Hello, my name is Georgia Woodsley, and thank you very much for joining me for this session, Comorbidity, balancing Multiple Nutritional Needs for Patients with Obesity. We'll start the session by thinking about whether it's ever possible to have a one size fits all plan when it comes to obesity, or whether actually we should be thinking or considering something a little bit more made to measure. We will therefore be then thinking about the obesity paradox and how this may influence our obesity care plan.
And then we'll look at the different elements of individualization and the benefits of doing this. We'll then move on to thinking about some specific cases where our patients have a comorbidity. We'll think about cases where the comorbidity causes the obesity in inverted commas.
We'll think about cases where the obesity causes the comorbidity. And then we will finally think about cases where obesity and the comorbidity are not linked, but you still do have to manage those two conditions concurrently, balancing the needs carefully for both. So can we ever have a one plan fits them all?
Is there a standard obesity care plan, this kind of cookie cutter factory produced plan that is going to be suitable for all of them? On the face of it, it might appear so because we have to identify obesity in all our cases. We need to do a nutritional assessments.
We need to do a physical assessment, and then we need to give a dietary recommendation. Now here's where things are going to get different because that dietary recommendation may not be the same for every patient. Similarly, that standard plan for monitoring might be different for each patient.
It may not be standard. And finally, a standard maintenance plan again, we possibly don't have a standard. So although it might feel like we can roll out our normal obesity care plans and rub our hands together and think job done.
In fact, as we'll see throughout this session, we need to be very much more specific and being aware that we need to have something much more tailored for each individual. So every case of obesity will be different to a smaller or larger extent, and this is because we are going to have to think about the different patient factors, their motivations, their likes, their dislikes, their routines. We'll have to think about owner factors and we'll have to think about environmental factors.
We will also have to think about the cases where we have one or more conditions going on, and in the presence of comorbidities, how are we going to balance the needs of both of those conditions. So comorbidities are actually pretty common, so you are going to be seeing these cases in your clinics. At the weight management clinic at the University of Liverpool, 84% of our dogs and 73% of our cats have another condition that is concurrent with their obesity, and you can see from the stats here the sort of things that we are commonly seeing.
So for dogs, by far the most common thing we see alongside obesity is orthopaedic disease, but we do also see things like cardio respiratory problems, dermatological problems, and so on. For cats, it's actually elementary issues that are most commonly appearing alongside the obesity, but again, we do see orthopaedic disease and dermatological disease is also pretty common. So there are going to be many cases where you will need to balance the needs for all of these conditions.
So to give you an idea of the things that we are typically seeing, these are just some of my patients that over the years we have discovered have a comorbidity of some sort. So we have Alf, he had neoplasia. We've got Sio here with neurological deficits.
Ollie had Boas syndrome. Charlie unsurprisingly had osteoarthritis and then we picked up renal disease, cardiac disease, Cushing's, hyperthyroidism, disc disease, dermatitis, and some really rare diseases such as Leora's disease. Cats in a similar way.
We've seen many different cases over the years that have a comorbidity. We had Eli with diabetes mellitus. Polly had hepathic lipiddosis.
Poor little Ollie down the bottom here not only had urinary disease but also had diabetes mellitus. So alongside his obesity we then are juggling three different diseases. Again, dermatological disease, liver disease, chronic kidney disease, and cardiac disease, and these are just some of the examples of cases that you may well be seeing in your clinics also.
Then we should consider how the age of our patients affects what we would maybe be recommending to them. If we think about juveniles first of all, we know that a high percentage or much higher than we would like certainly of juvenile cats and dogs do have obesity. This is Mabel.
She is only 9 months old and as you can see, I'm sure from her picture, she already has a degree of overweight and actually we will need to be. Supporting her growth, using the growth charts to map and track her growth, and really waiting until skeletal maturity before we can actually deal with that excess weight, because we don't want to, we don't want to affect her growth. And so monitoring is key for these patients that are still in their growth phase, but now also have obesity.
We then want to think about the other end of the scale. What about our seniors? And again at the weight management clinic, 37% roughly of our patients would be considered senior.
And so we've got Tuckery here at 17 years old. We have Paddy here at 12 years old. These are quite common for us also.
