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Diabetic Cat Care

DIABETIC PEARLS      GLEANED      DIRECTLY FROM      DR. ELIZABETH HODGKINS'      FORUM DISCUSSIONS

One of the saddest days in the FD journey many of us have taken, was the day Doc decided it was time to pursue another avenue within the veterinary field and stopped participating in forums.  Fortunately, her words of wisdom are not entirely lost and have been captured in an effort to continue to help as many diabetic cat owners as possible.

The following are direct quotes from Dr. Hodgkins' on-forum discussions about TR;

The veterinary profession's history with FD is nothing short of pitiful. We, collectively, have completely dropped the ball, not only in how we have mismanaged this disease once cats have it, but we have also failed to understand what causes it. Feline Diabetes is a human-caused disease that kills cats. Today, almost all vets have backward ideas of how to deal with this disease. A vet's idea about waiting to see if toxic BG levels will disappear on their own is incorrect.


TR = TIGHT REGULATION

Where the BG levels are brought closer to a cats normal BG levels and maintained there by careful testing and dosing of insulin.

Multiple dosing is rather miraculous, I must say. But then, it makes sense. This is what the pancreas does naturally, so the more we can mimic that, the better for the cat. Not sure why this hadn't occurred to everyone (including me) long ago, it is so logical.

TR is sort of like life, don't you all think? As Gilda Radner, God bless her, said, "It's always something..."

There ARE so many variables, and for the life of me, I cannot explain those cats that just seem to "get" what they are supposed to do right away and the others who are so much tougher. I see this in my practice. Many of my patients do well quickly, some do so well so fast I myself can't even believe it, and then there are others that just struggle for weeks, even months. Then WHAM! One I will have given up on ever getting off the juice just does IT, one day getting 2-3 shots and then none. Remember Dee with Bo, the cat that had been diabetic for some while , ON STEROIDS for some weird autoimmune disease, that went off in about a month on TR (and off steroids, of course)? That was weird. That cat simply should NOT have done that. But he did. Then I will get another cat that is pretty new, looks really straightforward, that will give me fits. All I know is this: I have NEVER worked with TR in any cat that has not done better health wise, much better, on this regime, than on any other. Yes, we all focus on the remission, and I am the worst of the worst about this, but compared to other protocols, this one gives health back to cats better than the others, and when I refocus on that, it seems the remissions come more easily. Almost like the universe withholds the big prize until I take my eye off it and start looking for quality of life instead. Sorry for all the philosophy, but I, like all of you, can get discouraged sometimes and I have to rethink what I am REALLY trying to do. Then the big prize seems to come.

Instability of BG in FD patients, especially fairly new ones, is common. The system, and particularly the liver and pancreas (two organs that have to get back into sync again and dance like Fred Astaire and Ginger Rogers), takes time for things to get re-regulated. Yes, it is always a good idea to look for other causes of poor regulation after things are looking good, but in any event, you have to give insulin. No matter what is causing the BG instability, it is certain that only insulin can control the roller coaster. And, if no outside influences seem to be in play, or even if they are found, you just keep right on shooting against the numbers you get...

Rapid rises are not well understood since no one has done the kind of intricate research to document the levels of endogenous insulin, food-derived glucose and glucagon in the diabetic cat at the various times and phases of the regulatory process. When a FD cats has a certain BG level and then eats followed by a drop in BG we can reasonably assume the cat's own pancreas has done its thing and secreted its own insulin in response to food, causing a post-meal fall in BG. That's simple to understand. But when sudden bounces occur, there are several possible explanations so it is harder to know for sure what is happening. In my view, the approach is the same no matter the cause of the spike, supply more insulin from outside, because one thing we CAN say in such cases is that the cat's pancreas is not operating normally (in which case it would be working to blunt the rise) and we have to intervene...

It is wonderful to see everyone start wondering "what if?" I mean it. This is exactly the way all great insights occur, it was what gave me the opportunity to discover that my own boy, Punkin, would respond the way he did to "low carb" food instead of w/d (Good God, THAT was a long time ago!) and what has allowed all of the better ways we now manage our diabetics to evolve. We MUST be willing to ask, and answer the "what if" questions. Not many folks are asking those, and that is why we have all been stuck in the old ways that don't work for so long. So, I do not want any of you to stop asking that question. I only ask that you not make yourself exhausted with all of the questions so that it all becomes a blur. Are there more refinements to TR that have yet to be discovered? I am absolutely certain there are. And it is places like this where those refinements will be discovered and implemented, working with real cats with real FD. But it is also OK to rest a while and just do the basics while our cats slowly get better.

The illuminations will come even then. So, what am I trying to say? Experiment, please, but when you get confused or fatigued with trying to refine, fall back on the basics and let what we already know works, work.


INSULIN

My insulin of choice is bovine based PZI.

Cats that are allowed to remain at high BG levels do not recover, they simply do not. That, and that alone, is the "this way or none" position that I hold. Insulin is not my hill to die on, it's just easier to accomplish the lower BG numbers, consistently, with PZI, especially in chronic diabetics.

