Dog Health Improvement – what’s working?

I am grateful to Dr Brenda Bonnet for sending me a copy of an interesting and useful paper published in January by a team from the University of Copenhagen Department of Veterinary Medicine. [Mapping of initiatives to prevent inherited diseases and exaggerated phenotypes in dogs – Bruun, Fredholm, Proschowski & Sandøe]

The team describes and examines 4 types of initiative designed to address the negative effects of dog breeding. These are: research, actions in the breeding community, education of the buying public, and legislation. The study draws on source material from the FCI and Kennel Clubs, animal welfare organisations, published research, and legislation.

I’ll cut to the chase and say that the report’s conclusions and recommendations mirror a couple of key points I’ve written about numerous times in this column:

• We need data and evidence, but endlessly seeking more data or the “perfect” set of data  won’t make much difference to dog health
• The real issue that we need to address is human behaviour change and most of the solutions developed so far have been developed in isolation and fail to “join the dots” in what is a complex system

Research initiatives

There are 3 main types of research initiative; epidemiological studies to establish evidence of the prevalence and severity of diseases; research to develop tests and diagnoses of diseases; and research to develop treatments. In the UK, the VetCompass studies that I have written about previously are among the most well-known and useful epidemiological research. These studies, together with breed health surveys (run by the KC and breed clubs), provide good baseline data and the potential to measure improvements over time. They also enable us to set objectives for improvement and to prioritise among different conditions. Our UK Breed Health and Conservation Plans are the key documents summarising this research and individual breed improvement plans.

We are all aware of the pace of development of new DNA tests but a major concern is the relevance of these. Just because a particular mutation has been found in a breed doesn’t necessarily mean it is associated with the clinical manifestation of a disease. Resources such as the IPFD’s Relevance Ratings in their DNA test database make it clear where tests are worth considering within a breed’s improvement plan.

Additionally, it’s all too easy for breeders and buyers to mistake “health-tested” for “healthy” and we still have a lot of education to do in this regard. 

Initiatives by breeding organisations

The Danish paper acknowledges that Kennel Clubs and Breed Clubs have taken some effective action to improve breeding programmes but admits these are limited to dogs within the registries. We know there are at least as many “pedigree” dogs bred outside the UK KC registry and, therefore, these breeders are hard (or impossible) to reach with education programmes.

Unsurprisingly, amendments to Breed Standards are one attempt to limit the negative effects of extreme conformation or exaggeration.

Traditions like coat colour and specific conformational aspects are quoted as being considered to be equally important as health and welfare, which mitigates against many of the necessary improvement actions being adopted by breeders.

The paper describes breeding programmes imposed by Kennel Clubs as being “a balanced consideration of many aspects related to the breed, its health and breeders”. For example, the size of a breed is important and if too many criteria are included, many dogs would be excluded from breeding with a resulting further loss of genetic diversity and the emergence of new diseases. There will always be debate about whether KCs have got the balance right and the pace of improvement that is possible.

Initiatives such as Breed Watch and Breed Health and Conservation Plans are 2 key elements we have here in the UK, to support judges, breeders and breed clubs.

Open Studbooks and the introduction of unregistered dogs or cross-breeding with phenotypically similar dogs are other strategies available in some Kennel Clubs. These have the potential to increase genetic diversity and help breed away from issues in some breeds.

The paper concludes that the effectiveness of initiatives by the FCI and KCs is difficult to evaluate. They doubt whether instructions are being followed by show judges and breeders. They also worry that any improvements will be very slow to be seen.

Initiatives to influence buyers

There is plenty of research to suggest that many buyers do not emphasise health in their decision-making. Fashion and societal influence (e.g. via social media) often play a larger part in determining choice of breed.

There have been campaigns by veterinary groups and animal welfare organisations to discourage people from buying brachycephalic (and other) breeds. The paper concludes that these have not “had any measurable effect”. It is clear that traditional marketing campaigns and ever more websites with information for buyers simply won’t work (on their own). This, of course, takes me back to my point about the science that is missing is Behavioural Science.

Legislative initiatives

You’d have to have spent the last year sleeping under a rock not to be aware of the legislation that has been introduced in Germany, Austria and the Netherlands to address welfare issues in pedigree dogs (breeding and exhibiting). The Norwegian court cases against the NKK and breeders of Cavaliers and Bulldogs have also been widely discussed.

