Nutraceuticals: The Good, The Bad, and the Worthless

        By:  Loren W. Noblitt, D.V.M., M.S.

     A question that I am asked very frequently (almost daily it seems), is, "Can I (safely) give my dog or cat the same over-the-counter (OTC) supplements that I take?" The answer is, "it's complicated." I mean, seriously -- EFAs, PUFAs, EFA, EPA, DHA, GLA, LPO -- What do all these letters and abbreviations mean? What do essential fatty acids do anyway? How should you use them? What dosage? What brands are available? Are they all the same? What about probiotics, cranberry extract, and appropriate liver support?

     Ok, Ok, Ok - it's REALLY complicated.
    
The term "nutraceutical" is defined as "a food or a part of a food that provides medical or health benefits."  Nutraceuticals and dietary supplements are commonly used in both veterinary and human medicine.
     
Since there is no regulatory body for the manufacturing of nutraceuticals, it becomes difficult to assess product quality.  Drugs regulated by the FDA must meet specific manufacturing standards. Nutraceuticals...not so much.  Studies have shown that nutraceuticals are commonly mislabeled; may contain impurities, such as heavy metals, toxins, bacteria, molds; may have variable quantities of active ingredients; may fail to dissolve (thereby remaining ineffective).  Though the label may say "X mg", it is possible that some capsules have less (even zero) and some may have more.

That's the clear advantage of Nutramax products:  What they say is in each capsule, really is. 

     Case in point:  Many of the OTC glucosamine and chondroitin products are made from shark cartilage or other hard-to-metabolize products.  They often pass through the gastrointestinal tract without reaching significant levels in the joints, largely because of stomach acid degradation.  Some of these products come from other countries (i.e., Mexico, China, Brazil, Malaysia, etc) and are not proven to be toxic free or even effective, at all.  It is for all of these reasons that the Veterinarians at Zionsville Animal Hospital consistently recommend products like Dasuquin, Cosequin, Proviable probiotics, Denosyl, and Welactin fish oils -- all of which are made by the Nutramax company.

     To date, the Nutramax company has done virtually all of the available Veterinary studies in terms of effectiveness, batch variance, and bioavailability.  They have the research around their Cosequin product to prove it works, and better yet, the NEW! Dasuquin has added soybean and avocado extract, which has been found to reduce pain and inflammation, as well.  Does this mean that only their products are effective?  Likely not, but we can't say for sure.  The same holds true for the Omega 3's, probiotics, cranberry extract, and liver support (to name just a few). 

     Welactin has been extensively studied and remains the top additive of omega 3 essential fatty acid available to pets in the form of a supplement.  Of note here is the Hill's Pet food company and their j/d (Joint Diet) fortified with serious omega 3 fatty acids.  Hill's veterinary nutritionists say that you'd need to give ~two (2) dozen fish oil capsules to a large dog to approximate the omega 3's in a serving of Hill's j/d food.  These products are all promoted and sold at Zionsville Animal Hospital for these reasons.  Hill's j/d food is available upon request.

What's the BIG DEAL about Fish Oil (Omega-3 and 6 fatty acids) anyway?
Omega-3 and 6 fatty acids are classified as "essential"-- hence the term Essential Fatty Acids, or EFAs -- because humans and other animals are unable to synthesize them naturally.  Omega 3's have received much attention lately, and the important thing to know about them is they come in two varieties EPA and DHA, both are good!. 

Most EFAs are obtained from fish, crustaceans, and vegetables.  It was once thought that omega 3's were the better of the two because they were more anti-inflammatory than the omega-6's; however, this is no longer considered to be the case by Veterinary Dermatologists.  There is evidence that fish oil works to decrease the itching threshold, or "pruritic threshold", in dogs and cats with allergic skin disease (pollen allergy or atopy) and a recent clinical trial demonstrated a steroid-sparing effect of fatty acids due most likely in part to suppression of histamine and prostaglandin release.  Welactin fish oil is free of any proteins, which are the allergens in diets. Thus, theoretically, it should be safe to feed fish oils to animals with dietary allergies, so long as they're produced by reputable companies (i.e., Nutramax) that have repeatable quality control measures.  Your veterinarian may opt to withold fatty acids in the early stages of a dietary food trial (if a food allergy is suspected in your pet) in attempts to not "muddy the waters" in trying to arrive at a diagnosis. 

Fish oil is often used in cases of joint disease and osteoarthritis because of these inherent anti-inflammatory effects, and also a joint lubrication effect.

     When fatty acid supplementation is needed, it should be done at 180 - 200 mg of combined EPA and DHA fatty acids per 10 pounds of you pet's bodyweight.  The table below lists some of the preferred veterinary supplements on the market, and provides an omega-3 EFA dose per capsule or pump.  Zionsville Animal Hospital carries all 3 of these products and will be available via our online pharmacy coming soon:
            
        Product                                Omega-3 EFA Concentration/Dose         Amount per Pet
1)  Nutramaxlabs Wellactin                        270mg/capsule                             1 capsule per 20lbs
Omega3 Canine Gel-caps

2)  Nutramaxlabs Wellactin                        250mg/capsule                              1 capsule per cat
Omega3 Feline Gel-caps

3)  Nutramaxlabs Wellactin                      1300mg/5ml (1 tspn)                        5ml per 35kg
Omega3 Canine Liquid

     Ultimately, studies demonstrating the clinical benefits of a nutraceutical should be evaluated.  For example, several peer-reviewed studies exist documenting improvement in clinical signs with chronic osteoarthritis in dogs or horses given glucosamine or chondroitin sulfate (or combinations of these compounds). However, clinicians should examine how the studies were conducted, to determine their likely validity, because many studies are poorly designed or executed.
    
