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Nutritional Plan: Matching Diet to Disease
Marie E. Kerl, DVM, DACVIM (Small Animal Internal Medicine), ACVECC and
Paula A. Johnson, DVM
Institution of appropriate, timely nutritional support in the an- septicemia. An inverse relationship between body-mass index
orexic or critically ill patient has become accepted medical and mortality in critically ill patients suffering from acute re-
practice in people and animals. This article focuses on the spiratory failure, multiple organ failure, congestive heart fail-
2,5
benefits of appropriate nutrient intake in critically ill animals, ure,andcomahasbeenestablished. Thedeleteriouseffectsof
recommendednutrientrequirements for dogs and cats receiving negative energy balance on critically ill patients occur in mul-
3
enteral feeding, and mechanics of food preparation and delivery tiple body systems (Table 1).
for a variety of feeding tubes. General nutrient requirements for Thedetrimentaleffectsofmalnutritionduringseriousillness
all patients, specific recommendations for certain illnesses such should prompt the clinician to diligently provide appropriate
as renal failure, pancreatitis, and hepatic disease, and nutritional nutritional support for critically ill patients. Selecting the ap-
alterations for critical illness are reviewed. Commercial liquid propriatedietaspartofafeedingprotocolwillbeinfluencedby
diets manufactured for people and pets, and pet-food diets multiple factors including clinical status of the patient, nature
practical for formulation of gruel are presented. Institution of and of the disease process, availability of certain diets, and route of
weaning from feeding are explained. administration. In patients with a functional gastrointestinal
©2004Elsevier Inc. All rights reserved. tract, studies clearly demonstrate that enteral nutrition is the
5-7
preferred method of nutrient delivery. In other words, if the
ood is love. Although this adage learned from our grand- gut works, use it. If a part of the gut works, then use the part
Fmothersmaynotbecompletely correct, there is indisput- that works. This article will focus on the appropriate nutrient
able evidence that malnutrition is detrimental to health and composition and consistency of food for various feeding de-
healing.1 Provision of appropriate nutritional support for criti- vicesandmedicalconditions,recommendedfeedingschedules,
cally ill humans and animals improves organ function, de- and return to voluntary food intake.
creases infections, hospital stay and cost, and improves overall
outcome.1,2 Goals of nutritional support should include satis- Meeting Nutritional Needs
faction of nutritional requirements with concurrent anticipa- Feeding protocols should be tailored to meet the needs of each
3
tion and prevention of associated complications. individual patient, as determined by the clinician’s assessment
An understanding of the detrimental effects of inadequate ofhistoricalandphysicalexaminationparameters,bodyweight
nutritional support on critically ill patients requires recogni- and body condition score, interpretation of complete blood
tion of the difference between simple starvation and stressed count and serum biochemical profile, acid/base status, and the
starvation. Simplestarvationoccursinnormal,healthyanimals particular disease process diagnosed. Nutrient requirements
when denied nutritional intake. During simple starvation the include water and electrolytes, energy-supplying nutrients (eg,
bodyundergoesmultipleadaptationsthatultimatelyresultina 8
decreased metabolic rate, resulting in energy conservation to carbohydrates, lipids, and proteins), minerals, and vitamins.
maintain body mass. These adaptations include increased pro- Before initiation of a specific feeding protocol, the patient
ductionofinactivetriiodothyronine(T3)comparedwithactive should be euvolemic, hydrated, and electrolyte abnormalities
thyroid hormones, and utilization of glucose and fat as the should be resolved. Hypovolemia should be addressed with
primary sources of energy. In contrast to simple starvation, appropriate therapy and monitoring tailored for each individ-
stressed starvation occurs during illness or injury. Counter- ual. Ongoing fluid requirements should be calculated to satisfy
regulatory hormones such as glucagon, epinephrine, and in- maintenance needs, correct dehydration, and address ongoing
9
flammatorycytokinesarereleasedduringseriousillness.These loss. Feeding should be delayed until preexisting fluid and
hormones alter the physiologic response to starvation; energy electrolyte abnormalities are corrected to avoid exacerbating
expenditure does not decline appropriately and tissue catabo- gastrointestinal hypoxia secondary to increasing cellular me-
1,4 tabolism, and to prevent hypophosphatemia and hypokalemia
lism results. related to refeeding syndrome (see article by Dr. Michel, pp.
