Nutrition Flashcards
what are the 2 categories of dietary sensitivities?
non-immunologically mediated
immunologically mediated
what are the 2 sub categories of non-immunologically mediated dietary sensitivities?
repeatable
non repeatable
what are repeatable non-immunologically mediated dietary sensitivities?
those that happen on every exposure
what is an example of a non-immunologicaly mediated repeatable dietary sensitivity?
food intolerance e.g. lactose deficiency in adult cats
what are examples of a non-immunologicaly mediated non- repeatable dietary sensitivity?
dietary indiscretion
intoxication
contamination (poisoning)
what is an immunologicaly mediated dietary sensitivity?
food allergy (hypersensitivity)
can immunologicaly mediated dietary sensitivities be repeated?
yes
are immunologicaly mediated dietary sensitivities often proven?
no - owners will often stop investigations once pet improves
what is the definition of a food allergy?
immunologically mediated, adverse food reaction to a dietary component - usually a protein
what dietary component often leads to food allergy in animals?
proteins
why is it remarkable that more adverse food reactions do not occur?
the gut is always exposed to foreign antigens
what is in place within the body to reduce the likelihood of AFR?
defence mechanisms
what are some of the defence mechanisms found within the gut to prevent AFR?
gut is designed not to let large molecules through
large molecules are broken down into unrecognisable components by the time they reach the blood stream
peristalsis leads to constant movement of food
villi enhance food movement
what is oral tolerance?
body learns food is not harmful through complex sequence of signalling and processing events which result in tolerance of foreign antigens
what happens if there is a failure of oral tolerance?
leads to adverse food reaction
what type of hypersensitvity reaction do most AFRs manifest as?
type 4 - delyed hypersensitivity
when are signs of most AFRs seen?
days after the food is eaten
anaphylaxis is rare
where are clinical signs of AFR commonly seen?
dermatological
GI
what are the most common food allergens in dogs?
beef
dairy
wheat
what are the most common food allergens in cats?
beef
dairy
fish
what do the common food allergens of dogs and cats reflect?
common ingredients in commercial diets
what food intolerance is commonly seen in boarder terriers?
canine epileptoid cramping syndrome
in what animals is canine epileptoid cramping syndrome commonly seen?
boarder terriers
what AFR is seen in canine epileptoid cramping syndrome?
allergy to gluten
what are the cutaneous signs of food allergy?
pruitus
erythema
what is the most common food allergic reaction?
cutaneous
if a patient presents with dermatological issues is it likely to be food allergies?
no - much less common than atopy and flea allergy
are cutaneous food allergy signs seen with GI signs?
no - usually seen without
what are the GI signs of food allergy?
V
D
what are the 3 broad signs of food allergy?
cutaneous
GI
systemic
what are the systemic signs of food allergy?
anaphylaxis
what type of diarrhoea is seen with food allergy?
LI
colitis and blood seen within
what is the urge to defecate like with LI diarrhoea?
urgent
if GI signs of food allergy are seen what must be investigated?
all causes as GI signs are non-specific
at what age do pets tend to present with food allergy?
young
likelihood decreases with age but not impossible in an older pet
what must be done before allergy is investigated?
other causes of the clinical signs excluded as/when appropriate
what type of diarrhoea is seen with food allergy?
large intestinal pattern most common but any pattern possible
what are the 4 stages of diagnosis and management of food allergy?
exclusion/limitation
challenge and rescue
provocation and rescue
maintainance
what is involved in the exclusion/limitation stage of food allergy management?
all possible allergens excluded from diet
novel protein used
patient fed water and diet only
lasts several weeks
what will the patient be fed during the exclusion/limitation phase of food allergy diagnosis?
specific diet
may use novel protein
water and diet only
how long does the exclusion/limitation phase of food allergy diagnosis last?
several weeks
what is involved in the challenge and rescue phase of food allergy diagnosis?
patient is put back on their normal diet
if their symptoms reoccur then it proves the diet is an issue
what is involved in the provocation and rescue phase of food allergy diagnosis?
one food added in at a time to see if symptoms are triggered
what is the benefit of the provocation and rescue phase of food allergy diagnosis?
may enable animal to eat a wider range of foods
how long should pets be on an exclusion diet to see skin improvement?
10 weeks to marked improvement
how long should pets be on an exclusion diet to see GI improvement?
6 weeks to full resolution
should blood testing be used for GI manifestations of food allergies?
no- has no clinical utility
what are chronic inflammatory enteropathies?
group of diseases with chronic GI inflammation
what signs suggest chronic inflammatory enteropathies?
