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Use of Therapeutic Diets not Related to Weight Loss

When the nutritional assessment indicates a patient may benefit from consuming a purpose-formulated therapeutic diet, the clinician needs to focus on specific nutrients of concern (Table 8). When a patient has a single disease condition and no additional nuanced feeding or diet requirements, it may be adequate to simply choose a therapeutic diet designed for the disease. In diseases in which diagnostics and staging affect nutrients of concern (e.g., CKD) or when patients have multiple disease conditions and/or additional feeding or diet requirements, consider all nutrients of concern before selecting a diet. Otherwise, it is easy to overlook a nutrient of concern and inhibit or negate the treatment plan for the patient’s condition. For example, if a dog receiving a low-fat diet to manage chronic pancreatitis is diagnosed with CKD, a dietary change to address the CKD may result in recurrent pancreatitis symptoms if both disease conditions are not considered.


Table 8

Nutrients of Concern for Diseases and Select Specific Conditions
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Adverse food reaction >

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Specific Conditions

Nutrients of Concern

Notes

Cutaneous adverse food reaction

  • Limited antigen diet
    • Novel/hydrolyzed protein
    • Limited ingredients
  • Ingredients impact success of treatment
  • Noningredients may also impact success (e.g., additives, Food intolerance Maillard production reaction)

Food intolerance

Food-responsive chronic enteropathy

Inflammatory skin condition >

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Specific Conditions

Nutrients of Concern

Notes

Non-food-related skin condition

  • High n-3 fatty acids
    • Consider n-6:n-3 ratio
  • High vitamin A
  • High vitamin E
  • High zinc
  • Added antioxidants
  • Individual diseases may require different supplements and doses

Osteoarthritis >

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Specific Conditions

Nutrients of Concern

Notes

 

  • High EPA/DHA
  • Added glucosamine
  • Added chondroitin
  • Added antioxidants
  • Low energy density if overweight/obese
  • Additional supplementation may be required to achieve optimal dose
  • High n-3 fatty acid supplementation may result in gastrointestinal disturbance

Neurologic conditions >

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Specific Conditions

Nutrients of Concern

Notes

Cognitive dysfunction

  • Added lipoic acid
  • Added carnitine
  • High EPA/DHA
  • Added antioxidants
  • Synergistic effects of nutrients when combined

Idiopathic epilepsy

  • High medium-chain triglycerides

Anxiety

  • Added L-tryptophan
  • Added hydrolyzed casein
  • Added antioxidants
  • Modified fiber

Cardiovascular disease >

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Specific Conditions

Nutrients of Concern

Notes

Degenerative valve disease

  • Controlled sodium
  • High EPA/DHA
  • Avoid low protein
  • Supplement potassium as required
  • Maintain optimal body and muscle condition

Hypertrophic cardiomyopathy

Dilated cardiomyopathy

  • Controlled sodium
  • High EPA/DHA
  • Avoid low protein
  • Added taurine
  • Added carnitine

Urolithiasis >

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Specific Conditions

Nutrients of Concern

Notes

Calcium oxalate

  • Low oxalate ingredients
  • Controlled calcium with appropriate calcium to phosphorus ratio
  • Avoid vitamin C supplementation
  • Low relative supersaturation
  • Added water
  • Many of these nutrients of concern can be incorporated into other diets but may be difficult to identify unless specifically labeled for this use
  • Aim for USG ≤1.020 (dogs) or ≤1.035 (cats)
  • Struve urolithiasis in dogs is typically infection related and special diet may not be required long term

Struvite

  • Controlled magnesium
  • Controlled phosphorus
  • Controlled protein
  • Target acidic urine pH
  • Added water

Urate

  • Low purines
    • Does not necessarily mean low protein
  • Target alkaline urine pH
  • Added water

Cystine

  • Controlled cystine
  • Controlled methionine
  • Target alkaline urine pH
  • Added water

Lower urinary tract disease >

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Specific Conditions

Nutrients of Concern

Notes

Matrix-crystalline plugs

  • Based on mineral content of the plug
  • Added water
  • Many of these nutrients of concern can be incorporated into other diets but may be difficult to identify unless specifically labeled for this use
  • Aim for USG ≤1.020 (dogs) or ≤1.035 (cats)
  • Struve urolithiasis in dogs is typically infection related and special diet may not be required long term

Feline idiopathic cystitis

  • Added antioxidants
  • High EPA/DHA
  • Added water
  • Low energy density if overweight/obese

Pancreatic disease >

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Specific Conditions

Nutrients of Concern

Notes

Endocrine

Diabetes mellitus

  • High soluble and insoluble fiber
  • Low carbohydrate (cats)
  • High protein (unless contraindicated, e.g., proteinuria)
  • Low energy density if overweight/obese
  • Consistency of meal timing and insulin regimen are most important

