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Melanie Cole (Host): There are about a million dogs and cats with diabetes in the US alone. University of Florida veterinary researchers have led a dramatic paradigm shift in how dogs are treated and monitored for diabetes by focusing on early detection and prevention of the disease and by simplifying insulin therapy.

Welcome to UF Vet Med Voice with the University of Florida College of Veterinary Medicine. I'm Melanie Cole and joining me today is Dr. Chen Gilor. He's an Associate Professor of Small Animal Internal Medicine, Small Animal Clinical Sciences at the University of Florida College of Veterinary Medicine. Dr. Gilor, it is a pleasure to have you with us today, as we start talking about managing diabetes in pets and I mentioned just a little bit about it in my intro, can you speak about the prevalence of diabetes in companion animals?

Chen Gilor, DVM, PhD (Guest): Thank you for having me, Melanie. It's a little bit similar to what is happening with people in that some of the prevalence of diabetes is determined by genetics, but a lot of it is determined by the environment. And as our environment changes and we gain weight and we are exposed to different allergens and different bacteria, we are developing diabetes more and more, both Type 1 and Type 2 diabetes.

Host: As we've heard, UF veterinary researchers have led this dramatic paradigm shift in how dogs specifically are treated and monitored for diabetes by focusing, which is the same in humans, to focus on early detection and prevention and simplifying insulin therapy. How are you changing that paradigm for management of diabetic pets and how have you adapted tools and concepts Dr. Gilor, from human medicine, so that owners are no longer bound by that old paradigm of it has to be administered at exactly the same time every day. And only after the animal has eaten a full meal, as it used to be with humans. Tell us a little bit about how you have changed that?

Dr. Gilor: So for most dogs out there still, they are treated with two injections a day, maybe, one injection a day, rarely, but most importantly, those injections are administered after the dog has eaten a full meal because we're counting on the carbohydrates that are being absorbed from the food to counteract some of the action of that insulin.

So most insulin formulations, traditional formulations, peak at around four to six, seven, eight hours after injection and to bqalance that peak insulin, the dog must eat, or else they will develop life-threatening hypoglycemia. What we've been doing in here in the last couple of years together, with collaborators in Australia and Italy is developing a protocol for, basal insulin. Basal insulin being and insulin that doesn't peak that much.

It has a fairly flat time action profile, meaning it basically delivers the same amount of insulin action throughout the day. And so there's no need feed the dog when you give the insulin. And whether you skip a meal or you eat a different type of food or, different quantity, it has nothing to do with that insulin injection.

Now in the past, let's say 3, 4, 5 years ago, the assumption was that, such an insulin is not going to be enough to control diabetes in dogs and what we found, very interestingly is that, not only do we get very good control over diabetes, but it's oftentimes better than the traditional approach of twice daily injections with traditional insulin formulations.

So we reached this sweet spot where we get better control we'd less effort in a way, and with less restrictive protocols. So owners no longer need to worry so much about, A being there twice a day, and B, worry about having the dog eat a certain amount of food, and a specific type of food, and only then give that dog the injection.

So, for a lot of owners, this used to be, or still is, a huge problem and a huge cause of stress because their daily schedule is bound to that insulin injection and to those meals. So they know that they have to be there at, let's say eight in the morning and eight at night and they have to watch the dog eating and that dog has to eat a full meal and only then they can give the injection. And for a lot of dogs, that schedule is not that obvious. So some dogs eat readily and consistently, but for many other dogs, it's not the case. For many dogs, especially when they have diabetes, their appetite is not that consistent. They don't always want to eat the same type of food and they don't always want to eat at exactly the time when you feed them. And recently we found at least one reason for why that is. We didn't know that until recently, but, it seems like diabetes is causing disruption in the gut barrier function of dogs and so they basically have what looks like inflammatory bowel disease and that leads to local and systemic inflammation. And that probably, is at least a big part of the reason for why their appetites are not that consistent.

Host: Do you feel, this is so interesting, Dr. Gilor, do you feel that owners are often uneducated about the difference between dogs, cats, and humans when it comes to disease management and as a result the high stress levels, as you mentioned, it's really, it's a burden on the families. What would you like other providers to know about counseling their patients about the early detection and prevention and what's involved.

And that it's not as difficult because many owners can't afford that emotional, financial, and time commitment. And as a result, many of these animals and pets are being euthanized way too early. What would you like other providers to know about counseling their patients and the families about this disease management?

Dr. Gilor: That's an excellent question. I think education is really important and it starts with education of veterinary students and general practitioners out there. The most important thing that I want providers out there to know is that, we cannot raise the expectations of owners, without giving them the tools to meet those expectations.

And we have to understand, what the overall goal is. And so for a lot of veterinarians out there, they concentrate on let's get the blood glucose to a level of X and that's okay, but that's not the primary goal. The primary goal is to have a dog or a cat that are well-controlled clinically, that are not peeing all over the house, that are not developing complications like diabetes ketoacidosis and severe hypoglycemia and that's are not losing weight excessively. And if you meet all these clinical goals, then the blood glucose doesn't matter anymore. And what I see very frequently, a lot of patients that are referred to me, sre referred for a blood glucose that is uncontrolled and that label of being uncontrolled is based on criteria that are really bogus.