So interestingly, of course, with our seniors they are more likely to have a comorbidity. Something is more likely to have gone wrong as the body ages, so we've got current things, but we also need to think that in the future comorbidity is quite likely. And so again, we want to keep a close eye on these individuals.
Then we have to factor in age-related changes, so things like sarcopenia, which is age-related muscle mass loss. Now that is going to be very normal as our pets age, but it can be quite hidden by the obesity. So unless we are checking for it, we don't know that it's happening or to what degree.
So an interesting thing to just be aware of. And then we also see as cats age, their digestive capacity. Reduces, so thinking about our dietary recommendation there, and they have a reduction, both dogs and cats in their sense acuity.
So things like sense of taste and sense of smell do diminish as pets age. And is that going to affect the food acceptance if we are looking for a dietary change? Would we want to be doing a dietary transition a little more gradually in our real seniors just to help them accept their food?
So lots of considerations based on age alone. So this is where we really have to think about individualised obesity care for every single one of our patients. There isn't unfortunately a standard obesity case and therefore we can't have a standard obesity care plan.
Although many elements may be similar, we want to be very aware of what we want to achieve for these. Individuals, so I always think it's good to have a list of aims. So we want a plan that is specific to the individual needs.
We want precise weight loss aims. What do we want to do? Do we want to improve mobility?
Do we want to improve quality of life? Do we want to allow that dog to jump in the car again? Be precise with your aims.
And that's when we then need to think about that tailored dietary recommendation. We may also think about adjusted targets for these individuals, and I'll come to that in a moment. We may also need to think about further testing for these individuals because they may well have other things going on.
And whereas it wouldn't be appropriate to test a 3 year old, it might well be appropriate to test a 13-year-old for certain conditions. And then we should also consider whether we need to adjust the monitoring schedule. Are we being considerate to the pet's needs?
How much support is that owner going to need? And again, this is going to be different for every single case. So let's think about precise weight loss aims.
So the first thing of course, we need to consider is the benefits of complete weight loss, and by complete I mean returning them back to an ideal weight. And the studies show us that if we have our pets at an ideal weight, they will live longer. Therefore, if they have a degree of overweight or obesity, their longevity is likely to be shorter.
The other reason for thinking about returning these individuals to their ideal weight is to avoid disease and managing all of those risks that they will be prone to in that overweight or obese status and of course broadly for every patient we'd be thinking about improving quality of life. But for some cases, and again I'll discuss this shortly, it may not be appropriate to return that pet to its ideal weight. It can get to get that complete amount of weight loss that we desire, and in actual fact, partial weight losses may be just as beneficial and in fact might be more appropriate for our case.
So rather than thinking about having to climb up the whole mountain before we reach our end goal, what about having places along the way where we could consider stopping? So when we think about partial weight losses, we think about improving quality of life. That's certainly on our list.
We think about improving function, probably mobility function, the ability to run, the ability to jump, and so on. And also then we'll be thinking about reducing the impact of the obesity or the comorbidity or both that is currently ongoing in that patient. And really importantly, and you'll see why shortly, we will be thinking about partial weight loss to preserve lean body mass.
Now why am I talking about lean body mass? Surely in an obesity lecture we'd be thinking about fat mass. Well, we must think about lean body mass as well because of the obesity paradox.
So the obesity paradox is a theoretical model that was first developed in humans, and what the theory suggests is those humans with an increased BMI and therefore have increased amounts of adipose tissue, when they have a chronic wasting disease such as cardiac disease, renal disease, cancer, or diabetes. If they have that increased BMI, their survival of those diseases is better. And if we think about it, that kind of makes sense because if you have a time in your life where you may not want to eat very much, you have body fat reserves to rely upon.
Also, if you have got good muscle mass and your body has not needed to use your muscle as an energy source, again, you would imagine that that is beneficial to you. So what was found in all the studies that looked at this was that it is actually the lean mass that is key alongside having some spare adipose tissue to rely upon. So it's both of these things together and that's why we are talking about it.
And it's because of this cachexic effect. So cachexia, in contrast to sarcopenia, is the loss of lean mass that is associated with wasting diseases. So when you have renal disease or diabetes, cancer, and so on, your body is put into a state where it will break down not only body fat mass for energy, but also start breaking down your lean mass.
