Page 24 - Small Animal Clinical Nutrition 5th Edition

24 Small Animal Clinical Nutrition

VetBooks.ir Table 2-1. Guidelines for quality of evidence that can be used for veterinary clinical nutrition.

Evidence guidelines
Evidence grade
Examples of nutritional studies
Evidence obtained from at least one properly
1
randomized, controlled, clinical study that used Dietary modification for treatment of cats and dogs
with naturally developing chronic kidney disease.
the nutritional product in the target species with
animals that had developed the disease naturally.*
2 Evidence obtained from randomized, controlled, Effects of a dental food on plaque accumulation and
clinical studies conducted in a laboratory setting gingival health in dogs.
that used the nutritional product in the target Energy restriction in obese cats and dogs fed foods
species with animals that had developed the varying in protein, fat, fiber and carbohydrate content.
disease naturally.*
3 Evidence obtained from one or more of Use of foods using novel or hydrolyzed protein sources
the following:* for animals with adverse food reactions.
At least one appropriately designed clinical Myocardial failure in cats associated with taurine deficiency.
study without randomization.
Cohort or case-controlled analytic studies.
Studies that used acceptable models of disease
or simulations in the target species.
Case series.
Dramatic results from uncontrolled studies.
4 Evidence obtained from one or more of Hepatic disease and nutritional therapy.
the following: Nutritional management of most diarrheal diseases.
Opinions based on clinical experience
(textbooks, monographs or proceedings).
Descriptive studies.
Studies conducted in other species.
Pathophysiologic justification.
Reports of expert committees.
*Data published in peer-reviewed journals is preferred.

ence; however, it does provide another dimension to the deci- physiologic principles, studies conducted in other species and
sion-making process that also considers the patient’s and logical conclusions based on data derived from patients in clin-
owner’s preferences (Forrest and Miller, 2002). Evidence-based ical studies (Rosenberg and Sackett, 1996). The advent and
clinical nutrition (EBCN) attempts to efficiently integrate proliferation of randomized, controlled clinical studies
medical and nutritional research with clinical practice. increased the quantity and quality of clinically valid evidence.
Figure 2-1 is a conceptual model for evidence-based clinical When possible, veterinarians should use information derived
decisions (Hayes et al, 1996). Analysis reveals that the best evi- from systematic, rigorously controlled clinical studies (obvious-
dence-based clinical decisions are made when clinical expertise, ly, larger trials involving more patients are preferable) to make
research evidence, owner or patient preferences and available diagnostic and therapeutic decisions. EBM and EBCN do not
resources overlap. This model can be easily adapted to veteri- always provide definitive answers, but they do provide a frame-
nary clinical nutrition in which assessment of the patient, food work for making decisions and understanding the risk-benefit
and feeding method lead to a comprehensive feeding plan relationship of various feeding and therapeutic plans.
based on the best current evidence (Thatcher et al, 2000). Understanding the rules of evidence is necessary to understand
Clinical expertise is needed to obtain a dietary history and EBM and EBCN (Sackett, 1993; Berg, 2000).
assess a patient’s nutritional and health status. This assessment
must often include other pets in the household. Clinical and
nutritional expertise provides individualized care for a specific RULES OF EVIDENCE
patient’s needs. Owners exercise their preferences for medical
and nutritional care by seeking second opinions, choosing alter- Scientific evidence is the product of appropriately designed and
nate treatments, exercising economic constraints and adhering carefully controlled research. A single study does not constitute
(or not) to recommended feeding or therapeutic plans. Today, evidence; rather, it contributes to knowledge derived from mul-
more clinical and nutritional information is available to pet tiple studies that have investigated the same scientific question.
owners than ever before. Pet preferences are most commonly Unfortunately, no central repository for clinical nutrition infor-
recognized in veterinary clinical nutrition through palatability mation exists nor is there a system for establishing quality evi-
choices for certain types of foods. dence. Several classification schemes are useful for establishing
Integrating clinical expertise with current best evidence from rules of evidence for recommendations about clinical nutrition.
medical and nutritional research is complex. Veterinarians usu- One method is to use a pyramid to rank clinical evidence
ally attempt to base their decisions on the best evidence avail- (Figure 2-2) (Forrest and Miller, 2002; SUNY, 2003).
able. This evidence often represents extrapolations of patho- Traditional sources of evidence include textbooks, personal