V
D
dysorexia
weight loss
any lasting more than 3 weeks
what must be done before chronic inflammatory enteropathies suspected?
all other causes of GI clinical signs of inflammation must be excluded first
what extra GI diseases can cause GI clinical signs?
exocrine pancreatic insufficiency
local abdominal inflammation (hepatic/renal)
metabolic diseases - PSS, hypoadrenocorticism, hyperthyroidism
how can other causes of GI signs be excluded before chronic inflammatory enteropathies suspected?
lab testing (faecal analysis, bloods)
abdominal US
how is CIE diagnosed?
if al other diagnostic tests are normal
what are the causes of chronic inflammatory enteropathies?
food responsive disease
antibiotic responsive disease
idiopathic disease
how can food responsive chronic inflammatory enteropathies be managed?
diet trial
how can antibiotic responsive chronic inflammatory enteropathies be managed?
metronidazole or other antibiotic used to manage patient
what patients is antibiotic responsive chronic inflammatory enteropathies considered in?
GSD
how is idiopathic chronic inflammatory enteropathies diagnosed?
endoscopy to diagnose / confirm and exclude other microscopic or structural disease
how is idiopathic chronic inflammatory enteropathy thought to occur?
patient identifies own gut as harmful causing inflammation and damage to villi which worsens inflammation
what were idiopathic chronic inflammatory enteropathies previously known as?
IBD
what causes idiopathic chronic inflammatory enteropathy?
loss of immune tolerance of mucosal flora
GI inflammation
shift in flora
leads to further inflammation
how is chronic inflammatory enteropathy diagnosed?
exclusion of other causes
biopsies indicative of inflammation and architectural changes
what architectural changes may be seen which indicate chronic inflammatory enteropathy?
villi atrophy
what are the 2 methods of obtaining intestinal biopsy?
laparotomy
endoscopy
what is the benefit of laparotomy for intestinal biopsy?
enables multiple full thickness biopsies
enables full exploration of other organs
what is the risk of laparotomy for intestinal biopsy?
risk of dehiscence ~10%
surgical risks e.g. peritonitis
what are the benefits of endoscopic intestinal biopsies?
minimally invasive
small biopsies
what are the disadvantages of endoscopic intestinal biopsies?
small biopsies
cannot reach jejunum so will not reflect disease here
what are the main complications and consequences of chronic inflammatory enteropathies?
dehydration
protein malabsorption
hypocobalaminaemia
GI haemorrhage
GI perforation (rare)
why can chronic inflammatory enteropathies lead to protein malabsorption?
gut inflammation prevents protein absorption
what is the result of protein malabsorption?
PLE
hypoalbuminaemia
what is the effect of hypoalbuminaemia?
reduction in oncotic pressure
fluid begins to leak from vessels
what signs can be seen with protein malabsorption?
effusions (pleural and peritoneal)
oedema
thromboembolic events
why are patients with protein malabsorption more at risk of thromboembolic events?
blood more viscose due to reduced fluid
what can be an effect of GI haemorrhage?
anaemia
what is hypocobalaminaemia?
low B12
what can be an effect of GI perforation?
septic peritonitis
what are the standard therapies for chronic inflammatory enteropathies?
maintain fluid balance
nutrition
anti-emetics
appetite stimulants
what must be stabilised in chronic inflammatory enteropathy patients before nutrition starts?
haemodynamically stable (hydration and volaemia)
what are the main supportive therapies for nutrition of patients with chronic inflammatory enteropathies?
exclusion diet
dietary modification
tube feeds if necesary
what may affect appetite in chronic inflammatory enteropathy patients?
low B12
when should a new diet be introduced?
once home to prevent aversion
what are the standard therapies for idiopathic chronic inflammatory enteropathies?
immunosuppression
what additional drugs may be given for idiopathic chronic inflammatory enteropathies?
fenbendazole
metronidazole
B12
anti-platelet drugs
what drugs can be used for immunosuppression of idiopathic chronic inflammatory enteropathies?
preds
what is the benefit of immunosuppression for treatment of chronic inflammatory enteropathies?
allows gut time to recover normal flora
what should animals be fed if on a dietary trial?
diet exclusively and water
will improvement be seen with dietary trials if the patient does not have food allergy?
possibly as if patient is being fed high quality, highly digestible diet they may improve
what are the main diet options for food intolerance or sensitivity trials?
novel protein / carbohydrate
hydrolysed protein
what are the main novel protein / carbohydrate diet options?