And so preserving lean mass and having some adipose tissue. Is shown to equal better survival. So that's really interesting because this is now suggesting that a degree of overweight or not obesity but certainly overweight is beneficial should you get one of these diseases.
But what about in cats and dogs? Well, really interestingly, a similar findings were found. So there are studies looking at chronic kidney disease and survival and also heart failure and again looking at survival, but diabetes, renal disease, heart failure, and cancer.
Thought to be very similar. Again, these studies highlighted the key element being maintenance of lean body mass, so making sure that the body has got a fat store to break down for energy, not having to go to that muscles, and breaking that down as an energy source. Because this is so relevant in terms of our patients, if they have a chronic wasting disease, but also as they age, because if we think about it, those diseases are much more common in our seniors, muscle condition scoring becomes a vital part of that overall assessment that we should be doing.
WSABA have great resource on muscle condition scoring. And I think now we are all much, much better at body condition scoring. Muscle condition scoring is still getting a little bit left behind, so I'd really encourage everybody to try and have a go at muscle condition scoring every patient.
The reason for doing this is because when we see muscle loss, we of course get loss of strength in that limb. But we also see impaired immunity, impaired wound healing, and increased morbidity and mortality. So we really do need to know and understand if our patient is losing lean mass and muscle mass.
So I've got a quick video here just to show you in a moment how to muscle condition score a dog, and of course you would apply very similar principles if your body condition scoring a cat. Comparing this as we go through this video with this highlighted image on the left hand side here. So what you will see me doing is palpating the skull first of all.
Then I'll be moving to the spine and then to the scapula and then to the wings of the ilia. I'm feeling for bony prominences and judging how much muscle mass is either side of all of them. So as you can see, starting at the skull here, I'm feeling for that crest on top of the head.
I'm then feeling in those eye sockets, moving then down to the spine, feeling over the scapula, feeling for that scapular ridge, and then feeling down those spinal prominences. I like to rock back into like that so I can judge that muscle mass either side, then feeling for the wings of the ilia. I usually also like to have a good feel of the hind limb, and in this case, you don't need to feel.
You can see how well muscled this dog is in a very hairy breed, of course, you would need to get your hands on and feel for that muscle mass back there. And the more you do this, the more comfortable you will get with what normal feels like. And of course that's really important to understand what normal is, so that then we can feel immediately when we've got something abnormal.
Now just looking at pictures, it's a little bit more difficult, but I can highlight some places here for you on Alf that does sadly show severe muscle loss in his case. So looking first at that eye socket, you can see it's quite sunken. That tissue that should be there on the skull is now lacking.
Similarly, on the top of his head, we've got this very prominent crest. Now that's normal in some dogs, but it's not normal to be not associated with good muscle mass either side, and on palpation, you can't feel any muscle. It's just straight to the skull.
When you feel down his scapula, you can feel that crest very, very prominently again suggesting we are lacking muscle mass in that area and you can see his spine in this case. We've lost the muscle mass almost completely either side, so those bony prominences. Sticking through.
And I always feel like they're almost hanging off their spine when they have severe muscle loss in this way. It kind of, that's what it looks like to me. And again, you can see this muscle mass on the back leg isn't normal.
It's not what we'd expect to see there. So assessing muscle mass and lean tissue mass is really important in these cases and more so because you can have age-related sarcopenia, disease-related achexia, and obesity all in the same patient. So you need to go looking for it.
So how on earth do we try and maintain lean mass while we are also getting weight loss, such as in an individual like Barney here? How are we going to do it? Well, the majority of the initial amounts of weight lost when we do a weight loss plan is fat mass, and we get very little amount of lean mass loss in the 1st 20%.
The problem is when a dog or cat has got a lot to lose, the more weight they have to lose or they do lose, the more lean mass is lost. So we've kind of got a continuum. So we for these cases when they are senior or when they have a chronic wasting disease or both, we think about stopping their weight loss at around 15 to 20% down from where they started, and this is really to avoid that lean mass loss.