While much of the new legislation does send strong signals about what is and is not acceptable, there appear to be significant variations in interpretation and enforcement. We’ve seen the same issue with the UK breeder licensing regulations, with huge variations between different local authorities. Legislation also risks driving breeders underground; unhealthy dogs will still be bred but are invisible to law enforcers. The unintended consequences of badly thought-through legislation should not be underestimated.

So, what works?

It would be easy to conclude from the Danish paper that nothing much works! I have written previously about the COM-B behavioural change model (Michie et al) and I still think this holds the key to achieving breed health improvements. The focus has to be on human behaviour change (breeders, judges, buyers, owners, vets) and we will need a different combination of initiatives for each group. It would be helpful to have a “roadmap” of options for different groups and it would be even more helpful if there was increased collaboration and pooled resources rather than multiple scattergun approaches.

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The Evidence Pyramid Revisited

This is the 9th anniversary of my “Best of Health” articles. It’s hard to believe I’ve been writing these for 9 years! Thank you to everyone who reads them and to those who correspond with me following their publication. You can find a complete archive of my articles on my blog at: https://sunsongdachshunds.wordpress.com/health-welfare/our-dogs-best-of-health-articles/

Last month I wrote about the challenges of cherry-picking data from published research studies and how they can be used to generate click-bait headlines in the national press and on social media. I emphasised the importance of breed clubs collecting their own data with robust health surveys. Ideally, these should include gathering responses from owners of dogs that aren’t part of the show community or that aren’t KC registered. These non-show and non-KC data have the potential to demonstrate whether or not there are differences in the health of these different sub-populations of our breeds.

My caveat at the end of last month’s article was that more data won’t improve dog health or longevity. There is little point in endlessly arguing with the published research or debating whether or not the sample in a survey is truly representative of what’s happening in a breed.

I was reminded of an article I wrote in 2017, following the Breed Health Coordinators’ Conference. One Of the presentations was by Dr Zoe Belshaw from the Centre for Evidence Based Veterinary Medicine at Nottingham University. Zoe talked about the so-called Trust Triangle which describes the different types of information you might come across and the levels of trust that can be associated with each.

A variation of this is the Evidence Pyramid which has expert opinion at the bottom, followed by Case Studies, Cohort Studies and Randomised Control Trials (RCTs). These latter 3 are unfiltered information which may be available as Open Access papers. Sitting above these are a series of filtered information sources such as Systematic Reviews (meta analysis). These publications dissect and critique a set of primary research papers in order to arrive at “the best evidence” to support a particular case (or to disprove it). This is the sort of work that Zoe’s colleagues do at the Nottingham Centre for EBVM and they then publish what can be considered to be best practice for vets and clinicians to adopt. As with all science, “best practice” today could well change if new research evidence emerges.

This all seems quite logical but, recently, I was intrigued to read an article by Dr Michael Putnam, an Associate Professor of Medicine in Wisconsin who argued that the Evidence Pyramid is flawed.

One of the points he makes is that, in the real world, when a medical professional needs an answer to some obscure clinical question, they rarely dig through published case reports. Their pragmatic approach is to ask a respected colleague for their expert opinion because they feel this carries more weight than reading some randomly published paper.

Putnam argues that systematic reviews are emphatically not the highest level of evidence. This is a good point because they are simply a view of the actual evidence collected from a range of RCTs and observational studies. Obviously, this then depends on the quality of the review process and the input papers and studies which are in the review pool. Many of the studies included in these reviews will involve small sample sizes and (sometimes) dubious methodologies particularly when it comes to statistical analysis. I have had several conversations recently about papers published on research into intervertebral disc disease where the statistical analyses were less than ideal and/or where the studies were underpowered due to small sample sizes. The reason I queried these papers was that the findings contradicted previous studies (both in dogs and humans). Luckily, I have some very capable statistician friends and am in contact with researchers to whom I can turn for a critical appraisal of new papers.

