Sunday, November 7, 2021

Dog Owners Recount DCM Heartbreak in FDA Comment Docket

     September 21, 2021, the FDA CVM hosted a virtual Listening Session on the Oversight of Pet Food. In addition to the live, recorded session of oral presentations, a comment docket was opened for public submissions and closed 11:59PM EST on 10/25/2021.

In total, the docket has 137 published entries. Broken down by topic:

  • ~20 pertain to the use of 4D (dead, dying, diseased, down) meat in pet foods
  • ~12 are on the subject of transparency and access by the public to FDA (and/or AAFCO) meetings
  • ~12 are in regards to various other issues or general opinions of the FDA
  • Nearly 100 are about diet-associated (non-hereditary) dilated cardiomyopathy (DCM)

Of those, a handful are from concerned pet owners, advocates, and veterinary professionals. The vast majority, however, are the heart-wrenching personal stories of affected pet owners and their dogs, including those deceased, those continuing to battle, and those recovered. These pet owners represent only a minuscule fraction of the over 1100 complaints submitted to the FDA (as of 7/20/2020) and yet they are a poignant reminder that this issue is more than data, statistics, research papers, and debates between academia and industry. 

There are real dogs, real people, real families, and such real heartbreak underlying this investigation. Many of them have called on the FDA to take more action towards this issue.

Tuesday, October 19, 2021

What's in a DVM?

 

 What's in a DVM?

Are not those whom we call doctor, for any given species, just as competent?


    Veterinarians, much like physicians, dentists, pharmacists, nurses, and others, are healthcare providers. Veterinarians and physicians, particularly, are two sides of the same coin, providing roughly the same scope of services to two different populations of patients: humans and non-humans. But what exactly happens in a DVM curriculum? How does it compare to an MD program? What exactly is the scope of veterinary medicine? Given the frequency with which veterinary professionals seem to find their status as medical professionals undermined, answering these questions is prudent. Let it be emphasized that the purpose of this article is not to disparage any other healthcare profession or to imply the superiority of another. Rather, the aim is to highlight the rigor that is present in both programs and illustrate that veterinarians are just as much medical professionals as any other practitioner, prompted by shared experiences across the profession where our competence, qualifications, and education are routinely questioned.  

Undergraduate

    Both pre-veterinary and pre-medical students complete the equivalent of ~four years of prerequisite coursework at the undergraduate level. These prerequisites typically include a standard general curriculum (English, communications, history, etc) as well as specific STEM upper-division electives such as biochemistry, physiology, anatomy, cell biology, and the like. Once completing those prerequisites, students must apply to their respective programs, a process which entails submission of transcripts, multiple application essays, standardized testing, and letters of recommendation from professionals in the field.

Graduate (DVM, VMD, MD, DO)

    In order to become a licensed professional, students must complete four years at an accredited institution. The AVMA (American Veterinary Medical Association) and COE (Council on Education, US Dept of Edu) are responsible for accreditation of veterinary colleges, whereas the LCME (Liaison Committee on Medical Education) oversees accreditation of medical colleges. The curriculum must be a minimum of four academic year equivalents and include a minimum of one year of hands-on clinical training for a veterinary program. Veterinary programs are increasingly incorporating clinical experiences into earlier phases of the curriculum, but historically, the 4th year is reserved for hands-on clinical experiences in a teaching hospital. For MD programs, there must be 130 instructional weeks (one academic year is roughly 30 weeks). In the “required clinical experience” section, it is stipulated that the faculty of the medical school define the requirements. Traditionally, the 3rd and 4th years are clinical years in an MD program.

Didactic coursework, or “classroom” material, is very similar for the two disciplines. Both accreditation standards highlight the need to foster a lifelong commitment to learning. Consider the excerpts from the standards below:

 

Veterinarians

“an understanding of the central biological principles and mechanisms that underlie animal health and disease from the molecular and cellular level to organismal and population manifestations.”


“understanding of normal function, homeostasis, pathophysiology, mechanisms of health/disease, and the natural history and manifestations of important animal diseases, both domestic and foreign.”




“Instruction in both the theory and practice of medicine and surgery applicable to a broad range of species. The instruction must include principles and hands-on experiences in physical and laboratory diagnostic methods and interpretation (including diagnostic imaging, diagnostic pathology, and necropsy), disease prevention, biosecurity, therapeutic intervention (including surgery), and patient management and care (including intensive care, emergency medicine and isolation procedures) involving clinical diseases of individual animals and populations. Instruction should emphasize problem solving that results in making and applying medical judgments.”



“instruction in the principles of epidemiology, zoonoses, food safety, the interrelationship of animals and the environment, and the contribution of the veterinarian to the overall public and professional healthcare teams.”



“opportunities for students to learn how to acquire information from clients (e.g. history) and about patients (e.g. medical records), to obtain, store and retrieve such information, and to communicate effectively with clients and colleagues.”

“opportunities throughout the curriculum for students to gain an understanding of professional ethical, legal, economic, and regulatory principles related to the delivery of veterinary medical services, personal and business finance and management skills; and gain an understanding of the breadth of veterinary medicine, career opportunities and other information about the profession.”




“Opportunities throughout the curriculum for students to gain and integrate an understanding of the important influences of diversity and inclusion in veterinary medicine, including the impact of implicit bias related to an individual’s personal circumstance on the delivery of veterinary medical services.”

“knowledge, skills, values, attitudes, aptitudes and behaviors necessary to address responsibly the health and well-being of animals in the context of ever-changing societal expectations.”

Physicians

“content from the biomedical, behavioral, and socioeconomic sciences to support medical students' mastery of contemporary medical science knowledge and concepts and the methods fundamental to applying them to the health of individuals and populations.”

“includes content and clinical experiences related to each organ system; each phase of the human life cycle; continuity of care; and preventive, acute, chronic, rehabilitative, and end-of-life care.”




“instruction in the scientific method and in the basic scientific and ethical principles of clinical and translational research, including the ways in which such research is conducted, evaluated, explained to patients, and applied to patient care”.


“incorporates the fundamental principles of medicine, provides opportunities for medical students to acquire skills of critical judgment based on evidence and experience, and develops medical students' ability to use those principles and skills effectively in solving problems of health and disease”



“ instruction in the diagnosis, prevention, appropriate reporting, and treatment of the medical consequences of common societal problems.”



“specific instruction in communication skills as they relate to communication with patients and their families, colleagues, and other health professionals.”

“prepares medical students to function collaboratively on health care teams that include health professionals from other disciplines as they provide coordinated services to patients. These curricular experiences include practitioners and/or students from the other health professions.”

“medical ethics and human values both prior to and during their participation in patient care activities and require medical students to behave ethically in caring for patients and in relating to patients' families and others involved in patient care.”


“opportunities for medical students to learn to recognize and appropriately address biases in themselves, in others, and in the health care delivery process. The medical curriculum includes content regarding the following:
- The diverse manner in which people perceive health and illness and respond to various symptoms, diseases, and treatments
- The basic principles of culturally competent health care
- Recognition of the impact of disparities in health care on all populations and potential methods to eliminate health care disparities
- The knowledge, skills, and core professional attributes needed to provide effective care in a multidimensional and diverse society”




    Side by side, it’s easy to see how comparable the curriculum requirements for the two programs are. While it would be incredibly time consuming to detail the exact curriculum for the many accredited degree programs for veterinarians and physicians, I can readily speak to the education I’m receiving. If a medical student (or recent graduate) would like to add their experience to this article, please reach out and I would be happy to include it as well (caitlin@docofalltrades.net). 


