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Vol. 21, No.

8 August 1999 20TH ANNIVERSARY

CE Refereed Peer Review

Nutritional
FOCAL POINT Management of
★ Managing canine diabetes
mellitus requires a consistent
feeding plan and food that
Diabetic Dogs
minimizes postprandial
fluctuations in blood glucose Angell Memorial Animal Hospital, Boston, Massachusetts
concentrations. Rebecca L. Remillard, PhD, DVM

KEY FACTS ABSTRACT: The goals of nutritional therapy in the management of diabetes mellitus are to ap-
proach physiologic blood glucose levels, match postprandial glucose absorption with insulin
therapy, attain and maintain optimal body weight, reduce the likelihood of diabetic complica-
■ Dietary modification, in tions, and address other concurrent disease conditions amenable to dietary therapy. Managing
conjunction with insulin therapy, diabetes mellitus requires a consistent feeding plan and food that minimizes postprandial fluc-
is an effective adjunct in the tuations in blood glucose concentrations. Because fiber modulates blood glucose levels and
control of diabetes mellitus in favors optimum body weight maintenance, the single most effective dietary tool in the medical
dogs. management of diabetic dogs is feeding a diet containing insoluble or soluble fiber at 8% to
18% on a dry-matter basis.
■ The single most effective dietary

D
change is to include moderate iabetes mellitus (DM) in dogs is a complex disorder caused by a multi-
amounts of insoluble and/or tude of factors; it is characterized by an insulin deficiency or dysfunc-
soluble dietary fiber. tion that results in hyperglycemia and abnormal lipid and protein metab-
olism. In 1985, a revised classification system divided diabetes in humans into
■ For most dogs, feeding at the four categories: insulin-dependent diabetes mellitus (IDDM or type 1), non–
daily energy requirement for ideal insulin-dependent diabetes mellitus (NIDDM or type 2), gestational diabetes,
body weight in conjunction with and secondary diabetes.1 DM in dogs is broadly classified as IDDM or NIDDM
adequate pharmacologic control based on the need for insulin.1 –3
of diabetes mellitus will maintain When approximately 75% of pancreatic beta cells have been destroyed in pa-
a desired body weight. tients, the ability to maintain normal blood glucose level is decreased.4 IDDM is
characterized by low blood insulin levels, and therefore the patient is dependent
■ For obese animals, a conservative on an exogenous insulin source. Immune-mediated insulitis may play a role in
weight-loss protocol should be development of IDDM in dogs because beta-cell–specific antibodies have been
instituted after primary medical identified in approximately 50% of diabetic dogs studied.5
problems have been stabilized. Non–insulin-dependent DM is classically characterized by insulin resistance
in peripheral tissues and/or dysfunctional beta cells.6 NIDDM is less common
in dogs than in cats and not well described but still accounts for approximately
one in five cases of diabetes.7,8 NIDDM has been referred to as a relative insulin
deficiency because blood insulin levels may be increased, decreased, or normal.
Patients with NIDDM are not completely dependent on administration of ex-
ogenous insulin to maintain glucose homeostasis. The number and intrinsic ac-
tivity of glucose transporters are decreased in humans and rats with NIDDM.9 The
pathophysiologic defect in NIDDM more likely involves depletion of glucose
Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

