Obesity, Diabetes and Weight Loss

Obesity is an increasing health concern for dogs and cats in modern urban society and contributes to an increasing number of serious diseases in pets. High quality, affordable pet food is available in every neighborhood. Snacks are now available from an unlimited number of sources. 30 years ago pet superstores did not exist, cats and dogs frequently ran free all day, yards were larger and owners had more free time to walk and play with their pets. This problem is still never seen in feral populations of canines and felines. The disappearance of the extended, and, to an increasing degree, the nuclear, family structure has placed our pets in a much more prominent position in the home than in our grandparent’s generation. We dote on our pets because there are our constant companions, faithful friends and fuzzy children. Unfortunately, this devotion is often excessive and our four legged kids end up paying the price of overindulgence on our part. The obesity problem CAN be caused by metabolic disease, such as with hypothyroidism in SOME dogs or cats and contribute other medical conditions, such as arthritis in both dogs and cats and should always be considered first. However, most often obesity is a result of one simple problem: too many calories eaten compared to those burned by activity. Indoor pets are especially at risk for being overweight because of reduced activity. Small living spaces, dependence on the automobile and long work hours for owners have created the modern problem often referred colloquially to as the dreaded “condo-bod”.

When an animal (or human) consumes any type of food, it is broken down into simple sugars in the digestive tract. Unused energy (glucose) not needed by the body is converted by the liver into fat to be utilized later when food is scarce. The problem in household pets is that there is never a scarcity of food.

Evolution has designed the body to carry a certain amount of fat to provide energy between meals. Canines in the wild, like wolves and coyotes, go long stretches between meals. Therefore storing some fat is a healthy and necessary function. Feral cats on the other hand, eat small meals of protein throughout the day and do not store much fat at all. This characteristic of felines makes them highly susceptible to a specific liver problem called hepatic lipidosis if they are allowed to become obese and for some reason stop eating. This potentially life-threatening disease can occur in as little as 2-3 days. Cats were not designed to burn fat stores efficiently, and instead starvation causes the liver to become clogged with fat and subsequent liver failure. Some connections between obesity and disease are easy to understand. Overall, obesity reduces quality of life and shortens lifespan. One study by Purina showed that dogs with ideal body conditions live on average 15% longer than obese pets.

The following diseases occur at a higher rate in obese pets and owners than in lean individuals;

- - - -

Arthritis –see the document addressing this subject on the same webpage Cruciate ligament tears of the knees Vertebral disc disease and back injuries Heart and cardiovascular disease, thromboembolic strokes- High blood pressure (hypertension) - Respiratory distress - Diabetes mellitus - Cancer predisposition

- Overheating

- Anesthesia risk

Fat Tissue: Fat is stored in individual cells referred to as adipose cells or adipocytes. Everyone grows a set number (and dies) with a constant number of adipocytes upon reaching maturity. This is why liposuction works in people (note: liposuction is very damaging to dogs and cats). If fat cells multiplied, then the missing fat would be immediately be replaced for no benefit. Fat cells do not increase in number as obesity develops. Instead each adipocyte expands to hold more fat in each cell. Traditionally, fat storage (adipose tissue) has been viewed as a silent calorie repository, waiting for extra energy demands to shift it back into the blood stream. Recent research has now shown fat is dynamically and metabolically active and functions as an endocrine (hormonal) tissue. FAT IS NOT AN INERT STORAGE SUPPLY. It produces some very harmful substances when the adipocytes are stretched beyond normal size with obesity. Many of these substances are highly inflammatory. This would account for the higher levels of long term body damage associated with cardiovascular, pancreatic, joint and cellular disorders secondary to high force musculoskeletal trauma due to increased body mass and excessive cellular oxidation. Additionally, the overstretched fat cells become a highly active source of hormones released to affect numerous cell receptors and functions and include;

Leptin Resistin Adiponectin PAI-1 TNFα

IL-6 Estradiol (E2)

- hormone that stimulates hunger in the brain and is an inflammatory marker – proinflammatory factor associated with Type 2 diabetes – fat burning hormone reduced in diabetic patients – increased in obesity and promotes clot formation

