Update on Diet-Associated Dilated Cardiomyopathy

Last week brought a revealing announcement from the FDA. After frequent and persistent petitioning from Veterinarians, Veterinary Nutritionists, and concerned Caregivers, the FDA finally released a list of the brands that have been linked to cases of diet-associated dilated cardiomyopathy (DCM). Since June 27, my inbox and social media sites have been blowing up with shares, retweets, and emails from concerned friends and family. The story was even picked up by major news outlets, like CNN and ABC, adding to the fervor.

But I’m conflicted about this report. On one hand, certain pet food manufacturers have taken a very cavalier approach to their diet’s role in this preventable and potentially deadly disease. Because only a relatively “small percentage” of dogs develop diet-associated DCM on their foods, they insist that there is no problem, ignoring the overwhelming evidence to the contrary.  On the other hand, the FDA’s report paints a broad stroke over specific brands and is being interpreted (at least by the concerned friends and owners I’ve talked to) as an indictment of all “grain-free” or of certain manufacturers, which is a less than helpful oversimplification of a complex problem. As I advised in my post last fall (and this bears repeating here) I would urge caution before panicking and rushing to change your dog or cat’s food without considering what to change to. By all means if you are feeding a diet that has been associated with heart disease in other dogs then a change is warranted, but before jumping to another potentially problematic diet (just because it is not on the list) it is important to step back and look at what we know and don’t know to date.

 

Not a diet-associated DCM case, but could have been if we didn’t get him on the right diet for his breed and health status.

Recap of the Problem …

In 2017 Veterinary Cardiologists began noticing an increased incidence of DCM in Golden retrievers. This is a breed (along with other large breed dogs) with an increased risk of DCM in general, but the number of cases and age at onset of disease was not typical. This prompted a closer look at potential contributing factors and Veterinary Cardiologists then reached out to the larger veterinary community for information on other cases of unexpected or atypical DCM in any dog. Initially, the common thread was the feeding of a diet marketed as “grain-free.” Since that time the FDA Center for Veterinary Medicine (FDA-CVM) and researchers at both Tufts University and University of California, Davis, Veterinary Schools have been collecting data and working on finding a root cause of this potentially fatal disease. They have found that not only were Veterinarians seeing cases of DCM in dogs fed diets marketed as “grain free”, but also in dogs eating diets that use uncommon animal proteins (like kangaroo and bison, whether grain-inclusive or not) or that were made by smaller manufacturers that may or may not be adequately formulated for long-term feeding.

From the FDA update June 27, 2019.

So what do we know?

  1. Not all cases are taurine deficient. Many of the dogs diagnosed with diet-associated DCM in the last 2 years had low taurine levels, but not all. Whether low or normal taurine levels were measured, most dogs if caught early had improvement in clinical signs and reversal of cardiac changes when their previous diet was stopped and taurine was supplemented.
  2. Not all dogs eating “grain-free” diets are affected. There are an estimated 20 million dogs eating diets marketed as “grain-free” that include some combination of legumes (peas, lentils, chickpeas, pinto, etc.) or potato (sweet or white), or both, and only (only?!) 515 reported cases of diet-associated DCM in dogs since 2017.
  3. Large breed dogs are at an increased risk, but even small dogs are affected. Large breed dogs account for 338 out of the 515 reported cases, but Shih tzus and Shetland Sheepdogs are on the list, too.
  4. Dry dog foods are the predominant type reported, but raw and home-cooked make the list, too. This probably has more to do with the relative popularity of these diet types rather than some inherent risk/benefit of a particular food type.
  5. “Grain-Free” is a marketing ploy and not based on any scientific or nutritional studies. There is no proven health benefit to avoiding grains in your dog’s diet unless they have a documented food allergy (which is actually very uncommon). Grains play a lot of roles in the diet, and most of these roles are pretty helpful at optimizing health.

Meeting with Dr. Weeth to make sure we are keeping our hearts and whole bodies healthy.

What don’t we know?