transporters and/or a dysfunctional receptor/post- an owner until the patient becomes ketoacidotic.
receptor intracellular signaling event resulting from trans- Body condition scores (BCSs) for diabetic dogs range
lational suppression of the transporter genes.10–12 In from emaciated (BCS = 1) to obese (BCS = 9) depend-
dogs, NIDDM appears to be associated with obesity ing on the severity and duration of disease; most dia-
and possibly a subsequent down-regulation of peripher- betic dogs, however, have a BCS greater than 5.18 BCSs
al insulin receptors similar to that noted in humans.13 provide estimates of total body fat composition (r2 =
Some authors consider the pathogenesis and clinical .90a) via the palpation of subcutaneous fat stores at spe-
picture of IDDM and NIDDM to be different,1 where- cific anatomic sites; thus this method is still useful
as others report that patients may initially appear to when patients have diseases associated with muscle
have one type but either progress to the other type or wasting.19 Many diabetic dogs are obese, and therefore
alternate between the two through the course of the attainment of an ideal weight (BCS = 5) is an early
disease.3 The cause is probably multifactorial; genetics, goal. Studies in obese dogs suggest that obesity causes
immune-mediated disease, obesity, inflammatory/infec- insulin resistance that may be resolved with weight
tious conditions, exogenous drugs, concurrent disease, loss.15,20,21 As a dog loses weight, insulin requirements
and pancreatic beta-cell degeneration have been sug- may decrease.22
gested. Regardless of pathophysiology, most diabetic A small number of diabetic patients with a history of
dogs should be considered to have IDDM and treated maintaining optimal weight or being overweight will
with insulin and dietary management unless there is a have lost weight as the disease progressed and could be
strong indication that the diabetes is secondary.3 underweight at the time of diagnosis. Underweight dia-
Dietary recommendations cannot be made based on betic dogs may regain weight with insulin therapy as
research alone because of the paucity of well-designed cells, once again in the presence of insulin, metabolize
studies using diabetic dogs. Therefore the state of the serum glucose and fat (through improved lipoprotein li-
art in making dietary recommendations is based on re- pase activity). The feeding plan for underweight dogs
search in normal and diabetic dogs, extrapolations from should include increased caloric intake in the form of fat
other species, and simple clinical experience. as well as increased fiber. Adding vegetable oil or cooked
animal fatb to the diet and feeding meals frequently may
PATIENT ASSESSMENT improve body weight (BW) in addition to providing
Dogs diagnosed with DM may be of any age and sex better glycemic control. In clinical experience at Angell
but are more commonly 4 to 14 years of age; females Memorial Animal Hospital, however, most of these un-
are affected twice as often as are males. Breeds appar- derweight dogs do not attain normal weight; continue
ently at higher risk include the keeshond, puli, cairn to be difficult to control; and have some other compli-
terrier, miniature pinscher, and poodle.14 Obese dogs cation, usually one that includes the pancreas (exocrine
have been shown to be glucose intolerant and hyperin- insufficiency and/or cancer).
sulinemic.15 Regardless of the etiology, therapy must be
directed at eliminating the clinical signs of hyper- KEY NUTRITIONAL FACTORS
glycemia and preventing the development of chronic Key nutritional factors emphasize food-related issues
secondary complications. that markedly affect the management of a disease. The
Dogs with DM are usually presented for examination consequences of an absolute or relative insulin deficien-
because of polyuria, polydipsia, polyphagia, weight loss, cy are a constant catabolic state with increased hepatic
and diminished activity and thus have fasting hyper- glucose output; decreased tissue utilization of glucose;
glycemia and glycosuria.3 Weight loss in the face of and concurrent increases in glycogenolysis, lipolysis,
polyphagia, the hallmark of DM, occurs as the disease and proteolysis. Therefore key nutritional factors for
progresses. Weight loss is not always synonymous with managing diabetic pets include specific dietary nutri-
being underweight; an obese dog could have a history ents (nutrients of concern), food type and digestibility,
of losing weight but still be overweight at the time of and a feeding schedule (see Current Feeding Recom-
presentation, which is true for most diabetic dogs. Ad- mendations and Diet Characteristics Helpful in Man-
ditional physical findings may include lethargy, hep- aging Diabetic Dogs). These factors help to successfully
atomegaly, cataracts, and dehydration.16 Other disease aThis
conditions (e.g., infection, hypokalemia, hypomagne- indicates that 90% of the variation in BCSs can be ex-
plained by differences in total body fat content.
semia, renal failure, pancreatitis) or concurrent use of bOne tablespoon of fat is approximately 150 kcal; feeding a
drugs that decrease insulin secretion or cause insulin re- dog 1 tbsp of fat per 30 lb BW per day increases caloric intake
sistance may precipitate a diabetic ketoacidotic state.17 by approximately 15%. The added fat should be divided
The clinical expression of DM may not be apparent to among the meals fed.

AT-RISK BREEDS ■ PRESENTING SIGNS ■ BODY CONDITION SCORES ■ OBESITY


Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

manage diabetic dogs when the


primary disease is controlled with Current Feeding Recommendations and
insulin or other pharmacologic Diet Characteristics Helpful in Managing Diabetic Dogs
treatments. The goals of nutri-
Nutrients of Concern
tional therapy are to approach
physiologic blood glucose levels, Water Available ad libitum
match postprandial glucose ab-
Carbohydrate Referred to as nitrogen-free extract; approximately 50%
sorption with insulin therapy, at-
tain and maintain optimal BW, (DMB)
reduce the likelihood of diabetic
Fiber 8%–18% crude fiber (DMB; insoluble and/or soluble fiber)
complications, and address other
concurrent disease conditions Energy intake A reasonable initial estimate of daily energy intake is 1.6 ×
that are amenable to dietary ther-
RER for neutered dogs and 1.8 × RER for intact dogs; RER
apy. Caloric intake, nutrient
composition of the diet, form of is approximately 15 kcal per lb BW
the food, feeding schedule, and
Fat 6%–10% (DMB) when dog is at optimal weight or needs
control of concurrent disease
must be considered in planning to lose weight; fat contents of 10%–20% can be used if
the dietary management of dia- weight gain is indicated; no recommendations can be
betes.2 3 made at this time concerning omega-3 fatty acid content

Nutrients of Concern Protein 18%–25% (DMB) with a protein digestibility >85%


Nutrients of concern, in de-
creasing order of importance, are Minerals Foods formulated as complete and balanced according to
water, carbohydrate (sugar, fiber), AAFCO recommendations for adult maintenance provide
energy, fat, protein, and micro- an adequate supply of macro- and microminerals
nutrients (minerals and vitamins).
A diabetic dog’s current diet Vitamins Foods designed as complete and balanced according to
should be evaluated in terms of AAFCO recommendations for adult maintenance provide
these nutrients and then com- an adequate supply of fat- and water-soluble vitamins;
pared with recommendations for antioxidant formulations of vitamin C, α-tocopherol, and
diabetic dogs. If key nutrients in
beta-carotene may be given
the current food(s) do not match
the recommended levels, chang- Food Type
ing to a more appropriate food is Form A dry diet is preferred over a canned diet, and a canned
indicated. diet over soft–moist foods