A paper published by Prof. John Ioannidis (Stanford University) in 2016 said that there is massive production of unnecessary, misleading, and conflicted systematic reviews and meta-analyses. Instead of promoting evidence-based medicine and health care, these instruments often serve mostly as easily produced publishable units or marketing tools. He concluded that “China has rapidly become the most prolific producer of English-language, PubMed-indexed meta-analyses. The most massive presence of Chinese meta-analyses is on genetic associations (63% of global production in 2014), where almost all results are misleading since they combine fragmented information from mostly abandoned era of candidate genes.” More shockingly, a 2022 paper by Ioannidis stated that simulations show that for most study designs and settings, it is more likely for a research claim to be false than true and that many research findings may simply be accurate measures of the prevailing bias.

What should be at the top of the pyramid?

Putnam argues that RCTs should be at the top of the evidence pyramid. However, he goes on to say that we should acknowledge that many RCTs are poorly designed, underpowered and subject to bias. Therefore, instead of the pyramid having discrete layers that differentiate between sources of evidence, the model should recognise that some trials are worse than some cohort studies. In other words, there is more of a blurred boundary between observational studies and RCTs. The case for this reengineering of the Evidence Pyramid was also made by Murad et al in the BMJ in 2016.

Does it matter in the real world?

We are encouraged to consider Evidence Based Veterinary Medicine as an underpinning principle for recommending approaches to diagnosis and treatment of canine health conditions. The quality of evidence should determine the confidence in recommendations.

In practice, there don’t seem to be that many published RCTs that are of relevance to us but there are numerous observational and cohort studies (retrospective and prospective). Putnam ended his article by saying that “good observational studies may be better than bad RCTs and that we should read and judge each paper by its individual merits, not by its strata on a colourful pyramid.”

So, in the real world, it might be worth reading the “Limitations” section of any research paper before you read the full paper. It’s also worth reading the “Conflicts of Interest” declaration to find out who funded the study. I think it was Sid Vicious who said “Today, everything’s a conflict of interest”! 

We don’t need change, we need improvement!

It’s 14 years since Pedigree Dogs Exposed but actually much longer since some of the challenges associated with the health of pedigree dogs were first discussed. My first “Best of Health” article was published in March 2014 and in it I described canine health improvement as a “wicked problem”.

Wicked problems do not have optimal solutions. They are typically characterised by having multiple stakeholders who often have diverse views of what’s wrong, what’s needed and how to address them. Everyone has an opinion on some aspect of the problem and what needs to be done to solve it. The trouble is, different people disagree about what needs to be done. They are also the realm of unanticipated consequences where somebody implements a supposedly simple solution that ends up making things worse.

We are not alone in having to deal with wicked problems, of course. The economy, climate, health, crime and many other societal issues fall into the category of wicked problems, yet many governments still believe that “evidence-based policy-making” will lead to viable solutions. Governments have tried for at least the past 40 years to draw on research and evidence to inform policy decisions. When I was consulting in the criminal justice sector in the early 2000s, there was much effort put into documenting “what works” in the belief that it could be replicated and rolled-out more widely. Research groups such as the Justice Data Lab collated and published studies to show “what works” to reduce reoffending.

In some ways, we’re not that different in the world of dog health; there is a huge investment in collecting better evidence (supposedly) to help us solve our big health problems. That, of course, is a perfectly rational approach; evidence helps us to understand the scope and scale of any problem, and we can then develop optimal solutions to address them. The trouble is, there’s strong criticism from outside our community that we’re not improving things fast enough and, in some cases, there’s no evidence of improvement at all. In an increasingly complex and polarised society, is the best we can hope for to manage our wicked problems, rather than to solve them? 

Cherry-picking evidence

However rational we might like to be, in reality, the views and opinions of people and groups often means that decisions are political rather than purely being based on any available evidence. There have also been examples of evidence being cherry-picked to make a particular case (e.g. selective choice of photographs to illustrate either “good” or “bad” health in a breed). Some argue that we don’t have enough evidence but that’s always going to be true in a complex, evolving, situation. Others happily put their own spin on the evidence they have looked at. Everyone is entitled to have their own opinions; they are not entitled to have their own “evidence”, though.

One of the other big challenges to evidence-based policy-making is the wide variety of mass communication channels now available through social media. While we’d all like to hope we can participate in courteous conversations in discussion groups, we’ve probably all found ourselves on the end of some wildly polarised conversation. At their worst, some of these groups degenerate into playground squabbles, abuse and trolling. The end result is a multitude of parallel-world echo-chambers where people rarely hear anything other than views that they can align with. This intensifies biases and means that alternative evidence simply doesn’t get any airtime. Back in 2017, I wrote about alternative facts and the post-truth world.

