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Animal Wellbeing with Dr Sarah Howard

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Animal Wellbeing with Dr Sarah Howard

How would you treat osteoarthritis in a dog? How about metabolic disease in a horse? Can you give animals the same nutrients and herbal remedies as humans?

Today we are joined by integrative veterinarian Dr. Sarah Howard, who answers these questions and much more, including the differences between conducting studies in animals versus humans, how to treat some of the conditions commonly seen in in our furry companions, and what signs and symptoms to look out for. 

Covered in this episode

[00:54] Introducing Dr. Sarah Howard
[01:39] Scientific studies in animals
[04:29] Sarah’s journey into integrative veterinary medicine 
[05:56] History of integrative veterinary medicine
[07:54] The challenges of agribusiness and animal studies
[11:59] Different drugs for different species
[16:04] Regulatory bodies overseeing animal medicine
[18:30]  Animals using foods as medicine 
[22:39] Using evidence from human studies for treating animals
[27:34] Treating osteoarthritis in dogs and cats
[35:00] Obesity in animals and proper nutrition
[41:53] Skin issues and allergies
[44:26] Liver disease  
[45:53] Behaviour and anxiety
[47:53] Canine faeces consumption and the microbiome 
[51:10] Clinical indications for nutrient deficiencies
[53:13] Signs of toxicity


Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us in the studio today is Dr. Sarah Howard. Sarah first studied chiropractic science at Macquarie University, before transferring to the Bachelor of Veterinary Science at Sydney Uni, graduating in 2012. Because of her longstanding passion for nutrition, Sarah then completed postgraduate studies in equine behaviour and nutrition at Charles Sturt Uni. After that, Sarah honed her clinical skills in both rural and urban practice for five years, before joining Blackmores, where she's now the Technical Services Veterinarian for PAW. Welcome to FX Medicine, Sarah. How are you?

Sarah: I'm really well. Thank you, Andrew. It's an absolute pleasure to be here.

Andrew: Now, this is something that greatly interests me. Today we're going to be talking about integrative veterinary medicine, and it's something that, you know, years ago I would never even contemplated. I see its importance in not just practice but research,  because do you get a placebo response? I guess you do. But it's I guess harder to get a placebo response in pets because they really don't care how you feel about it, they just want relief if they've got pain.

Sarah: That's right. I guess it depends on what you're measuring. In a lot of ways, it's actually harder to see a good response in a study, unless you're using an objective measure. So, for example, if you're looking at the effectiveness of something for osteoarthritis, be that a drug or a supplement, you can't really ask the dog whether it hurts.

Andrew: No.

Sarah: So, you either rely on subjective measures, so be that what the owners are seeing at home, or what the vets are seeing in their consultation or their clinical assessment, or you rely on...there's only a couple of objective measures that you can use for osteoarthritis or for joint pain, one of them being ground plate technology, so looking at how much pressure the dog will put through each limb on a plate. 

Andrew: Ah! Yep.

Sarah: So, in a lot of ways, it's actually more difficult to establish accurate results because they can't talk.

Andrew: Yeah, that's exactly right.

Sarah: So, a lot of it is observational, which sometimes can mean weaker results and weaker evidence.

Andrew: Like, it has its own conundrums there because they can't say, "Ow," and they can't say, "Ah." You know, they can't tell you other than behaviours like, "I'm wagging my tail. I'm happy now, or, you know, if..." For instance, you've done equine stuff, so I'm a horse, I'll nudge you. They can't tell you that they've had relief. It must be poignantly frustrating.

Sarah: Very much so. And I think that I often... I've got friends who have children who aren't sort of at the stage where they can talk yet, and hearing their frustration of knowing whether their child is finding relief from certain medications or certain treatments that they're undergoing I find very similar to the frustrations I have as a clinician. 

Andrew: Yeah.

Sarah: So, I think you could almost relate paediatrics to vets in that sense. And a lot of it is behaviour-based and there's...god, there's just so much scope when you're looking at veterinary behaviour and so much nuance is there as well, and a lot of the time clinicians might not be aware of certain behaviours and owners might not be aware of what certain behaviours mean, because that's probably another four or five years of study in and of itself to learn that.

Andrew: And you've indeed studied this in horses. 

Sarah: Yeah, I have.

Andrew: I want to just backtrack though. Take us back to the beginning. Where did this love of integrative veterinary science, the passion for integrative nutrition and veterinary care, where did that spark? Where did it all begin?

Sarah: Well, it probably began from my interest in terms of human health and nutrition, and I think with a lot of people it comes from personal experiences with different conditions and seeing the benefits of nutritional approaches and different natural supplements for my own health. I guess I've had a few negative experiences with conventional medicine for myself and I have had equal frustrations when I was working as a conventional vet in practice with my patients as well. And since leaving practice, I have really dived headfirst into the world of integrative veterinary medicine, which perhaps is a little annoying because it would have been nice to actually learn that this world existed while I was still in practice because it's certainly something that I would have pursued back then, and I'm not saying I won't in the future, but seeing, I guess, I never really knew that all of the advances that are made in human integrative medicine can be equally transferred over to pets with the same benefits.

Andrew: When you say equally, we're going to delve into that because there are some nuances in how different compounds work and their safety within different animals. We know this with drugs, where certain drugs that are quite "safe," but for human use, are absolutely toxic for various pets, and they change. Let's start off. Integrative veterinary care, where did that begin? Where's the history of integrative veterinary care?

Sarah: So, I don't know exactly when it began, but when it became more of a recognised field, I believe was early '80s, coming from a group in America. So, the group is actually called now the American Association of Holistic Veterinary Medicine, and that was established in the early '80s by a group of very passionate clinicians who were well versed in nutrition and natural supplementation and integrative medicine and started using those techniques in pets and seeing benefits, and they wanted to establish a community of like-minded vets to try and progress this field more into the mainstream.

