Fat, Fuzzy, or Foundered?

Transcription

1 Fat, Fuzzy, or Foundered? Navigating weight loss methods and concerns of insulin resistance, equine Cushing's disease (PPID), & equine metabolic syndrome.

2 Overview 1. How to tell if your horse is fat 2. Understanding the endocrine system and Equine Metabolic System Pituitary Pars Intermedia Dysfunction (PPID) Insulin Resistance (IR) 3. Methods for weight loss, Diagnosis and Treatment

3 Concerns with condition Over-conditioned often fat, obese NOT a comical condition Well-conditioned, breed standardsoften over the ideal/healthy weight **Change OUR expectations!! Under-conditioned, skinny - no one wants to see a skinny horse More medical conditions associated with fat than with moderately thin

4 Concerns with over-conditioning Increased stress on the heart and lungs Greater risk of laminitis or founder Increased risk of developmental orthopedic (bone and joint) problems in young, growing horses More strain on feet, joints, and limbs Worsened symptoms of arthritis Less efficient cooling of body temperatures Fat build-up around key organs which interferes with normal function Reduced reproductive efficiency Greater lethargy and more easily fatigued Just to name a few!

5 Quantifying Condition Scales Not convenient Gives accurate number Doesn t account for fat pads Weight tapes Helpful for administering medication/dewormer Follow trends Only measures heart girth Can calculate approximate weight Doesn t account for fat pads Weight (lb) = Girth (in) Girth (in) Length (in) 330

6 Body Condition Score Body condition score (BCS) Grades fat stores in 6 regions of the body CREST WITHERS TAILHEAD Average the score of each body part to give overall score Score 1-9; 1 = emaciated & 9 = obese. Score 4-5 = ideal weight More concerned with fat stores (regional adiposity) not 5 # of lbs. Not all fat is benign, just like in people. SHOULDER RIBS LOIN

7 Many visual aides available Based upon Henneke Body Condition Scoring System Henneke et al. EquineVetJ(1983)15(4): Pick one system and follow it closely to monitor weight gain/loss and regional adiposity Please use handout to understand how we BCS your horse.

8 Body Condition Score 1

9 Body Condition Score 2

10 Body Condition Score 3

11 Body Condition Score 4 IDEAL!

12 Body Condition Score 5 IDEAL!

13 Body Condition Score 6 Love-Handle

14 Body Condition Score 7

15 Body Condition Score 8 Rain gutter Heart shaped butt

16 Body Condition Score 9

17 So what do you think, Doc? Fat or Thin?

18 Let s break it down What would you score the neck?

19 Average each score for overall BCS 1. Work with a friend for a second pair of eyes 2. Assign score for each body part (1-9) 3. Total all numbers for body parts i.e Divide total by 6 i.e. (always round up) 5. Over ideal body condition.

20 What would you score the withers?

21 Average each score for overall BCS 1. Work with a friend for a second pair of eyes 2. Assign score for each body part (1-9) 3. Total all numbers for body parts i.e Divide total by 6 i.e. (always round up) 5. Over ideal body condition.

22 What would you score loin?

23 Average each score for overall BCS 1. Work with a friend for a second pair of eyes 2. Assign score for each body part (1-9) 3. Total all numbers for body parts i.e Divide total by 6 i.e. (always round up) 5. Over ideal body condition.

24 What would you score tailhead?

25 Average each score for overall BCS 1. Work with a friend for a second pair of eyes 2. Assign score for each body part (1-9) 3. Total all numbers for body parts i.e Divide total by 6 i.e. (always round up) 5. Over ideal body condition.

26 What would you score the ribs?

27 Average each score for overall BCS 1. Work with a friend for a second pair of eyes 2. Assign score for each body part (1-9) 3. Total all numbers for body parts i.e Divide total by 6 i.e. (always round up) 5. Over ideal body condition.

28 What would you score the shoulder?

29 Average each score for overall BCS 1. Work with a friend for a second pair of eyes 2. Assign score for each body part (1-9) 3. Total all numbers for body parts i.e = Divide total by 6 i.e. /6 = 6 (always round up) 5. Over ideal body condition.

30 Average each score for overall BCS 1. Work with a friend for a second pair of eyes 2. Assign score for each body part (1-9) 3. Total all numbers for body parts i.e = Divide total by 6 i.e. 36/6 = 6 (always round up) 5. Over ideal body condition.