Water Formulation Fixed; products designed to be sold through veterinarians


When glucose is present in the usually have fixed formulations (i.e., the ingredient
urine, an osmotic diuresis occurs formulation does not vary from unit to unit)
and water loss via urination in-
creases. Ad libitum potable water Digestibility Diets containing dry-matter digestibility coefficients of
is recommended and is usually 70%–80% are desirable; highly digestible (i.e., >90%)
accomplished by providing ad li- and poorly digestible (i.e., <70%) diets should be avoided
bitum access to water (e.g., hav-
unless warranted in dogs that have difficulty maintaining
ing several water bowls in differ-
ent places available at all times). optimal body weight

Feeding schedule Most owners can feed two equal-sized meals daily: one
Carbohydrate
Sugar. Commonly used sources at the time of insulin injection and the other 8–10 hr later
of carbohydrate in dog foods in- AAFCO = Association of American Feed Control Officials; BW = body weight; DMB = dry-
clude barley, corn, rice, wheat, matter basis; RER = resting energy requirement.
oats, and sorghum. These ingre-

GOALS OF NUTRITIONAL THERAPY ■ OSMOTIC DIURESIS ■ DIETARY GUIDELINES


Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

dients are primarily composed of starch (more than (range, 0.1% to 4.2%) products. However, the analytic
60% starch), although they differ in their nutrient anal- crude fiber method required by the Association of
ysis and availability of protein, fat, minerals, and vita- American Feed Control Officials (AAFCO)32 excludes
mins. Glucose from dietary starch digestion is the most variable fractions of insoluble (hemicellulose, cellulose,
potent secretagogue of insulin; diets that result in more lignin) and soluble (pectins, gums, resistance starches)
manageable postprandial blood glucose increases are fibers and therefore underestimates the fiber content.
recommended for diabetics. In humans, glycemic index Total dietary fiber as described for human foods is
and dietary carbohydrate concentrations explain almost probably a more meaningful estimate when comparing
90% of blood glucose and insulin responses to a different fiber levels across foods, but this information
meal.24,25 is rarely available for pet foods.33
Glycemic index classifies foods based on their blood Fiber types are differentiated by their physiologic
glucose–raising potential; this valid and potentially use- characteristics and in vivo systemic effects. Soluble
ful concept is also deceptively complex.2 6 There are a fibers (pectins and gums) are soluble in water and in-
number of unresolved problems and unanswered ques- crease the viscosity of the intestinal contents, thereby
tions (particularly of a mixed-carbohydrate meal). Pre- delaying gastric emptying and slowing intestinal transit
dicting glycemic response is no longer based on the dif- times. The increased viscosity is also thought to slow
ference between a simple versus a complex carbohydrate glucose absorption.34 Viscosity markedly affects the ex-
but depends on a variety of such factors as the carbohy- tent of intraluminal mixing of digesta and digestive en-
drate type, the matrix in which the carbohydrate is zymes, which can shift absorption sites and subsequent-
found, type of processing the carbohydrate has under- ly the rate of nutrients entering the bloodstream.35
gone, and total amount of carbohydrate consumed.2 7 Soluble fibers are fermented in the colon to short-chain
For example, extrusion is the process of cooking a grain fatty acids (SCFAs; acetic, propionic, and butyric acid).
to gelatinize the starches, which increases digestibility. Butyrate appears to be used by colonocytes, whereas pro-
In one study, dog foods containing 67% extruded corn, pionic and acetic acid are absorbed. These properties re-
rice, barley, or oats had small intestinal and total gas- sult in an acidic colonic pH and increased colonic bacteri-
trointestinal tract starch digestibility coefficients above al numbers, colonic mucosal mass, fecal dry matter, and
98%.28 When these grains were fed whole to dogs, how- water content.36 Soluble fiber incorporated into foods at
ever, their dry-matter digestibilities were lower and dif- 5%, 10%, or 13% DMB did decrease postprandial blood
fered according to the level of fiber in the grain (rice is glucose and insulin levels in normal dogs.37,38 The clinical
the most digestible, oats are the least). significance of feeding soluble fiber to diabetic patients
The glycemic and insulin responses of normal dogs may be limited to a particular type because only some
to diets containing the same amount of different carbo- gums—not all soluble fiber types—have been reported to
hydrate types (corn, wheat, barley, rice, and sorghum) lower fasting and postprandial blood glucose levels.
have been investigated.29 Sorghum produced the lowest Insoluble fiber is primarily composed of cellulose and
postprandial glucose response; however, there was an structural polysaccharides, which are relatively resistant
unexplained, disproportionate response between glu- to digestion, ferment slowly, and increase intestinal
cose and insulin levels (i.e., sorghum produced the low- residue and transit times.39–41 Insoluble fibers reportedly
est blood glucose levels but did not produce the lowest have less of an effect on gastric emptying, lowering of
insulin levels). Starches that resist intestinal hydrolysis, blood glucose, or colonic microflora compared with
called resistant starches, have resulted in significant re- soluble fibers.34 However, there is evidence to support
ductions in postprandial glycemia and insulinemia in the hypothesis that feeding foods with moderate
humans and may prove useful in diabetic pets.30,31 Di- amounts of insoluble fiber substituted for starch has a
etary carbohydrate content is not commonly reported; positive effect on glycemic control in dogs. Diabetic
it is referred to as nitrogen-free extract and is a calculat- dogs eating foods with more than 50% digestible car-
ed, not a determined, value. The dog foods successfully bohydrate and 10% to 15% DMB cellulose had signifi-
used in managing canine diabetes contain 45% to 55% cantly better glycemic control than did dogs fed the
nitrogen-free extracton a dry-matter basis (DMB). same food without the insoluble fiber.42,43
Fiber. The amount of crude fiber in the various types Fiber helps modulate postprandial blood glucose lev-
of commercial dog food ranges from 0.4% to 25% on a els by several plausible mechanisms: delaying gastric
DMB; estimates of crude fiber in grocery-brand dog emptying, slowing carbohydrate digestion and
foods (i.e., foods generally available in grocery or pet monosaccharide absorption from the small bowel, alter-
stores as opposed to therapeutic diets) average 3.7% for ing gastrointestinal hormones (which in turn affects
dry (range, 1.5% to 10.9%) and 1.5% for canned nutrient metabolism), and producing SCFAs that may

