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Royal (Dick) School for Veterinary Studies, University of Edinburgh, Roslin, Midlothian, Scotland, UK
3 To whom correspondence should be addressed. E-mail: m.chandler{at}ed.ac.uk.
KEY WORDS: • malnutrition • nutritional assessment • body-condition score • dogs • cats
In the 1970s the prevalence of malnutrition (undernutrition) in general human medical patients was estimated to be 30–50% (1). This rate has persisted in human hospitals; data from the 1990s show estimates of 40–50% (2,3). These values may in part represent the interrelatedness of nutrition and disease; disease may contribute to malnutrition due to inappetance or malassimilation; and malnutrition contributes to increased disease risk and decreased ability to recover (4–6). The prevalence of malnutrition in veterinary hospitals is estimated to be similar to that in human hospitals; however, no studies have documented this possibility.
The use of laboratory analyses to determine nutritional status is not commonly practiced in veterinary medicine and is not consistently predictable in human medicine. Serum concentrations of visceral proteins have been examined as tools for assessment of nutritional status in human medicine. A decrease in serum albumin concentration is a negative prognostic indicator in human medicine, but there is controversy regarding the pathogenesis of hypoalbuminemia in these patients (7). Serum albumin concentration may be decreased in some types of malnutrition, but this may also occur in some hepatopathies, nephrotic syndrome, some intestinal diseases, and in the acute-phase response of illness or injury. Interestingly, serum albumin concentrations were also found to be within reference ranges in human patients with anorexia nervosa who had lost 30% of their body weight (7). A decrease in serum albumin concentration can be masked by hemoconcentration due to dehydration.
Other proteins used to evaluate nutritional status in human medicine include transferrin, thyroxin-binding protein, retinal binding protein, and fibronectin. These include some acute-phase reactants that may be increased due to disease. These parameters have not been evaluated in veterinary patients for assessment of nutritional status.
Serum proteins that have been evaluated in small animals as potential markers of nutritional status include insulin-like growth factor I (IGF-I)4 and creatine kinase (8–10). Serum IGF-I shows good correlation with nutritional status in healthy animals (9,10) but thus far has only been examined in research studies and has not been applied widely to clinical patients. Serum creatine kinase concentration has been assessed as a marker of nutritional status in cats (8), but it is also subject to increases or decreases with disease states.
The ability of surgeons to reliably determine human patients' nutritional status based on questionnaires and clinical examinations was significantly correlated with serum albumin, transferrin, and cholesterol levels and with weight loss (11). In this study, researchers concluded that surgeons are able to assess nutritional status using clinical judgment and supported the use of history and body-condition scoring for assessment of nutritional status.
In veterinary patients, body-condition scores (BCS) provide a semiquantitative method of evaluating body fat and lean body tissue percentages (12–14). Scoring systems for dogs and cats have been developed using systems of 1–5 points, 6 points, and 9 points, with lower numbers reflecting thinner conditions and higher numbers indicating fatter animals. In both dogs and cats, a BCS system using a 9-point scale has shown good correlation (0.92 for dogs and 0.91 for cats) with percentage of body fat as determined using dual-absorption X-ray absorptiometry (13,14). Reproducibility of scoring among observers was very good and was estimated at 0.86 for dogs and 0.89 for cats (13,14).
The objectives of this study were to assess the nutritional status of dogs and cats at admission to the hospital by the Internal Medicine Service based on clinical history and BCS using the 9-point scale. Serum albumin concentrations were also recorded.
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METHODS AND MATERIALS |
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 TOP METHODS AND MATERIALS RESULTSDISCUSSIONLITERATURE CITED |
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Cats and dogs >6 mo of age that were hospitalized for 
1 night were included in the assessment of initial nutritional status. Only animals that were admitted for a disorder not previously diagnosed at the Royal (Dick) School for Veterinary Studies were included (i.e., no revisiting or continuing cases). Study participants were prospectively selected over eight 1-wk blocks that occurred between June and October 2002. Available data included BCS, appetite- and weight-change information, and serum albumin concentrations for 72 dogs and 60 cats.
