TOPICAL REVIEW

Homemade Diets: Attributes, Pitfalls, and a Call for Action Rebecca L. Remillard, PhD, DVM, DACVN At one time, it was estimated that the majority of dogs and cats in the United States received 90% or more of their nutrition from complete and balanced commercially prepared foods, and this estimate was reaffirmed in a 2004 survey. However, 4 years and several pet food and treat recalls later, fewer pet owners are feeding commercial pet food products exclusively and more are asking questions and looking for alternatives. As in any market-driven economy, there are many more alternative diets and food products available today from which pet owners may select. A difficult to measure but growing number of clients are feeding homemade diets that provide 100% of their pet’s nutrition, while a larger number are feeding a combination of products, treats, and home prepared meals. Most practitioners can attest to this increase in their client’s interest in homemade meals and to having insufficient knowledge to assist them. At a time when motivated clients are considering homemade for their pets as an alternative, veterinarians are less than adequately versed in canine and feline nutrition and dietary options. The article addresses the two most important health issues concerning pet owners and veterinarians about homemade diets: nutritional integrity and food safety. © 2008 Elsevier Inc. All rights reserved.

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lients have become increasingly interested in the nutrition of their pets, noticeably more so since the recent pet food recalls.1,2 Some owners attribute greater long-term health benefits to feeding a “more natural” or “organic” food to their pet and in the US spent $520 million in 2005 on pet food products labeled natural. Sales of “natural” pet foods in the US are estimated to reach $1.042 billion in 2010 with the “organic” segment approaching $100 million.3 Feeding commercially prepared pet food offers several advantages over home prepared meals such as convenience, consistency, reasonable assurance of quality and nutritional balance, plus a cost savings. However, a growing number of owners are willing to forego the advantages of commercial products and prepare homemade foods for their pets for a variety of reasons. This shift is being noticed in a number of places. For example, the vast majority (!80%) of pet owners seeking nutritional advice from a web site (Veterinary Nutritional Consultations, Inc. at www.petdiets.com owned by the author) that provides this service requested information on both commercial and homemade diets options for their pet. Another web site (Davis Veterinary Medical Consulting, PC, at www.balanceit.com, “pet lovers” site) offering online tools where owners select ingredients for a homemade diet specific for their healthy pet opened in early 2007 and averaged 190 clients purchasing at least one recipe per month in the first year.

From the MSPCA Angell Animal Medical Center, Boston, MA. Address reprint requests to: Rebecca L. Remillard, PhD, DVM, DACVN, MSPCA Angell Animal Medical Center, 350 South Huntington Ave, Boston, MA 02130. E-mail: [email protected] © 2008 Elsevier Inc. All rights reserved. 1527-3369/06/0604-0171\.00/0 doi:10.1053/j.tcam.2008.04.006

A Growing Disparity In the US, most dogs and cats are fed one or more commercial pet food products daily.4,5 Veterinarians, according to pet owners, are still the best source of health care for their pets.5 Yet a 2003 survey suggested that, although owners wanted a specific nutritional recommendation for their pet from their veterinarian, they usually did not receive such advice.6 The American Animal Hospital Association (AAHA) Compliance Study found that a majority of clients (55%) did purchase the recommended food when a therapeutic pet food recommendation was made, while less than 5% declined the food recommendation due to cost.6 Fifty-nine percent of all dogs and cats in the same study were diagnosed with a condition that would benefit from a therapeutic diet, yet compliance (continued follow-through) was only about 12%. Simultaneously, as veterinarians decline offering nutritional recommendations, data about the lack of nutrition education during veterinary school training are surfacing throughout internet pet chat groups.7 A survey of some 4000 US veterinarians graduating between 1989 and 1992 indicated that 70% of the respondents believed that there was inadequate time allowed for nutrition education in the veterinary curricula, and half concluded that the quality of nutrition training available in the curricula was inferior. Additionally, 55% of respondents indicated that there was inadequate time devoted to nutrition in continuing education programs with 25% believing that the quality of continuing education nutrition training was inferior.8 The issue of less than adequate nutritional training for veterinarians is beyond the scope of this review but there is no doubt this lack of confidence veterinarians have with nutrition feeds into the growing number of clients seeking alternative diets, including diets made at home, without professional advice. A recent survey indicated that among 54 pet owners who provided at least

