The Importance of a Digestible Diet For Management of Diarrhea
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CASE BY CASE: NUTRITION PEER REVIEWED
CASE BY CASE: NUTRITION
The Importance of a Digestible
Diet For Management of Diarrhea
Julia Fritz, DrMedVet, DECVCN, Napfcheck – Specialist Veterinary Nutritional Advice, Planegg, Germany
Jan S. Suchodolski, DrMedVet, PhD, AGAF, DACVM (Immunology), Texas A&M University School of Veterinary
Medicine and Biomedical Sciences Gastrointestinal Laboratory, College Station, Texas
Anton, a 2.5-year-old, 21-kg (47-lb), intact male The medical history revealed that, as a puppy, Anton
standard poodle (FIGURE 1) was presented for a was diagnosed and treated for Giardia species infection
nutrition consultation to a board-certified veterinary (treatment with fenbendazole 50 mg/kg once daily). At
nutritionist (EBVS [European Board of Veterinary the same time, he was suspected of having intestinal
Specialisation] European Specialist in Veterinary and dysbiosis based on fecal bacterial culture results.
Comparative Nutrition, DECVCN [diplomate of the Treatments for his chronic diarrhea and intestinal
European College of Veterinary and Comparative dysbiosis included various dietary trials. Based on the
Nutrition]). Anton had a history of chronic diarrhea owner’s feedback, a diet consisting of raw meat with
(>3 weeks’ duration). The feces appeared soft, sticky, cooked potatoes or rice was associated with better but
“cow patty–like” (Purina fecal score 6 out of 7; not satisfactory clinical response. On recent physical
bit.ly/3URgsmq), and were foul-smelling; the examination, Anton was bright, alert, and had a body
frequency of defecation was multiple times a day. The condition score (BCS) of 4/9. No abnormalities were
owner reported that the first feces in the morning are noted. A fecal examination for parasites was negative.
typically formed, but later in the day stools are soft as
described above (FIGURE 2). The owner stated that A detailed dietary history revealed that Anton’s current
Anton has had these problems since puppyhood. food consists of a mix of commercial dry kibble and
Abstract
Saklakova/shutterstock.com
A 2.5-year-old dog with a history of chronic diarrhea for more than 2 years was presented for a nutritional consult.
As a puppy, the dog was treated for Giardia infection and suspected intestinal dysbiosis. At the time of the consult,
he had been on a commercial diet, but up to 15% of his diet consisted of low-digestible treats (e.g., rawhides,
tendons). During detailed questioning about a timely association between his diet, treats, and the clinical signs of
diarrhea, the owner mentioned that the patient appeared to have more frequent episodes of severe diarrhea after
receiving treats. Simple elimination of treats with poor digestibility led to rapid clinical improvement and a long-
term positive outcome over a follow-up period of 4 years.
34 JANUARY/FEBRUARY 2023 todaysveterinarypractice.com
PEER REVIEWED CASE BY CASE: NUTRITION
Take-Home Points
The majority of animals with A detailed and accurate dietary Foods or treats with poor
chronic gastrointestinal signs history, probing owners for digestibility may negatively
are classified as food responsive possible associations between influence the intestinal microbiota
or have a food-responsive different diets and treats fed to and can be associated with
component and may respond to their pet and the development diarrhea.
empirical dietary management. of clinical signs, can be helpful
as the mechanism of adverse
food reactions is often not well
understood.
canned food (daily amounts: 250 grams dry kibble Upon careful and detailed questioning about a timely
[lamb, herring, egg, pea, quinoa] and 250 grams association between his regular diet, receiving treats,
canned food [beef, poultry, chicken]). The owner stated and the clinical signs of diarrhea, the owner mentioned
that Anton is a very picky eater and often refuses to eat that Anton appeared to have more frequent episodes of
his commercial food. As a result, the owner has been severe diarrhea after receiving soft beef strips and
offering various treats during the day to entice Anton rawhides. Typically, he appeared to have no diarrheic
to consume his food. These various treats include dried episodes when receiving cheese as a treat.
beef jerky, soft beef strips, rawhides, cheese, venison
lung, and venison tendon. Anton receives an estimated
total of almost 100 grams of these treats per day PRESUMPTIVE DIAGNOSIS
(650 grams per week). Based on the clinical history, adverse food reactions,
including either food intolerance or food allergy, were
initially considered as the main differentials. Previous
dietary trials included novel protein diets that were
unsuccessful. Because the owner was a veterinarian,
owner noncompliance was not considered as a potential
cause for dietary trial failure.