31 Fit vs. Fat vs. Thin?

32 Fit vs. Fat vs. Thin?

33 Fit vs. Fat vs. Thin?

34 Fit vs. Fat vs. Thin?

35 Fit vs. Fat vs. Thin?

36 Equine Metabolic Syndrome How do we get from Fat to Fuzzy & Foundered? 1. What is the link between obesity and insulin resistance? 2. What is insulin resistance and what does the suspect horse look like? 3. What is the link between insulin and laminitis? 4. What is Equine Metabolic Syndrome (EMS)? 5. What is PPID a.k.a. Cushing s disease?

37 Insulin Resistance 1. A horse becomes fat due to diet, predisposing them to insulin resistance which can lead to laminitis. 2. Insulin resistance may cause a horse to become fat or develop regional adiposity leading to further metabolic issues inducing laminitis. 3. Not all fat horses are insulin resistant and not all insulin resistant horses are fat. 4. Our goal is to identify and manage the insulin resistance horse before the onset of laminitis (aka Founder).

38 Insulin Resistance clinical signs 1. Cresty neck = classic sign 2. Obesity, regional adiposity 1. Tail head 2. Shoulder 3. Sheath/Udder 3. Usually 5-15 years old 4. Breed predisposition/genetics 1. Pony breeds 2. Morgans 3. Arabians 4. Warmbloods 5. Saddlebreds 6. Paso Finos 7. Most breeds possible, but unlikely in Thoroughbreds & Standardbreds 5. Evolutionary adaptations 6. Easy-Keepers ; Stay fat on air

39 Endocrine system 101 Definition - the glands and parts of glands that secrete hormones, etc into the circulation to control bodily metabolic activity. Glands/Organs of importance: Pituitary gland - at base of brain Secretes ACTH Adrenal glands next to kidneys Secretes Cortisol Pancreas near stomach Secretes Insulin Adipose tissue regional adiposity! Secretes Adipokines (fat hormones)

40 Endocrinology 101 Insulin 1. Insulin is a protein produced by beta cells in the pancreas. 2. Regulates carbohydrate and fat metabolism. 3. Primarily responsible for removing blood sugar (glucose) from the blood stream 1. Moves glucose into muscle cells and liver cells to be stored as glycogen 2. Moves glucose into fat cells (adipocytes) to be stored as triglycerides 4. Integral in thousands processes in the body including the production of other proteins

41 Insulin Resistance - defined 1. The failure of tissues to respond appropriately to insulin and take up glucose. 2. What happens 1. Insulin is not 100% effective 2. Glucose and sugars stay in the blood stream 3. Pancreas secretes more insulin to try and remove glucose from the blood stream 3. Result is high levels of insulin in the blood stream 1. Hyperinsulinemia 4. Can still have a normal blood glucose level. 1. compensated *occurs in horses 2. uncompensated similar to human Type 2 diabetes GLUCOSE GLUCOSE INSULIN GLUCOSE GLUCOSE

42 How does IR relate to laminitis? IR and hyperinsulinemia ( insulin levels in the blood stream) Leads to an increased risk of laminitis (pasture-associated) Insulin given at supraphysiologic doses over 2-3 days has been shown to induce laminitis (experimentally)* The laminae may be very sensitive to insulin levels. More research is required. Number of theories: 1) Laminae (hoof tissues) starved of glucose 2) Vasoconstriction (decreased blood flow to the laminae) 3) Adipokine-induced inflammation (inflammatory hormones secreted by overstuffed fat cells) targets the laminae Decrease the laminitis threshold Obesity + Insulin Resistance put horses at a high risk of developing laminitis *De Laat et al Equine Laminitis: induced by 48 h hyperinsulinemia in Standardbred horses. Equine Vet J 2010, 42:

43 Equine Metabolic Syndrome (EMS) Defined as having three characteristics 1. Regional adiposity OR generalized obesity 2. Insulin Resistance (IR) 3. Laminitis A predisposition to laminitis A current or a previous bout of bilateral lameness Sole bruising, foot soreness, etc Wide white lines w/hemorrhage Rings around hoof wall Often without changes on x-rays Our goal is to diagnose horses as soon as possible in order to institute preventative therapy and treatment before the onset of laminitis (aka Founder).

