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No Grain, No Gain

Good day to all our valued clients!


It is with sadness that I start my first blog, prompted by an unfortunate recent case. Last week, I saw another case of nutritional Dilated Cardiomyopathy in a beautiful, wonderful Golden Retriever from a loving family. They were doing what they thought was best for their dog, based on recommendations from pet stores and current ideology in some circles. This case of nutritional Dilated Cardiomyopathy prompted a veterinary search on my end, which resulted in me discovering that across North America as high as 40-50 percent of households feed so called ‘no-grain diets’ in hopes of providing a ‘natural, healthier’ option without corn. The veterinary community has known the risks associated with raw food for decades now, however ‘no grain’ has become a more recent option in the last decade. The FDA has reported two studies - one in 2018, and one in 2019, citing case reports from across North America related to Dilated Cardiomyopathy. Fifty percent of these dogs were fed Acana, Zignature, and Taste of the Wild, followed by smaller companies like Blue Buffalo.


Dilated Cardiomyopathy is a very difficult heart disease that can result in heart failure very quickly. Most of our medications have only small effects in extending life and improving it. Taurine deficiency is the underlying reason behind this disease, directly related to feeding pea/lentil/sweet potato combinations. Sadly, this disease is growing rapidly in relation to the popularity of these diets. Furthermore, most of the patients fed these diets are underweight and HUNGRY, leading to immunosuppression and behavioral problems. If you see and feel ribs on your dog, please know they are undernourished. Look at the formula you are feeding. We recommend feeding a large brand name company like Royal Canin, Hill’s Science Diet, Eukanuba/Iams, or Purina. These companies will provide balanced, tested, and researched diets, with regular quality control checks. The risks from contamination and deficiencies are much less than with other pet food products. You can find most of these brands at pet stores, although you may have to search at the back of many! Our vet nutrition store stocks Royal Canin veterinary diet and our staff can assist you in finding the right selection. We use the veterinary diets to treat, and prevent disease because they work, often as replacements for medications. If your dog has been on a no-grain diet now for some time, switching to a veterinary diet will stabilize taurine levels. However, any large brand name diet will as well.


Don’t hesitate to contact us to assess your dog’s body condition score, and nutritional needs. We are here to ensure your happy loyal friend gets the best chance ever at a great quality of life with you!


Thank you for your patronage!


Kind regards,

Dr. Eva Dudzic


Diet-Related Myocardial Failure in Dogs

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July 20, 2018 (published) | May 5, 2021 (revised)

Mark Rishniw; Paul Pion; Mark Kittleson




Introduction


In 2018, anecdotal reports emerged that some grain-free diets, or diets containing legumes as the main non-meat component, were resulting in taurine deficiency and potentially contributing to dilated cardiomyopathy (DCM).  However, as the situation evolved, several groups of cardiologists have investigated this issue and have not come to a conclusion regarding how these diets cause DCM — some have implicated these diets causing taurine deficiency in a specific breed (e.g. Golden Retriever) (Olsen 2018) (Morris Animal Foundation 2017), while others have shown a relationship between the implicated diets and DCM but failed to find an association with taurine deficiency (Adin et al 2018).  Here's what we know so far.



What is the latest information about myocardial failure and grain-free diets?

Which diets have been implicated?

Is taurine thought to play a role in the grain-free-diet-associated myocardial failure?

What should I do if a client is feeding grain-free diets to their dog(s)?

How much taurine should I supplement?  Can I overdose with taurine?

What resources are available for me and my clients?


What is the latest information about myocardial failure and grain-free diets?


In July 2018, the FDA first issued a warning about diet-associated DCM in dogs.  This was based on observations of veterinary cardiologists, and reports to the FDA of "untoward" cases.  Several cardiologists have investigated this issue and have not come to a single conclusion — some have implicated diets and taurine deficiency in specific breeds (e.g. Golden Retrievers) (Olsen 2018) (Morris Animal Foundation 2017), while others have shown a relationship between the implicated diets and DCM but failed to find a strong association with taurine deficiency (Adin et al 2018).


In June 2019, the FDA updated their warning about grain-free diets and DCM. In this report they provided data about the number of reports submitted, the breeds affected, and the companies most commonly involved. .



Which diets have been implicated?


Multiple grain-free diets made by smaller dog food manufacturers have been implicated.  The June 2019 FDA report provides a list of pet food brands that have been most commonly implicated.  Almost 50% of the cases reported to the FDA were being fed Acana, Zignature or Taste-of-the-Wild diets.  However, 13 other companies' diets were also listed.




FDA analysis of the diet composition found that 91% of cases of DCM potentially due to diet were being fed a "grain-free" diet, and 93% had peas/lentils as the major grain substitute.




In one study, Kangaroo and Red Lentil diet was implicated (Adin et al 2018).  Therefore, rather than focusing on specific brands, clinicians should focus on the main ingredients in any "grain-free" diet.  Clinicians should note that several companies manufacturing such diets have started to address the concerns by producing marketing literature and possibly changing diet composition, but this does not mean that a particular diet is "OK".  If it's grain-free and legume-based,and not a prescription diet for a specific clinical problem, then it is considered a suspect diet.


It is important to note that no prescription diets that are nutrient-restricted (i.e., from the major prescription diet manufacturers) have been implicated or reported in sufficient numbers to warrant listing by the FDA.



Is taurine thought to play a role in grain-free-diet-associated myocardial failure?


