Tuesday, 7 August 2018
Words by Lucy Grieve
Rossdales held their first 'Weight Wise' clinic on 16th June 2018 at the Diagnostic Centre in Exning, Newmarket. Horse owners were invited to book an appointment where their horse was weighed on an electronic weighbridge, nutrition and body condition scoring was discussed with Georgina Gatehouse from Spillers, and weight-tape and veterinary advice was discussed with the ambulatory vets, Mark Grant, Lucy Grieve and Paul Martynski.
Owners received goody-bags containing a weight record chart, baseballs caps, the NEWC grazing muzzle advice leaflet, weight-tapes from Virbac and forage hand scales donated by Horse Requisites of Newmarket.
There was a super uptake of the clinic and owner feedback was extremely encouraging. The opportunity for some dedicated one-to-one advice on all things regarding weight, nutrition and management, was welcomed. Similarly, getting an accurate starting weight and learning how to body condition score and use a weight tape, meant that owners had a clearly defined start point and end goal, with the confidence to know what they were aiming for and how they could achieve it.
The practice was inundated with owners who couldn't make the date and so there are plans to run a second clinic towards the end of autumn. It appears that there are plenty of owners who are determined to achieve a healthy weight for their horses, they just need the information and the support to do so.
Words by Nicky Jarvis
Government statistics show that nearly 62% of people in the UK are overweight with 27% considered to be clinically obese (body mass index of 30 or higher) compared to just 15% in 1993. With rising obesity levels questions have been raised over how to tackle patient issues and how best to achieve effective weight loss. Studies also show that between 29-39% of dogs and 19-29% of cats are thought to be overweight and many small animal practices have invested time in weight management clinics. But how much success do our human and small animal counterparts have and what lessons can we take forward to the equine world?
In companion animal practice only a few studies exist on the success of weight loss programmes and many are focused on short-term results rather than return of the animal to optimal weight. In one study, which included client education, only 53% of the dogs enrolled completed a six month weight loss programme. Owner related issues such as lack of compliance and illness were cited as reasons for not completing the course and interestingly the more obese animals were most likely to be lost to follow up. One factor for lack of compliance may be that diets aim to achieve a safe weight loss of 1% bodyweight per week and for the first 6 to 7 weeks this is meaningful to the owner. However, without regularly reducing the feed ration further, weight loss quickly falls to 0.3% BW per week. Whilst still a significant percentage for a cat or a dog, this can prove frustratingly slow to the owner.
Like humans, cats and dogs also show the ‘rebound effect’ when it comes to weight loss. One study showed 48% of dogs and 46% of cats began to gain weight at the end of a weight loss programme. So is finding ways to support and motivate horse owners long-term just as important as that initial short term success?
Weight gain is often insidious and in small animals many risk factors have been identified. Breeds such as the Labrador, Pug and Golden Retriever have a higher prevalence of obesity thought to be linked to early life rapid weight gain seen in the growing phase of these breeds. Certainly in humans, rapid weight gain in growing children has now been linked to an increased likelihood of obesity in adulthood. The existence of a ‘thrifty gene’ is often discussed and debated in native ponies and cobs. And with recent studies demonstrating specific genetic markers in horses which result in elevated insulin levels, increased obesity and laminitis could we soon be soon be able to identify ‘at risk’ horses before they become obese?
And what becomes of those animals that never even enroll on a weight management programme. Two small animal studies from 2008 and 2014 suggested that vets discussed the weight and body condition of overweight dogs in less than 2% of consultations. So do some of us struggle to raise the subject of an overweight horse?
Guidelines for human doctors recommend regular screening of patient weights and active encouragement to join commercial weight loss programmes that have been found to be far more effective than ‘going it alone’. In fact a doctor can now refer a patient to Slimming World and similar organisations on the NHS. However doctors find that lack of time and knowledge, fear of causing offence and a belief that intervention would be ineffective hold them back from raising the subject with patients during routine consultations.
A study led by Professor Paul Aveyard and published in the Lancet looked at the efficacy of a scripted ‘brief’ opportunistic intervention by GP’s in terms of encouraging patients to lose weight without the advice being deemed ‘inappropriate’. Patients attending a routine consultation were invited by the practice receptionists to weigh themselves on arrival at the surgery and then at the end of the consultation the GP was asked to spend just 30 seconds advising those patients deemed to be overweight:
GP: “While you’re here I just wanted to talk about your weight. You know the best way to lose weight is to go to (Slimming World or Rosemary Conley) and that’s available free on the NHS.”
GP: “Yes and I can refer you now if you are willing to give it a try?”
Patient: “Yes, OK.”
GP: “Ok, what you need to do is to take this envelope to reception…….. And I’d like to see you again in 4 weeks time please if that is OK?”
