Answers to Posed Questions
“The cases listed by the FDA are cases that are confirmed.”
In the FDA report released on June 27th, 2019, all cases that had a diagnosis of DCM were released to the public. Here it is quoted from their article: “Brands that were named ten or more times are featured below. For a granular, case-by-case breakdown of DCM reports submitted to the FDA, see Canine Dilated Cardiomyopathy Complaints Submitted to FDA-CVM Through April 30, 2019 .”
Here are some example as to some of the descriptions submitted to the FDA in the case report.
“DCM and CHF Taurine not measured .”
This provides no helpful information and could easily have just been the veterinarian’s opinion since there is no evidence of tests that were done.
“(b)(6) (half sister; (b)(6) - (ICSR) of 2063133) diagnosed with DCM and CHF so screened by RDVM for BNP which was elevated. Evaluated at (b)(6) 2/1/19. ARVC/diet-induced DCM with ventricular arrhythmia. Diet changed to Royal Canin Early Cardiac and will re-evaluate in 3 months I have diet sample. 3 other dogs in household (1 had normal BNP, other 2 not yet evaluated) .”
This case jumps to the conclusion that it is diet-induced DCM even though it states that there is a genetic link to another dog that was reported to have DCM and the results of changing the diet were not reported.
As you can see these are not confirmed cases of diet-induced DCM. The FDA picked out 13 cases to do necropsies on, and only 10 of them actually had DCM . That gives these reports a 23% inaccuracy. You must also consider that these are most likely 13 of the most conclusive, well-documented cases. If you extrapolate the 23% misdiagnosis found in the necropsies, then 121 dogs of the 524 pets would have been misdiagnosed. That’s 121 dogs that could have potentially been treated for the disease they actually have, and this is what is troubling. In addition, only 41.7% of the blood tests submitted had low taurine.
All that the FDA requires is a diagnosis from a veterinarian or a veterinary cardiologist to be a “case.” “For the purposes of this investigation, the FDA defines a “case” as an illness reported to FDA involving a dog or cat that includes a diagnosis of DCM. … The numbers below only include reports in which the dog or cat was diagnosed with DCM by a veterinarian and/or veterinary cardiologist .” This does not say anything about the diet, or that DCM was confirmed, just diagnosed.
“Every test on these foods has shown them to be safe, you are correct. "Tests on the foods", not on what happens when the dogs' ingest the foods. Just because a food is nutritionally balanced on paper, does not mean the nutrients are bioavailable to the dogs' body.”
“The FDA did not say low taurine was the only cause of dietary DCM. They stated half of the dogs had normal taurine levels. It doesn't matter how much taurine is in the food, as a matter of fact, as you well know, dogs do not need taurine added to their food. They can synthesize their own taurine from the amino acids cysteine and methionine. Dogs need nutrients, not ingredients. Ingredients are simply the vehicles that deliver nutrients. The fact ingredients are balanced on paper, does not mean the nutrients are bioavailable to the dogs body when they are ingested. It is why board-certified veterinary nutritionists or PhD small animal nutrtionists should be formulating diets.”
132 of the cases reported to the FDA contained blood and/or plasma taurine tests . Combining this with a test of the food will give you the ratio absorbed (bioavailability). You can also do this with any other nutrients of concern.
“if there is no problem, can you tell me why these foods that are "safe", are suddenly adding taurine to their diets?”
“By the way, I wonder why Diamond Foods suddenly is advertising to hire a Vet Cardiologist, as are some other companies having a hiring frenzy?”
We can only speculate on questions like this as there’s no proof as to the mindset of the decision makers. My personal thought is that misinformation spreads fast, so it’s easiest for them to spend the couple cents to add taurine to the bag and appease as many customers as possible. There is no harm in adding the taurine, so for them it is a minor cost to appease their clientele even if it is not necessary.
“Can you cite scientific research these companies have published on why it was a good idea to almost double the fiber in some of their formulas? Or why it seemed to happen after Canada, years ago, sold their glut of peas to U.S. dog food manufacturers?”
I am not sure how to answer this because I’m not sure where you are getting your “double the fibre” information. Most of these foods contain between 4-6% fibre, which is the same as the foods with grains. For example, some grain free foods on the list: Acana Pacifica Dog has 6% fibre, Taste of the Wild Sierra Mountain has 5%, Fromm Chicken Au Fromage has 6.5%. Compare that to some foods with grains: Fromm Chicken A La Veg has 5.5% fibre, Acana Wild Coast has 5%, and Hill’s Prescription Dental Care has 10% fibre. As you can see, this statement does not appear to be true. I also don’t understand what is wrong with Canada selling its products to the USA. I personally like to support our Canadian growers. I much prefer this to these companies buying from China.
“While doing your research, please research the difference between DCM and dietary DCM. DCM cannot reverse itself...ever! It can only be managed with meds. It never goes away.” “Dietary DCM exists because it is being reversed. There are many, many decades of research in genetic DCM and other forms. Please show me the research stating genetic DCM can be reversed. There are none because it can't. As a former (human) cardiology tech, I can tell you it isn't reversed in humans either.”
“Heart conditions not due to food cannot be reversed with or without (diet change) meds. I made a rather good living out of college (University of Maryland Hospital) working in the cardiology field.”
“I know the other reasons and there are many. However, DCM caused by flea meds, heartworm meds, infections, genetics, is not going to be reversed by a diet change.”
“We are not talking about DCM caused by other factors as you have listed many you believe contribute. We are talking about dietary DCM. DCM that is reversed by, in some cases, by diet change ALONE. You have not replied to how that can possibly happen.”
This is simply incorrect. Dietary DCM as of yet has no confirmed mode of action, only theories relating to taurine and phytic acid. This means it is impossible to compare the differences between it and other causes of DCM. As stated by Dr. Weigner (MD, FACC) and Dr. Morgan (MD, PhD), “Dilated cardiomyopathy (DCM) can be caused by a variety of disorders. In more than 50 percent of cases, however, no cause can be found, and the cardiomyopathy is called "idiopathic." Some causes of DCM are reversible and the condition improves once the cause is treated or eliminated or the condition subsides. Other causes of DCM produce irreversible damage .” In a paper called Cardiogenetics, Quarta et al. stated in their paper “Dilated cardiomyopathy (DCM) is a genetic or acquired heart muscle disorder characterized by dilation and impaired contraction of one or both ventricles. In the acquired forms of the disease, if the pathogenic agent is persistent, undiagnosed or untreated, permanent ultrastructural and morphological changes may lead to irreversible dysfunction. Conversely, when DCM is promptly recognized and treated, the heart may show an extraordinary ability to recover from left ventricular(LV) systolic dysfunction .” In a study by Khochtali et al., they reported reversing DCM with hormone therapy caused by hypothyroidism and concluded that DCM cases should make sure to test thyroid function in order to rule out hypothyroidism as a cause . DCM is also talked about in a book titled Laboratory Diagnosis of Viral Infections, in which they talk about how DCM caused by viral infections can be reversed depending on the severity of the infection .