GLYCEMIC INDEX ■ NITROGEN-FREE EXTRACT ■ SOLUBLE VS. INSOLUBLE FIBER


Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

directly affect hepatic glucose metabolism. 44–47 Al- DM should effectively maintain a desired BW. It is best
though the mechanism is not precisely known, long- to initially calculate DER as a multiple of resting ener-
term consumption of guar gum has been shown to in- gy requirement (RER) based on the standard formulas
crease plasma insulin levels and improve glucose for normal animals. A reasonable initial estimate of
homeostasis in humans.48,49 DER is 1.6 × RER for neutered dogs and 1.8 × RER
In vitro, propionate has been shown to inhibit hepat- for intact dogs (RER is 70 × [BW in kg]0.75, or 15
ic glucose production and stimulate glucose utilization kcal/lb BW).56 Patients should be reevaluated monthly
via glycolysis.48 SCFAs administered parenterally to rats and food amounts adjusted as indicated by body condi-
(and possibly those absorbed from the large bowel) in- tion and weight.
crease the concentration of plasma proglucagon-derived After medical problems have been stabilized, a con-
peptides (GLP-1).50,51 GLP-1 is a potent insulin secreta- servative weight-loss protocol may need to be instituted
gogue and an inhibitor of glucagon secretion and gas- for overweight animals. Frequent monitoring and read-
tric acid secretion and emptying.52,53 Normal dogs fed a justment should be the norm rather than the exception
highly fermentable fiber (8% DMB) for 14 days had in weight-loss programs for animals with such concur-
significantly lower blood glucose but greater GLP-1 rent diseases as DM. A weekly loss of 1% to 4% of
and insulin concentrations compared with dogs fed the weight is considered safe, although it may take several
same concentration of a less fermentable fiber source.54 months to a year to achieve an ideal weight in severely
An ideal fiber content and type have not yet been es- obese animals.57,58
tablished; based on a limited number of published ca-
nine studies and personal clinical experience, a moderate Fat
amount (8% to 18% crude fiber DMB) of insoluble In diabetic dogs, abnormalities in lipid metabolism
fiber evidently improves glucose management in dia- are manifested as increased serum concentrations of
betic dogs. Results of some published studies in dogs triglycerides, cholesterol, lipoproteins, chylomicrons,
and other species indicate that the same level of soluble and free fatty acids. Lipid derangements can occur for
fiber may be equally effective.54,55 several reasons but appear to be related to decreased in-
sulin levels; most serum lipid values improve with in-
Energy sulin and dietary therapy (decreased fat, increased
Before making feeding recommendations to owners, fiber).3 Cardiovascular disease accounts for the majority
it is important to emphasize that a diabetic animal’s of deaths in humans with diabetes; canine patients,
clinical response to dietary manipulation depends on however, are more likely to suffer from pancreatitis as-
the level of control achieved over the primary disease sociated with persistent hyperlipidemia.59–61 Although
process as well as the presence or absence of concurrent diets high in fiber (10% to 25% DMB) have decreased
disease.17 For example, ideal BW may not be achieved if overall dry-matter digestibilities, fat digestibility re-
there is poor control of the diabetes or if such compli- mains above 90% when the fiber source is powdered
cations as hypothyroidism or hyperadrenocorticism are cellulose.39,62 Therefore feeding a lower-fat (12% or less
present. Owner education and consistent reevaluations DMB), high-fiber diet is recommended to minimize
are important tools in adjusting the food, dose, and the risk of pancreatitis, control some aspects of hyper-
feeding plan. lipidemia (chylomicrons), and reduce overall caloric in-
Basal metabolic rate may actually be decreased in un- take to favor weight loss or maintenance.
regulated diabetic patients because of decreased tri- Major initial benefits reported with omega-3 fatty
iodothyronine (T3) levels. The thyroxine (T4)-deiodi- acid supplementation in humans with DM included
nase system that converts T4 to T3 is directly responsive markedly lower serum triglycerides; moderately de-
to blood insulin levels (i.e., as blood insulin levels de- creased levels of cholesterol; a general increase in high-
crease, T3 levels decrease). Basal metabolic rate is direct- density lipoprotein concentrations; and reduced blood
ly responsive to T3 concentrations and therefore bal- pressure, viscosity, and platelet aggregation. In addition,
ances energy expenditure, presumably with energy all of these benefits potentially reduce the risk of
(glucose) intake. T4 levels may be decreased, and cau- atherosclerosis, coronary heart disease, and stroke.34
tion should be taken not to interpret a low T4 level at However, some diabetic patients that consume omega-3
this time as being diagnostic of hypothyroidism (euthy- fatty acids have increased levels of blood glucose, glyco-
roid sick syndrome). hemoglobin, low-density lipoprotein, and cholesterol.63
For most animals within the ideal BCS range (4 to Because there is little cardiovascular risk associated with
6), feeding at the daily maintenance energy require- canine diabetes, the use of omega-3 fatty acids may not
ment (DER) in conjunction with adequate control of be warranted given the potential loss of glycemic control.

