ACVN Nutrition Notes: Treatment of Obesity
Justin Shmalberg, DVM, Diplomate ACVN
This new column explores one of the most common topics in nutrition: obesity. Recent research has better characterized the condition and identified new therapeutic approaches, which are discussed in-depth.
Obesity is a frequently encountered condition in small animal veterinary practice and arguably the most common form of malnutrition.
Weight loss in overweight animals is associated with greater longevity, increased vitality, and reduced pain.1 Recent research has better characterized the condition and identified new therapeutic approaches.
Obesity is commonly defined either mathematically or descriptively. Table 1 identifies mathematical definitions; alternatively, obesity is described as a clinical condition characterized by excessive accumulation of body fat that leads to pathology or impaired function.
Estimates suggest that at least 25% to 30% of dogs and cats in industrialized countries are obese. The prevalence of overweight animals warrants clinical efforts aimed at treatment and prevention of this nutritionally responsive disease.
The body condition score (BCS) provides an objective measurement for assessment of nutritional status; both 5-point and 9-point scoring systems (Figures 1 and 2) have been validated for veterinary use by advanced techniques that determine body composition.
When used appropriately, BCS permits calculation of ideal body weight (BW), a value necessary for estimating any overweight animal’s caloric intake for weight loss. Table 2 describes how to calculate ideal BW in dogs. BCSs also identify obesity in cats; however, mathematical equations are generally unnecessary, as most cats should weigh between 3 to 5 kg when lean.
An educational component may be required when explaining an animal’s BW to its owner, as owner disagreement can be common when veterinarians identify an overweight patient.2
Risk factors for canine and feline obesity are outlined in Table 3.
|Table 3. Risk Factors for Obesity|
|Canine Risk Factors6,15,18-20||Feline Risk Factors7|
Caloric restriction increases lifespan in a number of species, and obesity has a negative association with longevity in humans and dogs.
A lifetime feeding study in Labrador retrievers showed that:3
- Lean dogs live, on average, 1.8 years longer than obese dogs.
- Radiographic and clinical signs of osteoarthritis (OA) were detected earlier, and were generally more severe, in the group fed ad libitum compared to energy-restricted control dogs.
A reduction in spontaneous activity associated with OA likely further decreases energy expenditure, contributing to an obesity–arthritis cycle. Conversely, recovery from orthopedic injury, such as cranial cruciate rupture managed with or without surgery, is improved with concurrent weight loss.4
Other pathologies associated with canine obesity include respiratory diseases (eg, tracheal collapse), cardiovascular disease, and insulin resistance.5,6
The effect of feline obesity on longevity has not been confirmed. However, obesity is associated with diabetes mellitus (see Diabetes Mellitus in Obese Cats), hepatic lipidosis, dermatologic diseases (eg, alopecia, epidermal scaling), various gastrointestinal disorders, and feline lower urinary tract disease.7 A link with OA is expected, although this is less well studied than in dogs.
Diabetes Mellitus in Obese Cats
Diabetes mellitus (DM) is one of the most commonly recognized sequelae of obesity in cats, which has drawn considerable research interest given similarities to the development of DM in obese humans.Cats generally develop noninsulin-dependent diabetes mellitus (NIDDM):
- NIDDM is characterized by insulin resistance, which progresses to hyperglycemia then possible glucotoxicity or exhaustion of insulin-secreting pancreatic beta cells.7
- Amylin, a co-secretory product of beta-cells, normally inhibits food intake and limits hyperglycemia; however, there is evidence in humans that amylin may be critical to formation of amyloid and destruction of beta-cells.26
- Increased BCS in cats is associated with higher levels of amylin and insulin, even in nondiabetic animals, suggesting possible parallels to human DM.26
Dogs also develop insulin resistance with obesity, but chronically secrete high levels of insulin without evidence of loss of sensitivity in pancreatic beta-cells.27,28 This likely explains the rarity of NIDDM in dogs.
Read Feline Diabetes Mellitus: Updates on Diagnosis & Treatment in the July/August 2013 issue, available at todaysveterinarypractice.com.
