Hi everyone, welcome to our session. We're gonna be looking at nutrition and diabetes. And I just wanted to start with a, a, as you can imagine, a little bit of an introduction, looking at, you know, what we're gonna be covering the next sort of hour.
There are a few little caveats to this webinar which I think is really important just to keep in the back of your mind at all times and. Yes, we have like an, an ideal situation in an ideal world. A we'll, we'll eat diet B and everything will go perfectly and everybody knows that doesn't happen with diabetics.
So feeding the diabetic patient can be really, really difficult. Feeding any animal, that might be just a little bit inappetent or is feeling unwell is going to be tough. It really is.
There's also, you know, all those feedback mechanisms that are that are occurring within the animal, you know, if the blood glucose level is, is high, there's a feedback mechanism within you that says you don't need to eat very much, it's your blood glucose is high. So there's, there's all of those things going on as well. It's very stressful for the owner and I'm a big believer that that.
Hairiver stress really does impact on the animal, and really does affect those feeding regimes that we have. So when we look at diabetes, please keep that in in your mind. Feeding regimes will really do differ between dogs and cats, as do the different types of medical management, and that will differ from individual to individual.
And so there is no one golden rule when it comes to feeding a diabetic patient. Those nutritional recommendations are really gonna be guided by the vets treatment regimes. The body condition score of the animal, especially in cats, an obese cat compared to, you know, a nice lean cat is gonna be quite different, that's gonna be different for a dog, and the owner requirements are a big part of that as well.
So please remember, there is no one definite answer when it comes to diabetes and nutrition. The only answer that is always correct with nutrition is depends. And, and it really, really does.
So I'm gonna go through and cover, you know, a whole spectrum of different things, and it's very much, your role as that veterinary professional, whether you're a vet or a nurse, to take that information and apply it to the patient that's in front of you in that consult room. So, just to sort of recap, just to sort of, you know, get it, get it sort of bit in there and just to sort of review really about, you know, the role of insulin and getting that energy source within that cell. And I love using this infographic, and it just reminds me of those, you know, those brook toys that you have for for for toddlers when you have to get the right shape into the right hole.
That's exactly what insulin is into that insulin receptor. So those pink blobs are cells, and you can see it just says body cell. It could be literally any cell within the body, so whether it is .
You know, a hepatocyte, a myocyte, you know, an eyeball cell. You know, whatever type of cell it is, we need to get glucose inside of that cell for, for that cell to be able to do the job it wants to do, you know, all those metabolic, you know, chemical pathways, those crab cycles, and all those sort of really intricate type of things that we, you know, that we all learn at college. We don't really need to recite that.
Please don't recite that back to the owner. But what we need to just Keep in mind is the fact that all body cells need an energy source. That energy source, you know, in this instance we're looking at glucoses outside of the cell.
It's in the blood plasma, it's in the interstitial fluid. But we need it inside that cell. How's it gonna get in?
We need some insulin and view insulin as a key. So the key comes along and fits into the key lock, the insulin receptor, and it opens the glucose channel, the, the, the gateway, the door, so to speak. So, yes, you need a key, you need a key lock, and you need that doorway to open.
And without any of those elements, that glucose won't go from outside to inside. So as you can see there in the middle picture, the, the key is in the door lock, the insulin has gone into that insulin receptor, opened that glucose channel and the glucose goes into the cell, acts as the energy source and does the job we want to do. So obviously from a diabetic point of view, there could be a few things going on.
It could be that we have an absolute deficiency of insulin, or just not enough insulin, so it could be one or, you know, all the other. Or it could be that we do have insulin, but all of the insulin receptors are, are broken, the door locks are broken. And That can be through overuse.
If we've got, you know, high, you know, blood glucose for a high period of time, and that could be through diet, that could be through stress, that could be through an endocrine issue. There's lots and lots of different reasons. The insulin receptor that the door lock becomes overused quite, quite easily in all fairness.
And sometimes we do need that blood glucose to go back down to normal. The insulin receptors have a, let's call it a rest, and we get back on board and then start working again. And that's what we see with, insulin resistance, and cats that, you know, then go back into remission.
So whether we have unmanaged or even uncontrolled diabetes, like I said before, it could be that we don't have enough insulin, we're not, you know, the pancreas isn't producing enough insulin. We could have insulin resistance, so the, the door locks aren't aren't functioning well. Those cells, those pink blobs and the previous pictures still need an energy source.
They still need something that that energy from somewhere in order to be able to work. And where are we going to get that energy from? Well, if the glucose isn't able to go from outside to inside, we're gonna have to use either fats or proteins.
We have 3 macronutrients when it comes to nutrition, and that is carbohydrates, fats and protein. So if one doesn't work or we're unable to use it, we default to the other two. And that's what we're going to do, especially with feline diabetic nutrition, we're defaulting to to using fats.
So let's have a look at these energy sources and and let's look at proteins to start with. And you can see there in that diagram, we've got protein at the top, it's digested into peptides and amino acids, so it's broke the chain of proteins is broken down. It's then obviously absorbed, goes off to the liver, those amino acids are deaminated, transaminated, you know, all those different things.
Transaminated, they're turned into other body proteins, whether that's enzymes or hormones or antibodies. They're actually used as the energy source of deaminated. So, .