Once food allergy was ruled out as unlikely, food
intolerance became the presumptive diagnosis.
Additional supportive evidence for food intolerance was
that fecal consistency was more normal in the morning
and became progressively worse during the day, and
FIGURE 1. Anton, a 2.5-year-old, 21-kg (47-lb), intact male FIGURE 2. Feces at presentation. They often appear soft,
standard poodle with clinical signs of chronic diarrhea. sticky, “cow patty–like” (Purina fecal score 6/7).
todaysveterinarypractice.com JANUARY/FEBRUARY 2023 35
CASE BY CASE: NUTRITION PEER REVIEWED
infectious etiologies are considered rare; for example,
prevalence of parasites has been reported in just up to
Various recent studies have 6% of dogs in a recent study evaluating 466 pet dogs.1
Similarly, the prevalence of C jejuni was 5% (10 out of
shown that the majority of dogs
185 shelter dogs)2 and of Salmonella, 2.5% (60 out of
with CE, especially those with 24 222 pet dogs).3
milder clinical activity scores and
More frequent causes of chronic diarrhea are chronic
no signs of systemic disease, enteropathies (CE). CE is an umbrella term that
respond to dietary modulation. encompasses different subgroups of chronic intestinal
disorders that are classified based on treatment
response. These include food-responsive, fiber-
responsive, immunosuppressant-responsive, and
antibiotic-responsive enteropathy.4 The
chew treats with suspected low protein digestibility pathophysiology of these subgroups is not well
were clearly associated with the severity of diarrhea. understood, but it is likely a combination of intestinal
Furthermore, the amount of these chew treats as a dysbiosis, inflammation, degradation of the protective
percentage of the total daily food intake was considered epithelial mucus layer, and increased intestinal
high (approximately 15%). A positive clinical response permeability. The severity and extent of these changes
to a homemade diet consisting of raw novel meat vary between individual animals; therefore, no clear
sources and potatoes further supported the suspicion biomarkers are available that consistently predict which
that poor digestibility of the provided food as the most therapy patients will respond to best. For that reason, a
likely reason for poor stool consistency. sequential treatment approach is employed, with
dietary trials often used as the first step.5-7
THERAPY AND MANAGEMENT
The initial approach to dietary management was to
instruct the owner to completely eliminate all
commercial chew treats with poor digestibility from
Anton’s diet and to provide small amounts of cheese
treats instead, which typically have high digestibility
and historically were not associated with Anton’s
diarrhea. The current food (dry and wet food) was not
changed initially. The owner was then instructed to
bring Anton in for a follow-up exam in 14 days.
There was a rapid clinical improvement in a few days.
Fecal frequency was reduced to once daily and the fecal
score was consistently a 2/7 (FIGURE 3).
At the follow-up visit 2 weeks later, the owner reported
that Anton was producing solid feces for the first time
in years. Long-term follow-up over 4 years revealed that
Anton’s stool consistency and frequency remained
normal.
DISCUSSION
Clinical signs of chronic diarrhea can be due to
multiple causes. Differential diagnoses include infectious
causes, such as with parasites or specific bacterial FIGURE 3. Picture of feces after owner was instructed to
stop feeding treats with poor digestibility.
pathogens (e.g., Salmonella, Campylobacter jejuni). True
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PEER REVIEWED CASE BY CASE: NUTRITION
Various recent studies have shown that the majority of beneficial short-chain fatty acid–producing bacteria,
dogs with CE, especially those with milder clinical overgrowth of Escherichia coli and C perfringens, higher
activity scores and no signs of systemic disease, respond fecal pH, and an increased level of metabolites linked
to dietary modulation. Depending on the study, with inflammation.20,21
between 55% and 81% of dogs with CE were classified
as having food-responsive enteropathy.8-11 It is likely
that food-responsive enteropathies are by themselves an
umbrella term, as a variety of diet types have been
shown to induce clinical remission in these studies.
Higher amounts of protein
These include highly digestible gastrointestinal diets,
hydrolyzed diets, fiber-enriched diets, and novel from low-digestible sources
protein diets.4,7,10,12 There is no clear predictor, however, can lead to negative effects on
of which diet may work best for any patient. Therefore,
it is advised to obtain a detailed dietary history that the intestinal microbiota.17,18
includes probing owners for possible associations
between different diets fed to their pet and the
development of clinical signs.