    First year, the focus was on learning “normals.” We spent hours in the anatomy lab dissecting cadaver dogs and ponies. Our systems courses covered endocrinology, musculoskeletal systems, immunology, reproduction, ophthalmology, cardiology, respiratory science, neuroscience, renal systems, and digestion. Introduction to nutrition, diagnostic imaging, animal welfare and ethics, parasitology, animal behavior, histology, embryology, and molecular biology also joined the fold. Once weekly, we met for a hands-on course to practice clinical techniques, from blood draws and catheter placement to client communication exercises. In groups of four, we collaborated throughout the year with other healthcare professional students and a faculty member to solve a problem for a local member of the community (facilitating access to care, providing resources to contact needed healthcare professionals, etc).

    Second year was like first, except recognizing and intervening with abnormals in the same systems. Anatomy became pathology. In addition to the systems courses, we had microbiology, toxicology, dermatology, population medicine, and, perhaps most exciting, surgery and anesthesia. All second year students have the opportunity to perform closely supervised spay or neuter surgery on a shelter animal prior to adoption. Another student, with supervision, directs and monitors anesthesia. Students remain responsible for the care of their patient until discharge. Much like during first year, the course practicing clinical techniques continued to meet once weekly.

    Third year and fourth year provide advanced core and elective curriculum as well as teaching hospital rotations. On breaks and vacations, students are able to schedule externships with veterinary practices and shelters. Core curriculum at this stage continues to build upon the first two years, adding additional clinical context and encouraging active decision making for disease diagnosis and treatment protocols. In the clinic, students are expected to take the lead on presenting cases, working closely with the resident and faculty veterinarians to provide the needed care to patients. This includes every stage of the process, from gathering a history with the owner, planning diagnostics, interpreting diagnostics, listing differentials, and developing a treatment plan. Students provide updates to owners for hospitalized patients, assist the veterinary nurses with hourly treatments, and write up discharges for the resident and faculty to review. 

Licensing

    Veterinary students take their NAVLE in their fourth year of curriculum. NAVLE stands for North American Veterinary Licensing Examination. It is a 360 question multiple choice exam on clinical scenarios and clinically-relevant material. Competencies include clinical practice, communication, professionalism, business management, animal welfare, and preventative healthcare. Species covered aquatics, bovine, camelids and cervids, canine, equine, feline, ovine and caprine, porcine, pet birds, poultry, reptiles, and non-feline/canine small mammals. The NAVLE was introduced in 2000. Prior to NAVLE, veterinarians were licensed through a National Board Exam (NBE) and Clinical Competency Test (CCT).

    Medical students take the USMLE (United States Medical Licensing Examination). This is a three step examination that occurs over various phases of the medical curriculum. Step 1 occurs at the end of second year. It is a basic sciences oriented systems and processes exam that consists of no more than 280 multiple choice questions. Step 2 is taken at the end of 4th year and is more clinically oriented. It happens over two days. One day is a multiple choice exam of no more than 318 questions. The second day consists of examining and diagnosing actors as patients. Finally, Step 3 is taken after the first year of residency. It is also a two day exam. Day one is 232 multiple choice questions on basic clinical science principles and knowledge. Day two is focused on diagnosis, treatment, disease management, and prognosis. It focuses on clinical decision-making, and consists of 180 multiple-choice questions and 13 virtual case scenarios.

Post-Graduate Training (Internship/Residency)

    This is where veterinarians and physicians diverge substantially. Internships and residencies are available to students and professionals of both fields, allowing new graduates or practitioners interested in specializing to work under the supervision of more experienced specialists. Veterinarians may elect to do an internship after graduation and may then further pursue residency, typically in anticipation of specializing. A veterinarian can also practice independently immediately following graduation, so long as they are licensed through the NAVLE. Roughly 30% of veterinary students pursue internships after graduation. For those that go straight into practice, many seek employment as an associate veterinarian under the mentorship and guidance of a more experienced veterinarian.  
    For MD graduates seeking to become licensed physicians, an internship or residency is a requirement. The exact requirement varies on a state by state basis, but typically those seeking license to practice medicine must have at least 12 months of post-graduate training.

Final Thoughts

    Due to my interest in interdisciplinary initiatives and One Health, I’ve had the privilege of corresponding with incredible individuals across all types of medical and non-medical professional fields. Many of them have been a pleasure to connect with, and there has (almost) always been a mutual respect and admiration for the unique and valuable perspectives that each field brings to the table in terms of solving complex problems facing our world today. At the same time, I have repeatedly encountered scenarios where the competency and relevance of veterinary professionals has been questioned in terms of having a seat at the table. “You must really love animals to plan to go through eight years of school and not even be a real doctor,” said one of my best friend’s family members to me. “Can veterinarians even prescribe medications?” was asked of my classmate by a different health professional student at an interdisciplinary school activity.

“You don’t learn real medicine.”

“Dogs and cats don’t get the same quality of care.”

“If a medical issue is complex for animals, you just put them to sleep. There’s no advanced medical care.”

A list such as this could go on indefinitely with the input of my peers and future colleagues.

    Veterinarians are proficient in a clinical setting. General practitioners perform routine surgery on a weekly basis, provide preventative and wellness healthcare, dental prophylaxis, dental intervention, diagnose and treat common illnesses, and manage chronic disease. Specialists exist in all varieties: ophthalmology (yes, your pet can get cataracts removed!), orthopedics (total hip replacements are done in dogs), soft tissue surgery (I’ve assisted with a lung lobectomy), oncology (pets get chemo too!), endocrinology (both dogs and cats are frequently managed for conditions like hypothyroidism, hyperthyroidism, and diabetes mellitus) cardiology, neurology, sports rehabilitation, pathology, diagnostic imaging, internal medicine, and on.

    Veterinarians also work outside of a clinical setting. Veterinarians manage international animal trade and help prevent the introduction of foreign disease. They work at the state and federal level on disease surveillance and wildlife management. They work in research to investigate new clinical modalities and pharmaceuticals for humans and animals (the CEO of Pfizer is a veterinarian). They work in food supply safety and regulation. They work in shelters to manage not just medical care, but operations and welfare standards. This short list is not exhaustive, but hopefully highlights some of the many ways in which veterinarians contribute to society as medical professionals outside of solely the practice of medicine on non-human animals.

    The unique experiences, education, and perspectives that different medical and healthcare professionals bring to the interdisciplinary table are all invaluable. We all face shared challenges and ones that are unique to our profession. No two medical fields can be compared as identical because they simply are not. A veterinarian will never have to navigate the extensive laws and liability surrounding practice on human beings or tell someone their child has cancer. A physician will never have to learn the complex nuances of various animal species or euthanize a childhood pet. Nonetheless, the curriculum is rigorous for all of these fields and none of these professions should belittle or tear down the others. The complex and dynamic issues facing our world today require complex and dynamic solutions. Solutions that will require teamwork from professionals of all backgrounds. It is essential, then, that mutual respect, understanding, and curiosity underlay these interactions.


Thank you for reading!

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Thursday, September 2, 2021

My Dog Got Sick After I Changed Her Food.

 My dog got sick after I changed her food. 

It was my first year of veterinary school, and I started her on a diet to try and finally lose the extra weight she'd been carrying for too long. My dog loved food. The first red flag was when she had less appetite. "Well, it's a diet food," I thought. "She probably doesn't like it as much, or it's helping her stay full." 

The second red flag was a loss of energy. My dog was older, 12 at the time. "Well, she's getting up there," I thought. "She isn't going to act like a puppy forever." 

The third red flag was smaller, less frequent stools. Again, this was a new diet for weight loss. "It's higher in fiber," I thought. "That should cause bigger stools, more often, but maybe she's just adjusting." 

Finally, my dog collapsed. It was a brief episode, she was back to herself afterwards, but I was out of reasons. That night, we drove to my old workplace back home and I had her seen. 

Monday, August 30, 2021

An Open Letter On Entering a Profession In Crisis.

     Normally, I like to keep it science-y here. As any long-time readers know, I'm very passionate about evidence-based medicine and accessible science communications. This one is personal. Feel free to turn back now. 

