Introduction

Nutrition is an essential part of veterinary patient care and a fundamental component to maintaining patient well-being, preventing disease, and improving clinical outcomes of healthy and sick small animals.¹ In addition to the medical reasons why discussing nutrition is important, studies have shown that clients want their veterinarian’s advice on their pet’s nutrition,^2,3 and general practitioners continue to be the most commonly sought-out source of nutritional information.^4–12 However, research has shown that veterinarians are not consistently discussing nutrition during appointments.^13–15 One US study³ found that 90% of clients were interested in receiving nutritional recommendations from their veterinarians, but only 15% of clients felt they actually received guidance on what to feed their pet.

There are many perceived barriers for veterinarians in regard to initiating a discussion involving nutrition with clients.^9–11,13,14 To help combat these barriers, the American Animal Hospital Association (AAHA) and World Small Animal Veterinary Association (WSAVA) adopted nutrition as the fifth vital assessment along with temperature, pulse, respiration, and pain in 2010 and 2011, respectively, and created free nutrition resources for practitioners to use. Despite the guidelines that nutrition should be assessed at every patient visit^1,16 and the availability of associated hospital and client tools for over a decade, a recent study¹⁴ surveying over 2,700 veterinary healthcare team members showed that only 64% (1,747/2,740) of respondents recognized nutritional evaluation as the fifth vital assessment. Furthermore, only 27% (741/2,740) of respondents were aware of the WSAVA guidelines. Lumbis et al¹⁴ also found that while veterinarians were the most frequent source of nutritional advice in practice (96% [2,288/2,390]), veterinary nurses or technicians were also a valuable resource (61% [1,468/2,390]), followed by reception staff (23% [552/2,390]). However, when veterinarians were asked about their confidence in their support staff’s nutritional knowledge in a recent survey,¹³ < 13% (47/381) responded that they believe their support staff have quite a bit or considerable knowledge of nontherapeutic food, and that percentage only increased to about 24% (87/370) when asked about therapeutic foods.

Shortcomings of effective small animal clinical nutrition education may also be an underlying cause for the lack of knowledge, training, and reinforcement once students enter practice regarding the importance of nutritional assessments and client discussions during every patient appointment. A lack of confidence and knowledge in nutrition has been found in previous surveys.^4,13,17,18 Moreover, 1 report¹⁹ surveying deans and faculty members from 63 European veterinary schools showed that despite nutrition being considered an essential subject in veterinary education, recent graduates’ skills and performance were seen as not entirely sufficient in this area. Due to this lack of confidence among practicing veterinarians and veterinary faculty members in effective clinical nutrition knowledge training, there has been a call for a more rigorous small animal nutrition component in veterinary education to enhance students’ competency and ability to apply nutritional principles clinically.^19,20 Nonetheless, there remain potential obstacles to integrating nutrition education in veterinary curricula, including limited curriculum time, lack of funding for hiring trained nutritionists, and inadequate knowledge or comfort in nutrition among current faculty members.^19,21

The primary objective of this study was to evaluate whether a small animal general practitioner’s formal companion (small) animal nutrition instruction in veterinary school or their engagement in clinical nutrition after graduation impacts the perceived confidence levels veterinarians have in their own knowledge, as well as their support staff’s knowledge, of nontherapeutic food versus therapeutic food. Additional objectives were to determine how these factors (formal training and engagement in clinical nutrition) affected perceived barriers to discussing nutrition with clients as well as the frequency and overall positivity of their clinical nutrition discussions.

Materials and Methods

Results

Out of 3,997 surveys distributed to 1,000 AAHA members and 2,997 non-AAHA members, 403 veterinarians (131 AAHA members, 272 non-AAHA members) elected to participate in the survey, indicating a 10% response rate; however, some respondents did not answer every question. Of those who responded, 87.2% (306/351) worked predominantly in companion (small) animal general practice, while 12.8% (45/351) worked in specialty, emergency, or another type of practice; 28.8% (100/347) of respondents reported practicing for 10 years, 39.5% (137/347) for 11 to 24 years, and 31.7% (110/347) for 25 or more years.

When asked to describe the amount of formal instruction in companion (small) animal nutrition received in veterinary school on a 4-point Likert scale, most veterinarians responded that they received very little (185/352 [52.6%]). Approximately a third (119/352 [33.8%]) responded that they had some nutrition education, while only 9.1% (32/352) stated that they had a significant amount, and 4.5% (16/352) said they had none. Veterinarians reported roughly similar proportions of training regardless of how many years they had been practicing.

