Clinician's Forum: Expert Views from a Cross-Specialty Panel on Therapeutic Diets for Adverse Food Reactions

ArticleOctober 202229 min readPeer ReviewedSponsored

Sponsored by an educational grant from Blue Buffalo


Participants
  • Nolan Frantz,* PhD, Nutrition Technology Group, Blue Buffalo

  • Alice Jeromin, BS (Pharmacy), DVM, DACVD, Consultant, Veterinary Allergy & Dermatology

  • Donna Raditic, DVM, DACVIM (Nutrition), CVA, Nutrition and Integrative Medicine Consultants

  • Adam Rudinsky, DVM, MS, DACVIM, The Ohio State University

Moderator
  • Leighann Daristotle,* DVM, PhD, Professional Services Veterinarian, Blue Buffalo

* Dr. Daristotle and Dr. Frantz are Blue Buffalo employees.


KEY TAKEAWAYS

  • Food-responsive diseases are collectively referred to as adverse food reactions, which include food allergies and food intolerances.1 These diseases often manifest with dermatologic or GI signs.

  • Therapeutic diets can play a key role in both the diagnosis and management of adverse food reactions.

  • Both limited-ingredient diets and hydrolyzed diets are commonly used for the diagnosis and management of adverse food reactions. Neither diet has been shown to be preferred for all situations; the type of diet should be selected based on individual circumstances.

  • Blue Buffalo carries a line of therapeutic diets that are specially formulated and manufactured with rigorous standards to meet the needs of many pets with adverse food reactions.


Dietary Considerations for Food Allergies & Food Intolerances

Therapeutic diets are used across many veterinary specialties to help diagnose, treat, and manage various diseases, including food-responsive diseases, collectively referred to as adverse food reactions. Adverse food reactions include both food allergies and food intolerances. Food allergies differ mechanistically from food intolerances in that food allergies are an immunologic response to dietary antigens,1 whereas food intolerances are nonimmunologic responses caused by metabolic, pharmacologic, and/or idiosyncratic reactions.1 Although GI signs can be exhibited in both conditions, food intolerances do not present with the dermatologic signs commonly seen with true food allergies.1 Understanding how to effectively use therapeutic diets in the diagnosis and management of these conditions is an important tool in the management of clinical signs for this population of pets and their owners.

Dr. Daristotle: What clinical presentations lead you to suspect adverse food reactions in dogs and cats? What proportion of patients have both dermatologic and GI signs?

Dr. Jeromin: I tend to see food allergies most commonly in young dogs. Otitis externa is commonly seen with adverse food reactions, so ear infections are a common sign.2 These dogs are generally pruritic or erythematous, which can result in pyodermas or recurrent yeast infections. The literature says 38% of food-allergic dogs start showing clinical signs before 1 year of age, but food allergies can start at any age.2,3 When I get a patient with GI signs or a history of GI issues with skin signs, the lightbulb kind of goes off for me; we’re going to consider food allergies, especially if clinical signs are nonseasonal. As for cats, they run their own show. Anything can look like food allergies in a cat—miliary dermatitis, eosinophilic granuloma. I’m not going to jump to psychogenic alopecia right away; I’m going to try to investigate the underlying cause. Is it food allergy and we didn’t do a proper elimination diet trial? The literature says the mean age of onset of clinical signs in cats is 4 to 5 years.1,4 Cats always like to do things a little differently.

Dr. Rudinsky: As far as presentations to the internal medicine service, I normally see patients with diarrhea, vomiting, and weight loss, which are classic GI signs. Once they have any sort of concurrent dermatologic sign, that’s going to raise my concern for food allergy immensely and change how I approach them therapeutically, dietarily, and otherwise. I really emphasize that the dermatologic component can vary—from recurrent ear problems to other classic signs of atopic dermatitis.

Dr. Raditic: It’s wonderful to hear from a dermatologist and an internist. I get patients referred to me from both of those services and also often straight from the general practitioner, often presenting with both dermatologic and gastrointestinal signs. I try to explain that the gut is a tube on the inside, and the skin’s the tube on the outside, so both can be involved in food allergy, and food plays a huge role in the health and well-being of the immune system, as well as the lining of the gut and skin.