    In less than a year, I'll be a veterinarian, but I am already very much a part of this profession. I have been there in the flurry of CPR on a dog whose name I don't even know-- because he arrived already coding. I have spent day after day with long term ICU patients providing nursing support to get them back with their family. I have worked through strings of 14-16 hour days. I have cried alongside people I barely know in the collective grief of providing a suffering animal permanent relief, a safe and peaceful passage to the rainbow bridge. And I have suffered. 

But I've also played with puppies. I've assisted in the wonders of helping new lives come into this world. I've cuddled kittens. I've danced in the play yard with the boarding dogs. I've laughed. I 've worked alongside so many amazing people. I've loved my patients. I love interacting with pet owners. And I love this field. 

    I love this field so much, I'm currently staring down more than $200,000 in student loans-- and that's with scholarship aid! I love this field so much, the mounting debt and the bad days and the sights of suffering and the long hours and the sleepless nights and the grueling curriculum rarely haunt me. I love this field so much, I am at total peace with the awful debt to income ratio that awaits me, burdened with the knowledge that I and my colleagues will be almost certainly overworked and underpaid.

But today I had an experience that shook me. One that was not the first, and will not be the last, and is not unique to me, but that represents a really dark side to being in this profession:

Some of the people whose pets we treat see us as monsters. 

   

Saturday, August 28, 2021

When is correlation due to causation?

    "Correlation isn't causation," is an accurate statement that is, unfortunately, oft' misemployed when members of the public discuss science or research. Specifically, it is used (incorrectly) to undermine actual instances of causative relationships. "Correlation," refers to an association between two events, scenarios, or factors. "Causation," refers to such things directly impacting one or the other in a cause-and-effect type of relationship. What becomes confusing is that correlations can be due either to a non-causative, indirect relationship (such as a common causative factor, or simply random chance) or to a mechanism of causation. Whenever causation is present, correlation is as well. 

Rather than broadly dismissing actual instances of causation by appealing to the existence of a correlation between two values, one must ask themselves: When is correlation due to causation? 

Thursday, August 5, 2021

Biochemical Analysis of Dog Foods Provides New Clues On Causes of Diet-Associated DCM

    Research Cited: August 5, 2021 "Investigation of diets associated with dilated cardiomyopathy in dogs using foodomics analysis" Smith et al., Scientific Reports volume 11, Article number: 15881 (2021) https://doi.org/10.1038/s41598-021-94464-2

    If you aren't familiar with the ongoing investigation into atypical Dilated Cardiomyopathy in dogs as it relates to diet, please see the Comprehensive Diet-Associated DCM Q+A and Nutrition page for additional information and resources. 

    Much of research investigating diet-associated DCM in dogs thus far has focused on the clinical pictures of affected and unaffected dogs in relation to their diet and patient factors. New research published in the open-access journal Scientific Reports took a deeper look, instead, at the diets themselves. This research took an approach previously dubbed 'foodomics,' or the in-depth study of food, nutrients, and their relation to individuals, health, and disease. While the findings of this study did not identify a definitive cause or mechanism for the atypical cases of DCM that have been seen in recent years (and continue to be diagnosed), it did open several doors for further research, bringing us one step closer to identifying the problem. Because Scientific Reports is an open-access journal, anyone can read the paper without paying. However, the methods and analysis are very technical, and may be less approachable for some readers. For that reason, important information is summarized below in a way more readily accessible to the average pet owner. 

Thursday, July 8, 2021

Raw Re-Visited: Recent Research

    Raw diets have previously been discussed on this blog in early 2019, with the ultimate takeaway that the inherent risks associated with raw food diets are not offset by any current evidence of benefit from this feeding method. That position is shared by many public health and veterinary organizations, including the FDA, the CDC, AVMA, AAHA, and WSAVA. However, raw food diets remain an increasingly popular feeding option for pet owners to pursue, both in commercial and homemade forms. The purpose of this update is to review emerging literature from 2020 and 2021, re-evaluating the risk-benefit tradeoff of a raw food diet. 

Sunday, June 27, 2021

Doggie Dentistry: Is Non-Anesthetic Better?

     More than ever, owners are taking proactive initiative in their pet's oral health as veterinarians recommend annual comprehensive dental care for both dogs and cats. The health of the teeth and gums is incredibly important; periodontal disease is the most common disease of companion animals! Disease of the mouth can have downstream effects on other organ systems. While we can often be reasoned through our fear of the dentist, a proper oral exam for dogs and cats requires anesthesia-- this allows the veterinarian to fully open, examine, and radiograph the pet's mouth, which is a very stressful experience for an awake patient. However, anesthesia is equally stressful to many owners, and the combined use of anesthesia, radiographs, and dental care can make the appointment rather pricey. This has led to a rise in "non-anesthetic teeth cleanings" offered by groomers and other pet care professionals. This alternative appeals to a number of pet owners, for good reason! It costs less, it doesn't involve anesthesia (so it's perceived as safer) and in many cases, it's quicker, too. Unfortunately, non-anesthetic cleanings are not a safe or reliable alternative to ensuring dental health in your dog or cat. They offer essentially no benefit other than cosmetic, and may even be dangerous or painful to your pet. The individuals offering these services often have the best of intentions, and simply do not realize the immediate and indirect risks associated with the procedure. 

Thursday, May 6, 2021

Canine Diet-associated Dilated Cardiomyopathy Timeline

 Please see the Comprehensive Diet-Associated DCM Q+A and Nutrition page for additional information and resources. 

Background: Research in the 1980s-2000s previously linked DCM in both cats and dogs to taurine-deficiency, and in dogs to L-carnitine deficiency and certain lamb and rice diet formulations. Currently, there is concern regarding a link between grain-free and/or high-pulse diets and DCM in dogs. A timeline of this current concern is as follows:

Thursday, April 1, 2021

Pondering Prescription Diets: Science or Scam?

As our pets age (sometimes even in youth) it is a sad reality that they may develop chronic health conditions requiring long-term management. Luckily, as modern medicine marches forward, the treatment options available continually expand. Astute pet owners may take notice of the ever-growing array of dietary solutions marketed for disease management in companion animals. These diets, available both online with a prescription or directly through veterinarians, provide tailored nutritional support for conditions of the skin, gut, liver, kidneys, urinary bladder, and even brain. Par for the course of nutrition information available online, however, misconceptions and misplaced criticism abound. A common allegation states that these diets are scams, because they don’t contain specific medications, they use ingredients similar to those of traditional diets, and they’re often expensive. This has led some pet owners to question why a prescription is even necessary! Like with most pet food misconceptions, a bit of background information readily remedies these concerns.

Tuesday, March 30, 2021

Why Are (Some) Grapes Toxic For (Some) Dogs?

    As an emergency veterinary nurse, I saw many dogs presented for toxin exposure. Rat bait, prescription medications, NSAIDs, chocolate ... grapes? While many pet owners are still surprised to find out grapes are toxic, veterinarians have been suspect of the fruit as early as 1998, when an association was noted between otherwise unexplained kidney failure and recent consumption of grapes or raisins. These concerns were popularized in a 2001 JAVMA Letter to the Editor, and several studies followed to try and discern the mechanism underlying this association. Curiously, only some dogs experienced the kidney injury, and not always the first time they ate grapes. It was also never clear what amount of grapes was toxic, as it seemed to vary considerably between case reports. For over two decades, answers eluded researchers, prompting poison control centers to treat any exposure to any amount of grapes as a medical emergency, and leading veterinarians to urge pet owners to never allow their dog to consume grapes. These recommendations haven't changed, but as of March 2021, the cause of toxicosis may have finally been revealed. 

Saturday, March 13, 2021

Investigating Internet Information for the Savvy Skeptic

In this world, nothing can be said to be certain... but that which is published on the internet? 