We are finding that Lantus is amenable to a sliding scale approach just like PZI. It seems to have an ACTUAL duration of activity quite similar to PZI in most cats. The German TR groups seem to think that Lantus can't be used with a scale, but I doubt that is a hard fact, just someone's belief. Not sure why. In humans Lantus is virtually always used with another shorter-acting insulin so maybe someone is transferring the directions for its use in humans to cats. We have had a couple of cats do well on Lantus and sliding scale...certainly there is no rationale for a sliding scale being harmful with Lantus or any other insulin.


HANDLING INSULIN

As far as warming the insulin is concerned, I would strongly advise against it for several reasons:

1) This will reduce its potency. The best way to kill off your insulin in a hurry is to leave it out of the refrigerator, so we know for a fact that even room temperature is destructive.
2) Cats have very different subcutaneous tissue characteristics than humans. They have far more sub q of very different tissue density than humans. Comparing what a human feels and what a cat feels in the same situation is not realistic.
3) Humans have to give themselves far more insulin into that much smaller sub q space than we give our cats.
4) The vast majority of cats do not react when they receive their dose of cold insulin as though they feel pain, so we conclude that they do not have that sensation. Since it seems unlikely that insulin injections cold are painful for most cats, and because warming insulin almost certainly changes the potency of the insulin you are administering (e.g. if you think you are shooting 3 units but with warming or shaking or rolling, you are really giving 2), then it gets very difficult to really assess how your cat is responding to any given dose. You are almost back to the "shooting blind" situation.

With two different strengths and production batches of insulin, all of the quality issues the others have brought up can be the problem. I have never seen U40 be less effective than U100 as a matter of course. Compounded insulin has been handled more than manufactured insulin (e.g. Idexx) and if handled properly, should be just as potent in either strength. But let's face it, human beings are not robots, and one batch of compounded insulin produced by humans is invariably going to have been handled differently than any other batch. I think BCP works fine in general, but compounded insulin’s have a shorter expiration date than manufactured insulin’s for a reason.

I have never heard that insulin doesn't need to be refrigerated except for sterility, and I have to say that notion seems to defy logic. The fact is that if you contaminate insulin as you use it and then refrigerate, you will certainly slow germ growth, but won't kill them off, so there would still be a great risk of infection when using such a contaminated vial. On the other hand, all organic molecules are more stable at lower temperatures (that's one of the reasons we refrigerate food), and insulin is no different. If shaking damages insulin, it is hard to imagine that warming doesn't do the same, perhaps at a slower rate, but degradation all the same.

With TR, not only do we handle the vial more in the beginning with TID or QID dosing, but most cats need less and less insulin over time which means each vial lasts longer and must be handled carefully so the potency can be preserved over all those trips out of the fridge and back, and all that time. Sure, getting new vials at regular intervals is ideal, and should be done whenever there is a question about potency.


TREATMENT

A cat whose diabetes is uncontrolled means getting mid-range and high numbers. Your kitty's liver is working against your efforts because it believes those high numbers are the correct ones after so long as a diabetic. Your objective with PZI will be to get your cat down to the high double digits and low triple digits (less than 150 as much as possible). Over time with truly good numbers, the cats liver will start to "get it" and stop producing new glucose causing the rebound you see.

The reason to do +6 readings is to know what your cat's BG number is at the point at which you could dose again. If it's high, then you give more, as opposed to checking every 12 hours only to have your cat spend 6 hours at a high number when you could have intervened. When a cat shows some consistency in staying down for 8-10-12 hours at a time, it becomes less important to make that +6 check, because you have little reason to think you are going to need to shoot at that point.

PZI peaks at around 6 hours ps, give or take a tad, so we want to check at that peak and shoot again if that peak is above the level we are trying to achieve. The idea isn't to put the cat into a BG roller coaster as is true with conventional management methods, but to flatten out the BG level over the entire 24 hours of every day AS MUCH AS POSSIBLE. This is what the functioning pancreas does; it shoots out small amounts of insulin every time it perceives an unacceptable rise in BG (and does this WAY more often than three or four times daily). So, the animal stays pretty level all the time. We try to sort of duplicate this natural regulation of BG by the healthy pancreas by dosing more than once or twice daily. We try to take advantage of the work done by the previous insulin dose by giving more AS SOON AS that previous dose is exhausted, rather than waiting for the BG to go all the way back up again so the new dose has to do all that work all over again. The old method seems kind of futile put that way, doesn't it

You will want to test at least three times daily, at about 6-8 hour intervals timed to coincide with the peak action of the PZI insulin you are dosing. Feeding should happen at the same regular times you would feed any normal cat on wet food. So, let's say you feed about 4 ounces of wet food at 7AM and 6PM. That's set. If you also do your first test of the day at 7AM, you would give insulin then as well if the BG is high enough. Then, IF YOU CAN, you want to test again at about 1-2 PM.
If your schedule doesn't permit this on workdays, then test AS SOON AS you get home, say 5PM. Give another dose of insulin as needed. Feed at 6PM (regular feeding time). Then try to test again at about 11PM or so. Shoot again as needed.

You will be able to be more regular with testing and shooting on the weekends, if you are like most people. If your weekday schedule is more flexible and you can test and shoot at more regular intervals during the week, so much the better! Some folks test every 6 hours, or 4 times daily. This requires a REALLY flexible schedule, and while nice to do, isn't necessary for getting really good results on this protocol.