The amino acids have the, the, as the name suggests, deaminated, they have the nitrogen element taken off and they produce the same amount of energy as a carbohydrate does. So it's a really nice way of actually, you know, producing energy when we, we really, really need it. The problem is, is that we do not store protein in our bodies.
There's no reserves to call on. Obviously with fat, there is, it's quite, you know, easy. You, you, you use your subcutaneous fat as your energy source.
We don't have that in our bodies. So any . I'd hate to call them reserves, but any areas where we have lots of large amounts of proteins is actually your, your muscles.
So that lean body mass, the muscles, is used as the energy source. And that's why it's so, so important that we're actually monitoring muscle condition score of all of our diabetics. Because if we're not able to use the glucose as the energy source for the cell, and we end up using proteins and we're not getting enough, alternative energy sources in our diet, whether it's through fat or proteins, we're gonna start using that, the muscle, the lean body mass in our, in our patients that we're seeing now.
So muscle condition scoring is really important, it is quite. A subjective measure, and there is, there are new scoring muscle condition scoring systems coming about using ultrasound on very specific muscles and measuring the depth of that muscle, and actually being able to put a, a number, you know, a quantitative rather than that sort of qualitative semi-subive sort of measure that's there. But this is why we have and we need to make sure we've got good protein sources in in our diabetic diets.
So what's the other energy source, but the other energy sources fats, and whether we are supplying this in the diet, or whether the animal is getting this from its subcutaneous storage system, it will still supply double the amount of energy that both proteins and carbohydrates do. We approximate that carbs and proteins provide 4.5 calories per gramme, and fats on average supply 9 calories per gramme.
So double the amount of energy per gramme, which is, you know, that's can be good in certain situations. So what happens is the fats are broken down into those fatty acids and the glycerol, that's what the triglycerides are. And then they metabolised to form ATP, you know, in that crab cycle, you know, that citric acid cycle and everything else.
So. Again, a really good way of getting energy into these animals. The problem is, is one of the byproducts of that, metabolic sort of cycle is ketone bodies.
Keto bodies are good, but they can also be bad if they're left to build up. So we know that our, brain cells actually prefer using ketone bodies. Our heart cells also prefer that energy source as well.
So, yes, really good in in certain situations. The problem is, is the way that we get rid of ketones, which that, that byproduct of the fats being broken down, is actually a little bit by use by feedback. Mechanisms by insulin.
And if we have an absolute, deficiency, so no insulin being produced, or even, you know, just not enough, we're not gonna be able to get rid of those ketone bodies, and it does, you know, build up and create that sort of, ketosis, and then we can go on to have ketoacidosis and so on. So it's really important that we, we do. Have some form of insulin production going on there so that we we're not becoming ketotic.
So really close monitoring of animals is is needed. And this is one of the reasons why, for some of the, the newer medical managements, so the SGLT2 inhibitors in cats, we're gonna be monitoring ketone production. So whether that's .
In the UK, we're looking at ketones, in the urine, that's what's on the licence for the enzygo. In America, we're actually going to the licenced states to monitor blood ketone levels. So it does depend which country you're in, where you're listening to this webinar, what form of ketones we're going to be monitoring depending on the licence for those medications, but basically we just don't want the ketones to build up and these animals to become ketoacidotic.
So like I said before, ketones, really important sort of energy source, and the more ketones build up, we need that insulin to help with that metabolism of the ketones back into carbon dioxide and water. So ketones are produced at low levels. We all have ketone bodies in our bodies.
Like I said, the brain cells use ketones all the time. And in uncomplicated diabetes mellitus, that's, you know, that's, that's quite useful. But we don't want them to build up to a level that causes clinical problems.
And one of the things that's really important is, like I said, is monitoring these different reference laboratories will have different reference ranges for blood ketones. And depending on what you eat, when you last ate, we alter your reference range for those blood ketones. So I've given some examples here and you know, imagine you've, you know, it's middle of the day, you've had your breakfast, you've had your lunch, you're just eating, you know, a, not a ketogenic diet, a normal sort of, you know, everyday diet.
You'll, you will still be producing ketones cause you're still gonna be digesting fats and The reference range, lot, like I said, lots of different laboratories will give lots of different ranges. This is an average of lots and lots of different reference laboratories. The Fed state, is 0.1 millimo per litre in cats.
If we fasted that cat overnight and then took the blood ketones, the fasting reference ranges was between 0.3 and 0.7.
And that's because the bodies go, Oh, we've not eaten in a while. Let's, you know, let's use some fats up, and this is the problem with cats, they're so good at metabolising their subcutaneous fats. This is why we get things like hepatic lipidosis.
So you can see there, just fasting overnight jumps that level up quite significantly. If we put these cats onto a metabolic food, so, the ones that would spring to mind are things like Purina DM, Hills MD, you know, those low carbohydrate, higher fat, higher protein foods, then that ketone blood level will, will increase. You know, we're looking at 1 to 3 milli, so it's almost 3 times the amount there.
So you can see how a reference range for blood ketones is quite a different thing to define. I should note that for diabetic ketoacidosis, you can see there we're getting numbers of greater than 15 milli per litre. So there is a huge significantly difference in those ranges between, you know, healthy and those those unhealthy diabetes DKA cases.