So we have here a dog that is a body condition score 9 out of 9. It means he's got 40% of his weight to lose. And so let's just see what is actually happening to describe this point a little better for you.
So we can see here that if we break this weight loss up, he's got 40% to lose in the 1st 10%, it is all fat mass, and that's what we'd expect in the next 10%, so up to 20% of fat of weight loss, again, we predominantly got just fat mass. After 20%, we now start to get more and more lean loss, although yes, we are still losing fat mass, we are now losing lean mass also. And so this is why for these patients we stop them at 15-20%.
We want them to have enough fat loss to make them feel better, to improve their quality of life, do all those partial weight loss benefits, but not put them in a detrimental place or a detrimental state by losing this lean mass. So thinking about that obesity paradox and just how key lean mass is for long term survival. The good news is in terms of partial weight loss is that we don't have to actually wait until we've reached that 15 to 20% to see benefits.
This study in particular highlights really nicely the benefits of small amounts of weight loss, and just 6 to 9% of weight loss showed noticeable physical benefits of that. Weight loss to the individual, particularly to mobility. So if we have a dog with arthritis, at the very least, let's get them to lose 6 to 9%.
Let's make them feel better, you know, we may not want any more weight loss than that, and this is where your judgement and your individualised recommendations are going to come in. So let's have a look at some specific cases. So our first type of case is going to be cases where the comorbidity, the thing that's going on alongside, is actually somehow the cause of obesity or is part of that picture.
And let's just think about the causes of obesity just for a moment, because I think the moment we do, most people start pointing the finger at the owner. They must be feeding too much, feeding too many treats, and so on. So yes, we do of course have pet owner factors that play a part here, but that isn't the only factor.
We also think about causes in terms of genetics. We think about it in terms of the environment, who they live with, what other pets live in the house, and so on. Then we think about it in terms of diseases, which we'll come back to.
We think about it maybe in terms of different drugs causing an issue and increasing appetite. And then of course we've got the pet's own factors. What are their motivations?
What are their desires, their preferences, and so on. So let's think about diseases. Well, hyperthyroidism is hopefully the one that sprang to your mind.
And this is because hyperthyroidism is often kind of blamed for causing weight gain. And in all honesty, if they do have an underactive thyroid, then they probably do have a degree of overweight because their metabolism is very, very low. Weight loss is extremely difficult, and so this is one of the, one of the situations, one of the other diseases where we are going to get obesity, resulting.
However, I think it's not to overstate how often this happens because prevalence is way, way lower than I think a lot of people perceive. In fact, in dogs as a population as a whole, only up to 0.8% of dogs are thought to have an underactive thyroid.
So actually it's really, really rare. At our clinic at the weight management clinic at Liverpool, we have a referral population, so these are probably some of the most extreme, some of the most difficult, and probably ones that have failed in their weight loss previously, and we still only have very, very low amounts, so only 14 dogs out of nearly 500, as you can see, genuinely had. An underactive thyroid.
So although we may always test for it because we do have this more difficult population to deal with, I wouldn't go wasting an owner's money immediately on thyroid tests because it is very rare in essence. Let's have a think about this case. So this handsome fella here, this is Jackson.
So Jackson is an Alaskan malamute cross chow, never seen one before. Very handsome devil he is. He's 8 years old.
He is described as lethargic and quite exercise intolerant, and I met him when he was 58 kg. So what did we do? We have a standardised workup that we do for all our patients to make sure that we are gathering every piece of information that we need.
We do a nutritional assessment which includes pre-appointment questionnaires, more questions within the consultation. Then we of course also do a physical examination and review of their history. And what we found for Jackson was that he has a history of osteoarthritis, so weight loss is going to be really beneficial for him, particularly in terms of pain reduction and mobility.
So we knew that pretty quickly. We then also as a standard, do biochemistry, haematology, and test the thyroid function. And it was a bit of a surprise to us because we weren't necessarily anticipating it, but Jackson's thyroid levels did come back as low.
So he is one of those examples of just a very small minority where we do find hyperthyroidism to be an issue. And so what we are looking for for Jackson is a partial weight loss plan because of his age. So what is that going to look like?