You test when you can (we all have to work, and I understand that). But it is illogical to me to test a cat at 6+ or more, get a high reading, and do NOTHING about it. Something inside of me thinks this is just plain wrong. I certainly understand that shooting at these "off" times may give you a nice low number that you can't shoot against just before bed, but I strongly feel that in the end, it is always better to shoot against high numbers rather than trying to keep to a schedule, if it means that an owner ignores a BG of 180+ because it's not shot time. As diabetic cats on TR settle down and get themselves back to normal, it is impossible to predict what kind of bumps up and drops will happen. One night you may see a big rise (just shoot against it in the AM) and the next night there may be no rise at all, or a very insignificant one. So, all we can be certain of is this test, right here and now, and that's the one we have to address...thank goodness this seems to work.

I want to add here that while slavish devotion to testing to "catch" that upswing is admirable, one big (relative to TR anyway) number per day does not put you out of the game. I mean it. I don't want any of you to think that if you see a 222 in the AM that everything you did the day(s) before is for naught. I have had plenty of cats whose owners are far less willing to test so often who have done very well nonetheless. They put up with those overnight bumps and even so, they get the reward in the end. It might take a tad longer if you aren't "being your cat's pancreas" quite as well, but I don't want to create a bunch of completely sleep-deprived zombies out there. It's bad for TR PR....so, test as your heart dictates (and pocketbook will allow), but when you can't get up at O'God-thirty, don't worry.


THE LIVER

The liver is a "horse" when it comes to doing its job. I'm not sure just which strains you mean, but if you mean making it work too hard too long to produce glucose when we give insulin, the only time the liver seems unresponsive to falling glucose is when it is "idling" because the glucose has been nothing but high for a long time (an unmanaged diabetic) and it thinks it doesn't have to be vigilant about hypo anymore. Cats on dry food with their constant dietary glucose infusions have livers like this. So, when those cats get an overdose of insulin, and their livers are "on vacation", they are the ones that get hypo. But they don't hypo because their livers are worn out, but because their livers have been idle for so long. We know that their sugar-making abilities are intact because when we start them on TR, and start talking their BGs down more gradually, they spring back to life and actually fight the normalization of the BG. The suppression of the liver by constant high BG is gone and it begins to do its job of dealing with falling BG again. Early on, this is actually a problem because the liver doesn't realize that the BG fall is a good thing, and it tries to stop that fall long before normal BG is achieved.

I have never seen a liver's ability to make glucose become exhausted except in cases of frank liver failure (cirrhosis, liver cancer, etc.) and even there, it happens very late in the day. BG maintenance is such a critical duty of the liver, and so necessary for survival, that it has a very strong endurance as a function.

The physiology of the mammalian liver, and even of the cat's unique version of the mammalian liver, is in the literature and has been for some time. General physiologists did this work many, many years ago. I learned most of it in vet school and later grad school work in physiology.

Interestingly, there has been little application of this knowledge to what we observe in diabetic cats. I think this is largely because there has been almost no real creativity in managing diabetic cats or even in understanding their disease and its causes. We have simply given insulin to an animal that had an APPARENT lack of insulin. Simple, too simple. In fact, we have had access to quite enough knowledge about how the cat's liver works to understand just about everything that happens in well-managed diabetics (or badly managed ones, for that matter). That's why I keep saying "it's not rocket science." All of the answers to this disease are there and have been for a long time. The profession simply hasn't had the incentive/motivation to take that knowledge and apply it. This is in large part because of the lack of funding for clinical studies except from the pet food companies. The pet food companies will not give money for studies that apply known feline physiology to management of diabetes. Such application will lead no where they want to go at this point in time. I know that sounds very cynical and biased, but unfortunately, it is the truth. If I still worked in the industry, I wouldn't be able to be writing this post....

You are getting pretty good numbers except those periodic highs, usually in the AM. My belief is that after a good day his liver reacts overnight. This is a very common reaction to good numbers in a cat whose liver still believes that 300-500 is "normal." I ask my clients to try to blunt this. Sometimes it means feeding a bit less at night and/or testing and shooting late to keep enough insulin on board to stop that overreaction. It takes some time for the liver to relearn what normal is after months or years of living with very high numbers. The liver's job is to make sure that the BG doesn't go too low, and it makes glucose from amino acids (stored or dietary) whenever it "thinks" that the BG is too low.

A blunting dose at bedtime is a good idea. Insulin allows us to establish the normal internal environment by using externally delivered insulin. The only way to "retrain" the liver is to give it the normal environment as much as possible. It then begins to "understand" the new normal state, which was the old normal state. Obviously, the liver doesn't really "know" anything, but the feedback mechanisms within the liver get reset, just as they got reset when the cat was constantly hyperglycemic. If you think about it, the only way the liver "knew" what was normal when your cat was very young was the normal state of things at that time. This is the reason that early diabetics do quite well with diet change only because the abnormal environment of hyperglycemia hasn't existed long enough to convince the liver that "normal" is 300-500. After a period of time under hyperglycemia, however, the liver really has no choice but to "reset" itself.