Dr. Jeromin: Sometimes on initial presentation, you have an owner who has already diagnosed presumed food allergies in their pet. How many times do you hear, “Oh, I took him off all beef!”? I’d rather have a client who hasn’t done any reading about it or spent $300 on an unreliable IgE serum test for food so I don’t have to break all that down, because once they get that in their head and they get that paper that says what that dog or cat’s allergic to, it’s hard to say, “Sorry, I’m the bad guy here, but all that work you did it, it’s not true.”

Dr. Rudinsky: Especially on the GI side of things. Owners will give their dog half a rotisserie chicken as a treat, and at the end of the day, the dog has a relapse in its GI signs and they want to call it a chicken allergy. Then, all of a sudden, they don’t want to feed anything with chicken in it, which may or may not actually be the problem. We need to start from a clean slate and break down all that information they’re finding online, so much of which is misinformation. People are just inundated with this misinformation, and we’re often behind the starting line.

I try to explain that the gut is a tube on the inside, and the skin’s the tube on the outside, so both can be involved in food allergy.—Dr. Raditic

Dr. Jeromin: Mentioning the chicken, do you think there’s a saturation point, Dr. Rudinsky? For example, some protein-allergic dogs can’t handle even a smidge of allergen, but do you think there’s some that can handle so much and then beyond that they react?

Dr. Rudinsky: From a GI standpoint, I would say it’s a very small segment of our chronic GI patients that are actually food-allergic. I think those dogs and cats that have food intolerances, where it’s more chemically based rather than immunologically based, you probably do have this threshold, which is different than with pets that have a true food allergy and may not be able to handle any amount of their given allergen.

Dr. Raditic: We have to think about absolutely everything that goes on them and in their mouth. Anything and everything—all the chews, treats, rawhides, the flea, tick, heartworm preventives. Even if they’re more primary GI chronic enteropathy, I use the word food allergy for them, and I do that because people recognize that term. Pet owners recognize if someone is allergic to peanuts and eats a peanut, that person goes to the hospital. We go ahead and get them on a diet and give them that strict time period during which their clinical signs will hopefully resolve. Once that has happened and they’re in a stable place, we make 1 change at a time. I will usually start with a fruit or vegetable; we’ll try a carrot and give that for a week. As far as commercial treats, if there’s contamination with other ingredients that can occur—which is perfectly legal for over-the-counter diets—I usually explain that treats have even less quality control. So, the contamination factor there is going to be too high, so usually, I am using 1 thing at a time, 1 change at a time, and what we want to do is give that a good week, then we can check it off and just go through that very slow process of trying to build a few treats that they can comfortably give. It’s important to reinforce the message that their dog is special and needs to avoid their allergens at all costs. Every relapse is more damage to the skin surface, more damage to the gut lining, and it’s going to make it more difficult to get them stable again and back on track.

Dr. Rudinsky: I think getting a core list of things owners want to feed can also be helpful. The other thing that I’ve had a lot of success with is having clients bake the canned food to use as treats. For example, if I’m prescribing Blue Buffalo HF Hydrolyzed for Food Intolerance, the owner can buy a case of that canned food to go along with the dry diet. When you turn it into a cookie by slicing it into rounds and baking it, owners feel like it’s a nice activity that can bond them to their dog and allow for that treat reward system they are likely used to.

Dr. Daristotle: Dr. Frantz, regarding formulation and manufacturing, what makes these foods that are used for elimination trials different from over-the-counter diets?

Dr. Frantz: Obviously, there are a couple different kinds of diets—whether that’s hydrolyzed protein or a truly novel protein, but as we design those foods, we want to limit the number of ingredients as much as possible. The end goal is to have a balanced diet, a complete diet that sustains the animal and doesn’t cause any GI issues or other complications. So, finding protein sources that meet that criteria is important, and as we build those diets, a lot of the things go into the process in terms of what carbohydrate sources we’re using and trying to make a diet that avoids the common allergens as much as possible. There are always animals out there that are allergic to something specific or have some unique restriction, so it’s impossible for every diet to work for every animal, but there are 2 categories that pets often have success with: hydrolyzed diets, meaning the proteins have been hydrolyzed down to the point where the body doesn’t necessarily recognize them in the same sense—so you’re tricking the immune system in a way so they’re not reacting to those proteins—or a novel protein diet, where you’re finding a truly new protein that the animal has not been exposed to and not developed an allergy to. Finding truly novel proteins and really good, high-quality, hydrolyzed proteins is a challenge, especially with the diversity of pet foods these days, given that so many protein sources are available over the counter to the consumer and that pets have potentially already been exposed to. In today’s day and age, that’s a lot of what we struggle with in trying to find unique diets that meet our needs to support this type of animal.