44 Insulin Resistance may be a precursor 1. New research indicates many horses with Cushing s disease (PPID) also have IR. 2. Could IR be a precursor to PPID or do they occur together? 3. Let s talk about the similarities between IR and PPID

45 Equine Cushing s-like Disease Just a reminder Glands/Organs of importance: Pituitary gland - at base of brain Secretes ACTH Adrenal glands next to kidneys Secretes Cortisol Pancreas near stomach Secretes Insulin Adipose tissue regional adiposity! Secretes Adipokines (fat hormones)

46 *** Pituitary Pars Intermedia Dysfunction, formally known as equine Cushing s disease Pituitary Gland Sits below the hypothalamus (the general of the metabolism) and the optic nerve (daylight impacts the pituitary). Two lobes Posterior Oxytocin, vasopressin Anterior ACTH, FSH, MSH, Anterior pituitary further divided into sections (pars) Pars Intermedia*** Pars Nervosa Pars Distalis

47 Normal pituitary function The hypothalamus secretes CRH (Corticotropin Releasing Hormone) CRH CRH stimulates the Anterior Pituitary to release ACTH (Adrenocorticotropic Hormone) ACTH adrenal gland CORTISOL CORTISOL ACTH enters the blood circulation and travels to the adrenal gland The adrenal gland makes cortisol, the stress hormone, and releases it into the blood stream. Cortisol from the blood stream reaches the hypothalamus and tells it to decrease production and release of CRH and thus ACTH and Cortisol

48 Abnormal pituitary function - horses CRH The horse is unique from other species with Cushing s-like disease (hyperadrenocorticism) The pars intermedia of the anterior pituitary gland actually enlarges CORTISOL The abnormal par intermedia does not respond to the body s signals of too much cortisol in circulation ACTH adrenal gland CORTISOL The pars intermedia continues to produce more ACTH which causes The adrenal glands to continue to produce cortisol

49 Cortisol the stress hormone Moderate amounts of cortisol are necessary for proper functioning of many organs Too much cortisol has detrimental effects on those same organs. Increased fat production Weakened immune system Increased urine output Poor digestion, prone to EGUS Poor performance to name a few

50 Pituitary Pars Intermedia Dysfunction (PPID) - Formerly known as equine Cushing s Disease: Clinical Signs 1. Usually > 15 years of age 2. Hair coat abnormalities 1. Delayed shedding of winter haircoat 2. Increased hair length 3. Dullness of haircoat 3. Retention of winter hairs 1. Back of legs 2. Belly 3. Behind elbow 4. Beneath jaw 4. Shift in metabolism 1. Easy keeper to Hard keeper 5. Regional Adiposity 1. 6 regions of fat Cresty neck 6.. Lameness/Laminitis, poor performance, infertility, etc. 7. Increased thirst/urination

51 PPID and Insulin 1. High levels of circulating cortisol can affect insulin levels in the body. 1. Inhibit insulin activity (thus increasing amount of insulin in body) Hyperinsulinemia often seen in PPID 2. Further questions we don t have answers for: 1. Is IR a precursor for PPID 2. How can we diagnose both PPID and EMS before we see clinical signs Fat, fuzzy and foundered

52 To summarize: EMS PPID Age - <15 yo Pony, Morgans, Arabians, Warmbloods, Saddlebreds, Paso Finos, other Normal hair coat Obesity or regional adiposity Age > 15 yo Any breeds, prevalent in pony breeds Long, thick, sometimes curly, delayed shedding, excessive sweating Weight loss, swayback, pendulous abdomen, regional adiposity still possible and all can predispose to laminitis!

53 Hypothyroidism 1. Low thyroid hormone levels in the blood stream EMS horses have normal thyroid hormones 2. No longer a commonly recognized cause of obesity in adults Thyro-L (levothyroxine) is utilized not as a supplement for low thyroid hormone but for a weight-loss supplement 3. Actual hypothyroidism 1. Disease in foals 2. Low circulating thyroid hormones

54 Diagnosis & Treatment Whether EMS or PPID our GOAL is to diagnose early and establish a treatment protocol to PREVENT laminitis. OVERVIEW: 1. Diagnose PPID & Meds 2. Diagnose IR & Meds 3. Weight Management 1. Exercise 2. Diet

55 Diagnosis for EMS & PPID A large part of diagnosis can be correctly made through physical characteristics. Test to detect early disease Test to monitor treatment Pre-treatment vs Post-treatment Are the treatments working? Do we need to get more aggressive with treatment? Lets start with PPID

56 Diagnosis PPID Resting ACTH concentration PPID if ACTH > 35 pg/ml Blood sample collected; must be centrifuged within 4 hours. ACTH with pain and stress, no testing during laminitis flare-up ACTH in late summer and autumn in healthy horses (Negative if ACTH < 50 Aug-Oct) ACTH adrenal gland CRH CORTISOL CORTISOL Seasonal stimulation of ACTH Possibly helpful in pre-ppid diagnosis Careful interpretation required Likely positive if very high ACTH Dexamethasone Suppression Test TRH stimulation

