This episode is made possible ad-free with the support of the Purina Institute!
We have a wonderful (but anxious) German Shepherd with chronic diarrhea that just isn’t going away. Her owners would like to handle this without medications if possible. Veterinary nutritionist Dr. Raj Naik is here to talk about the case, our options, and the importance of considering the microbiome as we treat GI disease.
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LINKS
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ABOUT OUR GUEST
Dr. Raj Naik developed a special interest in clinical nutrition while at the Virginia-Maryland College of Veterinary Medicine. After completing a rotating internship at a large specialty hospital in New Jersey, his love of nutrition brought him to the University of Tennessee to pursue specialty training in small animal clinical nutrition. Dr. Naik joined Nestle Purina shortly after completing his residency. As a Veterinary Communications Manager and one of several board-certified veterinary nutritionists at Purina, Dr. Naik serves as a liaison between Purina and the veterinary community. Outside of his day job, Dr. Naik recently served on the Board of Regents for the American College of Veterinary Nutrition. In his free time, you will find Raj attempting to entertain his son along with his wife, dog, and two cats.
EPISODE TRANSCRIPT
Dr. Andy Roark:
This episode of the Cone of Shame Veterinary Podcast is made possible ad free by our friends at Purina Institute.
Dr. Andy Roark:
Welcome, everybody, to the Cone of Shame Veterinary Podcast. Guys, we’ve got a great episode today. It’s me and my friend board veterinary nutritionist, Dr. Raj Naik. And we are talking about a poor German Shepherd with chronic diarrhea and anxiety. I love the GSDs, they tend to be anxious dogs, and anxious dogs tend to have soft stools sometimes. What do we do about it? How do we break this thing down from a nutrition standpoint? Let’s get into this episode.
Kelsey Beth Carpenter:
(singing) This is your show, we’re glad you’re here, we want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.
Dr. Andy Roark:
Welcome to the podcast, Dr. Raj Naik. Thanks for being here.
Dr. Raj Naik:
Thanks for having me.
Dr. Andy Roark:
Oh, my pleasure. My pleasure. I’m super excited to talk to you today, I love having you on the podcast. I have a case that I want to break out with you. You up for this?
Dr. Raj Naik:
Absolutely. I love cases.
Dr. Andy Roark:
All right, perfect. I have an interesting one. I have a five year old female, spayed German Shepherd named Aspen, who she’s a chronic diarrhea dog. Well, I see this client a lot, they’re in and out. Aspen is an anxious dog, she’s a clinger, she barks when moms leaves, just a regular high strung German Shepherd that keeps having these bouts of diarrhea.
Dr. Andy Roark:
Mom is a bit of a naturopath. Not, not over the top, she doesn’t hate medications or anything that, but she is having some concerns about continuing just to medicate this dog to deal with diarrhea. She wants something that’s going to be sustainable, that’s going to help get these outbreaks under control. That just doesn’t feel so heavy handed to her. And so I wanted to bring that to you and have you coach me through this. Raj, how do you treat that?
Dr. Raj Naik:
Oh man, so this is such a good case because this is, I think a classic case that you’re going to see in general practice. And of course, we’re going to go through the initial diagnostic workup of what can we do to figure out what is the chronic diarrhea? What is the cause of the chronic diarrhea? What is the main root cause of these anxiety concerns? But, as a nutritionist, I almost immediately go to what’s going on with this dog’s microbiome? How can we modify this dog’s microbiome to help whatever other treatment we’re going through? And so I think about things like probiotics and prebiotics and how we can actually modify that dog’s microbiome to help enhance their recovery.
Dr. Andy Roark:
Okay. All right. Let’s unpack this because you jumped to … It was interesting that your mind went there. That’s not where my mind went so I want to walk with you. So high level real quick, give me a breakdown. Your mind goes straight to microbiome, tell me about that. Define some terms for me, give me an idea of why in the disease process your mind goes here.
Dr. Raj Naik:
Yeah. The microbiome is really interesting, especially in this particular case because we have a behavioral issue as well as a GI issue. And the microbiome is, the definition is the collection of microorganisms and their genes and the microenvironment that they’re in, in a specific area. And for this particular dog, I’m thinking is GI tract. So this dog’s GI tract is the home to a lot of beneficial bacteria, as well as some potentially pathogenic bacteria that is, it’s kept in balance normally. And when that balance shifts, we can potentially run into health issues, like maybe we’re seeing in this dog. So what that shift is called, it’s called a dysbiosis. We can correct that dysbiosis, then maybe we can have an effect on this dog’s particular issues.
