Evidence Based Supplements for Pets

Ken Lambrecht DVM

Medical Director Westside Family Pet ClinicFitness & Rehab Director 4 Paws Swim & Fitness

Presented January 22, 2012

Practical Small Animal Nutrition University of Wisconsin School of Veterinary

Medicine

www.slideshare.netklambdvm@gmail.comwww.westsidefamilypet.comFacebook.com/westsidefamilypet

Challenges…

Bug LANCE

Our role as veterinarians

1. Trusted advisors/scientists2. Gatekeepers3. Interactions/side effects4. Above all do no harm6. Preventive

Nutritional Assessment, Breed Specific/Breed Groups

Identify at risk dogs/breeds when doing nutritional assessment and counsel client

Sporting breeds/athletic dogsService dogsBreeds prone to Degenerative Orthopedic DiseaseBreeds prone to inflammatory skin or bowel

diseaseBreeds prone to cardiac, kidney, immune system

problems etc

Why do we have to go there?

Human parallels/client demandDesire to reduce NSAID side effectsCost effective?A more natural approachPreventive

Definitions

Supplement = anything added to food after initial formulation

Nutraceutical = concentrated nutrient modules that are added to the food that have proven health benefits

Lack of FDA Oversight or …why this is all necessary!

DHEA ACT of 2008 clarified rules for supplements to be treated as foods (not drugs) and requires no scrutiny other than basic food processing & safety

Almost Total lack of FDA oversight!

Quantity of ingredients not regulatedPurity not regulatedQuality not regulatedHealth benefit not regulated

None of these are verified or enforced by FDA!

Client Dialogue

What supplements do you give your dog?

What amounts?What food do you feed? Is anyone in household allergic to fish

or shellfish?

Support for our Recommendations

Published peer reviewed controlled studiesExpert opinions of board certified specialists DACVN DACVIM DACVS & DACVSM other special certifications CCRT, CCRP Pain management certificationSupplement Company research

Evidence based nutritional supplements

Grade 1 Randomized, controlled clinical study

Grade 2 Randomized controlled laboratory study

Grade 3 Clinical, cohort or case controlled analytic studies or dramatic results in uncontrolled studies

Grade 4 Opinions based on clinical experience, studies conducted in other species, reports of expert committees

CE related to supplements 2006-2012

Boarded nutritionistsLisa Freeman DVM PhD DAVNKathryn Michels DVM Ms DACVN Tony Buffington DVM Ms PhD DACVN Joe Bartges BS PhD DVM DACVN DACVIM Boarded InternistsDr Phil Roudebush DVM DACVIMDr Deb Zoran DVM PhD DACVIMMichael Lappin DVM PhD DACVIMGreg Ogilvie DVM DACVIM

Sports Medicine specialistsDr Sherman Canapp DVM ACVS DACVSMR CCRT Joseph Wakshlag, DVM, PhD, DACVN, DACVSMR

Many sources of non-verified benefits!

BreedersInternetLocal big box & boutique retailersRandom bloggers, magazines etc

Our challenges

No incentive to prove they workQuality control issues for OTC productsDose issuesLots of misinformationThis is a challenging area!

Key Resources to find evidence based studies (or the best experts if studies haven’t been done)

www.consumer lab.com AAVN & ACVNPublished roundtablesWell referenced blog & magazine articlesHuman medicine parallels

Keeping our efforts focused on treatment & prevention of common

diseases

ObesityPeriodontitisOsteoarthritisInflammatory bowel diseaseInflammatory skin diseaseCancerImmune system diseasesCardiac, Renal, Hepatic

What our clients want to know

Which ones does my dog really need?Can I give them the same ones I take?How can I keep the cost down?How can I give it easily? ( is it in food? etc)

Our biggest challenges

What is the correct dose?What evidence is there to support?Does it contain what it says it does on label?Purity/Contaminations/Interactions

What is the best seal of approval?

Follow your passions!