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138 half of their pet’s diet from homemade foods specifically prepared for their pet, only 16 reported use of a recipe designed for pets. Of these recipes, eight were from a veterinarian, three were obtained from the Internet, and five were from other sources.5 Owners feeding a homemade (cooked or raw) diet to their dog or cat are no longer an uncommon presentation for most practitioners. Pet owners are interested in homemade diets for several reasons that generally fall into one or more categories: (1) health concerns about additives, preservatives, and contaminants; (2) inability to understand pet food label ingredients and subsequent distrust; or (3) lack of a suitable commercial product for a particular set of medical conditions in their pet. Clients are becoming increasingly dissatisfied with practitioners who routinely, automatically, and only recommend one or two major commercial brands and will not consider other diet alternatives. When an owner strongly prefers to cook for their pet, it is better to provide them with a well-designed homemade recipe rather than leaving them to prepare foods according to their own or other well-intentioned pet owner’s recipes. More often than not, such recipes are more complicated than need be and still contain nutritional imbalances. It is possible for practitioners to help clients provide balanced homemade diets. Veterinarians should offer to work with their clients who wish to feed such foods and locate the resources to provide practical advice about nutritionally balanced homecooked pet foods for a reasonable fee.

Benefits of Homemade Diets Setting aside the nutritional imbalances because those can be corrected and the raw food issue because simply cooking lowers those risks, there are several potential advantages to homemade diets for both clients and practitioners. Feeding homemade diets give clients a greater sense of direct involvement in the care of their pet. Some clients want to be involved in the total care of their pet, healthy or ill, which includes preparing their meals. Homemade diets are more costly and far more time consuming than feeding a commercial diet. These diets are inconvenient when the pet is boarded, hospitalized, or traveling with the owner. However, for a growing number of clients, these negatives are small relative to the knowledge, confidence, and sense of control they have over the food they feed to their pet. The idea of feeding their pet something that may in the end be harmful is more worrisome than these inconveniences. Whether justified or not, a growing number of pet owners have questioned or believe the pet food supply to be unsafe.9 Hence they have decided to take back control over that aspect of their lives. Their primary care veterinarian should, if at all possible, accommodate their decisions while remaining an advocate for the pet. This extra service and willingness to address the owners’ concerns and help them find a healthy food solution for the animal can only strengthen the veterinarian– client relationship. Clients do not necessarily expect their local veterinarian to have expertise in all areas of veterinary medicine, but more clients do

Topics in Companion Animal Medicine expect their primary care veterinarian to work with various specialists as needed for their pet. The pet owner may then become a better client with a new comfort level after working with their local practitioner to obtain a feeding plan backed by a nutritionist. Practitioners also can benefit when accommodating special client requests, not only from improved client loyalty, but from increased revenue through incorporating specialty consultants in the management of patients and selling the most appropriate supplements. Properly formulated homemade diets can be a useful tool within a practice, generating revenues while offering clients a sound alternative. Homemade diets formulated for a healthy pet can often be modified to accommodate different medical conditions as they arise with relatively small changes as opposed to changing to another commercial product. Nutrient levels can be altered as needed with relatively minor changes in the recipe to accommodate emerging medical conditions as the pet ages. Homemade diets can be a very effective tool for food allergy patients. A simple one- or two-food homemade diet can be used initially to diagnosis food allergy or intolerance. If successful, appropriate additions and nonflavored supplements could balance the diet for long-term feeding. Use of a homemade formulation also would allow for single item substitutions when the owner was ready to test various foods. Veterinarians should be able to assess the overall suitability of a homemade diet and, if the recipe is questionable, then provide resources for the client to pursue so that both are comfortable with the diet.

Evaluating Homemade Diets Practitioners will encounter a wide variety of pet food recipes from breeders, pet chat-room groupies, and the popular press.10 Improving the balance in such recipes is not a simple task and beyond the skill set of most practitioners. The ingredients should be selected on the basis of nutrient content, tolerance, availability, and cost. It requires software, formulation skills, nutritional knowledge, and access to databases of available ingredients. Veterinarians therefore should be willing to (1) assess an existing recipe; (2) offer nutritionally adequate recipes for healthy pets; or (3) if a specific dietary formulation is necessary for medical reasons, help the client obtain advice from a veterinary nutritionist. Boarded veterinary nutritionists, like other veterinary specialists, have advanced training and can be of particular assistance with homemade therapeutic diets. Correcting imbalances are generally not difficult, time consuming, or expensive for nutritionists; hence, most recipes can be completed and balanced. Practitioners can initially screen a recipe for nutritional adequacy by answering a short list of questions (Table 1). If the recipe fails or is questionable in any area, the practitioner should refer the client to a nutritionist if they wish to continue feeding that recipe. Nutritional services are available through the American College of Veterinary Nutrition (www.acvn.org), Colleges of Veterinary Medicine (Michigan, Ohio, Tufts, UC-Davis, and Univ. of TN), pri-