So you're not gonna mix those, you know, is it decay, is it just because it's on the food, you're not gonna mix those up. But I think it's important that we do, you know, you do know that these, these things, you know, are gonna alter depending on what diet we feed them. So our goals of treatment for these diabetic cases, whether you're a dog or a cat, are all roughly the same.
It doesn't matter which medication, you know, medical management we're on, we really want to reduce down the visible symptoms that those owners are seeing. So that are things like the excessive thirst, subsequently the frequent urination. These animals are really hungry.
And if you, you know, use that picture that I showed you with the 3 pink blobs and the keys and, you know, the insulin and all those sort of things, these cells need food. They need that food, and they can't use the glucose. So, you know, it's that's starving even though they're eating a sort of, acronym, sorry, analogy that we tend to use.
So that increased hunger is there. And as soon as we start managing that blood glucose, the blood glucose is going down because it's going in the cell. That hunger, that incessive hunger really just drop off quite quickly.
Sudden weight loss because obviously we we using our subcutaneous stools that are there and that lethargy, that weakness, that fatigue goes quite quickly as well. So this, you know, explaining, you know, why we need to use insulin or why we need to use a different energy source from a nutritional point of view, can really help explain to owners why we have these goals of treatment and that mechanisms of, you know, getting that energy into cell really does help the clinical signs that the owners are seeing. So like I said before, just to really remind you, this is the, the, the 3 pink globs.
We need to get energy in that cell. We really need to, we need to really reduce the amount of glucose outside the cell and get it inside. And this is what the SGLT2 inhibitors do.
And here in the UK, Slimalgo, that that's what it does is we're basically washing that, glucose out via the, the kidneys. We are assuming, making an assumption that we, we still do have some insulin being produced by the animal. And that's what's gonna help, you know, make sure that our ketone levels don't get too high.
It's gonna make sure that that cell is getting some glucose within it. Otherwise we need to provide those cells with a different type of energy source. So, the SDLT2 inhibitors, some of you will have already used it, and I do know there's a few practises have used it a lot and having some really successful outcomes for it.
We're really gonna increase the amount of urine excretion of that, that glucose, and that, again, drops that glucose level down, gives those insulin receptors time to heal, to mend, to actually become receptive to insulin again. So, like I've already said, monitoring is through urine ketone levels. And when it's, we're looking at nutrition for these cases, it's a difficult one because no one's done any actual research work on what's the best diet to use alongside the SDLT2 inhibitors.
So, just to be aware, in America, there is a US there is a licenced product, it's called Bxaca. It is the same class of medica, it's a class of drug. It's a one day tablet rather than a liquid.
And when they actually did all the research work to gain that licence, they used Purina DM diets and, they actually, you know, found that that was absolutely fine diet to use. There was no problems with it. It wasn't, let's try this diet compared to that diet with these meds or any.
I think, so the role of nutrition has not been fully investigated in these cases. But if you think back to the, the picture with the, the free pink cells that, that, that are there, those cells need an energy source. And we don't know how much insulin these animals are producing.
So providing calories in the, in the form of fats and proteins might be useful. We're monitoring our ketone levels so we know if you know, we're digesting metabolising. More fats than we should, and we're producing too much ketones, and do we have enough insulin to help with the removal of that?
We're monitoring those anyway. Hopefully you're monitoring your muscle conditions schools, so we're making sure that, you know, the protein level in that diet is sufficient as well. But it's a, it's very much a watch this space.
Someone out there will be doing some research work looking at the SDL2 inhibitors and the role of nutrition. So we need to be aware of that. Obviously if these animals are overweight, if they're obese as well, then we need to use a diet that's appropriate for that.
I'm we're gonna cover that in a in a little bit. So what happens if we're using insulin? So the more traditional route of control of diabetes in cats.
So insulin with nutrition, . It's a very, very different thing than with dogs, so I am gonna split the species out for for this. So Giving insulin in cats, it works more like a basal insulin.
So there's two types of insulins that that that we use for diabetics in in mammals in general. So in humans, there are two types of insulin that you would take if you were a diabetic. There's a basal insulin which you take once a day, and that basal insulin, will give you the, like a 24 hour, almost baseline amount of insulin that that's there.
When you then have your three meals a day, you would use a very short acting insulin for those poster prandial hypoglycemic sort of spikes that you that we do all have when when we eat. So in cats, the insulin acts more like a basal insulin, and the cat's diet needs to reflect that. So we know in cats that free choice feeding, and I'm gonna explain what free choice feeding is in in a minute, a low carbohyd excuse me, a low car can't even speak, no carbohydrate diet is the route to go.
And like I said before, you know, we need to make sure that, you know, we're getting . Those different energy sources for those cells there. So low carb white diet is ultimately the way to go, and I've given you, there's, there's a really nice, research paper, it's quite recent, 2023.
There's a QR code next to it, and I hope I've done it correctly, that QR code should take you to that paper. It's a really, really nice paper. Look, retrospectively at, you know, quite a lot of diabetic cats.
What worked, what didn't work, what really affected their quality of life. There's a lot of owner input there as well, looking at quality of life. So it's a really nice paper to have a look at.
Just one of those elements to do with your quality of life is obviously nutrition. And what they found was cats that were fed a low carbohydrate wet food were 3 times more likely to go into remission than those on a standard diet. That also included, some, let's call them therapeutic diabetic foods that weren't necessarily low carbohydrate as well.