There's really no need to keep the blood glucose at any specific level, at any specific time as long as the dog is clinically fine. And so a lot of vets out there make the mistake of concentrating on numbers instead of concentrating on the patient and they insert that anxiety to owners and that creates a lot of problems. In terms of expectations, I have a lot of owners that come to me with this idea that their dog has to be controlled, just like a human with diabetes would have to be controlled because, you know, we all worry about all these longterm complications of diabetes, except that those don't really happen in dogs.

So there is one, very common complication of diabetes in dogs, which is, cataracts and depending on how you treat them, they're probably going to devote counteracts regardless of what you do. And so for me, one of the first decisions that I need to make when I talk to owners of a diabetic dog is how far do you want to go in terms of preventing cataracts? Because for most dogs out there, that are treated with most traditional approaches, they will develop cataracts. And if we just make that assumption that the dog will develop cataracts, then we don't have to keep their blood glucose any more controlled than what I described before in terms of clinical signs. So again, it's not about the numbers anymore, but about keeping them clinically controlled. And once they understand that, a lot of the pressure is removed.

And for, I would say a very tiny minority of owners that are willing to take an extra step try to prevent cataracts, then the goal changes into okay, to prevent cataracts, we need to normalize blood glucose, like they do in people. And then we need to treat your dog like they people with diabetes. And I think that's the biggest gap in understanding there is this notion out there that, we will treat dogs like dogs, but we will get results like they get in people and you cannot treat a dog with two injections a day and all the insulin formulation that is not very effective or very predictable. Those two injections twice a day, and that's it, get results that are as good as what they get in, let's say Type 1 diabetic kids, which are treated with five to seven or maybe more injections a day, or are just on an, insulin pump.

And I explain to people, you know, if you want to achieve the same level of control as we can achieve in a Type 1 diabetic person, then we need to do the same things that we do for a Type 1 diabetic person, which means constantly responding to changes in their blood glucose, constantly being there and monitoring their blood glucose and constantly injecting insulin when needed. So it's a very, very different approach. We can do it in dogs, but most people wouldn't have the time or the money, even though we have the medical knowledge to do that. So as long as they understand this gap in expectations, and how you get there, then I think, owners would feel a lot better.

Host: Dr. Gilor, I do have some questions before we wrap up about some other studies about those insulin formulations, continuous glucose monitoring, but I would be remiss if I did not ask you about lifestyle, as we're speaking about prevention. Where do exercise, diet, blood pressure control, obesity in our pets, because a lot of them sit around, they don't get out the way that maybe they used to.

They don't get as many walks. I have a dog. I know that she's not getting that much exercise these days. And she has developed cataracts. Where do those lifestyles fit in to this total picture of disease management or possibly prevention?

Dr. Gilor: So we don't have data on any of these questions. We have only epidemiological studies that show the relationship, the association between changes in diets and the frequency of obesity and all these things. But we don't actually have any good randomized studies that show that this treatment or that intervention actually lead to better outcomes and actual prevention of diabetes.

We assume that those will be viable, but we don't have the data yet. And one of the big reasons for that is that one of the biggest gaps that we have in veterinary medicine is that. we don't have any criteria for diagnosis of pre-diabetes. So not having the criteria for diagnosis, we are unable to apply interventions or treatments, to prevent progression to diabetes.

We are working on that, but, it's probably going to take a few years before we get there. We are putting a lot of effort into prediabetes diagnosis in cats. And we need s lot of help with that. So, if you know any people out there that would like to contribute to research in veterinarian medicine, especially in prediabetes in cats and dogs, that would be fantastic.

We need all the help.

Host: Well, certainly, and I hope you'll come on again and update us as we do learn more because it would seem to be a very interesting topic to research. And as we wrap up, do you have any other studies that you would like to tell other providers about along with your best advice as we're using some of those concepts from human medicine in regards, you just mentioned prediabetes tests and assessment of beta cell mass.

There's so much that would go into this complex disease. What would you like to tell other providers about what you're doing there at the University of Florida College of Veterinary Medicine and any final thoughts that you have?

Dr. Gilor: My main research focus these days, is two fold. One is, continuing to simplify protocols of treatment for dogs and cats that are already diagnosed. So we are studying new insulin formulations, including long acting insulin formulations. But, that's out of necessity. What I really want to do and where I really think we need to put a lot of our efforts is in diagnosed with prediabetes. And again, especially in cats where we already have the therapies, and the potential interventions to prevent diabetes, once we diagnose it early enough, and we just need to be able to make that early diagnosis.

So we've been working on using hemoglobin A1C in cats. We just finished a study on developing a reference range for that test in cats, a global reference range that you can, basically a test that you can use anywhere in the world. We are working on measuring beta cell mass in cats so we can develop novel tests for prediabetes and we've been working on developing an easy protocol, a practical protocol for an oral glucose tolerance test that is hopefully going to give us the same result as they get in people in terms of reliable screening for diabetes, but without inducing stress, in cats where stress is a huge problem, when you try to, do any tests on them, especially for diabetes. So that's what we've been working on in the last couple of years.

Host: Thank you so much, Dr. Gilor. This is a fascinating topic. Thank you for sharing your expertise and your research with us today. And to listen to more podcasts from the experts at the University of Florida College of Veterinary Medicine, please visit vetmed.ufl.edu/ufachievers. That concludes today's episode of UF Vet Med Voice brought to you by the University of Florida College of Veterinary Medicine, advancing animal, human and environmental health. I'm Melanie Cole,