The pathophysiology of obesity is related to a number of hormones secreted by adipose tissue, known as adipokines. The mechanical consequences of excess fat accumulation are intuitively understood, but only recently have the metabolic and hormonal consequences been better described.
Leptin is produced by fat cells and, in normal individuals:
- Suppresses appetite
- Increases energy expenditure.
However, both humans and dogs develop leptinemia when overweight, possibly due to leptin resistance. Adverse effects from high circulating leptin have not yet been fully described in dogs.6
Adiponectin, a more frequently studied adipokine:
- Increases insulin sensitivity by increasing skeletal muscle glucose uptake and decreasing hepatic production of glucose.8
- May also increase fatty acid oxidation and reduce inflammation.9
Increased adiposity appears to be inversely correlated with serum adiponectin levels. Research has found that:
- 20% of obese dogs develop metabolic abnormalities characterized by increased insulin and decreased adiponectin levels10
- Weight loss reverses hypoadiponectinemia11
- In other studies, however, no changes in adiponectin levels were found before or after weight loss in dogs.12
Hypoadiponectinemia consistently occurs in obese cats,8 which may explain why they have more severe insulin resistance and increased predisposition to NIDDM.
A number of other adipokines that create a chronic mild inflammatory state in obese individuals have been characterized in humans and laboratory animals. This may contribute to obesity’s documented adverse effects.9 Hormones, such as TNF-alpha and C-reactive protein, are elevated in some obese dogs, and decrease after weight loss.12
Future investigations and therapies are likely to focus on the hormonal components of excess adipose tissue.
OBESITY INTERVENTIONS: EXERCISE
Active dogs, as measured by pedometers, have lower BCSs than inactive dogs.13
Paired with Therapeutic Diet
A recent study demonstrated that active dogs fed a therapeutic diet formulated for weight loss used approximately 25% more energy than inactive dogs, while achieving 2% weight loss weekly.14 Each 1000-step interval was associated with an approximately 2% increase in daily energy expenditure. Other studies suggest that, for each km traveled, caloric expenditure increases by approximately 2 kcal/kg0.75.15
Underwater Treadmill Therapy
Underwater treadmill therapy has been part of a successful weight loss program in combination with owner education, a high-protein low-fat diet, and owner-supervised exercise.16 A recent study demonstrated that a healthy dog, walking at a normal pace in elbow-height water for 30 minutes daily, would use 2.5% more calories per day (eg, 25-kg dog consuming 1000 calories daily uses 25 additional calories).17
Therefore, exercise, unless performed over extended distances, is unlikely to cause weight loss without concurrent restriction of caloric intake.
OBESITY INTERVENTIONS: MEDICATION
Dirlotapide (Slentrol, zoetis.com), a selective microsomal triglyceride transfer protein inhibitor, is licensed for treatment of obesity in dogs. It prevents lipoprotein formation in the enterocyte, increasing intracellular concentration of lipids, which is thought to increase circulating levels of the hormone PYY, a satiety signal that acts on the hypothalamus. While the complete mechanism of action of dirlotapide is unclear, appetite reduction is most likely responsible for weight loss.
In clinical and field trials, dogs given dirlotapide:21
- Were not fed any specific diet; owners were asked to make minimal dietary changes before starting the drug
- Lost weight at a rate of approximately 0.74% to 1.4% per week, which is consistent with rates observed for caloric restriction associated with therapeutic weight-loss diets
- Demonstrated some adverse reactions including, but not limited to, gastrointestinal signs and elevated alanine transaminase and aspartate aminotransferase
- Regained some weight during an 8-week monitoring period following discontinuation of the drug.
The starting dose for dirlotapide is 0.05 mg/kg (0.01 mL/kg) PO Q 24 H for 14 days. Refer to the product insert for further dosing instructions.
Weight Loss: Nutritional Challenges
Many manufacturers claim their diets facilitate weight loss through alterations in nutritional composition or via inclusion of dietary supplements. A recent survey of such foods demonstrated significant variability in caloric density as well as in the provided feeding instructions.32 Product labels are, therefore, an unreliable source of nutritional guidance for obese animals.