Dr. Andy Roark:
Okay. So I think about what I know about microbiome and we talk about the GI tract being the gut shock organ for dogs, is that why the anxiety does that? Is that why that plays into your assessment in this case?
Dr. Raj Naik:
Yeah, absolutely. So, you hear this term like, “Oh, I have a gut feeling about this particular subject that we’re talking about”. There is a true actual gut feeling because there is a vagus nerve running from your GI tract up to your brain. And so there is a strong influence from the microbiota that are in your GI tract on your brain function through various metabolites, through various neurotransmitters. And what’s interesting is we now know that with certain probiotics, you can actually affect brain function by altering GI microbiome. And so for this dog, I’m thinking, oh, I have this back of my mind, all this research on, say for example, a Bifidobacterium longum bacteria, BL999. And if I can use it as a probiotic in this dog, then potentially I can help mitigate some of those anxious behaviors that we’re seeing.
Dr. Andy Roark:
Okay. Are there diagnostic approaches that you take to look into this? Do you start empiric treatment and see if you get results? How do you start to unpack that?
Dr. Raj Naik:
The nice thing about some probiotics is they’re very, very safe and so you can start them right off the bat without necessarily doing indices ahead of time. But that being said, if you’re trying to really work up this dog, there are things like a gut Dysbiosis Index that can be very beneficial before and after you start treatment to say, “Hey, this treatment is actually working to help stabilize that gut microbiome and we’re it to a place where we really want it”.
Dr. Andy Roark:
Okay. Talk to me a bit about probiotics. Walk me through a little bit of the science of probiotics in general and then specifically how we start to introduce them in a case like this. How do we bring that across to the pet owners?
Dr. Raj Naik:
Yeah. So probiotics are a bit mysterious, you hear all this kind of hoopla around them and you don’t really necessarily know how they work. The whole goal of probiotics is to change that micro-environment in wherever you’re administering them. So in this case, we’re going to change the micro-environment of the gut. So those probiotics are going in there, they’re competing for nutrients with those potential pathogens, they’re physically blocking the pathogens from attaching to the GI tract epithelium. They can produce antimicrobial compounds and metabolic products that can actually fight off those pathogens. And when we are trying to figure out what probiotic to use, there’s a few actual considerations that we want to take. There was a study done a few years ago by a gentleman named Scott Weiss, who does a lot of this infectious disease research.
Dr. Raj Naik:
And he looked at a few labels of 25 different probiotics on the market for veterinary species. And he found actually that only two, two of the 25, had a label that was accurate and actually accurately described the contents of that particular probiotic. Which leads to a conversation about regulation by the FDA and things like that. But the point is, we’re looking for something that is safe, it’s viable, it’s going to be alive when you actually administer it to the animal and it’s efficacious. So how much research has gone into that particular strain of probiotic? And is it done by a reputable company because that’s really key, quality and safety, efficacy.
Dr. Andy Roark:
Okay. So, yeah. All right, that makes sense. When we start to administer to our patients and things, how many set expectations for the clients here? So I’m going to talk to them, I’m talking to them about Aspen. I’m like, “Hey, she’s an anxious dog. We can have these things, I want to put her on a probiotic”, in your mind to put this probiotics use, is this a daily thing forever? Is this an as needed? Is it a pulse treatment and then we’re going to withdraw after we’ve reset the microbiome? What walk me through the actual mechanics of me putting this into play in a meaningful way.
Dr. Raj Naik:
Yeah. Good question. So for acute situations, potentially, we only have to do it for a certain period of time. So let’s take Aspen’s diarrhea, if it’s acute, we can do it for just a set number of day. If it’s chronic, a good probiotic is actually, what it’s going to do is it’s going to go in there, it’s going to do its thing, and then it’s going to get pooped out. And that the whole goal is we don’t want it to take up residents in the GI tract. And so because of that, you do have to use a lot of probiotics daily in order to achieve that effect long term. But that’s a good thing, that’s really, really what we want.
Dr. Andy Roark:
Okay. What’s the response time on treatment like this? Are we looking at five days, is this an immediate thing? Again, people don’t get upset about what you give to them, they get upset about the difference between what they got and what they expected to get. So I don’t want to over promise because we’ve all seen that where, I had a client call me just a couple of days ago and he was like, “Oh, you know my dog’s having these soft stools and things”, and then he listed nine different things that he had done and five different diets he’d been on. And I was like, “When did this start?”, and he’s like, “Two weeks ago”. And I’m like, “Oh, buddy, okay. We’re going to start over”. But again, that happened. And people have expectations in their mind, I want to set good expectations.
