[00:00:02]Introduction: Welcome to All Cats Considered, a podcast from the Feline Veterinary Medical Association. Here we interview professionals from across the veterinary world and take deep dives into the latest evidence based research, developments, studies and guidelines that improve feline health and well being. We are the home for veterinary professionals seeking to enhance the care of cats through high standards of practice, continuing education and evidence based medicine. In each episode you'll hear interviews with a variety of experts in our field covering a wide range of topics and the latest developments in feline health. We'll share the key points you need to know to improve your patients care. Let's dive in and listen to this week's experts. [00:00:45] Yaiza Gomez Mejias: So with a growing number of veterinary dietary options, recommending a specific diet can be difficult, especially when cats may suffer different diseases simultaneously. So this is a challenge we often experience in small animal practice and up to now there were no specific resources to help us. But Cecilia has recently published this nutritional approach guide and the article explores the nutritional management of cats with multiple health conditions. She details a step by step process to assess nutritional needs and select compatible dietary strategies and she also uses case studies to illustrate the practical application of her suggestions. I really liked the way you combined the existing scientific evidence with a holistic approach and things that you have experienced in practice as well. Could we start with, could you start talking about what are nutrient sensitive diseases and why is nutritional management important for them? [00:01:44] Cecilia Villaverde: First, I also want to say thank you for liking the paper. I would like to thank my co author Marta Herberta as well. This was really tricky to write. This is such a wide topic. To answer your question about nutrient sensitive diseases, are those diseases where dietary therapy is part of the overall management of the case? So in this case you would be using diet as some sort of medication or part of the therapy? Right. So the role of diet in non transensitive diseases varies. It can be like central, like for chronic kidney disease, or it can have more of a supportive role. It's not that non, it's not that it's not important to consider dieting non nutrient sensitive, but the diet itself is less critical. Like if I have a cat with Cushing's disease, I just want the diet to be complete and balanced and fed it enough amounts. But I don't have to give specific nutrient modifications. Right. So when we talk about nutrient sensitive diseases, we're talking about those where we make some changes. You know, we use a diet with specific modifications that can help either with quality of life or survival. [00:02:55] Yaiza Gomez Mejias: And why is nutritional assessment so crucial for cats with comorbidities thanks for this question. [00:03:03] Cecilia Villaverde: Nutritional assessment is always important, but it's particularly critical when we have a cat with multiple conditions because they are all different cats with comorbidities. Every cat is its own universe. Right. And all diseases, even though we call them one name, will present differently. Right. With different clinical signs, with different laboratory abnormalities. So we need to identify all of those things. Of course, during your workup, but also in your nutritional assessment, you're going to identify which systems are more affected. What are the risks for malnutrition? Individual for each case. Is my body condition score good? Do I have time to play around and try different diets or am I more in a rush if it's a very thin animal? So do your nutritional assessment, your advanced nutritional assessment, and you can have more information on that on the WSAVA Global Nutrition Committee website to get some tools. I think they are also cited in the article as well. [00:04:00] Yaiza Gomez Mejias: Yes, they are. Yeah. And I find them really, really helpful. In the article, you mentioned how valuable the physical examination and a good history taking is. Can you name a few risk factors we may identify once we chat with the owners and examine the cat that may indicate a need for nutritional adjustments? [00:04:21] Cecilia Villaverde: Yes. So, for example, in the physical exam, your body condition score and your muscle condition score would be very important. They are geared towards sort of estimating body composition of the cat, both the fat deposits and also the muscle mass. Right. And definitely abnormal BCS and body condition score and abnormal muscle condition score will be risk factors not always modifiable by diet, like when an animal is underweight or overweight. Definitely calories play a big role when a cat is muscle wasted. Diet can be supportive, but it won't always solve the problem because the reasons for muscle wasting