Most commercial diets are formulated assuming a higher caloric intake than that consumed by most pets. As a result, a reduction in the calories fed further reduces intake of essential vitamins and minerals. A study that evaluated the essential nutrients provided by a maintenance diet when hypothetically fed for weight loss found that intake of multiple nutrients may be suboptimal.33
OBESITY INTERVENTIONS: NUTRITION
Caloric restriction is considered the primary treatment of small animal obesity. However, reduction in volume of food and number of treats fed is often a significant barrier for owners.
High-protein diets are recommended during the weight loss period. Animals have well defined amino acid requirements; providing additional protein can prevent possible deficiencies of taurine or other amino acids. In addition, high-protein diets preserve lean body mass during weight loss.22
Recent research has shown that:23-25
- A high-protein diet (≈120 g/Mcal) allowed cats to consume about 10% more calories to achieve the same degree of weight loss as those fed a lower-protein alternative (≈90 g/Mcal).
- Cats fed a high-protein diet consumed a higher number of calories than those on a lower-protein diet and better maintained their weight following weight loss.
- Cats fed ad libitum on a high-protein diet (≈120 g/Mcal) showed an increase in daily energy expenditure. This effect may be due to a principle called dietary thermogenesis, in which different energy substrates have different energy costs associated with metabolism.
- High-protein diets may increase palatability of reduced-calorie diets, as cats typically prefer protein to fat and carbohydrate.
Carbohydrate & Fat
Modifications in carbohydrate and fat concentrations are variable in therapeutic weight-loss diets. Fat is often reduced since it provides over 2 times as many calories by weight as carbohydrate or protein. However, essential fatty acids are required and fat cannot be reduced below a certain threshold. Carbohydrate and protein are commonly both increased in a diet when fat is reduced.
Fiber is added to increase both volume and weight of a food, while minimally affecting its caloric content. It is the most controversial nutrient modification for obesity because studies examining rates of weight loss or satiety have had mixed or poorly-controlled results.22
- Insoluble fiber, like cellulose or peanut hulls, is eliminated in the feces and increases fecal volume, which can be negatively perceived by some owners. Diets with large amounts of insoluble fiber may reduce food consumption in cats.
- Soluble fiber, generally fermented by intestinal bacteria, is employed in other weight-loss diets.
- Crude fiber percentage on most product labels refers to insoluble fiber, while total dietary fiber (TDF) reported by some companies better reflects both soluble and insoluble fiber sources.
A recent study in obese dogs demonstrated that a high-protein, high-fiber diet (103 g protein, 97 g TDF/Mcal) produced greater weight loss (1% vs 0.7%/week) than a high-protein, moderate-fiber diet (104 g, 56 g TDF/Mcal).29
Diets formulated for weight loss may increase moisture content of canned diets during extrusion to increase food volume during caloric restriction.
High-moisture diets reduced ad libitum caloric intake of cats in 1 study,30 while another showed no intake difference during the weight loss period. The latter study did show that weight regain was significantly reduced.31
It has been hypothesized that some animals find canned food more palatable, but this likely depends on pre-existing preferences.
Weight-loss diets occasionally incorporate ingredients purported to improve the efficiency of weight loss.
- L-carnitine has been suggested to help increase weight loss and preserve muscle mass.22 It is responsible for transporting acyl groups from fatty acids into the mitochondrial matrix, and may also increase muscle mass.
- Fish oils are a source of the polyunsaturated fatty acids EPA and DHA (omega 3). Some limited work examined the effect of EPA on preventing the decrease of adiponectin and increase in insulin seen in obese cats.8
- Other diets provide increased antioxidants, conjugated linoleic acid, chromium, and other nutrients, but there is limited information supporting use of these compounds.
Talking to Pet Owners About Obesity
While owners frequently consider nutrition a cornerstone of wellness care, they may be reluctant to accept obesity as a legitimate medical disorder in need of appropriate and targeted treatment. Counsel owners that obesity and its adverse effects negate dietary strategies aimed at promoting health, and also provide evidence-based recommendations.
Click here for an in-clinic form, Developing Protocols for Obese Animals, for guidelines on how to formulate a successful weight loss plan.
Go to Clinical Resources to download the client handouts, Nutritional Recommendations for Your Overweight Dog and Nutritional Recommendations for Your Overweight Cat, for use in your practice.