Moving from talk to action

There are a few groups, networks and organisations that continue to defend evidence-based discussion and use collaborative approaches to discuss strategy but they too struggle to get enough people to move from talk to action.

It’s pretty clear that many of the dog health and welfare problems are passionate causes for some people but will, inevitably, be difficult to resolve. More research and more evidence has not resolved the conflicting views; at least not fast enough to benefit the dogs. There is evidence that working at a smaller scale, at breed level, can lead to successful and lasting improvement. I’ve previously written about the pivotal role of Breed Health Coordinators and, each year, we see these individuals given recognition through the International Canine Health Awards. We should encourage more of these breed-level approaches but we do have to recognise they are very dependent on having effective leadership in place. I’m not convinced there’s much effort being put into identifying and developing the breed leaders of the future.

Campaigners, governments and dog people often look for simple solutions to solve these complex problems (change the breed standard, mandatory health-testing, compulsory licensing, more regulation etc. etc.). Vocal leaders among these groups sometimes try to impose their own preferred solution in an effort to “do something”. It’s quicker to “do something” than to acknowledge others’ views and to find ways to collaborate on developing longer-term viable solutions.

Each breed has a unique history that has led it to where it is today and we also have to recognise that, in some cases, large proportions of breeders fall outside the breed club community. I have argued previously that it is important for breed clubs to engage with these people if they want to be taken seriously as guardians of their breed.

There are no neat and quick solutions to the wicked problems associated with canine health and welfare. If that’s what some people continue to search for, they will be bitterly disappointed. We do need the research, the data and the evidence but these alone will not lead us to finding simple solutions to our complex problems. The useful solutions we come up with will necessarily be based on the best available evidence but also based on our ability to collaborate and agree shared objectives. I suspect we’d make more progress if all the groups who “want to do something about dog health” put more effort into improving the way they collaborate than on coming up with the next quick fix aligned to their individual agenda.

“If you truly want to understand something, try to change it” – Kurt Lewin

Who’s looking at the bigger picture?

It’s very easy to get so focused on what’s going on in your own breed (or breeds) that you lose sight of the bigger picture and wider context of what’s happening in the world of dogs. For some breeds, particularly the brachycephalics, there has been a huge amount of scrutiny for many years. The most proactive breed clubs and Breed Health Coordinators have focused on getting messages across about good breeding practices and the value of health screening programmes. Some, though, are less proactive and are perhaps wondering what new legislation is going to hit them. If their short-term focus is on tinkering with their Breed Standard or uptake of a single-gene DNA “health” test, I suspect they will be in for either a disappointment or a shock. While it may be true that “backyard breeders” are the cause of many health issues through poor breeding practices and a disregard for the Breed Standard, it’s likely that those in breed club communities will be impacted first. Breed club communities and those who show their dogs are an easily identifiable target for criticism.

At a National level, Kennel Clubs have to juggle and balance priorities across multiple breeds. Decisions that are made for one breed can often have wider implications across other breeds. Here in the UK, there was a time when the KC would consider implementing “Control Schemes” in specific breeds. Probably the best-known example is CLAD testing in Irish Setters.

With effect from 1 July 2005, the Kennel Club would only register Irish Setters that are proven to be clear of CLAD, or hereditarily clear of CLAD e.g. both parents are clear. With effect from 1 January 2008, the Kennel Club ceased to accept any registrations for Irish Setters produced from a CLAD carrier parent mated to a clear or hereditarily clear parent. Breeders wishing to register progeny from a carrier after this date were required to apply for permission prior to the proposed mating, and applications are dealt with on a case-by-case basis.

Hindsight is a wonderful thing

I remember going to a meeting more than 20 years ago with Professor Jeff Sampson (the KC’s geneticist at the time) where we asked if a control scheme could be introduced for Miniature Dachshunds so that cord1 PRA could be eradicated from the breed. Thankfully, in hindsight, Jeff argued that this would not be in the best interests of the breed and could actually make things worse by further reducing genetic diversity. We had similar discussions with the KC about banning registrations of Mini Wires that were affected by Lafora Disease or that were untested. Hindsight is a wonderful thing and we now know that early onset PRA in Miniature Dachshunds is not caused solely by the cord1 mutation. We have also been able to reduce the risks of breeding Lafora-affected puppies without having the constraints of a Control Scheme.