    Whether about pets, politics, or parenting, we've all been there: looking something up online only to find conflicting information around every corner. In today's digital age, we have the cumulative wealth of human knowledge (...mostly) available at our fingertips... and yet it seems that every trip to google is an homage to that campfire game of two truths and a lie. Luckily, there are a few strategies on your side for evaluating every internet expert. 

Friday, February 19, 2021

New Diet-Associated DCM Study: Feb 2021

     Another retrospective study (Walker et al. 2021) concerning dilated cardiomyopathy in dogs was made available for pre-proof access, meaning that the article has been peer-reviewed and accepted for publication, but will undergo some further editing/formatting for final display in the journal. This research, published in the Journal of Veterinary Cardiology, can be accessed with a subscription or single purchase, but is otherwise not available to the general public. 

    The study itself is somewhat similar to the paper published in December (Freid et al. 2020). It is a retrospective analysis of dogs diagnosed with DCM and CHF (congestive heart failure) at NC State University College of Veterinary Medicine between 1/1/2015 and 07/10/2019. Dogs were excluded if their diet history was unknown. The analysis divided dogs into two groups based on whether their diet was grain-free (GF) or grain-inclusive (GI) at the time of diagnosis. Dogs eating GF at the time of diagnosis were switched to GI as part of the treatment. They're therefore referred to as pGF (prior grain-free). The authors further divided the pGF group based on the length of time a GF diet had been consumed (6 months - 2 years, 2-3 years, and 3+ years). 

    The findings of this study are consistent with previous research, providing further evidence that grain-free diets are associated with a lower mortality, reversible form of DCM, which in turn is associated with improved outcomes following diagnosis. This study does not provide insight to the exact etiology of this observation, but reinforces the need for continued investigation. The authors acknowledge several limitations, including small sample size, and encourage further research. 

Summary of Data:

  • 67 dogs met the inclusion criteria, 43 eating GF and 24 eating GI. 
    • 23 breeds were represented, 19 in the GF group and 11 in the GI group
      • Great Danes, Dobermans, and Labrador Retrievers were most represented in both groups, 18/43 (42%) in GF and 16/24 (67%) in GI. 
    • Age varied significantly between groups, with GF median age of 6 years and GI median age of 9 years
  • 21/43 (49%) GF dogs died and 19/24 (79%) GI dogs died during the study period. 
    • The effect of diet on survival was not statistically significant when considered overall
  • Survival was also assessed in the context of dogs that lived at least 8 days following initial diagnosis, to consider the impact of treatment therapy on dogs that lived to undergo it.
    • For these dogs, previous diet was significantly associated with survival, with pGF dogs that switched diet having better outcomes than dogs eating GI at time of diagnosis
      • Within this group of dogs that survived at least one week, median survival time was 465 days for pGF and 263 days for GI. 
      • Consuming GF diet for a longer time prior to diagnosis was associated with greater mortality (risk of death).
  • On average, pGF dogs reduced medication doses over time while GI dogs increased or maintained medication doses over time. 
  • There was a significantly greater decrease in LVIDdN (diameter of the left ventricle of the heart) over time in the twenty six pGF dogs re-evaluated when compared to the seven GI dogs re-evaluated. 

Additional Resources

Published Research


DCM Resources / Reading

    Sub-group for Veterinary Professionals


General Pet Nutrition Resources / Reading

WSAVA: FAQ, Guide to Nutrition on the Internet (Dogs) (Cats)

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Saturday, February 13, 2021

Diet-Associated / Non-Hereditary DCM Q&A (2021)

 


   This question list is compiled based on common objections/questions surrounding the FDA's investigation into DCM in atypical breeds in association with grain-free/high-pulse diets. The information provided comes from my personal knowledge background as a veterinary student, conversations I have had with cardiologists, nutritionists, and veterinarians close to the subject, public interviews or statements from experts, and published academic literature on the topic, the latter two linked where referenced or at the end. If you have any questions or input, please use the contact form to the right, the comment section of the post, or email info@docofalltrades.net 

This is intended to be educational only. If you have questions or concerns about your pet's health, please contact your veterinarian to schedule an examination. 

Use the table of contents below to jump to a specific topic. You can also share this Q+A via the weblink or on Facebook. You can copy the link url from any of the questions below to link someone directly to that specific part of the Q&A. 


Conflicts of Interest

    It's a common misconception that "this was all incited by a nutritionist trying to defend the waning sales of big pet food companies as grain-free diets skyrocketed." No part of this claim actually follows. This investigation was announced to the public in 2018, but cardiologists had been in contact with the FDA for several years prior to discuss atypical cases of DCM that they were diagnosing, with an apparent common factor in diet. The incitement of this investigation was discussed in The Washington Post and New York Times. Each story provides some insight into the various cases cardiologists across the USA were seeing that prompted contact with the FDA. 

    The confusion with the involvement of nutritionists likely comes from a commentary published in JAVMA co-authored by Dr. Lisa Freeman, a veterinary nutritionist, and several colleagues. This commentary was published after the FDA's public announcement and was intended to review historical knowledge of diet-associated DCM and recap the (limited) information we had so far on the emerging issue being investigated by the FDA. In addition, it sought to alert veterinary professionals to a potential issue and encourage vigilance. In no way did this piece broadly condemn certain diets as an absolute cause for the issues being seen. The summary read (emphasis added): 

"Pet food marketing has outpaced the science, and owners are not always making healthy, science-based decisions even though they want to do the best for their pets. The recent cases of possible diet-associated DCM are obviously concerning and warrant vigilance within the veterinary and research communities. Importantly, although there appears to be an association between DCM and feeding BEG, vegetarian, vegan, or home-prepared diets in dogs, a cause-and-effect relationship has not been proven, and other factors may be equally or more important. Assessing diet history in all patients can help to identify diet-related cardiac diseases as early as possible and can help identify the cause and, potentially, best treatment for diet-associated DCM in dogs."

    This was published in 2018, and now in the face of continued caseloads and emerging findings, researchers still, in some cases even more strongly than ever, believe that there is a strong risk factor for the development of DCM secondary to certain diets. However, it is clear that this 2018 piece in no way claimed any kind of certainty. 

    Dr. Freeman does have several disclosures listed. This is not unusual. As a nutritionist, her job inherently involves working with the manufacturers of pet foods to ensure quality and safety for companion animals. As a specialist and as someone in academia, she is sought for speaking engagements. Disclosure of potential conflicts is an ethical standard in scientific publications, and is considered an act of transparency. Previously speaking for a company or receiving a research donation from them does not mean that one is beholden to that company to defend or exonerate them. While disclosures should always be reviewed and considered in their context as a source of potential bias, and while sometimes that bias reveals itself, such real or perceived conflicts do not inherently invalidate research or commentary. 

    Even still, several major brands manufacture and sell grain-free diets (such as Purina and Hill's). These major brands also have not experienced catastrophic loss of market share to boutique brands. The insinuation that they would feel so threatened by smaller manufacturers that they would craft an elaborate conspiracy involving a federal agency investigation into the death and illness of dogs rather than just shifting course on their own marketing strategies is, for lack of a better word, absurd. 

    Unfortunately, this issue has not been free from the influence of politics, industry, or bias. Pet food is a huge, profitable industry, and so is pulse legume farming. Some aspects of both industries have been threatened by the investigation at hand, in the loss of grain-free sales as reported by Pet Food Industry, and the subsequent estimated loss of pulse legume profits. Pulse grower associations have donated funds to research that they believe will vindicate their crops. Highly implicated brands have invested in disinformation campaigns downplaying this issue. A group of senators wrote to the FDA about being careful of the impact of their words, noting that the investigation was of significant interest to several groups of people, including farmers in their states. 