GLP-1 ■ BASAL METABOLIC RATE ■ LIPID DERANGEMENTS ■ OMEGA-3 FATTY ACIDS


Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

Protein TABLE I
When insulin levels are low or ineffective, the body Balanced Generic Homemade Diet (1000 kcal/day)
“assumes” that blood glucose is low and begins to ca- for a 40-lb Adult Dog with Diabetesa
tabolize heart and skeletal muscle to supply amino acids
As-Fed Formulation
to gluconeogenesis as a substrate for the production of Ingredient Amount (g/day)b
“new glucose.” As insulin levels fall, serum glucagon in-
creases. Glucagon decreases protein synthesis and in- Rice (long-grain, white, cooked) 332
creases amino acid membrane transport, protein Chicken (dark meat, cooked) 202
catabolism, and amino acid conversion into glucose via Fiber (Fiber One Cereal®, General
gluconeogenesis. Studies completed in humans, rats, Mills, Inc, Minneapolis, MN)c 53
and dogs demonstrate that the catabolism of skeletal Vitamin/mineral supplement d
16 (1.5 tablets)
muscle is directly proportional to serum levels of amino Bonemeal 16
acids, insulin, and glucagon. It is therefore important ®
to provide protein of a quality and in a quantity that Salt (Morton’s Light Salt, 6
Morton International, a subsidiary
will meet the amino acid requirements of the diabetic of Rohm and Haas, Philadelphia, PA)
animal, which may have increased skeletal catabolism
and urinary losses of amino acids during periods of low Fat (corn oil) 5
insulin/high glucagon blood levels. Daily total 630
Protein quality is the quantity and ratio of the essen-
tial and nonessential amino acids and digestibility and Dry-Matter Analysis Compared
with AAFCO Allowances for Adult Dogs
metabolizability of dietary protein. Food for diabetic Nutrient AAFCO Homemade diet
dogs should contain approximately 18% to 25% pro-
tein DMB, preferably from an animal source and with Dry matter (%) ≥12 43
a true protein digestibility above 85%. Dietary protein Energy (kcal/100 g) 350 366
has been implicated in the pathogenesis of canine dia- Protein (%) 18 25
betic renal disease, and restricting protein has been rec- Fat (%) 5 10
ommended to retard the progression of the nephropa-
thy; however, there is currently very little scientific data Fiber (%) None 10
upon which to modify protein recommendations for Calcium (%) 0.60–2.5 1.6
human or canine diabetics.64 Phosphorus (%) 0.50–1.6 1.1
aFormulated using Mixit-Win, version 2.34, 1999, Agricul-
Micronutrients tural Software Consultants, Inc., San Diego, CA, and Food
Although high-fiber (approximately 10% DMB) diets Processor® Plus, Diet Analysis Software, version 5.03, 1990,
do decrease overall diet dry-matter digestibility and have ESHA Research, Inc., Salem, OR.
bApproximate conversions between grams and dry volumes: 1
been reported to inhibit the absorption of some ingested
tsp = 5 g, 1 tbsp = 15 g, 1 cup = 250 g. Owners should be en-
minerals, instances of clinically important deficiencies of couraged to use a dietary gram scale to weigh these foods con-
vitamins or minerals induced by dietary fiber have not sistently. All items should be mixed together in a blender to
been found in humans or dogs. In general, when a com- prevent dogs from picking out single food items. When a
plete and balanced diet is consumed in quantities suffi- homemade diet is fed, the patient should be examined by a
cient to maintain optimum BW, there is no need for ad- veterinarian regularly. Vitamin/mineral supplements should
not be cooked, heated, or stored with the food; instead, they
ditional vitamin or mineral supplementation. However, should be kept separate from the food and administered just
patients with uncontrolled diabetes, on weight-loss pro- before, during, or after a meal to ensure proper dosing. Over-
grams, or with other concurrent diseases are at greater all digestibility and availability of the vitamin and mineral
risk of developing a micronutrient imbalance when con- supplements are improved when using a United States Phar-
suming home-cooked foods (hamburger and rice) or macopoeia (USP)–labeled product and when the product is in
the small intestine along with a meal composed of proteins,
single-item diets (e.g., eating just baby food or just fats, and carbohydrates.
chicken). Patients with poor appetites should be fed a c To increase fiber content, Post® 100% Bran™ (Kraft Foods