are multiple. It can be due to disease, to aging, et cetera, but definitely warrants intervention. Right. So those would be ones on the physical exam, of course, the weight, not. Not so much the weight alone, but the weight history or the weight evolution that you can catch any changes in the wrong direction quickly enough. And also on the history, I would say doing a good diet history is very important. And that's probably really hard because you need a lot of time to do that. Right. Getting details on the food intake. Okay. In the. During the history taking, it's very important to pay particular attention to the diet history. Right. And to figure out not only what the cat is eating, but also how it's eating that food. Make sure you include treats and any other items because for a lot of cats that have multiple diseases and you have to balance so many balls. Right. It's important that you know where you are right now. So when I do a good diet history, I can get what's the calorie intake right now? Where is my protein intake or my phosphorus intake? And the nutrients of interest are gonna vary depending on your combo of diseases. But when you have a baseline, then it makes it much easier to choose the diet because you have goals from that baseline, if that makes any sense. [00:06:20] Yaiza Gomez Mejias: Yeah, yeah, definitely. Yeah. I find the advice you've given is so clear in the article. It's so cool. I wish I had had this article available when I was studying nutrition because it's always consumed so much time. [00:06:35] Cecilia Villaverde: It is hard. [00:06:36] Yaiza Gomez Mejias: Yeah, it is hard. [00:06:38] Cecilia Villaverde: And as you said at the beginning, there's so many options out there. And that's a good thing, right? Having choices is always good, but it can be paralyzing sometimes. [00:06:47] Yaiza Gomez Mejias: Could you tell the audience the main components of a feeding plan that you mentioned in the article? Especially those in nutrient sensitive diseases. [00:07:01] Cecilia Villaverde: A feeding plan is always going to be answering the three questions, right? What do I feed, how much do I feed, and how do I feed it? Right. So usually when we have a cat with multiple diseases, what do I feed? Diet choice is gonna be the tricky one, right? But you also have to decide how much of that diet you'll have to feed to maintain a good body weight and body condition. And also how are you gonna provide that, like free feeding, portion control, using toys, however you decide it's best for that particular individual. Right. When you have to decide on a diet for your feeding plan and you have multiple diseases, then. And what I put on the. On the article was sort of a step by step approach. So first you do your nutritional assessment to figure out what you're dealing with, what's your baseline? And then you would do your wish list. So what do I want? [00:07:56] Yaiza Gomez Mejias: Right. [00:07:56] Cecilia Villaverde: This cat has kidney disease and diabetes and adverse food reactions. So for each condition, you write what you want. You can also do that for the life stage. Right? Okay. This is a senior cat that's kind of thin. So I want this, this and that, or this is a growing kitten. So you would make all of those lists. And then after having your list of wishes or what you really want, you would check how compatible those wishes or those goals are. Sometimes they will be fully compatible, sometimes they will be partially compatible, sometimes they will be incompatible. Like an example of incompatibility is diets that we use for weight loss compared to diets for chronic kidney disease. They're as incompatible as can be, for example. So depending on compatibility, you are going to be able to make like a reasoned decision on, okay, I'm going to use this diet much easier if the diseases are fully compatible. Of course, if they're not compatible, then you have to prioritize according to quality of life, according to survival risk. Even in incompatible or partially compatible situations. All diets are different. Right. Not all kidney diets are the same, not all diabetic diets are the same. Ideally, you would be able to navigate those different brands to choose the one that will be the most adequate for your patient. And for that, it's very important that you obtain the nutritional information from the manufacturers. So that was a long answer. [00:09:20] Yaiza Gomez Mejias: Yeah. But very, very helpful. And I love the concept of the wish list. It shows you how important it is to know what you want. [00:09:30] Cecilia Villaverde: Yes, yes. It sometimes is very easy to say, oh, kidney, kidney diet, liver diet. It's not always like that. Right. Like you need to be specific, like, what do I want specifically for each condition? And that's a really good intellectual exercise, I think as well. And then you will see that a lot of diets that you wouldn't think might work for this maybe could for this particular