Humanstudieshavedocumentedhypermetabolicstateswith 10
specificdiseaseprocessessuchasneoplasia,thermalburns,and 49-53, this issue). The energy-supplying nutrients, carbohy-
drates (including starches, celluloses, and oligosaccharides),
lipids (fats), and proteins should be provided in appropriate
8,11,12
FromtheDepartmentofVeterinaryMedicineandSurgery,Universityof ratios for the given species (Table 2).
Missouri at Columbia, Columbia, MO. Carbohydrates play important roles in health maintenance.
Addressreprint requests to Dr. Marie E. Kerl, Department of Veterinary Disruption of homeostasis may alter the ability to utilize or
Medicine and Surgery, University of Missouri at Columbia, 379 East synthesizecarbohydratesappropriately.Starchesareusedasan
Campus Drive, Columbia, MO 65211. E-mail: KerlM@missouri.edu energy source. Insoluble fibers such as cellulose (also referred
©2004Elsevier Inc. All rights reserved.
1096-2867/04/1901-0003$30.00/0 to as crude fiber or total fiber) promote normal mechanical
doi:10.1053/S1096-2867(03)00081-1 function of the gastrointestinal tract, and soluble fiber main-
Clinical Techniques in Small Animal Practice, Vol 19, No 1 (February), 2004: pp 9-21 9
TABLE 1. Deleterious Effects of Negative Energy Balance on Various Body Systems
Body System Effect of Negative Energy Balance
Gastrointestinal Increased transit times, villous atrophy, reduction in absorptive capabilities, increased risk of bacterial translocation
Renal Increased urinary calcium and phosphorus excretion, decreased ability to excrete acid, increased gluconeogenesis,
decreased glomerular filtration rate
Immune Decreased humoral immunity, decreased barrier function (skin and mucosal surfaces), decreased inflammatory
response, decreased leukocyte motility and bactericidal activity
Pulmonary Decreased response to hypoxia, decreased lung elasticity, decreased secretion production, altered permeability,
decreased tidal volume
Cardiovascular Increased incidence of arrhythmias, decreased weight of the heart muscle
Musculoskeletal Increased muscle weakness, increased muscle wasting
tains intestinal hygiene. Oligosaccharides act through fermen- includingthebrain,retina,myocardium,liver,platelets,leuko-
tation and are a direct source of nutrients for the large intes- cytes, and skeletal muscle. It is required by the liver to synthe-
tines. Fermentation promotes the growth of normal size bile acids to aid in the absorption of dietary fats. Other
gastrointestinal bacterial flora while inhibiting the growth of functions include regulation of calcium flux, neurotransmis-
pathogenic bacteria, and improves digestion and nutrient ab- sion,antioxidantfunction,andstabilizationofcellmembranes.
sorption. Fermentation also helps to maintain an intact gastro- Cats lack the ability to synthesize taurine and sustain ongoing
intestinalmucosalbarrier,whichplaysavitalroleinpreventing losses in the bile and feces, making taurine an essential amino
8
bacterialtranslocationfromtheguttothesystemiccirculation. acid in this species. Although the exact mechanism is un-
Lipids (including omega 3 and omega 6 fatty acids) are a known,taurineisthoughttoplayanimportantroleinbioelec-
primary source of energy for cats and dogs (1 g lipid 9 kcal trical potentials for the myocardium and retina. Clinical signs
energy) and a have an important structural role in cellular associated with taurine deficiency include reproductive failure,
membranesandlipoproteins.Omega3and6fattyacidsarenot developmentalabnormalities,retinaldegeneration,anddilated
10,12,14
synthesized by the body, and are therefore essential fatty acids. cardiomyopathy.