- an inflammatory cytokine and promotes insulin resistance - an inflammatory cytokine and promotes insulin resistance and cancer - major estrogen molecule, increases risk of cancers, thrombosis, asthma

Diabetes and Obesity:

There are three main types of diabetes mellitus (DM) currently recognized. Diabetes insipidus is not sugar dependent and is a brain origin (pituitary) disease. However, DM patients do not always present with typical signs or treatment response and can have more than one type simultaneously. Certain breeds, such as Terriers, Cocker Spaniels, Dachshunds, and Poodles are more frequently affected. In fact, diabetes mellitus is a complex disease with numerous hereditary, physiological, lifestyle and concurrent disease factors that affect the patient. As a complex disease, most of the true types are poorly recognized and are termed “disease clusters” with overlapping common features, plus unique aspects that differentiate them in how they appear and respond clinically. Collectively, these overlapping patient groups are called “constellations” as apposed to strictly defined and separate groups called “cohorts”. These differences are the reason why some diabetics are so difficult to regulate.

- Type 1 diabetes: Results from the body's failure to produce insulin, and presently requires the patient to receive injected insulin. (aka as insulin-dependent diabetes mellitus - IDDM for short, aka juvenile diabetes.) This is not obesity dependent, may be due to a genetic mutation in the insulin gene and leads to a lack of insulin production. This is the typical form of diabetes in dogs.

- Type 2 diabetes: Results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. This form was formerly referred to as non-insulin-dependent diabetes mellitus (NIDDM for short) and aka adult-onset diabetes. This is the typical form of diabetes in cats.

- Gestational diabetes: Occurs when pregnant females, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM. This is not generally an animal problem, but has been reported in both cats and dogs.

Also recognized minor form; Maturity onset diabetes of the young (MODY): Refers to any of several hereditary forms of diabetes caused by mutations in an autosomal dominant gene (inherited from either parent) disrupting insulin production. There are currently 11 recognized forms in humans. Research has not found these in pets yet due to financial limitations.

Diabetes mellitus (latin for “Honey-Sweet “) The signs most associated with this form of diabetes are increased water intake (polydipsia), increased urination (polyuria) – together referred to as “PU/PD”, and increased hunger (polyphagia). Clinically, the patient can gain weight, lose weight, become lethargic and often physically looks “rough” with ungroomed haircoat, flaky skin and tires easily. The medical risk to the patient is metabolic meltdown while scrambling to use fat as an energy source alternative (diabetic ketoacidosis), uncontrolled dehydration from the high blood sugar resulting when high urine sugar “sucks the water out of the patient”, bacterial infections of the urinary tract, generalized infection and a toxic affect on the nerves (diabetic neuropathy). In addition to the onset of various diseases, not limited to the list above, Type 2 diabetes mellitus is the most commonly recognized and is a rapidly expanded source of concern in pets, especially cats. It is often the result of insulin resistance, an earlier affect in obese pets and people and is known as metabolic syndrome. Insulin resistance often progresses to full Type 2 diabetes mellitus (T2DM). This is often seen when hyperglycemia develops after a meal, when pancreatic β-cells are unable to produce sufficient insulin to maintain normal blood sugar levels (euglycemia) in the face of insulin resistance. The inability of the βeta-cells to produce sufficient insulin in a condition of hyperglycemia is what characterizes the transition from insulin resistance to Type 2 diabetes mellitus. At the cellular level, excessive circulating insulin appears to be a contributor to insulin resistance via down-regulation of insulin receptors. This down- regulation occurs due to prolonged and repeated elevations of circulating insulin. As the pathological overproduction of insulin is relatively rare in individuals with normal fat

cells, it is more likely the cause of the insulin resistance associated with repetitive hypoglycemia and type 2 diabetes and sustained increases in blood glucose. T2DM patient daily Mg administration, restoring a more appropriate intracellular Mg concentration, contributes to improve insulin-mediated glucose uptake in humans. Whether this applies to cats and dogs is open for investigation and is not yet in use.

Diabetes Treatment:

The mainstay of all diabetics care is exercise, diet, weight control and insulin replacement. Without lean body mass, insulin resistance and all the other risk factors persist, even if blood sugar is controlled. Exercise acts to combat the hormonal affects of overfilled adipocytes through release of proteins from skeletal muscle that combat their negative health effects through mechanisms not well understood yet.