These days, the KC’s health and genetics advisors are very much aware of the challenges associated with loss of genetic diversity and, I believe, the current policy is that Control Schemes are not considered to be an effective tool for managing inherited diseases. This is a good example of how the role of the KC is to understand the bigger picture and to educate breed clubs and breeders on the potential adverse consequences of what might seem like “simple” solutions.

The KC policy that puppies from merle-to-merle matings cannot be registered is another example of where seeing the bigger picture can (and should) influence a decision. The number of merle-to-merle matings was always very low and the risks of breeding health-compromised puppies was known to be high. As such, this decision made sense across multiple breeds where the merle gene is present. The impact of this policy on genetic diversity is low but the impact on avoiding significant health risks is high.

Unintended consequences

I’m sure there are plenty of other examples where breed clubs might argue for registrations to be restricted on the basis of health tests or where they believe there are health issues associated with particular aspects of the Breed Standard (e.g. conformation or colour). Stepping back and considering the bigger picture and potential undesirable consequences might lead us to alternative approaches. For example, if people can’t register with the KC, will these dogs continue to be bred outside the KC system or will their breeders register them with false details? In the former case, we still end up with unhealthy dogs that may suffer from lifelong illnesses and, in the latter case, we end up with a KC registry based on unreliable information. The KC might also have to consider whether a decision that apparently makes sense in one breed would have knock-on effects if applied to other breeds.

At an international level, the challenges of joining the dots and making sense of varying KC policies and diverse national legislation are even greater. Our KC has reciprocal agreements with many other KCs and the FCI acts as a worldwide body for 98 members and contract partners, with oversight of 355 breeds.

What is truly in the best interest of all dogs?

The International Partnership for Dogs is another organisation taking a broader perspective on the world of dogs. They have recently published their Annual Report for 2021. In her opening remarks, Acting CEO Katariina Mäki says “we continue to work with our stakeholders to educate our global community and promote what is truly in the best interest of all dogs”. She also says “We need collaboration among our stakeholders now more than ever”. That group of stakeholders includes KCs, groups with breed-specific interests, academics/researchers and members of the pet industry, including DNA test providers. Their Harmonization of Genetic Testing for Dogs Database now includes 82 academic and commercial Genetic Test Providers (GTPs) in 22 countries. IPFD’s online platform dogwellnet.com is their main channel for connecting with the dog community and, if you haven’t already done so, I’d recommend joining the 2000+ people who have signed-up for a free account which will give you access to all of their resources. If you’re a breeder or breed club officer, the information and tools available for 182 breeds are immensely valuable. Over the past couple of years, IPFD has put a lot of effort into creating over 1000 Breed Relevance Ratings for the list of nearly 2000 breed-specific DNA tests that are available. These evidence-based ratings, together with Globally Relevant Integrated Health Profiles (GRIHP) describe the big picture of health on conditions of interest within a specific breed.

Next month, IPFD will be running their second Virtual Dog Health Workshop with a focus on Genetic Diversity. I’ve been invited to attend, so I expect there will be plenty to share in future “Best of Health” articles.

COMPRAM: A model for collaboration

In October, I attended a webinar run by the Operational Research Society of which I am a member which I thought had some relevance to problems we are trying to solve in the world of pedigree dogs. The speaker was Professor Dorien De Tombe from the Netherlands who has developed a methodology for solving complex societal problems. Examples of complex societal problems include climate change, terrorism, urban planning, poverty. Healthcare issues such as obesity, malaria and SARS-COV2 are also included.

These are real-life problems with a high degree of complexity and with many different individuals, groups and organisations involved; often with conflicting agendas and where emotions can run high. One of the key points is that they are interdisciplinary problems and cannot, therefore, be solved by one particular set of experts or narrow interest groups that have their own “simple solution” in mind.

De Tombe’s COMPRAM model for dealing with these types of problems was endorsed by the OECD in 2006 when they advised governments to adopt the approach to handle problems that threaten global safety. Hindsight is a wonderful thing, of course, and she pointed out that most governments failed to act in an appropriate way to deal with the complexity of SARS-COV2. The result, unsurprisingly, is a whole series of unanticipated and undesirable consequences (a topic I have written about before).