Veterinarians with more formal instruction in companion (small) animal nutrition during veterinary school reported increased confidence in their own nutritional knowledge (P < .01) and in their staff’s knowledge of therapeutic and nontherapeutic food (P < .01); means and distribution are summarized (Figure 1). Veterinarians with more formal instruction in companion (small) animal nutrition during veterinary school did not report significantly different levels of positive interactions around client conversations on nutrition or on time spent discussing nutrition during a typical appointment.

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Frequency distribution of answer options selected by 403 veterinarians for the survey question pertaining to how much confidence they have in their own and their staff’s knowledge of therapeutic and nontherapeutic food (ie, none, a little, some, quite a bit, or considerable) compared with their reported formal nutrition instruction (ie, none, very little, some, a significant amount). Bar plots show reported confidence for each subgroup (1 = low; 5 = high) and the mean (white diamond), median (dark line), and quartile range (bar) for each reported amount of formal nutrition instruction.

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.22.12.0577

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When asked “What keeps you from discussing nutrition during a healthy pet and sick pet appointment?” veterinarians who reported a significant amount of formal instruction in companion (small) animal nutrition were more likely to say, “Nothing dissuades me from discussing nutrition” during healthy pet appointments (14/32 [43.8%]), as compared with those who reported having none (4/16 [25%]), very little (27/185 [14.6%]), or some formal instruction (25/119 [21.0%]; χ = 15.0; P = .002). Veterinarians who reported no formal instruction in nutrition were more likely to choose “I have limited knowledge around non-therapeutic food” during healthy pet appointments (4/16 [25.0%]) when compared with veterinarians that reported having very little (38/185 [20.5%]), some (12/119 [10.1%]), and a significant amount of instruction (2/32 [6.3%]; χ = 9.2; P = .027). Similarly, veterinarians who reported having no formal instruction were more likely to choose “I have limited knowledge around therapeutic food” during sick pet appointments (3/16 [18.8%]) when compared with veterinarians that reported having very little (4/185 [2.2%]), some (1/119 [0.8%]), and a significant amount of instruction (0/32 [0%]; χ = 21.4; P < .001).

In their professional careers, most veterinarians surveyed expressed interest in learning about canine and feline nutrition. When asked to rank their interest on a 1-through-5 Likert-like scale, 72.2% (290/403) of veterinarians were very or extremely interested in learning more about therapeutic food, as opposed to 50.6% (204/403) for nontherapeutic food (Figure 2).

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Frequency distribution of answer options selected by 403 veterinarians described in Figure 1 for the survey question pertaining to how interested (ie, not at all, a little, somewhat, very, or extremely) they are in canine and feline nutrition related to therapeutic (gray) and nontherapeutic (black) food.

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.22.12.0577

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On average, veterinarians reported spending 2.16 h/mo (SD = 2.15 h/mo) researching or looking up therapeutic food (n = 392) versus 1.48 hours (SD = 2.09 hours) on nontherapeutic food (387; P < .001; Figure 3). The amount of formal instruction a veterinarian reported having in nutrition did not correlate to the amount of time reported researching or looking up nutrition in practice. Practicing veterinarians reported that the most time per year was spent referencing and looking up published guidelines for the veterinary profession (mean = 3.03 hours, SD = 3.65; n = 385) or by participating in continuing education focused on nutrition (mean = 2.75 hours, SD = 2.50; 387). Less but appreciable time was spent speaking with industry representatives (mean = 2.21 hours, SD = 2.77; n = 387) or veterinary nutritionists (mean = 1.28 hours, SD = 2.36; 385; Figure 4). Overall, as veterinarians reported more time in self-education activities per year, they reported more confidence in their own knowledge of foods (P < .01) and more confidence in their staff’s knowledge of foods (P < .01; Figure 5). Those who spent the most time learning about pet nutrition, regardless of the avenue they chose, were more likely to rate their own nutritional knowledge of therapeutic food highly (P < .05). Veterinarians who spent more time in self-education activities reported significantly higher levels of positive interactions with clients about recommending a change to a therapeutic food (r = 0.25; P < .001) and to a nontherapeutic food (r = 0.16; P = .002). Veterinarians who spent more time in self-education activities also reported providing more nutritional recommendations during an appointment for both therapeutic food (r = 0.25; P < .001) and nontherapeutic food (r = 0.17; P = .001; Figure 6).