Well, we are going to need a dietary modification. We need to put him on a therapeutic diet, something that's suitable to get weight loss for. We then needed to identify what his ideal weight should be, and in Jackson's case this was 33 kg.
However, we determined that partial weight loss because of his age, we don't want him to lose any more lean mass than he may already be losing as he ages, so we set a target weight for him of 43 kg, and of course he was going to need thyroid hormone replacement medication. So our big aims for Jackson one, we needed to reduce his weight because this osteoarthritis will benefit hugely. We needed to correct those thyroid levels and of course that will make weight loss a lot easier for him.
We wanted to improve mobility and we wanted to improve his quality of life. Happily, I can share with you that Jackson actually did extremely well. And just a few months later, we can see him here at 42 kg.
Yeah, he's had a good haircut, but I assure you this was a huge amount of weight loss for him. You can see in his body shape, his stance, and, and so on, how beneficial this actually was for him. So he actually ended up losing 28%.
Excuse me. Of his starting weight, and that was the combination of, not only thyroid replacement therapy, but that weight loss diet also. It's a very successful case, and we've not left him in a detrimental position for the future should something else go wrong.
So, we were very happy with this. One of the other things that people often talk about is the cause of obesity due to various drugs. Oh, it's because he has been on steroids or the steroids have been to blame.
It wasn't me, it was them. They were the things that caused the obesity. And so what we need to educate owners before we start these types of medications, so steroids and antiepilepsy medications, is that both of these will increase appetite.
They don't make the pet gain weight, but They do increase appetite. Increased appetite means more food seeking behaviours. That means that when they are doing it more, they are going to be generally a little bit more successful.
They are going to raid the bin. They are going to break into shopping bags and bags of food. They are going to be eliciting extra treats from their owners, and it's that higher calorie intake, of course, that then leads to the obesity.
So it's still in essence. Taking in too many calories, it's just the underlying mechanism is this increased appetite. It's not the actual drug itself that is causing us the issue.
Worth considering. OK, what about cases where the obesity kind of causes the comorbidity or certainly is associated with the comorbidity? Now you will read many studies.
These are just 3 listings prevalence and risk factors of having obesity, and we know that there are many, many things on those lists of risks when it comes to these cases. I wanted to look at two specific ones though, with you, because I think these are common, and hopefully this will help you deal with them when you see them in your clinics also. So the first one is orthopaedic disease, and then we will think about respiratory disease.
So to think about orthopaedic disease, I wanted to introduce Romeo to you. So when you are presented with a dog with orthopaedic disease, we should probably ask ourselves firstly, will weight loss be beneficial? For me?
Yes, absolutely it will be. Then we should ask ourselves when should we start the weight loss because is surgery due? Are we trying to avoid surgery, where are we in terms of the timings?
Then we'll need to think about the adjustments that you may need to make to the plan. How much weight loss is actually necessary. And there's that study again saying that 6 to 9% of weight losses will display noticeable physical benefit to those with mobility issues.
So for me, I'd be thinking about at least 6 to 9% for these cases. So when I met Romeo, he was 7 years old. He had elbow dysplasia, I'm really poor, quite poor mobility as a result of that.
He weighed 42 kg and so kind of unsurprising those joints are carrying around a mass, a weight that they are not designed to. So of course they're going to be under a lot of pressure and inflammation as a result. So again, we did our work up with Romeo.
We did our full nutritional and physical assessment, and of course we we discovered this severe elbow OA, which we, which we suspected anyway. We did routine bloods as we would do normally. Now I'm not suggesting that if Romeo came to you in clinic, you should do all these bloods straight away.
This It is much more because we are a referral clinic that we do this, and 9 times out of 10, nothing comes up on them. But just occasionally, as we saw with Jackson, it does. So that's why we always test.
Think carefully about where your owner's money is best spent. Initially, if there's nothing else going on that you're worried about, tests may not be, essential. So we need a weight loss plan for Romeo.
We will need dietary modification, and because he, has so restricted mobility, we would probably want a heavier calorie restriction than we would normally give. So what we do is we reduce the portion by an additional 5%. That's well within safe limits, but that's so that we can ensure that we get good weight loss for this dog.