home cooked
commercial
what should you do if a client wishes to feed home cooked diet to their pet?
advise they seek a referral to a specialist nutritionist
what are the main novel protein / carbohydrate diets?
hills d/d
eukanuba Dermatosis FP
Dechra specific food allergen management (non HY)
what are the main hydrolysed protein diets?
purina HA
Hill’s z/d
Royal canin hypo/allergenic
dechra specific food allergen management (-HY)
what are the main nursing considerations for chronic inflammatory enteropathy patients?
hydration status
inappectance
nausea
nutrition or malnutrition status
abdominal discomfort
hypoproteinaemia
diarrhoea or faecal scauld
how should hydration status be managed?
replace ongoing losses (v/D)
calculate deficits
how may inappetance or nausea be managed?
TTE
antiemetics
how can nutrition / malnutrition be assessed?
WSAVA assessment
what patients are more at risk of malnutrition?
septic
burns
what % weight loss would suggest that a patient is likely malnourished?
WL >10%
how should nutrition of chronic inflammatory enteropathy patients be managed?
tube feeds
B12 and potassium supplementation
how can abdominal discomfort be managed?
analgesia
where should all food intake be recorded?
hosp sheet
what parameter related to nutrition should be assessed and recorded daily?
BCS
weight
what effect can fluid balance have on weight?
most weight loss seen in hospital patients is due to fluid changes
how much weight fluctuation in hospital is likely due to WL?
1%
when is patient nutritional support needed?
if <80% RER voluntary intake
>10% weight loss after fluid balance
>3 days hyporexia
severe underlying disease present
what is microenteral nutrition?
small amounts of nutrient rich fluid given to help prevent villi atrophy and maintain gut integrity
what is the benefit of microenteral nutrition?
prevent villi atrophy and maintain gut integrity so that when the patient begins to eat again the gut is ready
should syringe feeding be used?
no - especially not cats
how can animals be encouraged to eat?
feed little and often
change feeding posture
low fat diet
feed from height
supplement fibre
encourage voluntary eating with warmed foods, owner, own food
what is the benefit of feeding little and often?
enrichment
what is the benefit of low fat diets?
faster gastric emptying to reduce nausea
good for reflux and regurge
what is the benefit of fibre supplementation?
supports large bowel or colonic disease
what may be causing abdominal discomfort in chronic inflammatory enteropathy patients?
GI ulceration
GI dilation
reflux pain
how can GI ulceration be managed?
omeprazole
sucralfate
how can pain from reflux be managed?
manage oesophagitis
postural feeding
what is the disadvantage of using opioids for GI pain?
may exacerbate or cause ileus
what drug may be given for GI pain?
buscopan
how can diarrhoea / scald be managed?
keep bottom clean and dry
apply topical barrier
avoid patient grooming
use absorbent bedding
ensure top layer of bedding is soft not vetbed!
what is the role of buscopan?
spazmolytic
how can patients with diarrhoea be kept clean and dry?
tail bandage
clip
use towels gently
warmish hairdryer over fur
what topical barriers may be used for diarrhoea patients?
cavilon spray
vasaline as extra barrier in extreme cases
what is cavilon spray?
no sting barrier film
how can patient grooming be prevented when necessary?
distraction
enrichment
buster collar
how can beds be made absorbent?
layers of inco sheets
what should be monitored daily about chronic inflammatory enteropathy patients?
weight
appetite
demenour
V/D - try to quantify
hydration status
HR
RR
comfort
bloods: electrolytes and proteins
what is the benefit of adequate and appropriate nutrition to hospitalised patients?
reduces morbidity and mortality
reduces length of hospitalisation and complications
improves recovery time
when should nutrition be started in hospital?
asap
why should nutrition be started as soon as possible in hospital?
many positive benefits
prevention of villi atrophy and bacterial translocation
what does WSAVA class nutrition as?
the 5th vital sign
what can be used to asses malnutrition?
WSAVA toolkit
what may indicate malnourishment/
loss of muscle mass
low BCS
weight loss of >10%
poor coat condition
what amount of weight loss is considered significant?