57 PPID Medication: Pergolide ACTH adrenal gland P CRH CORTISOL CORTISOL Pergolide mesylate Dopamine receptor agonist Parkinson s disease 1. Prascend FDA approved 1mg tablet $1.99/day 2. Compounded No FDA oversight Lack of consistency/stability $0.74/day Dosing 1mg daily horses 0.5mg daily ponies Some horses require 4-5 mg/day Side effects: Loss of appetite, dullness Discontinue x 2 days (or appetite returns) ¼ dose x 2 days, ½ dose x 2 days, ¾ dose x 2 days

58 Other medications Cyproheptadine Less effective than pergolide Blocks serotonin Expensive Bromocriptine Less effective than both pergolide and cyproheptadine Dopamine agonist Infrequently available Supplements If it sounds too good to be true then it probably is There is no natural pergolide. 1. Chasteberry (Vitex-agnus castus) 2. Magnesium 3. Chromium There is limited scientific information regarding their effectiveness.

59 Weight management - PPID The Classic PPID easy-keeper to hard-keeper Old horse with sway back, can t eat enough! 1. Resolve dental issues Annual oral exam +/- float 2. Exercise! Modulate insulin levels Good for maintaining muscle mass Excellent for joint health 3. Dietary changes

60 PPID Feeding Feed high calorie but low carbohydrate feeds 1. Primarily grass hay based diet 2. Forage Dengi w/o molasses 3. Hay stretcher 4. Fat calories beet pulp, vegetable oil, corn oil 5. Pelletized fat supplements likely still have some carbohydrates for palatability 6. Some senior grains 7. Mineral/vitamin supplement Buck Hill Veterinary service is in no way affiliated with Blue Seal feeds or Lucerne Farms

61 Diagnosis Insulin Resistance 1. Fasting Insulin <20uIU/ml 2. Resting Insulin:Glucose Insulin = uiu/ml Glucose = Oral Sugar (Glucose) Test (OST) Fasting 1 flake hay 10pm Karo syrup (light color, not lite) 75 cc per average sized horse 1 hour prior to blood draw Test insulin between 8-10am 4. Combined Insulin:Glucose Test BG Curve Baseline Insulin & 45 min Insulin Insulin will be elevated with: 1. Large grain meals 2. Pregnancy 3. PPID 4. Illness 5. Pain 6. Stress

62 IR medication 1. Metformin 1. Human Type 2 diabetes 2. glucose production by liver 3. Enhances insulin activity & sensitivity 4. Poor absorption by horses 5. Marginal effectiveness 6. Pioglitazone 2. Levothyroxine (Thyro-L) 1. Thyroid hormone increases metabolic rate for weight loss 1. Not supplementing a deficiency 2. If >700lb 1. 4 tsp (2 scoops) 3. If < 700 lb 1. 2 tsp ( 1 scoop) months 5. Gradually wean-off over 1 month 6. $ /day Especially for horses that cannot exercise i.e. experiencing laminitis episode Some supplements 1. Cinnamon 2. Artichoke leaf 3. Psyllium 4. Fenugree 5. Ginger 6. Kelp

63 Weight management Weight Loss 1. physical activity 2. caloric intake Regular exercise Improves insulin sensitivity even before weight loss or a change in fat distribution

64 Weight Management Step 1 Exercise Regimen exercise sessions per week Riding or Lunging minutes per session Start with walk 2. Then increase duration and intensity of exercise 1. Once at 30 minutes then extend to 5 sessions per week 2. Once at 30 minutes walk consider adding trot 1. Usually safe to add 1 minute trot per week 2. If already in reasonable fitness can walk, trot, canter 5 sessions per week 3. Ponies hand-walked 10 minutes per day lost weight! 1. Won t self-exercise!

65 Disclaimer: We do not have PhD s in equine nutrition the following is a compilation of the latest and most accurate recommendations based on solid scientific research Weight Management Step 2 Calorie reduction 1. Eliminate pasture access Confine to drylot 2. Limit pasture access Use grazing muzzle Limit time on pasture 3. Restrict/limit hay intake 1.5% body weight 4. Eliminate grain from diet Replace with ration balancer For horses with hyperinsulinemia : Important to minimize insulin spikes by decreasing carbohydrate intake Decrease glycemic response 1. Know the carbohydrate content that is fed 2. amount of carbohydrates fed