Evidence based Supplements: The big 3

1) Fish oils (EPA & DHA)2) Chondroprotectants (joint supplements)3) Probiotics, prebiotics4) Others (Denamarin, anti-oxidants, Vit D)

Fish Oils ( EPA & DHA)

IndicationsEvidenceDose/SourcesChallenges

Indications

Osteoarthritis (2010 first published/peer reviewed)

Heart Disease (2007 first one I could find) although studies go back to 1998.Inflammatory skin disease (1990’s)Cancer (1990’s)Kidney diseasePeriodontitis & Obesity

Indications

Osteoarthritis affects roughly 20% of dogs Johnson SA “Osteoarthritis, joint anatomy Physiology &

pathology” Vet Clinics of NA Sm An Pr 1997;27:699-723

Feline elbow arthritis affects 90% of cats over 10 years of age

Hardie EM, Roe et al Radiographic evidence of degenerative joint disease in geriatric cats 100 cases JAVMA 2002;220:628-32

Indications

Kerwin SC Osteoarthritis in cats. Top Companion Anim Med. 2010 Nov;25(4):218-23.

Abstract Osteoarthritis is a common radiographic finding in older

cats, with a prevalence of up to 90% in appendicular joints. Many cats experience impaired mobility from osteoarthritis; however, there are more and more treatment options available, including diet modification, environmental modification, medical therapy, and physical rehabilitation. Continuing challenges involve accurate diagnosis and outcome assessment of treatment, but considerable progress has been made in the last decade.

First Evidence: Cardiac

Caren E. Smith, Lisa M. Freeman et al Omega-3 Fatty Acids in Boxer Dogs with Arrhythmogenic Right Ventricular Cardiomyopathy unpublished 1998?

Conclusions and Clinical Importance: These data suggest that fish oil, but not flax oil, supplementation for 6 weeks reduces arrhythmia in Boxers with ARVC and that it could be useful in treating this common disease.

Further studies are needed to determine optimal dose and duration of treatment.

Evidence/dosing : Cardiac

The author (Dr Lisa Freeman Waltham Focus 2000) currently recommends a dosage of 40 mg/kg EPA and 25 mg/kg DHA in dogs. The amount of EPA and DHA in individual

fish oil supplements varies widely so it is important to know the exact amount in brand of supplement recommended.

Capsules that contain approximately 180 mg EPA and 120 mgDHA can be purchased over the counter at most human pharmacies or health food

stores. Higher dosages can be obtained from medical supply catalogues and are more feasible

large dogs.

Evidence: cardiac

Omega-3 Fatty Acids in Boxer Dogs with Arrhythmogenic Right Ventricular Cardiomyopathy Journal of Veterinary Internal Medicine Volume 21 Issue 2 pages 265–273, March 2007

Caren E. Smith1,  Lisa M. Freeman DVM, PhD, DACVN1,†,  John E. Rush1,  Suzanne M. Cunningham1,  Vincent Biourge2

Evidence: Cardiac Human

Christine M. Albert, M.D., M.P.H. Et al Blood Levels of Long-Chain n–3 Fatty Acids and the Risk of Sudden Death N Engl J Med 2002; 346:1113-1118 April 11, 2002

CONCLUSIONSThe n–3 fatty acids found in fish are strongly associated with a reduced

risk of sudden death among men without evidence of prior cardiovascular

disease

Base-line blood levels of long-chain n–3 fatty acids were inversely related

to the risk of sudden death both before adjustment for potential

confounders

Evidence: Osteoarthritis-Dogs

Rousch J K et al “Evaluation of the effects of dietary supplementation with fish oil omega 3 fatty acids on weight bearing in dogs with osteoarthritis” JAVMA Vol 236 No 1 Jan 1, 2010

Evidence Osteoarthritis -Cats

Lascelles, et al “Evaluation of a Therapeutic Diet for Degenerative Joint Disease in Cats” J Vet Intern Med 2010 1-9 (this diet contains omega 3’s & Perna GLM as well as glucosamine & chondroitin sulfate)

Evidence : others

Periodontitis Soukup, Jason DVM AVDC American

Veterinary Dental Forum Oct 2009 several citations (human & pet)

Obesity Ishiota, K et al Treatment of obesity in

dogs through increasing energy expenditure by mitochondrial uncoupling J Vet Intern Med 2004 18:431 (a level 2 evidence based study cited by Dr Phil Roudebush)

Dose/Sources

Deliver at least 40 mg/kg EPA and 25 mg/kg DHA per day to treat cardiac disease (Lisa Freeman DVM DACVN)

Addendum: Dr Greg Ogilvie recommends dosing fish

oils based on DHA 30mg/kg 1/21/12 University of Wisconsin Small Animal

Nutrition Seminar Madison, WI

Dose: Consumerlab.com

Range of EPA + DHA Concentrations and Pill Sizes: The concentrations of EPA and DHA in the pills and liquids

can vary by as much as tenfold -- from as little as 8% to over 80% of the fish oil content. Concentration depends on the source of the omega-3's, how the oil is processed, and the amounts of other ingredients included in the supplement.