We do cause the liver to hop around a bit when we first start the heavy pressure of TID or QID dosing with substantial amounts of insulin. Unfortunately, in the early stages, we have no choice but to continue to do so because the liver is like a child having a tantrum at this stage, and if you don't keep pushing down, it never learns that these lower numbers are OK. At least that is the way it looks from outside the cat, in the many, many cases I have worked with. I wish more than anyone else we could understand why some livers just will not "get it" quickly while others seem to get with the program right away. Yes, gender and length of time the disease has existed, and degree of prior mismanagement all play a role. But those are not the only factors, because we do see some cats that just shouldn't do well quickly that go ahead and get on board with relatively little struggle. Genetics play a big role, no doubt about it. And maybe some other factors we don't even know about. So, having said all that, I guess those good numbers make me want to advise you to keep this up as you have been doing for a bit longer. Right now, I think big doses of insulin (assuming the insulin is potent and fully effective as given) are the better course rather than worrying about reactive rebound. I think smaller doses will give the intuitive response: higher numbers overall.

As far as predicting how the bounces will go and when, well, that isn't possible yet with your kitty. And don't forget, she is still post-surgical, with the complications of all the endogenous steroids a stressed body like this will produce. I fear I haven't offered you much help here, except to say...persistence is so important in TR.

Drops show that the liver is less reactive, but the absence of clinical hypo tells us that that the liver is in fact providing the brain the glucose it needs. The brain is the only organ that must have glucose, so not much is needed in the circulation. The old dogma had owners attempting to control hyperglycemia, but deliberately not doing "too good" a job of that. Owners were told to have one foot on the brake, but to keep the other firmly on the accelerator. This is a self-defeating approach, but necessary if you still feed the intoxicating carbs while you try to deal with the intoxication. There is no need to do things this way anymore.

The dry-food fed liver is not the same thing as a wet food fed liver. One is asleep and the other is wide awake. Feeding dry (and Karo) puts the liver's sugar making function into relative dormancy, leaving the cat unprotected no matter what protocol the animal is on. It is an exceedingly BAD idea.

"An overdose on a liver that is not yet functioning properly will result in hypo," is correct. I am only talking about the liver's ability to respond to hypoglycemia, and that comes back quite quickly, within a few days off dry. If there were other dysfunctions in the liver, those are not going to be relevant to this function we are most interested in here.

A slight elevation in a cats liver numbers is evidence of very early, very low-grade hepatic lipidosis. Almost all long-standing diabetics on traditional protocols have HL. Many do not have liver enzyme elevations as a result because it is a chronic thing that the cats have been living with for some time, but diabetes and fat accumulation in the liver (the cause of HL) go together like peanut butter and jelly. They have similar causes, primarily the feeding of relatively low quality and quantity protein, absolutely high processed carbohydrate, to an obligatory carnivore. Cats with HL, like cats with FD, respond well to switching back to the diet they evolved to consume.

HL is extremely easy to treat (although most vets are terrified of it) with a change in diet. Cats that are so sick from HL that they are not eating on their own, need merely to be force fed, or tube fed, and they typically recover quickly and completely.

TR cannot be accomplished if fear of hypo continues to drive the cat's management. The two are mutually exclusive. The old method absolutely guarantees that a cat will remain diabetic; 29 years of vet practice proves this to me. I am not willing to have my own patients managed this way, and have convinced all of my clients to at least try it my way. Their cats don't hypo, and the majority stops needing insulin. It's that simple.

As the liver and pancreas normalize under the influence of normal BG levels, rapid drops and big rebounds subside and a level, steady-state, and much better health for the cat, become the new status quo. "Rebound," or, as I call it, "little temper tantrums of a confused liver," are hard to predict. But when you home test and shoot accordingly, you can keep correcting these tantrums and eventually they become less intense and less frequent.


SLIDING SCALE

As far as the sliding scale of insulin dosage goes; the scale is a dynamic thing. By that I mean that you readjust your dosages according your cats response. The objective, of course, is to find that you need less and less insulin to achieve the same amount of BG control, until you don't need any at all!

I disagree with the theory that a cat "settles into" a dosage of insulin because, while it is true that the cat's response to a particular dosage schedule will change over the first few days or weeks, it shouldn't stop there. The "settling" should never end because the cat should (and in the majority of cases does) take over completely making external insulin administration unnecessary. The cat will respond differently over time because proper administration of the right insulin and diet over time changes the way the pancreas and the liver relate to one another, so you see different (and usually more and more positive) response to your dosing of insulin.


HYPOGLYCEMIA

 
How to get over fear of clinical hypo? Stop believing in it! I don't mean to trivialize this fear; I shared it for the first 15 years that I was a vet so I know exactly what it feels like. But I will swear to you on everything I hold dear that I have never seen a clinical hypo in a cat on the right diet. Cats eating wet food (that isn't loaded with carbs, as some commercial canned foods are) have livers that are quite capable of making sure that CLINICAL hypo doesn't occur with the sliding scale approach. Now, I am not saying your kitty couldn't ever have a double digit BG...he certainly could (and I like these, frankly). But the only way you will know he is lower will be to test him as he will not be acting at all different than if his BG was much, much higher.