Dr. Andy Roark:
So help me understand this, when I present this as a therapeutic option, I think a lot of us send home and I’ll just be honest with this. When I comes to GI upset, diarrhea, things like that, I go back and forth with being a good antimicrobial steward and also wanting to give the pet owner something where I’m like, this is a thing that is actually addressing your problem because I want you to see value in coming in the visit. And I’m just being honest about how I have those thoughts, I know I’m not the only vet who has those thoughts. I am increasingly trying to lean on the side of good antimicrobial stewardship. I know it’s important, but I still sometimes worry. I go, what if I send them home and this persists? What if it takes too long? What if they’re impatient? What it’s not robust enough a response? And so, yeah, help me with that as far as what expectations I should set in their mind and what I can expect as the doctor treating it.
Dr. Raj Naik:
I can’t tell you how much I love that you brought up antimicrobial stewardship, because it is one of my soap boxes. I’ll start with how long. Usually if we’re talking about an effective GI probiotic and there is, this goes back to a good company doing great research. You have probiotics out there that we have control studies looking at diarrhea and acute diarrhea in dogs resolves after four and a half days with metronidazole. But if you use Enterococcus faecium, SF68, which is that effective probiotic, that resolves up almost two days earlier. So it can be highly effective very quickly and say a little over two and a half days.
Dr. Raj Naik:
But I think setting those expectations, like you brought up is so important. These aren’t miracle drugs and they’re not drugs at all. And that’s the point. So you have a situation where you may be able to resolve acute diarrhea very quickly. Some dogs have to be on this for say, a couple weeks before you’re going to see effective control of their diarrhea. And then you have another probiotic that we’re talking about with anxiety that you don’t necessarily see full effects until up to six weeks after they’ve started. So if you’re trying to manage something like fireworks anxiety, certainly you’re going to have to start that well ahead of July 4th.
Dr. Andy Roark:
Right.
Dr. Raj Naik:
Yeah.
Dr. Andy Roark:
Okay. So, yeah. So for Aspen, then we’re probably talking about a pretty significant runway, right? If we want to have maximum benefit and we continue to have diarrhea with this dog.
Dr. Raj Naik:
Yeah. And so if I may with the antimicrobial stewardship.
Dr. Andy Roark:
Please.
Dr. Raj Naik:
I think the way you’re approaching it is absolutely fantastic and I see that need between I need something that’s going to work really effectively now. And with some of those antimicrobial drugs, things like metronidazole or Clavamox, if you use a probiotic at the same time as you’re administering those, they may get killed off depending on the probiotic. There are probiotics available, like Enterococcus faecium SF68 that are not killed off by certain antimicrobials like metronidazole. And so doing the research to find out which ones actually stay alive is very important.
Dr. Andy Roark:
Okay. So talk to me a little bit about that with the antibiotics then. So you were saying, if you’re going to do antibiotic therapy and you want to do a probiotic as a supplement to that, so I’ve seen, I know with people, a lot of times we’ll take antibiotics and then start to start a probiotic to repopulate the gut. Do you recommend doing some sort of probiotic therapy through the course of antibiotics? Is this something that we want to add towards the end of the antibiotic therapy? Talk to me a little bit about the integration of antibiotics and probiotics, if we want to use them together.
Dr. Raj Naik:
Absolutely. I would start them at the same time if you can. And again, key is finding out that probiotic that actually will survive that antimicrobial. The earlier that we can institute probiotic therapy, the more like we are to mitigate that, say antibiotic associated diarrhea that we see with Clavamox. In cats, you actually see that if you start, you mentioned FortiFlora at the same time as Clavamox, you reduce the incidence of diarrhea in these cats. And so, as early as possible is my answer.
Dr. Andy Roark:
Okay. That makes sense. And then we talked about treating through the end of clinical signs. Do you usually tell people you’re in this for X amount of days, just plan on it? Do you tell them to continue beyond remission of clinical signs? So we talked about onboarding with this, where is where’s the off ramp?
Dr. Raj Naik:
Yeah. Acutely, I would say within, you could probably stop after resolution of clinical signs within three days or so. A lot of these dogs, especially this German Shepherd that we’re talking about, chances are he’s going to have to stay on it long term because he’s got some sort of German Shepherd chronic enteropathy that we would love to actually diagnose. Maybe the owner’s not going to let us this particular time. So they may need to stay on it for life.