Exocrine

Pancreatitis

  • Added antioxidants
  • High EPA/DHA
  • Added water
  • Low energy density if overweight/obese
  • Dietary fat recommendations may depend on baseline intake and degree of hyperlipidemia

Exocrine pancreatic insufficiency

  • Achieve optimal body condition
  • In most cases no specific diet is needed with appropriate enzyme supplementation
  • Assess serum cobalamin and supplement if indicated
  • In cases with persistent soft stool, additional fiber supplementation may be warranted

Gastrointestinal >

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Specific Conditions

Nutrients of Concern

Notes

Acute vomiting, diarrhea

  • Highly digestible
  • Low to moderate fat
  • Difficult to identify digestibility unless specifically labeled for this use

Chronic enteropathy

  • Limited antigen diet
    • Novel/hydrolyzed protein
  • ± modified fiber
  • ± low fat
  • Assess serum cobalamin and folate and supplement if indicated

Intestinal dysbiosis

  • Modified fiber
  • Assess serum cobalamin and supplement if indicated

Fiber-responsive colitis

  • Moderate to high fiber
  • Mixed fiber types
  • Fiber can be separately supplemented

Large bowel diarrhea

Constipation

  • Moderate to high fiber
  • Mixed fiber types
  • Low energy density if overweight/obese
  • Increased water
  • Investigate underlying causes (e.g., hypercalcemia, hypokalemia, obesity)

Obstipation

  • Highly digestible
  • Low energy density if overweight/obese
  • Difficult to identify digestibility unless specifically labeled for this use
  • Caution with high-fiber weight loss diets

Other endocrine >

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Specific Conditions

Nutrients of Concern

Notes

Hyperlipidemia

  • Low fat
  • Consider EPA/DHA supplementation

Feline idiopathic hypercalcemia

  • Controlled calcium
  • Avoid excess vitamin D
  • Avoid excess vitamin A
  • ± increased fiber
 

Hyperthyroid

  • Low iodine
  • Impossible to achieve necessary level of iodine restriction without specific formulation and production procedures
  • Specific nutritional modification not required if hyperthyroidism is managed by other means

Liver disease >

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Specific Conditions

Nutrients of Concern

Notes

Encephalopathic

  • Low fat
  • Low protein
  • ± B12 supplementation

Copper-associated hepatopathy

Portosystemic shunt

  • Low copper
  • Added zinc
  • Only specifically designed low-copper diets are below AAFCO minimums

Microvascular dysplasia

Chronic hepatitis

Nonencephalopathic

  • Moderate protein
 

Kidney >

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Specific Conditions

Nutrients of Concern

Notes

Protein-losing nephropathy

  • 25–50% protein reduction from current intake
    • Meet essential amino acid requirements
  • High EPA/DHA
  • Low phosphorus if azotemic
  • Protein recommendations will depend upon the degree of proteinuria
  • Many medications used to address proteinuria and hypertension may exacerbate hyperkalemia, and reducing dietary potassium intake may help

Acute kidney injury

  • Moderate protein
  • Consider as a critical care disease category when hypercatabolic

Chronic kidney disease

  • Low phosphorus
  • ± potassium supplementation
  • High EPA/DHA
  • Increased energy density to maintain body and muscle condition (unless obese)
  • Excess protein
  • Many medications used to address proteinuria and hypertension may exacerbate hyperkalemia, and reducing dietary potassium intake may help
  • Consider vitamin D supplementation • Protein intake can vary based on staging, presence of uremia, and proteinuria

Obesity >

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Specific Conditions

Nutrients of Concern

Notes

 

  • High protein
  • Moderate to high fiber
  • Low energy density
  • Increased nutrient to calorie ratio
  • Moderate to low fat
  • Restriction below RER is not recommended with over-the-counter products

Dental disease >

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Specific Conditions

Nutrients of Concern

Notes

 

  • Mechanical action or masking flavor for
    • Plaque or tartar reduction and/or prevention
    • Control of bad breath odor
  • Mechanical brushing and dental prophylaxis are most effective

Critical care >

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Specific Conditions

Nutrients of Concern

Notes

 

  • Highly digestible
  • Increased energy density
  • High fat
  • Added antioxidants
  • Texture more amenable to tube feeding slurry use
  • Difficult to identify digestibility unless specifically labeled for this use

These guidelines are supported by generous educational grants from Hill’s Pet Nutrition, Inc., Purina® Pro Plan® Veterinary Diets, and Royal Canin®.

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