specifically formulated homemade recipe using ingredi- Inc, Northfield, IL) can be used; to decrease fiber content,
ents that dogs will consistently consume and be given a Kellogg’s® All Bran® (Kellogg Company, Battle Creek, MI)
vitamin–mineral supplement known to be in proper can be used.
d Theragran M ® (Mead Johnson and Co., Evansville, IN)
balance with the recipe (Table I). adult vitamin/mineral tablet.
Macrominerals. Increased urine output associated AAFCO = Association of American Feed Control Officials.
with DM may increase obligatory loss of such elec-

GLUCONEOGENESIS ■ AMINO ACIDS ■ PROTEIN QUALITY AND DIGESTIBILITY


Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

trolytes as sodium, potassium, chloride, calcium, and but it may exist as a complex with nicotinic acid and
phosphorus. A ketoacidotic diabetic may have whole- amino acids to form a “glucose tolerance factor” that
body potassium and/or phosphorus deficits despite may aid insulin action. Chinese subjects with NIDDM
normal or near-normal serum concentrations. The ke- receiving 500 µg of Cr twice daily for 2 and 4 months
toacidotic state hastens the urinary loss of cations and had improved fasting and 2-hour insulin values.75 How-
moves intracellular potassium into extracellular spaces. ever, these beneficial effects were associated with Cr in-
Correction of acidosis with fluid, glucose, and insulin takes higher than the upper limit regarded as safe and
can cause a precipitous decline in serum potassium.65 adequate in the United States.76 Because investigations
When serum calcium, potassium, or phosphate con- evaluating Cr supplementation in canine diabetics have
centrations are difficult to maintain, measuring serum not been done, Cr supplementation is at best intriguing
magnesium and/or giving a loading dose of magnesium based on information from other species and from nor-
and then providing supplemental magnesium should be mal dogs.
considered.66,67 Body magnesium stores are depleted via Substantiation of micromineral benefits in diabetics
an osmotic diuresis when hyperglycemia is poorly con- has been confounding in most species.77 Improvement
trolled.68,69 In a magnesium-deficient patient, insulin may occur in malnourished patients receiving supple-
sensitivity may improve with supplementation but the mentation, but no micromineral has been implicated in
clinical signs of diabetes are not expected to resolve the pathogenesis of DM. For example, manganese defi-
with dietary repletion of magnesium alone. In general, ciency has also been associated with alterations in in-
treatment of DM that results in glycemic control will sulin secretion, carbohydrate and lipid metabolism, and
also correct macromineral deficiencies if the patient is impaired glucose utilization; repletion of manganese in
fed an adult maintenance food; however, excess dietary deficient animals restores normal glucose tolerance and
phosphorus should be avoided in dogs with renal im- improves insulin secretion, yet treatment of diabetic
pairment. Foods that meet AAFCO recommendations subjects with manganese supplements had no impact
for adult maintenance should supply adequate amounts on glycemic control.78 Iron overload can cause glucose
of macrominerals to compensate for the increased on- intolerance due to pancreatic damage secondary to
going losses in controlled diabetic dogs. hemochromatosis; however, iron status does not seem
Microminerals. Changes in micromineral nutrition to play a role in the pathogenesis of DM.79 Selenium
status associated with DM have been evaluated in deficiency has also been associated with changes in glu-
many species. Zinc plays a clear role in the synthesis, cose tolerance or insulinlike activity but does not ap-
storage, and secretion of insulin as well as the confor- pear to play a role in the development or manifestation
mational integrity of insulin. Whole-body stores of of DM.68
zinc are usually low in diabetic humans and rats, In general, until proven otherwise, providing a food
which affects the ability of islet cells to produce and se- with microminerals supplied according to AAFCO rec-
crete insulin and compounds the problem.70,71Diabetic ommendations for an adult maintenance diet should
complications in humans are postulated to be related suffice for most patients with DM. For clients interest-
to increased intracellular oxidants and free radical pro- ed in antioxidant supplementation, an over-the-counter
duction associated with decreases in intracellular zinc human antioxidant formulationc (1 tablet/dog/day)
and zinc-dependent antioxidant enzymes.72 The rela- containing zinc, selenium, copper, and manganese is
tionship among diabetes, insulin, and zinc is complex well within the AAFCO allowances.
with no clear cause and effect. The exact mechanisms Vitamins. DM may increase or decrease vitamin bal-
underlying altered zinc metabolism in diabetes have ance, and, conversely, vitamin status may affect the de-
not been adequately identified to make specific recom- velopment and manifestations of DM. Much of the in-
mendations. vestigative work in this area is controversial and needs
Chromium (Cr) is an essential nutrient involved in clarification but probably involves protecting diabetics
normal carbohydrate and lipid metabolism; require- cAntioxidant vitamin and mineral supplement containing