REBOUND WEIGHT GAIN PREVENTION
After the weight loss period, it is suggested that nearly 50% of dogs regain more than 5% of BW in a “rebound” phenomenon; dogs maintained on a weight-loss diet gained less than those switched to maintenance diets.34
Reduction in energy expenditure, after target weight is achieved, has been observed in dogs and cats.
- Cats: One study found that energy expenditure decreased 19% compared to baseline expenditure during weight loss, and was decreased 12% after weight loss.35
- Dogs: The energy expenditure needed to maintain post-loss BW was found to be only about 10% greater than that needed for weight loss.36
Therefore, dogs and cats may require an energy-restricted high-protein diet after ideal weight is achieved, and dietary management for treatment and subsequent prevention of obesity is likely lifelong.
BCS = body condition score; BW = body weight; DM = diabetes mellitus; NIDDM = noninsulin-dependent diabetes mellitus; OA = osteoarthritis ; TDF = total dietary fiber
- German AJ, Holden SL, Wiseman-Orr ML, et al. Quality of life is reduced in obese dogs but improves after successful weight loss. Veterinary J 2012; 192:428-434.
- White GA, Hobson-West P, Cobb K, et al. Canine obesity: Is there a difference between veterinarian and owner perception? J Small Anim Pract 2011; 52:622-626.
- Kealy RD, Lawler DF, BNallam JM, et al. Effects of diet restriction on lifespan and age-related changes in dogs. JAVMA 2002; 220:1315-1320.
- Wucherer KL, Conzemius MG, Evans R, Wilke VL. Short-term and long-term outcomes for overweight dogs with cranial cruciate rupture treated surgically or nonsurgically. JAVMA 2013; 242(10):1364-1372.
- Pelosi A, Rosenstein D, Abood SK, Olivier BN. Cardiac effect of short-term experimental weight gain and loss in dogs. Vet Rec 2013; 172(6):153.
- Diez M, Nguyen P. Obesity: Epidemiology, pathophysiology and management of the obese dog. Encyclopedia of Canine Clinical Nutrition. Aimargues, France: Royal Canin Centre de Recherche, 2006, pp 2-57.
- German AJ, Martin L. Feline obesity: Epidemiology, pathophysiology and management. Encyclopedia of Feline Clinical Nutrition. Ithaca, NY: Royal Canin, 2008, pp 3-49.
- Mazaki-Tovi M, Abood SK, Schenck PA. Effect of omega-3 fatty acids on serum concentrations of adipokines in healthy cats. Am J Vet Res 2011; 72(9):1256-1259.
- German AJ. Barking up the wrong tree: What’s the deal with obesity, adiponectin and inflammation in dogs? Vet J 2012; 194:272-273.
- Tvarijonaviciute A, Ceron JJ, Holden SL, et al. Obesity-related metabolic dysfunction in dogs: A comparison with human metabolic syndrome. BMC Vet Res 2012; 8:147.
- Tvarijonaviciute A, Tecles F, Martinez-Subiela S, Ceron JJ. Effect of weight loss on inflammatory biomarkers in obese dogs. Vet J 2012; 193:570-572.
- Wakshlag JJ, Struble AM, Levine CB, et al. The effects of weight loss on adipokines and markers of inflammation in dogs. Brit J Nutrit 2011; 106:S11-S14.
- Warren BS, Wakshlag JJ, Maley M, et al. Use of pedometers to measure the relationship of dog walking to body condition score in obese and non-obese dogs. Brit J Nutrit 2011; 106:S85-S89.
- Wakshlag JJ, Struble AM, Warren BS, et al. Evaluation of dietary energy intake and physical activity in dogs undergoing a controlled weight-loss program. JAVMA 2012; 240(4):413-419.
- National Research Council Ad Hoc Committee on Dog and Cat Nutrition. Nutrient Requirements of Dogs and Cats. Washington DC: National Academics Press, 2006, pp 35-7, 179-181, 231-234, 276-277.
- Chauvet A, Laclair J, Elliott DA, German AJ. Incorporation of exercise, using an underwater treadmill, and active client education into a weight management program for obese dogs. Can Vet J 2011; 52:491-496.