If you are trying to get as much EPA or DHA from the smallest serving size (i.e., fewer or smaller pills or smaller liquid amounts), look for supplements with higher concentrations of EPA and DHA. A more concentrated product will generally allow you to ingest less total fish oil 

Dose/Sources

Use high quality products that are fresh, mercury free and have antioxidants (Vit E)

Sardines & anchovies for safety & sustainabilityBioavailability, free form etc 40mg EPA/kg for anti-inflammatory (30mg

DHA/kg for anti-cancer)

60lb Lab needs 1200 mg EPA (would usually deliver 2/3 or 900 mg DHA)

8 180 mg EPA/120mg DHA capsules 3 400 mg EPA /120mg DHA capsules 2 700 mg EPA /120mg DHA capsules

1 ml=180mg EPA 1ml=148mg EPA 1ml=165mg EPA

Liquid supplements

391 mg EPA/capsule 325mg EPA/capsule 250 mg EPA/capsule

Capsule Forms (OTC & Veterinary)

Challenges: Cost for large dogs

Directions:For Adults, take one (1) softgel daily, preferably with a meal.Supplement Facts:Serving Size: 1 SoftgelAmount Per Serving - % Daily Value:*Calories 15, Calories from Fat 15, Total Fat 1.5 g - 2%*, Saturated Fat 0 g, Polyunsaturated Fat 1 g **, Monounsaturated Fat 0 g **, Cholesterol < 5 mg - 1%, Fish Oil 1,400 mg (1.4 g) - **, EPA (Eicosapentaenoic Acid) 700 mg - **, DHA (Docosahexaenoic Acid) 280 mg - **, Total Omega 3 Fatty Acids 980 mg - **.*Percent Daily Values are based on a 2,000 calorie diet.**Daily Value not established.Other Ingredients:Gelatin, Vegetable Glycerin, Food Glaze. Contains <2% of: Enteric Coating (Sodium Alginate and Stearic Acid), Ethylcellulose, Medium Chain Triglycerides, Mixed Natural Tocopherols, Soybean Oil.

Contains fish (Anchovy, Mackerel, Sardine) ingredients.

Challenges: Compliance

294mg EPA/cup

300 mg EPA/cup

390 mg EPA/cup

Consumerlab.com: Concerns

Concerns and Cautions:While fish oil supplements are generally considered safe, there are a few caveats and cautions you should take into consideration before you buy. While krill oil has not been as extensively studied as fish oil, it is reasonable to assume that the same concerns and cautions apply. The most common side effects are fishy smelling burps and diarrhea. 

Up to about 20 grams of fish oil can be well tolerated by most adults. However, such high amounts may not be beneficial and the FDA recommends that consumers not exceed more than a total of 3 grams per day of EPA and DHA omega-3 fatty acids, with no more than 2 grams per day from a dietary supplement. 

Be aware that cod or other fish liver oils are not always a good substitute for fish oil supplements as these may be high in vitamins A and D. Because these vitamins can be toxic, make sure that you do not exceed safe levels (see Multivitamin Product Review for Tolerable Upper Intake Levels (ULs) for vitamins and minerals).

The only significant safety concerns regarding fish oil involve its apparent "blood thinning" effect. On this basis, fish oil should be used only under a physician's care by people with bleeding disorders such as hemophilia, those taking strong prescription blood thinners, such as Coumadin (warfarin) or heparin, and those expecting to undergo surgery.

If you take blood pressure lowering medication, be aware that fish oil may further lower blood pressure.

High doses (over 3 grams per day) of fish oil may suppress the immune system. Unless medically necessary, such doses should be avoided, particularly by immunocompromised individuals.

Contrary to earlier reports, fish oil does not appear to adversely affect blood sugar levels in people with diabetes.

Some people are allergic to proteins in fish and krill (among other foods).