You don’t have to look very far into the world of pedigree dogs to see that we too face a number of complex societal problems. Animal welfare, puppy farming and cruelty are obvious examples where “simple solutions” such as yet more legislation have consistently failed to make much of an impact. Similarly, the health of pedigree dogs including inherited diseases, genetic diversity and exaggerated conformation are also clearly complex. We can add into the mix some of the more current discussions about what should or should not be registered by the Kennel Club and we have a series of interconnected issues with widely diverging views on what “the solution” is.

Knowledge, power and emotions

De Tombe has been developing methodologies and tools for handling these sorts of complex problems since 1994. In fact, she avoids using the term “solving” and prefers to say “changing” because a solved problem for one person or group is often the start of a problem for other individuals or groups. All these problems have 3 main elements: knowledge, power and emotions. 

We know there are problems with pedigree dogs; lots of data has been collected and analysed and there is ongoing research to develop our knowledge further. Different individuals and groups have “power” and often also their own definitions of both the problem and a desired solution or end goal. We have seen that these complex problems result in high emotions; you only have to read the social media posts of dog owners, breeders, vets and campaigners to see this.

The process for handling these problems can be broken into 2 phases. In the first phase, the problem is defined. In the second phase, the problem is changed (solved). All too often, people who are emotionally invested in the problem leap straight to phase 2 and present their preferred menu of (what they believe are) solutions.

Problem definition is critical

My reflection on the De Tombe approach is that organisations such as the Kennel Club and the International Partnership for Dogs invest significant effort in working with the right people to define the various complex pedigree dog problems. 

Problem definition starts with becoming aware that there is a problem, asking questions about it and actively putting it on the agenda to be handled. In the case of the KC, the Dog Health Group and its 4 sub-groups are multi-disciplinary experts who can analyse data, exchange knowledge and begin to conceptualise the problem. The definition of a problem usually includes some historical perspectives (how did a breed originate, what did it look like, what were its genetic origins) as well as the current situation. It may also include a recognition that the current situation could become much worse if no action is taken.

To the rest of the world, perhaps this looks like delaying tactics or “kicking the can down the road” but the aim is two-fold; firstly to develop an expert understanding of a particular problem and secondly to build collaborative relationships with those who have the power to own and implement solutions.

Start with the end in mind

Changing the problem starts with considering the detailed data and evidence, plus defining the desired goal. The desired goal is the direction in which the experts or those involved in the problem would like to change the problem. Goals are about what we might want to improve, increase or reduce (e.g. increase longevity, reduce welfare harms). They are not what we might want to “do” (e.g. change the Breed Standards, make health testing mandatory, prevent particular dogs from being registered). Start with the end in mind!

In this second phase, other groups or individuals (beyond those experts who initially defined the problem) can come together to develop ways to handle the problem from the basis of good evidence. In the case of pedigree dogs, representatives of breed clubs are key people to involve. For health issues, each breed has a Health Coordinator and many also have health committees and the KC tries to work closely with these to formulate viable changes. The development of Breed Health and Conservation Plans is a good example of the collaborative approach taken. The Brachycephalic Working Group is another example of how a group of people with different views has been brought together to develop a consensus action plan. The 4 International Dog Health Workshops and, more recently, the IPFD’s DNA Test Reporting Workshop are further examples of how a collaborative approach can lead to practical and supported improvement actions. 

Pitfalls to avoid

There are many pitfalls in the process of handling complex problems. I’ve already mentioned the desire of some people to leap to solutions which they are passionate about before the problem or goal has even been defined.

Inviting the wrong people to participate in the process can also lead to inappropriate solutions if, for example, a small group of “loud voices” dominates the discussion. Groupthink is another team issue whereby poor quality analysis and decision-making goes unchallenged. Inviting “outside experts” to comment or play devil’s advocate can help avoid this.

It’s all too easy to end up with negative reactions to the solutions that are proposed and implemented. A key step in the De Tombe approach is for the decision-making team to take time to discuss the possible consequences and reactions before going ahead with them. Elijah Goldratt said “The world of business is awash with ill-considered solutions to ill-defined problems”. 

There are already some great examples of collaborative approaches to handle complex canine problems and we should always bear in mind that, for every complex problem, there is an answer that is clear, simple and wrong!