So, what's where I believe that it sort of became more recognised, and it's really grown since then. So, there's a few different associations and groups and journals now that exist. However, it's still very much in its infancy in comparison to the human integrative medicine world.

Andrew: Oh, sure. Well, but even then, you know, there's a lot of conjecture and, you know, browbeating that human nutrition, supplementation and that sort of thing doesn't work, and you get a negative study because they cherry-picked either research, or looked at a stupid dose, or something like that. So, this is the interesting thing with people who do it, compared to people who look at it.

Sarah: Yes.

Andrew: What I find interesting though is when you look at agri-business, let's take dairy. They have a formula and it's like a set formula. If you wanted to be a successful dairy farmer in Australia, you have to use supplemental feed to the tune of $11 a day, full stop. And if you want to use $10.50, that ain't going to work.

Sarah: I think certainly, I'm more familiar with the companion animal side of things, but certainly if you're looking at agriculture and the use of supplementation in, say, dairy cows or lambs or feedlot meat cattle, it's all about the money at the end of the day. So, it's all about the value and it's all about maximising the nutrition for people. So, it's actually driven by people, rather than the animals themselves, the welfare of the animals themselves, yeah.

Andrew: Yeah. But as you say, it's the productivity from a monetary perspective, and yet we have economies that...you know, we have healthcare costs that are burgeoning because we've got diabetes. We've got women who cannot work because of endometriosis, and to me it's ridiculous.

Sarah: I think we both have different frustrations obviously. Yeah, no, it's... certainly, and I've spent a lot of my life in the equine industry, so, from pony club from the age of six, and horses are very much in my blood, which is why I actually became a vet in the first place. 

Andrew: Yeah.

Sarah: I’ve never been very involved in the racing industry, but certainly, in the performance horse industry, it was completely normal to give our horses probably four or five supplements every day in their feed 

Andrew: Yep.

Sarah: And it's actually very common. I would find it hard to even find any horse owner who is not giving at least one supplement.

Andrew: I thought it was very interesting that way back we used to have...where I used to work in a pharmacy, we used to have horse trainers coming in to procure Creatine, which back then was only used for human nutrition as I knew it then, and it was extraordinarily expensive. So, we used to procure this raw material without the middleman, and we used to have this sort of mini-business from all these horse trainers using Creatine...

Sarah: Yeah, performance.

Andrew: ...for performance. So, they knew about it back then. It was the people who wanted the cutting edge who wanted it back then. Now it's available to everybody who has a pet.

Sarah: So, I wonder if back then it was anecdotal or clinical literature and evidence that was backing it because a lot of the time, and this is the struggle that we have in integrative veterinary medicine, is the lack of solid research. This just really frustrates me. A part of my role is product development, and so I spend many hours scaling the literature, finding evidence for different ingredients. And I feel rather jealous of people who work in human product development because I think, "Gosh, you must have such an easier time finding evidence for these ingredients."

We have a hard enough time having high-level research papers written for pets as it is, because of very stringent ethics issues, and they're getting more and more strict every year. But, yeah, we have a hard enough time getting pharmacological research papers across, let alone natural supplements and herbal ingredients and nutrition papers written. They're very few and far between. And the problem with the veterinary industry in the mainstream, I'm not talking about the integrative vets at the moment, but mainstream vets, conventional vets, is, and rightly so, they need to see the solid hard, high-quality gold standard research for something before they utilise it. And if that doesn't exist, then quite often they will be very dismissive of whatever product or ingredient or supplemental herb that they're looking at.

Andrew: But it's also very specific to each species, isn't it?

Sarah: Very, yeah.

Andrew: For instance, pharmacologically you can have...let's take NSAIDs, right? So, in humans, you have the class of NSAID drugs, or nonsteroidal anti-inflammatory drugs, and there are many, right from the ibuprofen, through the meloxicams, all sorts of NSAID drugs, and yet they are species-specific when we're talking about that kind of stuff.

Sarah: To an extent, to an extent. So, if you're looking at a difference between dogs and cats, there's quite often quite a big difference. So, they do share quite a lot of drugs, in particular NSAIDs, but dogs can tolerate paracetamol. For cats it's fatal, is completely toxic for… 

Andrew: Right. Right. So, NSAIDs are virtually the same, so the ibuprofen is toxic for cats as well?

Sarah: Veterinary NSAIDs like meloxicam and... Well, there's a whole variety of different COX-2 inhibitors and things like that. They usually can be used fairly equally between the species, not all of them, but cats have a far, far less drug set that they can use..

Andrew: Yeah.

Sarah: …so they're much more sensitive to different toxicities. But if you're looking at some human NSAIDs, yeah. So, if you're looking at paracetamol, it can be used in dogs, not commonly though because we do have quite a lot of canine-specific NSAIDs that you would prefer to use, but for cats, it's completely fatal. So that's just a perfect example of the huge difference in their metabolism.

Andrew: And also something that struck me as odd was that when we're looking at human studies on a compound, be it natural or pharmacological, the research starts with sales, you know, proof of concept, and then they go, rats in a road entity, right? And then they might use dogs, and then primates. So, can't they just take out the dog part and can go, "There you go, it’s suitable for dogs?"

Sarah: Yeah, it would be nice. The hard thing is, is that a lot of those studies these days don't get the ethics approval. So, the kind of older studies back in...I think even in the early 2000s we were still doing quite a lot of studies that...where basically the animals were unfortunately euthanised at the end of the study, and these days it's very hard to get ethics approval for doing those sort of papers. So, I think that there is quite a lot of evidence that exists for certain things, but certainly, for newer technologies or for herbs that are only coming into the veterinary world now, it's very difficult to get those high-quality randomised controlled trials.

Andrew: Oh, for sure. It's a trial to get them for humans.

Sarah: Yeah.

Andrew: But I guess as we've noted before, where vets don't deal with one species, doctors deal with one species. Vets deal with a multitude of species. So, to get the evidence for not one species but a multitude of species, that must be a real trial.