Consumerlab.com: Concerns

Contamination:One product, 1-800-PetMeds Super Omega 3 for Cats and Dogs, exceeded the contamination limit for dioxin-like PCBs (or dl-PCBs, which are PCBs with established toxicity). It contained slightly more than the 3 picograms per 1,000 milligrams (mg) limit established by the Global Organization for EPA and DHA (GOED). The U.S. FDA has not set a limit. It is unlikely that this exposure alone would cause toxicity, but it is preferable to avoid unnecessary exposure to toxins. However, bear in mind that, in comparison to a serving of most fish, even this product contains only a small amount of

PCBs.  Consumer lab accessed online 1/22/2012

Consumerlab.com: Concerns

Joint Supplements

IndicationsEvidenceDose SourcesChallenges

Indications

Osteoarthritis affects roughly 20% of dogs Johnson SA “Osteoarthritis, joint anatomy

Physiology & pathology” Vet Clinics of NA Sm An Pr 1997;27:699-723

Feline elbows arthritis affects 90% of cats over 10 years of age

Hardie EM, Roe et al Radiographic evidence of degenerative joint disease in geriatric cats 100 cases JAVMA 2002;220:628-32

Evidence: Dogs

Sanderson RO et al “Systematic review of the management of canine osteoarthritis.”  Vet Rec 2009 Apr 4;164(14):418-24.

between 1985 and July 2007. Sixty-eight papers were identified and evaluated. They considered four alternative therapies, one use of functional food, two intra-articular agents, six nutraceutical agents, 21 pharmacological agents, two physical therapies, three surgical techniques and two combinations of weight control.

Evidence continued

There was a high level of comfort (strong evidence) for the efficacy of carprofen, firocoxib and meloxicam, …. a moderate level of comfort for the efficacy of etodolac in modifying the signs of osteoarthritis.

There was also a moderate level of comfort for the efficacy of glycosaminoglycan polysulphate (Adequan), licofelone, elk velvet antler and a functional food containing green-lipped mussel.

Evidence continued

There was weak or no evidence in support of the use of doxycycline, electrostimulated acupuncture, extracorporeal shockwave therapy, gold wire acupuncture, hyaluronan, pentosan polysulphate, P54FP (extract of turmeric), tiaprofenic acid or tibial plateau levelling osteotomy

Question…

Why wasn’t glucosamine/chondroitin sulfate mentioned, nor the two forms of physical therapy or weight control????

Commonly used joint supplement “ingredients”

Glucosamine HCLChondroitin sulfate ( LMW or not)Perna Green Lipped MusselAvocado Soybean Unsaponifiables (ASU)Elk Antler

Evidence: Glucosamine & Chondroitin Sulfate

Neil, K et al “The role of glucosamine and chondroitin sulfate in treatment and for prevention of osteoarthritis in animals JAVMA 2005 Vol 226:7 1079-88

Evidence: Humans The GAIT study

“Glucosamine, Chondroitin Sulfate, and the Two in Combination for Painful Knee Osteoarthritis” N Engl J Med 2006; 354:795-808 Feb 23, 2006

Glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with osteoarthritis of the knee.

Exploratory analyses suggest that the combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate-to-severe knee pain. 

Evidence: human study

Humans—Several clinical trials have been performedin humans with mostly favorable results. Despiteflaws in study design and assessment of outcome inearly studies, moderate effects were detected.72-74

In a meta-analysis and quality assessment of 15 randomizeddouble-blind placebo-controlled studies, all but 1revealed beneficial effects in terms of decreasing painand improving mobility, with greater effects detected forchondroitin sulfate than glucosamine.109

Evidence: humans-prevention

Furthermore, glucosamine prevented the progressive joint-space

narrowing that was detected radiographically in placebo-treated

patients.113

“Extrapolating from these studies, the best effects of glucosamine supplementation will be achieved with preventative use, or at least in patients with incipient

lesions for whom use for advanced osteoarthritis is not likely to

yield favorable results.

In a major study 81% of labeled products (human) were not what the label stated

Almost all studies done with high quality Glucosamine HCL and low molecular weight purified chondroitin sulfate (Nutramax patented products)

www.Consumerlab.com

Challenges: Quality

88. Russell AS, Aghazadeh-Habashi A, Jamali F. Active ingredient consistency of commercially available glucosamine sulfate products. J Rheumatol 2002;29:2407–2409.

89. Consumer Laboratory Web site. Product review: joint supplements (glucosamine, chondroitin and MSM). Available at:

www.consumerlabs.com/results/gluco.asp. Accessed Jan 30, 2004

References from JAVMA April 2005 article

If cats do agility should they get joint supplements???