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Percentages of veterinarians described in Figure 1 who reported on average how much time (ie, never, < 1 hour, 1 to 5 hours, 6 to 10 hours, or > 10 hours) they spend researching or looking up therapeutic (gray) and nontherapeutic (black) food per month.

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.22.12.0577

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Percentages of veterinarians described in Figure 1 who reported on average how much time (ie, never, < 1 hour, 1 to 5 hours, 6 to 10 hours, or > 10 hours) they spend speaking with industry representatives (n = 385), participating in continuing education (387), speaking to veterinary nutritionists (387), and referencing and looking up published guidelines (385) for the veterinary profession per year.

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.22.12.0577

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Frequency distribution of answer options selected by 385 to 387 veterinarians described in Figure 1 who reported confidence in their own knowledge and their staff’s knowledge of therapeutic and nontherapeutic food (ie, none, a little, some, quite a bit, or considerable) compared with their reported cumulative time spent self-educating per year. Bar plots show reported confidence for each subgroup (1 = low; 5 = high) and the mean (white diamond), median (dark line), and quartile range (bar) for each reported amount of nutrition education.

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.22.12.0577

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Frequency distribution of answer options selected by 385 to 387 veterinarians described in Figure 1 who reported their frequencies of providing nutritional information and their frequencies of conversation positivity compared with their reported cumulative time spent self-educating per year. Bar plots show reported percent for each subgroup and the mean (white diamond), median (dark line), and quartile range (bar) for each reported amount of nutrition education.

Citation: Journal of the American Veterinary Medical Association 261, 7; 10.2460/javma.22.12.0577

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For respondents who answered that they spend 6 or more hours each month researching or looking up food, an additional open-response question was asked in regard to what their motivation was to explore nutrition. Of these respondents, 68.8% (22/32) said their motivation was patient well-being, followed by knowing more about food quality and feeding practices (11/32 [34.4%]) and by preventing disease (8/32 [25%]).

Discussion

This study demonstrated that small animal general practitioners who self-reported receiving at least some formal companion (small) animal nutrition instruction during veterinary school and those motivated to continue to learn about nutrition while in practice are more confident in their own, as well as their staff’s, clinical nutrition knowledge. Although weakly correlated, veterinarians who reported devoting more time to clinical nutrition continuing education also indicated that they discussed nutrition more frequently during appointments and felt that a nutrition conversation was a more positive interaction with a client for both sick and well pet appointments. Additionally, veterinarians that felt they had a significant amount of formal instruction reported that nothing dissuaded them from talking about nutrition with clients, while those who reported having no formal instruction indicated they had limited knowledge of therapeutic and nontherapeutic foods. Therefore, it is important to address veterinary nutrition education gaps to increase the veterinary healthcare team’s engagement in nutritional discussions with their clients for both healthy and sick pets.

While greater efforts and attention have been paid to teaching nutrition in veterinary schools over the past few decades,^19,20 over half of the veterinarians we surveyed responded that they felt that they received “very little” companion (small) animal nutrition education throughout their veterinary schooling and approximately a third only received “some,” which is consistent with previous studies^4,17,18 indicating veterinarians feel their clinical nutrition curriculum was insufficient. The continued finding that this facet of the veterinary curriculum remains insufficient is important. Veterinarians and the veterinary healthcare team play a critical role in providing nutrition consultation and influencing clients to adopt healthy dietary habits for their pets; however, this conversation is not occurring at every veterinary appointment.^3,13,14 In our study, we found that veterinarians who perceived they had more formal instruction in companion (small) animal nutrition during veterinary school reported they are more confident in their own nutritional knowledge and in their staff’s knowledge of therapeutic and nontherapeutic food and are less likely to be dissuaded from discussing nutrition with clients. This suggests the importance of increasing the quality and quantity of small animal clinical nutrition in the veterinary curriculum.