Sarah: Well, yeah. I mean, if you're talking about companion animals, most of the papers are published in dogs and horses.

Andrew: Yep.

Sarah: I think cats are very few, very few, because I think the challenge is with cats is their sensitivity to certain things. The ethics is one thing, the sensitivity to different ingredients is another. And also cats are harder to give anything to. Dogs are much...

Andrew: Love, for instance.

Sarah: It's harder to get love from cats too. I'm not actually a cat person, so I'm sorry if offended any of you who love cats.

Andrew: You don't own a cat, the cat owns you.

Sarah: But in terms of giving, whether it be a drug or a natural supplement to a dog or horse, it's so much easier. 

Andrew: Right.

Sarah: But giving things to a cat is, as any cat owner would know, a real challenge and can be almost life threatening sometimes, yeah. So, the drive for getting that research funded is always going to be stronger in horses and dogs, compared to cats.

Andrew: As I understand it, the appropriate regulatory body for veterinary medicines...

Sarah: The APVMA?

Andrew: Right, APVMA.

Sarah: Yeah. So, it's the Australian Pesticides and Veterinary Medicines Authority. So we share...the regulatory body is shared between all agriculture pesticides as well.

Andrew: That's really interesting. So, that's an Australian pinnacle body. What's the world sister bodies? Are they intertwined? Like, for instance, you know, FDA versus TGA in Australia for human, Medsafe for New Zealand. They're sort of similar, but they have their own little nuances in how they are set up as a framework. Do you have that when you're looking at overseas medicines, or is it pretty much blanket like?

Sarah: It's very different in each country.

Andrew: Got you.

Sarah: Australia is pretty strict. I believe New Zealand is even stricter. America is pretty relaxed, compared. So, there's a lot of...there's a lot more natural health supplements on the market in America compared to Australia, and we can't import them over here without going through some really rigorous and strict sort of regulation hurdles. So, there's a product registration process that needs to go through in Australia if you're wanting to obtain a product that has therapeutic benefits, and it takes minimum 24 months for that to occur, hundreds of thousands of dollars, and that's to register a product that has ingredients that are already registered. To register a new ingredient for use in veterinary medicines, it is...I think the last one was done over 10 years ago. It's nearly impossible. 

Andrew: Oh, wow.

Sarah: It’s doable, but again, it comes down to the challenges of getting ethics approval. You need to prove that that ingredient is safe. And so...

Andrew: In that species?

Sarah: In that species, at that dose, in that formulation. So, it's very challenging. I know some Asian countries have very strict regulatory systems as well for veterinary medicines…

Andrew: Ok.

Sarah: …and veterinary medicines including natural supplements. 

Andrew: Right, right.

Sarah: So, it's very different in each country and the APVMA is among one of the stricter bodies, which is challenging.

Andrew: Well, challenging, I guess sort of rightly so because...

Sarah: Challenging but good, yeah.

Andrew: ...as you've said before, where because you're dealing with so many different species, it's hard to then say, "Oh cool. You know, there's evidence for," as I've read a few months ago... This was in 2018. Orangutans grab a certain leaf and rub it onto their arthritic joints for pain relief.

Sarah: Really?

Andrew: Yeah.

Sarah: What's the leaf?

Andrew: So, I can't remember. It's the first...

Sarah: Oh.

Andrew: It's the first use of nutrition, if you like, as a medicine rather than for deficiency. Like, for instance, we know that elephants go into caves to graze the tusks against the cave walls…

Sarah: Yes.

Andrew: …but that's for mineral deficiency, so that's for a supplementation and ensuring of adequate nutrition. This is as a medicine.

Sarah: And do you believe that it's because of their primate's higher level of intelligence that they actually know to do that?

Andrew: I don't know. We're dealing with elephants here. They're pretty intelligent, you know?

Sarah: That's interesting.

Andrew: But, you know, I was...it peaked my interest because it's the first time I've seen or heard of an animal choosing a particular type of leaf specifically for a particular ailment, rather than, you know, dogs chew grass for worms. You know, that sort of...

Sarah: So, that's very controversial, the eating grass thing.

Andrew: Yeah, that's right, that's what I'm saying.

Sarah: So, I can talk about that if you want.

Andrew: Well, I'd love to actually, let's delve into it.

Sarah: Okay. So, there's a few kind of myths around different behaviours that...let's call...let's just talk about dogs. So, a lot of people believe that their dogs will eat grass when they're feeling sick to purge whatever is causing them to feel sick. It's pretty controversial and I think the challenges of really knowing what that behaviour is about is impossible, because you can't really ask the dog. But certainly behaviourists have done quite a lot of analysis of this, so, behaviour, and it's actually considered a pretty normal behaviour of a dog and something that they would have developed, you know, many, many thousands of years ago when they lived in the wild, 

Andrew: Yep.

Sarah: And I think it reflects their innate omnivorous disposition because dogs are omnivorous. Cats are obligate carnivores, but dogs actually do require some fibre and some carbohydrates and vegetable material in their diet. 

Andrew: Right.

Sarah: There’s other people that say that it may reflect that the dogs are bored, and that they're just going outside to graze on some grass because they're bored, like any boredom eater would do, or that it might reflect a dietary insufficiency, so they're going on that sort of innate...

Andrew: Mineral type thing?

Sarah: Yeah. And some do say that maybe the grass is a purgative and that can sort of help to eliminate something in their system, but on the whole, it's pretty low. They've done a lot of kind of reviews of dogs eating grass, and it's the minority that will actually use it to vomit or that have it associated with any gastrointestinal upset. 

Andrew: Yeah.

Sarah: So, it's pretty...is kind of like normal scavenging, grazing behaviour that's just in their instinct, I guess.