    Dr. Solomon, Director of the FDA's Center for Veterinary Medicine, has acknowledged the need to tread carefully in the face of this pushback: "Although CVM’s investigation must be driven by science and our public health mission, we are acutely aware that promoting transparency and public awareness may not be kind to everyone’s bottom line."

    It's very telling that within the two 'camps' of thought ('yes diet is an issue' vs 'no this is blown out of proportion'), the loudest objections are coming from those directly involved in the industry as it pertains to the formulation and sale of non-traditional diets. We shouldn't ignore that some profits are hurting, but ultimately investigation must be driven by good faith desires to understand the underlying issue in the interest of companion animal health and welfare, even if that means some businesses may be harmed. 

The FDA's Most Recent Update

    The FDA's most recent update reaffirmed that diet remains a potential factor, despite multiple industry news outlets claiming otherwise. VIN News Service has contacted the FDA directly to clarify this. The actual update from the FDA can be accessed by the public, as well as a new Q+A on their investigation. Excerpts include (emphasis added): 
  • "If there is one point I want to drive home, it’s that the best thing you as a pet owner can do is to talk to your veterinarian about your dog’s dietary needs based on their health and medical history."
  • "Our veterinarians, animal nutritionists, epidemiologists and pathologists have been working with veterinary cardiologists and nutritionists from academia, industry and private practice to better understand the clinical presentation of the cases and potential ties to diet, such as bioavailability of critical nutrients and how well a dog digests these nutrients."
  • "As we look further into the role that diet may play in these cases, we hope to explore additional avenues of inquiry such as formulation, nutrient bioavailability, ingredient sourcing, and diet processing to determine if there are any common factors."

    Less than a year ago, a headline began to circulate that '150+ studies find no link between diet and DCM.' The problem: most of those studies were not looking for or evaluating such a link! Of the 150+ cited sources, only FOUR are actual studies on the current issue of DCM and grain-free/legume-rich/non-traditional/BEG diets. Two are literature reviews on the current issue. Three represent different iterations of the FDA investigation. Only a handful more pertain to (different types of) diet-associated DCM at all. The majority are on other forms of DCM, and a handful don't pertain to DCM and dogs at all. 
    This literature review has been widely criticized by veterinarians, including cardiologists in a VIN News piece and by 'SkeptVet' Dr. Brennan McKenzie in a piece for Veterinary Practice News. Emily Brill with The Canine Review also investigated and reported on the underlying conflicts and controversy surrounding this literature review. 
    To summarize a few issues: Study authors omitted discussion on the significance of observed reversal of DCM in dogs following diet change. They mischaracterized the need for medical recommendations in the presence of clinical observations, regardless of the status of ongoing research. The study authors disclosed no conflict of interest, despite that four of the five work for the consulting group that formulates for Zignature, the second-most frequently named brand in the FDA update. One is even named as Zignature’s veterinarian on staff. The conclusions claim that there is no association between DCM and diet, despite the fact that correlation very much presents itself as a 'link.' Ultimately, the literature review is a misleading opinion piece that discussed mostly unrelated literature to come to an unjustified conclusion that leaves pet owners and other interested parties less informed than they would otherwise be. 

Genetic DCM, Predisposed Breeds

    DCM most commonly occurs in two specific breeds: Doberman Pinschers and Great Danes. A few other breeds are classically considered predisposed as well; Portuguese Water Dogs experience a specific and unique juvenile form of the disease. Boxers are prone to 'Boxer Cardiomyopathy,' medically known as Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC). This disease can mimic the appearance DCM or occur simultaneously with it. At least one family of Dalmatians have been documented to experience low-protein diet-associated DCM. Taurine-deficient DCM has been documented in a family of Golden Retrievers. Cocker Spaniels have also been associated with taurine-deficient DCM. In general, larger and giant breed dogs are more likely to experience DCM than smaller breed dogs, which are more likely to experience mitral valve heart disease. DCM is the 'second most common cardiomyopathy in dogs," but still only represents about 10%. Mitral valve disease represents a whopping ~75% of canine heart disease in the US. 
    DCM is more common in certain breeds, and genetic markers have been identified for some breeds, but it is not exclusively a genetic disease. DCM can be 'primary' (directly related to the heart, as in genetic conditions that certain breeds are predisposed to) or 'secondary'(directly related to something other than the heart, such as a toxin, an infectious disease, a nutrient deficiency, or an endocrine disease). 
    Primary DCM is a progressive condition that can be improved and slowed with medications, but cannot be reversed in the sense that the dog can be weaned off of medications and return to normal cardiovascular function. However, secondary DCM can sometimes be reversed and 'cured,' such that medications can be discontinued and heart parameters can return to normal, or almost normal, values. This usually requires that the underlying cause be addressed before irreversible damage has been done to the heart tissues. Double board certified specialist Dr. Sherry Sanderson, Internist and Nutritionist, has discussed primary vs secondary DCM in a podcast interview with Down With Dogs. 
    
    To bring this all around to the FDA's investigation, there are two important considerations: That the entire investigation began due to cardiologists sounding the alarm over non-predisposed breeds presenting with DCM, and dogs predisposed to primary DCM can also develop secondary DCM. The two conditions are not mutually exclusive. In fact, the FDA has discussed recovery seen in two Dobermans that saw reversal of their disease process upon switching diet. These dogs may still develop and succumb to primary DCM. But that they improved with a therapy change suggests that they had a secondary form of the disease. Geneticist and Veterinary Cardiologist Dr. Joshua Stern has discussed genetic DCM in the context of diet-associated DCM cases in several webinars. While these were not recorded for public access, Dr. Stern is continuing to research diet-associated DCM and still does not believe genetics to be the primary underlying cause for these cases. 

    The FDA 2019 data includes 59 classically predisposed dogs (Doberman, Dane, Boxer, and Mastiff), 95 Golden Retrievers (which are not predisposed to heart disease but may be more susceptible to nutritionally-mediated DCM), 75 mixed or unknown breeds, 86 large breed dogs (Labrador Retriever, German Shepherd, German Shorthaired Pointer, Weimaraner, Standard Poodle), and 59 medium or small breed dogs (Pit bull, Aussie, Sheltie, American Bulldog, Bulldog, and Shih Tzu). Dogs as young as five months and dogs as old as 16 years have been reported. Dogs as small as 4 pounds and as large as 212 pounds have been reported. All breeds, ages, and sizes are represented. This is not likely to be attributable to an underlying genetic condition. The FDA has dubbed these cases "non-hereditary DCM." DCM is sometimes a genetic disease, but these cases under investigation do not appear to be genetic in origin. 

    There are a number of other factors that have been discussed and investigated as a potential underlying cause. The potential for other factors has not been ignored. However, diet remains the single most common denominator among reported cases. This is along with a disproportionately high number of cases from diets with relatively low market shares. This trend would not be expected from chance. It also would not be expected if the underlying cause were something like vaccines, flea and tick medications, or environmental pesticides-- these factors would impact the general dog population as a whole, and we would expect reported cases to mimic market trends in terms of diet being consumed. Additionally, a trend would likely emerge, and be noticed by clinicians, where dogs presenting with illness were recently vaccinated with a specific vaccine, recently put on a specific flea medication, or recently exposed to a new yard pesticide. Instead, what clinicians have observed is a trend with a specific diet type-- grain-free or legume-rich. 

    Other known causes of DCM include tick-borne illness and severe unmanaged hypothyroidism. In the 2019 update provided by FDA's Vet-LIRN, they reported that 18 dogs had a history of hypothyroidism and 17 dogs had a tick-borne disease. These causes are being explored, but are not turning up answers. In the Kansas State Forum presentation, the FDA showed a diagram comparing the geographic distribution of tick-borne illness and of the reported cases. This comparison did not suggest a strong correlation with regions of high tick-borne disease levels.  




Researchers continue to investigate a variety of potential causes. Up to this point, diet remains the most consistently identified common factor. 