So 42 kgs currently we said that his ideal weight really should be 33 kg and if we can possibly do this prior to surgery, we are going to make that surgeon's job and life a lot easier by doing that. So when we think about our When we think about our priorities, we've got to reduce the weight, reduce the surgical risks, improve his mobility, and improve his quality of life. So there is no better way to compare the benefits of weight loss than with videos.
So this is Romeo when I first met him, and what we do is we record all our patients walking up and down this corridor. There he is. It's kind of hard work for him to trot like this.
You can sort of see that slightly abnormal gait, low head carriage. When he comes back towards you, you'll see a little bit of head bobbing. Come on, mate, you're all right.
You can do it. There we go. He's trying, but you can see that there is generalised lameness there.
Compare that to what happened after weight loss, and there we can see him. Trotting down the corridor with so much ease, so much more energy, yes, he's still lame blessing we can't take that joint disease away. But look at the improvements to his mobility.
Head carriage is much higher. He's finding trotting so much easier now. This was a wonderful result for Romeo.
So when we have these cases, we need to think carefully about the benefits, whether it's elbow disease, cruciate disease, and so on. And so Romeo did end up at 33 kg just as we had hoped, and that was a 22% weight loss. So really nice weight loss for him, and you can see by his DEXA scan pitch is also just loss of body fat mass all over.
OK, moving on to our respiratory cases. Now you will see many of these brachycephalics in practise. I'm very, very sure because in years gone by they weren't so popular.
Now they are super, super popular and so respiratory disease is going to be a really common comorbidity. So when we think about respiratory disease, we think about things like tracheal collapse, of course Boass for these for these brachycephalics, and just take a look at Bella's nose there, just how closed those naaries actually are, so synoptic nerves. Are really, really common, very long, soft palates, laryngeal collapse.
These all go as part of the syndrome and enlarged tonsils and hypoplastic tracheas also. So we know that brachycephalics have an issue here. In years gone by, the wait clinic at least, we would have predominantly seen Labradors.
But if we look at some data from Banfield Hospital, this is in the US, and the types of breeds that they are seeing coming through with overweight, you can see that Perg and English bulldog are top of the list, and I would also agree. So rather than Labradors coming through my door, I see pug after pug after pug. They are very, very common, and of course we have this horrible mix of obesity and boas, and you can see here actually Labrador coming much, much further down in terms of popularity and obesity.
So what are we going to do with this patient with Bella? So Bella is an entire female and she had Bella, and what they were hoping to do when they referred her to us. It was to avoid the need for boA surgery.
It's a tall order, I think, but that was what they were hoping. So our work up again was done, our assessments, both nutritional and physical, and we discovered that, you know, she snores and surprisingly, and me, she's quite lethargic, and we're getting some regurgitation. So really classic signs of that Bresyndrome.
Blood showed us nothing abnormal and so we needed a weight loss plan for her. We needed dietary modification. That was going to be a weight loss diet because we really need to significantly reduce that neck fat.
All that additional fat mass around that trachea pressing on it, making this respiratory disease worse, and we either needed to put her in a better position for surgical intervention or if it was at all possible avoid surgery. So we determined her ideal weight should be 7.6 kg.
That's a big drop. So for Bella, we needed to reduce the weight. Reduce surgical risks again, improve her respiratory effort, and let's get rid of that snoring if we can, and again improve her quality of life.
And a little time onwards. In fact, it was just over a year. Here is Bella now.
So she ended up at 7.3 kg in actual fact, so did slightly better even than we were asking for. And look at the amazing transformation.
The reduction in that body fat mass, particularly around her chest and around her neck. Now she's still a pug. She's still going to have the spare skin in that area, but the skin is very baggy.
It was, it was very free. Now it wasn't pressing down like it was in her when we first met her. So a really, really good result.
And actually what was an absolute bonus for Bella was it was then determined that this 35% of weight loss meant she didn't need the boa surgery. Her snoring disappeared. Her exercise intolerance disappeared.
And if we look at her scans, it's unsurprising, particularly in this neck region here you can see the reduction. In that body fat mass, but also look at her lung fields. Look how large they are now.
