Repost: CIL – Care and Feeding

Another repost to bring good information to the top!

——————

Today I’d like to talk about diets for dogs with Canine Intestinal Lymphangiectasia (CIL). Simply put, there are two common forms of this disease which have somewhat different, but overlapping, dietary requirements. These are:

  • Primary lymphangiectasia (lymphangiectasia by itself), and
  • Lymphangiectasia secondary to Inflammatory Bowel Disease (IBD).

“Secondary” here means that your dog has a disease (IBD) which is causing another disease (lymphangiectasia).  When a disease is “secondary,” it means that treating the first (primary) disease will often fix the secondary disease.  What this means is that, with lymphangiectasia that is secondary to IBD, treating the IBD is more important.

So, what you need to feed your dog will differ somewhat, depending upon which form your dog has.  And here’s the catch:  Even with all the testing you’ve done, and even with your vet’s best guess, YOU may not know which form your dog has.  In this case, how your dog reacts to food will provide important information about his dietary needs.

There are generally two items in the diet that may need to be strictly controlled (FAT and PROTEIN), and what you need to do will depend upon which form of the disease is present.  We’ll look at this separately, and then we’ll look at what typically happens in a case where the situation is unclear.

PRIMARY LYMPHANGIECTASIA (FAT is the enemy)

In primary lymphangiectasia, the big enemy is fat.  If you can control the amount of fat in the diet, you can (in some cases) control the disease.  Treatment is simple and straightforward and typically consists of anti-inflammatory drugs and an ultra low-fat diet.  The diet may also be high in protein.  With luck, treatment will resolve the disease as long as strict dietary adherence is maintained.

LYMPHANGIECTASIA SECONDARY TO IBD (PROTEIN is the enemy*)

If lymphangiectasia is secondary to IBD, your path is not so clear.  IBD is usually caused by protein intolerance (a negative reaction to certain kinds of proteins), so it becomes important at this point to determine whether or not your dog is reacting negatively to proteins in the diet.  The protein source in most diets is some kind of meat, so this is where you will need to look.  It is still critically important to reduce dietary fat, especially early in treatment.

Steps to take:

  1. Eliminate commonly fed proteins (especially chicken)
  2. Feed a hypoallergenic prescription diet, OR
  3. Slowly, and one at a time, introduce LEAN proteins that your dog has never eaten (examples of lean meats are bison, venison, kangaroo, whitefish such as tilapia or cod, or turkey).
  4. Observe over 24 hours what changes, if any, are seen in your dog after exposure to these proteins.

There are commercial, prescription diets available which can be tried initially.

Low fat diets include:

  • Royal Canin Gastrointestinal Low Fat
  • Hills w/d® Canine Low Fat

Hypoallergenic diets include:

  • Purina HA hypoallergenic dog food
  • Royal Canin Hypoallergenic dog food
  • Hills z/d® Canine ULTRA Allergen-Free

Your vet may recommend one of these diets.  These diets can provide a good starting point, but may not provide you with the full answer.

IF PRIMARY LYMPHANGIECTASIA IS SUSPECTED BUT YOUR DOG FAILS TO RESPOND TO THE LOW FAT DIETS

This happens quite a lot.  What it usually means is that your dog has an additional protein sensitivity that hasn’t been diagnosed.  You will need to begin to conduct low-fat protein trials to try to find a protein source that agrees with your dog (see “steps to take,” above).

ADDITIONAL TREATMENTS THAT MAY BE RECOMMENDED

  • Anti-inflammatory drugs are frequently prescribed.  These are often steroids, like prednisone.
  • Metronidazole (flagyl) is an antibiotic with anti-inflammatory properties.
  • Tylan (tylosin) is also sometimes recommended, especially in cases where the intestinal disease is suspected to be complicated by Small Intestinal Bacterial Overgrowth (SIBO).

So far we’ve talked about dietary needs and prescription products.  Many owners of lymphie dogs have found these products to be inadequate, and have turned to homemade or “hybrid” diets (diets containing but not limited to commercial products).  We’ll talk about these in another post.

— Louie’s mom

*SPECIFIC proteins, and you may have to figure out which ones.