Dr. Raditic: What kind of quality control is used for novel and hydrolyzed diets as far as assuring us that these veterinary therapeutic diets are indeed antigen-free?

Dr. Frantz: It’s not just about selecting a hydrolyzed or novel protein. It’s also about avoiding cross-contamination. The term we like to hear is that they’re making it on a “dedicated line,” but even with a dedicated line, you need to take into account all the upstream controls of raw materials—how the ingredients are being batched together and if a common batching system is being used. You can get a lot of cross-contamination that way. So, with Blue Buffalo’s NP alligator diet, one of the ways we went about it was making not only a hydrolyzed protein diet but also using a more novel protein. We also had to be sure that we didn’t have cross-contamination, so we developed a very detailed program, not only to test the finished products but also the raw materials and to validate our extrusion and canning process, including a strict cleaning protocol. So, we make sure we’re testing at different steps during the process to detect any evidence of cross-contamination. We do this through ELISA testing, which tests for the protein, or PCR testing, which can measure any leftover genetic material and is a very sensitive test. In both cases, you can pick up even very small amounts of contamination. It’s not necessarily possible to test for every possible allergen, but we focused on some of the key ones like chicken and beef. Initially, we tested for a larger set of allergens to see how consistently we would see other common allergens like soy or egg. So, we developed a very robust testing plan that screens raw materials for some of the other common animal proteins, then we test the finished product, so the food goes through a rigorous process to ensure the product’s not going to have a contamination issue. We learned a lot while developing our program and routine testing protocols; when you test every single lot of product you make, you’re going to find some contamination, and then you reject that product and keep it from going on the shelves. The last thing we want to do is have a therapeutic diet that doesn’t do what it’s supposed to do. Our goal is to make the owners’ and veterinarians’ lives easier with a product they can count on, and that’s really what we try to deliver through this robust testing process.

The last thing we want to do is have a therapeutic diet that doesn’t do what it’s supposed to do. Our goal is to make the owners’ and veterinarians’ lives easier with a product they can count on, and that’s really what we try to deliver through this robust testing process.—Dr. Frantz

Dr. Raditic: I always tell my clients over-the-counter diets are average diets for average healthy dogs and cats. Once you’ve come to an internist, dermatologist, or nutritionist, you probably don’t have the average healthy dog or cat. When you get into veterinary therapeutic diets, they’re made with research, science, knowledge, and quality control. They’re made more like medicine. Dr. Frantz, are there other benefits to these diets? Other nutrients and functional ingredients to help these patients?

Dr. Frantz: Yes, absolutely. Unique fiber profiles that really help nourish the microbiome, including the right prebiotic fibers to help those good bacteria thrive, are developed. A lot of our formulas have a decent amount of either fish oil or DHA and EPA that come from those products that can help reduce inflammation and help with some skin and coat issues. There’s a lot of technology built into these diets, and we also understand that these diets are often being used in pets that are having an immunologic response to their diet. We will have additional antioxidants and a higher level of vitamin E and C to help support that immune response.

Dr. Raditic: Compared to over-the-counter diets, veterinary therapeutic diets provide so much detailed nutritional information that’s at your fingertips; we can reach out directly to these companies, we have product guides and input from PhD animal nutritionists. So, the quality control—the idea that these diets have added functional ingredients to try to balance that inflammatory response5—really sets them apart from over-the-counter diets.

Dr. Daristotle: How do you decide which type of diet to use in a given patient, whether it’s novel protein or hydrolyzed?