  1. We don’t know the true scope of the problem. In people, underreporting of adverse drug effects is a well-known problem with some reviews indicating that as high as 95% of adverse reactions go unreported. Which means we may be seeing only the  5% of actual cases that were reported to the FDA and it could be closer to 10,000 dogs that are affected. It takes time to report a suspected adverse food event and Veterinarians and Caregivers may not realize the value of this reporting. Additionally, many owners may contact the pet food manufacturer if there is a problem rather than the FDA assuming that the information is getting relayed to the government agency.
  2. We don’t know where the problem is coming from. All grain-free diets are being targeted by media outlets and some enthusiastic pet “advocates”, but we don’t know if this is a problem with all grain-free diets (probably not), peas and legumes (maybe, especially at high amounts), and/or questionable formulations and manufacturing processes (probably, yes). When peas are included at relatively low levels in the diet (less than 20% of the total recipe) or as occasional treats they do not appear to cause a problem, but none of the diets from any of the brands on the FDA’s recent list have gone through controlled feeding and digestibility trials to prove that they are safe and healthy for dogs at the level of legume inclusion they use, which can be over 40% of the recipe when all types and portions are added up.
  3. We don’t know if this is an ingredient, dog, or manufacturer problem (or maybe all three). I suspect we will find that peas and potatoes in the hands of experienced formulators and experienced pet food manufacturers and for the majority of dogs are not the problem. The problem will be (like it was in the early 2000s when poorly formulated lamb and rice dog foods were causing DCM in dogs) a failure of certain manufacturers to account for variation in ingredient quality, changes in digestibility with processing, and individual variation in the dog population. Do affected dogs have low taurine production? Do they have increased loss from their gut? Do they have normal production and gut handling, but a low total food intake and are just getting inadequate intake overall? Meeting minimum nutrient levels on paper is not enough. Pet food manufacturers must know or hire knowledgeable individuals with an understanding for how nutrient levels vary in the raw materials, how they are affected by other ingredients or nutrients in the mix, the effect of cooking (or lack of cooking) on nutrient stability and bioavailability, and the wide range of variability in genetics and food intakes in the dog population. Basing diet formulations on market trends rather than nutritional science is a recipe for disaster.
  4. We don’t know if the percentages of the brands reported simply represent their popularity and market share or an underlying problem with these companies.  Maybe the three most frequent brands reported are really no better or worse than the least frequent three brands, they are just better at marketing their diets so more people buy them. I don’t have access to those market insights to know whether this is true or not, but I bet these companies do.

At the end of the day, diet-associated DCM is a preventable condition and manufacturers who are selling foods that are labeled as “complete and balanced” have an ethical and fiduciary obligation to meet that label promise. Having an idea about pet foods, being a dog trainer/breeder/owner, inheriting a family pet-food business, and/or writing a book about dogs and cats (even if it’s about food) does not qualify a person to know what it takes to keep a large population of dogs and cats healthy. No free passes because you didn’t know what you didn’t know, no matter the sincerity, especially if it ends up with disease and death.

And if you are a Veterinarian who is seeing cases of suspected diet-associated DCM or are a Caregiver with a dog or cat who has been diagnosed with suspected diet-associated DCM, please report it by following the link here so we can help the FDA get to the bottom of this problem before more dogs and cats get sick.

 

Dr. Weeth keeping dogs and their hearts healthy!

Happy (and Safe) Feeding,

 

Dr. Weeth

 

30 thoughts on “Update on Diet-Associated Dilated Cardiomyopathy

    • Hello perfectpanicky,

      I was disappointed to see it on the list, too. When Nutro was purchased by Mars in 2007 they made a number of very positive changes and I was happy to have another option for owners. Prior to 2007 they were more than a little questionable and the previous owners had a tendency of putting profits over animal health. That seemed to have changed around under Mars so we will see how they respond to these reports.

      Dr. Weeth

      Liked by 1 person

  1. Thoughtful article on this emerging problem, thank you! It would be extremely helpful, however, if your point about golden retrievers and increased risk of DCM could be clarified to state that they are at increased risk of nutritionally-caused DCM, as opposed to genetic DCM. This is because there now is a perception in the general public that DCM is only a golden retriever problem, and that this whole controversy over “grain-free” or “BEG” diets doesn’t apply to other breeds. Yes, there is prior scientific evidence that indicates goldens and a small number of other breeds are sensitive to taurine deficiency, which puts them at increased risk of DCM, but they do not suffer from genetic DCM like certain breeds such as Dobermans. I am afraid that your article will simply reinforce the notion amongst the public that it is only a golden retriever problem.

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    • Hi Claudette,

      Thank you for reading and taking the time to comment. I heard similar feedback from others and made some changes to the post a few days ago. Hopefully, they clarify my point but let me know if still room for misinterpretation.