Diet

Feeding regimens are the first place to start when addressing obesity. Two or three small meals a day, rather than free-choice feeding (keeping a full bowl), allows the body to utilize calories more efficiently and store less fat. Table scraps tend to be high in fats and salt. They are often given in addition to the pet’s regular diet that already contains an adequate number of calories for energy. REMEMBER THAT A DIET CHANGE IS ALSO AN INSULIN ACTIVITY CHANGE.

The single greatest misconception in clients’ efforts to control weight is summed up by the unavoidable question of “Since I feed one (or two or three) cups (or cans) of food, how much should I cut it down. The problem is that all foods have different density of calories as derived from fat, sugar and carbohydrate content. Fiber type and concentration and digestibility (bioavailability), feeding schedules and snacks are also key factors in calories stored or used. Breed, age, gender and reproductive or growth stage will also influence calorie needs. Ekanuba light® is higher in fat density that Purina growth® formula. There is no truth in labels on pet food, unlike the requirements by the FDA for our food. The short answer for all is either simple – less food than you are feeding now, or more a more scientific approach.

1. Simple format first: Stop fatty (meat types for dogs) and carbohydrate snacks for cats and dogs. Dogs: Replace snack cookies and doggy snausages with green beans, squash slices, broccoli and carrot slices for dogs. They are natural omnivores and can (and will) eat all 5 of our human food groups. Feed 25% less food volume and replace the difference with pet vitamins, minerals, veggies and soluble fiber (instant oatmeal). Add instant oatmeal at 2oz for those up to 20 pounds, 4 oz for dogs up to 60 lbs and 8 oz for those heavier than this. No raisins (toxic), brown sugar (calories) or nuts (fat). Plain oats or unflavored canned pumpkin mixed with hot water or low salt broth and glopped onto the morning meal will slow down carbohydrate use and is filling. These are soluble fiber sources. A big bonus is that soluble fibers trap bile along with triglycerides and cholesterol for elimination in the feces. Insoluble fiber, like brans/fruit skin and root vegetable skins) bind up critical vitamins and minerals and are used mostly for temporary conditions like constipation.

Cats: These carnivores should be fed a lower volume of a grain free, high quality meat diet because cats have NO MECHANISM for carbohydrate processing. Cats stay hyperglycemic for 5-6 hours after a meal with grains or sugars (standard cat kibble or cookie type snacks). Most commercial foods have grain as filler. All kibbles use glutens and grain starches to hold their shape during processing and shipping. These are really CHEAP FILLERS for cats and not part of their natural diet. Innova® canned. Blue Buffalo®, Wellness® brand and Evo® (canned and kibble) are better than most all other choices (Pet’s Naturally in Sherman Oaks and Petsdirect.com can be helpful). Feed only that amount that can be eaten in two hrs twice daily. Any extra is not eaten due to hunger. It is important to not cause weight loss too quickly. Starvation is not the answer to obesity. Cats cannot metabolize fat rapidly without serious ill-effects. Check with a veterinarian to establish an ideal weight and timeline for weight loss. Cats may develop a serious condition called Fatty Liver Syndrome if forced to lose weight too quickly.

OR: Veterinary Rx diets. The problem of obesity and associated pet disease is so common that the scientific pet food companies have developed specific Rx diets for these patients. SOVG offers multiple Rx diet choices for pets including W/D, O/M, M/D, D/M for both cats and dogs (canned and kibbles). R/D (in prepackaged meal portions) is an option but has twice the carbohydrates of D/M and M/D. A prescription drug called Slentrol® is now also available to assist in pet weight loss success. Speak to our desk about these choices.