     In summary, neutraceuticals are not regulated by the FDA, as they are not considered to be "drugs." This means that they can be sold without scientific proof of effectiveness, without assuredness of safety and consistency from batch to batch, and without mandatory testing to determine the optimal dosage in target animals.  There are numerous anecdotal reports of these medications helping numerous individuals (both human and animal) but one should keep in mind that scientific investigation is continuing. 

     The best thing to do for your pet is to follow your veterinarian's advice and use reputable products when it comes to fish oil, glucosamine/chondroitin, or other supplementation, when possible.  If this cannot be done for whatever reason, try to keep the following suggestions in mind to help weed out inferior OTC nutraceutical products.

1.   Price.  Cheaper compounds are less likely to be of high quality. This has been the general observation with chondroitin sulfate.

2.   Pay attention to whether or not the product has a lot number and an expiration date.

3.  There is a general USP veterinary page (for veterinary drugs, requires free registration) and the USP Dietary Supplement Verification Program page, which provides a list of suppliers that have voluntarily submitted their products for USP verification and approval. These products carry the following mark:
                                                      
4. Claims of safety or efficacy.  If a nutraceutical claims a medical benefit on the label, there should be a New Animal Drug Application (NADA) number accompanying the product. While this is "mandated" by law, it is often ignored.  A NADA tends to suggest higher quality, because the manufacturer has bothered to abide by FDA regulations for drug manufacture.

5. Ingredient list. All ingredients should be listed by order of magnitude based on weight.

6. Scientific evidence supporting manufacturer's claims. Some manufacturers have begun providing data for their specific products through independent scientific studies. These studies should ideally be peer-reviewed and published. Importantly, they should be clinical studies, not in vitro studies. There are institutes, affiliated with universities and medical schools, who are beginning to investigate nutraceutical claims scientifically. These include The Nutraceuticals Institute, The Institute of Nutraceutical Research, and others.

7.   Testimonials in place of valid research.  Many companies provide testimonials from "satisfied clients".  These should be ignored, and companies that promote these instead of scientific research supporting their claims, should be viewed skeptically.

8.   Membership in National Animal Supplement Council (www.nasc.cc). This industry group has a close relationship with FDA and strict guidelines for member companies regarding quality control and adverse event recording. Member companies are likely to have better quality products.

Several websites exist that may help you investigate specific nutraceuticals:
1. www.quackwatch.com
2. www.herbalgram.org
3. http://nccam.nih.gov
4. www.navigator.tufts.edu/index.html
5. www.consumerlab.com
6. www.biovalidity.com

Photos coutesy of:  www.nutramaxlabs.com

Feline Diarrhea: Tritrichomonas and Giardia

                                          By:  Loren W. Noblitt, DVM, MS

Few conditions are more frustrating for veterinarians (and owners) than feline diarrhea.  I know that I always cringe a little inside when I'm confronted with these cases.  Primary causes of diarrhea, like gastrointestinal inflammation, infection, dietary changes, and cancer should all be considered, as well as secondary causes like liver, metabolic, and pancreatic disease.  The first diagnostic step (if the answer isn't obvious) is to obtain baseline blood work (CBC/Chemistry/Thyroid level), a fecal sample, and a urine sample.  Sometimes, a gastrointestinal (GI) blood profile test is indicated on a case-by-case basis.

In the infectious category, usually the cause will be related to bacterial infection, either from stress (immunosuppression that allows low level anaerobic, "bad" bacteria to thrive), dietary indiscretion (introduction of "bad", foreign bacteria either from human food, trash, feces, or an animal carcass), or a very recent food change (malabsorption, food intolerance, or digestive problems).  When treatment for these more common causes fails to yield resolution of diarrhea, or if the diarrhea has been a chronic longterm issue for your cat, the veterinarian likely will discuss Tritrichomonas foetus (T. foetus) and Giardia.

T. foetus and Giardia are both protozoal diseases, meaning that they are neither bacteria nor virus, but rather a life-form in-between (so to speak); they are both transmitted by the fecal-oral route (through direct contact with feces), and Giardia can be found in unclean water.  Let's now discuss the salient features of each of these pathogens, focusing on risk factors, diagnosis, and treatment.

