Nutritional consulting in regular veterinary practices in Belgium and the Netherlands

Abstract Background Increased interest in nutrition by dog and cat owners stresses the importance of providing tailored nutritional guidance for each patient by veterinarians. The World Small Animal Veterinary Association (WSAVA) has provided guidelines to help veterinarians implement this in every‐day patient care, by screening patients for the presence of nutritional risk factors, establishing tailored nutritional plans and providing adequate patient follow‐up tools. Objectives This study aimed to assess the use of nutritional assessments in companion animal practices, and to investigate differences between Dutch and Belgian veterinarians. Methods A survey was conducted among Dutch and Belgian veterinarians. Of the 423 respondents, 53% were from Belgium, and 47% were from the Netherlands. Results Only 21% had prior knowledge of the WSAVA nutritional assessment guidelines. General trends in the usage of nutritional assessments were similar in the examined countries. Aside from weighing, diet evaluation by collecting dietary information and body condition or muscle condition scoring were used infrequently, mostly due to insufficient knowledge of the methods. Nutritional recommendations were often made as part of a treatment plan, and were mostly made by veterinarians, but in Dutch practices also by veterinary nurses. Conclusion Despite the fact that nutritional recommendations are a regular part of treatment plans, nutritional risk factors may be missed due to a lack of completely performed nutritional assessments. It remains important to promote the benefits of regular nutritional assessments to veterinarians, which will improve patients’ health.


INTRODUCTION
Nutrition is an important topic in veterinary practice (Bergler et al., 2016;Vandendriessche et al., 2017). Increased awareness of nutritionrelated diseases and popularity of alternative diets have made veterinarians indispensable for early detection of nutritional imbalances and risk factors (Dillitzer et al., 2011;Laflamme et al., 2008;Rajagopaul et al., 2016). Hence, it is essential for veterinarians to provide tailored nutritional guidance for each patient at every consultation to provide optimal patient care (Freeman et al., 2011).
To aid veterinarians in incorporating complete nutritional assessments in regular patient care, global nutritional assessment guidelines were developed by the World Small Animal Veterinary Association (WSAVA) (Freeman et al., 2011). These guidelines describe inclusion of nutritional assessment as the fifth vital assessment in regular patient care. This starts with identification of nutritional risk factors for disease through a complete dietary and lifestyle history, and bodyweight and body composition assessment through body condition and muscle condition scoring. Evaluation of these factors results in tailored nutritional recommendations, a feeding management strategy, and a followup plan with regular monitoring and compliance assessment.
Despite these efforts, routine implementation of nutritional consultations and assessments remains limited, and dietary recommendations are often provided after development of nutrition-related diseases (Bergler et al., 2016;MacMartin et al., 2015;Rolph et al., 2014;Siebert et al., 2016). For instance, routine assessment of body composition is uncommon; therefore, leaving development of sarcopenia or obesity to go unnoticed, impairing nutrition's preventive role (Bruckner & Handl, 2020;Freeman, 2012).
Most of the aforementioned studies describe specific parts of nutritional assessment, and vary in study design. For instance, some included estimates of veterinarians or pet owners (Bergler et al., 2016;Siebert et al., 2016;Vandendriessche et al., 2017), while others included objective conversation analysis of consultations (Mac-Martin et al., 2015) or retrospective analyses of patient files (German & Morgan, 2008;Rolph et al., 2014). These differences make them difficult to compare and draw conclusions on the integration of nutritional assessment in clinical practice. Additionally, the diversity in geographical locations could limit extrapolation of the results to other countries, as veterinarians in different regions are expected to have different attitudes and education in small animal nutrition (Becvarova et al., 2016). Thus, this study was conducted to assess the incorporation of the methods as described by the WSAVA nutritional assessment guidelines (Freeman et al., 2011) in veterinary practices in Belgium and the Netherlands. Furthermore, differences between both countries regarding nutritional assessments were studied.

Data collection
An anonymous web-based questionnaire (www.surveymonkey.com) was distributed to Belgian and Dutch veterinarians via dedicated social media groups and the newsletter of Utrecht University, the Netherlands. As the WSAVA nutritional assessment guidelines are mostly aimed towards dogs and cats veterinarians that treat animal species other than dogs and cats as the majority of their patients were excluded from this study. The survey was accessible between May and June 2016 in Belgium and between February and May 2018 in the Netherlands.
Complete sections of incomplete questionnaires were included in the analysis.