She can expand her lungs now she can get air in properly and so of course it's going to be really influential for her and even her abdomen, if we compare there again, you can see lots of Loss of abdominal body fat, meaning that breathing, is just going to be so much easier for her without all that pressure, within her chest. So, you know, when we see these boas cases, weight loss is just so vital if we're going to avoid any problems. So what about cases finally where we have obesity and something else, but they are actually not related in any way, so we have this unrelated comorbidity.
Well, one of the ones that we may see fairly commonly, because it's a very common disease, is something like chronic kidney disease. Chronic kidney disease is a primary killer in both cats and dogs, sadly. So as cats and dogs age, we need to have this on our thinking list in terms of what we may be worried about, never mind if they have obesity also.
So our questions again when we have this case will weight loss be beneficial? Well, I think always it's going to be beneficial. When should we start the weight loss?
Again, it's going to depend on the patient's condition, how stable they are, and so on. What adjustments to the plan will I need? This is where we really need to think carefully about the diets that we're using.
Now this study here, I don't have time to talk in depth too much about it, but this is very much supportive of that obesity paradox. And what this study describes is in terms of body weight and survival with cats with chronic kidney disease. And the short story is that those with the lowest body condition and the highest body condition have the shortest amounts of survival time.
And actually there is a sweet spot just with a small amount of overweight where survival seems to be at its best. So this again supports that theory that actually not removing all the reserves that this individual may have is beneficial not only in terms of improving their quality of life but not exacerbating their other disease that they've got going on. So this is something we need to think about.
So this is Ruby. Ruby, is 7.3 kg when we met her 9 years old, so is considered to be senior.
So what are we going to do with Ruby? So our standard workup, as we do with all our patients, we don't do thyroid for our cats because an underactive thyroid in cats is virtually unheard of. It's certainly not worth testing for.
But what our biochemistry and haematology bloods did show us was an elevated urea and creatinine. So warning bells are going off. We are now quite concerned about her kidney function.
So at this point we need to know more. We need to have a proper diagnosis of this chronic kidney disease, and we also need to do a staging of chronic kidney disease, which I'll talk about a little bit more in a moment. So we have a senior cat with a chronic wasting disease.
We know that the obesity paradox should be playing a part here. So we were looking at a partial weight loss plan that is going to include dietary modification because if we are going to get weight loss, we still need to do that safely, and I'll talk more about diet choice very shortly. One of the things though that we were certain about right from the start is that we wanted a lot of wet food in Ruby's recommendation, and this is really to make sure that we are keeping her nice and hydrated, that she's taking in sufficient amounts of fluid each day.
Cats with chronic kidney disease, as I'm sure you know, can be PUPD, and dehydration is going to exacerbate their condition. So Be really careful. Ruby's ideal weight was determined at 3.5 kg.
So once we'd identified that ideal weight, we then needed to think about, well, that's not going to be appropriate. What is our target weight going to be? So we set a target weight for her and some modest weight loss, 5.3 kg.
That's what we wanted her to be, to get all the benefits, but none of the negatives from weight. So, reduce her weight, preserve her lean body mass, so, so important. Prevent the progression of her disease, her CKD.
Of course, we don't want to make this worse, but we do, of course, want to improve her quality of life. But which diet? This is the difficult question, which I'll come to in a moment.
So chronic kidney disease should be staged, and the gold standard. In doing this is the iris staging system. All information for this can be found.
At iris.com and there's so much amazing information both for us as veterinary professionals but also for pet owners to help them understand this disease in their, in their pet. Now once we've identified the stage using serological parameters, we then go on and substage.
Sorry, looking at urine and also looking at blood pressure. So that's how staging occurs. Now there is actually a tool which is available now that if we are worried about one of our senior patients and if they may get chronic kidney disease in the near future, we now can predict the future, which is really cool, and it is this tool called Renal Detect that is hosted on the Royal Canon platform.
What renal detect allows you to do is put in serological parameters and urine specific gravity, and it will give you a risk. So it will say that this patient is not at risk of chronic kidney disease in the next year. They are at risk or they do actually.
Already have chronic kidney disease. And so this is a great addition to any senior clinics and I thought it would be worth mentioning because if we have a senior patient with obesity doing this, or using this tool, it could be very, very useful in terms of what's coming in the near future. The reason that we need to carefully consider what stage our patient is at is because at stage 2 kidney disease we need to start considering a change to a clinical renal diet.