Omega 3 fatty acids have anti-inflammatory properties that Glutamine,themostabundantaminoacidinbloodandbody
inhibit the synthesis of chemical inflammatory mediators. tissues, is considered nonessential in times of health. This
Omega 6 fatty acids are essential for prostaglandin synthesis amino acid becomes essential during disease and illness, how-
and some hormonally active molecules, and they have a posi- ever, because the glutamine synthesis pathway becomes atten-
8 10
tive effect on the immune barrier function of skin. uated. Whenthisoccurs, the pool of available glutamine be-
Proteins are molecules composed of amino acids connected comes significantly decreased. Glutamine plays a role in
bychemicalbonds.Thearrangementofthesebondsresultsina nitrogen transport, gluconeogenesis, RNA and DNA synthesis,
3-dimensional configuration that determines the nature and and renal ammoniogenesis. It is a key fuel for rapidly dividing
roleofeachprotein.Proteinshavenumerousfunctions,includ- cells such as enterocytes, endothelial cells, renal tubular cells,
ing rebuilding and maintaining tissues and serving as carrier and lymphocytes. There is an inter-organ glutamine cycle to
molecules, message transmitters, enzymes, antibodies, and mobilize glutamine stores in muscle and provide glutamine for
sources of energy. A decrease in protein availability in a sick or mucosal repair, to generate substrate for renal ammoniogen-
5,10,15,16
injuredanimalthatcausesanegativenitrogenbalancecompro- esis, and to support lymphocyte function. Simple star-
8
mises the ability of the body to heal or fight infection. vation, metabolic acidosis, trauma, sepsis, endotoxemia, and
The following 3 amino acids are of special importance in malignantneoplasiaalter the stability of this cycle by changing
critical veterinary patients: arginine, taurine, and glutamine. the ability of various organs to release or uptake glutamine
Arginine is a required intermediate of the urea cycle, and it is (Table 3).16 Because glutamine is an important fuel for rapidly
importantinwoundhealingandimmunefunction.Arginineis dividing cells, enterocytes may not be able to heal and regener-
an essential amino acid in both cats and dogs; however, cats ateappropriatelyafterinjury.Clinicalsignsofglutaminedeple-
demonstrateclinicalsignsofdeficiencymorerapidlythandogs. tion include protein catabolism leading to muscle wasting and
Arginine is an intermediary in the urea cycle, and its absence cachexia, decreased gastrointestinal barrier function with in-
leads to hyperammonemia from failure of urea production. creased bacterial translocation, and immune-system dysfunc-
Ultimately,hepaticencephalopathyoccurs.Clinicalsignsasso- tionwithstimulationofinflammatorycytokines.Thecombina-
ciated with hepatic encephalopathy include vomiting, ataxia, tion of these negative consequences can lead to multiorgan
17
vocalization, hypersalivation, and tremors. For cats, serious dysfunction. Supplementation of glutamine in humans has
signs can develop within hours of consuming an arginine-defi- beenassociatedwithshortergastrointestinalhealingtimesafter
3,10,13 18,19
cient meal. radiotherapy or chemotherapy.
Taurine is an amino acid found in body tissues and cells,
Diet Selection and Preparation
TABLE 2. General Requirements for Protein, Fat, and The most physiologically sound, cost effective, and safest
Carbohydrate for Normal Healthy Cats and
Dogs (DM dry matter basis) meansofprovidingnutritionalsupportisvoluntaryoralintake.