 

Repost: CIL- Homemade and Hybrid Diets

UPDATE:  12/18/2012

Louie’s CIL was triggered a few months ago, which forced us to stop adding a can of commercial food to Louie’s diet.  His only source of protein is spirulina, which means he now receives no animal proteins at all.  

Original post:

Yesterday, I wrote a little bit about the different dietary needs of dogs with CIL.  Today I want to talk about home cooked and hybrid diets.

Many of us have tried the commercially available prescription foods and found them inadequate.  In our case, we had discovered one product that Louie could eat, which was subsequently reformulated by the manufacturer to include ingredients we knew he could not tolerate.  We scrambled around like mad to buy up what we could of this food, but realized after all was said and done that we would probably need to find ways to stretch our food supply over the long term.  So our “hybrid” diet was born.   Others have used different homemade diets with varying degrees of success.

There are a few important things to bear in mind when home cooking for your CIL dog.

  1. The ideal diet will most likely contain one form of protein and one source of carbohydrates.
  2. The diet needs to be balanced (that is, it needs to contain all the nutrients a dog needs to stay healthy).
  3. The diet needs to be strictly controlled for fat content (we’ll talk more about fat content in another post).
  4. The diet should be high in protein to address the protein loss that occurs from the disease process.
  5. The diet should be low in fiber.

Here is where things get tricky.  I am not a veterinary nutritionist, nor am I qualified to create balanced and complete diets from scratch to treat intestinal illness.  Initially I was prescribed a diet by a veterinary nutritionist that contained the following ingredients:

  • white rice
  • baked chicken
  • balancing supplement
  • oil

I dutifully prepared this diet for Louie for several weeks, but he continued to decline in health.  As he continued to decline, I began to experiment, cutting out the oil and then using less and less chicken to see if I could find a level of fat for him that was tolerable (remember that I had only been told that he had lymphangiectasia). Ultimately it became clear that I could not, and at this point I concluded that, in his case, fat was not the only problem.  I had to change his protein source, too.  That’s when I started scrambling to buy up whatever I could find of the discontinued food that he’d been able to eat.

After I had purchased all the old, prescription food that I could find and he began to do better again, I decided to try a new approach.  I had heard about a different kind of balancing product, a dehydrated, organic “base” made by the Honest Kitchen company, called Preference.  This product supposedly contained all the nutrients a dog would need, minus the protein.  The way it’s used for a healthy dog is simple.  Add meat to the dehydrated mix, add water, and off you go.

I purchased some of this and started experimenting with it, eventually landing on a formula that I continue to use today.  Without getting too caught up in the details of all the trial and error we did, here are the main things I ultimately included in his diet, with the good and the bad on each one and the reason for their inclusion.

  • Honest Kitchen Preference (GOOD:  provides many nutrients, very low in fat / BAD:  Very high in fiber, contains little protein)  1 part
  • Plain mashed potato flakes (with water added) (GOOD: provides carbohydrates for weight gain, nutrients, improves the stool, easy to use, very low in fat, very low in fiber / BAD:  Contains little to no protein)   2 parts
  • Powdered spirulina supplement (GOOD: packed with high quality protein that is well tolerated which comes from a non-animal source, fat-free, adds micronutrients)
  • Multi-strain probiotic in very small amounts (GOOD: helps keep the stool firm and keep the intestinal tract from developing bacterial overgrowth)
  • Bone Meal (GOOD:  Supplemental calcium, all dogs need this).

The Preference and the potatoes provide the  bulk of the diet.  The potatoes are very important.  They  cut back the overall fiber content of the meal, add high quality carbohydrates for weight gain, and help the consistency of the stool.

We usually mix up a big batch of this for him, which will last four days or so, and add a can of the prescription food that we purchased during the food drive to each batch, mixed in well.  You can experiment with adding small quantities of any lean meat or fish that your dog might find tolerable to this mix.

That’s what we do, but there are different foods that others have had success with.  These include:

CARBS

  • white rice
  • sweet potato
  • quinoa (a high protein carb source)

PROTEIN

  • soy powder
  • tofu
  • egg white
  • venison
  • rabbit
  • bison
  • kangaroo
  • antelope
  • whitefish (cod, tilapia)
  • 99% fat free turkey

There are a few things that I think are very important to mention.  One is about balancing the diet.  You’ll notice that I use one part Preference to two parts potato.  While this mix corrects the fiber content to tolerable levels, it dilutes the nutritive value of the food (mostly contained in the Preference.)