“It is NOT ingredients, it is about formulation. Please tell me what doubling the amount of fiber in dog food does to bioavailability?”
As we stated earlier, not really sure where the “doubling fibre” claim comes from. Please refer to our example above. In addition, a formulation is a combination of ingredients, especially since the list from the FDA contains brands with a wide range of meat to peas/lentils/potatoes ratios. Also, some of the brands mentioned have foods where the peas and lentils don’t come up until the twentieth ingredient with percentages listed on the ingredients, so the argument of there being too much of them in the formulation is false.
“Some of these companies list a meat source and then the next 8 ingredients include, green peas, yellow peas, chickpeas, potatoes, garbanzo beans, red lentils. Their is no scientfic research on that much fiber in dog food.”
“Corn does not usually show up in an ingredients list a half dozen times under different names (yellow corn, white corn, red corn, etc.).”
Below are some of the more exotic formulas from brands listed by the FDA:
Acana Appalachian Ranch: Deboned beef*, deboned pork*, deboned lamb*, lamb meal, beef meal, pork meal, whole green peas, red lentils, pinto beans, beef liver*, beef fat, catfish meal, chickpeas, green lentils, whole yellow peas, deboned bison*, whole catfish*, herring oil, lentil fiber, natural pork flavor, beef tripe*, lamb tripe*, lamb liver*, pork liver*, beef kidney*, pork kidney*
Zignature Kangaroo: Kangaroo, Kangaroo Meal, Peas, Chickpeas, Pea Flour, Sunflower Oil (preserved with Citric Acid), Flaxseed, Red Lentils, Green Lentils
Taste of the Wild Pine Forest: Venison, lamb meal, garbanzo beans, peas, lentils, pea protein, pea flour, egg product, canola oil, fava beans, tomato pomace, natural flavor, ocean fish meal
4health Grain Free Duck & Potato: Duck, duck meal, sweet potatoes, peas, garbanzo beans, potatoes, chicken fat (preserved with mixed tocopherols), ocean fish meal
Earthborn Holistic Primitive Natural: Turkey Meal, Chicken Meal, Peas, Dried Egg, Pea Starch, Chicken Fat (preserved with Mixed Tocopherols), Whitefish Meal, Flaxeed, Natural Flavors, Pea Fiber
BLUE Wilderness® Bayou Blend: Deboned Alligator, Menhaden Fish Meal (source of Omega 3 Fatty Acids), Peas, Pea Protein, Tapioca Starch, Pea Starch, Chicken Meal (source of Glucosamine), Dried Tomato Pomace, Chicken Fat (preserved with Mixed Tocopherols), Dried Egg Product, Deboned Catfish, Flaxseed (source of Omega 6 Fatty Acids), Potatoes, Natural Flavour, Fish Oil (source of ARA-Arachidonic Acid and DHA Docosahexaenoic Acid), Shrimp Meal
Kirkland Signature Nature’s Domain Salmon & Sweet Potato: Salmon meal, sweet potatoes, peas, potatoes
Fromm Game Bird: Turkey, Duck Meal, Turkey Broth, Lentils, Chickpeas, Peas, Potatoes, Turkey Liver, Chicken Meal, Pea Flour, Dried Tomato Pomace, Chicken Fat, Dried Egg Product, Pea Protein, Salmon Oil, Goose, Chicken, Sweet Potatoes, Flaxseed, Cheese, Pheasant, Quail, Duck
Merrick Grain Free Real Rabbit + Chickpeas: Deboned Rabbit, Turkey Meal, Pork Meal, Chickpeas, Lentils, Peas, Pea Protein
California Naturals Dog Food: Venison, Green Lentils, Red Lentils, Peas, Sunflower Oil (Preserved with Mixed Tocopherols, a Source of Vitamin E), Flaxseed, Pea Fiber
Natural Balance Grain Free Sweet Potato & Venison: Sweet Potatoes, Venison, Pea Protein, Potato Protein
Orijen Tundra: Fresh goat (5%), fresh wild boar (5%), fresh venison (5%), fresh Arctic char (5%), fresh duck (5%), fresh wild boar liver (5%), fresh duck liver (5%), fresh mutton (4%), fresh steelhead trout (4%), fresh wild boar kidney (4%), mackerel (dehydrated, 4%), whole pilchard (4%), lamb (dehydrated, 4%), mutton (dehydrated, 4%), Alaskan cod (dehydrated, 4%), blue whiting (dehydrated, 4%), herring (dehydrated, 4%), whole red lentils, whole green lentils, fresh whole green peas, fresh whole chickpeas, fresh whole yellow peas, whole pinto beans, lentil fibre, duck fat (2%), fresh mutton tripe (1.5%), herring oil (1%), fresh goat heart (1%), fresh goat kidney (1%), fresh goat liver (0.5%), fresh venison liver (0.5%), fresh venison heart (0.5%), fresh mutton liver (0.5%), fresh wild boar heart (0.5%), fresh whole navy beans, freeze-dried goat liver, freeze-dried venison liver
Nature’s Variety Instinct® Raw Boost® Grain-Free Recipe with Real Venison: Venison, Turkey Meal, Salmon Meal, Peas, Canola Oil (preserved with Mixed Tocopherols and Citric Acid), Herring Meal, Chickpeas, Tapioca, Suncured Alfalfa Meal, Freeze Dried Lamb, Lamb Meal, Natural Flavor, Menhaden Fish Meal, Salmon Oil, Pumpkinseeds, Montmorillonite Clay, Salt, Freeze Dried Lamb Liver, Freeze Dried Lamb Spleen, Freeze Dried Lamb Heart, Freeze Dried Lamb Kidney
NutriSource Prairie Select: Quail, duck, green lentils, duck meal, peas, garbanzo beans, pea flour, sunflower meal, turkey meal, chicken fat (preserved with mixed tocopherols and citric acid), flax seeds, alfalfa meal, natural flavors, red lentils
Nutro Duck & Lentils: Duck, Duck Meal, Dried Potatoes, Chickpeas, Lentils, Dried Sweet Potato, Potato Starch, Canola Oil (Preserved With Mixed Tocopherols), Sunflower Oil (Preserved With Mixed Tocopherols), Potato Protein
Nutrish Zero Grain Salmon, Sweet Potato & Pea: Salmon, Chicken Meal, Menhaden Fish Meal, Sweet Potatoes, Dried Peas, Pea Starch, Dried Plain Beet Pulp, Tapioca, Whole Dried Potatoes, Chicken Fat (Preserved with Mixed Tocopherols), Whole Flaxseed, Turkey Meal
We do not recommend all these brands but are trying to point out that there is a vast difference in quality across grain free foods. We are not saying they are all good, but if you are making the point that all grain free foods are primarily peas and lentils it must be consistent across all of them. Otherwise it’s just a basic nutritional argument about food quality that has nothing to do with grains or not.