Nutritional status
Clinicians from the Internal Medicine Service of the Hospital for Small Animals obtained histories and performed physical examinations of the patients. The existence of unintentional weight loss or failure to grow and/or decreased voluntary food intake during the previous month were determined during the initial history taking. Body condition was assessed using a 9-point scoring system during the initial physical examination. For each patient, age, breed, sex, and weight were recorded along with the diagnosis or presenting complaint. After the animal was hospitalized, serum albumin concentration was determined using an automated colorimetric procedure (Techron RA Systems, Miles, Diagnostics Division, Tarrytown, NY). The reference ranges for serum albumin concentration were 28–36 g/L for cats and 26–35 g/L for dogs.
Statistical analysis
Data are expressed as median values. Correlation of serum albumin concentration and BCS values was determined using Spearman's rank correlation with significance at P < 0.05. Association of decreased appetite (present or absent) and weight loss (present or absent) with BCS (<5 or 5) was determined using 
2 analysis with significance at P < 0.05. All analyses were carried out in S-PLUS 2000 (Insightful, Seattle, WA).
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RESULTS |
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TOPMETHODS AND MATERIALSRESULTSDISCUSSIONLITERATURE CITED |
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The median BCS for the 72 dogs was 6.5, and 20 (27.8%) of the dogs had a BCS of <5. Based on owner reports, there were 25 (34.7%) dogs with a history of decreased food intake, and recent weight loss had occurred in 33 dogs (45.8%).
Of the 72 dogs, 20 had a serum albumin concentration value below the reference range (<26 g/L).
There was no significant correlation between serum albumin concentration and BCS (
= 0.178, P = 0.133; Fig. 1). In addition, there was no significant association between a BCS of <5 and decreased appetite (2 = 2.66, P = 0.103). In contrast, there was a highly significant association between a BCS of <5 and recent weight loss (2 = 22.26, P < 0.001).
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The median BCS for cats was 4, and 32 (53.3%) cats had a BCS of <5. Based on owner reports, 34 (56.7%) cats had recent weight loss, and 32 (53.3%) had decreased food intake.
Of the 60 cats, 27 (45%) had a serum albumin concentration below the reference range (<28 g/L). In contrast with the dogs, there was a significant correlation between serum albumin concentration and BCS ( = 0.360, P = 0.006; Fig. 2). In addition, there were significant associations between a BCS of <5 and decreased appetite (2 = 7.05, P = 0.008) and recent weight loss (2 = 19.55, P < 0.001).
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DISCUSSION |
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TOPMETHODS AND MATERIALSRESULTSDISCUSSIONLITERATURE CITED |
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The dogs in the study had an acceptable median BCS; however, over one-fourth had a BCS of <5, and a large percentage (45.8%)had recent weight loss. The median BCS of >5 may reflect a population that was previously overweight but came to the hospital after losing weight. These patients may be at greater risk for not receiving nutritional support in the hospital, because their apparently good body condition may not alert the clinician to their nutritional needs. Furthermore, unintentional weight loss in obese human patients who are hospitalized due to illness or injury is associated with increased loss of lean body mass rather than fat stores, and this is also likely in obese cats and dogs (15). This loss of lean body mass would likely be associated with similar deficiencies in immunocompetence and healing as in a normal-weight individual (5,16).
Although most of the dogs with low serum albumin concentrations had a history of weight loss or inadequate food intake, there were many dogs with this history that still had a serum albumin concentration within the reference range. Serum albumin concentration may not be a sensitive indicator of malnutrition in dogs; many of the dogs with decreased serum albumin concentration had gastrointestinal disease or a hepatopathy that accounted for a loss of or failure to synthesize albumin rather than lack of nutrient intake.
The cats in the study had a median BCS of 4, and over one half of them had a score of <5. Approximately one-half of the cats had decreased food intake and weight loss. The reason for the poorer nutritional status for the cats compared with the dogs is unclear. Cats with disorders that cause weight loss often have a change in body shape that makes body-condition scoring difficult; they appear to lose lean body mass but retain periabdominal fat. The owners may have been unaware of the cats' weight loss and may not have presented them to their veterinary surgeons as early as the dogs were presented. It is also possible that there was a longer delay and a consequent longer duration of illness before the cats were presented to the referral center.
The serum albumin concentration of the cats but not the dogs correlated with the BCS. This may reflect an initial higher BCS in the dogs. However, it is also possible that albumin is a better indicator of poor body condition and poor nutritional status in cats than in dogs.