Those cats that have clinical hypos are always cats that either eat dry food, and/or eat high carb wet foods, and/or have had IV glucose given to them, and/or have had Karo or similar given to them etc. In such cases, the liver is depressed in its ability to supply glucose to meet the need when BG falls (part of the liver's job description). If a cat has not experienced any of the above, it will not get clinical signs of hypo with the sliding scale approach and daily testing. It simply will not.

I have never had a client tell me their cat (on wet food and the protocol I use) went low like this and wouldn't eat, so I just say feed at this point (and not a whole bunch, 2-3 ounces), but I say that more to make my clients think I am not a complete wacko than because I think the cat really needs more food (assuming it's not mealtime anyway).

I have worked with hundreds of cats on TR. During that time (10 years), I have never seen a single clinical hypo (seizures or anything close). I have had people tell me it happened to them, but when I begin to ask the questions I need answered to fully evaluate whether TR was really being practiced, things get muddled. I mean, all kinds of complicating things are going on in these cases.

Once this happened in cat on a "holistic" all wet food diet. Very perplexing until further exam showed that the cats "all wet" diet was mostly rice, barley, and other cereals cooked by the owner (all organic of course). Well, sorry, THAT is not a lapse of TR "dogma." We say cats on wet food don't hypo, but cat's on high carbs, whether those come from cooked cereal, pancake syrup licked off the owners plate after breakfast (yes, had one of those once too),Karo, IV dextrose, high carb treats fed along with the low carb canned or raw, etc. that is not really TR, can have clinical hypos. Until I see a real TR cat hypo, I will continue to believe it does not happen in cats without severe underlying liver disease (like cirrhosis or liver cancer). Cats with these underlying problems do not survive no matter what you do.

I am, as you all know, against using insulin to lower BG and then pumping a diabetic cat full of new glucose precursors (food) to get it back up; Cats roller-coaster enough without us MAKING them do so.

Don't let a few lower double digits discourage you. They truly ARE better than those highs. Ex-diabetic cats that go off insulin luxuriate in the mid double digits, telling us that is what their pancreases and livers (and brains) prefer given a choice in the matter.

"Too low" is a different thing to different people. As you know, I believe that a true too low is a rare, possibly extinct thing in TR. Even though we see numbers that would make an owner using the conventional protocols run for the Karo and call the ER, if a cat is at one of these low numbers, looking around for mischief to get into, grooming itself in complete relaxation, or rolling around on the floor to scratch that itch in that hard-to- reach spot, completely unaware that there is anything amiss, I say that cat is not too low. I know from working with so many cases of FD that nerve-rattling lows provide the stimulus to the cat's systems to get back into alignment with each other, that's why so many "honeymoons" occur, even on conventional protocols, after deep lows.


FEEDING ON LOWER NUMBERS

I want to add something here for all the newbie’s. Using insulin to get the number down and then food as a tool to deliberately get the number back up won't work in TR because it is self-defeating. If you MUST respond to a low number (20-40), feeding a small amount of wet is all you do, and I would only do that if the cat seems hungry. The body will NEVER get things sorted out if we are doing all of the managing from outside and never let the pancreas and liver get things sorted out for themselves. That is the failure of traditional protocols...they depend entirely on outside regulation of the cat's glucose homeostasis. This DOES NOT WORK. We simply do not have the capability to do the job better than the cat's own system.

Feeding at low numbers is NOT to get the number up quickly. We do not want to get the number up, just make sure the brain has enough glucose from protein. So, you don't want to give food until you see a spike.

GIVING INSULIN AT LOW NUMBERS

I think giving insulin at low numbers can actually be counter productive. If you think about it, the liver, even once it is retrained and completely onboard with health and recovery of the diabetic, still has the job of keeping BG from going too low. If the cat is happily going along at 110, and it gets insulin from outside, it's no different than the cat having to run hard and long to get away from a coyote. In such a situation, the liver is supposed to get busy and get more glucose into circulation. So it does, in both situations. In other words, when we shoot at low numbers, we make the liver do something we really don't want it to do. I know this is weird, hearing me say that there are times when shooting is a bad thing (and not because of hypo, but because of the effect of doing so on the liver), but if you don't really need insulin, you want to just let the body be.

The rationale for not shooting at these near-normal levels is to see if the pancreas of the cat will handle the matter itself. You never know when the pancreas will feel "up to" handling these small rises, and if you shoot from outside, you certainly do obscure that observation. Additionally, if the pancreas and the liver are getting into sync with each other at such a time, giving insulin causes the liver to do exactly as it should if a fairly big burst of insulin shows up (our dosing, even when conservative, is always excessive compared to the much smaller, measured and frequent doses that come from the operating pancreas in response to the gradual rise in BG that happens in any animal. We are, after all, a very crude substitute for the operational pancreas under the best of circumstances). So, at some point, all of us want to find out what the cat itself can do. We don't want to go too long before we decide that the cat needs help from outside, that's for sure. So, the answer to your question is really a matter of whether you can follow the rising BG (given your schedule) and wait a bit, or whether you cannot test again in the near future and don't want to risk the BG getting too high before you can get back and test again.


