Introduction

In 2011, the World Small Animal Veterinary Association Global Nutrition Committee introduced its Nutritional Assessment guidelines,¹ following the American Animal Hospital Association (AAHA) 2010 introduction of Nutrition as the 5th Vital Assessment; that should be measured, recorded, and addressed in veterinary patients at each visit².

While this might first appear tedious and time consuming, just as measuring temperature, pulse, respiration, and pain, this 5th assessment can easily be incorporated into a routine exam.

The introduction of the WSAVA Global Nutrition Toolkit, http://www.wsava.org/WSAVA/media/PDF.pdf, containing 19 tools useful for the general practitioner, has made this process all the easier.

The process to routine nutritional assessments are easily completed in 3 steps: First is the nutritional screening, followed by the assessment of risk factors, and finally determining if an extended nutritional assessment/diagnostics/treatment are needed or not.

Risk factors are further defined as patient factors, diet factors, and management and environmental factors.³

• Patient factors: age, life stage, activity, nutrient sensitive disorders, body condition score (BCS), muscle condition score (MCS)
• Diet factors: nutritional balance or imbalance, spoilage, contamination, unconventional diets
• Management and environmental factors: frequency of feeding, timing, location, method of feeding, housing, other pet influences, access to outdoors, and enrichment

Implementation Plan

Education and Awareness

This author first sought “buy-in” by discussing the guidelines and the culture of excellence in medicine and service with doctors of the practice. All agreed this was in the best interest of the patients and clients and recognized the importance of the entire practice team participation and support. To this end, several months of staff meetings, facilitated by doctors reviewed the importance of nutrition and our value to the public in being able to perform these assessments and recommendations with confidence.

Exam Templates

To simplify the process and ensure completeness, nutritional assessment questions and prompts were incorporated into the existing exam template, which already had the other 4 vital assessments of temperature, pulse, respiration, and pain, and were formatted into a SOAP document. These were automatically saved within the paperless software and a copy generated for the client.

Identified additions included:

• Weight today and previous weight
• Diet(s): name brand and ingredients
• Amount fed
• Frequency fed
• Treats
• Supplements
• Medications
• Body condition score (BCS)
• Muscle condition score (MCS)
• Nutritional assessment of diet(s) being fed
• Nutritional recommendation

Example Exam-Template

History, Physical Exam Findings, Assessment, and Recommendations

Date performed________________________________

Performed by_________________________________

History

• Diet/Food_____________________________________________________________________
• Amount(s)________________per day/_____________________per feeding
• Frequency______________________
• Treats___________________________________________________________________
• Vitamins/Supplements______________________________________________________
• Flea products__________________________________________________________________
• HW prevention_________________________________________________________________
• Current medications_____________________________________________________________
• BP (on senior cats)______________________________________________________________
• Previous VX RXN (if giving vx)_____________________________________________________
• Did you bring a stool sample______________________________________________________
• Microchip_____________________________________________________________________
• Have you recently traveled with your pet?___________________________________________
• Are you planning to travel with your pet?____________________________________________
• Any health concerns to discuss with doctor___________________________________________
• Other questions for the doctor_____________________________________________________

Do you have a PetPortal?_________________Would you like one?_____________________________

Would you like us to go over costs of services with you?______________________________________

Physical Exam Findings

Cat Fake’s physical examination is below.

• Weight today is___________________________________
• Previous weight___________________________________
• Body condition score (1–9)__________________________
  (1-ematiated, 5-ideal, 9-grossly obese)
• Temperature_____________________________________
• Attitude and appearance__________________________________________________________
• Hydration level____________________________________________
• Eyes, ears, nose, throat___________________________________________________________
• Capillary refill time/Mucous membranes______________________________________________
• Oral exam/Calculus level (0–4)_____________________________________________________
• Cardiovascular/Heart rate_________________________________________________________
• Pulmonary/Respiratory___________________________________________________________
• Peripheral lymph nodes___________________________________________________________
• Abdominal palpation_____________________________________________________________
• Urogenital_____________________________________________________________________
• Anal glands and rectum___________________________________________________________
• Skin/Integument and nails________________________________________________________
• Musculoskeletal/Neurologic function_________________________________________________
• Muscle condition score (1–4)______________________________________________________
  (4-normal, 2-mild muscle wasting, 1-severe muscle wasting)

Pain score (0–5)_____________________________________________________________________

Assessment

Nutritional assessment________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Recommendations

Nutritional recommendatoion(s)_________________________________________________________

__________________________________________________________________________________

Comments

Incorporating nutritional assessment into our standard exam protocol has helped this team feel they are practicing best medicine. A side benefit was the increased pride and teamwork that developed. How often could an illness have been more easily diagnosed if a more complete picture of the patient’s health and environment had been provided? Knowing that a new food was introduced, or that the BCS has changed dramatically could be the factors that trigger a more extensive assessment and diagnostic workup, thus hopefully earlier detection on an underlying issue, both nutritional or metabolic.

Of course, any new program should be continuously reviewed and updated, based on user feedback.

The WSAVA Global Nutrition Committee Toolkit Website is available for free downloads of their materials for the practitioner, and are available in English, Chinese, and Spanish.

Example case: Copper

Presentation history:

• 3-month-old M Vizsla
• Diet: tested under AAFCO feeding trials brand
• Treats: Vitamins from the veterinary hospital
• Feeding frequency: 3x/day
• In for vaccines and exam

Medications:

• Heartworm/flea prevention from vet

PE:

• Temp: 101.1 F
• Wt: 8.18 kg; Previous Wt: 10.0 kg
• BCS: 5/9
• MCS: 4/4
• Cardio/Pulmonary: normal
• Pain 0

Nutritional assessment:

• Diet factors: AAFCO diet...good
• Patient factors: normal
• Environmental/Mgmt factors: appears appropriate

Risk factors: nothing identified

Extended assessment: not needed

Treatments:

• Routine puppy vaccines and exams

Routine exams, no risks factors, you are done!

Barriers to Implementation

As in any change in practice protocol, there are potentially many reasons a necessary and valid idea fails to be initiated. Effecting change necessitates a team approach with near total “buy-in” that this change will result in better medicine, improve efficiency, provide professional growth, and is actually doable. Taking the time to educate the entire team will improve confidence and acceptance. The template used above in an actual busy general practice validates the feasibility of incorporating nutritional assessments into everyday exams.

Other than the practice team, potential other barriers may be client perceptions that the clinic is just trying to market their own brand of nutrition for profit, time management, disinterest, and of course, the confusing information available on the internet from “experts”. Use of neutral, unbranded materials, such as the 19 tools provided in the WSAVA Toolkit, http://www.wsava.org/WSAVA/media/PDF, can greatly assist the busy practitioner.

• Lack of knowledge by the practice team and client
• Lack of confidence
• Lack of acceptance by practice team
• Perceived time commitments
• Client perceptions
• Internet information

References

1.  WSAVA Nutritional Assessment Guidelines Task Force Members, et al. WSAVA nutritional assessment guidelines. J Small Anim Pract. 2011;52(7):385–396.

2.  J Am Anim Hosp Assoc. 2010;July/August Vol. 46.

3.  VetCINA, 2014;44.4:644–666.