Survey
The survey consisted of three main sections, with a total of 66 multiple choice and open-ended questions. The first section of the survey consisted of 17 questions about practice demographics (Appendix).
Estimates of the proportion of cats, dogs, and exotic animal species as percentage of the responding veterinarians' total number of patients on a yearly basis were obtained. These questions were followed by inquires on the number of staff and their function in the respondent's practice, their years of experience since graduation, and whether any members of the veterinary health care team were specifically responsible for nutritional consultation. If applicable, the educational background of this team member was asked. Lastly, participation in nutrition-focused continuing education was explored.
The second section consisted of 25 questions about nutritional screening. The veterinarians were asked to provide estimates on the frequency in which they measured and registered weight, body condition score (BCS) and muscle condition score (MCS) of their patients, the specifications on the used scoring system, and to specify reasons for infrequent use of these methods. Next, estimates on the use of specific dietary history questions, such as the type of food that is being fed to the patient and the food amount, and the use of nutritional surveys were obtained. The respondents were also asked whether they were familiar with the WSAVA nutritional assessment guidelines.  (Kim, 2017). Statistical significance was set at p < 0.05 and trend results as 0.05 < p < 0.10. Data were presented per country when a significant or trend difference between countries was found.

Respondent population
An overview of the participating respondents' practices is presented in  Approximately half of the clients were estimated to initiate feeding according to the prescribed feeding plan, and approximately half of these clients completed the dietary regimen. Feeding costs were considered the main reason for non-compliance (Table 7). The respondents also suggested difficulty to maintain a strict diet, cheaper and more easily acquirable other foods, conflicting nutritional recommendations from others such as a breeder or friend, or a lack of long-term motivation, as common reasons for non-compliance.

TA B L E 3
Overview of the estimated percentages of consultations in which the respondents document nutritional evaluation methods in the patient's record after assessment, and comparisons between Belgian and Dutch respondents Use of other nutritional assessment is enough 29 11.1% 15 6.4% Abbreviations: BCS, body condition score; MCS, muscle condition score.
The respondents commonly indicated differences in the amount of food that had to be fed, for example the ability to feed more kibble in weight loss diets while retaining the same caloric intake, and recommended gradual transition to the new diet to increase compliance (Table 8). Nutritional recommendations were commonly monitored by follow-up consultations and telephone calls (Table 9).

Client education
Many respondents educated their clients on the risks of becoming overweight after neutering and recommended adjustments to the animal's diet, whereas growth-related nutritional risks were discussed less often (

DISCUSSION
Veterinarians play a key role in providing nutritional guidance for their patients, as the veterinary health care team is an important source of nutritional information for pet owners (AAHA, 2003;Schleicher et al., 2019). However, this study shows that nutritional assessment, as described by the WSAVA nutritional assessment guidelines (Freeman et al., 2011), is often omitted during consultation in veterinary practices in Belgium and the Netherlands. These trends tended to be similar in both countries, with differences mainly being present in practice demographics. Even though most data consisted of estimations by

TA B L E 9
An overview of the different methods that are used by the respondents to increase compliance of dietary recommendations and a comparison between Belgian and Dutch respondents, and the association with factor 'country' (NL: N = 86; BE: N = 171)  (Bergler et al., 2016;Bruckner & Handl, 2020;Lumbis & de Scally, 2020). As such, it has been suggested that veterinarians would assess nutrition only when it was relevant to the patients' presenting complaint (Bruckner & Handl, 2020). The same situation applied to our respondents in the case of BCS assessment.