Andrew: I mean, our dog will sometimes, you know, just go and chew a little bit of grass, but whether it's an availability issue, I can't contest that. But I just think it's interesting that he'll just go and nibble on a few blades of grass or a couple, hardly enough to supplement a diet. 

Sarah: Yeah.

Andrew: But then I also see that he doesn't necessarily use it to vomit,

Sarah: No.

Andrew:  it's just like, "Oh yeah. Oh, what's that? Oh, I don't know." What I find funny is, as you say, he'll have a bone sitting there. Maybe he's just using this as an aperitif for the bone.

Sarah: A palate cleanser.

Andrew: A palate cleanser, yeah. I mean, who knows? But...

Sarah: Who knows?

Andrew: But I agree with you that I would doubt that that amount of grass would be a purgative. You know, it's like...

Sarah: No. And I think a lot of the time people will say the dog vomit because they might eat the grass really quickly and inhale quite a lot of air or grass and it irritates the stomach and then they bring it up. Who knows? And that's the thing. Quite a lot of the time we are guessing.

Andrew: Yes, absolutely. So, it's from our own issues rather than something else. We've covered some of the issues facing veterinary science with regards to research, that there may not be a pool of research to jump from. So, what can be done? Like, how appropriate is it...as I said, given not one species but multiple, how appropriate is it to jump from, say, human studies on various compounds?

Sarah: Yeah, that's a great question. So, it's appropriate in some situations. I think when there is a lack of solid evidence for a certain ingredient, let's use an example of, say, curcumin. So, there is some evidence for using curcumin in dogs and it's good evidence, but it's still quite sparse. So, if a clinician was wanting to trial a curcumin-based product in, say, a dog with osteoarthritis and using it for its anti-inflammatory benefits for the dog's joints, but wanted to see the evidence, then using human literature is an option, but it's really important for the clinician to acknowledge that they are leaning on the human literature for this certain choice, 

Andrew: Yeah.

Sarah: And I think it's also important, and this is what a lot of the more discerning integrative vets would do, is to lean on their past clinical wisdom or colleagues' clinical wisdom because there is a lot of anecdotal evidence that exists.

So, if they have been a vet for 20 years and they've used curcumin in a human product for a long time and they've seen a lot of results and they've had low rates of adverse reactions, then I would imagine they would feel comfortable continuing without, say, you know, a randomised controlled trial supporting their use of that. However, it's also important to be quite selective with ingredients in terms of their general safety profile, and you can look to human safety profiles on different herbs, and if there's a herb that's perhaps not completely safe even in humans, you probably would be very, very careful with using that in patients without the evidence to support that it's safe. So that's an important point.

Most of the time I make it sound like integrative vets sort of ignore the lack of evidence a lot of the time. Most of the time they really try and practice evidence-based medicine, absolutely, but there is more of a push from the clients and the pet owners to incorporate natural supplements and ingredients...

Andrew: For sure.

Sarah: ...in patients' treatment regimes, and without the solid evidence that exists for a lot of these ingredients, there is still a body of anecdotal evidence and human literature that clinicians can lean on. They just have to do so carefully and ensure that the owner is well aware of perhaps the lack of completely solid safety information that exists. So, it's a risk benefit. 

Andrew: But this is evidence-based medicine. This is exactly what McMaster University taught. You know, the double-blind placebo-controlled randomised trial is not necessarily what you can lean best practice off. It just depends on how many patients you have. 

Sarah: Yeah.

Andrew: For instance, rare cancers have NAFL cancers to do a trial on. So what they do is they might treat like a thymoma, for instance, a thymus gland tumour, or they'll treat that as they would lung cancer because is similar. That's the best you got. You know?

Sarah: Yeah. You do the best with what you've got...

Andrew: That's exactly right.

Sarah: ...a lot of the time, yeah. And randomised controlled trials, yes, they are the gold standard, but the results can... If you were to do a randomised controlled trial and then do the exact same trial two months later, you might get slightly different results. So, it's never going to be an exact science, and I think a lot of the time people need to lean on the anecdotal evidence more so than they are willing to do in veterinary medicine, and lean on experience and intuition and, you know, clinical evidence that exists that might not be supported by a systematic review or randomised controlled trial, because I think that we're neglecting a huge amount of beneficial treatments that are out there for our pets with...

Andrew: One word I've just picked up you saying a few times. Being a human practitioner, if you like, I say patient, I mean, a human. You say patient, you mean an animal.

Sarah: Yeah, veterinary patient, animal.

Andrew: Veterinary patient, they are an animal patient.

Sarah: There's an animal patient and their owner is the client.

Andrew: Right. I was just interested by that. So, let's go into some of the conditions because, you know, there's a whole range of conditions I would gather, I'm going to guess, that there are some like, "Yeah, heck yeah, we can get really good results," and some that are like, "Look, we can try it, and tell us about this experience stuff.”

Sarah: Yeah, sure.

Andrew: So, give us a few conditions first that are popular. I'm going to...I know one in my brain that owners are frustrated with and they get very poor results with, but you can go.

Sarah: Okay. So, most conditions, I believe there is a basis for using an integrative approach. Whether, as we've been talking about, the evidence exists or not, I think that there's still scope in most conditions. But the most popular and most common conditions where integrative medicine has perhaps infiltrated mainstream conventional veterinary medicine, probably number one would have to be joint disease, osteoarthritis.

Andrew: Ok, yep.

Sarah: So, it's quite common now to take what's called a multimodal approach to managing cases of osteoarthritis in dogs, cats, horses, whatever species that you're dealing with. And what that means is you're looking at the patient from a few different aspects. So, number one would be weight management is probably the most crucial part of managing osteoarthritis, let's say in a dog or a cat. Horses, probably less so because horses are probably less likely to be obese than a dog or a cat, but dogs and cats really, it makes sense. If they're carrying an extra 10 kilos, probably for a dog, not so much a cat, they're carrying an extra, say, 20% over their ideal body weight, that is just going to amplify the load through their joints.