Dog Chow® Complete Adult with Real Beef: Whole grain corn, poultry by-product meal, corn gluten meal, beef fat naturally preserved with mixed-tocopherols, ground rice, soybean meal, beef, egg and chicken flavour, meat and bone meal, animal digest
Beneful® Originals with Real Beef: Beef, whole grain corn, barley, rice, whole grain wheat, chicken by-product meal, corn gluten meal, beef fat naturally preserved with mixed-tocopherols, soybean meal, oat meal, poultry by-product meal, glycerin, egg and chicken flavor
Purina ProPlan EN Gastroenteric Low Fat®: Brewers rice, barley, corn gluten meal, poultry by-product meal, animal digest
Hill's® Science Diet® Adult Healthy Mobility: Chicken Meal, Whole Grain Wheat, Brewers Rice, Whole Grain Sorghum, Cracked Pearled Barley, Brown Rice, Soybean Meal, Dried Beet Pulp, Chicken Liver Flavor, Pork Fat, Soybean Oil, Fish Oil, Lactic Acid, Flaxseed
Hill's® Prescription Diet® t/d Dental Care: Brewers Rice, Whole Grain Corn, Chicken By-Product Meal, Powdered Cellulose, Pork Fat, Soybean Mill Run
Royal Canin Renal Support S: Corn, brewers rice, chicken fat, brown rice, chicken by-product meal, natural flavors, dried plain beet pulp, wheat gluten, fish oil, calcium carbonate, psyllium seed husk
Royal Canin Medium Adult Dog: Brewers rice, chicken by-product meal, oat groats, wheat, corn gluten meal, chicken fat, natural flavors, dried plain beet pulp
The argument that if you combine all of the different forms of lentils they would be higher up in the ingredients list doesn’t equate to the same as foods that already have corn and wheat as the first ingredient. This is because one is a hypothetical and one is definitive. Also, you can see that many of these foods ingredient split as well across either multiple grains or multiple forms of the same grain.
“Look up the affects of lectins and phytic acid (phytate) on vitamins and nutrients in the body. Research a daily legume, lentil, tuber, diet on a body.”
We agree that they should not have a high phytic acid diet. However, here are the phytic acid levels of different ingredients: Corn 0.7-2.2%, Lentils 0.3-1.5%, Peas 0.2-1.2%, Rice 0.1-1.1%, Wheat 0.4-1.4%, Soybeans 1-2.2% . Those are all in dry matter. That means if you were to apply them to a wet ingredient you would have to factor in moisture content. As you can see by these numbers, two different foods, one with corn and one with the same amount in lentils and peas, the one with corn would be higher in phytic acid. If the food has corn as the first ingredient it will be exponentially higher in phytic acid than a food with peas and lentils as mid to late ingredients.
“I think Dr. Greg Aldrich, PhD, president of Pet Food Ingredient and Technology Inc., and research professor and pet food coordinator at Kansas State said it best. "Some of the novel ingredients in diets involved and lack of publicly available research on their use in pets, compared to the relatively much larger amount of research in corn, wheat and soy (50 years of research) has given formulators a lot of understanding about them." His best line was, "marketing has outpaced science."”
People and animals have been eating and digesting meat for tens of thousands of years. There are many studies into how meat is digested and the nutrient content of meats. Most people eat meat every day, it is a major staple of our diet.
“I understand not every company has the money to hire over 500 full time scientists like Purina. Or not every company, like Royal Canin, can spend more money than any other company in research. They can't afford feeding trials that last longer than a year like big companies, they are expensive. But, some of these companies do not have "one" qualified person, not one.”
“Formulate with non-qualifed formulators. Chemical engineers, industrial engineers, degrees in equine nutrition and the list goes on and on?”
“Their company should have been placing our dogs before marketing and $$$$ and been using qualified formulators and doing research!”
I’m not sure where to start here… saying that these companies don’t have qualified employees is irrational. I’m not saying every single pet food company has the best and brightest, but clearly you can’t accuse every food of being made up entirely of unqualified people. Manufacturers employ full-time nutritionists . As for marketing dollars, the therapeutic diets spend the most money on marketing by sponsoring the veterinary colleges. Some of the foods listed do extensive marketing, but many of them do little to none.
“I have two friends that own two different independent stores in my town. We don't talk about it anymore because they are in total denial, even though I bought my dog's food from them. I'm mad for them also. They got sucked down the same rabbit hole we all did and went all in on BEG diets. What are they supposed to do? This is their livelihood?”
Don’t be fooled. A pet food store can easily change their grain free products over to those with grains. In many cases the foods containing grains would even buy out the grain free foods from the store, making it cost them nothing. It would literally be easier for a store to lean into the DCM scare. You should commend your friends for standing up for what they believe is right rather than condemning them thinking they are just trying to make money.
“More importantly, [corn] contains cysteine and methionine the two amino acids needed for dogs to synthesize their own taurine.”
“Peas are deficient in methionine so why add so many in the bag? There is a huge difference.”
This is getting back to the issue of taurine. Here are some cysteine (Cys) and methionine (Met) levels in various ingredients m(g/100g):
Corn: Cys 26, Met 67 
Peas: Cys 32, Met 82 
Lentils: Cys 118, Met 77 
Ground Chicken: Cys 188, Met 446 
Ground Turkey: Cys 179, Met 500 
Ground Lamb: Cys 198, Met 425 
“Taurine should not have to be added to dog food. It's added to cat food because they can't synthesize taurine.”