Method of motivation
The irregularity in which complete nutritional assessments were performed might cause nutritional risk factors to go unnoticed, and has significant consequences for patient care (Bergler et al., 2016;Vandendriessche et al., 2017). For instance, failure to identify animals that are routinely fed unbalanced diets can lead to diet-induced disorders, thus impeding patient health (Dillitzer et al., 2011). On the other hand, unnoticed dietary risk factors limit opportunities of early dietary intervention. In fact, animals in specific life-stages and animals with cardiovascular disease obtained the least recommendations in the current study, even though these conditions are frequently associated with nutritional risk factors such as sarcopenia and cardiac cachexia, respectively (Freeman et al., 2003;Freeman, 2012;Gompf, 2005;Willems et al., 2017). Additionally, many respondents did not include supplementations of essential nutrients when recommending an HCD, raising the question whether long-term use of an incomplete HCD is recognised as a nutritional risk factor. Eventually, failure to recognise nutritional risk factors can directly affect a patient's health and quality of life (Freeman et al., 2011), which is prevented by regular use of complete nutritional assessments (Bergler et al., 2016;Vandendriessche et al., 2017).
A lack of detailed nutritional knowledge and a feeling of incompetence in nutrition have been suggested to limit nutritional assessments and nutrition-related discussions with animal caretakers during consultations (Bergler et al., 2016;Siebert et al., 2016). Indeed, many respondents indicated having insufficient knowledge about body composition assessment methods, which might signal a lack of general nutritional knowledge. Aforementioned can result in a reactive instead of a pro-active attitude towards nutrition, as was found previously (Bergler et al., 2016). This attitude can have further consequences in owner compliance and adherence to nutritional recommendations, as it causes uncertainty in owners about the benefits of dietary change (Abood, 2008;MacMartin et al., 2018). Currently, compliance and adherence to dietary recommendations were estimated as being moderate, with costs as a common reason of non-compliance.
As owners willingly endure costs of veterinary care if they perceive that their animals' well-being or health is positively affected (Coe et al., 2007), a lack of concise and clear communication on the costs and the anticipated effects of nutritional recommendations may exist (Wayner & Heinke, 2006). Improving nutritional knowledge in veterinarians is therefore essential to increase confidence in nutrition-related skills and communication and will result in an increased detection of nutritional risk factors and in improved owner compliance to nutritional recommendations.
The WSAVA guidelines can aid veterinarians in the process of incorporating nutrition in regular patient care, as they provide a clear overview of complete nutritional assessments and their use (Freeman et al., 2011). Since their release, the guidelines have been expanded with the t'Global Nutritional Toolkit' , which provides extensive supporting materials, such as videos on body composition assessment and dietary history forms (WSAVA, 2021). The nutritional assessment guidelines have been integrated in various nutrition-related continuous education courses since their release, and are widely propagated via the WSAVA. Still, the majority of the respondents were unfamiliar with the guidelines, and similar findings were reported previously (Lumbis & de Scally, 2020). Thus, it is essential to increase awareness on the guidelines. This may be achieved by continued inclusion of nutritional assessment as a fifth vital assessment in continuing education, including non-nutrition focused lectures and veterinary conferences, but also by expanding the role of nutrition in veterinary curricula (Becvarova et al., 2016;Lumbis & Scally, 2020). Another way the WSAVA may improve its reach is by collaboration with practice management software companies, to incorporate nutritional assessment as a (mandatory) field in patient records to increase the frequency of performed nutritional assessments.
There was a little difference between Belgian and Dutch respondents when considering the usage of nutritional assessments. Some differences were found in the nutritional recommendations for disease, and the means of follow-up after recommending dietary change. These differences may be related to practice demographics, as Dutch practices tended to be larger and could allow for outsourcing of nutritional consultation to other employees. As such, Dutch veterinary nurses were responsible for approximately one-fifth of all nutritional recommendations, suggesting lower involvement of Dutch veterinarians in nutrition. The influence of other factors, such as disease prevalence, differences in the years of experience of veterinarians in the sampled populations, an altered approach to nutrition in curricula (Becvarova et al., 2016) and attitudes of owners and veterinarians towards nutrition (Abood, 2008), cannot be excluded. Between-country differences, however, were only moderately associated with the factor 'country' , and it is to be expected that the cause of the differences is multifactorial. The current findings matched the results found previously in Germany (Bergler et al., 2016;Bruckner & Handl, 2020) and the United Kingdom (Lumbis & de Scally, 2020), and it is possible that the same factors apply for multiple countries, warranting further study. tions. For instance, the percentage of HCDs in which a board-certified nutritionist was involved was not determined, and the time for which these unbalanced diets were prescribed was not clear. Our findings may therefore differ from the actual situation. Finally, the current study did not address the specific factors that influence the use of nutritional consulting. As such, this may prove a direction for future studies in order to find specific solutions to increase the use of nutrition in everyday practice.
In conclusion, the current data showed that nutritional assessment as described by the WSAVA nutritional assessment guideline was scarcely integrated in clinical practice. Most notably, nutritional evaluation by discussing diet and assessment of the animal's body composition were carried out irregularly, even though nutritional recommendations were often implemented in treatment plans. As a result, patients without clinical signs may be at risk of nutrition-related disease due to underdiagnosed nutritional risks. General trends in the usage of nutritional assessments were similar in the examined countries, offering the possibility that the use of nutritional consulting is affected by the same factors in different countries. This offers the possibility to identify potential barriers to implement nutritional assessments in veterinary practices across countries. As veterinarians play a key role in identifying poor nutritional management or poor nutritional status, efforts to raise awareness on the importance of regular nutritional assessments should be continued. This includes additional education of students, but also extended post-graduate trainings.

APPENDIX
Survey containing questions about nutritional consulting in veterinary practice

Questions Answers
Composition of the practice

Questions Answers
Healed according to the owner Open answer Other reason Open answer 54 Please specify any other reason that is being used by the owner to stop the diet: Open 55 In how many cases is a home-made diet recommended as a (part of) a therapy?
Open 56 When a home-made diet is recommended, how do you choose the composition of this diet?
After consultation with a diplomate in nutrition The risk of the development of overweight The necessity to reduce the amount of food or changing to a diet with a lower energy density 65 Specific for growing dogs and cats: how many owners are informed about: Necessity to give nutrition that has been developed to support a growing animal The correct time to switch to adult nutrition The risks of giving too many snacks during growth The risks of giving supplements during growth 66 Which of the following information moments are organised by the practice?
Puppy and/or kitten parties

Obesity clinics
Behavioural clinics

Senior screenings
Other None