Complexity of Factors

    The FDA has stated that "DCM is a complex medical condition that may be affected by the interplay of multiple factors such as genetics, underlying medical conditions, and diet." This statement, while true, also applies to virtually anything in medicine. Biological systems are complex, and it may be centuries before we fully understand all the nuance underlying them. However, that does not preclude recognizing avoidable factors that cause a substantial increase in lifetime risk of certain diseases. Cancer is a complex umbrella of medical conditions that are affected by the interplay of many factors, including genetics, diet, and environment. Despite the complexity of these processes, we still acknowledge risk factors, such as exposure to carcinogenic compounds.  
    Since many of the dogs that recover are on medications, doesn't that mean diet change has nothing to do with improvement? It's a common question, and one with a very simple answer: cardiac medications improve function and treat heart disease, to reduce symptoms, slow the progression of disease, increase patient comfort, and extend patient life, but they do not cure heart disease. What that means is that typically, a dog started on cardiac medications will be on those medications for life and will experience some degree of disease progression over time, even if they show initial improvements secondary to medication administration. However, what is being seen in dogs that switch diets and start cardiac meds is substantial improvement up to complete reversal of heart disease. Additionally, some of these dogs are able to wean off of their cardiac medications and return to being clinically normal. This is not typically seen with heart disease, and there are very many dogs that receive these medications as part of routine therapy for heart disease. The only apparent explanation is change of diet. In previously documented nutritional DCM cases, diet and nutritional supplementation alone was shown to be sufficient for curative reversal of the disease. 

    To go more in depth... Administration of pimobendan has not resulted in complete discontinuation of medical therapy for CHF in any published clinical trials. The outcomes of dogs on pimobendan in clinical trials do not suggest that DCM improves to such a degree that medical therapy will be stopped or echocardiographic measures will normalize. Reduction of echocardiographic measurements is not the same as a complete resolution of clinical signs and echocardiographic evidence of cardiomyopathy, the latter of which is being reported in the cases in question. Pimobendan does not “cure” DCM, and yet dogs in cases reported to the FDA are showing a complete recovery from the disease. It is unlikely attributable to the administration of pimobendan as a primary factor. 

    Taurine is, generally speaking, documented to produce a positive inotropic effect, but it isn’t considered standard of care for DCM of genetic origin. There is no data that documents such a significant positive inotropic response in dogs with DCM supplemented with taurine alone, in the absence of a taurine deficiency. While taurine may improve some parameters, and dogs with DCM may benefit clinically from administration, much like pimobendan, it does not “cure” DCM (unless the DCM is secondary to taurine deficiency).

    To pull this all together… administration of medical therapies like pimobendan and taurine alongside a diet change can be confounding variables, but they also appear to be unlikely contenders for standing alone as explanations for the observed disease resolution. The presence of these variables does not invalidate or undermine the importance of the role of diet in the etiology of this disease. Providing the best medical care for these animals is the ethical responsibility of a clinician, even if that reduces the research value of case evaluations. 

Looking For A Cause & Past Examples

    The FDA made the public aware of this investigation in 2018, and now in 2021 we still have many more questions than answers. Even research done independently from the FDA has not offered a clear underlying cause and mechanism. This is understandably frustrating to pet owners, and truly, any member of the public or industry without a background in research. The unfortunate reality is that these things take time, especially with limited funding or ethical concerns. For example, doing clinical trials on dogs to determine if certain diets induce heart disease would entail trying to induce heart disease in said dogs. When using client-owned animals for prospective studies, it can be difficult to control variables without compromising patient care (for example, withholding taurine supplements or heart medications or not recommending a diet change). It is unsurprising, albeit frustrating, that we don't have a definitive answer yet-- and the truth is, we may never have the rock-solid, air-tight 'proof' that some are looking for. Most recently (August 2021) researchers may have identified several avenues for future research to hone in on a specific cause and mechanism. 

To best illustrate how this compares to other situations, we can look to the (ongoing) 2007 FDA Jerky Investigation, the long-known but poorly-understood association between grapes and canine renal failure, and finally, the link between tobacco and lung cancer. 

    In 2007, the FDA began receiving and collecting reports of illness associated with jerky treats marketed for pets. Between 2007 and the end of 2015, they collected over 5000 complaints involving over 6000 dogs, over 1000 of them deaths. A variety of adverse events have been reported, including GI distress, elevation of liver enzymes, and renal or urinary dysfunction. Most striking has been 'Fanconi-like syndrome' or FLS, a loss of certain nutrients in the urine that is typically seen only in specific breeds with a genetic predisposition, such as basenjis. Removal of the jerky treats from the pets diet has resulted in improvement alongside appropriate medical treatment. 
    The FDA has tested these treats and to this day has not uncovered an underlying cause for these observations. They have tested for bacteria, metal contaminants, irradiation, pesticides, antibiotics, antivirals, mold and related toxins, rodenticides, known kidney toxins such as melamine, and a variety of other toxins. 
    The FDA has explained some of their challenges in undercovering an underlying cause to these cases:
  • "In human illness outbreaks caused by foodborne bacteria or contaminants, FDA works in concert with the Centers for Disease Control and Prevention (CDC) and state boards of health, which collect and track cases of foodborne illness. Unfortunately, there is no equivalent for pets, which means that it is difficult to accurately evaluate the scope of an outbreak."
  •  "Very little is known about the possible causes for non-genetically related (acquired) Fanconi Syndrome cases in dogs, but certain toxins, medications and infections have been linked to its development in dogs and people."
  •  "When a person dies unexpectedly, it is not unusual for a medical examiner to perform an autopsy to try to determine the cause of death. When a pet dies, it is much less likely that qualified veterinary pathologists will have the opportunity to examine the body. By the time FDA receives reports of deaths in pets, the body often has already been cremated or buried, eliminating the chance for scientists to gather more information about potential causes for the pet’s illness. "
  • "Finally, FDA has limited access to market data about food items for pets. FDA regulations do not require product registration for foods, whether they are intended for people or animals. "

Many of these challenges and limitations can easily apply to the DCM investigation as well.  

 

    As early as 1998, an association was noted by veterinarians between acute kidney failure in dogs and recent ingestion of grapes or raisins. In 2001, these concerns were voiced in a JAVMA Letter to the Editor.  To this day, the toxic principle underlying this observation remains unknown. Not all dogs that ingest grapes experience signs of toxicosis, and a toxic dose has not been determined. 
Update: In March 2021, the reason for grape toxicity may have finally been uncovered. 
    Despite not understanding the pathophysiology of these observations, ingestion of any amount of grapes in any size dog is treated as a medical emergency by veterinarians and pet poison control centers, including recommendations for a medical professional to safely induce vomiting where indicated, collect baseline blood values and perform serial rechecks, and run IV fluids. Grapes and raisins are not necessary for the health of dogs, and with no way to predict which dogs will experience an adverse event, the safest approach is to treat every exposure as potentially deadly and provide medical intervention as such. 