However, the amount of food Louie eats each day, due to his disease, is probably three to four times what he would eat if he were healthy.  So, overall, each day he is getting the right amount of nutrition.  You must either feed a lot of food using this approach, or you need to add balancing agents (such as BalanceIT supplement) to the diet.  

Neither of the dry ingredients (Preference or potato) has a significant amount of protein.  It is imperative that you add protein to this diet in some form.  I use the powdered spirulina because it is extremely well tolerated.  There is also protein in the can of prescription food I sometimes add (but even with this, he still needs the extra protein from the spirulina).  Spirulina is a very efficient form of protein and, for a dog Louie’s size (10 lbs), approximately 1/8 of a teaspoon per meal is all he needs.

Finally, it will be noted that this diet is extremely low in fat.  Much of the fat Louie gets is contained in the can of prescription food we often add to this mix.

Fat is important because some essential nutrients are fat soluble, that is to say that they will only be carried into the body through the intestines after they have been dissolved in fat.  You cannot feed a no-fat diet and expect your dog to live, much less thrive.  This diet may ultimately lead to problems based on limited absorption of those fat-soluble nutrients, and you may need to find ways to increase the fat content.  

Having said this, I will also say that I have a dog who is alive and doing well today by any standard, far better than the typical prognosis for this disease would suggest he would have done.  Feeding this ultra-low fat diet to him is a calculated risk that I have undertaken willingly, knowing that it may lead to other problems down the road.  However you look at it, he’s had four years (so far) that he wouldn’t have had if I had not been willing to take that risk.

Sometimes people tell me that their vets are recommending increased dietary fat because of these concerns.  I always worry when I hear this.  The truth is that (to the best of my knowledge) we do not actually have reliable data on how much fat is required to keep a dog healthy.  We do know that, with a CIL dog, too much fat is deadly.  I take my chances here, but I do it with eyes wide open, and would encourage others to make their own decisions in much the same way.  

CIL dogs are very sensitive to added fat.  Even tolerable amounts may take a few days to adjust to.  If you want to increase the fat content, do it slowly, carefully, and observantly.  

Achieve stability first.  Then, from a stable point, you can work to determine the maximum amount of fat your dog can handle and feed no more than this.  

Repost: Canine Intestinal Lymphangiectasia 101

This is an excerpt from a post written several years ago.

———————————–

 

This is probably the single, most important post I wrote during the past two years of operating the forum.  It’s a basic primer and FAQ rolled into one, based upon the collective experiences of myself and other members there.  It’s reproduced here, virtually verbatim.  If you are unlucky enough to have a dog with CIL, this might be the most important information you ever find on the internet:

Lymphangiectasia is not a disease that responds quickly to treatment. Many of us here have seen multiple ups and downs on the road to remission. This is not a disease where you can give a pill and see instant improvement. The improvements happen slowly, and it is not uncommon to see periods of inappetence (not eating), extended diarrhea with or without blood, vomiting, and numerous other apparent setbacks while they are struggling to get stable.

There are a few very serious rules of thumb that need to be kept in mind during this recovery period, and some commonly seen issues.

1) Getting food into them is not as important as getting the intestinal inflammation under control. Controlling inflammation effectively will only happen if they are fed the correct foods for their condition. Ultra-low fat diets are critically important. If lymphangiectasia is secondary to IBD, then avoiding triggering proteins is also critical. Feeding snacks or fatty foods to entice them to eat is never the right thing to do, no matter how thin and bony they may become. Until the inflammation is controlled, nothing they eat will get to where it needs to go to provide nutrition. All you are doing by feeding fatty or favorite foods is making your dog worse. Appetite can be improved in many cases using anti-nausea drugs, like Cerenia, and acid reducing drugs, like famotidine (pepcid). Put yourself in your dog’s shoes (pads? booties?) and imagine how your your appetite would be if you were vomiting and your own intestines were swollen and inflamed. There’s a good reason your dog does not want to eat! Be patient.