case. [00:09:51] Yaiza Gomez Mejias: Yeah, it is an interesting intellectual exercise, but sometimes it's difficult when you're, when you're dealing with the multitasking as you do in general practice, having a clear idea of what you, what you're meant to want. And these lists that you, these examples that you've used in the article are really, really helpful. Thank you again. [00:10:10] Cecilia Villaverde: No, it's also complicated because label information is not very complete or in the right unit. So you kind of have, do some digging to figure out the nutrient information that you want in the right units. So if you have someone in your practice who is math inclined or nutrition inclined, it's good for, for that person to keep diet information up to date for everyone in the clinic and to help out with that for sure. Like, not everybody likes numbers. [00:10:36] Yaiza Gomez Mejias: No. And you made it really easy because you included the mathematical, the operation, like the, the maths. [00:10:43] Cecilia Villaverde: Yeah, nutrition shouldn't be that hard. So I mean, it's was great, was good. [00:10:49] Yaiza Gomez Mejias: So my next question is how do commercial and homemade diets compare for cats with complex needs? I thought we would mention here the JFMS article about commercial versus homemade diets as well. It wasn't so called like that, but maybe we could link it in the podcast. But yeah, the question. [00:11:09] Cecilia Villaverde: I wrote that with Dr. Chandler. [00:11:11] Yaiza Gomez Mejias: Yeah, exactly. I think we should link it to these episodes because I think people would be interested in having taking a look at that as well. And so, yeah, the question was how do commercial and how my diets compare for cats with complex needs. [00:11:25] Cecilia Villaverde: Yeah. So thanks for mentioning that paper. Like, if anybody needs more information, we really spend a lot of time there talking about pros and cons of each approach. I would say commercial tends to be my preference. Just because it's cooking for your pet can be really tough. Like it's a lot of time, effort and also economic resources to buy your ingredients having proper storage. It's a lot of time that you're going to be taking out of maybe playing with your cat or getting yourself some rest. So it's a big investment, I think, in time and mental effort. But I would say with a homemade diet you have a bit more flexibility. Right. So let's say that we have some diseases that are theoretically compatible, like all my nutrient goals. None of them are opposing each other. However, there's no commercial options out there. So then a homemade diet would be a great choice. That said, some companies are stepping up and we are now getting diets that are geared towards multiple conditions. So one of the main reasons I get asked to do homemade diets in the past was kidney disease and food allergies, for example, because all of the kidney diets in the market were using common ingredients. Right. So if you had a cat with a food allergy and kidney disease commercial options, none of them were great. Like, you would have to choose one or the other and then make some compromises. So with a homemade diet, you would be able to choose ingredients that are novel to the patient, but also modified for the kidney disease, for example. Right. But now we have some choices that are adequate for both. And some companies do have diets geared towards multiple diseases, or they may be geared towards one, but they have a secondary claim. Like a lot of feline diets have urinary claims, even though they're not urinary diet. So I would say a homemade diet would be your best choice. If nothing commercially is available or nothing that's available commercially, the cat will eat. That said, some cats don't like homemade diets, to be fair, and they really prefer their dry food or their wet food. So again, it's gonna be a case by case basis. But my recommendation would be try to find something commercial. Nothing really fits. You can consult a veterinary nutrition specialist to help you do a homemade diet that's fully customized to that gut. In those cases, something that you find on the Internet or in a book is not gonna be that helpful. Right. Because you wanna address the particular gut needs, not a generic cat that exists online. Right. I would say that's a good summary. Choosing between commercial and homemade. [00:14:04] Yaiza Gomez Mejias: Yeah, I love the approach to write the article in that respect because you take into account the individual particularities of each cat and also you keep it very realistic in terms of the cat. [00:14:18] Cecilia Villaverde: Yeah. Some people just cannot dedicate their time to home cooking. And there's nothing wrong with that. That's like everybody has a life and every cat has a preference or multiple preference. So you, if you don't adjust to that, your dietary recommendation is not going to work because they're not going to use it. So it's good to be very