Yes, this we can agree with. As you can see above, as long as there is enough meat in the food, and the pet does not have a condition that prevents them from absorbing or synthesizing taurine from cysteine and methionine, then they should not need added taurine.
“I didn't come up with these ridiculous degrees formulating, the companies formulating did. I suggested the other day you start calling them. Have you made any calls? A master's degree is not qualified to formulate food. Someone that goes to Veterinary school and has 8 years of education, needs another 3 to 4 years to become a Veterinary Nutritionist. That's six more years of education compared to a masters degree.”
“Facts to me are what gets reported by scientists that have a much higher pay grade than I ever had, especially when those scientists are published and respected in their field. Facts are peer-reviewed published research. Facts are the FDA releasing the names of confirmed cases, not the unconfirmed cases.”
A thing that is known or proved to be true .
“For those of you worrying about the companies contributing to research through Universities and WSAVA, please contact your company and ask them why they are not contributing.”
That’s like asking why a family owned company doesn’t come in and spend as much as Tylenol. These pet food companies would have to spend the billions that Royal Canin, Hills, and Purina does in order o get their voice heard. If they did that then they would have to increase their cost because they would be taking money away from ingredient quality. Some of these companies do spend a lot of money on their advertising, but not all of them.
“the large pet food companies that so far appear to not cause increased risk of DCM, have spent decades with nutritional specialists researching balanced diets. I'm afraid they have my confidence, Julia with a biology degree does not.”
In fact, these therapeutic diets are not all balanced and do not all meet the minimum requirements of AAFCO. “Another concern with making therapeutic diets freely available to the public is that some do not meet the recommended nutrient standards for healthy pets. Depending on the disease they are designed to manage, they may contain unusually high or unusually low levels of protein, amino acids, sodium, or other nutrients .” Let’s take a quick look at a couple of pet foods.
Orijen Original: Fresh chicken meat (13%), fresh turkey meat (7%), fresh cage-free eggs (7%), fresh chicken liver (6%), fresh whole herring (6%), fresh whole flounder (5%), fresh turkey liver (5%), fresh chicken necks (4%), fresh chicken heart (4%), fresh turkey heart (4%), chicken (dehydrated, 4%), turkey (dehydrated, 4%), whole mackerel (dehydrated, 4%), whole sardine (dehydrated, 4%), whole herring (dehydrated, 4%), whole red lentils, whole green lentils, whole green peas, lentil fibre, whole chickpeas, whole yellow peas, whole pinto beans, whole navy beans, herring oil (1%), chicken fat (1%), chicken cartilage (1%), chicken liver (freeze-dried), turkey liver (freeze-dried), fresh whole pumpkin, fresh whole butternut squash, fresh whole zucchini, fresh whole parsnips, fresh carrots, fresh whole Red Delicious apples, fresh whole Bartlett pears, fresh kale, fresh spinach, fresh beet greens, fresh turnip greens, brown kelp, whole cranberries, whole blueberries, whole Saskatoon berries, chicory root, turmeric root, milk thistle, burdock root, lavender, marshmallow root, rosehips, enterococcus faecium. ADDITIVES (per kg): Nutritional additives: Zinc chelate: 100 mg
Hill’s Prescription Weight Management: Whole Grain Wheat, Whole Grain Corn, Powdered Cellulose, Chicken Meal, Corn Gluten Meal, Whole Grain Sorghum, Soybean Mill Run, Chicken Liver Flavor, Pork Fat, Soybean Oil, Pork Liver Flavor, Lactic Acid, Caramel color, Potassium Chloride, Choline Chloride, L-Lysine, vitamins (Vitamin E Supplement, L-Ascorbyl-2-Polyphosphate (source of Vitamin C), Niacin Supplement, Thiamine Mononitrate, Calcium Pantothenate, Pyridoxine Hydrochloride, Vitamin A Supplement, Vitamin B12 Supplement, Riboflavin Supplement, Biotin, Folic Acid, Vitamin D3 Supplement), Iodized Salt, minerals (Ferrous Sulfate, Zinc Oxide, Copper Sulfate, Manganous Oxide, Calcium Iodate, Sodium Selenite), Taurine, L-Carnitine, Calcium Sulfate, DL-Methionine, L-Threonine, L-Tryptophan, Mixed Tocopherols for freshness, Natural Flavors, Beta-Carotene
The recommended feeding guide for a 60lbs dog on Orijen is about 2 cups, while the Hill’s Prescription food is 5.5 cups of food. Note that the Orijen is so nutrient dense compared to Hill’s that you feed nearly 1/3 the amount to get the same amount of nutrients as dictated by AAFCO.
“I'm not even getting into the topic of the urban legend that is "grain-free". A myth that consumers bought into, and many dog food companies happily reaped the rewards.”
I’m not really sure how to answer this. Grain free foods aren’t a myth, roughly 30% of pet foods are grain free. If you’re talking about why they’re grain free the main reason is because of a scare in 2007 when wheat from China was infected with melamine and killed approximately 8500 pets. In an overcorrection people just decided to avoid all grains. I don’t believe grains are bad in general, only the ones with low nutrient density, the main culprits of allergies, or foods that use them in excess.
“some of those foods do contain prescription medications. The prescription food that I feed has tryptophan in it. In Canada, that is a prescription only medication (for humans too!), that treats mood disorders.”
This one isn’t all that relevant to DCM in particular. However, I did want to mention that, no, therapeutic diets do not contain prescription medications. They are “prescription” because some of them don’t meet AAFCO guidelines, and therefore are not supposed to be fed long term. Tryptophan is an essential amino acid found in meet and is especially high in turkey, the one that makes you sleepy.
“Just like human doctors doing research are sponsored by drug companies, animal doctors studies are sponsored by Dog Food companies. Therefore these studies are often biased.”
Yes, this is why it’s very hard to assess reports from vets about DCM and why we typically refer to human cardiology research as they aren’t influenced by any pet food companies. They would have no bias as far as grain versus grain free pet foods goes, and much of the research predates this argument.
“I had my dogs on one type of food and was told it was really bad for them so I switched and one of them got diabetes from eating the prescription food, because it was full of complex carbohydrates. In other words soya, corn and wheat.”