      Thanks!
      Dr. Weeth

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  2. As a breeder of Golden’s I find the biggest flaw in this so called study is the pedigrees. Today the breed is in huge trouble because the breed is in bred to (literally) death. As a breeder I can promise you that you won’t be able to find my more than 10% of Golden’s in the USA that are not related.

    Liked by 1 person

    • Hi Ilene,

      I’ve heard the same from Golden breeders and others in the dog show world. And one could argue that this is true for many of the other pure breeds as well. We need more responsible breeders who understand the need for genetic diversity to ensure health of the lines.

      Dr. Weeth

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  3. Than you Dr. Weeth. I have a question about adding toppers to my dog’s kibble. I typically add home cooked chicken or beef (1/4 – 1/3 cup) and a heaping tablespoon of cottage cheese a.m. and p.m. to his food. He weighs about 75 pounds. Is this okay? Also, I have been feeding Chicken Soup for the Soul Adult formula. Do you have an opinion on this food or do you only recommend food manufactured by companiess that follow WSAVA guidelines?

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    • Hi Elizabeth,

      I think the WSAVA guidelines are a good place to start, but I don’t think that a company has to employ PhD Nutritionists or DACVNs AND do feeding trials to make good food. There are some good diets across the spectrum of brands and price-points. I expect the owners of a pet food company to seek out expert help with formulations, manufacturing, and testing of products to ensure animal health. There are some smaller companies that don’t have the resources to do this all in-house but seek out expert guidance and actually listen to them, and there are larger companies that have the financial resources to do quality control and testing and chose not to because it cuts into their profits. And vice-a-versa.

      When you look at the questions in the WSAVA guidelines I do expect companies to have answers to the questions one way or another. For example, if the customer service rep on the phone doesn’t know how much sodium is in their food I expect that the company to have that information already and they will get back to me when located. But if they tell me that “sodium is not important in dog foods” or “that’s proprietary” then that is a red flag that the company in question hasn’t bothered to do basic nutrient analyses on that diet.

      For your pup, 1/4-1/3 cups of cooked chicken breast or ground beef is probably 1-2 ounces depending on how finely chopped so would be added between 35 to 100 kcal per meal (1 ounce of chicken breast vs 2 ounces of 80% lean ground beef) and 1 tbsp of cottage cheese is about 20 kcal so at most you could be added 240 kcal per day to the diet or the equivalent calories of 2/3 cup of the dry dog food. This is about 15% of the calculated daily requirement for a 75 lb dog shouldn’t unbalance the base kibble, BUT, if the cooked meats and cottage cheese are actually more than or if your dog has a low total energy requirement and isn’t eat that much of the dry food than it could be contributing to a dietary imbalance.

      Dr. Weeth

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  4. I’d just like to point out one thing not mentioned in this article: the FDA reported explicitly stated that these DCM cases reported were NOT confirmed to be diet-induced or genetic. That means the numbers for Great Danes, dobermans etc. which are breeds already heavily prone to hereditary DCM might be skewing the perspective. Many owners who reported them even said themselves “this is probably genetic but I’m reporting just in case” in their report notes.

    So while there is a lot of data and information it is currently not what I would call “useable” data, the information cannot be used to draw any conclusions at this stage. And admittedly I was a little shocked and disappointed that the FDA didn’t ask only for DCM reported cases of confirmed nutritionally mediated DCM.

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    • Hi Artemis,

      Thanks for reading and bringing up an interesting and important point. You are correct. This is just a list of all cases of heart disease reported to the FDA, not confirmed cases of DCM that was definitively caused by the diet. There are a lot of problems with collecting diet history for nutritional epidemiological studies. For example, some people may change the diet just before diagnosis because the dog has become “finicky” or they may not remember the diet that was being fed and may record a similar sounding brand or name. We definitely need more answers and I am hopeful that ongoing studies out of Davis and Tufts will get us closer to an answer.

      Dr. Weeth

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  5. Hi Dr. Weeth, Thank you for this article. I do however have a couple of concerns that perhaps need clarification. My fear being that these statements are taken out of context and used to bolster the argument that the FDA report is of no importance.
    The first is your statement regarding diet change. Specifically “I would urge caution before panicking and rushing to change your dog or cat’s food unless medically indicated.” Can you clarify exactly what you mean by this? Certainly you’re not suggesting waiting until the dog develops DCM to change diets.
    My second concern is the statement regarding Golden Retrievers and DCM. “This is a breed with an increased risk of DCM in general, but the number of cases and age at onset of disease was not typical.” My understanding of the breed and the issue is Goldens do not develop primary (hereditary) DCM but may be more susceptible to Taurine deficiency and NM-DCM (diet related). Again, can you please clarify? Thank You!