Similar to malnourished critically ill human patients who have a poor outcome compared with better-nourished patients (5), cats with poor body condition are reported to have a lower survival rate than cats in good body condition (17). This may reflect common causes of the cats' weight loss and death; however, it may also represent increased severity of disease in underweight cats. That study also noted that cats fed a dry diet that was purchased from a pet store, specialty retailer, or veterinary surgeon had a decreased risk of emaciated body condition compared with cats fed dry food that was purchased from a grocery store.
These data reinforce the importance of determination of nutritional status including dietary history at the time of admission to the veterinary hospital. Early determination of nutritional status will enable clinicians to provide appropriate nutritional support to their patients and thereby decrease the rates of morbidity and mortality.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 M. L. Chandler and D. A. Gunn-Moore thank the WALTHAM–Royal Canin Company and Nestlé Purina PetCare for support of their respective lectureships.
4 Abbreviations used: BCS, body-condition score; IGF-I, insulin-like growth factor I.
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LITERATURE CITED |
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TOPMETHODS AND MATERIALSRESULTSDISCUSSIONLITERATURE CITED |
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1. Bistrian, B. R., Blackburn, G. L., Vitale, J., Cochran, D. & Naylor, J. (1976) Prevalence of malnutrition in general medical patients. J. Am. Med. Assoc. 253: 567–570.
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3. Naber, T. H., Schermer, T., deBree, A., Nusteling, K., Eggink, L., Krumminel, J. W., Bakkeren, J., van Heerevelt, H. & Katan, M. B. (1997) Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications. Am. J. Clin. Nutr. 66: 1232–1239.
4. Pennington, C. R. (2001) Malnutrition in hospitalised patients. In: Artificial Nutrition Support in Clinical Practice, 2nd ed. (Payne-James, J. J., Grimble, G. & Silk, D., eds.), pp. 149–164. Greenwich Medical Media, London, UK.
5. Giner, M., Laviano, A., Meguid, M. M. & Gleason, J. R. (1996) In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition 12: 23–29.[Medline]
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7. Sitges-Serra, A. & Franch-Arcas, G. (2001) Nutritional assessment. In: Artificial Nutrition Support in Clinical Practice, 2nd ed. (Payne-James, J. J., Grimble, G. & Silk, D., eds.), pp. 165–176. Greenwich Medical Media, London, UK.
8. Fascetti, A. J., Mauldin, G. E. & Mauldin, G. N. (1997) Correlation between serum creatine kinase activities and anorexia in cats. J. Vet. Intern. Med. 11: 9–13.[Medline]
9. Maxwell, A., Butterwick, R., Batt, R. M. & Camacho-Hubner, C. (1999) Serum insulin-like growth factor (IGF)-I concentrations are reduced by short-term dietary restriction and restored by refeeding in domestic cats (Felis catus). J. Nutr. 129: 1879–1884.
10. Maxwell, A., Butterwick, R., Yateman, M., Batt, R. M., Cotterill, A. & Camacho-Hubner, C. (1998) Nutritional modulation of canine insulin-like growth factors and their binding proteins. J. Endocrinol. 158: 77–85.[Abstract]
11. Lupo, L., Pannarale, O., Altomere, D., Memeo, V. & Rubino, M. (1993) Reliability of clinical judgement in evaluation of the nutritional status of surgical patients. Br. J. Surg. 80: 1553–1556.[Medline]
12. Burkholder, J. (2000) Use of body condition scores in clinical assessment of the provision of optimal nutrition. J. Am. Vet. Med. Assoc. 217: 650–654.[Medline]
13. Laflamme, D. (1997) Development and validation of a body condition score system for cats: a clinical tool. Feline Pract. 25: 13–18.
14. Laflamme, D. (1997) Development and validation of a body condition score system for dogs: a clinical tool. Canine Pract. 22: 10–15.
15. Pennington, C. R. (1997) Disease and malnutrition in British hospitals. Proc. Nutr. Soc. 56: 393–407.[Medline]
16. Kiyama, T., Witte, M. B., Thornton, F. J. & Barbul, A. (1998) The role of nutrition support affects the early phase of wound healing. J. Parenter. Enteral Nutr. 22: 276–279.
17. Doria-Rose, V. P. & Scarlett, J. M. (2000) Mortality rates and causes of death among emaciated cats. J. Am. Vet. Med. Assoc. 216: 347–351.[Medline]
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