Diabetes is directly linked to causing cardiomyopathy . Hill’s Prescription Multi-Benefit w/d, which is recommended for use with diabetic pets, is 45% carbohydrates, 16% of which is fibre. That means 29% of it is starch and sugars. Orijen Original is 19% carbohyrates, with 5% being from fibre. That means there is twice as much starch and sugar in the Hill’s food than Orijen. Also consider that Hill’s recommends feeding 430g of food to a 60lbs dog, and Orijen recommends feeding 240g to a 66lbs dog. Therefore, a 60lbs dog on Hill’s is getting 125g of starch and sugar, whereas on Orijen they would be getting only 34g of starch and sugar.
“Larger companies also do research for bioavailability and digestibilty. Using Royal Canin as an example, this is what RC does beyond AAFCO trials. They do palability trials, digestibillity trials, blood parameters, relative supersaturation trials, stool confirmation, amino acid anaylsis, fatty acid analysis, toxicology and stability studies, clinical trials for efficacy in conjunction with veterinarians and pet owners. They also have peer-review research published. They can have 800 dogs in trials at any one time. Do you realize some of these companies do none of these things? Zero.”
There is no basis to say that other companies do not do this kind of testing. It is an accusation with no evidence. We have personally received blood tests from companies in the past and all of these tests are readily available from third party testing facilities, which offer a more reliable outcome since they aren’t employees of the company.
“You said the FDA is looking into genetics. Could you explain to me how Golden Retrievers, not prone to genetic DCM, suddenly a few years ago became prone overnight? Or why the University of Illinois is now studying cases being diagnosed in small dogs (Pomeranians, Boston Terriers and Schnauzers), also not predisposed to genetic DCM?”
No, we cannot, because that is why it is being research. However, the way genetics and breeding works is that even if one dog has a genetic predisposition for DCM it can be passed on very quickly. One male dog could have hundreds of offspring in its lifetime, and those puppies could have exponentially more. It is something that required sufficient research to assess.
“I'm so glad you brought up lamb and rice. An issue that occurred years ago when formulating with lamb. Lamb is a lower taurine meat, therefore harder to formulate. Companies doing research are now formulating successfully with lamb.”
What basis is there that every company that makes a lamb and rice formula is formulating a more balanced pet food then every brand that makes grain free food? Here is an example of a Purina food with grains, lamb, and no added taurine, methionine, or cysteine, or anything that would contain high levels of them:
Purina ONE® SmartBlend® Lamb & Rice: Lamb (source of glucosamine), rice flour, whole grain corn, whole grain wheat, chicken by-product meal (source of glucosamine), corn gluten meal, soybean meal, beef fat naturally preserved with mixed-tocopherols, mono and dicalcium phosphate, glycerin, calcium carbonate, liver flavour, salt, caramel colour, potassium chloride, dried carrots, dried peas, Vitamins [Vitamin E supplement, niacin (Vitamin B-3), Vitamin A supplement, calcium pantothenate (Vitamin B-5), thiamine mononitrate (Vitamin B-1), Vitamin B-12 supplement, riboflavin supplement (Vitamin B-2), pyridoxine hydrochloride (Vitamin B-6), folic acid (Vitamin B-9), menadione sodium bisulfite complex (Vitamin K), Vitamin D-3 supplement, biotin (Vitamin B-7)], Minerals [zinc sulphate, ferrous sulphate, manganese sulphate, copper sulphate, calcium iodate, sodium selenite], choline chloride, L-lysine monohydrochloride, sulphur.
There’s nothing to insinuate that the formula has been changed to adapt to the studies proving a link between lamb and rice and DCM.
“Since you did bring up the subject, the FDA also did not say just grain free. They included exotic meat. While you do not consider kangaroo, rabbit, bison,venison, etc.exotic, those meats do not have decades of research behind them.”
Although these meats may not be a staple of our diets in North America, they are in certain cultures in regions. Research done outside of North America is just as valuable as research done inside North America.
“Those high end, expensive diets, developed over the past decade are the ones without the research. They are the latest fad and every company wanted to jump on the train.”
Fromm Family Pet Food developed a testing laboratory in 1924 to develop a fox distemper vaccine. They developed their pet food company in 1948. This a 70 year old company that has been doing their own research to develop their pet foods. Many of these companies have their own testing facilities and laboratories.
“You talk about Purina One and nutrient density. Nutrients come from many different ingredients, not just meat. Purina One has been fed to dogs for a long time, I wonder why dietary DCM wasn't an issue?”
Purina ONE has a feeding guide of 3.5 cups for a 60lbs dog, while Acana’s is 2 cups for a 66lbs dog. This means that you can get the same amount of nutrients in Acana in less food, making it more nutrient dense. Many people will refer to this as fillers in the case of Purina ONE because there would be an extra cup and a half of food.
“You can't be serious about the two diets you posted. Acana lists the first ingredients as deboned chicken, deboned turkey, turkey giblets and chicken liver. Meat is weighed as it comes into the plant, not as it goes into the bag. It is 70% moisture. Now look at the next ingredients, whole red lentils, whole pinto beans, whole green peas, whole green lentils, whole chickpeas, pumpkin seeds. Could they find anymore antinutrients or fiber to throw in the bag?”
In actuality, if you look at the food that I referenced below, you will see that there are six meats in a row, two of which are meals before the lentils. There is a lot more meat than the above statement gives it credit for. Plus, this food contains eight ingredients that they would deem as “antinutrients.” However, these ingredients contain nutrients of their own. As compared to the Purina ONE we were comparing it to, it contains seven “antinutrient” ingredients that are third, fourth, fifth, seventh, ninth, tenth and eleventh ingredients. This comment also forgets that Acana also lists what percentage of their protein comes from plant sources, in this case it’s 25%, meaning 75% of the protein comes from meat.
Acana Meadowlands: Deboned chicken, deboned turkey, chicken liver, turkey giblets, chicken meal, catfish meal, whole red lentils, whole pinto beans, whole green peas, pollock meal, chicken fat, whole green lentils, whole chickpeas, lentil fiber, whole blue catfish, cage-free eggs, rainbow trout, pollock oil, natural chicken flavor, chicken heart, chicken cartilage, whole pumpkin, whole butternut squash, mixed tocopherols (preservative), sea salt, zinc proteinate, dried kelp, calcium pantothenate, kale, spinach, mustard greens, collard greens, turnip greens, whole carrots, whole apples, whole pears, freeze-dried chicken liver, freeze-dried turkey liver, pumpkin seeds, sunflower seeds, copper proteinate, chicory root, turmeric, sarsaparilla root, althea root, rosehips, juniper berries, dried lactobacillus acidophilus fermentation product, dried bifidobacterium animalis fermentation product, dried lactobacillus casei fermentation product.