A recent study demonstrated that only a small In Anton’s case, intestinal dysbiosis was suspected based
percentage of clinicians obtain a detailed dietary history on abnormal fecal bacterial culture results. A recent
for their patients. The same study also showed that if study has demonstrated that fecal bacterial culture,
the first dietary trial fails, a significant number of dogs although still commonly used, is not useful to assess the
may still respond to a second (66%) or third (44%) intestinal microbiome as most bacteria are strict
dietary trial if a more complete dietary history is anaerobes that cannot be cultured using standard
obtained in practice.13 There are several potential laboratory procedures.22 A molecular-based test for
reasons for the high percentage of dogs that are food assessing intestinal dysbiosis, the fecal Dysbiosis Index
responsive, and these mechanisms are likely (bit.ly/3Ug3ygz), was not available at that time, and
overlapping. Many veterinarians suspect food allergies consequently, it remains unknown whether Anton had
and use, for example, hydrolyzed protein diets and an altered microbiome.22 While major changes in the
report high success rates. It is important to note that intestinal microbiota are often secondary to antibiotic
the prevalence of true food allergies in dogs is suspected administration23 and changes in the mucosal structure
to be rather low.14 Another mechanism by which in CEs,24 it is important to note that inadequate dietary
hydrolyzed protein diets may improve clinical signs is substrate, in this case low-digestible protein, can also
due to their high digestibility, or because some other induce gastrointestinal signs, even if there are no or
unidentified food component in the original diet has only minor shifts in the microbiome.19 Therefore,
been eliminated. The base food ingredients in fiber- dietary trials with diets with improved digestibility
enriched gastrointestinal diets are typically also highly should be considered even in animals with suspected or
digestible and, together with the fiber component, can confirmed dysbiosis, as dietary modulation alone has
modulate the intestinal microbiota.12 Fiber-enriched shown partial recovery of the microbiome over time.25,26
diets have also been shown to lead to clinical
improvement in dogs with acute large bowel diarrhea.15,16 There are several possibilities if fecal consistency is
more normal in the morning and becomes progressively
High amounts of treats with poor digestibility (i.e., worse during the day. The stool overnight has spent the
rawhides) were the main reason for the clinical signs of longest period of time within the colon, allowing the
chronic diarrhea in this case. Higher amounts of most water reabsorption. In addition, the pet is more
protein from low-digestible sources can lead to negative active during the day, and with each meal or treat,
effects on the intestinal microbiota.17,18 For example, peristalsis is triggered more frequently (gastrocolic
1 study noted increased amounts of poor digestibility reflex). Based on the experience of the authors, this can
protein sourced from slaughter byproducts led to often suggest problems with digestibility. In such cases,
increases in enterotoxigenic Clostridium perfringens and the authors probe for details about the type of food—
looser stools.19 High amounts of proteins were also especially treats—and also the routine and timing of
associated with shifts in the microbiota, a decrease in foods and treats. Nutritional management is often
todaysveterinarypractice.com JANUARY/FEBRUARY 2023 37
CASE BY CASE: NUTRITION PEER REVIEWED
BOX 1 Scoring Index27
Different scoring systems have 1. Attitude/activity
been developed to assess the Scored 0–3
2. Appetite
severity of inflammatory bowel 0 = normal
disease (IBD) in dogs. The most 3. Vomiting
1 = mild change
commonly used clinical scoring 4. Stool consistency
is the Canine IBD Activity Index, 2 = moderate change
5. Stool frequency
or CIBDAI. The CIBDAI score 3 = severe change
is the summation of 6 different 6. Weight loss
clinical signs: attitude/activity,
appetite, vomiting, stool Summation of 6 variables
consistency, stool frequency,
and weight loss. 27 This numeric
index and scoring system can Total Composite the CIBDAI Score
be used by the clinician to
guide therapeutic strategies for 0–3 4–5 6–8 9 OR HIGHER
canine patients with IBD. Clinically
insignificant Mild lBD Moderate IBD Severe IBD
disease
performed empirically as a first step in those animals include, as in Anton’s case, simple elimination of
with milder clinical activity scores (BOX 1) and no signs low-digestible treats. Additional steps may include
of systemic disease, even before extensive testing is dietary management with highly digestible
performed to investigate for underlying intestinal gastrointestinal diets, hydrolyzed protein diets, and/or
disorders and/or microbiome dysbiosis. These can the addition of fiber either as supplements (e.g., psyllium
husk, cellulose) or fiber-enriched diets.7,28,29
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