Dr. Andy Roark:
I like this interaction between probiotics and other therapy modalities. Talk to me a little bit about how nutrition integrates into this. So you’ve got these diarrhea dogs or repeated diarrhea dogs. Are we changing that dog’s diet to something that supports GI health in the short term? Are we leaving them on their regular food to avoid transitioning back and forth? What are your thoughts on changing diet while using a probiotic, trying to get through these bouts of repeated diarrhea?
Dr. Raj Naik:
Yeah. I think that’s such an excellent point. Having the right diet there available for that dog is critical because we need to supply that probiotic with the food that it needs to do its job. And often that food comes in the form of what we call a prebiotic. Prebiotic is just a fancy term for a, usually is some sort of fiber source, a non-digestible carbohydrate that the probiotic can munch on and then create short chain fatty acids, which are beneficial to the host and sustain itself that way. And so if we’re providing the right food for not only the probiotic, but for the pet him or herself, that could go a long way in resolving some of the issues that we’re seeing. What’s interesting about microbiome research and diet is that when you shift, when you change a dog’s diet to something completely different, their microbiome shifts with that diet.
Dr. Raj Naik:
And so in the short term, if you were to change to a highly digestible diet, which is often what we’ll use for this chronic diarrhea patient, then you are potentially shifting that microbiome back to, closer or to the baseline for that dog. Oftentimes these dogs need to stay on that diet long term in order to maintain that good microbiome level for them. But you may be able to change it back once they’re actually a little bit better. Or, what diet am I going to choose for this dog? I think is probably where you’re hoping to go [inaudible 00:18:03]. Yeah.
Dr. Andy Roark:
Yeah. That’s why we’re starting to drill into this. I’m seeing some, you’re advocating it seems a more high fiber diet, as opposed to some of the, I don’t know, more easily digestible, fully digestible diets. So, yeah.
Dr. Raj Naik:
Yeah.
Dr. Andy Roark:
Talk to me about that.
Dr. Raj Naik:
I think that, so starting out a highly digestible diet doesn’t necessarily mean that it doesn’t have any fiber in it. So, that-
Dr. Andy Roark:
Right. I didn’t mean to, I know, I heard that coming out of my own mouth. I’m like, that’s not exactly what I’m getting at. But, yeah.
Dr. Raj Naik:
No, it’s confusing. It’s confusing. You hear this term highly digestible and you think, oh, well, it’s just chicken and rice, right?
Dr. Andy Roark:
Yeah. I’ll be like, that is the metaphor in my mind. When you say, explain this to the pet owner in a simple metaphor that they’re going to get. I taught to them about chicken and rice, just in a metaphorical sense, not in an actual sense. But I’ll be honest and say that’s what’s in my mind.
Dr. Raj Naik:
Yeah, absolutely. And I think that’s a good metaphor. What we remember with these therapeutic, highly digestible diets is they’re complete in balance. So you can feed these diets long term to these pets and they’ll be usually totally just fine as long as they’re formulated for adult maintenance. But if we have a dog that isn’t necessarily responding to that highly digestible, complete and imbalanced diet, the next place I would go is that high fiber diet that you were talking about. If this dog has a large bowel diarrhea, that’s where I’m going. And I think that’s an overlooked therapeutic modality for a lot of these dogs, especially this German Shepherd. He’s most likely got, just based on his signal, he’s most likely got a large bowel diarrhea.
Dr. Andy Roark:
Right. Is that a breed specific? Because when I see the German Shepherds, it immediately goes to it. The big thing is, it’s a luxury dog, for whatever reason, I’m immediately going to large bowel. And then the other thing is when I see, and again, correct me if I’m wrong here, but when I see those 10, 11 month old puppies that are just having ongoing diarrhea fiber responsive colitis, things like that into my mind, just based on the age of the pet. First of all, is that accurate? And then second of all, are there other signals that really make you think large bowel?
Dr. Raj Naik:
Yeah. I think that’s a really good example and a good watch out because if you have a 10 month old puppy that is having large bowel diarrhea and chances are, if it’s this breed, yes, you’re right. That is what we’re seeing. We have to be careful with those higher fiber diets that I was talking about because some of them are not formulated for puppies. We have a high protein requirement in these dogs, we have other macronutrients, micronutrients that we have to have at certain levels. And the fiber sometimes gets in the way of absorbing some of those nutrients. So what I always do is look at the patient in front of me. What what can I do for this particular patient? What have I tried already? And do I maybe need to consult with a nutritionist to come up with a plan to make sure that this dog is getting what they need?