“You mention Hills SD having too much Vitamin D. As long as humans or machines are involved in the food chain, there will be errors. Have you looked at FDA recalls?”
“They recalled their food and paid for the testing of dogs being fed those foods and the retesting until Vitamin D levels returned to normal.”
“The foods linked to DCM have not been recalled by FDA yet many foods recommended have been recalled. Who’s writing these articles regarding DCM. Makes you wonder why.”
“Science Diet stepped up to the plate. Start paying for echoes and make your case.”
Purina Recalls [21,24]: March 2019 (contained rubber pieces), March 2016 (inadequate vitamin/mineral levels), March 2015 (inadequate thiamine levels), August 2013 (salmonella contamination), May 2012 (Low thiamine), July 2011 (Salmonella contamination), June 2011 (Salmonella contamination), 2007 (Melamine poisoning) 1983 (Mislabeling), 1978 (PCB contamination)
Hill’s Recalls : January 2019 (vitamin D toxicity), June 2014 (Salmonella contamination), April 2007 (melamine poisoning), March 2007 (Melamine poisoning)
Royal Canin Recalls : May 2007 (Melamine poisoning), April 2007 (Melamine poisoning), February 2006 (Excessive vitamin D3)
Purina Lawsuits: January 2015 (killed thousands of dogs, ), December 2016 (over-charging for therapeutic diets)
This is what has been reported about the lawsuit and how Purina responded to FDA investigations: “Extensive amounts of complaints of sick or dying pets linked to Purina’s Beneful Dog Food have been received by FDA for at least the past 4 years [as of 2016].
In 2013 when FDA investigated Purina Beneful, the pet food company…
Refused to allow FDA to take pictures, refused to provide FDA with copies of documents, refused to disclose pet food ingredient safety testing measures, refused to disclose exact ingredients used in the batches of pet foods linked to pet illness and death.
A 2015 lawsuit against Purina Beneful refused to allow the testimony of two veterinarians; one regarding a statement that consumers expect a pet food to be safe when they buy it and the other because he relied on scientific literature instead of performing testing that would result in intentional death of more dogs .”
Hill’s Lawsuits: Early 2019 (killed thousands of dogs with vitamin D, ), December 2016 (over-charging for therapeutic diets)
The FDA announced the voluntary recall in January 31st for Hill’s. It was updated March 20th, and then updated again May 15th. They took four months to do a full recall. In a statement issued to vets in February, 2019 it says that reimbursements will be issued for cans purchased between September 1st and February 1st. We have not been able to find updates to this stating whether they will reimburse any products between February 1st and their most recent recall date. This means that they were selling it three to four months before their first recall, and then another three and a half months before they did their final recall . Their reimbursement qualifying conditions include: the patient was fed one or more voluntarily recalled dog food canned products, the voluntarily recalled food was purchased between September 1, 2018 and February 1, 2019, that only one reimbursement per patient (duplicate submissions will not be honoured), reimbursement requests will be reviewed for voluntarilry recalled products in the United States, and a completed ‘Patient Reimbursement Request Form’ and all supporting documentation included in the ‘Reimbursement Checklist’ must be submitted . It specifies the United States, so it is unclear as to how this effects animals outside of the USA. We should also note that the money goes to your veterinarian and it is up to them to reimburse or not charge clients. The form also says, “Your clinic will receive a reimbursement per the details provided in the patient reimbursement request form as soon as possible after receipt of the forms If you are a Hill’s customer… If you are not a Hill’s customer, processing may take longer.” This means that your vet is the one reimbursed and that reimbursement is delayed if they do not sell Hill’s products. The Patient reimbursement form also states, “I consent to the use by Hill’s of this information for any purpose related to the recall. I certify that the information contained in this form is true and correct to the best of my knowledge .”
Royal Canin Lawsuits : December 2016 (over-charging for therapeutic diets)
“The case was filed in the US District Court of Northern California in December 2016. The plaintiffs claim that the accused companies are in violation of anti-trust and consumer protection laws for making certain veterinary diets available by prescription only in order to willfully overcharge consumers. ”
Orijen Recalls : November 2008 (Lack of radiation treatment to enter Australia)
“You talk about Vets selling prescription diets. Where else would you buy a prescription diet? They are not for all dogs, only dogs with special dietary needs.”
It should be noted that Hill’s is the only one allowed to say “Prescription Diet” since they have the phrase trademarked for their own foods. The FDA states that anything sold to “cure, mitigate, treat, or prevent disease is viewed as a drug and cannot be a food .” Drugs must undergo intense testing to ensure safety and efficacy. However, therapeutic diets in pets are the exception, and also do not contain drugs. The FDA has left it up to the brands to do their own efficacy and safety testing. This means when you buy a veterinary diet, the only proof that it does what it says is from the company that makes it, with no cross-checking from the FDA. Legally a food is “articles used for food or drink for man or other animals, chewing gum, and articles used for components of any such article… The Supreme Court decided if the law is unambiguous – not open to more than one interpretation – then the law itself should be enforced. In other words, the court would not allow a government agency (FDA in our case) interpretation of law if the law was written clearly and precisely .” Somehow, the FDA interpreted another law: “A food shall be deemed to be adulterated- (5) if it is, in whole or in part, the product of a diseased animal or of an animal which has died otherwise than by slaughter;” as them not having to hold pet food to the same standards as human food . This is disturbing as to what these foods are putting in them to fit the classification as not a food article. The aftermath of this is that the FDA depends on veterinarians to prescribe these diets only when needed, especially since “some therapeutic diets have nutrient levels that are appropriate for treating certain diseases but could be unsafe for healthy pets .” It is the responsibility of the vet to not prescribe these foods to pets that are healthy. “Veterinarians also need to be involved because sometimes a therapeutic diet doesn’t do what it is meant to do .” Tufts University also states that the ingredients in these pet foods are no different than the ones used in typical pet food . All of the extra cost to these diets is due to testing. This emphasizes that numbers matter to the makers of “scientific diets,” not ingredient quality. So to put it bluntly, therapeutic diets should not be available anywhere until they meet the same standards as other prescription products, i.e. drugs.
“Have these implicated companies participate in a study with a specific number of dogs being fed their diets. If there is nothing wrong, that should prove it. Of course, that would involve spending more dollars in research, which would result in less dollars in marketing, something they have never been willing to do.”