pragmatic in here, I think. [00:14:39] Yaiza Gomez Mejias: Yeah. And people get really stressed with the. When the pet doesn't, doesn't eat. Like I had a client yesterday who ran them like, no, you didn't. We're the second, the second day of the dietary transition. What can we do to make the transition a little bit more bearable? And actually that's one of the questions I wanted to ask you. You usually say, right, let's make a five days transition period. And then you assume that the client is going to do it. But if it doesn't happen because the cat doesn't want to in five days, what tips have you got to help in this? [00:15:17] Cecilia Villaverde: I mean, you know, cats, cats are going to cat. And I mean, I have two cats and if they don't eat, I also freak out. Even though my intellectual side of me is like, don't freak out. So I would say sometimes five to seven days, which is my usual recommendation for dogs, doesn't really apply to cats. For some cats you just sometimes have to go slower and some cats really like the new one for a few days and then they stop eating it and then people freak out. So I would say the slowest the better. Like first try to identify what's driving this catch cat. Like, especially if you know the current diet. Like if they're eating currently, they're eating wet, I'm gonna try to find something wet as well. Right. Or for example, my cats like the chunks. Some cats like the mousse. So if you can get close to that texture that they prefer. And then if it has to take a month, it has to take a month. Like most of the dietary recommendations we give are forever or for a very long term. So I would say sounds like trite, but it's, it's not a speed race. It's like a long distance race. So if it has to take a month, then it takes a month. Putting in the different dishes, putting in toys. So it's fun, like making the experience as pleasurable as possible and especially try to take the pressure out from the caregivers. Right. Like, oh, I know this guy should be eating this diet and I'm not doing it and I'm feeling really stressed out. Right. Let's all relax, take a step back. We're going to do what's best. And sometimes, like if the cat won't eat the diet that you think it's best, then you go for second best. Like compromising is part of life. And I've had patients where definitely you have to prioritize one disease over the other just because the patient won't eat. So you can also, sometimes for diet transitions, you can use something like mirtazapine, especially at the beginning to get them to eat it. And then when they get used to eating it, then you can retire the medication. My main advice is don't rush. Don't rush. There's things we can do to make it easier, there's options, and especially take that pressure off of your clients that they're already stressed enough. [00:17:23] Yaiza Gomez Mejias: Thank you. Thank you for the advice. It's very reassuring because I think I was going in that direction. I guess what we have to make sure ensure is that we follow up the case and we ensure that over time we manage to get there without pressure. [00:17:40] Cecilia Villaverde: But I'm going to, I'm going to tell you one thing. Like I, I do a lot of cases remotely where I get information from the vet and information from the client and the amount of times where the medication list don't match up, where the diet doesn't match up. It's scary. Like, scary scary. Like the vet is convinced that they're giving this medication, giving this diet and then I get the information from the client and nope, they're giving something. So, but they, it's not that they're lying. Like they're telling it to me. Like, it's, it's just things have changed and you need to be proactive in the follow up. You're making a very good point that you just need to be on top of it. Like check, check in with messages, with email. However, your clinic checks in because as you said, you get really nervous if they don't eat, then you might change things and then, yeah, it's absolutely normal and you won't always know. So it's important that we ask. Yeah. [00:18:37] Yaiza Gomez Mejias: And then we look after the animal, but the first person who looks after the animal is a caregiver. One interesting thing that I used to find really difficult when I studied nutrition at the uni and when I came across this topic in your article, I found it extremely easy to understand. So thank you again. Why is it important to compare nutrient content on a calorie basis rather than an as fat basis? [00:19:05] Cecilia Villaverde: Yes, I mean, the short answer to that is that as fat, it has a lot of confounding factors, right? But ect, as fat is grams of nutrient or milligrams per 100 grams of food or per kilo of food. So as fat information is very useful if I want to know how many grams of something a cat is eating. Right. But when I want to compare different diets that have different moisture content or different energy density, that's not really helpful