VetriScience Glycoflex III

Active Ingredients Per Tablet or 2 Chews:Glucosamine HCl (Shrimp and Crab) . . . . . . . . 1000 mgMethylsulfonylmethane (MSM) . . . . . . . . . . . 1000 mgPerna Canaliculus(GlycOmega™ brand Green Lipped Mussel) . . . . . . 600 mg

N,N-Dimethylglycine HCl (DMG) . . . . . . . . . . .100 mgdl-alpha Tocopheryl Acetate (Vitamin E) . . . . . . 50 IUCalcium Ascorbate (Vitamin C) Tablet . . . . . . . .30 mgAscorbic Acid (Vitamin C) Chew . . . . . . . . . . .24 mgManganese (as Manganese Amino Acid Chelate) Tablet .10 mgManganese (as Mn Proteinate) Chew . . . . . . . . . 10 mgGrape Seed Extract . . . . . . . . . . . . . . . . . 5 mgL-Glutathione . . . . . . . . . . . . . . . . . . . .2 mgSelenium (as Sodium Selenite) . . . . . . . . . .0.002 mg

GlycOmega™ is a trademark of Aroma New Zealand Ltd. Patented in : Austria, Belgium, Switzerland/Liechtenstein, Cyprus, Germany,

Denmark, Spain, Finland, France, United Kingdom, Greece, Italy, Luxembourg, Monaco, Netherlands, Portugal, Sweden, Ireland, Albania, Lithuania, Latvia, Macedonia, Romania, and Slovenia. European Patent No. 1 227826

DASUquin

DASUquin combines NMX1000®* ASU (avocado/soybean

unsaponifiables) decaffeinated tea Cosequin's FCHG49®* glucosamine hydrochloride TRH122®* low molecular weight chondroitin sulfate to provide the most comprehensive joint health management formula available for dogs.

U.S. Patent Nos. 5,587,363 and 6,797,289 (Additional Patent Pending)

Nutramax DASUquin

“We also support studies including efficacy, bioavailability (absorption) and safety at leading veterinary schools such as Cornell, Colorado State, U.C. Davis, N.C. State, Tennessee, Texas A&M and Tufts to name a few. More information is available to veterinary professionals.”

Joint health research & review articles using or referencing Nutramax Laboratories products or ingredients (80+ references)

Challenges: Convenience of “functional foods”

By FDA law Glucosamine cannot be added to food to a therapeutic level (unless therapeutic effect is proven)

By using Perna GLM Royal Canin seems to have sidestepped this regulation …..or is it the EPA/DHA that is working or ….synergism?)

Evidence: Since July 2007 or emerging

2007 VetriScience force plate study abstract at NAVC “submitted for publication”

2010 Feline functional food (RC Mobility JS) containing Perna GLM, glucosamine, CS & omega 3 published, peer reviewed

2011 DASUquin force plate study 5 dogs Dr Daryl Millis not published

Others?

Challenges: Summary

Which combination of ingredients?Force plate studies vs in vitro?Perna vs manufactured ingredientsQuality of ingredients

Challenges: bottom line

Nutramax DASUquin ® or VetriScience Glycoflex®

Royal Canin Feline Mobility JS ®Royal Canin Canine Mobility JS ®

Nutramax & VetriScience have patented products, both have some studies (mostly in vitro) to support their use, both have extensive human lines

Others????

Probiotics/prebiotics

Definition

Probiotic products contain helpful bacteria and/or yeasts that assist in balancing the levels of indigenous microorganisms in the human (pet) body.

Prebiotic serves as food or support for probiotic

e.g. FructooligosaccharidesSynbiotics combinations of the two

Indications/Evidence: Human

Diarrhea (antibiotic, viral or chemo induced)Vaginal bacterial infectionsReduce cancer promoting enzymes in gutPrevention of allergies & atopic disease in infantsPrevention of respiratory tract other infectious

diseases and treatment of urogenital infectionsInflammatory diseases of GI tract VRL#3 has Mayo clinic studies as top 2

references

Evidence : Pets

Immune system stimulation in puppiesImmune system stimulation in catsDiarrheapreviously mentioned human diseases?

Contra-indications

PancreatitisCompromise of intestinal mucosal barrierOthers?