So that low carb, wet diet is really the route that we need to go. And there's quite a lot of research supporting that as well. So, Whichever, you know, formulation you use, whichever manufacturer of that diet you use is, is gonna be up to you in your practise, but that low carb element is really, really important.
The wet food element there as well, really helps to actually reduce that damage. More so, a little bit to do with the way that the kibbles are constructed. So low carb, wet foods, 3 times more likely to go into remission than those on a standard diet, and there's the reference for you.
So that's what we need to be doing really for, for our, diabetic cats. So what I've done here is I've just sort of given you, this is all of the, you, you can see that PPVD is Purina, Propan, veterinary diets, RCs, Royal Canon, Hills. So those are the three most used therapeutic diets here in the UK.
There's the names of them all. And you can see that, you know, the amount of, carries per gramme is fed. Then the protein fat, crude fibre and all the rest is gramme per 100k count and that's how we should be .
You know, comparing, that's the word for it, comparing these diets, and the, the column on the, the far right shows you the percentage of calories, . I'm just trying to there we go, it's the percentage of metabolizable energy is carbohydrates. So theoretically we want that to be as, as you know, as low as possible really because we want a low carb food.
And you can see there that the Purina DM is 14.6, Hills MDs at 12, and you can see there's the Royal Canyon diabetics at 25. They, it works, their diet works slightly different.
So you can see that there's there's that variance there. So you can actually compare and all of these figures are widely available, they're just in the, the food compendium. So please have a look .
But we need a low carbohydrate food. These are all of the dry diets, and the wet diets, you can again, please have a look and compare yourself and, and, you know, see what's there. But these are just the dry diets, so you can see that it, it really does differ, depending on the, the food supply that's there.
So insulin and nutrition with dogs, they are completely different. They really, really are. So the diagnostics, the monitoring and the treatment of DKA may be the same.
The long-term management of diabetes, you know, needs to be split out. It really, really does. So when we're looking at feeding, we would feed dogs twice a day.
Cats, like I've already said, we would free choice feed, and I'll explain that in detail in a minute. So with dogs, dogs very much a little bit more like, you know, you're gonna give the insulin, it's a little bit more short shorter acting on average, so we're gonna give the insulin when we give the food. And in dogs, what we were looking for is is a diet which is low in simple sugars with a moderate overall carbohydrate content.
And what we know is by reducing down the simple sugars, so that's your, your glucose, your fructose, that those, just singular molecular sugars, we can increase the . It the other carbohydrates are the fibres, and that really really does help dogs. So dogs and cats, the nutrition, very, very different.
Have put some treats in here and I think this is something that, in an ideal world we would go, yeah, don't feed any treats. And I do hear some veterinary professionals really strict, don't give treats. The problem is, is that your owners that own a pet bond is really, really important.
And some owners will still give treats. It doesn't matter what you do, what you say, it will occur. So I think it's important that we have this discussion with owners, and we guide them, you know, what are the correct type of treats.
What's the quantity that we're going to be given? When are we going to be giving them? Can we use alternatives?
And I think that's the sort of route that we do need to be going down, . You know, these owners are gonna be giving injections, you know, it's quite an overwhelming time for them. There's huge guilt that they're causing pain every time that they're giving an injection, and those food rewards are an important aspect to with that sort of emotional bond with them, with their dog, so.
Talk about this, use treats that are appropriate, but we want treats that are that are low in sugars, those simple sugars. So similar sort of chart, and you can see there that the carbohydrate level on the right hand side is, is quite, quite different. The blue means it's a wet food as well, and you can see there that the carbohydrates, the fat contents, are all, you know, roughly the same.
But I think it's important just to sort of more to highlight the very, the, the huge difference there is between feline nutrition and canine nutrition. So Looking the difference between cats and dogs, it's those macronutrients that are gonna differ. So for cats, low carbs, all low carbs and higher fat and protein, but for dogs, because we are giving insulin, we're not managing with with food or using things like the SGLT2 inhibitors.
We're giving a fixed amount of insulin, so what we're looking for is, you know, just a reduction in those simple sugars, but the fibre is, is still there. So they're not classed as low carb foods. Things that are similar in both feline and canine nutrition, are things like this.
We need diets that have what we call fixed formulas. So this is the same recipe for every single batch of food, the same sourcing of ingredients for every single batch of food, and that the quantitative ingredient formulation doesn't change. So imagine I give you all the same recipe.
I'm gonna give you all a Jamie Oliver recipe to make a lasagna. It's got the same recipe on it. It's got the same list of ingredients, the same amount of grammes of ingredients.
I'll put money on every single lasagna that gets presented to me. It probably taste slightly different. It will look slightly different.
It'll be cooked a little bit differently as well. It, there's a really nice study that Mike Davies, did looking at renal diets, and he gave A group of nurses, all the same, recipe, he asked them to go off and make the food and they had something like, you know, 100 grammes of mince. Well, some were getting.
5% fat mince, some were getting, you know, 10%, some were getting the 15%, some were going to the butcher getting a steak and getting a mince, you know, you can go to some supermarkets and get mince when it's actually beef and pork mince. So even though the ingredients are the same. The quality of those ingredients can change greatly.