NOT FEEDING AT SHOT TIMES

Food has nothing to do with giving insulin. You need to get that idea out of your head…until he has low numbers.

The idea of feeding and insulin came BEFORE TESTING. People were blindly giving their cats insulin, so as a buffer the vets would recommend you feed them. BUT you are TESTING your cat through home testing, you know she is 300BG, why give her food unless it is feeding time. They just are unrelated when you are testing.


FOOD

NO dry food can be used for diabetic cats. Also, no dry food should be used for well cats because that is where diabetic cats come from! This is the most important point in all of TR. I do not care what you read on a bag. Pet food companies get to lie on their packaging and marketing materials with impunity, there is no oversight for such claims (and if AAFCO or FDA want to take exception to this allegation, I welcome it). They won't ever do so, however, because having to show the public how pitifully little data constitutes their oversight of pet foods would be a huge embarrassment to them. Better to let me babble on unchallenged...maybe folks won't believe me will be their hope).

Further, no dry foods have ever been tested for efficacy in diabetic cats (or well cats for that matter) except in owned pets after the owner buys the stuff, where those foods have failed those "tests" miserably. So, whatever you choose to feed your kitty, it cannot be dry kibble and should be as low in non-meat ingredients as you can possibly get.

Consider, Purina is owned by Nestle, one of the largest companies (of any kind) in the world, Hills is owned by Colgate Palmolive (need I say more) and Iams is owned by Proctor and Gamble (who bought it for 2.2 BILLION dollars). The shareholders in these kinds of companies, people like you and me who have mutual funds they plan to retire on, want those investments to grow, right? The people who run these companies are business people, not scientists or nutritionists. The nutritionists have their jobs at the pleasure of the business managers. People who buy pet foods and their veterinarians are the ones who can change things, change will not come from the pet food companies themselves.

On the other hand, there are companies like Felines Pride can and do care. They are beholdin' to no one but their own conscience. (Feline Pride is no longer available).

Because of the number of cats I have (I breed Occicats) I purchase Omas Pride and feed a combo of organ meat and bone-in ground rabbit and chicken with added Platinum Performance supplement. Feline's Pride raw is an excellent product for smaller groups of cats, and takes the work and guesswork out of raw for owners.

I have one cat that will not eat raw (he is not diabetic) and he eats Fancy Feast turkey and chicken grilled variety. DM canned is a good product (I hold the patent on the canned formula), but it is not imperative for diabetic cats. DM dry is a terrible diet and should not be fed to any cat, let alone diabetics. m/d canned is Hill's attempt at getting around the DM canned patent (they added wood fiber to change the formula...no matter that indigestible wood fiber is wrong for cats), and m/d dry not only has the high carb that DM dry does, but also the wood fiber of the canned version. Another example of Hills "ingenuity" at the expense of the pet. As I tell many of my clients, today, for cats, the worst canned is better than the best dry cat food.

Getting to canned alone is a huge leap. Raw meat as part or all of a cat's diet is the "gold standard". I am convinced but I could die a happy woman if I knew I was leaving a world in which no cat ate "cattle feed", but some combination of meat-based, low carb diet instead.

I recommend against fruits and veggies in a commercial diet for two reasons:

1) Cats do not eat this stuff naturally. Depending on how much is in a canned diet, it may or may not matter much. But it can be pretty hard to tell how much is in there. Fruits and sugary veggies are worse than the more fibrous veggies, for logical reasons.

Sugars tend to alkalinize the urine in cats. I have had at least one cystitis cat that did well on FF and then reblocked on Nature's Variety and another that reblocked on Wellness canned...thus my mistrust of fruits and veggies for cats.

2) I hate for the pet food companies to get positive feedback (and sales) for their fruit/veggie combo canned diets. This trend will only get worse as the pressure against dry foods mounts. It is already happening. FF has just announced a new line of canned food "Restaurant-style" or some such. This line is going to look like a "fine meal," greens and all, in a nice human restaurant. Balderdash. I fear that we might win the "anti-dry food" battle only to lose the "cats are not humans and should not eat like humans" war if pet owners readily buy the canned foods already out there that have these non-cereal fillers. The pet food companies are going to try to make a profit, a big profit, on their pet food products, that is certain. The more they can convince us to buy foods containing non-meat ingredients at high prices for our cats, the harder it will be to force them to make more meat-based foods.


FIBER

As you know, the original work that Nelson did purported to show that dietary fiber was useful in management of feline diabetics. That study was very flawed (although accepted as inviolate proof of the concept for 3 decades) because the high-fiber diet and the control diet were both high carb. Although his cellulose-containing diet did seem to provide better control than the regular high carb diet, neither provided good regulation or return to health, much less remission.

It is interesting to speculate that high fiber in low carb diets (if the fiber sources were low enough in carbohydrate and sugar), might be helpful. The only problem to be avoided is making the cat consume diets with so much indigestible bulk that GI problems result. The natural diet of the cat would contain about 2% or less of fiber (this is the fiber content of a skinned rat. One assumes that a cat would not eat the hide or would regurgitate the hide if consumed as this is what the "hairball regurgitation" phenomenon is for). So, if we learned that veggie fiber in low carb diets helped diabetics, we would have to be very careful not to disregard possible adverse consequences of including it on a chronic basis. Of course, once a diabetic is in remission, fiber might not be necessary any more. And once there are no more diabetic cats at all, it would be unnecessary altogether.