So as soon as you can remove that excess load, they're immediately going to become more comfortable. The less stress that go through the joints, the less likely the cartilage is to continue breaking down, and it's a simple fix that's not only going to benefit their joints but also many other aspects of their health. So that would be the first aspect of multimodal management. The second aspect would be looking at lifestyle modifications, 

Andrew: Yep.

Sarah: And that would include exercise, the type of bedding that they have…

Andrew: Giving the owner, giving the client, a stern talking to.

Sarah: Yeah, I guess so. Well, all of this is you're having to convince the client, so that's another challenge which we can talk about. But lifestyle modifications, so when you're talking about exercise, encouraging regular, gentle exercise. So, a lot of people might think, "Oh, the dog is really sore, I'm not going to exercise it." No, no, no, that’s just going to make it worse. So they need to move those joints, increase the lubrication of the joints, the flow of the joint fluid, the blood flow to the joints. Osteoarthritis is an incurable, progressive disease, so we're not going to be able to do miracle cures here, but we need to try and maintain the health of those joints as much as possible.

Andrew: Yeah, move it or lose it.

Sarah: Exactly. And the benefits of exercise also then relate to the first point of weight management. So, if you can get the dog or the cat moving in a way where they're not putting the joints under load, so I'm talking about swimming if you're looking at dogs, gentle walks. I would restrict things like jumping, running, twisting, things like that. 

Andrew: Yeah. 

Sarah: You know, stairs can be difficult, but, you know, a regular walk of half an hour a day on a lake is perfect. Swimming is amazing because you're taking the load off the joints but they're still going to be burning calories and improving muscle strength and condition, which is going to support those joints even further.

So once you can get them exercising more, hopefully, that will help with the weight control, and as soon as they're losing the weight and they're feeling less load through the joints, they're going to be more inclined to exercise more. So, it's a win-win situation there. 

Bedding, you're wanting soft, supportive bedding. So, trampoline beds are great. Anything that they're sort of not lying on cold, hard floors is good. So, other lifestyle modifications, you might be trying to restrict going up and down the stairs, jumping in and out of cars, jumping on and off beds, things like that.

Andrew: That's a big one, jumping in and out of cars.

Sarah: Yeah. So, that's...

Andrew: How do you… Apart from, like, Snoopy, as soon as you start to lift him up, his bum caves in and he goes, "Uh-oh, we go to the vet." You know? Like, he doesn't like being lifted. So, how do you do that? Particularly elderly owners with a larger dog, they can't lift them out of their car, what do they do? Use a ramp?

Sarah: Really hard. Yeah, so you can get little ramps and little steps and things like that, yeah, absolutely.

Andrew: Great.

Sarah: And the same thing with if you really want the dog to be on your bed at night, put a little step there for them so that they don't have to jump on and off.

Andrew: Or a lift. No, I'm kidding.

Sarah: Probably some lifts exist in some people's homes. So, that's really important, and yeah, so things like that. There's therapeutic exercises that you can do for dogs and cats involving, you know, joint mobility exercises, massage, things like that. Acupuncture is becoming a lot more mainstream. So, there's a few different acupuncture courses you can actually do now to become a qualified veterinary acupuncturist, and there's actually quite a lot of conventional practices which are incorporating acupuncture into their work now, which is really excellent to see. 

Andrew: Cool!

Sarah: And acupuncture can just do wonders for lots of different conditions as we well know. Laser therapy, physiotherapy, all of that can be used as well as adjunctive treatments.

Supplementation. So, supplementation is pretty mainstream with osteoarthritis, which is excellent. Supplementation usually involves glucosamine and chondroitin, with the addition of other ingredients to support that. So, you might be thinking of MSM, manganese, Vitamin C, some natural anti-inflammatories, fish oils, green-lipped mussel, and those sorts of things.

There are some herbal supplements which are becoming a bit more popular on the market as well for osteoarthritis, like I mentioned curcumin and things like that. So that's pretty mainstream. There's also...there's these injections that patients are given for osteoarthritis, which is like an injectable nutraceutical, 

Andrew: Yep.

Sarah: So it's obviously not an oral...it's not a nutraceutical really because is not oral, but it provides building blocks for building healthy cartilage and reducing this...

Andrew: Yeah, humans have this as well.

Sarah: Yeah, okay. So, in humans is it...what is the compound? Is it pentosan?

Andrew: Now you’ve caught me…yes, I think it is, pentosan polysulfide.

Sarah: Right. Okay. So there you go. So that's pretty mainstream in veterinary practice now, and most dogs who are diagnosed...well, and cats, but more so dogs who are diagnosed with arthritis are started on this regime of injections, alongside everything else. So, there is definitely a place also for pharmaceutical intervention in a lot of cases of osteoarthritis, and that generally involves the use of nonsteroidal anti-inflammatory drugs. But to try and delay us having to use those drugs, we try and implement all of the other lifestyle modifications, supplementation, weight management, gentle exercise, and adjunct therapies before we get there.

Andrew: Now, you've mentioned weight management. You just said previously that horses tend not to have obesity issues. Is that right?

Sarah: So, that's not exactly true, there are definitely a cohort of ponies and some horses who will develop metabolic diseases that result in weight issues. So, ponies, in particular, can develop equine metabolic syndrome, which is sort of the equivalent of your insulin resistance and...

Andrew: Yeah, pre-diabetes.

Sarah: Yeah. And there's also quite a lot of horses who will end up developing Cushing's disease…

Andrew: Oh.

Sarah: …where you also see the same sort of issues, so insulin resistance and the like. And those, particularly the equine metabolic syndrome patients, will have issues with weight management. So, it's not that it's not as big a problem, but it's not as linked to joint issues as you might see in the dog and cat world. Yes.

Andrew: Is it true that in the natural environment, animals don't suffer obesity in that they normally regulate their own metabolic needs or is that really part of that life is damn hard in the wild? For instance...