Dr. Andy Roark:
So when you see those cases again, so especially, let’s talk about the young dogs. And we say, hey, we’ve got these young dogs, there’s an ongoing problem, we’re trying to increase fiber, we’re still want to make sure that growth needs are being, things like that. We need to talk to the nutritionist. How do you bring that to the client? How do you say to them, hey, I know you think this is just some soft stool that’s going on and on, but we need to bring this other person in and really start to get serious. How do you broach that conversation? How do you get them on board with the changes that we’re making? Because now we’re no longer talking about grocery store dog food, we are a hundred percent into the realm of like, okay, this is nutrition and we’re doing this and your dog is special. At least in the short term, give me some communication approaches to help people explain it and to get pet owners on board with going on this journey with me.
Dr. Raj Naik:
Absolutely. It’s such a good question because I think a lot of people struggle with this in practice, is talking about nutrition as a therapeutic modality. One, talking about it as a therapeutic modality and two, talking about it as a diagnostic tool potentially. So, the third option that we haven’t talked about yet is a hydrolyzed or elemental type diet, where we are trying to figure out if this dog has a IBD or a food allergy or something like that. And so I always talk to owners about this being something that they’re doing every day already. Number one, you have to feed your dog and two, something that we can use as a tool in the toolbox. We’re going to look at the animal as a whole and tackle things from all different angles. And I think most owners are happy once you explain to them that you’re using it as a therapeutic tool and a diagnostic tool. Are happy to go down that road with you at least for a little while. And you say, let’s reevaluate this in a month and see what’s happening.
Dr. Andy Roark:
No, that makes sense. I do appreciate that. Okay, good. All right, cool. I’m feeling pretty good about where we are with Aspen. I think I can work with mom and explain to her what the plan is and why the plan is, I think I can meet her needs. Are there any last words of advice? Are there any pitfalls I need to look out for? How do you see GP’s get this wrong? What can she talk me into that’s ultimately a bad idea or where do I go off the rails here and get myself in trouble?
Dr. Raj Naik:
Yeah, and it’s not necessarily that you… It’s not your fault, it’s nobody’s fault. It’s just that we’re busy. The follow-up, the follow-up is really what’s critical. So I can send a bag of dog food home with this client, or a probiotic home with this client and say, good luck. Or I can have a technician call them back in, say a week or two weeks and work through any issues that they might be going through. I’ll use a completely separate disease process as an example, but obesity is the number one disease that I see a problem with this for. So we send home a bag of dog food, we say, good luck, we’re going to get some weight off your dog. Then the owner gives up a weekend because they can’t deal with the begging, they can’t deal with not giving treats to their dog or giving fewer treats. And then you check back three months later and they haven’t done anything with the actual plan. And same goes with any other disease process that we’re going through. So the follow-up is key.
Dr. Andy Roark:
No, that totally makes sense. Awesome, Raj. Thanks for being here. Where can people learn more if they’re getting a lot out of this and they want to dig deeper, you and I just touched on the microbiome concepts and the science that’s there. I know that there is a lot of information education coming out in this realm. Help people get started unpacking this and exploring more.
Dr. Raj Naik:
Yeah, there are fantastic resources on the purinainstitute.com. So purinainstitute.com, and then if you’re interested in the microbiome, there’s a microbiome forum tab that you can click on and deep dive into all of this. If you’re interested in learning more about those conversations that you brought up, Purina Institute has a lot of resources to help you have those conversations about nutrition with owners. And I really, I point this website out to students to general practitioners, to specialists often to say, here’s how to talk about nutrition. So I’m a huge advocate for that platform and it’s called Center Square. That can be found on Purina Institute.
Dr. Andy Roark:
All right, thank you very much. I’ll put links to all this down in the show notes. Thanks for being here and thanks for your help.
Dr. Raj Naik:
Thanks for having me. I really appreciate it.
Dr. Andy Roark:
And that is our episode. Guys, I hope you enjoyed it, I hope you got something out of. I did, I like this episode. I was jotting notes down, this is stuff that I’m going to use in the exam room. Guys, thanks again to my friends at Purina Pro Plan Veterinary supplements for making it possible for us to bring this to you. Gang, take care of yourselves. Be well. I’ll talk to you soon. Bye.
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