The American College of Veterinary Nutrition developed a list of 29 nutrition-related competencies for veterinarians, to provide a basis for discussion of the nutrition education needs of veterinary students.^20,22 Under the AVMA Council on Education standards, the competency in nutrition fits under treatment planning, health promotion, disease prevention, food safety, and case management skills. The challenge is that many veterinary nutrition courses were structured to provide a strong foundation in nutrient metabolism, feeds, and feeding principles, but were limited in their ability to prepare students to apply nutrition principles clinically.²⁰ It has been found in the context of human nursing and medicine that when students considered their nutrition education to be relevant to future clinical practice, they reported higher clinical confidence, achievement, and satisfaction with their nutrition training.^23,24 Veterinary curricula must continue to expand nutrition programs to further guide how to apply nutrition principles clinically, and effectively discuss these principles to develop general practitioners who can perform nutritional assessments and communicate nutrition recommendations to pet owners.^25–27 With a limited amount of space in an already packed curriculum, 1 proposed consideration is to recommend fundamental comparative nutritional courses as part of veterinary students’ prerequisite training, allowing for space in the veterinary nutrition courses to teach more advanced, clinically relevant material.²⁰ Since not all undergraduate institutions may offer comparative nutrition coursework, another solution could be for veterinary schools to require current students to take a nutrition selective course, whether it be on campus, at a different vet school, in a private practice (distributive model), or virtually.

Finding space in the curriculum is a start; however, obtaining trained veterinary staff to teach clinical nutrition has also been challenging. A Board Certified Veterinary Nutritionist® provides training in nutrition to veterinary students, veterinarians, veterinary technicians, and animal owners. Less than half of the veterinary schools and colleges in the US and Canada currently have one of the 90+ Board Certified Veterinary Nutritionists teaching a nutrition course.^28,29 With that said, more than half of the schools do utilize adjunct faculty and guests who are boarded in nutrition to provide supplemental clinical nutrition teaching, often in the form of guest lectures and laboratories. Nutrition is a curricular field in which there is potentially conflicting literature and changing recommendations.³⁰ Thus, veterinary faculty are challenged to deliver nutrition content that is perceived as relevant by students, which is more demanding in the absence of a Board Certified Veterinary Nutritionist who remains current and interested in this area of study. A recent study²⁹ reported that veterinary students at schools with a Board Certified Veterinary Nutritionist faculty member were more likely to perceive higher emphasis on nutrition education.²⁹ For programs without a Board Certified Veterinary Nutritionist, developing alternative resources such as online nutrition courses to be taught in conjunction with trained nutrition faculty is a possible consideration.²⁰ One of these resources is the Mark Morris Institute (https://www.markmorrisinstitute.org/teaching.html), a purely educational organization that offers veterinary schools customizable, noncommercialized small animal nutrition courses at no charge. These courses are taught by independent, unbiased boarded nutritionists and internists primarily in academia.

Notwithstanding a perceived insufficient amount of clinical nutrition curriculum, most practicing veterinarians in our study expressed continued interest in learning about small animal nutrition. This survey found that having more formal small animal nutrition instruction correlates with increased interest in nutrition but not in actual follow-through when it comes to time spent participating in clinical nutrition continuing education. A reason could be that veterinarians with more formal instruction feel confident in nutrition, so they spend time on another topic for continuing education in which they feel less confident. Overall, participants indicated that there was an increased interest in learning more about therapeutic food as opposed to nontherapeutic food, and more time was spent researching or looking up therapeutic food. This is not surprising, especially for veterinarians from schools without a Board Certified Veterinary Nutritionist. Without faculty who are interested and trained in clinical nutrition serving as role models to veterinary students, the perception may be that nutritional support is only considered and required for patients that are ill, malnourished, or at risk of malnutrition.^31,32 Therefore, evaluating the nutritional status of every small animal patient and making a nutritional recommendation as the minimum standard of veterinary care and prevention may not be prioritized. A way to help overcome this gap is utilizing educational partnerships with external organizations, including the AAHA, WSAVA, pet food manufacturers, and so forth. These organizations have created many tools as well as additional training for the veterinary community.