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Table 1. Quick Assessment of Homemade Diet Recipe Review each of the following aspects of the diet. If the response is affirmative for each section, the practitioner may, with some assurance, believe the diet will most likely meet the nutritional needs of most companion dogs and cats. If the response to any one of these five criteria is negative or uncertain, then the practitioner should not endorse the homemade recipe without confirmation from a nutritionist. Yes No Protein (meat) Source 1. The final diet should contain 25 to 30% cooked meat for dogs (one part meat to two or three parts grain) and 35 to 50% cooked meat for cats (one part meat to one to two parts grain).a 2. The overall protein quality (amino acid profile) in a homemade food is good to excellent with animal (muscle or organ meat) protein. Liver or egg (25% of protein portion) can correct most potential amino acid deficiencies in homemade diets using vegetable protein sources. Cats fed a homemade formula exclusively and dogs on vegetarian diets should receive 200 to 500 mg taurine daily as a safe measure or test blood taurine levels annually. 3. In an ovo-lacto vegetarian diet, eggs are the best protein. 4. In a vegan diet, high protein (soybean, pinto, or chickpea) beans provide the next best option, however, due to low digestibility, the amino acid bioavailiability may be poor for dogs and cats. Yes No Carbohydrate (grain) Source A grain generally supplies little protein and mostly carbohydrate as starch for energy. The grain should be in greater quantity than meat to keep the total protein less than 50%. Optimal grain to meat ratios should be at least 2:1 to 3:1 for dog foods and 1:1 to 2:1 for cat foods.a Cooked corn, rice, wheat, potato, or barley are better than 85% digested by both dogs and cats. If more fiber is needed in the diet, the grain could be brown rice, sweet potato, or oatmeal. Yes No Lipid (fat or oil) Source A source of fat may or may not be present and the diet still be adequate; however, if the diet must be more calorie dense (more calories/per volume), add fat to the diet to regain or maintain body weight and condition and increase palatability. All types of fat (animal [butter, poultry skin, or meat trimmings], vegetable, or fish oils) can be used for added calories. If the specified meat source is “lean” (white or game meats), an additional animal, vegetable, or fish fat source may be needed. Changing the cut of meat (sirloin to chuck) or fat content (10 to 35%) in ground meat will also increase the fat content of the whole diet and provide essential fatty acids. Yes No Calcium Source Homemade diets require a specific calcium supplement and most often no additional phosphorous is needed. Readily available calcium carbonate fed at 0.5 g/4.5-kg cat/d and at least 2.0 g/15-kg dog/d will most likely be appropriate for a diet with the above meat and grain portions. Yes No Multivitamin and trace mineral source 1. Supplements providing vitamins and micro-minerals are not optional. These nutrient requirements cannot be met using “whole” foods such as fruits and vegetables because the pet can simply not consume enough vegetable material to meet the stated AAFCO recommendations. Therefore synthetic supplements are required to ensure a complete diet. 2. There is currently only one veterinary supplement suitable to complete homemade diets (www.balanceit.com). Adult OTC vitamin–mineral tablets that contain no more than 200% of the recommended daily allowances for people work well for both cats and dogs at onehalf to one tablet per 30 lbs, respectively, per day and will not over-supplement pets with nutrients known to be toxic at high doses. Specific nutrients of concern for cats such as arginine, arachidonic acid, L-carnitine, and choline can be purchased as individual nutrient products. Levels of these nutrients in feline homemade diets can only be estimated but appear to be adequate using animal proteins and those specific supplements may not be needed. Iodized salt should be used whenever salt is suggested because it is difficult to meet the iodine requirement. Sea salt and kelp do not contain reliable or sufficient amounts of iodine. aFinal

cooked weights of food do vary in water content; therefore, weighing is more accurate than measuring by volume.