They really, really can. So it's not just having the same recipe for every batch, it's the same sourcing of those ingredients, and it's the fact that those ingredients are the same quality as well. We know that, you know, you can get Chicken that's fed on corn, as opposed to chicken that's just fed, let's call it chicken feed, and you'll, you'll know a corn fed chicken, they look quite, yeah, almost yellow, the, the meat, the fat is, is yellower.
So even though those chickens could be on the same farm, they've been fed differently and will affect the, the, the nutrient, the quantitative ingredient formulation that that is there. So we need to make sure we're using a diet that, you know, keeps, keeps to the same and also just something called batch testing. So batch testing isn't required for the nutrient quantity, it is required for things like the health and safety stuff, so contaminants, you know, and mould, that that sort of thing.
But we want to make sure these foods are batch tested so that we know we're not going below the minimum of something and we're not going above the maximum of something that it's keeping to the same every single batch. And that's what we need for diabetic control, especially in dogs where or and in cats where we're giving insulin. If every batch is the same, that's really gonna help the veterinary surgeon with that stabilisation.
If we're chopping and changing. And the owner might not even be aware that they're chopping and changing. They're going and buying the same brand of food each time, we're getting different ingredients and, and, and stuff, and that can affect that diabetic control that's there.
So fixed formula diets is, is what we need for both dog and cat diabetics. So like I said before with dogs, we want low simple sugars, and we all know you've you've all heard of the glycaemic index. The problem with the labelling on pet foods is they don't have to include the carbohydrate content.
Like, not at all, at all. So you'll see the amount of protein, the amount of fat, the amount of vitamin A, the amount of, you know, all these sort of things. If it's a, a diet, a wet diet or semi-moist diet, they have to put the water content, but they don't have to include the carbohydrate content at all.
So you don't even have to put in the amount of carbs that are in the food. You can imagine there are definitely some of these manufacturers aren't gonna be putting in how much is simple sugars, how much is soluble fibre versus non-fermented in all these sort of different types of carbohydrates. So you can have a little look at the ingredients and that might help you a little bit, you know, to sort of pick out the types of carbohydrates that could be present, but it is almost impossible on some of the food labelling to to pick this out.
And I've included this graph just to sort of demonstrate this. So at the bottom, we've got foods classed as low GI foods. So these are, you know, really good glycaemic index, you know, you'll eat them and you'll have that for your breakfast.
You'll have your oats for your breakfast, your porridge oats, and that will keep you going to lunchtime. You know, you can see there that the blood glucose level is eked out over a longer period of time. The other ones with the high GI index, you know, your biscuits, your cakes, you, you know, all of those processed foods.
They're high in simple sugars, so you'll get a, a higher spike and then you'll crash back down. That's like eating your Cocoa Pops for your breakfast. The thing is, and this is the deliberate reason I've used this graph is on an ingredients on a pet food label it will say it will literally just say rice.
You have a look at those, those descriptors there, you'll see on the bottom, the first one there is basmati rice. So all human diabetics, you always get told to eat basmati rice, it's a lot better for you. It's actually better than home meal, you know, whole grain rice.
If you have a look at the top, the sort of 5th, 6th 1 down is actually jasmine rice. So jasmine rice has high GI index. So just by putting rice on that label isn't really gonna help, give you an indication, is that a, a, a good, you know, carbohydrate source for a diabetic.
So, just to, you know, labelling is it can be really, really difficult, can really, really confusing. So yes, using a therapeutic, commercially made diabetic diet is gonna be easier. We know they're fixed formula.
We know, and the labelling on those will have the types of carbohydrates, whether they are, you know, simple sugars, complex carbohydrates, the fibre sauce, and, and so on. So one of the things that we really need to avoid in dogs is semi-moist foods, and semi-moist foods are everywhere, and the reason that they're everywhere is that they are really, really palatable. So this is my, my Google search.
I've just put in semi-moist foods. I'm here in the UK, so these are gonna be UK based foods, and you can see there that first picture, they're, you can see what they're like. They're, they're not dry like a kibble, but it's not wet food, but it's in the kibble shape.
The moisture content is going to be a lot higher, and you can see they're nor . The moisture content for labelling it really depends on where you are. If it's below sort of sort of 10% or even 8%, depends on where you are, it doesn't have to be included, but you can see here the moisture content on these foods put a little label in the in the top right hand corner is 18%, so it is on there, so.
What helps these foods retain their moisture is the question. So I circled it there, it's the glycerin. And this Ingredients label is actually from 123.
The 4th image along is Eden, it's got a little picture of a wolf and this is duck and tripe. That's the ingredient label from from this food. So the listerine.
As the name suggests, the first three letters GLY is a form of glucose. It's that's where it's derived from. So when that is consumed in the body, that is metabolised into a simple sugar.
And you know, we don't want that for our diabetic dogs. You will not find semi-moist diets for cats because the way that they metabolise things like the glycerine, some of them are are propylene glycol they use, that can cause liver problems in in some cats. So it's, it's really, really difficult to find semi-moist wet diets for cats.
So for our nutrition for our diabetic dogs, even if these are fixed formula, even if these are, you know, everything that we want them to be, please don't use the semi-moist foods, the simple sugar, the glucose content is too high for our diabetics. It's, you know, something just to be really, really aware of. So, feeding diabetic cats, feeding any cat can be really, really tricky.