- Shmalberg J, Scott KC, Williams JM, Hill RC. Energy expenditure of dogs exercising on an underwater treadmill compared to that on a dry treadmill. AAVN Proc, 2013.
- Corbee RJ. Obesity in show dogs. J Anim Physiol Anim Nutr 2012; epub ahead of print.
- German AJ, Holden SL, Gernon LJ, et al. Do feeding practices of obese dogs, before weight loss, affect the success of weight management? Brit J Nutr 2011; 106:S97-S100.
- Bland IM, Guthrie-Jones A, Taylor RD, Hill J. Dog obesity: Owner attitudes and behavior. Prevent Vet Med 2009; 92:333-340.
- Wren JA, Ramudo AA, Campbell SL, et al. Efficacy and safety of dirlotapide in the management of obese dogs evaluated in two placebo-controlled, masked clinical studies in North America. J Vet Pharmacol Thera 2007; 30(S1):81-89.
- Roudebusch P, Schoenherr WD, Delaney SJ. An evidence-based review of the use of therapeutic foods, owner education, exercise, and drugs for the management of obese and overweight pets. JAVMA 2008; 233(5):717-725.
- Vasconcellos RS, Borges NC, Goncalves NV, et al. Protein intake during weight loss influences the energy required for weight loss and maintenance in cats. J Nutrit 2009; 139(5):855-860.
- Wei A, Fascetti AJ, Liu KJ, et al. Influence of a high-protein diet on energy balance in obese cats allowed ad libitum access to food. J Anim Physiol Anim Nutrit 2011; 95:359-367.
- Hewson-Hughes AK, Hewson-Hughes VL, Miller AT, et al. Geometric analysis of macronutrient selection in the adult domestic cat, Felis catus. J Exp Biol 2011; 214:1039-1051.
- Henson MS, Hegstad-Davies RL, Wang Q, et al. Evaluation of plasma islet amyloid polypeptide and serum glucose and insulin concentrations in nondiabetic cats classified by body condition score and in cats with naturally occurring diabetes mellitus. AJVR 2011; 72(8):1052-1058.
- Verkest KR, Fleeman LM, Rand JS, Morton JM. Evaluation of beta-cell sensitivity to glucose and first-phase insulin secretion in obese dogs. AJVR 2011; 72(3):357-366.
- Verkest KR, Rand JS, Fleeman LM, Morton JM. Spontaneously obese dogs exhibit greater postprandial glucose, triglyceride, and insulin concentrations than lean dogs. Domest Anim Endocrinol 2012; 42:103-112.
- German AJ, Holden SL, Bissot T, et al. A high protein high fibre diet improves weight loss in obese dogs. Vet J 2010; 183:294-297.
- Wei A, Fascetti AJ, Villaverde C, et al. Effect of water content in canned food on voluntary food intake and body weight in cats. Am J Vet Res 2011; 72(7):918-923.
- Cameron KM, Morris PJ, Hackett RM, Speakman JR. The effects of increasing water content to reduce the energy density of the diet on body mass changes following caloric restriction in domestic cats. J Anim Physiol Anim Nutrit 2011; 95:399-408.
- Linder DE, Freeman LM. Evaluation of calorie density and feeding directions for commercially available diets designed for weight loss in dogs and cats JAVMA 2010; 236(1):74-77.
- Linder DE, Freeman LM, Morris P, et al. Theoretical evaluation of risk for nutritional deficiency with caloric restriction in dogs. Vet Quar 2012; 32(3-4):123-129.
- German AJ, Holden SL, Morris PJ, Biourge V. Long-term follow-up after weight management in obese dogs: The role of diet in preventing weight regain. Vet J 2012; 192:65-70.
- Villaverde C, Ramsey JJ, Green AS, et al. Energy restriction results in a mass-adjusted decrease in energy expenditure in cats that is maintained after weight regain. J Nutrit 2008; 138:856-860.
- German AJ, Holden SL, Mather NJ, et al. Low-maintenance energy requirements of obese dogs after weight loss. Brit J Nutrit 2011; 106:S93-S96.