Dr. Rudinsky: We have no comparative studies that really provide guidance on which type of diet to choose. When I’m going to be picking either a hydrolyzed diet or a limited-antigen diet, there are a few things I take into account, and once again, these are presented with GI signs. Hydrolyzed diets tend to be more easily digestible than their parent protein source, as hydrolysis is the basic biochemical breakdown of macronutrients, which I think can benefit a lot of proximal GI cases. A vomiting cat may do really well on Blue Buffalo HF, for example, whereas the novel-ingredient diets tend to be a little bit higher in fiber content, and I like those more for my patients with large-bowel signs. The Comparative Gastroenterology Society did an informal, unpublished poll of who chooses hydrolyzed as their first-line and who chooses novel protein, and it was a 60/40 split, so people have their preferences, and these may vary based on clinical signs, but there’s clearly no single agreed-upon choice for every patient.

Dr. Raditic: A lot of clients come to me for homemade diets, and sometimes, when they realize what it takes to make a homemade diet, as far as time and trying to ensure it’s complete and balanced, we will wind up discussing therapeutic diets. I tend to use hydrolyzed diets because often there are so many proteins that my patients have already been exposed to, which complicates identifying a novel protein for that patient. Finding something truly novel gets more and more difficult for our patients, given the wide range of proteins found in commercial diets these days.

Dr. Jeromin: As far as what diet I would pick for a cat, oftentimes it’s whatever we can get the cat to eat! We send owners home with what we call a “kitty buffet,” with 2 cans of each type of elimination diet and a Ziploc bag of the dry food, and I tell them to call me to tell me which one he likes.

Dr. Daristotle: If the pet’s still growing, how should we approach diet selection for a diet trial or putting them on a therapeutic diet?

Dr. Raditic: It depends on how young the dog is and the breed, because small breeds mature more quickly. Oftentimes, I’ll either look at the AAFCO statement in the product guide and see if the diet is AAFCO-certified for growth. But it’s also easy to just pick up the phone and ask somebody at the company, “Would my 9-month, large-breed dog be okay on this diet?” If there is something missing, they’ll be the first to tell you, and sometimes adding supplemental ingredients to that diet is an option.

Dr. Frantz: That’s one of the unique things we did with our novel-protein diets. They’re actually formulated for all life stages. One of the unique differences between a hydrolyzed protein and a regular protein is those hydrolyzed proteins tend to be more free of ash or bone content, so they’re lower in minerals, and that’s a good thing for digestibility and adult animals, but when it comes to puppies or kittens, they’re going to need a little bit more calcium and phosphorus. So, with novel protein diets, you’re going to get a little bit more of that. And for those who like to be interactive, pet owners—at the guidance of a veterinarian or nutritionist—can always add some supplements with some of the hydrolyzed foods to make it work.

Dr. Jeromin: Dr. Rudinsky, as an internist, are you seeing many patients younger than 1 year that are food-allergic with GI signs?

Dr. Rudinsky: Yes. I think we see both food intolerance and food allergy patients that are pretty young. What’s interesting about our GI cases, as opposed to a lot of medicine ailments, is it’s across age groups—from immature animals up until the 18-year-old cat with chronic diarrhea. That being said, I do think we’re seeing more food allergies in younger pets. I see more of them with those concurrent dermatologic signs, and we’re seeing dogs coming in earlier and earlier.

Dr. Jeromin: When diagnosing these conditions in young patients, I love for all of my atopic patients to be on an elimination diet for life, because there are some studies showing it keeps their atopic flareups down.6,7 I tell that to the owner, and usually by the time they get to the specialist, they’re going to do as they’re told because they’ve been through a lot. I say, “Let food be thy medicine and medicine be thy food.” If I can control many clinical signs with food, I don’t have to use drugs, and they like that, as do I.

When diagnosing these conditions in young patients, I love for all of my atopic patients to be on an elimination diet for life, because there are some studies showing it keeps their atopic flareups down.—Dr. Jeromin

Dr. Raditic: When it comes to keeping a pet on a therapeutic diet long-term, I communicate to the owner that, by the time they get all the diagnostic testing done, as well as various medical therapeutics and everything that goes into symptomatically treating these flareups, versus buying the best food possible and reducing clinical signs, it makes sense to put your money into these diets.