140 vate hospitals (www.mspca.org), and online consultants (www.balanceit.com, www.petdiets.com).

Common Problems in Homemade Diets It is difficult to specifically characterize homemade diets designed by pet owners because each recipe is unique and variable. However, there are three major areas of potential concern with homemade diets: (1) Is the nutrient profile appropriate; (2) Does the client make the recipe according to instructions; and (3) Does the client deviate from the recipe over time? Each of these problems has been reported to cause malnutrition in pets.11–16 Most diet recipes contain excessive protein because of the perception that the diet of dogs and cats should be mostly meat, which then in turn creates an imbalance of calcium. Commonly used meat, grain, and vegetable sources contain more phosphorus than calcium; therefore, homemade foods may have inverse calcium (Ca) to phosphorus (P) ratios as high as 1:10. Homemade recipes recommended by pet owners and some veterinarians recommend feeding bones (cooked or not) or the addition of bone meal or calcium phosphorous. These additions may not only be difficult to obtain but these do not resolve the inverse Ca:P ratio. Additionally, feline foods designed by clients are commonly deficient in fat and have a low energy density or contain an unpalatable fat source (vegetable oil), which reduces food intake. Homemade foods for both dogs and cats are rarely balanced for micro-minerals (iron, copper, zinc, iodine) and most essential vitamins because owners choose over-thecounter (OTC) pet vitamin-mineral supplements assuming they are complete. The vast majority of OTC pet supplements do contain some but varying amounts of the minerals and vitamins required daily by the dog or cat, but none contain all in sufficient concentration to balance and complete a homemade diet. In one review (Remillard RL, personal review of OTC pet supplements 1997, unpublished data), pet supplements sold in pet stores, online, and veterinary offices contained between 0 and 300% of the vitamins and microminerals required daily by dogs and cats when fed at the recommended label dose. These products were designed as harmless treats and were never intended to balance the pet’s nutritional intake because the manufacturers’ assumptions had been the animals were eating commercial complete and balanced diets. OTC pet supplements do not balance a homemade diet. In 2006, an all-in-one vitamin and mineral veterinary product (BalanceIT ® supplements, DVM Consulting, Prof. Corp., www.balanceit.com) specifically designed to balance homemade canine and feline diets became available to pet owners. The products, however, do not come with feeding or dosing instructions. The owner can only obtain a dosing recommendation from a veterinarian or veterinary nutritionist. This helps to ensure proper use of the product within a complete and balanced dietary formulation. Even after the diet has been properly balanced with one or more vitamin-

Topics in Companion Animal Medicine mineral supplements, owners have been known to eliminate those products because of inconvenience to obtain or administer, expense, or a failure to understand its importance. Therefore, diets once balanced become grossly unbalanced when owners omit the supplements. Many owners who make their pet’s food according to published canine or feline recipes, over time, make their own ingredient substitutions that may not be correct. Human nutritionists teach us to eat a variety of foods for a nutritionally sound diet. Owners extend that principle to their pet’s nutrition and use a variety of ingredients. Nutritionally, this may or may not maintain balance depending on ingredients selected. Some owners choose the recipe ingredients for the pet’s food based on their own preferences, product availability, or affordability, which may not be appropriate for a patient with a medical condition. On the other hand, some owners mistakenly feed their pet according to current and popular human nutritional guidelines such as avoiding fat, sugar, cholesterol, and sodium, which is rarely, if ever, appropriate for pets. Unknowingly inappropriate substitutions can have negative consequences when intake of a particular nutrient or compound, eg, magnesium or oxalate, needs be controlled or minimized. Of particular concern for veterinarians is the use of uncooked meat, organs, and eggs in homemade pet food recipes. Meats used by pet owners, including those meats intended for human consumption, may be contaminated with microorganisms associated with food poisoning, thus posing an increased public health risk.17 Raw meat diets prepared by pet owners to be fed to dogs or cats have been documented to contain pathogenic organisms.18 –23 One option for pet owners making a raw meat homemade diet would be to feed whole (not ground) cuts after cooking the meat surface only and feed rare. Most of the food poisoning organisms are on the surface of the meat and searing the surface significantly reduces the potential bacterial load while preserving any perceived advantages to feeding the interior rare portion, although the risk of intramuscular parasites would still exist and nutritional benefit has not been documented. There is growing evidence to validate this public health risk. Pets fed homemade raw meat diets have been documented to shed viable organisms in their feces the same as those isolated from their diets. Dogs fed contaminated raw meat diets are therefore a source of household environmental contamination to people and other pets.19,24 –27 Household transmission of food-borne pathogenic organisms from dogs to people has been documented.28,29 Human infections of food-borne pathogenic organisms may occur when handling contaminated meat and egg products as well as products intended for pets (bones, pig ears, and treats).30 Individuals who clean the cat’s litter box or pick up their dog’s stool should consider the feces contaminated with viable pathogenic microbes. Extra precautions should be taken when persons (or other pets) in the household have immune suppressive (human immunodeficiency virus, feline leukemia virus, feline immunodeficiency virus) infections, are undergoing chemotherapy, or are using anti-inflammatory medica-