1a) The early stages of this disease are critical, and what you give your dog to eat during these early days is extremely important. Mixing foods is generally not a good idea, because your dog may be sensitive to an ingredient in one food and, if fed together, you will have no idea which food is causing the problem. Even tiny amounts of the wrong foods can cause major reactions.  The early days of this disease can be a race against time, and you need to observe your dog’s reaction to every single thing that is eaten. The only way to know if your dog is tolerating a food well is to feed that, and only that, and watch what happens.

Until you have them stable, treats should be completely off the menu. Once stability is achieved you might carefully experiment with low or no fat treats (Louie gets rice crackers for treats). Bully sticks and rawhides should never be given, as they are full of fat.

2) The recovery time (time to get them stable) is often long–six months, or maybe more. Prepare for a roller coaster ride, because your dog is not going to feel better overnight and, as mentioned above, there will be ups and downs. If you are reluctant to “put your dog through” what it takes to recover, please take a moment to think about what that means. No one here can make the decision for you to euthanize your dog. Many of us whose dogs have experienced remissions have had thoughts of giving up. Maybe most of us have. But in the end, many of us realized that what we “put our dogs through” was what it took to get them back to happy, stable lives. Please factor this in as you weigh your choices.

That said, not all of our dogs will make it. Only you know what’s best for your dog. If you are seeing improvements, even small ones, consider the above. But we understand that a dog that continues to decline despite all our best efforts may be more kindly served by that final, selfless act. We will support you here no matter what your decision might be. The purpose of this forum is to give you as much information and as many tools as possible so that you will be as comfortable as you can be with the decisions you make. 

3) Whatever we all thought we knew about feeding and nutrition needs to be left at the back door. This disease is not just serious, it is fatal if not treated correctly, and the recommended diets (the ones that work) will not contain all the fashionable ingredients that we’ve come to expect in quality foods. Not to put too fine a point on it, but I’d rather have my dog alive and eating a food that contains a grain than dead on a diet of organic, grain-free foods. That’s not to suggest that those things are not good things to shoot for when feeding pets, but here we look for stability above all else, and we’ve learned not to mess around with what works, once we’ve found it. Advice about feeding that is not appropriate for this condition or that may discourage someone from feeding an appropriate prescription diet is not acceptable here.

4) If you cannot bring yourself to monitor your dog’s food intake closely and to disallow virtually all treats and chewys, your dog is not going to make it. It’s really that simple. A lot of tough love is required.

5) We respect the knowledge and expertise of the veterinary profession, but a practical reality is that most vets will never see a recognized case of lymphangiectasia, and may rely on outdated information about treatment or consultation with colleagues who are familar with old methods. Most of the literature paints a gloomy picture of prognosis, which translates into some vets not trying very hard. To make matters worse, recent evidence suggests that some of the old-school treatments that are still being recommended may actually make your dog worse. Very specifically: Arm yourself with well-researched, current information before accepting advice to treat with Medium Chain Triglycerides (MCT) or coconut oil. And don’t be afraid to educate your vet about what you learn. 

Some vets seem over-reliant on anti-inflammatory drugs and dismissive of the important role that diet plays in treatment of this disease. Ask your vet (or other professionals) how many cases she/he has treated successfully and remember that the answers you need may come from many different places. Some of us here have been advised by our vets to euthanize dogs that eventually began to thrive. Every owner who comes here needs to realize that becoming your dog’s vocal and informed advocate is an important part of caring for a lymphie dog. Vets only have so much time to invest in learning about rare diseases they may never be asked to treat again; YOU have a responsibility to read and learn and to work to educate your vet. Your vet should appreciate this diligence on your part and, if they do not, you need to find one who does.

6) Many of us have discovered that our dogs do not tolerate chicken well. Therefore it is strongly suggested that chicken or chicken based diets not be fed unless you are certain it is not contributing to your dog’s illness. This is a particular problem with the Royal Canin dry formula low-fat prescription diets, which are made with chicken. One size does not fit all, however, so if your dog is doing well on this diet, please do not change it. Their canned formulas use different proteins, and are not a concern.

I wrote this post after answering the same questions multiple times and also after observing some common but potentially dangerous newbie mistakes and anxieties recur again and again.  I hope that bringing it out here to this blog will help to keep it in the view of those who will find the information to be of value.

— Louie’s Mom