Dr. Rudinsky: As we talk about younger patients’ GI signs from food intolerances, I think stress is another factor to consider. I do think that, in young dogs that are anxious, irritable bowel syndrome-type symptomology is common and definitely skews toward some of those younger patients that maybe weren’t well socialized or have more generalized behavioral disorders. I think it may be more common now because of the COVID pandemic, but I also think there’s increased clinician awareness. In terms of COVID, dogs weren’t going into social settings as often, and I do take that into account when I see patients with these signs. For young dogs with GI signs consistent with IBS, fiber has been shown to potentially be beneficial as well, so this can be something to try before considering other food trials.

Dr. Frantz: That’s what we have to try to get across to pet owners; with therapeutic diets, we’re really trying to make their lives easier. We’ve done the research so they don’t have to worry about trying to find a balanced diet that will work for their pet.

Dr. Rudinsky: When I’m making a diet recommendation to a reluctant client, I have them compare the cost of that diet to any pharmaceutical I use, with maybe the exception of prednisone. Medications like budesonide or cyclosporine are all going to be infinitely more expensive than the cost difference between a commercially available pet food and a veterinary therapeutic diet.

Dr. Daristotle: What are the benefits of fiber for the gut and the immune system?

Dr. Frantz: I think fiber has become much more of a hot topic in the past decade. I think the old theory was to make a diet as highly digestible as possible, which entailed extremely low ash and fiber. That was the old adage, I think, but since then, we’ve learned a lot more about probiotics, prebiotic fibers, and even postbiotics, which we can use to influence the gut. The easiest and most cost-effective way to do that is with the right fiber sources. We know that a lot of our immune system is in the gut; it’s impacted by the health and stability of what we reference as the microbiome now, and you see a lot of research around the microbiome and trying to figure out how to manipulate it. Any diet change will disturb that environment, so knowing what a diet will do and being on something consistent can really help avoid any unwanted shifts in that microbiome. That’s one of the points we’ve emphasized in our products—the importance of fiber. It’s not just about treating a GI disease or whatever. We do that in our puppy foods or kitten foods to try to get that right balance of digestibility and beneficial fibers.

Dr. Raditic: There has been a shift in focus from probiotics to prebiotics. What do we know about fiber, a prebiotic? Let’s play with fiber because we probably statistically have a better chance of creating a healthy GI microbial population and immune response by doing that.

Dr. Rudinsky: We just completed a study on acute diarrhea that will be published later in JAVMA. It showed that psyllium-enhanced, fiber-based diets outperform metronidazole for resolution of clinical signs without any of the deleterious effects of metronidazole. When we looked at the microbiome and metabolome of these dogs, including the dysbiosis index, secondary bile acids, and short-chain fatty acids, these dogs were much closer to being back toward normal values a month out from that diarrhea episode when they were treated with fiber as compared with metronidazole. How many times have we seen someone say, “Add some canned pumpkin”? We should consider instead turning to a therapeutic fiber-enhanced diet, because it’s nearly impossible to add enough canned pumpkin to an existing diet to get a therapeutic benefit. So, it’s nice to see companies like Blue Buffalo investing in fiber because it’s so impactful, and a manufactured diet is probably the best way to deliver it.

It’s nice to see pet food companies like Blue Buffalo investing in fiber because it’s so impactful, and a manufactured diet is probably the best way to deliver it.—Dr. Rudinsky

Dr. Frantz: It’s not just about any one given fiber source, right? It’s a blend of fibers, and that can be beneficial, too. Then, with more novel fibers, some fruits and vegetables, they can bring some antioxidants along with it that have a potential benefit, too, so we find that a nice mix of both soluble and insoluble fiber can really have benefits and perform nicely.

Dr. Daristotle: When we think about diet trials for dermatologic diseases versus for GI diseases, are they the same? How do they differ?