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Volume 23, Number 3, August 2008 tions.31 Additional caution should be emphasized when there are young children in the household as fecal– oral and pet food– oral contamination is possible. Veterinarians are trained in zoonotic diseases and have a responsibility to inform the pet owner who wants to feed a raw meat or egg diet of the potential health dangers. Food safety practices when handling the food, feeding dish, and feces should be emphasized and the need for good personal hygiene (hand washing) should be reinforced. Veterinarians should document such discussions with owners in the pet’s medical record. To date there is no evidence that feeding raw meat has a nutritional advantage over feeding cooked meat, and given the potential health risk, the FDA does not advocate feeding raw meat, poultry, or seafood to pets.32,33 Veterinarians who recommend or who know a client is feeding raw meat or eggs without giving full disclosure of the risks and precautions may face legal ramifications.17,34

Patient Assessment and Monitoring Patients that eat homemade foods should be seen for routine veterinary examinations (two to three visits per year). Because the nutritional profile of homemade foods is quite variable, a nutritional review is recommended at least twice a year where the practitioner and client compare notes on the recipe prescribed versus recipe made and significant deviations can be discussed. The client may record a 3- to 5-day food history so that the nutrient profile and ingredient substitutions can be reevaluated by a nutritionist if nutritional integrity is questionable. The nutritional adequacy of a diet can be grossly evaluated by noting the patient’s body weight, body condition, and activity level. Blood taurine levels should be checked annually on both dogs and cats consuming a vegetarian diet. Laboratory data such as albumin level, red blood cell number and size, and hemoglobin concentration are gross overall estimations of the animal’s protein and trace mineral status and can be used with other clinical observations to evaluate homemade foods. The skin and hair (color and texture) should be examined closely and an ophthalmic examination, including annual evaluation of the lens and retina, should be performed. These tissues are more visibly sensitive than others to nutritional balance.35–38 Stool quality could also be assessed as a gross estimate of diet digestibility.

Summary A disparity in veterinary pet nutrition has been underway for some time but has now become all too apparent. At a time when clients are motivated to consider alternative diets including homemade for their pets, veterinarians are less than adequately versed in pet nutrition and dietary options. Increasing the pressure on this disparity are the dramatic advances in the understanding nutrition plays in health and disease. Key nutritional factors (essential nutrients and bioactive food components) have been documented as potential modulators of health and disease.39 – 41 Through nutrigenom-

ics research, we are beginning to understand the ways in which food components affect gene expression and, hence, modulate health and disease. Clients have already begun requesting such information for their dogs and cats (also known as family members) in this regard. This is a call to action. To remain competitive, practitioners must consider raising their level of nutritional competency or incorporating the specialty of nutrition, through consultants, into their practice to meet this new client demand.