When this is not possible, then nutritional support can be
Nutrient Cats Dogs provided by enteral tube feeding. There are various enteral
Protein 30%to45%ofDM 15%to30%ofDM feeding methodsavailable, including nasoesophageal, nasogas-
Fat 10%to30%ofDM 10%TO20%OFDM tric, esophagostomy, gastrostomy, jejunostomy, nasojejunal,
Carbohydrates 50%ofDM 50%OFDM andgastrojejunalfeedingtubes.Placementofthesedeviceshas
10 KERL AND JOHNSON
TABLE 3. Glutamine Release or Uptake in Various Body Tissues During Health and Disease
Cell Type Health Simple Starvation Metabolic Acidosis Trauma Sepsis Endotoxemia Malignancy
Lung Release Release Release Increased Increased release Release
release
Skeletal muscle Release Release Release Increased Increased release Increased
release Release
Intestine Absorption Increased Decreased Increased Decreased Decreased
absorption absorption absorption absorption Absorption
Liver Absorption Release Release Increased Increased Increased
absorption absorption Release
Kidney Absorption Increased Increased Absorption Absorption Absorption
absorption absorption
Lymphocyte Absorption Absorption Absorption Absorption Increased Absorption
macrophage absorption
Tumor —————Increased
absorption
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beendiscussedelsewhere(seethearticlebyDr.Han,pp.22-31, sistency diets. Iams Eukanuba MaximumCalorie(IamsCom-
® ®
this issue andDr.Heuter,pp.32-42,thisissue).Althoughthere pany, Dayton, OH) and Prescription Diet Canine/Feline a/d
is no single ideal enteral formulation for all animals, there are (Hill’s Pet Nutrition, Topeka, KS), both classified as veterinary
some desirable characteristics for an enteral formula. These recovery diets, are commonly used for enteral feeding of criti-
10
characteristics include isotonicity, caloric density of 1.0 cally ill dogs and cats. Both of these diets have a smooth
kcal/mLorgreater, protein content of at least 4.0 g/100 kcal or consistency that makes them ideal for large-bore tube feeding
16% of total calories, 30% of calories from fat, and a fiber with minimal preparation. They are both rich in conditionally
5,7
componentof1.0-1.5 g/100 kcal. essential nutrients (taurine, arginine, and omega-3 fatty acids)
Asveterinarymedicinehasevolvedandthesophisticationof for critically ill animals and have a caloric density of 1.75
care that clients demand for pets has increased, the number of kcal/mL and 1.0 kcal/mL, respectively. These diets have a con-
enteralveterinarydietshasgrowntremendously.Dietselection sistency that makesfeedingthrough5-and8-Frenchtubes(eg,
is based on the disease process as discussed below, and also on nasoesophageal, jejunal) impractical. Refrigeration also causes
the formulation, nutrient composition, and consistency of the these foods to thicken. Warming to room temperature and
diet. Prescription diets have been specifically formulated to blending with small amounts of water facilitates tube feeding;
address a multitude of health issues in dogs and cats. Based on however, the calorie content per milliliter will decline when
formulation,dietsareclassifiedaseitherpolymeric(containing water is added (Table 4).
intact protein, polysaccharides, and long-chain triglycerides), Based on their composition, recovery diets may not be ideal
or monomeric (containing nutrients in small, hydrolyzed ab- for all hospitalized patients. For example, a patient with pan-
sorbable forms). Monomeric or elemental diets are liquid diets creatitis should not receive a high-fat diet. Other veterinary
containing nutrients that are readily available for absorption, diets are available for use both in certain disease processes and
with little or no digestion required. These diets are primarily general maintenance. Moist diets require blending with water
composed of amino acids, glucose, and oligosaccharides, and toconverttoagruelthatcanbeadministeredthroughafeeding
also include a source of fatty acids essential for humans. These tube. For example, to prepare a gruel using Hill’s Prescription
® ®
diets are sometimes indicated for treatment of severe gastroin- Diet Feline p/d (Hill’s Pet Nutrition), mix half a can (224 g)
testinal diseases such as pancreatitis, short bowel syndrome, of Feline p/d with three fourths of a cup (170 mL) of water,
severe inflammatory bowel disease, or demonstrated intoler- blend at high speed for 60 s, and then strain twice through a
anceofapolymericdiet.Disadvantagesassociatedwiththeuse kitchen strainer (approximately 1-mm mesh) to remove any
of monomeric diets include expense, dietary intolerance, and remaining large food particles (Fig 1). This yields approxi-
diarrhea caused by high osmolarity. There are no monomeric mately390mLofgruelwithacaloricdensityof0.9kcal/mLand
diets formulated for dogs and cats. Commercially available hu- a protein content of about 11 g/100 kcal. Table 4 lists multiple
®
man products include Peptamen (Baxter Health Care, Deer- diets available commercially, caloric density per can, caloric
®
field, IL), Vivonex HN (Norwich-Eaton Pharmaceuticals, density when prepared as gruel, and some medical conditions
®
Norwich, NY), and Vital HN (Ross Products Division, Abbot for which each diet is indicated. Addition of water facilitates
20
Laboratories, Abbot Park, IL). gruel passage through a feeding tube, but decreases the caloric
All of the commercially available pet-food diets are poly- density and therefore increases the volume of food an animal
meric diets. Routinely, polymeric diets are utilized for enteral requires.