2. Scientific Option

Use a predetermined chart for your pets’ needs and then calculate from the food what is correct. Good general dog guidelines for choices are as follows (dry food basis): Protein - 16% Fat - 7-15% (fat vs thin dog wt)

Fiber - 9-10 The table shows the daily calorie requirements for dogs in a variety of situations - indoor dogs, outdoor dogs, working dogs, and very high activity dogs. It includes the calories per lb of body weight. Use the "Inside" column for your average dog (activity punctuated by rest)

2.2 64 141 130 * N/A

4.4 53 233 211 * N/A

5.0 50 250 225 * N/A

5.5 49 269 242 * N/A

Wt Kcal/ lb Inside Outside Herding Working

6.0 48

6.5 47

7.0 46

7.5 45

8.0 44

9.0 43

288 258

305 273

322 287

337 300

352 312

387 342

* N/A

* N/A

* N/A

* N/A

432 N/A

477 N/A

10.0 42 420 370 520 N/A

11.0 41

12.0 40

13.5 39

15.0 38

16.5 37

18.0 36

20.0 35

22.0 34

25.0 33

28.5 32

30.0 31

32.0 31

36.0 30

40.0 29

44.0 28

50.0 27

451 396

480 420

526 459

570 495

610 528

648 558

700 600

748 638

825 700

912 770

930 *

992 832

1080 900

1160 1000

1232 1100

1350 1250

561 N/A

600 N/A

661 N/A

702 758

775 858

828 918

900 990

968 1065

1075 1182

1197 1317

* *

1312 1443

1440 1584

1560 1740

1672 1850

1850 2075

57.0 26

66.0 25

88.0 24

118.0 24

150.0 24

1482 *

1650 *

2112 *

2832 *

3600 *

2052 2297

2310 2601

2992 3361

3894 4431

4800 5580

Cats: (these are minimum levels for can food – reduce stats by 25% for dry wt ) Protein... 30% (> 10 g/100 kcal or > 45%ME) Fat ...... 9% Calcium.... 0.6% Phosphorus... 0.5% Taurine... 0.1% Thiamine... 5 mg/kg Choline..... 2400 mg/kg Carbs.......low as possible

Feed no more than 180-200 kcal/day to the average sized cat (less if they are gaining wt, more if they are too thin or pregnant)

Remember that you are the keeper of all foods and menu selections at home. Your pet’s weight is a direct outcome of your actions and choices. Our pets will live longer and happier lives as a result of you maintaining a lean weight for them. Your pocket will not be financially as stressed and any health challenge will be more easily treated.

Medical Treatment:

Insulin-

Although insulin is made by the pancreas in all higher vertebrates, they are similar protein molecules, but NOT identical. The amino acid sequence of the species-specific protein dictates which form works best for each pet species insulin cell receptors at a molecular level when injected as a supplement or replacement. Until the past year, over a dozen types of insulin were available. Dogs are identical to pig insulin and most similar to humans, while cats respond better to the beef insulin amino acid sequence. Currently, the human market is 99% of insulin sales and only two vet products are manufactured: Pro-Zinc® (90% beef + 10% pork) for cats and Vetsulin® (pork based) for dogs. Fortunately, both species can respond to human recombinant insulin forms. There are a variety of human insulins which vary in duration of activity. Most pets will require a subcutaneous injection of insulin every 12 hrs for the remainder of their lives to function normally. Dogs are often started on Humulin-NPH®, while cats never exposed to insulin prior to the current program can be given human

Glargine® with some reasonable expectation of healing the pancreas and recovering

from Type 2 diabetes mellitus. Be aware that insulins come in two concentrations- U100 and U40. The U100 is generally human form and more concentrated while the vet forms are U40 and more dilute to be able to dose smaller patients. IT IS CRITICAL that owners purchase the CORRECT U100 or U40 SYRINGES for each different type of insulin or severe dose problems will occur.

Treatment Plan:

1. Patients are initially estimated as to their insulin needs based on blood sugar levels and body weight. Food must be offered and taken within 1 hour before or after each dose of insulin for it to work correctly. Blood sugar levels are taken 3- 4 days later at the most active insulin time, aka the nadir (generally 4-8 hrs after the morning injection) as an outpatient check. It is standard to conduct urinary culture screens and general blood panels to uncover other problems associated with diabetes.

2. Patients that are stable are continued at the current dose for 2 weeks and then a day-long glucose curve is conducted to document the insulin affect on the body. A fructosamine sugar level is also taken to evaluate the two week long blood sugar average. Patients that are found to be stabilized are kept on the same dose and rechecked at one month and then every 3-4 months for blood glucose (BG) curves and fructosamine levels.