CARBS IN CANNED FOOD

I don't LIKE corn in cat foods. Having said that, corn gluten is the corn protein (like cats need veggie protein sources!) so not quite the problem that corn starch and corn flour are, generally. I would avoid these if possible, but sometimes the food the cat likes best, especially if just being transitioned to wet from dry, is what you have to go with. We are lucky that the amount in most canned foods is small, usually. I think this is because if there were a lot of these in the can the cat wouldn't eat the food at all. Canned foods don't get to have those tasty coatings to make cats eat lots of carbs the way dry does, so the companies know they have to include more meat or the cat won't eat it.


SWITCHING FROM DRY TO CANNED FOOD

Cyproheptadine (also called Periactin) is an antihistamine that can really help with those truly carb-addicted cats. It stimulates the appetite and helps in the beginning of the switch. Your vet may be able to Rx it for you. I agree that you may need to broaden your offerings to find what will "float" your cat's boat enough to make him consistent. Diarrhea during the switch is not typical, although wet fed cats that go back on dry for whatever reason sure do seem to get it commonly.

My experience in dealing with previously dry food fed cats that are switched to wet and given insulin is that within 24-48 hours you will not have to worry about hypo (the liver suppressive effects of dry food wear off very quickly, thankfully). So, you can at that point begin to be quite aggressive with your insulin doses just as you would if you started TR with a previously all wet food cat.


CONSTIPATION FROM FOOD CHANGE

A good part of the "constipation" complaints I get from owners whose cats have switched to wet (diabetic or otherwise) stems from the misperception of how much and how often the normal cat will have a bowel movement.

The reality is that the cat, as an obligatory carnivore, evolved to consume energy dense foods with little bulk/residue, leaving little to produce stool each day. There can be a big change in the amount of solid waste a cat produces when there is little indigestible matter in the diet. Also, some meats have little fat. I have found that rabbit, a wonderfully hypoallergenic meat, is usually very low in fat. This seems to cause a very dry, if small, stool. Other meats, like chicken seem to have more fat so the stool is less dry, in my experience. I think there have been many good suggestions on the forum for dealing with stools that are hard to pass (of course, there is nothing to do if the issue is simply that the cat is producing less stool than the owner is accustomed to).

Olive oil may work well, some members seem to have had good results with it. I like to add animal fat to the diet of cats to ease things. Most cats like butter and a pat a day can be helpful. I also encourage owners to feed some of the meat fat from their table to provide some lubrication and essential fatty acids. All of these ideas work, and work the same way, I imagine.

Petroleum jelly (the active ingredient in petromalt, laxatone and the like) also works, but is usually flavored with sugary vehicles so MIGHT be problematic for the diabetic cat. I like to do things as naturally as possible so using something with the name "petroleum jelly" (not sure how a cat in the wild would get any of this even if it were constipated) is off putting for me, even in the unflavored form.

I don't like fruits that are in Nature's Variety or Wellness for cats. Sugars tend to alkalinize the urine in cats. I have had at least one cystitis cat that did well on FF and then reblocked on NV and another that reblocked on Wellness canned...thus my mistrust of fruits and veggies for cats. I admit that the diabetics seem to do OK with these foods, but the cystitis cats may not do as well. Try to incorporate some raw with whatever canned you are using. This dilutes all of the stuff in any of the canned foods that can be detrimental.

If you feed dry, I cannot urge you to try TR. Dry food makes TR a futile and unjustifiably time-intensive project.


FEEDING TO LOWER BGs

List member said: “I keep reading that people (who are doing well with TR) are feeding their cats to see if it will bring their numbers down. I assume this is because food stimulates the pancreas into action causing the cat to bring his or her BG back in line.”

Dr. Hodgkins:
A drop after eating is, of course, the BEST evidence of a working pancreas and a calm liver. It's a very good sign.


HONEYMOON vs REMISSION

That term (honeymoon) is reserved for cats that have transient respites from insulin dependence because of some "jolt" to their pancreatic-hepatic axis and they get a brief reprieve. Then, when previous poor management continues, they relapse. We go for, and get, cats that return to normal and stay there. I guess I am just making a point about attitude here.


PANCREATITIS

There is NO DATA anywhere that shows that pancreatitis in the cat is a primary disease that has anything to do with fat in the diet. Once again, although everyone pays lip service to the "the cat is not a small dog" adage, most vets still treat cats as though they are just that, small dogs. Because we have so little direct science in cats, vets default to what they know, which is how to treat dogs.

I have just done some research in the literature on feline pancreatitis for the chapter on the subject in my book, and I can tell you that it is VERY unwise to give high carbs to a cat with diabetes, with or without clinical pancreatitis. Diabetes is a disease of the pancreas. I suspect that most, if not all cats with FD, have some degree of pancreatitis secondary to the carb assault that causes the FD. Therefore, trying to treat EITHER of these conditions with high carbs makes no sense. It is a dumb approach borne of what we know about dogs. Your kitty will not improve with either of these conditions until you remove the causes of both of them, intoxicating amounts of dietary carbs and resulting hyperglycemia. Fixing your cat will take a change in diet away from high carbs and low fat, to a more carb-restricted diet and enough insulin often enough to get those numbers down. It is really that simple.