Like we stated before, there are several companies on the list that do not spend much on marketing and put stock into good ingredients instead. In addition, a study to that effect would take years to complete properly and require thousands of animals to eat a particular food solely for that period and be under the same conditions. It would be timelier to look at the foods implicated, come up with hypotheses as to the causes and test them. Also, in civilized society, innocent until proven guilty applies. There is no evidence that they cause a problem so it is up to the accuser to provide evidence.
“the startling obesity issue in pet dogs?!? And why DCM? What about cancer in dogs now a days?!? Maybe the FDA should put their money into researching the fact that dogs are riddled with cancer? What are the numbers on cancer in dogs?!?”
“FDA stated that flea and tick meds are slow poisoning pesticides however vets are still distributing. This has also been known since the 1990’s. Food same thing been a huge problem for a long time. My point finally the FDA is slightly investigating. More research needs to be done before slandering our “ boutique foods””
“Good article. We posted something today on our page Pawz'N'Clawz. That states funny how there's nothing on the list about Mars. And Purina or Beneful which is known to be killing animals. And yet there's no mention of those foods. I guess money talks.”
These are interesting points and fascinating if you look at it closely. Statistically, compared to many other factors, such as cancer, flea medications, Diabetes, recalls, etc. that kill pets in a much higher rate, so much focus is being put on DCM. It would be interesting to understand why that is.
“I have read many articles on this subject matter...and yet the entire medical profile of the dog is still missing, i.e. prescribed drugs, add on dietary supplements, dog treats consumed, toys and bones mouthed and eaten, vaccination history, geological locations, visitations/daily exercise/activities to dog parks, trail hikes, their own neighbourhood lawn care, the dog’s actual genetics health history...some how all of these important factors are still missing from the research equation summary.”
“How many people feeding Acana for example fed that food exclusively? I used Acana but combined it with human food and also switched flavors several times.many dogs, like mine are allergic, and so people are searching for different proteins because their dogs are reacting to them. The allergy thing just throws another variable into the picture and it just gets more muddled.”
This is our point exactly. How can all these foods be blamed when we do not have a complete medical and nutritional history on the dogs in all of the cases reported? Until all the factors are considered no “conclusions” can be drawn. There may be a common factor that is missing in the equation. Even the fact that they are mostly grain free foods is not a true common denominator since the diets are not consistent in formulation or ingredients. For example, potatoes used instead of peas, variable meat sources, a wide range of amount of “filler” ingredients, etc. Treats are also a big deal and a lot of people don’t realize it.
“Perhaps it is not taurine. Perhaps it is thiamine that is the issue as lentils contain heat stable thiamine antagonizers.”
It’s possible, but it would show up in a blood test as being low. Many of the companies test for these essential nutrients when formulating their diets. Many of them even do testing on every batch before it leaves their facility. This would also end up showing up on the tests done by the FDA and veterinarians.
“I understand you have a horse in this race as you sell dog food. I have none.”
I do own a pet food store, so I understand why someone would think this, but I could easily switch to all foods with grains, make a taurine supplements and tell everyone they need to buy my product, but I don't because I have integrity and animals mean more to me then money. Realistically which do you think I'd make more money off, keeping my store the same in a small town, or marketing a taurine supplement as the cure for DCM all across Canada? You do have a horse to race in this and it's going to be harsh, not saying this is 100% the case, but it could be a factor for you. Like you said your dog got sick, so what do we as parents do when they're sick? We blame ourselves and say what could we have done differently. Now someone comes around and tells you it's not your fault, you tried your best. It's those food companies that lied to you. Now you don't have to blame yourself because you have someone else to blame. Not saying that's you necessarily, but people tend to want to hear it couldn't have been anything they did.
“I hope the exact mechanism is found quickly and I hope none of the foods you are recommending to your customers has one of them developing dietary DCM. People should be able to make a choice knowing all the facts, not just yours.”
I agree completely. We need to know the mechanism and if there is truly any link to grain free foods, nutrients in general, medications, etc. We need to take into account all possibilities and variables and access them. There also needs to be studies done to find the method in which the problem starts, how it works and how to fix and prevent it. My concern though is by deciding at the beginning what the cause is, due diligence is not being done. I have said it before and will say it again I don’t want anyone to blindly listen to me, I want to provide them with the tools to educate themselves.
“As a former (human) caardiology technician, that is why (human) cardiologists recommend humans take supplements if they eat a vegan diet. Because, antinutrients block absorption. Because too much fiber can cause nutrients to be excreted before they are absorbed. Vegans have a tendency to eat a lot of legumes and lentils. They recommend vegans take L-carnitine ( what cardiologists are recommending as part of the treatment for dogs). Taurine, one of the supplements used in treatment for dogs.”
“You always go back to the ingredient argument. It is NOT ingredients. Please stop saying that. It is formulation. It is heavy legumes and lentils. Dogs and people have been eating those ingredients for decades with no problem. Vegans, however, consume heavy legumes and lentils. The new dog foods (grain free) heavy legumes and lentils.”
We have addressed the “formulation not ingredients” argument in previous responses, but I would like to touch on the vegans eat lots of lentils which puts them at risk for DCM. I do believe, especially in pets, that meats are a crucial nutrient source, however when researching this I found a fascinating article while failing to find any articles to support your point. “A study published in 2014 looked at 198 patients to further investigate whether eating a strict plant-based diet could stop or reverse heart disease. It found of the 177 patients who stuck to the diet, the majority reported a reduction in symptoms and 22 per cent had disease reversal confirmed by test results .” The study implemented a strict Vegan diet as well as encouraging exercise and continuing any prescriptions they were on and had fascinating results. This study does prove as well that vegan diets do not as you imply cause DCM, but can actually potentially reverse side effects, something else that is being claimed to be impossible if it’s not the fault of grain free foods.
“It is NOT about grain in food. It is the lack of research done on novel ingredients and how to formulate them properly.”
If this were true the main food accused wouldn’t be Acana who’s most “novel” recipe is their Free-Run Duck:
fresh duck (18%), duck meat meal (17%), whole green peas, whole red lentils, fresh duck giblets (liver, heart, kidney) (7%), duck fat (6%), fresh Bartlett pears (4%), whole garbanzo beans, whole green lentils, whole yellow peas, dried duck cartilage (2%), lentil fibre, marine algae (1.2%) (pure and sustainable source of DHA and EPA), fresh whole butternut squash, fresh whole pumpkin, dried brown kelp, freeze-dried duck liver (0.1%), salt, fresh whole cranberries, fresh whole blueberries, chicory root, turmeric root, milk thistle, burdock root, lavender, marshmallow root, rosehips, enterococcus faecium.SUPPLEMENTS: Vitamin E, Zinc Chelate, Copper Chelate.