The study found that 77% of patients offered the service agreed to take part and over 40% went on to successfully attend the weight management programme. This success was also replicated in Hugh Fearnley-Whittingstall’s experiment featured in BBC One’s ‘Britain’s Fat Fight’ where a group of Bristol based GP’s were trained in the brief intervention technique. And 4 out of 5 patients reported they found the conversation both helpful and appropriate.
So perhaps this is something we can learn from the human world. If one of our biggest struggles is getting horse owners to recognise that their horse is overweight and motivate them to address the problem perhaps we need to start with that opportunistic conversation, our own ‘brief’ intervention at the end of a routine consultation. And as most weight gain is insidious perhaps by automatically producing a weight tape or body condition chart at every vaccination or dental check we can show owners with how much their horse has gained (or lost) in a few months rather than waiting until the situation harder to manage.
I'm thrilled to be asked by BEVA to write a blog on Westover's recently launched Equine Weight and Condition Club. RVN's within equine practice are such an under-utilised resource in comparison to their small-animal counterparts, introducing the idea of nurse-lead clinics to make use of the wealth of knowledge RVN's have is the perfect opportunity to create greater challenge within practice, whilst tackling one of the biggest health issues our profession faces.
Although we aim not to dissuade those with thin horses being interested in our service (following medical workup), this clinic is primarily aimed at dealing with the rising number of overweight and obese horses we see within practice. I can't stress enough how much easier it is to launch a service like this with a "whole-practice" approach. Within first-opinion practice, the ambulatory vets are those in most contact with clients, and therefore it's critical the nursing team can rely on those vets to upsell this service at any and every call they attend with an overweight horse. The flip-side of this is those that do embrace nurse-lead weight consults see their own workload reduced, as they can refer clients to nurses to discuss all things weight-related, freeing themselves up to do more challenging work. I'm sure many vets can relate to the difficulty of being stuck at a consult way beyond the scope of time left for a vaccine discussing variables like diet.
That's not to paint a picture that we are fortunate to gain every upsell the vets send our way - sadly as many will already realise, the issues surrounding obesity do not gain the sort of recognition or concern from clients that we would like, and therefore we don't get the volume of consults booked in that we would ideally like to see. By ensuring weight remains a high profile issue and not being deterred from discussing it we hope in time to secure a wider audience.
The most effective consults are held at the horses' location as opposed to the practice, as it removes subjectivity about grass quality and grazing management, and is particularly important if you have a predominantly leisure-horse caseload who may not all have transport. We aim to have an objective assessment of the horses’ condition and weight, as well as an open discussion about factors that may limit compliance to a diet and exercise plan: these plans must be bespoke in order to be successful, so if a client can only ride once a week due to work commitments or a horse is recovering from injury we need to take this into account. We weigh their current diet to the gram, usually creating great amusement amongst owners who prefer a “handful” method! We also discuss our starting point in terms of exercise and management. Much like the subjectivity over grass quality, you may have to be quite probing - I'm still amazed at how many feel a 20 minute walk around the block constitutes a physical challenge!
This consult is predominantly fact finding, so unless emergency measures need to be put into place we usually return to create a written plan incorporating diet, exercise and management changes to be sent to the client within 24 hours. This bides us time to consider all the variables at play in order to create the most effective plan possible.
Maintaining regular contact with our client's is also pivotal to our vision of the Westover weight programme. There is significant evidence in human medicine that those enrolled in group meetings see greater weight loss than those trying alone, so mimicking this feels like the obvious step. We are trying to create a forum group, giving clients the opportunity to discuss their difficulties with others going through the same. Although this is challenging whilst numbers are low, once you get a handful starting at the same time this soon adds additional value to the programme for minimal staff input. This forum is interspersed with regular information-based emails from myself as an RVN tackling weight related subjects –research articles on grass intake whilst grazing and how to use a grazing muzzle effectively as examples. This is a great way to engage with your client’s more, as well as upselling more services like nurse-lead clipping clinics or EMS blood sampling. This is all an additional revenue stream nurses can provide that is new to the practice.
The main struggle we face is retaining re-sees in cases receiving other ongoing veterinary intervention, or in cases that have improved to now be at a non-critical state. This relates to both the vets and clients perception of what a weight consult offers. If a horse has a vaccine and the vet puts a weigh band around the horse, this is enough for some clients, but I hope in time to alter this mindset and show that we could offer them so much more in terms of advice and support. Similarly, much like Weight Watchers offers it's gold membership to those who reach their target weight as a nod to the idea weight loss is a lifestyle, and not a one-off diet, I hope that by continually banging the drum that it's important to frequently re-assess our horses' health status and condition, client's will see the benefit of a re-examination even when their horse has dramatically improved to help formulate the most appropriate plan moving forward.