Early in the investigation of grain-free diets and DCM, taurine was considered a potential cause.  This was likely due to a high proportion of Golden retrievers being identified with myocardial failure.  This breed is known to have issues with taurine metabolism (Kaplan et al 2018, Ontiveros et al 2020). However, subsequent investigations failed to find that association (Mansilla et al 2019, Adin et al 2021, Donadelli et al 2020).  Therefore, currently, unless the breed is one that is recognized as susceptible to taurine deficiency, taurine analysis is not recommended.  Many, however, still do supplement taurine.  



What should I do if a client is feeding grain-free diets to their dog(s)?


There are several options that clinicians can consider, depending on the clinical presentation.


For dogs without cardiac clinical signs that appear healthy, changing the diet is the simplest and most conservative action until more definitive information relating to this emerging pattern is discerned.

If the owners do not wish to change the diet as a preventive measure without more information, consider an echocardiogram and testing taurine concentration in plasma and whole blood (see this link for sampling methods and submission requirements) if the dog is of a breed susceptible to taurine deficiency.

If myocardial failure is identified, change the diet and consider taurine supplementation if the dog is of a breed susceptible to taurine deficiency.

If taurine concentration is low, change the diet and initiate taurine supplementation.

Repeat the echocardiogram in 4 to 6 months to assess resolution of the myocardial failure.

Report your findings to the FDA.

If the owners do not wish to change the diet or perform an echocardiogram, and the dog is not of a breed predisposed to taurine deficiency, warn the owners of the risks of this activity.  If the dog is of a predisposed breed, consider measuring or supplementing taurine.



What is the prognosis for dogs with  myocardial failure associated with grain-free diets?


One multicenter study examined this question (Walker et al 2021).  The dogs in this study all had DCM and CHF associated with either grain-inclusive or grain-free diets.  Dogs on grain-free diets that had their diets corrected had better outcomes than dogs that had grain-inclusive myocardial failure (i.e. dogs that had traditional DCM).  However, the duration of feeding a grain-free diet prior to correction impacted prognosis, suggesting that the sooner the issue is recognized and corrected, the better the prognosis.  However, even dogs in which diets were corrected had a median survival of 1 year - lower than would be expected for a healthy (or fully-recovered) dog population.  This suggests that once in CHF, the disease is not completely reversible in all dogs, that dogs with severe disease will likely succumb to the CHF before the dietary change has a chance to take effect, and that some dogs might relapse despite dietary correction.


No studies exist showing the outcomes or prognosis for dogs that have subclinical myocardial failure associated with grain-free diets after dietary adjustment.



What resources are available for me and my clients?


You can refer your clients to Lisa Freeman’s blog that discusses this issue in detail.

The UC Davis website also has a page discussing the issue and the studies that are currently under way.


References


Journal Articles


Adin D, Freeman L, Stepien R, Rush JE, Tjostheim S, Kellihan H, Aherne M, Vereb M, Goldberg R. Effect of type of diet on blood and plasma taurine concentrations, cardiac biomarkers, and echocardiograms in 4 dog breeds. J Vet Intern Med. March 2021;35(2):771-779. 


Donadelli RA, Pezzali JG, Oba PM, Swanson KS, Coon C, Varney J, Pendlebury C, Shovelle AK. A commercial grain-free diet does not decrease plasma amino acids and taurine status but increases bile acid excretion when fed to Labrador Retrievers. Transl Anim Sci. July 2020;4(3):txaa141.


Kaplan JL, Stern JA, Fascetti AJ, Larsen JA, Skolnik H, Peddle GD, Kienle RD, Waxman A, Cocchiaro M, Gunther-Harrington CT, Klose T, LaFauci K, Lefbom B, Machen Lamy M, Malakoff R, Nishimura S, Oldach M, Rosenthal S, Stauthammer C, O'Sullivan L, Visser LC, Williams R, Ontiveros E. Taurine deficiency and dilated cardiomyopathy in golden retrievers fed commercial diets. PLoS One. January 2018;13(12):e0209112.


Mansilla WD, Marinangeli CPF, Ekenstedt KJ, Larsen JA, Aldrich G, Columbus DA, Weber L, Abood SK, Shoveller AK. Special topic: The association between pulse ingredients and canine dilated cardiomyopathy: addressing the knowledge gaps before establishing causation. J Anim Sci. 2019 Mar 1;97(3):983-997.


Ontiveros ES, Whelchel BD, Yu J, Kaplan JL, Sharpe AN, Fousse SL, Crofton AE, Fascetti AJ, Stern JA. Development of plasma and whole blood taurine reference ranges and identification of dietary features associated with taurine deficiency and dilated cardiomyopathy in golden retrievers: A prospective, observational study. PLoS One. 2020 May 15;15(5):e0233206.


Walker AL, DeFrancesco TC, Bonagura JD, Keene BW, Meurs KM, Tou SP, Kurtz K, Aona B, Barron L, McManamey A, Robertson J, Adin DB. Association of diet with clinical outcomes in dogs with dilated cardiomyopathy and congestive heart failure. J Vet Cardiol. February 2021;0(0):.


Proceedings


Adin D, DeFrancesco T, Keene B, Tou SB, Meurs K, Atkins CB, Aona BB, Kurtz KB, Barron LB. Echocardiographic Phenotype of Canine Dilated Cardiomyopathy Differs Based on Diet. ACVIM Forum 2018.


Rounds and Other Resources


1.  Olsen J. Taurine Deficiency Induced Dilated Cardiomyopathy in Golden Retrievers. 2018


2.  Morris Animal Foundation. Researchers getting closer to understanding dietary taurine and heart disease in dogs. 2017


3.  Measuring Taurine — VIN Medical FAQ


4. How to report a pet food complaint to the FDA.

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