3. Cats on Glargine® that are found to be normal to below normal BG have their doses reduced and rechecked monthly for an average of 4 months until they, hopefully, no longer require insulin.

4. Dogs and cats not found to be improved will have their insulin doses moved up or down, accordingly. BG levels are taken at 72 hour intervals until stabilization. Then the two week trial is started for fructosamine level assessment. Once water consumption and urination returns to normal and agrees with control via normal fructosamine and BG curves, the patient will be able to have 3-4 month rechecks.

Note: Home Glucose Monitoring: This is very beneficial for both the patient and veterinarian. Most pets stress to some degree while either enroute or staying at the clinic for a day long glucose curve. This releases epinephrine and norepinepherine (aka “adrenaline”) which drives up glucose release. The end result is that the patient is often adjusted for conditions at the clinic, not necessarily at home. This is especially true for nervous cats. A home glucose curve with blood taken every 2 hours for the 12 hours before and after the two consecutive insulin injections is very informative. Accuracy depends on how cooperative the patient is and the quality of the home glucometer. Most specialists will recommend the One Touch Ultra® model available at drugstores. It is fairly inexpensive, but the refill strips can be a bit pricey. They are still cheaper than 4-5 glucose curves at the clinic. There are dozens of other models, but these are often not user friendly or have severe inaccuracies when the glucose is very low or very high. Since these are critical blood value readings, saving a few bucks just to get good normal readings alone does not make

sound financial or medical sense. A diabetic crisis could cost up to $1000.00 if the wrong dose of insulin is chosen with a cheap glucometer. Blood samples should be taken from a reusable site, such as an ear margin or leg, not a sensitive area, like toe pads or lips.

Insulin Problems: MOST DIABETICS GET INTO TROUBLE DUE TO INSULIN RELATED PROBLEMS, due to owner oversight, not due to shifts in the disease or insulin dose changing.

- Giving the insulin too early or too late in the day. - Giving too little or too much. Both owners may not be aware the other already

gave a dose earlier or large bubbles change actual amount of insulin given. - Vetsulin® vial not rolled to mix the insulin properly. Human recombinants do

NOT need to be mixed. - Wrong needle type for insulin. - Insulin left out of refrigerator too long. - Patient not fed OR did not eat at time of insulin. There is no new sugar in blood

for insulin to push into body cells here.

Insulin Crisis:

In the event that too much insulin is given, the patient refuses to eat, or is sick from other diseases, the BG may drop too low. Once BG is below 40 mg%, the brain is deprived of sugar and ceases to function properly. The patient will appear “dopey” or drunk, may fall over or walk with a weave from side-to-side (ataxia) or even go into convulsions.

The immediate solution is to add sugar to the blood stream asap. Oral doses of Karo® syrup (this is sterile corn syrup) under the tongue will boost sugar levels in a few minutes. Pancake syrup, agave syrup and honey are substitutes that can be used. Note: Honey is known to carry bacterial spores that are potentially harmful in infants and compromised patients. ALL HONEY USED SHOULD BE PASTEURIZED.

The next step is to get the patient to the clinic or emergency service ASAP for BG testing and/or seizure control until the crisis is passed.

Ketoacidosis crisis- Diabetic patients in prolonged and elevated BG crisis will shift their basic metabolism from a sugar-based cell energy system to a fat-based metabolism. This is very hard on the body, especially the liver. The end result is a by toxic product called ketones. These diabetic ketoacidosis (DKA) patients must be handled as intensive care hospital patients until the metabolism can be shifted back to sugar use status. This is life-threatening and may take 8 hours to a couple of days in different patients.

Glucophagic Drugs:

Type 2 DM patients (cats), especially with insulin resistance, can sometimes benefit from drugs that upregulate the expression (production) of insulin receptors on cell surfaces. Despite a number of these available to humans (over 40 types), vet patients have the option of an oral drug called glipizide (Glucotrol®). This can regulate a minority of cats without insulin, but is more often used as an adjunct therapy with insulin when doses in

insulin resistant patients get too high. In addition to tablets, this drug can be compounded into a cat friendly flavor or a paste for application to the ear. There are no tests currently available to determine if this could be beneficial.