It really can. And we need to individualise the feeding plan for these animals. I've already shown you one study, it's a retrospective review of, of, you know, a lot of cats.
The chances of remission can be really proved by rapid control of that blood glucose, whether it's using insulin or the SGLT inhibitors and the high protein low carb diet. And if you want to do some more further reading around this subject, if you put into something like Google Scholar. Make sure it's Google scholar and not just normal Google.
Jackie Rand, diabetic cats, you'll find loads and loads of research papers, come up. She did a lot of work looking at, these kinds of diets and found that we can really improve the chances of, of remission for these. The feeding of cats from ad lib feeding, so ad-lib feeding is, you can have as much as you want whenever you want to.
Meal based feeding is something that we might need guidance on, and some, some veterinary surgeons will advocate that that's the way that they want that animal to be treated. Obviously, if you're a veterinary nurse, we are doing what's delegated to us by the veterinary surgeon. But I would really advocate something called free choice feeding in in these animals.
And I, I said I'd cover free choice feeding, so here's a slide on freecho feeding. So ad lib, ad lib is is short for the Latin adlibitum, which literally means as you please. So it is as much as you want, whenever you want, there is an unlimited supply, fill your boots sort of thing.
Free choice feeding is slightly different. Free choice feeding is, I'm gonna set you a daily amount of food. But you can have it whenever you want it, that free choice is there.
So they have the choice to eat it when they want, but once the daily amount is gone, that's it, you're not having any more. So with cats, we really need to be going down the route of free choice feeding. So this can and some owners will have difficulty with this, some cats will, They'll be conditioned, they'll be programmed, to actually feed meal-based already because that's when the owner does feed them before they go to work and when they come back from work.
And free choice might be difficult for some people if they, if, if they're out all day, they're not gonna be able to supply the food as it, as when they, the cat wants it. So, yeah, there are ways and means around this. Obviously things like, puzzle feeders, scatter feeding.
There is something called, there's a whole movement on the internet called no bowl feeding. And if you actually type that into your search engine, there's so much information that comes up. It's, it is absolutely amazing.
But alongside that, there's lots and lots of ideas. And you can go to food puzzlesforcats.com.
You can go to YouTube and there's hundreds and hundreds of videos on there of people doing their best, let's call it Blue Peter vaccination and making puzzle feeders, for cats. Cats, ideally, should eat between 15 to 20 times a day. And each meal, if, you know, in an ideal world and the cat was doing what it should be doing, is normally only between sort of 2 and 5 mouthfuls.
Not a lot, is it? And as humans, if I had a pet, I don't have a pet cat, but if I did have a pet cat and it came along and it looked at the bowl and ate 23 mouthfuls and walked away, your initial feeling would be, oh, it doesn't like that food. It's only at 2 mouthfuls and it's walked off.
That is completely normal, and that's the normal feeding behaviour that we want for these animals. So please talk to owners, not just about the food. How we feed the food, that feeding behaviour for cats is really important.
You remember me saying to you that, the insulin for cats works more as a basal sort of insulin. So we have that all day sort of level going going along. We don't have the, the, the peaks like we do for dogs.
We have that level going. Along all the day, that really fits in, doesn't it? With that 15 to 20 meals a day, which is just a couple of mouthfuls.
So we need to reprogram, these cats to feed 20 times a day, little mouthfuls at a at a go. For us and for dogs, when we eat our meal, we have feedback mechanisms that say stop eating you full. And those feedback mechanisms are your stomach stretching, we have chemoreceptors as well, but most of it is, as you know, is just stomach stretching going you you've you've eaten enough.
Cats don't work like that. With cats, they have these chemoreceptors to say, you've eaten enough protein in the food, you've eaten enough fat in the food, stop eating. It's not about that stomach stretching.
And those chemoreceptors work very, very fast. So just eating those two meals, you know, it's two mouthfuls, that's when it switches off and says, you know, you, you, you're done. So we've inadvertently cause quite a lot of, you know, behavioural changes in these animals, we need to change it back.
So free choice feeding is the route we need to go. But please talk to owners about this. So obesity control, this is really gonna be for our cats, I know in America they are seeing more and more, Overweight and obese dogs that are now getting that diabetic sort of more type 2 sort of issue going on.
Obesity control is a huge issue for our diabetic cats, and yeah, we can get these cats into remission with, you know, that correction of that obesity. Use the diet that works best to control that obesity in that patient. So whether it is those low carb foods, it might be an obesity food that we need to use, whatever cracks that obesity, the best way, not necessarily the quickest, but that gets you the goals that you want to achieve, that will be the correct diet, it really will.
And for some cats that are obese and are just so used to overeating, their chemoreceptors are not working anymore. Actually those, you know, low carb diets might not be the best one because they're really high, they are. Concentrated in calories, they still might overeat and that might not help with the obesity.
So actually using an obesity diet might be the root for that one. And using a diet that helps with their satiety to help make them feel fuller might be the route to go. So again, that first slide I showed you in for this webinar, what the message was, it depends, it really does depend.
I've written there consider what pre and probiotics are in the diet. The prebiotics are the fibre sources, probiotics are the, postbiotics as well are coming on board as well. That really does play an effect with, with obesity.
So QR code there as well for you. Probiotics have really, antibiotics have really shown, to help with, insulin sensitivity. DIO is diet induced, obesity.