feedingbecausetheyarereadilyavailable,moreaffordable,and Small-bore tubes (nasoesophageal, nasogastric, and jejunal
7
well tolerated by most animals. Examples of polymeric diets feeding tubes) will accommodate only liquid diets. Commer-
usedforenteralnutritionareoutlinedinTable4.Theoretically, cially available polymeric liquid diets formulated specifically
®
monomeric diets should be preferable for jejunal feeding, for veterinary use include canine or feline CliniCare , and
®
wherein the absorptive functions of the upper gastrointestinal feline CliniCare RF (Abbot Laboratories). Examples of poly-
®
tract are bypassed. However, polymeric diets seem to be well meric diets formulated for people include Ensure Plus , Pul-
® ®
tolerated by veterinary patients with jejunal feeding tubes. mocare ,andJevity (RossProductsDivision, Abbott Labora-
Diet selection is also based on the size of the tube chosen for tories; Table 4). These diets can be used in dogs; however, they
nutrient delivery. Large-bore tubes (esophagostomy and gas- should be used only on a short-term basis because they do not
trostomy tubes) will accommodate either liquid or gruel con- meetcaninenutrientrequirements.Dietsformulatedforpeople
NUTRITIONAL PLAN: MATCHING DIET TO DISEASE 11
TABLE 4. Canine and Feline Diets, Calorie Contents Per Can and Milliliter of Gruel, and Indications for Use in Enteral
Feeding Protocols
kcal/mL
Diet Kcal/can Blenderized Osmolarity Indications
A
Eukanuba Recovery (6.0-oz can) 340 kcal/can 1.75kcal/mL‡ Tra, Sep, Sx
B
Hills n/d (canine 14.75-oz can) 538 kcal/can Tra, Sep, Sx, HP, Neo
p/d (canine 14.75-oz can) 675 kcal/can 0.9 kcal/mL Tra, Sep, Sx, HP
p/d (feline 14.75-oz can) 663 kcal/can 0.9 kcal/mL* Tra, Sep, Sx, HP
a/d (5.5-oz can) 197 kcal/can 1.0 kcal/mL*** Tra, Sep, Sx, HP
k/d (canine 14.25-oz can) 527 kcal/can 0.62 kcal/mL† Kid, Hep, Cv
k/d (feline 14.25-oz can) 584 kcal/can 0.90 kcal/mL† Kid, Hep, Cv
h/d (canine & feline 14.25-oz) 506 kcal/can Cv
u/d (canine 14.75-oz can) 593 kcal/can 0.66 kcal/mL† Uro, Kid, Hep
c/d (feline 5.5-oz can) 162 kcal/can 0.62 kcal/mL† Uro, Gi
i/d (canine 14.5-oz can) 544 kcal/can 0.57 kcal/mL† Gi, Pan
l/d (canine 14.75-oz can) 534 kcal/can Hep
l/d (feline 5.5-oz can) 164 kcal/can Hep
Purina CV (canine 12.5-oz can)C 638 kcal/can Cv, HP, Tra, Sx
CV(feline 5.5-oz can) 223 kcal/can Cv, HP, Tra, Sx
NF (canine 12.5-oz can) 500 kcal/can Kid, Hep, Cv
NF (feline 5.5-oz can) 234 kcal/can Kid, Hep, Cv
EN(canine 12.5-oz can) 424 kcal/can Gi, Hep§, Pan
EN(feline 1.5-oz pouch) 117 kcal/can Gi, Hep§, Pan
CliniCare (canine 8-oz can)D 237 kcal/can 1.0 kcal/mL 340 mOsm/kg
CliniCare RF (feline 8-oz can) 237 kcal/can 1.0 kcal/mL 368 mOsm/kg
E
Ensure (8-oz can) 355 kcal/can 1.5 kcal/mL
F
Jevity (8-oz can) 250 kcal/can 1.06 kcal/mL 310 mOsm/kg
Osmolite HN 355 kcal/can 1.06 kcal/mL 310 mOsm/kg
Vital HN 355 kcal/can 1.0 kcal/mL 460 mOsm/kg
Vivonex HNG 355 kcal/can 1.0 kcal/mL 810 mOsm/kg
*blenderized 1/2 can 170 mL water.