66 How do we evaluate carbohydrates? Carbohydrate component of feed: Structural carbohydrates Cellulose Hemi-cellulose (Hind-gut fermentation) Non-structural carbohydrates (NSC) Simple sugars (glucose) Starches Fructans (fructose) (S.I. absorption)

67 Non-Structural Carbohydrates (NSC) -not all carbs are created equal- NSC (%) WSC (%) + Starch (%) WSC = Water Soluble Carbohydrates Those that dissolve in water Simple sugars glucose- absorbed in S.I. Significant glycemic response! Fructans fermented in colon Induces relatively smaller glycemic response ESC = Ethanol Soluble Carbohydrates Dissolve in 80% ethanol Subset of WSC Mostly simple sugars, fewer fructans Starch = many glucose molecules Once broken down can induce glycemic response

68 Where are carbohydrates on the label? This information is unfortunately not available on the feed back label. A veterinarian or nutritionist is usually on staff at feed companies to answer questions regarding carbohydrate quantities but this requires a phone call Buck Hill Veterinary service is in no way affiliated with Blue Seal feeds

69 Where are carbohydrates on the label? Feedstuff Soybean hulls 6.3 Alfalfa pellets 9.5 Average %NSC Alfalfa cubes 10.3 Alfalfa hay 11.5 Beet pulp 12.3 Warm season grass hay (Bermuda, Tifton, teff) 13.6 Soybean meal 16.4 Cool season grass hay (timothy, orchardgrass, brome) 18.8 Barley hay 20.8 Oat hay 22.1 Rice bran 24.2 Wheat bran 31.8 Wheat middlings 38.0 Oats 54.1 Barley 61.7 Corn 75.3 Buck Hill Veterinary service is in no way affiliated with Blue Seal feeds

70 Carbohydrate levels in some common senior and low carb grains Brand Grain Type Kcal/lb WSC (%) ESC (%) Starch (%) Blue Seal Sentinel Senior Poulin Grain Equi-pro Senior Blue Seal Carb-guard Blue Seal Sentinel L-S Poulin Grain Carbsafe Buck Hill Veterinary service is in no way affiliated with Blue Seal feeds or Poulin Grain

71 Carbohydrate levels in some common forage extenders Brand Kcal/lb WSC (%) ESC (%) Starch (%) Blue Seal Hay stretcher Blue Seal Beet pulp Poulin Grain Fibre-max Poulin Grain Forage Extender Buck Hill Veterinary service is in no way affiliated with Blue Seal feeds or Poulin Grain

72 Hay and pasture analysis: Because leafy, green OR course, strawlike hay can t be equated to sugar and calorie content Equi-Analytical (Dairy One) Analyze WSC, ESC & starch in hay, pasture, grain samples $30 Complete analysis of hay, pasture $18 Poulin Grain Hay analysis, NSC and ESC for clients Unable to analyze WSC at this time. Grass/Pasture sugar content variations: 1. Higher in the Spring 2. Higher after Autumn rains 3. Higher after a frost 4. Higher in the afternoon ** when conditions favor photosynthesis** 1. Safer in AM 2. Safer between late Spring and early Autumn

73 Soaking hay Why? Leach out WSC in order to reduce overall NSC levels in hay. How? Use large clean bucket and completely submerge flake hay When? At least 60 minutes for initial reduction in WSC. Soaking does not provide a predictable decrease in WSC content.* However it does substantially decrease the WSC content and is therefore recommended in managing laminitis Studies have shown that maximum WSC reduction may take hours of soaking hay.* *Longland et al Effect of soaking on the water-soluble coarbohydrate and crude protein content of hay. Vet Rec :

74 Mineral and vitamin supplements 1. Some mineral-vitamin loss due to soaking hay is possible. 2. Recommend average mineralvitamin supplement for horses 1. This is more than just a salt block. 3. Most major feed companies now sell a pelleted formulation so horses believe that they are still getting grain! 1. Still have calories and carbohydrates Brand Blue Seal Minivite Lite Poulin MVP Calories (kcal/lb) WSC (%) ESC (%) Starch (%) Buck Hill Veterinary service is in no way affiliated with Blue Seal feeds or Poulin Grain

75 To Summarize: PPID 1. Diagnose with ACTH test 2. Treat with pergolide as directed by your veterinarian 3. Exercise once laminitis is under control 4. Feed low WSC&starch feed 5. Soak hay if also IR IR 1. Diagnose with insulin:glucose or oral sugar test 2. Weight loss with thyroxine as directed by your veterinarian 3. Exercise once laminitis is under control 4. Feed low calorie, low WSC&Starch feed 5. Soak hay