So Obviously these animals have overeateen their energy requirements, they've become obese, and in this study they actually found that modulating the gut microbiota really improved insulin sensitivity. So there is some work going on looking at your gut biome. In dogs and in cats, and how we can shift that biome to actually improve the sensitivity is gonna be looking at, you know, absorption of glucose and all those sorts of different things.
So again, it's one of those things to really, really just be aware of and keep your ears open because, you know, that people will be talking about this quite a lot soon. So safe weight loss, we need to get these cats, these, these obese animals back down to their ideal body weight. Once you've got them back down to their ideal body weight, that really will help their diabetes.
We know that the subcutaneous fat that you carry acts as an endocrine organ, and it's reducing inflammatory, cytokines. It's producing all sorts of hormones. That really do affect that diabetic control.
So getting that weight off really does help. We would normally look at 1 to 2% of current body weight loss per week. But if that weight loss is too fast, we're losing 3% per week, 4%.
We actually need to increase the amount of food up a little bit. I normally would increase and decrease my feeding amounts by about 10%, which in a cat is only 4 to 5 grammes. It's, it's not a lot.
And this really highlights the importance of weighing the food out for our diabetic patients, because, just, you know, oh, it's a scoop and it's this amount, 10% is, is, is 4 to 5 grammes. You know, if I ate 10% more per day, I would put on weight. Or, you know, if I was on a weight loss plan, inadvertently eating 10% more than I should do, I'm not gonna lose weight.
So it's important that we weigh the amount out. I've not gone into huge, I've not gone into any details about how to calculate the amount of food to feed and and and so on, and you know that RER equation that's there. The equation I have given you here is the minimum amount of food that you can feed.
So if you imagine you, you, oh, I'm gonna feed 40 grammes per day and you drop it down by 10%. So, OK, well I'm 36. I'm gonna drop it down by 10%.
OK, well I know I'm, you know, let's say call it 50 something. I'm not very good at maths. And then we drop it down and we.
Drop it down, then there must be an endpoint that you cannot drop that diet, you know, the amount of food that you're feeding down any lower, you're gonna cause issues. And this is the formula that can tell you what that lower level is that you should not drop below. It differs between dogs and cats.
And what we're doing is we're taking the target body weight of the animal. So say we want that cat to be 4 kg, so we, it's 42.6k cow per or divided by the target body weight to the power of 0.75 per day, and that's, sorry, that's the dog one.
And in cats it's 42.2 per target body weight in kilos to the power of 0.711.
To do that funky to the power of. Get your smartphone, get the calculator app up and then turn your phone into . Landscape.
So hold it the, you know, that way round as opposed to that way. So hold it that way round. Calculator app on, it will turn into a scientific calculator.
There is a button there that says X to the Y. So you would put in the target body weight, hit that X to Y button and put in 0.75 or 0.711.
That'll give you a figure and you divide the 42. Whatever it is by that, that number. That will give you the amount of calories per day.
So, talked about diet, you know, what food we're feeding, we've talked about how we're feeding it, and we've talked about, you know, weight loss a little bit as well. When are we actually gonna put these dogs and cats onto their, let's call it their clinical therapeutic diabetic food? It's a highly, highly debated question.
It really, really is. So ideally, there's there's two ways of doing this, are we gonna. Put them on their medical management whether it is an SGLT2 inhibitor, whether it's the insulin.
And then change them, but when is that gonna be? Or are we gonna do it at, let's call it day 0, you know, congratulations, your cat's got diabetes. Here's the, you know, here's the insulin, here's the food, off you go.
When, when's, when's the best time? And again, it's that magic nutrition word that comes up all the time. It depends.
It depends on the appetite of the animal. If the animal isn't eating very well, is changing its diet gonna help you? Probably not.
We need these animals to be eating well and then transition them. You know, if they're in a hospital setting, we talk all the time about food aversions. That's another reason.
The severity of the diabetes, you know, that is ultimately going to be the priority. Concurrent diseases as well is gonna pop in there as well. So Owners have to be told about the importance of nutrition of the right diet at the time of the diagnosis.
That's a must. You cannot not tell an owner about the importance of nutrition when we're talking about controlling blood glucose. You know, it's, it's, you know, it's part and parcel, isn't it?
Priority does need to be given to the owners, and I've put in the inverted commas, mastering. Are they actually mastering, you know, that, that skill like we do when we're training to be vets and nurses. I can't think of another word, but owners have got to be competent in that requirements of the medical management first.
They've got to be Able to give the oral meds. They've got to be able to give the injection. They've got to be able to collect the urine sam, you know, that's the priority.
And it can be so overwhelming for owners as well. Mixing in with that, oh, I'm gonna change the food can be a little bit too much sometimes. I've recently spoken to some of the experts at the RVC and what they do is they actually recommend transitioning cats onto an appropriate diet, you know, that low carb food at around about day 14.
So you've got 2 weeks for the owner to, you know, just get their heads around, a new routine. Giving of the medical management, doing all the other things, and then we're gonna look. We're not gonna wait until 3456, you know, months down the line, because otherwise you're stabilising that animal onto the that let's call it diet 8, you, you, you might have even stabilised them, and now we're gonna change the food.