†blenderized 1/2 can 284 mL water.
‡mix well 1 can 32 mL water.
Abbreviations: Trauma Tra; Sepsis Sep; Surgery Sx; Hypoproteinemia HP; Neoplasia Neo; Kidney Kid; Hepatic Hep; Hep§ (not
associated with signs of encephalopathy); Cardiovascular Cv; Urogenital Uro; Gastrointestinal Gi; Pancreatitis Pan
A. Iams Company, Dayton, OH
B. Hill’s Pet Products, Topeka KS
C. Purina, St. Louis, MO
D. Abbott Laboratories, Chicago, IL
E. Abbott Laboratories, Columbus, OH
F. Ross Laboratories
G. Norwich-Eaton Pharmaceuticals.
should be used with extreme caution in cats because of their store homeostasis in patients with acute or chronic renal fail-
27
nutritional inadequacy. ure.
Specific dietary considerations for nutritional support in an-
Selection of Diet for Special Situations imals with renal failure include controlling dietary protein,
Certain medical conditions may benefit from dietary therapy phosphorous, calcium, and sodium intake, maintaining serum
28
that is somewhat altered from general feeding recommenda- potassium,andpreventingmetabolicacidosis. Dogswithnat-
tions. Animals with renal disease, gastrointestinal disorders, urally occurring chronic renal failure were evaluated for clini-
pancreatitis,hepaticdisease,orneoplasiacanbenefitfromdiets cal response to a diet specifically formulated to meet the above
that are specifically tailored for digestive and metabolic abnor- requirements. Dogs were separated into two groups, with one
malities caused by or associated with the underlying medical group consuming a balanced adult maintenance-type diet, and
®
21-24 the other group consuming a renal food (Prescription Diet
disorder. When enteral feeding is required for medical ®
management of individuals with these diseases, the following Canine k/d , Hill’s Pet Nutrition). The group consuming the
special considerations can provide a guideline for diet selec- renal food experienced fewer uremic crises and were less likely
tion. to die of renal failure than the control group over a 24-month
period.21 This study is in agreement with previous studies that
Renal failure documented the importance of protein restriction in the long-
term medical management of renal failure. Advantages of diets
Normalrenalfunctionsincludeexcretionofnitrogenouswaste specificallyformulatedforrenaldiseaseincludeameliorationof
products, regulation of acid–base and electrolyte status, stim- clinical signs of uremia, restriction of dietary phosphorous to
ulation of erythropoiesis, and regulation of calcium homeosta- minimize renal secondary hyperparathyroidism, reduction of
25
sis. Varying degrees of renal failure result in impairment of acid production by the kidneys, and delay of end-stage renal
28
one or more of these functions. Appropriate diet therapy can failure. There are a variety of commercially available canned
both ameliorate clinical signs of uremia and electrolyte imbal- and dry renal diets for dogs and cats that can be adapted for
21,26
ance, and delay the inevitable progression of renal failure. enteral feeding via esophagostomy or gastrostomy tube (Table
Anorexiaandnauseaoccursecondarytotheprogressiveeffects 4). Renal diets contain significantly reduced protein compared
of uremia and loss of homeostasis. Nutritional support via the withmaintenancediets.Aliquidprotein-restricteddietforcats
enteral or parenteral route provides essential nutrients to re- (AbbotCliniCareRFFeline)issuitableforfeedingviaanaso-
12 KERL AND JOHNSON
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