Dr Deb Zoran WVMA Oct 2010

practices clinical nutrition at Texas A & M To treat inflammatory bowel disease in catsGood for urinary tract, immune system,

diarrheas

Dr Joe Bartges at WVMA 2010

University of TennesseePrevent urinary infections minimum of 5

billion CFU’S (people 10 to 20 billion)Multi-strain bestImmune stimulant at higher concentrations

Challenges: Quality Control

Genus & species identifiedNot pathogenicGuaranteed number of live organisms at date

of manufacturer vs “good till date”Kept refrigeratedEffective in species being used in

Sources

Natural (yogurt, kefir, sauerkraut, etc)Supplements (capsules, packets)Pet Foods? (killed by processing unless added

after heat)

Consumerlab.com: viability 2006

Probiotics for Human Use: Only 8 of 13 Pass TestsConsumer Lab selected thirteen probiotic products for human consumption sold in the U.S. and/or Canada. Testing showed that four of these products provided less than one billion viable organisms in a daily serving — the minimum amount generally used clinically. In fact, one of these — a major pharmacy brand — provided less than ten percent of this minimum level. Only eight products were found to meet the one billion minimum and contain the amounts claimed on their labels. An additional six products tested through CL's Voluntary Certification Program also met these criteria. Some products provided several billion organisms per day, with one containing 35 billion. 

Probiotics for Pets: Only 1 of 3 Pass TestsConsumerLab.com also tested probiotic supplements marketed for use by pets. Among the three products selected, one was contaminated with mold and did not even contain its listed amount of probiotic organisms. Another provided only ten million organisms per day. Only one pet product contained a large dose of viable organisms — 2.3 billion per day.

Consumerlab:2011

Two other pet probiotics, tested through ConsumerLab.com's Voluntary Certification Program were found to meet their claimed amounts: Nutri-Vet Probiotics with Wild Alaskan Salmon Oil delivered its claimed 400 million cells per 2 teaspoon dose and Proviable DC for Dogs and Cats delivered all 5 billion cells per capsule. 

Comparing the daily dosage among the pet products reveals an enormous difference in the number of cells being provided, highlighting the need for pet owners to carefully compare products.

Challenges: which organisms

Nutramax Proviable DC®

Purina Fortiflora ®

VSL#3

Form Paste/capsule packet packet

Number of organisms

5 billion/capsule 758 million/pkt 458 billion/pkt

Species Enterococus faecium

Lactobacillus acidophilusL bifidumL bulgaricusL caseiL plantarum

Streptococcus thermophilum

Enterococcus faecium SF-68

Bifidobacterium breve, B longum, B infantis

Lactobacillus acidophilus, L plantarum, L paracasei, L bulgaricus

Streptococcus thermophilus.

Veterinary evidence

Baillon et al “Effects of probiotic Lactobacillus acidophilus strain DSM13241 in adult healthy dogs” Am J Vet Res 2004 65:338-43

Benyacoub J et al “Supplementation of food with Enterococus faecium (SF68) stimulates immune function in young dogs J Nutr 2003 133:1158-62

VetriScience

VETRI-PROBIOTIC EVERYDAY chews are recommended to support overall health of the dog.

Guaranteed Analysis:Moisture (max) 8.0%*Total Microorganisms: 286 Million CFU/gram  Bacillus subtilis**Bacillus coagulans  Lactobacillus acidophilus  Bifidobacterium thermophilum  Bifidobacterium longum  Lactobacillus fermentum  Lactobacillus casei  Bifidobacterium bifidum

  Enterococcus faecium*FOS (Fructooligosaccharides) 200 mg

Challenges: cost

Purina Fortiflora

Nutramax Proviable

VSL #3

Other human products

organisms

785M 5B 450B 1B to 36B

Cost for 5 billion organisms

$2.50 $0.25 $0.02 ??

Published Veterinaryresearch

Y Y N N

Our role as veterinarians

1. Trusted advisors/scientists2. Gatekeepers3. Interactions/side effects4. Above all do no harm6. Preventive

The future??

DHA concentrated to 1000 mg/capsule for large dogs Glucosamine/Chondroitin Sulfate/ASU (or Perna GLM) force

plate study with at least 50 dogs? Reach to the refrigerator for a probiotic for a specific

disease? Probiotics sprayed on the outside of food after cooked ? Prebiotics used like probiotics for immune support? FDA decides to regulate supplements????

Thank you for your attention! Questions?

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