VACCINATIONS

DO NOT vaccinate your indoor kitties or those that go outside under supervision for FELV. FELV is transmitted from an infected cat to an uninfected cat after very close and long-term contact. It is not airborne or transmitted via feces or urine. Mostly through an exchange of a great deal of saliva. FELV vaccine, along with the 3 year rabies vaccine, is most implicated in vaccine associate fibrosarcoma.

FIP vaccine is a complete and utter waste of time and I must say that any vet that uses this routinely on patient’s isn't even thinking. I mean it, if your vet asks to vaccinate your cat for FIP you must ask why. If he/she isn't able to give anything more than "that's what we do" you might want to change vets. I know many of you have vets you like and trust, and that is a good thing, I mean it. But even the American Association of Vet Practitioners and other "authorities" do not recommend this vaccine. It has a very poor testing history for even preventing FIP and is nothing more than another shot to give and charge for in vet practice. It has value in my eyes only for identifying doctors who don't care enough about patients to even examine vaccine protocols to make sure they are sane.

Rabies is tougher. I happily live in a county where rabies vaccination is not required, and I do not vaccinate my patients for rabies at all (I only use the 1 year when I have to give it, as when a cat is going to travel internationally). I board at my clinic so my clients don't have a problem boarding their cats with no rabies vaccines. I know Texas and a few other places are thornier about this, but never let your cat have the 3 year vaccine. This does not mean your cat needs to be given the 1 year every year, unless some authority is forcing the issue. The duration of immunity for virtually all vaccines that work at all is much longer than a year, so if your cat gets out and tangles with a skunk, or bites someone, and has had the 1 year within the last few years, it is not going to get, or give, rabies. The 1 year vaccine has that rating because the manufacturer only tested it for 9- 12 months and then stopped testing. Why would they test longer? It costs money to conduct long-term tests and long term tests will just reduce sales. A lose-lose for them, right?

Anyway, there are reasons to avoid vaccination as much as possible beyond sarcomas. Other, probably more common, health problems come from over-vaccination. The cat's immune system is very reactive, and annual vaccines can trigger autoimmune diseases of many kinds. I would not give FRVCP more than every 3 years and do not give even this in cats that are 6 years or more in age. We do not see the diseases this vaccine protects against in adult indoor cats, but we sure do see the side effects.

As far as the annual vet visit, I think it makes sense to see the vet once a year (there is currently a campaign to recommend wellness exams every 6 months with which I do not agree) especially to examine the oral cavity and, in older cats, to make sure there is nothing else afoot that is not causing signs that the owner notices. During such exams, I weigh the patient (this is the cheapest, least invasive, and most important "diagnostic test" in the world and will show early onset of many diseases). Few owners have scales sensitive enough to disclose low-grade gradual weight loss and I have diagnosed so many early hyperthyroidism cases this way, I can't even tell you. I pick up most of my hyperthyroid patients while their thyroid hormone levels are still in the so-called "normal" range, while the prognosis for cure is still excellent.

Each cat has a different need for routine vaccines and exams. If your vet isn't applying a risk-benefit kind of evaluation to YOUR cat, but instead is just doing the same thing, every year, for every cat, you MUST ask why. This is NOT appropriate medicine today, and every owner and every cat deserves better.

The recommendation that cats receive vaccinations at frequent intervals throughout life totally ignores basics of immunity, not surprising when you consider that government, which oversees human health issues like vaccine reactions and the risk/benefit analysis for vaccination in humans, doesn't give a wit for pet health per se. Pets, like people, derive quite solid immunity from the vaccinations that actually work, like the FRVCP, from the first few vaccine administrations, and revaccinating at frequent intervals in later life may actually reduce the effective immunity in the animal with this preexisting protection. Now, this is a well understood phenomenon in biological systems and is the basis for not vaccinating humans on an annual basis for anything (when was the last time you received any kind of vaccine?...I haven't gotten anything for decades and even my 19 year old son hasn't received any kind of vaccine for years). The reason we vaccinate pets every year for EVERYTHING has nothing to do with health imperatives, it has to do with the fact that vaccine manufacturers want it, vets have stopped thinking about the science of these protocols and just to it, and the government couldn't care less if pets die as a result. Federal and state governments figure they have bigger fish to fry than whether a few thousand cats die of vaccine reactions. And none of the involved industries are self-regulating. Sad but true.

The reason those of us who have actually thought about rational rabies vaccination recommend only the 1 year vaccine is because it does not have adjuvants. Adjuvants cause a hyper reaction to the vaccine, thus allowing the longer duration of immunity claims. But, adjuvants are strongly implicated in vaccine reactions, and not worth the risk. As I said in the earlier post, however, just because a vaccine only has a 1 year manufacturer's test behind it does NOT mean it lasts only that long.

Gleaned From Dr. E. Hodgkin's Forum Discussions as far back as 2004.

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