    This example is not related to dogs or veterinary medicine, but instead helps to illustrate the scientific process within healthcare fields. 
    Like many fad products adopted throughout history, early tobacco use in Europe was associated with a variety of spurious health claims, from reducing anxiety to curing headaches, toothaches, and arthritis. It was the panacea. Popularized in the 19th century by soldiers in WWI, cigarettes became a preferred form of tobacco use. It wasn't until the beginning of the 20th century that scientists observed lung cancer was becoming more common. In 1950, four retrospective studies were published detailing lung cancer patient's smoking history. At this time, there was still debate over whether the perceived increase in lung cancer was real, or an artifact secondary to improved awareness and diagnosis. In one paper, the authors write that the evidence is based 'upon clinical experience and records,' and 'none of these small-scale inquiries can be accepted as conclusive, but they all point in the same direction.'  In another, authors write "There is strong circumstantial evidence that cigarette smoking was an etiologic [causative] factor in cancer of the respiratory tract."
    Despite the emerging evidence that had swayed the researcher's positions on the subject, it wasn't until seven years later that the US public health service issued a statement on lung cancer being caused by smoking. A January 1964 report from the Surgeon General contained the following excerpts: 
  • "Few medical questions have stirred such public interest or created more scientific debate than the tobacco - health controversy . The interrelationships of smoking and health undoubtedly are complex . The subject does not lend itself to easy answers . Nevertheless , it has been increasingly apparent that answers must be found ."
  • "It is not feasible to submit human beings to experiments that might produce cancers or other serious damage , or to expose them to possibly noxious agents over the prolonged periods under strictly controlled conditions that would be necessary for a valid test . Therefore , the main evidence of the effects of smoking and other uses of tobacco upon the health of human beings has been secured through clinical and pathological observations of conditions occurring in men , women and children in the course of their lives , and by the application of epidemiological and statistical methods by which a vast array of information has been assembled and analyzed."
  • "Among the epidemiological methods which have been used in attempts to determine whether smoking and other uses of tobacco affect the health of man , two types have been particularly useful and have furnished information of the greatest value for the work of this Committee . These are ( 1 ) retrospective studies which deal with data from the personal histories and medical and mortality records of human individuals in groups ; and ( 2 ) prospective studies , in which men and women are chosen randomly or from some special group , such as a profession, and are followed from the time of their entry into the study for an indefinite period , or until they die or are lost on account of other events ."
    Today, there is little controversy surrounding the claim that smoking cigarettes is a very prominent risk factor in the development of a wide variety of diseases and illness. While we have had decades to put together the breadth of knowledge informing this belief, research pertaining directly to the effects of tobacco on humans does still come primarily from retrospective and prospective studies, rather than double-blind clinical trials. 
    For similar ethical reasons cited above, it is unlikely that such gold standard research will ever be conducted on dogs in the context of diet-associated DCM. But several retrospective analyses have contributed to discussion surrounding this disease, and several prospective studies are underway. It's easy to imagine how many lives may have been prolonged had investigation into tobacco use not taken so long to grab hold of public attention and begin to sway beliefs surrounding it. Given the nature of the diets in question, particularly their lack of necessity or health benefits, it stands to reason that avoidance until this concern is either further confirmed or laid to rest may be in the best interest of potentially prolonging companion canine lives. 

Funding

    The FDA's investigation into non-hereditary DCM in dogs, and all other endeavors, are funded by USA taxpayers. Every fiscal year, the FDA is provided a budget appropriation. 
    The ongoing research at academic institutions are funded in a variety of ways, including donations from the public. For example, a retrospective analysis on diet and DCM published recently (Freid et al. 2020) was funded by the 'Barkley Fund,' a memorial fund set up by the owners of a dog that passed from cardiac disease. Some of these studies may be funded in part by companies in the pet food industry. To quote myself from another article on this topic: One would be hard pressed to find research experts in any field who have never received financial support from companies or corporations invested in that field. For better or worse, that's the nature of our current economy. That is why it's standard to disclose such connections and important to critically evaluate methodology and obtain peer-review for any scientific studies. Processes like peer-review are in place to mitigate risk of bias, and researchers are mandated to disclose any potential financial conflicts that could be construed. Critical examination is warranted, but we cannot presume that every study partially funded by a grant from a corporation was swayed in that corporation’s favor.  

Original FDA Request

    There is a common misconception that the FDA "only requested cases from dogs eating a grain-free diet," therefore causing a bias in the sample pool. The original FDA request did not specifically ask for cases from dogs eating grain-free diets. It reads: "The FDA encourages pet owners and veterinary professionals to report cases of DCM in dogs suspected of having a link to diet by using the electronic Safety Reporting Portal or calling their state’s FDA Consumer Complaint Coordinators."

    The reason that the FDA did not ask for reports of all cases of canine DCM is because there are instances where DCM can easily be explained by factors other than diet-- for example, an adult Doberman Pinscher with a family history of DCM. If the FDA had to sort through data on cases that veterinarians could easily determine are not likely to be dietary in origin, it would bog down the entire investigation. There are cases reported from dogs eating grain-inclusive diets. Grain-free diets just vastly outweigh them. This doesn't appear to be a coincidence or isolated sample bias-- studies have also shown an association between non-traditional diets (like grain-free) and DCM when compared directly to dogs eating more traditional diets. 

    It's easy to wonder if some aspect of this boils down to a trend between what types of food people purchase and how likely they are to get an illness diagnosed by a veterinarian. However, to borrow a phrase from those pushing back on this issue, consumer purchasing behaviors are complex and multi-faceted. There are many assumptions that have to be true in order for this logic to follow. Even if we accept the assumption that the amount people spend on pet food correlates with the amount they're willing or able to spend at a veterinary clinic, there are both expensive and inexpensive grain-free diets, and both expensive and inexpensive grain-inclusive diets. Even still, it would be difficult to explain away such huge disparity between market share and the overrepresentation of some of the named manufacturers with the claim that those specific people feeding that specific food are the only people that take their pets to the vet or pursue advanced imaging and diagnostics. 
    There are also other scenarios to consider, even if we assume that grain-free diets are 'expensive' and grain-inclusive diets are 'cheap.' For example, what if someone spends less on dog food so that they can afford emergency care or advanced diagnostics for their pet? What if someone spends so much on a dog food that they believe is best that they can't afford expensive veterinary bills? Brands like Purina Pro Plan are popular among show and sport breeders and canine sport enthusiasts. Many of these dog receive health clearances, including an echocardiogram. 
    There is likely no doubt that certain socioeconomic circumstances preclude a diagnosis of DCM. But we shouldn't assume that consumer buying behaviors have such a large sway over willingness to spend on veterinary bills that it explains away the disparity observed in case reports. Additionally, studies comparing dogs eating non-traditional and traditional diets have continued to identify a link between non-traditional diets and heart abnormalities. These studies don't eliminate all extraneous variables, but they do remove the assumption that dogs eating traditional diets aren't being examined for heart health.  