Sarah: I think it's a bit of both.

Andrew: For instance, if a...let's say a lion, if they had a glut of the...you know, the wildebeests migrating through, would they get fatter?

Sarah: I think that they...I've watched a few David Attenborough documentaries, so I think...

Andrew: Just a few?

Sarah: Aren’t they amazing? But I think that they...it's a bit of a kind of feast and famine-type thing. So, if the meals are few and far between, they're going to try and eat and build up fat stores as much as possible, and then they might...

Andrew: Just like bears?

Sarah: Yeah, exactly. So then they might get leaner and leaner and leaner until the next fill. And they say that that's how people in, you know, caveman era used to be as well. You know, when it was summer and all the fruit was abundant, they'd get fat, and then in winter when everything was kind of sparse and lean and they'd get really skinny again, and that's sort of how...

Andrew: Try and chase down an animal.

Sarah: ...the human metabolism really evolved 

Andrew: Yeah.

Sarah: Whereas these days I think for our companion animals and horses... Well, you would consider a horse a companion animal now, they are exposed to the same challenges as people, definitely. So, obesity is a real problem, absolutely.

Andrew: So, obesity is just overfeeding, but then the...

Sarah: And under-exercising.

Andrew: And under-exercising. But the unconscious thing there, is that it is food that they are eating. What if it's the wrong food? What if it's a food that they never eat ancestrally? Take us through this one. This is a quagmire of the modern food industry.

Sarah: So this is really controversial, and I'm certainly not going to take a strong opinion one way or the other.

Andrew: Oh, why not?

Sarah: There's certainly some clinicians out there, particularly some integrative vets, who very much so will treat a dog or a cat as a human integrative clinician or naturopath would treat a human in terms of diet. So, they will strip out all of those commercial pet foods, strip out most of the kibble and the canned food, and they will basically prescribe a completely homemade nutritionally-balanced diet for their patient and see a lot of major improvements in the health of that patient. So, it's used very much as a therapeutic intervention in a lot of cases.

The important thing though to know is that a lot of home-cooked diets can be unbalanced. So, it's really important to use some sort of nutritional tool and there are some really good ones that exist online now, to ensure that the home-cooked diet is balanced. The problem generally lies with sort of overabundance of certain nutrients and a deficit of other nutrients. The main ones to be concerned about are calcium and phosphorus, and this is largely because in the wild, dogs and cats would have eaten the whole carcass, so including all the bones, which provide the calcium and phosphorus in the right balance that they need. A lot of the time when very well-meaning owners will make a home-cooked diet for their pets…

Andrew: That's true.

Sarah: ..they will often neglect. So they'll feed meat and veggies and fruit and really nutritious foods, but not necessarily giving the whole bones. And so calcium and phosphorus can be an issue. So, you do have to balance it and sometimes add in those minerals as an addition supplement.

Andrew: But there's issues with pre-cooking the bones from a safety aspect. Right?

Sarah: Oh, definitely no cooked bones. Yeah, no cooked bones. You know, cooked bones can't be digested well and they can often splinter and cause major life-threatening issues in the gastrointestinal tract, yeah.

Andrew: Absolutely. You only have to bite into a chicken drumstick to see just how sharp some of those bones can be, the finer bones particularly.

Sarah: And certainly bones, yes, they're the best thing for keeping teeth clean, but they're not without risk. 

Andrew: Ok

Sarah: It’s weighing out risk and benefit.

Andrew: So, when you say the right type of bone, is there a right type of bone for dogs versus cats?

Sarah: Yeah. Well, cats probably are pretty restricted because of their teeth are pretty small and their mouths are pretty small. So, cats you're more looking at things like chicken necks and chicken wings...

Andrew: A softer type bone?

Sarah: Yeah. And dogs do well with chicken necks, chicken wings because of the skin component, some dogs have more of a sensitivity to dietary fats. So you have to be a bit careful there, but chicken necks don't have any skin, so they're a pretty good option for most dogs, and even puppies can tolerate chicken necks quite well.

Andrew: Yeah. Chicken bones are pretty soft.

Sarah: Yeah. They're always raw. Some people will give a whole chicken carcass without the skin as a way of giving calcium and phosphorus, so that's kind of one of the...

Andrew: Okay, but without the skin, this is not what happens in nature. They will devour the carcass.

Sarah: Yeah, I know.

Andrew: What's gone wrong? Is it because we've stuffed up with the chicken?

Sarah: Well, I think chicken skin is particularly high in fat.

Andrew: Because we've done it. Humans have done that.

Sarah: Well, yeah, I don't think necessarily dogs and cats are going to be finding chickens in the wild to eat. 

Andrew: Yeah.

Sarah: They probably were going to be eating more leaner meat and leaner animals as well.

Andrew: Well, it's wild meat, yeah.

Sarah: But yeah, I mean, it might be something to do with major breeding practices that we have started to unfortunately select for dogs who have more sensitive gastrointestinal tracts. 

Andrew: Yeah. Yeah.

Sarah: It may be something to do with the environment and the exposure to different chemicals. I mean, gosh, like people, we're seeing such an increase in all these sorts of issues and allergies and everything, and don't get me started. I think we share a lot of...

Andrew: I'm going to get you started because...

Sarah: We share a lot of issues.

Andrew: Well, one of the other huge things is skin issues.

Sarah: Oh, absolutely. Yeah.

Andrew: So, you spoke about allergies. 

Sarah: Yep.

Andrew: You know, the skin thing one would say are fleas, some contact-type thing, but indeed it can be dietarily driven.

Sarah: It can be. The most common allergic skin disease seen in dogs is atopic dermatitis, or eczema, yeah, doggy eczema, and we actually call it... It's funny because in humans we mainly call it eczema, but in dogs, we basically call it atopic dermatitis across the board. And that is a sensitivity to inhaled allergens or allergens that contact the skin or are ingested. 