References 1. Stenske KA, Smith JR, Newman SJ, et al: Aflatoxicosis in dogs and dealing with suspected contaminated commercial foods. J Am Vet Med Assoc 228(11):1639-1640, 2006 2. Veterinary Research News. Developments continue in recall of pet food. Am J Vet Res 68(6):579-582, 2007 3. Kvamme J: Organic and natural predictions. Pet food Industry. www.petfoodindustry.com. April, 2007 4. Lund EM, Armstrong PJ, Kolar L, et al: Distribution of disease and diet type in a natural population of geriatric dogs and cats from private veterinary practice. In: 1966 Proceedings, Symposium on Health and Nutrition of Geriatric Cats and Dogs. Orlando, FL, 1996, p 56 5. Laflamme DP, Abood, SK, Fascetti AJ, et al: Pet feeding practices of dog can cat owners in the United States and Australia. J Am Vet Med Assoc 232(5):687-694, 2008 6. American Animal Hospital Association. The path to high quality care. Practical tips for improving compliance, Denver, CO, 2003 7. Bataller N, Thatcher CD, Pelzer KD, et al: Nutritional education at veterinary colleges of North America. J Vet Med Edu 18(1):11-16, 1991 8. Buffington CA, LaFlamme DP: A survey of veterinarians’ knowledge and attitudes about nutrition. J Am Vet Med Assoc 208(5):674-675, 1996 9. Wakefield LA, Shofer FS, Michel KE: Evaluation of cats fed vegetarian diets and attitudes of their caregivers. J Am Vet Med Assoc 229(1):70-73, 2006 10. Gray CM, Sellon RK, Freeman LM: Nutritional adequacy of two vegan diets for cats. J Am Vet Med Assoc 225(11):16701675, 2004 11. Streiff EL, Zwischenberger B, Butterwick RF, et al: A comparison of the nutritional adequacy of home-prepared and commercial diets for dogs. J Nutr 132:1698S-1700S, 2002 12. Donoghue S, Kronfeld DS: Home-made diets, in Wills JM, Simpson KW (eds): The Waltham Book of Clinical Nutrition of Dogs and Cats. London: Pergamon, 1994, p 445 13. Roudebush P, Cowell CS: Results of a hypoallergenic diet survey of veterinarians in North America with a nutritional evaluation of homemade diet prescriptions. Vet Derm 3:23-28, 1992 14. Niza MMR, Vilela CL, Ferreria LMA: Feline pansteatitis revisited: hazards of unbalanced home-made diets. J Feline Med Surg 5:271-277, 2003 15. Polizpoulou ZS, Kazakos G, Patsikas MN, et al: Hypervitamoinosis A in the cat: a case report and review of the literature. J Feline Med Surg 7:363-368, 2005 16. Fornel-Thibaud P, Blanchard G, Escoffier-Chateau L, et al: Unusual case of osteopenia associated with nutritional calcium

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Topics in Companion Animal Medicine 29. Sato Y, Mori T, Koyama T, et al: Salmonella virchow infection in an infant transmitted by household dogs. J Vet Med Sci 62(7):767-769, 2000 30. Grimsrud K: Public Health Advisory. Edmonton, Canada, Alberta Health and Wellness, 1999 31. Frederick JA, Glaser CA, Juranek DD, et al: Caring for pets of immunocompromised persons. www.avma.org/reference/ zoonosis/znimmpet.asp. Dec 15, 1994. 32. FDA. Guidance for Industry. Manufacturer and Labeling of Raw Meat Foods for Companion and Captive Noncompanion Carnivores and Omnivores. www.fda.gov/cvm/guidance/ Guide122.doc. 33. CVM Update. Tips for preventing food-borne illness associated with pet food and pet treats. www.fda.gov/cvm/foodbornetips. July 27, 2007. 34. Jack DC: The legal implications of the veterinarian’s role as a private practitioner and health professional, with particular reference to the human-animal bond: part 2, the veterinarian’s role in society. Can Vet J 38:653-659, 1997 35. Remillard RL, Pickett JP, Thatcher CT, et al: Comparison of kittens fed queen’s milk with those fed milk replacers. Am J Vet Res 54:901-907, 1993 36. Glaze MB, Blanchard GL: Nutritional cataracts in a Samoyed litter. J Am An Hosp Assoc 19:951-954, 1993 37. Sousa CA, Stannard AA, Ihrke PJ, et al: Dermatosis associated with feeding a generic dog food: 13 cases (1981-1982). J Am Vet Med Assoc 192:676-680, 1988 38. Harvey RG: Skin diseases, in Wills JM, Simpson KW (eds): The Waltham Book of Clinical Nutrition of the Dog and Cat. London, UK, Pergamon, 1994, pp 425-444 39. Dove RS: Nutritional therapy in the treatment of heart disease in dogs. Altern Med Rev 6:S38-S45, 2001 (suppl) 40. Deboer DJ: Canine atopic dermatitis: new targets, new therapies. J Nutr 134: 2056S-2061S, 2004 (suppl 8) 41. Watson TD: Diet and skin disease in dogs. J Nutr 128:2783S2789S, 1998 (suppl 12)