T. foetus is an emerging parasite in the feline world, however, it was first discovered in cattle as a cause of abortion (thus the species name: 'foetus'), and is spread as a venereal disease amongst cattle. Surveys have suggested that approximately 1/3 of all purebred cats are infected. It is rarely tested for and may be responsible for many of the cases of chronic diarrhea (e.g. inflammatory bowel disease) in cats.  A T. foetus organism looks very similar to Giardia so if viewed by in a fecal smear a misdiagnosis of Giardia is common. Fecal floats and Giardia snap tests are insensitive to it. T. foetus is a fragile organism whose life span out of the body is normally less than an hour. This lack of hardiness is due to the fact that T. foetus cannot form a cyst.  If T. foetus dries out, if it is refrigerated, or if it experiences temperatures above 105°F, it will die.  Good News!!! 

The protozoan lives in the intestinal lining of the large bowel.  It causes "cow pie" like stool that is often gassy and malodorous. The health of the cat is not usually adversely affected.  Cat breeders have commented that in symptomatic cats that the smell of the stool is a significant clue of an infection. It is important to note that an infected cat may or may not have clinical signs of tritrichomoniasis.

T. foetus is typically transmitted by an infected cat to other cats sharing the same litter box. Currently, the preferred and most reliable test to confirm diagnosis is a PCR test using the cat's stool sample.  Follow this link to see video of T. foetus and Giardia in action (Quicktime required): http://www.ncsu.edu/project/cvm_gookin/Tfoetusvideo.mov

Treatment of the T. foetus  infection is difficult due to drug resistance. Traditional antiprotozoal drugs such as Panacur and Metronidazole do not alleviate the symptoms, and as mentioned above, often is the first indicator that T. foetus infection may be present. Some antimicrobial drugs have been shown to improve symptoms but do not eradicate the parasite.  Ronidazole has had good efficacy in eradiation of the parasite in cats but has the potential for a variety of side effects, most notably, neurological side effects.  During treatment, the cat should be engaged in play activity regularly to ensure they are not experiencing neurological side effects, or motor skills impairment.  Two weeks of ronidazole, dosed at 30 mg/kg, once daily, is currently the recommended dosage. Care should be exercised (wearing gloves) while handling ronidazole, which can be toxic to humans.

During treatment, the cat should be keep isolated from other cats as to prevent the spread of T. foetus to another cat. Your cat should be fed a prescription high fiber food to help clear the organisms from the colon and to help heal the colon cells.  A common GI diet remedy in cats (boiled chicken breast and white rice) may be highly beneficial during and after treatment.

Treatment with ronidazole has shown good efficacy, and some positive results may be achieved after just two to three days of treatment, but completion of the two week cycle of drugs to avoid the risk of recurrence.  It is essential that a PCR test be conducted after treatment to verify that the organism has been completely eradicated.  It is also recommended that a follow-up test be performed a few months after the first.  Interestingly, cats that carry T. foetus and are not treated, usually cure themselves of the parasite within 2 years.

                                                                   
                                                    Giardia, in its motile Trophozoite form (above and below)

Photos courtesy of:  http://www.dpd.cdc.gov/dpdx/HTML/ImageLibrary/Giardiasis_il.htm

 

Giardia is a single-celled protozoan that affects the intestinal tract of mammals and usually causes diarrhea and can cause vomiting.  Definitive diagnosis comes from an enzyme-linked immunosorbant assay (ELISA) test using a stool sample.  Dogs and cats can become infected when they swallow Giardia that may be present in stagnant puddles of water or unclean drinking water. It is primarily contracted from the stool of infected animals, both wild and domestic.  Having giardiasis for a long time can cause weight loss, generally poor condition, and even death when the disease is serious. You might notice blood in your cat's stool from irritation that the Giardia parasite causes to the lining of the small and large intestines; however, many cats infected with Giardia do not show any signs of disease. The best way to prevent Giardia infection is to make sure that your cat has a safe, clean drinking water supply.  It is important not to allow cats to drink water from areas where other animals have left their feces.  Pick up soiled litter left by your cat or cats daily and place it in the trash.  Take care not to track animal feces into your house or environment where the cat will be.

The best treatment for Giardia is a six day course of an antiparasitic medication called Panacur (Fenbendazole), and on days #3 and #6 of the treatment, use wet wipes or soap and water to thoroughly clean your cat's rear end and tail.  This will cut down on the number of Giardia cysts that stick to the hair and will help prevent your cat from re-infection by normal cat grooming behaviors.  Bleach (diluted 1:20) or Lysol spray should be used to clean the litter boxes (allowing 10 minutes of good contact time before wiping), as these are both quaternary amines that are able to destroy the Giardia cyst lifeforms.  Importantly, a stool sample should again be checked in 1 month after the treatment was started to make sure the giardiasis is cured. 

As a veterinarian, I am often asked the question, "Can my cat (or dog) get Giardia from my dog (or cat)?"  The answer is Yes.  Either.  We typically recommend treating all the animals in the household when one animal is identified as being a Giardia carrier. 

Also of note, there is a chance that humans can be harmed by the same Giardia that affects their pets, but zoonotic infection (infection passed from animal to human) is extremely rare in this particular case.  It is likely that most people become infected with Giardia passed by other people rather than Giardia from pets.  Be sure to avoid contact with feces by using gloves, a bag over your hand, or a scooping device.  Also, be sure to thoroughly wash your hands after picking up feces.