Andrew: Really.

Sarah: But they're generally allergens that exist in the environment. So, the most common ones would be your dust mites, pollens, and grasses. It's a really common issue. So, atopic dermatitis is pretty much the bread and butter of most veterinary dermatologists, and most general practitioners will see a lot of cases of atopic dermatitis walk in the door.

Andrew: There are veterinary dermatologists?

Sarah: Yeah, there are.

Andrew: I have never come across a veterinary dermatologist.

Sarah: Yep. So, veterinary dermatologist... So, to specialise and become a veterinary dermatologist requires a lot more study and years…

Andrew: Yeah!

Sarah. …and generally, they have to go through a process of an internship and residency and sitting some pretty major exams to become a specialised veterinary dermatologist. 

Andrew: Hormonally-driven skin diseases?

Sarah: Less common. Much less common. So, again, you've got hypothyroidism can be related to skin diseases in dogs. Canine Cushing's or hypoadrenocorticism is associated with calcinosis cutis. Do you have that in people?

Andrew: Now, there's some homework. I think yes, but let's...

Sarah: Well, that's a perfect example of a hormonal-related skin condition, but far less common compared to your classic case of atopic dermatitis or allergic skin disease, which we can go into but probably we'll save it for another episode, but that again does require an integrative approach for proper management, including supplementation with fatty acids, improving skin barrier health, in combination with different pharmaceutical medications. So, we can do allergy desensitisation vaccinations, which I know are becoming more popular in human dermatology as well, 

Andrew: Mmhm!

Sarah: But that's pretty mainstream in specialist dermatology clinics, developing these allergen-specific immunotherapy vaccines for dogs with allergies. So, that's an example of the skin...an integrative approach to skin disease. We could talk for ages, but there's a few other conditions which really benefit from an integrative approach. A perfect one would be chronic liver disease or even acute liver disease, liver toxicities.

Andrew: Is this like a non-alcoholic fatty liver disease for pets?

Sarah: So, cirrhosis of the liver is seen, but we generally see chronic hepatitis of unknown cause in dogs. There can be liver toxicities, hepatitis secondary to drug therapy or chemotherapy. There's a lot of cases where the liver starts to become involved, and SAMe and milk thistle, two really commonly used ingredients that have luckily enough made it into mainstream veterinary medicine there. 

Andrew: Right.

Sarah: They’re routinely...I would almost say routinely prescribed in almost all cases of liver disease, which is just so exciting. So, that's really nice to see. Other conditions that we have started seeing with integrative medicine has crossed over to conventional medicine is behaviour. So, anxiety… 

Andrew: Anxiety, wow.

Sarah: …is just huge, yeah. So, there's a few...

Andrew: Do we treat the human here?

Sarah: You know what? It's interesting because a calm owner generally means a calm pet. And I think this is the same with people with babies as well, is that the calmer the parents, often...

Andrew: The less calmer.

Sarah: ...the calmer the baby. And I really do notice, or I did notice when I was in practice ,that a calm owner in a consult room generally led to a calm pet, and they definitely can feed off anxiety of their owners. So, you're right. Maybe we should be prescribing for the owner as well as the pet. But taking an integrative approach to anxiety is really important. It is definitely multifactorial, so we need to address environmental modifications. Diet is really important, as we know, the huge link between gut health and brain conditions and mental illnesses with...you know, 70% of immune tissue lies in the gut and all the neurotransmitters that are produced in the gut, it's just so important to make that link. So, diet is really important for anxiety, and then, of course, we can supplement these patients as well.

So, there's less available on the market, but things like hydrolysed milk protein is available, tryptophan supplementation, B vitamins, and things like that, supportive supplements like that, and often used in conjunction with these environmental behaviour modifications, appropriate training and interventions, and sometimes pharmaceuticals. So we do use fluoxetine in pets quite commonly, and not generally long-term, but certainly for a few months. And that's always recommended in conjunction with, or should be recommended in conjunction with, appropriate training and high-quality training modifications.

Andrew: Yeah. Now, just another subject. What about these, you know, issues of, say, certain species of dogs eating their own poop? 

Sarah: Ah, right!

Andrew: Some people say that it's just a behavioural type thing. It might be an anxiety. Some people say it might be because they're trying to redistribute the microbiota. Some people say it might be because there's a problem with the microbiota. What's going on?

Sarah: Again, a controversial issue. It is believed likely to originate from dogs behaviour in the wild or trying to keep their den clean. 

Andrew: Right.

Sarah: So, a lot of the time a dog may eat their poo because it is in their living quarters and they are trying to clean it up. It's pretty gross, but a lot of dogs actually just really like the taste, and so it's a pretty rewarding behaviour, and that's why they'll continue to do it. 

Andrew: Right.

Sarah: It’s pretty hard to eradicate. Some people do say you can lace the poo with Tabasco or you can give the dog pineapple and it changes the taste of the poo and tries to deter them. But I don't know if it's them trying to ingest faeces to try and alter their microbiome. I think that's probably a research paper that is due to be written in the future.

Andrew: I know this is rank. I get it. I know it. But sometimes I'm taking Snoop for a walk and he will drop one. And when I go to pick it up with a bag, there is a distinct smell of coffee, and like, I've got to isolate what chemical it is in coffee that is in like a skatole or something like that.

Sarah: It varies so much depending on what they've eaten as well.

Andrew: For sure.

Sarah: So, talking about trying to alter their microbiome, faecal transplants are being done quite commonly now in veterinary practice.

Andrew: Really? Is this with diseased dogs like ulcerative colitis and Crohn's or...

Sarah: Yeah. So, we don't really label inflammatory bowel diseases as ulcerative colitis or Crohn's in dogs, it's really just inflammatory bowel disease.

Andrew: Right.

Sarah: And quite a problem in cats as well, and really linked to small cell lymphoma of the bowel in cats. 