Prevalence

    The full scope of this issue is unknown for many reasons. Short of collecting a large random sample of dogs to be evaluated by cardiologists, we can't possibly hope to estimate how many animals are affected. DCM can exist as an occult disease, meaning the dog in question is asymptomatic. Even in dogs that have symptoms, those symptoms may be vague, non-specific, or even so subtle that they go unnoticed: decreased energy, lethargy, lowered exercise tolerance, an occasional cough. DCM can occur with arrhythmia, or abnormal heart rhythms, which are a risk factor for sudden death. Without an autopsy, which owners may not pursue for a number of reasons, that cause of death may never be determined. While not all dog owners are aware of an autopsy as an option, others lack the funds to pursue one, or elect not to in order to keep the remains of their pet. As discussed in the 'Annual Exams' section below, DCM is not something that would be picked up through routine canine healthcare. Even for owners with suspicion that their dog may be ill, there are barriers to the accessibility of veterinary cardiology services. These barriers may be geographic (no local practices), financial (specialty care is expensive), or simply the inability to make an appointment due to a high caseload seen by the relatively few cardiologists in the USA. 
    All of this means that the cases reported to the FDA (now >1100) are only the tip of the iceberg-- the cases that were both diagnosed and reported. Under the surface, you have an expanding base: cases diagnosed but not recorded, dogs with clinical signs that haven't been diagnosed, dogs without clinical signs that haven't been diagnosed, and dogs that died suddenly without an autopsy performed and will never be diagnosed. 
    Some mistakenly claim that unless 100% of dogs eating certain diets develop disease, diet is not the underlying cause of the disease process. However, many known risk factors for diseases exist that do not impact 100% of the exposed population, due to individual differences in genetics, environment, and epigenetics. For example, not 100% of people with chronic sun exposure will develop melanoma. Not 100% of people that smoke will develop lung disease. Not 100% of people with high cholesterol will develop heart disease. Biological systems are complex, and it may be centuries before we fully understand all the nuance underlying them. However, that does not preclude recognizing avoidable factors that cause a substantial increase in lifetime risk of certain diseases. 
    As of right now, there is no large-scale data available tracking cases of DCM seen by the ~300 cardiologists in the USA. Such data may make it easier to determine to what extent atypical breeds are presenting with this disease. However, collecting such data at the necessary scale would require the time and cooperation of dozens, if not over 100 institutions that may have no easy way of procuring it. Until such data can be collected, the reported experiences of clinicians seeing these cases should be sufficient to at least raise a flag of vigilance and concern.  
    Many individuals less cautious of this issue cite their annual exams with their vet as evidence of their pet's good health, despite feeding a grain-free or otherwise non-traditional diet. While annual exams are important for tracking your pet's general health over time, DCM is a disease that is not frequently revealed through standard routine diagnostics. DCM rarely causes a heart murmur that can be heard through your vet's auscultation by stethoscope. DCM may cause arrhythmias, but most dogs do not routinely get an EKG during their annual exam. Dogs with DCM may show no symptoms (occult disease). While a specific blood test, ProBNP, may suggest underlying heart disease, it is not routinely performed, and it isn't perfect. A standard blood panel would not show DCM. X-rays may show an enlarged heart, but are rarely recommended for otherwise healthy pets. An echocardiogram with a cardiologist is the only way to definitively diagnose a dog with DCM. 
    One reason some pet owners are reluctant to switch away from grain-free diets (or other non-traditional diets) is often cited as the very reason they started purchasing them in the first place-- the perception that they're healthier, safer, or hypoallergenic. However, there is no evidence that shows grain-free diets are associated with unique health benefits when compared to the more traditional, grain-inclusive diet formulations. Grain allergies are also incredibly rare, even as a subset of adverse food reaction which themselves are estimated to affect no more than ~10% of dogs with atopic dermatitis (itchy skin). These reactions are most commonly to chicken or beef. While grains are often reported on food allergy panels, these tests are notoriously inaccurate. 
    Even if a pet had a severe, broad allergies to grains (which is virtually unheard of), a commercial grain-free diet would still pose problems as cross-contamination of commercial pet foods is well documented to be an issue between formulas, with many diets containing trace amounts of undeclared proteins. 

Read more on this from the Clinical Nutrition Service at Cummings School of Veterinary Medicine at Tufts. 

Taurine / Grains

    A lot of people ask if they can just supplement taurine or add grains like boiled rice into their dog's food. There are several problems with this approach, the first and foremost being that we don't know that either of those things (insufficient taurine, or the actual absence of grains) are the underlying cause of these observations. Not all of the dogs reported to the FDA have tested low for taurine, and adding ingredients to a commercial diet runs the risk of introducing nutrient deficiencies by unbalancing the formulation. Rather than trying to fix a potentially broken diet, the safest thing to do is switch away from it until we know more. If some underlying common thread between these diets turns out to be, for example, something impairing taurine metabolism, no amount of added taurine would help unless the diet was also changed. 
    A common follow-up to that is confusion surrounding why many dogs are receiving taurine supplementation alongside a diet change after being diagnosed. In the simplest terms, this is being done just in case it helps expedite recovery. The recovery itself is still strongly thought to be predicated on the diet change itself.  

Grain-Inclusive Foods

    Many of the researchers investigating this issue believe the underlying cause to ultimately be one of poor formulation, not necessarily the inclusion of exclusion of any particular ingredients alone. That said, out of an abundance of caution, it may be best to avoid diets from any manufacturers with a significant number of case reports/complaints, even if the specific diets of interest are grain-inclusive, until more information is available. Grain-free diets or diets high in pulse legumes such as peas, chickpeas, or lentils, may also be worth avoiding, particularly in the absence of medical indication to feed such as diet. The next section contains some suggestions for considerations to have when evaluating pet foods. UC Davis has published guidelines as well: "While avoiding all suspect ingredients may be the most direct way to select a new diet, we suggest that a small amount of legume content in a well-formulated grain-inclusive diet may be OK. Our guidelines allow for no more than two legume ingredients in a grain-inclusive diet when found low on the ingredient list (below all meat and grain content). Importantly, these diets should still be tested by AAFCO feeding trial."

Choosing a Pet Food

    The World Small Animal Veterinary Association has put together a list of recommended questions to ask a pet food manufacturer when deciding on what to buy. These questions aren't comprehensive, and WSAVA doesn't advise how you should expect a company to answer, but they are a good place to start. Some people have criticized certain standards as being prohibitive to smaller companies. However, if a company cannot afford bare minimum standards for formulation and production quality, they should not be manufacturing dog food. Using the WSAVA recommendations and the advice of several veterinary nutritionists, here is what you should look for:

1. Companies should employ at least one, dedicated full-time nutritionist, and ideally, they should have several. This would be someone with a PhD in animal nutrition or a veterinarian boarded in nutrition as a specialty (DACVN). Some companies will state they 'work closely with nutritionists' or 'consult with a nutritionist.' While these are good practices, a consultant cannot provide the same level of dedicated and detailed oversight to formulation and product management as a full-time employee, or team of employees, can. 

2. The diets should be formulated by someone qualified to do so- such as a veterinary nutritionist. Experience in the pet food industry, or owning dogs, regardless of how many years, does not alone qualify someone to formulate diets. Much like in the first case, a team of qualified expert professionals is even better than just one or two. In the best case scenario, there will be not only nutritionists, but food scientists and toxicologists involved as well. 

3. Diets should undergo feeding trials that, at a minimum meet, and ideally exceed, AAFCO standards/protocols. In addition to feeding trials, diets should be formulated to meet nutrients profiles and undergo analysis of the finished product to confirm nutrient levels. Testing diets only for digestibility or palatability, or meeting AAFCO standards by formulation or analysis alone, is less ideal. 

4. Foods should be produced in facilities owned and operated by the manufacturer so that every aspect of production can be closely monitored. Ideally, foods sold in the USA should be manufactured in the USA. These facilities must be equipped with machinery, laboratories, and staff that can provide extensive, on-site quality assurance. Manufacturers that contract with a third party facility to produce their foods lose some degree of control over quality and also risk cross contamination if there are issues that arise with other diets produced at those facilities. 

5. Manufacturers should have transparent and extensive quality control protocols. This should include selection criteria for partners, analysis and sample tracking of externally sourced ingredients such as vitamin mixes, daily safety checks of product batches and facilities, physical inspection, and key nutrient testing before final packing. Some companies will save samples from each batch/lot in order to re-evaluate or investigate that diet should issues arise later. The presence of a recall history does not preclude a manufacturer having good quality control. However, the frequency with which recalls occur, the nature of the recall, and the manner in which the company proactively responds should be considered. 

6. Companies should be able to provide a complete nutrient analysis for any food they produce on an energy basis (grams per kcal) and additional information such as digestibility. 
7. They should have information on the caloric value for any formula readily available in kcal per gram diet and per cup. 

8. Companies should be investing in and conducting nutrition research that is relevant to the diets they are putting out onto the market, particularly when making health claims or introducing a novel formula that strays from traditional or well-researched norms. This research should be peer-reviewed and published. It is a red flag for a company to claim research as 'proprietary' and unavailable for review. Companies that do not engage in any research endeavors, or worse, actively oppose nutrition research, may be best avoided. 

Additional Resources

Published Research


DCM Resources / Reading

    Sub-group for Veterinary Professionals


General Pet Nutrition Resources / Reading

WSAVA: FAQ, Guide to Nutrition on the Internet (Dogs) (Cats)

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