ments are postulated to increase with increased glucose 5000 IU vitamin A (as beta-carotene), 250 mg vitamin C,
intolerance and diabetes. Cr supplementation improves 200 IU vitamin E (as α-tocopherol), 7.5 mg zinc, 15 µg sele-
the glucose–insulin system in humans with hypo- nium, 1 mg copper, and 1.5 mg manganese per tablet and
glycemia, hyperglycemia, diabetes, and hyperlipemia.73 that carries a United States Pharmacopoeia (USP) label
(Spring Valey Antioxidant Vitamins, Pharmavite Corp., Mis-
Cr improves insulin binding, insulin receptor numbers, sion Hill, CA). When recommending supplements, it is advis-
insulin internalization, beta-cell sensitivity, and insulin able to use products that carry the USP label, which indicates
receptor enzymes with overall increases in insulin sensi- a standardized formulation and ensures product disintegra-
tivity.74 Cr has no known enzymatic cofactor function, tion, weight, purity, and potency.

KETOACIDOSIS ■ MAGNESIUM ■ ZINC ■ CHROMIUM


Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

from oxidative and free radical damage.80–82 Supplemen- unit). A consistent “fixed” dietary formula eliminates this
tation of vitamins C and E in humans at a rate of two source of variables and need not be examined when
to 10 times the recommended daily allowance has been glycemic control is poor or weight begins to change.
suggested based on reported benefits in a few small tri- Highly digestible foods (i.e., those for which more
als and because these supplements are generally regard- than 90% of dry matter is digested) make it more diffi-
ed as safe and affordable.83 For clients interested in an- cult to control serum glucose and should be avoided.
tioxidant supplementation, an over-the-counter human Diets containing 8% to 18% crude fiber (DMB) typi-
antioxidant formulationc (1 tablet/dog/day) containing cally have dry-matter digestibility coefficients between
beta-carotene, vitamin C, and α-tocopherol is well 70% and 80%. Diets with less than 70% dry-matter
within the AAFCO allowances. digestibility and low fat concentrations may not ade-
In diabetic patients requiring intravenous fluid thera- quately maintain optimal BW.
py to correct polyuria/polydipsia, water-soluble B-vita- Dogs with difficult appetites that are fed homemade di-
min supplements should be administered until hyper- ets, table food, vegetarian diets, or single-food items are at
glycemia is controlled. Based on the daily vitamin greater risk of developing subclinical nutritional imbal-
recommendations for adult dogs and the vitamin con- ances. Foods designed, formulated, or prepared by owners
centrations available in most solutions,d a recommend- are rarely nutritionally complete, balanced, or consistent.
ed dose of 1 ml of B vitamins per 100 kcal DER will These patients may not only have protein–calorie malnu-
meet, and in some cases exceed, a dog’s daily B-vitamin trition but are more likely to have several vitamin and
(except for B12) requirements by severalfold. Most for- mineral imbalances concurrently (e.g., calcium and trace-
merly healthy pets and humans, however, have hepatic mineral deficiencies if no supplements are used and/or
stores of B12 that are sufficient for 3 to 5 years. subclinical vitamin A and D toxicities if liver is fed). A
well-formulated homemade diet (Table I) composed of a
Food Type and Digestibility meat and carbohydrate source readily consumed by the
Soft–moist canine foods contain increased amounts patient is preferable to unpredictable consumption of var-
of humectants (e.g., corn syrup, sucrose, dextrose, cane ious pet foods or single food items. Once a homemade
molasses, propylene glycol) to control water activity or recipe is determined to be successful (i.e., consistently
microbial growth and thus tend to have a hyper- made by the owner and consumed by the dog), insulin
glycemic effect compared with canned or dry foods.84,85 dosage can be determined and adjusted.
Fructose in the form of sucrose (or high-fructose corn
syrup) may also be used as a humectant in commercial Feeding Schedule
semimoist foods. The potential effects of fructose in Because insulin is usually administered in conjunc-
foods for dogs with DM have not been evaluated. tion with meals, feeding methods must complement
Soft–moist foods also have the highest digestible energy pharmacologic protocols. Feeding must be coordinated
content because highly digestible carbohydrate sources with administration of exogenous insulin. The goal is
are used. Canned and dry foods tend to have lower dry- to have glucose slowly absorbed when insulin levels are
matter and energy digestibilities and thus are preferred adequate, thereby minimizing postprandial hyper-
for diabetic pets. Dry foods may have a slight advantage glycemia. Ideally, small meals fed at the time of insulin
over canned foods in controlling postprandial blood administration and at regular intervals throughout the
glucose levels because dry foods empty from the stom- day result in minimal hyperglycemia.24,86 Most owners
ach more slowly than do canned foods; this is because can feed two equal-sized meals daily: one at the time of
stomach contents must have a high water content be- insulin injection and the other 8 to 10 hours later.22 For
fore passing into the duodenum. animals with poor glycemic control, feeding should be
A fixed-, as opposed to an open-, formula diet is also divided into three or more smaller meals to help main-
important in the overall successful management of dia- tain serum glucose concentrations within an acceptable
betic dogs (Table II). “Open-formula diets” are typical of range.1,24,87 For example, patients receiving two insulin
those purchased from the grocery or pet store; the exact injections daily and fed four equal small meals are fed a
ingredient formulation varies with market prices. Hence meal with each insulin injection; the other two meals
glycemic index and postprandial glucose response will are spaced equally throughout the day.
vary as the formulation varies over time (e.g., unit to
dProduct containing 50 mg thiamin, 2 mg riboflavin, 100 mg
REASSESSMENT
niacin, 2 mg pyridoxine, 10 mg pantothenic acid, and 0.4 µg Diabetes mellitus can be frustrating to manage. The
vitamin B12 per ml (B-Vitamin Complex, Butler Co., Colum- long-term side effects of poor glycemic control seen in
bus, OH). humans are uncommon in dogs.88 Clinical signs of im-