> 10%
5% if short term
what are the risk factors for malnutrition?
anorexia
poor appetitie for >3 days
disease
large protein loss
burns
head trauma
what are the types of muscle mass loss?
sarcopenia
cachexia
what is sarcopenia?
loss of muscle mass seen in old age
no underlying disease process
what is cachexia?
loss of muscle mass due to disease process
what are the 2 types of starvation?
simple
stress
when is simple starvation seen?
healthy patients who don’t have access to food
what happens to metabolism during simple starvation?
normal adaptions, glycogen stores utilised
what happens to protein stores during simple starvation?
conserved so no loss of lean muscle mass
what happens to fat during simple starvation?
fat usage increased
when is stress starvation seen?
when patients are unwell
clinical disease
what effect does stress starvation have on metabolism?
hypermetabolism
what effect does stress starvation have on protein stores?
breakdown of protein/muscle wasting
cachexia
what metabolic state are patients in during stress starvation?
catabolic
is time to malnutrition faster in simple or stress starvation?
stress
what is the difference in prognosis for recovery between simple and stress starvation?
poorer with stress starvation
what should be done before beginning nutrition?
assess hydration, electrolytes, acid-base balance and pain
ensure euhydrated
what effect does pain have on the gut?
slows peristalsis
what are the short term aims of nutrition?
provide for any ongoing nutritional requirements
prevent or correct nutritional deficiencies or imbalances
minimise metabolic derangements
prevent further catabolism of lean body mass
what are the long term aims of clinical nutrition?
restoration of optimal body condition
provision of required nutrients to the animal within its own environment
what are the main types of enteral feeding tubes?
NO/NG tube
O tube
gastrostomy (PEG)
jejunostomy
how long can NO/NG tubes be in place for?
5-7 days
short term
what is the main issue with jejunostomy tubes?
high rate of complication
what does the choice of feeding tube depend on?
patient tolerance
length of time tube needed
anaesthesia risk
clinician experience
complication risk
type of diet needed
cost
owner ability to use at home
what is refeeding syndrome?
complex metabolic derangements that occur when enteral or parenteral nutrition is fed to severely malnourished patients or those following a period of prolonged starvation
is refeeding syndrome common?
no but potentially fatal
how can refeeding syndrome be avoided?
patient needs time to adjust to food again so it must be reintroduced slowly
what is an anabolic state?
normal metabolism and digestion
why do patients need to be reintroduced to food slowly?
avoidance of refeeding syndrome
changing from a catabolic to anabolic state
what are metabolic changes in refeeding syndrome due to?
sudden increased insulin release
what metabolic changes are seen with refeeding syndrome?
severe hypophosphataemia
hypokalaemia
hyponatraemia
hyperglycaemia
hypocalcaemia
what are the clinical signs associated with refeeding syndrome?
peripheral pitting oedema
haemolytic anaemia
cardiac failure
neurological dysfunction
respiratory failure
how rapidly can refeeding syndrome progress to death?
within 2 days
how can patients be monitored for refeeding syndrome?
monitor bloods
when should feeding only commence?
once the patient is haemodynamically stable (fix fluid and electrolyte deficits)
what should reintroduction of feeding start with?
microenteral nutrition
what can be used as microenteral nutrition?
oral rehydration solution
how long should patient be tube fed for?
until voluntarily eating >85% of calculated energy requirements regularly
if no anorexia is seen how long should it take for the patient to be given full RER?
assess tolerance on day 1
could give 1/2 day one and then full day 2
if anorexia of <3 days is seen how long should it take for the patient to be given full RER?
over 3 days
D1 - 1/3 RER
D2 - 2/3 RER
D3 - full RER
if anorexia of >3 days is seen how long should it take for the patient to be given full RER?
over 5 days
describe reintroducing feeding for a patient anorexic for >3 days
D1: 1/4 RER
D2: 1/2 RER
D3: 2/3 RER
D4: 3/4 RER
D5: full RER
what is parenteral nutrition?
providing patients with nutrition via IV route when enteral is not available
what is the downside of parenteral nutrition?
multiple complications
can worsen outcomes if incorrectly managed
what must be first line nutritional support?
supported enteral nutrition
what makes up PN solution?
lipid
amino acids
carbohydrates
what forms of carbohydrate are included in PN?
dextrose
glycerol
where should PN lines be placed?
peripheral only
why must PN only be given peripherally?
high infection risk
what should the PN lines be monitored for?
signs of phlebitis
infection at cannula site
what must happen to PN mixture while it is being administered?
must be kept moving to prevent separation
what complications must be monitored for during PN?
metabolic complications
mechanical issues e.g. line occulsion
patient interference
sepsis
what is the most common complication seen with PN?
metabolic complications
how must PN lines be managed?
aseptically
what are the RER protein requirements for dogs?
4-5g per 100 kcal
what are the RER protein requirements for cats?
6g per 100kcal
once protein requirement has been met how should the rest of the PN components be divided?