Go to re-stabilize them and do those, those, you know, glucose testing again and all those that sort of thing. So. It does depend on the animal, it does depend on the situation.
Some animals you might not change the diet, depends on what concurrent diseases have gone on, you know, all those sort of things. But on average, we normally look at changing to an appropriate diet around about, you know, after a couple of weeks, day 14. I just wanted to put in a little bit here about concurrent disorders, diseases, because it does have a huge impact on nutrition.
The main one, being pancreatitis. 13% of diabetic dogs have pancreatitis. That's, that's quite a, quite an amount.
So yeah, please make sure that you, that when we're doing bloods, we add in that pancreatic specific lipase tests as well. And an appropriate diet. Most low fat GI foods are suitable for diabetic dogs.
We're not using the low carb, higher fat foods for these diabetic dogs. So actually from that pancreatitis point of view, that can be really helpful. But please, please remember that pain management and nausea management as well is really key cause if these dogs do have pancreatitis, and 13% of them will do, then that pain, that nausea will affect the amount of food that we're eating.
Likewise, in cats, this is a really good statistic in it, 50% of cats have pancreatitis, with, with that diabetes as well. And it's, you know, there's lots of other elements going in there as well. So please, pain management, nausea medication.
The appropriate diet isn't, you know, so for cats with pancreatitis, we don't restrict the fat content down, but we need to make sure that the fat is a good fat. So in both dogs and cats, we can get waxing and waning, pancreatitis, that can cause variances in insulin resistance, and thus insulin requirements. That intermittent loss of appetite, ketosis that will go alongside that.
Loss of appetite because we're needing a different energy requirement for those energy source for those cells. So teaching owners, you know, how to identify the signs of pain, identify the signs of nausea in cats and dogs can be really, really useful. So which diet are we gonna use?
Get back to that, it depends, doesn't it? You use the diet that's most suitable for that patient. And if you're unsure, just, just ask someone.
You know, all of those different food companies have technical helplines. We need to do what's best for that patient and its owner in the, we talk about contextualised care all the time, in the context that it's in. You know, diabetes differs from patient to patient, so the nutrition for that patient will alter accordingly.
It is more important that that animal is eating something than what it is specifically eating, so we need to make sure they are eating something. And really, you know, if you understanding those pet food labels can be really, really important to help guide owners. So like I said, dietary transitions, once that animals at home, eating well, look at transitioning onto the new food, don't start that food whilst it's hospitalised because we can get food aversions going.
If The cat's already stabilised on, you know, insulin therapy or, you know, an SGLT2 inhibitor, and we're now gonna change to a low carb diet. Please, please be aware that the insulin dose might need to be altered. Some of the research papers that I've looked at whilst I was writing this, this lecture, had all sorts of weird, weird and wonderful sort of variations.
Some were 30% reduction, some were 50% reduction in, in insulin dose. So, yeah, hence changing the diet at day 14. Not quite stabilised, it's a lot easier than doing it down the, down the line.
So just keep that in the back of your mind. And feeding these low carb diets, you're 3 times more likely to go into remission. So it's a bit like renal, you know, nutrition is part of the management of that chronic, condition.
In dogs, use that 3 to 5 day transition. We're not using a metabolic diet, so the changes aren't as great with and hyperglycemia isn't normally seen. So again, cats and dogs are gonna be slightly different for that dietary transition.
And lastly, I just wanted to sort of say about increasing hydration, and this isn't something I would normally put in a diabetic, webinar, you know, lecture, but because of the SDLT2s that we're now using in cats, we are. I think that the most basic, sort of easiest way to, to explain them is we are literally watching the glucose out, you know, via via the kidneys. And in humans, there's a lot of work done in humans.
We know that when you start on these inhibitors, there is an actual increase in urine output. . That can then diminish or return to baseline after a few days of treatment, but that does occur, and we need to make sure that these animals don't become dehydrated.
We need to make sure that we're keeping that hydration status up to help with that mechanism of how the SGLT2 inhibitors work. So lots of access to water, but be careful that owners aren't using, and there's a lot of them now. If you go into any pet shop, you'll see lots of broths, you'll see sort of tetrapats with chicken soup in them for dogs and for cats.
Oh, you know, that. Has calories in it. Lots of our oral hydration solutions also include glucose as well.
So please be aware of these. So yes, let's consider wet foods and to get that hydration status up. Obviously, water intake is vital.
We really need to be, you know, really aware that these animals are drinking enough, to help, you know, with that compensation from the polyurea that that is occurring. So in conclusion. Please make sure we're using those fixed formula fixed recipe diets.
Ideally, we want to maintain or obtain an ideal body condition score. So our obese animals, we need them to go back, you know, down to ideal our dogs maybe that are underweight, we need them to get back up. Those animals have lost that lean muscle mass, that protein not stool, but that protein store that's there, and we need to get that muscle bulk back on.
We need to feed a diet that's palatable for that animal, you know, it doesn't matter if it's the world's best food, if the animal's not gonna eat it or not eat enough of it, that's not gonna be good for them. So make sure it's palatable for the for the animal. Please give owners advice and guidance on all of the foods that includes the treats, that includes the human foods and all of those sort of elements.
We need to cover all of our bases. So thank you for listening. I hope there's been a few sort of things that you can pull out there that can, you know, help with your diabetic patients.
Thank you.