Predictably, veterinarians who spent the most time participating in continuing education focused on nutrition or referencing and looking up published guidelines also had more confidence in their own, as well as their staff’s, nutritional knowledge. Our participants reported that most time was spent learning online or by participating in formal continuing education, while less but appreciable time was spent learning directly from industry representatives or veterinary nutritionists. Interestingly, veterinarians who spent the most time speaking with industry representatives about nutrition were also more likely to rate their own nutritional knowledge of therapeutic food highly. Fortunately, as mentioned above, there are numerous continuing education resources and nutrition tools available. Intriguingly, in a recent survey¹³ veterinarians suggested that having more nutritional resources for clients would help them overcome roadblocks to nutrition discussions. Despite their existence, veterinarians knowledge of the freely available and accessible WSAVA nutritional assessment tools and resources, or the motivation to use them, appears to be deficient.¹⁴ These studies suggest that there is a continued need to raise awareness and prioritize both continuing education and effective nutritional tools as valuable resources among the entire veterinary healthcare team. Utilizing the entire team to engage and educate clients about their pet’s nutrition is vital as the structure of small animal veterinary practices evolves over time. This is important, as this study demonstrated that veterinarians’ confidence in their staff’s clinical nutrition knowledge increased as their own knowledge increased. Industry partners can help fill this knowledge gap by being an effective source of education and by raising awareness of current tools in veterinary clinics.

We found in our study that most practicing veterinarians surveyed were interested and motivated to learn about clinical nutrition. Being more engaged in continuing education led to higher perceived confidence in nutritional knowledge, increased frequency of nutritional discussions with clients, and more positive client interactions during nutritional conversations. Reported reasons that motivated veterinarians to invest time in nutrition continuing education included patient well-being, knowing more about food quality and feeding practices, and preventing disease. At a fundamental level, motivation is based on an intrinsic catalyst to act in a particular way that will change the underlying conditions and generate drive.³³ Discrepancy theory explains how the learner determines that there is a need to increase competency and the value of fulfilling that need. Very large discrepancies (eg, an overwhelming amount of over-the-counter pet food selection without adequate training) may promote high levels of anxiety. High anxiety is likely to be associated not with feelings of attraction but with feelings of aversion, which is not motivating.³³ Therefore, veterinarians who feel ill prepared to discuss clinical nutrition with their clients due to lack of knowledge and subsequent demotivation may then avoid this important and necessary discussion during appointments. Solutions to overcome these challenges are similar to those aforementioned.

Both this study and Alvarez et al¹³ revealed that tenured veterinarians (> 25 years of clinical practice experience) tended to be more confident in small animal clinical nutrition compared with their early-career (< 10 years of practice) counterparts. Possible reasons for this could be that experienced veterinarians learn to value nutrition more and prioritize it, especially as they become more comfortable and efficient with their time leading appointments. This could indicate that even if veterinarians are not prepared well through school, perhaps they are learning these values and skills through time, practice, and other means of continuing education. This also may suggest that veterinarians ultimately determine that clinical nutrition is important. Still, teaching them the importance of nutrition prior to graduation may be more efficient, and possibly less stressful, than having them learn over decades of experience and client interactions as found in this study. Additionally, new graduates need further preparation to achieve the skills and confidence to take on nutritional recommendations with their clients, especially during well-patient appointments.³⁴ Based on these findings, 1 solution is for more tenured practitioners to mentor early-career veterinarians to overcome barriers or knowledge gaps that can hinder nutrition discussions with clients.

There were several limitations to this study. The overall response rate was lower than expected, and some respondents did not answer all the available survey questions. Respondents choosing to participate in this survey may have greater interest in small animal nutrition in general, which could have skewed the data. For example, a larger percentage of AAHA members participated versus non-AAHA members; these practitioners may be more knowledgeable about nutrition given AAHA’s advocacy of nutrition as the fifth vital assessment. Additionally, the survey did not include where and when the respondent attended veterinary school, which may have shed some light on education gaps within specific academic curriculums. The level of perceived education was also evaluated from a 4-point Likert scale question, with “none,” “very little,” “some,” and “significant” as options. A more robust study with specific guidelines on what each answer means quantitatively, along with a larger pool of “significant” results, may have allowed for clearer outcomes when comparing concepts such as perceived confidence in nutritional knowledge, frequency of nutrition discussions with clients, and positive interactions with clients during nutrition conversations. Future studies to decipher these concepts could include more specific questions about what veterinarians learned through their clinical nutrition curricular experience. Additional work could also include evaluating veterinary technicians and additional healthcare team members’ interest, education, and engagement in clinical nutrition.

The results of this study demonstrated that considerable small animal nutrition education, either through formal instruction or continuing education during practice, translates to increased perceived confidence in nutritional knowledge and more frequent and positive nutritional conversations in the examination room. Given the importance of nutrition in maintaining overall pet health, increasing the quantity and quality of nutrition education provided to small animal general practitioners could significantly impact veterinary patient care.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org