B-VITAMIN SUPPLEMENTS ■ HUMECTANTS ■ POSTPRANDIAL HYPERGLYCEMIA


Small Animal/Exotics 20TH ANNIVERSARY Compendium August 1999

TABLE II
Approximate Nutrient Profiles of Foods Marketed for Canine Diabetics versus Average Grocery or Pet Store Brands
Crude
Diet Calories a Fat Protein) NFE b Fiber Fiber
Product Name Type (kcal) (DMB) (DMB) (DMB) (DMB) Type
Hill’s Prescription Dry 223 6.9 16.7 55.2 16.8 Insoluble
Diet® Canine w/d® Canned 347 12.0 16.5 53.9 13.5 Insoluble
(Hill’s Pet Nutrition,
Topeka, KS)

Eukanuba Veterinary Dry 253 8.0 29 48.3 2.9 Soluble


Diets® Nutritional
Weight Maintenance
Formula™ Glucose-
Control™ (The IAMS
Company, Dayton, OH)

CNM OM-Formula® Dry 276 6.0 22.8 48.6 15.2 Mixedc


Canine Diet (Pro-Visions, Canned 204 8.4 44.1 21.7 19.2 Mixedc
Pet Specialty Enterprises,
a division of Ralston
Purina Company,
St. Louis, MO)

IVD™ Select Care™ Dry 278 9.8 23.7 43.9 15.8 Mixedc
Canine Hifactor Formula Canned 282 7.9 24.7 47.6 15.9 Mixedc
(Innovative Veterinary
Diets, Newport, KY)

Waltham® Veterinary Dry 223 7.5 20.0 48.8 4.5 Mixedc


Diet Canine High
Fiber (Waltham Company,
Vernon, CA)

Grocery or pet Dry 350 11.8 23.6 52.8 3.7 Mixedc


store brands (n = 33) Canned 450 27.4 41.9 18.4 1.5 Mixedc
aCalories per 8 oz of dry food or 14 oz of canned food.
bNFE as a measure of carbohydrates.
cA mixture of soluble and insoluble types. Proper ratio for diabetics is unknown.

DMB = dry-matter basis; NFE = nitrogen-free extract.

provement are indicated by decreased water intake, uri- levels) or weight changes (intentional or unintentional)
nation, and food intake; achievement of weight goals; may require adjustments in the insulin dosage to main-
and a generalized increased thriftiness. Conversely, per- tain glycemic control. It is also important to monitor
sistent polyuria, polydipsia, polyphagia, urinary tract and control concurrent disease processes commonly as-
infections, and inability to achieve weight goals indi- sociated with diabetes. Reassessment may take place ev-
cate poor glycemic control. Response to treatment can ery 3 to 4 months if the animal is stable and reportedly
be assessed through careful questioning of the owner, doing well; if the patient should become symptomatic,
by performing a 12- to 24-hour blood glucose curve, however, reassessment may be necessary every 1 to 2
and by measuring glycosylated hemoglobin.89 Exercise weeks until control has been reestablished. Regardless
should be consistent from day to day because large vari- of how frequent the recheck visits occur, the owner
ations in activity level may affect glycemic control. should always be asked to describe the diet being con-
Dietary changes (e.g., increasing or decreasing fiber sumed by the dog and the feeding schedule.

EVALUATING TREATMENT RESPONSES ■ REASSESSMENT SCHEDULES


Compendium August 1999 20TH ANNIVERSARY Small Animal/Exotics

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blood glucose and insulin concentrations in healthy dogs. About the Author
Am J Vet Res 50:984–989, 1989. Dr. Remillard is the staff nutritionist at the Angell Memorial
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Contin Educ Pract Vet 10(12):1387–1392, 1988. Animal Hospital, Boston, Massachusetts. She is a Diplo-
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frequency on blood glucose, insulin, and free fatty acids in