Andrew: Right.

Sarah: So, in dogs they have been using faecal microbial transplant technology, not really technology, basically giving poo in a capsule orally to dogs with IBD, and dogs with particular bacterial overgrowth, so, Clostridium...again, same as people, Clostridium difficile.

Andrew: C diff, yeah.

Sarah: So, it's actually...

Andrew: For how long?

Sarah: For how long? I'm not sure actually.

Andrew: Is this something that moved across from veterinary science into the mainstream human thing, again?

Sarah: Right, so, historically. No, I don't think so. It probably has been moving in parallel, 

Andrew: Right.

Sarah: But certainly, it has been done for quite a few years in integrative vets, and I do know that some conventional vets are starting to do it as well, which is so exciting. So, they basically have a pool of dogs that they know have healthy faeces, and you can do a stool analysis to make sure that they don't have any parasites or bacterial overgrowth or viruses in their stool, and they will save the stool and give the owner capsules.

Andrew: A crapsule.

Sarah: A crapsule, yeah, basically, to give it orally, and then I know that they're also doing rectal sort of colonoscopy type...

Andrew: Implants, enemas.

Sarah: Yeah. So that's really exciting. There’s just…if you talk about where the evidence is leading, there is quite a lot of research being done with the importance of the microbiome for our veterinary patients, which is really exciting because it's a huge area of interest for me personally, yeah.

Andrew: Obviously we've said ad nauseam, pets can't communicate with us with speech. What sign do we look for, that might indicate that they're deficient in something and that they might benefit from supplementation?

Sarah: Okay. So, again, I think it depends on their condition. You can do some analyses now. So, vitamin D testing is becoming a bit more available. You can look for certain nutritional deficiencies using certain labs, so you can see that objective data. Pica is a behaviour which can often be linked to mineral deficiencies, and pica means basically eating some sort of foreign material, be that rocks or soil or licking certain substances. And you can see that in horses and in cows, and in dogs and cats as well. 

Andrew: Ok.

Sarah: So, that could be behaviour, but again, I guess to substantiate you would need to see the objective data and analysis of their blood mineral levels to make sure that's the case.

In terms of deficiencies, you will quite often see certain deficiencies related to certain conditions, and you know that they will likely need supplementation. So, for example, in IBD cases, most of these patients will be deficient in B12, so they should receive B12 injections to boost their B12 levels, and that's simply due to the lack of absorption in an unhealthy gut.

Andrew: Yeah.

Sarah: Other things that you might see is, so faecal consistency. If they are not absorbing fats and might have deficiencies of certain fat-soluble vitamins, you see a condition called steatorrhea where the stool is sort of frothy and floats to the surface, so you can analyse the stool in that way. They're an example, sort of a few examples, of different ways you can tell that an animal might be deficient in things.

Andrew: And what about particular toxicities? Are there any particular toxicities of vitamins with regards to, say, dogs versus cats? I seem to recall one or the other couldn't handle, and it doesn't make sense to me when I think about it, but couldn't handle quite large doses of...was it Vitamin A? Was it Vitamin D? I can't remember.

Sarah: So, Vitamin A toxicity does exist, I don't think it's...

Andrew: But that would be massive doses, wouldn't it?

Sarah: Yeah. So, I don't think it's too similar to people really.

Andrew: Yep, yep.

Sarah: Suddenly some cats who become really picky with their diet and some owners who think that they're doing the best, and no offence to them, but the cat might only decide that it wants to eat liver because it's really tasty, and they over time will start to refuse every single food but liver, so the owner will just continue to give the cat liver, and they will end up usually with vitamin A toxicity.

Andrew: Right, okay. Got you.

Sarah: In terms of different supplements, I can't think of any major differences between the species off the top of my head, but I know that there's been some issues with giving hops to dogs. 

Andrew: Yeah.

Sarah: That can end up being toxic over time. So, it's recommended if hops are used, to only use over a matter of a few months because it can accumulate. In terms of other toxicities, if we think of sort of things in the diet, so, quite a lot of people don't actually know this, but garlic and onion is toxic.

Andrew: For both dogs and cats?

Sarah: Particularly for dogs.

Andrew: Really?

Sarah: Yeah.

Andrew: I thought, like, garlic was okay, but onions were toxic or one or the other.

Sarah: No, it's the same family. So anything from the allium family, yeah. So, that's a no-no. Macadamia nuts are also a no-no.

Andrew: Grapes.

Sarah: Obviously chocolate, yep, grapes, sultanas, anything from that family...

Andrew: Have we found out what's...

Sarah: Avocados.

Andrew: Oh, really?

Sarah: Yeah. So, there's a whole host of different things that you need to be quite careful about in terms of feeding dogs home-cooked diets and giving dogs and cats left-over foods, yeah. Other things, so lily flowers are toxic to cats, all components of them. Even if they come into contact with the pollen, it can be severely toxic and cause acute kidney failure in cats, and that differs between dogs and cats. So, that's a perfect example. But so there are a few examples of some toxicities that are more commonly seen.

Andrew: There's so much to go into. I mean, we've alluded to it. There's so many species, but there's so much to go into. I'd love it of you'd join us on FX Medicine again sometime and we can maybe delve into some specific aspect.

Sarah: Yeah, of course.

Andrew: Maybe our listeners might have something that they'd really like answered. If that's the case, please contact us on Twitter, Facebook, you know, the usual platforms of social media, and, of course, our fxmedicine.com.au website or email at [email protected]. Dr. Sarah Howard, thank you so much for taking us through what is the tip of the iceberg today, and like really exploding some myths but giving us some responsible direction for where integrative veterinary science and care can help our pets, our loved ones. Thanks so much for joining us on FX Medicine today.

Sarah: Oh, an absolute pleasure. I was very happy to be asked to join the podcast, and will definitely be looking forward to the next episode.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.


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