Dr. Jeromin: As a dermatologist, I usually do a full 8 to 10 weeks on a diet trial. We also take a week to wean onto the new diet. We don’t abruptly change their food. I explain that the dog may get diarrhea or soft stool if they switch abruptly. We explain that, once they’re weaned over, they can eat nothing else for the duration of the trial. We check in with them every 2 weeks. I think the studies show that 90% of food-allergic patients will show improvement within an 8-week diet trial.8 With cats, anecdotally, it seems to me you will often know if a food trial is effective in a shorter period of time than dogs, but we still have them go the full 8 weeks.

Dr. Rudinsky: For young dogs with concurrent dermatologic and GI signs, I have the same approach. Where I differ is with pets that have suspected food intolerance, as they can display a robust response after only 2 weeks on a food trial. Depending on the clinical signs we’re treating, pets with food intolerances rather than food allergies will usually respond within 5 to 10 days. Cats often respond really dramatically within just a few days. Vomiting cats have been reported to respond within 24 to 72 hours in a lot of cases,9 so there’s a little bit more immediate gratification in those cases. A lot of my patients are presented with diarrhea, so for those, I usually don’t worry about a tapered food switch.

Dr. Raditic: As a nutritionist, I get a mix of those patients; usually, they have both skin and GI signs. I put them in what I call the “food bubble” and explain that this diet is the only thing they can consume during the food trial. I also make sure we look at the parasite preventives being used. We go through all the medications and supplements to make sure a pet isn’t inadvertently being exposed to an allergen through a flavoring.

Dr. Jeromin: And again, all of these conversations are time-consuming; we spend a lot of time with these clients educating and reeducating.

Dr. Daristotle: Do you have any tips on feeding a multi-pet household and how to make sure the pet being treated is getting the food and that you can monitor how much they’re getting?

Dr. Jeromin: Challenges certainly arise with food trials. For example, you have toddlers who like to drop table scraps and multi-pet households where separating the pets is challenging. For a multi-pet household, if there’s no reason not to, I like them to feed all the pets the same thing. Inevitably, you will have pets licking each other’s bowls or will struggle to feed them separately. I just think it’s easier if they can put them all on the food trial diet. You may get complaints on the cost, but as we discussed, it’s still preferable to other options.

Dr. Rudinsky: As an internist, where I don’t have the ability to intervene is in those early husbandry choices that pet owners are making at home. So, if you think about what we manage dietarily—obesity, gastrointestinal disease, dermatologic disease, cardiac disease, urinary disease—it’s very likely that, at some point, every pet is going to receive a targeted dietary recommendation, so that may be an area where general practitioners can set themselves and their clients up for success and discuss getting into the habit of individualized meal feedings for each pet in the early days of pet ownership.

Dr. Raditic: With mutli-pet households, I really do try to get them on the same diet, and oftentimes, once they see one pet start to reap some of the benefits of a therapeutic diet, they will even ask if they can put their other pet on that diet as well.

Dr. Rudinsky: Another thing to consider in multi-animal household is that, oftentimes, whether due to dermatologic signs where the pet is distracted and itching or chronic GI signs that have led to a decreased appetite, the pet you are targeting is often the animal in the household that is more likely to be a picky or reluctant eater. I think with chronic gastroenteropthies, we’re doing a better job at recognizing when we need to implement dietary therapy, but sometimes, we fail to recognize that we still need to use supportive care measures to help transition to a new diet, to control their signs and get them feeling good enough to accept that new diet. I use mirtazapine a lot in my cats for dietary adherence if I’m worried about the transition to a new diet. Once that animal starts feeling better, you can taper off those initial starter drugs, and once they’re eating robustly, you can then have a distinct mealtime. It’s not me sitting next to my dog for 4 hours in the morning trying to get them to eat that prescribed formula.

Dr. Daristotle: What are some of the most common mistakes you’ve seen with diet trials, especially when a patient comes to you with a diet trial that’s already been done?

Dr. Jeromin: In my experience, recommending over-the-counter, limited- ingredient diets is the number one mistake. The other would be running a blood test for food allergies, which doesn’t actually help determine which foods a pet can or cannot tolerate. It’s also common to see too short of a duration for a food trial.

