davis; vice president,American Academy of Veterinary Nutrition

Karyn Gavzer, MBA, CVPM, president of KGMarketing & Training, Inc

Managing Editor: Jennifer L. Schori, VMD

© 2007 Educational Concepts LLC


STEP8

for weight stability in obese-prone pets beselected. The amount of energy required tomaintain body weight is generally equivalent to110% of the calories fed during the activeweight loss period. The clients should start byfeeding this amount, then follow up with areweigh in 2 weeks. If the pet has maintained itsbody weight, then no further adjustments arerequired. If the pet has gained or lost weight,then further adjustments of 5% to 10% of thecalories should be made and follow-upscontinued until weight stability is achieved.

Reference 1. Small Animal Clinical Nutrition III. Lewis LD,

Morris ML, Hand MS — Topeka, KS: Mark MorrisAssociates, 1987; pp 1-10.

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