50:50 lipid:dextrose
what patients have decreased protein needs?
those with hepatic or renal failure
what patients have increased protein needs?
protein losing conditions
sepsis
burns
head trauma
practice
calculations
how can PN risks be minimised?
experienced personnel involved in all aspects
clear SOP
aseptic technique
prevention of patient interference
regular monitoring and recording of metabolic state
how should PN be delivered?
via CRI
how long should PN bags be open for?
24-48 hours max
when changing PN bags what must be replaced?
line and bag
why must PN be protected from light?
prevention of degeneration of B vitamins
should PN lines be removed for walking?
no - minimal removal to reduce infection risk
what can be done to avoid intestinal atrophy while on PN?
small amount of microenteral nutrition
what must be done to avoid hyperglycaemia in PN patients?
over 50% dextrose
over 4ml/kg/min
how must PN be stopped?
gradually
why must PN be stopped gradually?
avoid hypoglycaemia
why may hypoglycaemia be seen if PN is stopped too abruptly?
PN causes higher circulating insulin
how much weightloss is usually due to actual weight loss rather than fluid?
1%
what are the reasons that owners may have for choosing raw, vegetarian or vegan diets for their pets?
cheaper?
social media trends
personal beliefs
perception of quality of commercial food
allergies/problematic ingredients
health benefit claims
cooking for their pet is viewed as bonding
mistrust of companies
what are raw food diets known as?
BARF
what does BARF stand for?
bone and raw food
biologically appropriate raw food
what are the main options for raw feeding?
home prepared
preprepared and commercially available
why is the idea of a wild diet incorrect?
domestic dog is genetically different from wild relations
more omnivorous
lifestyle different so energy and nutrient needs are also
what makes domestic dogs more omnivorous?
increased capacity for starch digestion
what are the risks of raw feeding?
imprecise nutritional measurements
low vitamin and mineral content
microbiological infection
zoonoses
what is the most common bacteria found in raw feeds?
salmonella
what zoonoses are a risk with raw feeding?
listeria
toxoplasma
crypto
mycobacterium bovis
what is the link between raw feeding and hyperthyroidism?
if animals are ingesting gullet tissue they ingest the thyroid which can lead to hyperthyroidism
what are the risks with feeding bone?
fragments may damage the GI tract leading to peritonitis
what type of host are humans for toxoplasma?
paratonic host
what can toxocara cause in children?
blindness
what effect does home freezing have on pathogens in raw food?
not cold enough to kill them
what is the recommendation of WSAVA regarding raw feeding?
no properly documented evidence of health benefits
well documented risks
not advised
what are the raw feeding veterinary society counter arguments to WSAVA on raw feeding?
health benefits are researched and documented
outdated studies on microbiological risks
lack of evidence around risk of ingested bones
is there evidence of recent disease outbreaks relating to raw feeding?
yes - TB/salmonella
what are the key points to discuss with owners regarding raw feeding?
why do they want to feed a raw diet
risk management
when discussing with an owner why they want to feed a specific diet what are you main areas to consider?
dispel misconceptions with evidence
understand perspective (beliefs/culture/past experiences)
what should be involved in risk management discussions with owners that want to raw feed?
individual patient assessment with the vet
assess home environment - children/immunocompromised
sourcing and preparation of food
encourage monitoring in practice
what is essential when advising owners about raw feeding?
not to alienate
what type of diet can be used if raw feeding to remove some pathogens?
irradiated
what meat should not be used for raw food?
ground meat
why should ground meat not be used for raw diets?
more surface area and processing so more risk of surface bacteria
what can be done to reduce bacterial risk in food preparation?
cook food to 74 degrees prior to eating
ensure scrupulous hygiene
what treatment must all raw fed pets receive?
worming (anthelmintic)
why are vegetarian diets not suitable for pets?
cats and dogs have increased protein requirement than that of humans
what diet must cats be fed on?
obligate carnivores - must eat meat
essential dietary nutrients only found in animal sources
what may be lacking in vegetable proteins that is needed for pets?
essential amino acids e.g. taurine and arginine
what are the issues with commercially available vegetarian/vegan diets?
vast majority nutritionally inadequate
low palatability
reduced digestibility
low biological value
what support is available for owners that wish to do home cooking?
american college of veterinary nutrition specialists
what are the important considerations of client perspective around nutrition?
ensure non dismissive
supportive
educate about risk management
be understanding
empathetic
encourage monitoring
what should you discuss within practice regarding raw feeding?
discuss as a team
decide practice position
ensure individualised advice for owners
signposting to most knowledgeable staff member
evidence based leaflet for staff to take away