Without bringing up foods like:
Hill's® Prescription Diet® d/d® Canine Potato & Venison Formula:
Potatoes, Potato Starch, Venison, Potato Protein, Pork Fat, Soybean Oil, Pork Flavor, Lactic Acid, Dicalcium Phosphate, Fish Oil, Potassium Chloride, Venison Meal, Powdered Cellulose, Iodized Salt, Calcium Carbonate, Choline Chloride, vitamins (Vitamin E Supplement, L-Ascorbyl-2-Polyphosphate (source of Vitamin C), Niacin Supplement, Thiamine Mononitrate, Vitamin A Supplement, Calcium Pantothenate, Vitamin B12 Supplement, Pyridoxine Hydrochloride, Riboflavin Supplement, Biotin, Folic Acid, Vitamin D3 Supplement), DL-Methionine, Taurine, minerals (Ferrous Sulfate, Zinc Oxide, Copper Sulfate, Manganous Oxide, Calcium Iodate, Sodium Selenite), L-Tryptophan, Mixed Tocopherols for freshness, Natural Flavors, Beta-Carotene
Royal Canin Canine Selected Protein Adult Ko Dry Dog Food
Oat groats, kangaroo, canola meal, chicken fat, dried plain beet pulp, calcium carbonate, monocalcium phosphate, fish oil, salt, vitamins [DL-alpha tocopherol acetate (source of vitamin E), inositol, niacin supplement, D-calcium pantothenate, biotin, pyridoxine hydrochloride (vitamin B6), riboflavin supplement, thiamine mononitrate (vitamin B1), vitamin A acetate, folic acid, vitamin B12 supplement, vitamin D3 supplement], fructooligosaccharides, sodium tripolyphosphate, taurine, choline chloride, potassium chloride, DL-methionine, trace minerals [zinc proteinate, zinc oxide, manganese proteinate, ferrous sulfate, manganous oxide, copper sulfate, sodium selenite, copper proteinate, calcium iodate], rosemary extract, preserved with mixed tocopherols and citric acid.
Nature’s Logic Rabbit Meal Feast
Rabbit Meal, Turkey Meal, Millet, Chicken Fat (preserved with Mixed Tocopherols), Pumpkin Seed, Yeast Culture, Spray Dried Pork Liver, Dried Egg Product, Alfalfa Nutrient Concentrate, Montmorillonite Clay, Dried Kelp, Spray Dried Porcine Plasma, Dried Tomato, Almonds, Dried Chicory Root, Dried Carrot, Dried Apple, Menhaden Fish Meal, Dried Pumpkin, Dried Apricot, Dried Blueberry, Dried Spinach, Dried Broccoli, Dried Cranberry, Parsley, Dried Artichoke, Rosemary, Dried Mushroom, Dried Lactobacillus acidophilus Fermentation Product, Dried Lactobacillus casei Fermentation Product, Dried Bifidobacterium bifidium Fermentation Product, Dried Enterococcus faecium Fermentation Product, Dried Bacillus coagulans Fermentation Product, Dried Pineapple Extract, Dried Aspergillus niger Fermentation Extract, Dried Aspergillus oryzae Fermentation Extract, Dried Trichoderma longibrachiatum Fermentation Extract
If the lack of research causes problems for novel proteins from brands like Acana, then they would also apply to brands like Royal Canin and Hills. There have also been numerous articles including the ones from the FDA specifically stating they’re blaming grain free foods. “FDA Investigation into Potential Link between Certain Diets and Canine Dilated Cardiomyopathy ” is the name of the FDA article.
“And while many people look at antinutrients, including myself from a human cardiology standpoint, I wouldn't be surprised if too much fiber is involved.”
If that were the case Hill's Prescription Diet Digestive/Weight/Glucose Management w/d would be causing substantially more issues with it’s 16.8% fiber then Taste of the Wild Pacific Stream which has 3% fiber.
“I think there is a perfect storm of ingredients.”
If DCM was being attributed to one brand or flavor of a brand this could definitely be a possibility. It would be nearly impossible though for over a dozen different brands to hit a perfect storm all simultaneously though. Especially figuring you have a range from nearly devoid of meat to foods that get 85% of their proteins from meat.
“As for the NM-DCM group, yes I do belong. I am thankful for Dr. Stern and his research every day. Join the group. No one will know who you are. Don''t comment. Just read the comments of people that have lost their dogs, or those that are paying $$$$$ for treatment. Or those dogs that now how a heart size that is back to normal and functioning properly. Those are dog owners reporting those stories. Do you think they are lying?”
No, I don’t think they’re lying, just scared and confused. I am glad to hear their dogs are recovering, I simply don’t see any data proving it had to do with their foods being grain free. Without any evidence and with the inconsistency of the symptoms and test results it’s impossible to attribute it all to any one thing. It’s unclear if all these cases are even the same disease as some present with low taurine, some don’t, some get better with diet or medicine, some don’t etc. The inconsistencies force us to look at it with a wider scope and consider all variables and possibilities until we can conclusively prove anything.
 FDA Investigation into Potential Link between Certain Diets and Canine Dilated Cardiomyopathy, https://www.fda.gov/animal-veterinary/news-events/fda-investigation-potential-link-between-certain-diets-and-canine-dilated-cardiomyopathy?fbclid=IwAR3t4_U_jeGClOAJocFmjhuuyy8_rihjMpDohv23-eKypWMYCsfbkBG39Kc#diet
 Dilated Cardiomyopathy in Dogs & Cats: Complaints Submitted to FDA-CVM, https://www.fda.gov/media/128303/download
 Vet-LIRN Update on Investigation into Dilated Cardiomyopathy, https://www.fda.gov/animal-veterinary/science-research/vet-lirn-update-investigation-dilated-cardiomyopathy?fbclid=IwAR0FcdrGrdvsgMNnwm8zrmXeIV2s0SGJWpaf7yPMpcMDjqRwM8ywtlpx6pE
 Patient education: Dilated cardiomyopathy (Beyond the Basics), https://www.uptodate.com/contents/dilated-cardiomyopathy-beyond-the-basics?fbclid=IwAR0v4MwG4JAoovnb9iNNzbkeXFawGwmM4o9Dbaa64amHb_mnqZv