because, for example, wet foods, when you look at protein fat percentage, they're going to be 9%, 6%, they look super low, but when you remove the water from the equation, they're much higher. Right. So you cannot really use as fat to directly compare, even when you're comparing wet diet or dry diet just because their energy density is different. So the cat is going to eat more or less depending on how calorie dense a food is. So when you compare on a calorie basis, this is super individualized for the cat. And you can compare diets all over the board because you're already taking into account how much of that food that cat is going to be eating. So you can ask veterinary diets, the manufacturers should have that information. So you should ask your representatives from the different companies that you use to provide the nutritional information of their veterinary diets on a calorie basis. And this will allow you to easily compare different diets, not get confused, especially I would say, to caregivers, let them know, like I've had cases where I want to recommend a low fat diet, for example, and then they find a wet diet that looks very low, but then in reality so much higher. Because remember, a wet diet, you have to eat almost four times as much from a dry diet to meet your calorie needs. Right? So it's important for us, but it's also important that we tell our clients the caregivers that label information as fed information is going to be misleading so that they shouldn't be making decisions based on that. I think sometimes it's tricky to get into that sort of modification of the data so we can compare it, but once you do it, then it's really easy because you can compare all different foods, different brands compared to the requirement without having to do anything else. [00:21:18] Yaiza Gomez Mejias: Yeah, once you understand it, it's kind of missed that. [00:21:22] Cecilia Villaverde: Yeah, it's just, it's just hard with the way nutrition information is presented. Like as fed is the regulatory obligation. Some companies might present it dry matter, some companies present it for a thousand calories, some per 100 calories, some per mega joule. So I wish we were a bit more homogeneous and how we present nutritional information and that would be less work for everybody. But we just need to choose one way and be consistent. [00:21:51] Yaiza Gomez Mejias: And a last question before we finish. Why is it that it's generally not recommended to mix two different commercial therapeutic diets? [00:22:01] Cecilia Villaverde: I would say sometimes you can mix them, but a lot of the times it's not going to be helpful. Like, oh, if I have a patient with obesity and kidney disease, I'm just going to give half of a weight loss diet and half of a kidney diet. In that case, basically, instead of adding up the benefits, you're just diluting them. Right. So if I mix a high protein diet for weight loss and a moderate protein diet for kidney disease, I end up with an average protein diet. This is not gonna be phosphorus restricted, but the calorie density is also not gonna be that diluted. Right. Because you're adding a high calorie diet in there. So you're not gonna get the benefit for either disease. So I would say we need to consider this on a case by case basis. But I rather try to find one that works for all. Sometimes I have mixed. I would say the main reason I have mixed diet is when I want to adjust a fiber amount. Some fiber responsive diseases, maybe they need less fiber than the fiber enriched diet and too much fiber might be too much poop. And that's a lot of cleaning of the liter tray. So sometimes mixing a high fiber diet with an average diet, you can get the right. But in many cases you're just gonna lose the benefits of both when you mix two diets. So I would say it's probably a good idea not to do it as a rule. And then in a case by case basis, maybe you can find a situation where that would be helpful. But it's, I would say most in my, in my experience, most of the times that we mix diet, we're just not getting any of our wishes. [00:23:36] Yaiza Gomez Mejias: All right, well, thank you very much, Ceci, for your time and for writing this amazing article. I hope this episode encourages people to read it. [00:23:50] Cecilia Villaverde: I hope so. It was really hard to write, so I hope it's useful for clinics out there and veterinary healthcare teams. [00:23:58] Conclusion: Thank you for listening to this episode of All Cats Considered. We hope you enjoyed this interview. For more information on the topics discussed in this episode, please head over to catvets.com podcasts and explore the links in the show Notes. Don't forget to subscribe to this podcast on your platform of choice so you won't miss any episodes as we release them. Have thoughts or ideas about the interview you heard today? Share them with us by leaving a comment on our Facebook page or shoot us an [email protected] thank you again for joining. Joining us today.