1 Small Animal Endocrine & Exocrine Pancreatic Disease

• Nutritional Management of Small Animal Endocrine & Exocrine Pancreatic Disease

Outline

• Diabetes mellitus considerations include general, canine-specific, and feline-specific aspects.
• Pancreatitis considerations include acute vs. chronic disease and canine vs. feline management.
• Exocrine pancreatic insufficiency is also considered.

Objectives

• Explain the differences in pathophysiology of glycemic control & diabetes mellitus between dogs & cats.
• Formulate species-specific diet plans and feeding strategies for managing a diabetic pet based on pathophysiology differences.
• Identify key nutrients for patients with diabetes mellitus, acute and chronic pancreatitis, and exocrine pancreatic insufficiency.
• Differentiate how diseases impact nutrient digestion, absorption, or metabolism.
• Create a unique diet plan for patients with endocrine or exocrine pancreas disease based on case scenarios.
• Diet plans should consider common comorbidities, ingredient profiles (glycemic index, fiber solubility), diet profiles (high vs. low fat), and vitamin/mineral supplementation.

Diabetes Mellitus (DM)

• Hyperglycemia results from defective insulin secretion or decreased tissue insulin sensitivity.
• DM has secondary effects on carbohydrate (CHO), fat, and protein metabolism.
• Most dogs with DM have Type 1 (insulin deficiency), while most cats have Type 2 (insulin resistance).
• Comorbidities can impact either type of diabetes.

General Considerations & Nutrients for DM

• Energy requirements should be fulfilled.
• Ensure adequate water intake.
• Monitor carbohydrate intake.
• Provide adequate protein.
• Monitor fat intake.
• Provide fiber.
• Consider micronutrients, minerals & supplements.
• Cats may need arginine and carnitine.
• Antioxidants and omega-3 fatty acids can be beneficial.

Energy Requirements

• Insulin deficiency reduces glucose uptake and utilization.
• Polyphagia and weight loss are classic signs.
• Body condition score (BCS) can range from thin to obese.
• Metabolism changes to provide energy needs typically supplied by glucose.

Soluble Carbohydrates

• Carbohydrates most importantly stimulate insulin secretion.
• The glycemic index ranks how food impacts circulating glucose concentrations.
• A higher glycemic index has a greater effect on glucose levels.
• Complex carbohydrates have a lower glycemic index than simple carbohydrates.
• For dogs, the carbohydrate food source ranking is rice > wheat, corn > barley > sorghum, peas, lentils.
• For cats, the carbohydrate food source ranking is corn > rice > sorghum, peas.
• Potatoes are high in soluble carbohydrates, while soybean meal is low.
• Maintain consistency in the amount and sources of carbohydrates.

Fiber for DM

• Fiber in diabetes mellitus slows digestion and absorption.
• Soluble fibers bind glucose and water in the GI tract, decreasing absorption.
• Examples of soluble fibers: guar gum, pectin, psyllium husk, and inulin.
• Fiber may impact the digestion of some nutrients more than others.
• Studies on fiber are impacted by caloric intake.

Fiber: Disease Impact in Cats vs. Dogs

• Dogs with diabetes benefit from high insoluble fiber for improved glycemic control compared to low or mixed fiber sources.
• High insoluble fiber decreases fructosamine levels in dogs.
• Cats with diabetes have lower preprandial and mean glucose with high insoluble fiber vs. low fiber diets.
• Consider overall diet profile in macronutrient comparison studies for cats.

Fat

• Lipid metabolism abnormalities in diabetes include hypertriglyceridemia and hypercholesterolemia.
• Lipid abnormalities are more common in dogs.
• They contribute to insulin resistance.
• Dietary fat goals vary; restriction may support weight loss.
• Higher fat may benefit thin animals.
• Fat slows gastric emptying more than fiber and decreases the amount of carbohydrates for calories.

Protein

• Diabetes mellitus impacts include protein catabolism leading to muscle atrophy.
• Amino aciduria is rare.
• Use highly digestible (>85%) protein sources.

Vitamins & Minerals

• Animals are at risk of low K+, Phos, Na+, Cl-, Ca2+, and Mg2+.
• Supplementation is generally not required in stable diabetics.
• Conditions causing decreased food intake and increased GI or urinary losses exacerbate vitamin/mineral deficiencies.

Ideal Nutrient Profiles in Dogs

• Moderate protein (15-35% DMB or 5-7 g/100 kcal)
• Variable fat (25% DMB average), restrict if obese, do not restrict if underweight
  • Obese or hyperlipidemic: <2.5-3.5 g/100 kcal
• Low glycemic indices for carbohydrates (<60% DMB or <15 g/100 kcal).
• Moderate crude fiber (7-18% DMB)
• Moderate TDF (3.5-5.6 g/100 kcal)

Ideal Nutrient Profiles in Cats

• Low Carbohydrate: High protein (28-55% DMB or 7-13 g/100 kcal), moderate fat (≤25% DMB or ≤6 g/100 kcal), low CHO (≤20% DMB or <5 g/100 kcal), low crude fiber (<7%).
• High Fiber: High protein (28-55% DMB or 7-13 g/100 kcal), moderate fat (≤25% DMB or ≤6 g/100 kcal), moderate CHO (≤40% DMB or <10 g/100 kcal), high crude fiber (<7-18%).
• Low CHO preferred for most cats.
• 70% remission with low-CHO/low fiber diets vs 40% remission with moderate-CHO/high fiber diets.
• High fiber diets result in lower energy density and weight loss.