So thinking about that carefully. So we've got stages 1 to 4, so in stage 2 we need to start thinking about it. So this is where we now have a dilemma.
What are we going to feed Ruby? So standard dietary management of chronic kidney disease determines we need a diet with low phosphorus and moderate amounts of protein to, and we all, we do that because protein is the main source of phosphorus. On the other hand, we've got standard dietary management of obesity.
This includes a high protein diet and high fibre. So of course now we've got conflicting elements within this diet. So what are we going to pick?
So the key with chronic kidney disease is controlling the phosphorus. So let's compare. Excuse me.
So we are going to compare mature diets with a weight loss diet, and I'm picking a mature diet because good mature diets should already have reduced amounts of phosphorus in them, and they do this to guard against chronic kidney disease in the future. So they are a lower phosphorus diet, not all, I hasten to stress, because some of them will be very, very similar to an adult diet, so you need to look for one. That has a lower phosphorus amount if that's what you want.
So in this diet we have 2.22 grammes of phosphorus per 1000 calories per mega cow, and we, when we feed a senior diet for a mature diet, we feed for weight maintenance. It's really important.
Let's compare that to this weight loss food. So here we have 3.72 grammes of phosphorus per 1000 calories per megacal, but we feed this food for weight loss.
Now, so what? What does that mean? Well, let's take a closer look.
When we feed our senior diets, we're feeding for maintenance and to maintain that cat's weight, we would need to feed her 217 calories. Let's compare that to what we do with our weight loss diet. So with our weight loss diet, we have to cut calories because we want them to lose weight and in this case, we'd be feeding 106 calories.
Now what does that do to the phosphorus? So in our mature diet, we then get us delivering phosphorus of 0.5 grammes per day.
That's what 217 calories is going to give us. What about the weight loss diet? Well, that's actually going to give us 0.4 grammes.
Now the reason for looking at this and considering this is because, because we are feeding a lower amount of a weight loss diet, we are actually not giving high amounts of phosphorus as it may appear just by looking at the label, and it's only through doing these calculations of nutrients per megacal can you actually work that out. I'm not going to go into it. This is to reassure you.
That for some of these cases, a weight loss diet can still be appropriate. The key thing is to maintain a serum phosphorus to under 1.5 millimoles per litre.
So of course whatever you do, we are going to have to be doing monitoring also of those phosphorus levels to make sure that this is staying below that limit and also the kidney disease isn't progressing. So if we think about the 4 stages of chronic kidney disease in stage 1 and stage 2, we can safely attempt weight loss because using a weight loss diet we are actually giving slightly less phosphorus than they would even be having in a mature diet. Once we hit stage 3, and that, as you can see, is based on those serological parameters, stage 3 and stage 4, we now cannot and should not attempt weight loss.
We now need to move them onto a specific kidney diet, and that is the only safe thing that it will do at that point. Where we go from stage 2 to 3, we have to reprioritize. We have to prioritise the kidneys at that stage if we're going to get the extensions, to life expectancy.
So for Ruby, we were able Because she was determined to be in stage 2 kidney disease to attempt some weight loss, and here she is. So she went from 7.3 kgs down to 5.6 kg.
And then we discovered hyperthyroidism. This was some months later. And it was really unfortunate for her.
But of course, it just goes to show that even when you think you've solved the problem, life has a way of chucking something else in there. So, of course, then we had to, regulate her thyroid again and, and rebalance her weight, but that's the story maybe for another day. But complex case, but we were able to get successful weight loss.
So in summary, as we've seen, do things rarely happen in isolation, which is why we have to have this made to measure plans and recommendations for our patients. The cookie cutter plan is not going to cut it. Where we've got a comorbidity, we need to identify that comorbidity and then decide and agree on what our weight loss aims are actually going to be.
We don't want to exacerbate that disease further and so by tailoring that that weight loss plan, we can hopefully get and satisfy all those individual aims. We can hopefully improve their general function and improve the quality of life for every one of our patients. I really hope you found this session interesting.
Thank you very much for listening.