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    • Hi Wilamenapants,

      Thank you for reading and taking the time to comment. I definitely don’t want people to wait until their dog develops heart disease before changing the food, but I also don’t want people to rush changing to a diet that may be equally concerning and I hope the more recent edits better express my thoughts on this.

      As for dogs and heart disease, the two main types of heart disease veterinarians see in older dogs fall into two big categories: valvular degeneration in small breeds and dilated cardiomyopathy in larger breeds. In some, like Dobermans and Great Danes, there does appear to be a genetic difference as this risk runs higher in certain family lines than others. In Boxers there may be a role for abnormal carnitine production and in Cockers (one of the few exceptions to the large dog heart disease trends under normal circumstance) defects in taurine and carnitine production and handling can result in DCM, and both conditions occur in certain families rather than all Boxers or Cockers. On the other hand, studies published in the early 2000s showed that in a number of different Labradors and Newfoundlands across all family lines there was a lower conversion of cysteine to taurine compared to beagles. Unfortunately, researchers haven’t yet looked at other large or small breeds to see if this is true across a wider variety of dog sizes, but I suspect that Goldens will act more like Labradors than Beagles in their conversion of cysteine to taurine so you are correct in thinking that they are more sensitive to taurine deficiencies.

      Dr. Weeth

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  6. I appreciate all the information you give to the public. I myself buy Fromm: Salmon a la vegan for my 6 year old mixed breed chocolate lab, Akita, Chesapeake, and German Shepherd mix. Aka: Talkeetna mutt. I wouldn’t trade him for the world. I do worry about his diet now with all the latest updates involving certain brands of dogfood. I will follow your posts as much as possible. They are very informative. Thank you for all you do! Charlene Jones, Wasilla, Alaska. July 2nd, 2019.🙂🐕

    Like

    • Hi Charlene,

      Thanks for reading and taking the time to comment. High legume content seems to be the common thread between the majority of cases so I would be less concerned with the food you listed since it seems to have a combination of oats, rice, and barley as the primary carb sources. I’ve read where people are listing salmon as an “exotic” meat, but I don’t consider it as such so no worries about salmon from me. I’ve also had patients that have been eating the Fromm grain-inclusive diets for years and other than the occasional GI issue (which can happen on any brand of food) I had not seen the types of issues we are seeing today until they started including larger amounts of legumes in their formulas.

      Dr. Weeth

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  7. Thank you, Dr. Weeth, for your analysis of the FDA Report on DCM. I would like to add this thought ~ not everyone can afford an ECHO (expensive) nor even a blood test for taurine (least expensive); however, switching from a dog food manufacturer high on that list costs the least to avoid or prevent DCM. Seems a reasonable & simple “fix” until further research is done.

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    • Agreed! Haven’t been a fan of grain-free diets, especially high legume containing diet, since they hit the market 10 years ago. And many of the diets that include more traditional grains (barley, wheat, rice, and corn) are actually less expensive than the premium-priced grain frees so cost savings all around. 🙂

      Dr. Weeth

      Like

  8. All vet colleges should have statisticians and/or veterinary epidemiologists who could use the information on market share of different dog foods to adjust the data in the FDA report and thus make the comparison of different brands of food more useful.

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    • Thanks for reading and commenting, Paul. I think it would be very helpful to look at the data that way and I suspect the folks at the FDA-CVM are in the process of doing that, too. Hopefully between that and additional information about affected and non-affected dogs eating grain-free diets that is being collected at a few of the Vet Schools will bring us some more definitive answers soon.

      Dr. Weeth

      Like

    • Thanks for reading and commenting Ralph. I caught a few typos and errors that I missed in my enthusiasm to get this out to the public. I think I’ve fixed them all now, but if not you can let me know otherwise.

      Dr. Weeth

      Like

      • Dr. Weeth ~ Try Grammarly. It works better than SpellCheck, which doesn’t catch the usual culprits. Grammarly works with WordPress as well as other social media platforms to catch the usual errors that are easy to miss when in a hurry. Frankly, I read your content for your knowledge, insight, analysis & perspective because it is the best I’ve found. Thank you for that! ~ Eva

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  9. Hi Dr…thank you for that interesting article….im feeding my two, 7 months old pups (mixed medium breed) with Royal Canin Medium Junior….what do you think about this brand? Pls ignore the previous comment

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