Diet Forms

• Avoid semi-moist diets, which are high in sucrose, fructose, and other simple carbohydrates.
• Canned food is preferable because it provides an additional water source.
• There is no evidence that dry food increases the risk of diabetes in cats.
• Canned food may promote weight loss in cats.

Feeding Strategies: Energy Amounts

• DER for ideal weight + diabetic control = appropriate for most animals.
• Dogs: Neutered (1.6 x RER), intact (1.8 x RER), inactive/obese prone (1.2-1.4 x RER).
• Cats: Neutered (1.2 x RER), intact (1.4 x RER), inactive/obese prone (1.0 x RER).

Feeding Strategies: Dogs

• Feed twice daily with intermediate or long-acting insulin.
• Offer food first.
• Provide 50% calories per feeding.
• Exceptions to this include post-prandial hyperglycemia, chronically picky eaters, or acute hyporexia.
• Exercise decreases insulin requirements.

Feeding Strategies: Cats

• Administer twice daily insulin dosing with long-acting insulin.
• Allow free-feeding or use a timed feeder.

Feeding Strategies: Treats

• Maintain consistency.
• Use the same type, time, and amount every day.
• Avoid simple CHO or high fat.
• Vegetables for dogs can be considered.

Feeding Strategies: Weight Loss Plans

• Use a conservative weight loss approach.
• 1.0 x RER for dogs
• 0.8 x RER cats
• Decrease from current caloric intake by 20% from.
• Aim for 0.5-1% of initial body weight loss per week.
• Weigh every two weeks and assess BCS monthly.
• Monitor for remission in cats.

Feeding Strategies: Thin Diabetics

• Maintain crude fiber at <10%.
• Slightly increase dietary fat content.

Pancreatitis Nutritional-Related Risk Factors

• Hypertriglyceridemia
• Obesity (dogs)
• High-fat diet (dogs)

Stimuli for Pancreatic Secretion

• Cholecystokinin
• Dogs: Fatty acids, amino acids, peptides
• Cats: LCFA, proteins +/- amino acids
• Secretin

Feeding the Hospitalized Acutely Sick Patient

• Correct fluid & electrolyte abnormalities
• Address hypokalemia, hypomagnesemia, and hypocalcemia.
• Early enteral nutrition
• 10% caloric needs maintains GI integrity.
• Prevents hepatic lipidosis (cats).
• Improves food tolerance.
• Decreases hospitalization time.
• Decreases infectious complications.
• Diet profile
• Low fat, easily digestible in dogs (≤2.5 g/100 kcal fat).
  • "Gastrointestinal" diets
  • 2% milk cottage cheese + white rice (1:1 v/v)
  • Low-fat enteral liquid diets
• Moderate protein is good (5-8 g/100 kcal dogs; 9 -12 g/100 kcal cats or 7-10 g/100 kcal).
  • "Recovery" diets
• Gradually increase to RER to reach the target goal.

Long-term Considerations: Dogs

• Single episode
• Without hyperlipidemia
• Known trigger
• Transition back to normal diet
• Avoid dietary indiscretion
• Repeated episodes
• Fat restriction (≤2.5 – 3.5 g/100 kcal)
  • Low enough to maintain fasting triglycerides
  • Moderate protein
  • Mixed fiber sources
• Weight loss plan
• Multiple small meals

Pancreatitis: Common High-Fat Food Sources for Dogs

• Proteins: Beef, lamb & goat, rabbit, salmon, sardines, sausage, cured meat.
• Dairy: Non low-fat products.
• Miscellaneous: Tofu, peanut butter, many commercial treats (dry meat “jerky” treats).

Long-term Considerations: Cats

• Target nutrient profiles & diet types for management concurrently.
• Moderate protein
• Moderate fat (6 g/100 kcal)
  • Fat-restricted if hyperlipidemic

Exocrine Pancreatic Insufficiency (EPI)

• Pancreatic secretory products and enzymes for food digestion/absorption are crucial.
• Absence leads to maldigestion, undigested food components in the GI tract, diarrhea, microbiome dysbiosis, and malnutrition.
• Decreased pancreatic lipase reduces the impact of fat on CCK secretion.
• Decreased gastric emptying
• Decreased glucagon-like peptide-1
• Clinical signs include weight loss with polyphagia in dogs and hyporexia in 40% of cats, voluminous diarrhea in dogs versus unformed stool in cats, steatorrhea in dogs, and coprophagia/pica in dogs.
• Key considerations and nutrients include energy requirements, digestibility, fat, vitamins (fat & water soluble), and fiber.
• Goal: Meet energy needs and avoid nutrient deficiencies.
• A diet change is not needed for many patients.
• High digestibility of nutrient sources is crucial (>87% protein, >90% fat and CHO).
• Serial monitoring of BCS & MCS
• The caloric requirement decreases with disease control.
• Variable clinical effects of fat restriction in dogs
• Consider moderate fat if tolerated to promote weight gain as follows:
  • Dogs: 10-15% DMB; 3-4.5 g/100 kcal
  • Cats: 15-25% DMB; 4-6 g/100 kcal
• Medium chain triglycerides have possible benefits in humans due to portal circulation absorption.
• But this is not demonstrated in dogs/cats & limited evidence to suggest benefit.
• Decreased fat & other nutrient absorption and the potential to decrease enzyme efficacy can occur
• Low fiber is recommended with mixed/soluble fiber sources
• Crude fiber should be <5% DMB
• Enzyme supplementation with meals is important.
• Avoid ad lib feeding
• Cats may need gradual transition to meal feeding.