Dr. Rudinsky: I think looking at the nuanced needs of an individual when selecting a food for a diet trial is often overlooked. When I think of GI disease, the criteria I’m usually looking at in a diet for my patients is digestibility, fat content, fiber content, and hydrolyzed versus novel protein or novel ingredients. As we mentioned, there’s not really a clear definitive answer regarding whether hydrolyzed or novel is the better choice, but in a GI case, it’s helpful to consider the whole nutrient profile when choosing a diet. You can argue that putting a dog on a hydrolyzed diet would be a great option from an allergic standpoint, but if you happen to reach for something like a soy-based vegetarian option, it will be extremely low in fiber. So, regardless of what that does for that dog’s allergies, if the dog requires fiber for its GI health, you’re going to have worse GI signs. So, not considering the global perspective of a GI patient I think can sometimes lead diet trials a little bit astray. Plus, if it’s not set up right, you’re going to waste a lot of time as well as fatigue the client. I think that’s so true about diet trials because owners are fatigued when they’ve bought multiple diets. Now they’re finding out that diet wasn’t the right one or maybe wasn’t the best choice. So, getting the client onboard and maybe taking that extra time upfront to do some diet research will make everyone’s life a little easier down the road, including the person who is in first-opinion practice, because they’re seeing 98% of these animals for their follow-up, not the referral center.

Getting the client onboard and maybe taking that extra time upfront to do some diet research will make everyone’s life a little easier down the road, including the person who is in first-opinion practice, because they’re seeing 98% of these animals for their follow-up, not the referral center.—Dr. Rudinsky

Dr. Raditic: I think general practitioners also need to realize that a lot of the serum testing, saliva testing, hair, etc. for food haven’t been validated. These tests are unreliable and should not be used as a diagnostic test for food allergies.10-12 So, if they’ve been to their GP and did that, we have to break down that misconception and start over with a diet trial. Getting that commitment upfront that this is what it’s going to take is important, and we have to follow up continually to see how they are doing. One thing I do to help with the success of my diet trials is give my clients fecal score charts and itch tracker charts where they can rate their pet’s stool consistency and pruritus level daily. So, I get the owners doing something too during this period so they can start to see some numerical trends. I really would encourage general practitioners to give pet owners something like this to do so they can see the progress. Skin improvements and fecal improvements are like watching grass grow, but if we’re charting these signs, then we can actually show them if it’s getting better or worse. I think that type of approach and getting clients more involved so they can feel like they are part of the process is helpful. You form a team, and that client becomes more committed.

Dr. Rudinsky: I think those clinical scoring systems for chronic enteropathy or PLE can be very useful. Those are really nice because often we’ll see a diet trial that gets us 75% of the way there as far as control of clinical signs. And because the pet isn’t perfectly normal, an owner may have a hard time seeing that diet is still impacting their pet, and those scoring sheets provide a little bit of evidence to say, “Well, look at the improvement your dog has seen; maybe vomiting is the most frustrating symptom to you, but the diarrhea has resolved and your pet is putting on weight and we’ve made these improvements.” From a GI standpoint, the fecal scoring is also really helpful because the nature of stool can serve as clues to what you want to tweak dietary-wise. What does the fecal sample look like? What’s the fecal score? How’s the urgency? Where do we need to target in the gut to manage this? Those are all now forms that we have our clients do while they’re checking in. For any practitioner, those are publicly available (see Suggested Reading). You can include it with your intake forms, have an owner fill it out, and all you have to do is put the total score in the patient record. Another thing to keep in mind is that, if a practitioner can’t initially convince the pet owner to start a diet trial and instead we start a corticosteroid or something else, there’s often a tendency to say, “Well, a diet change wasn’t an option,” and if initially the dog’s not eating, then maybe you do need steroids to get it started, but we still need to circle back on diet because that’s still the ultimate goal for long-term maintenance therapy for that animal.

Dr. Jeromin: I agree. I tell them we’re going to try to control their allergic pet completely with food and use meds for flareups, because there will be flareups. Allergies are dynamic, not static. And like Dr. Rudinsky said about achieving 100%, we may not get to 100%, but we’re going to get that pet much more comfortable and then have the ability to treat with medication during those flareups, but we don’t want to keep them on those meds long-term if we don’t have to. We’d rather control the pet’s clinical signs with the food.

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