Medicine

Tasha McNerney CVT CVPP discusses best practices for anesthesia and pain control in a 0.8lb kitten. These cases are tricky and Tasha lays out why as well as what we can do to reduce the risk and decrease pain and discomfort of our patient.

Tasha and Andy talk through the importance of maintaining cardiac outflow, O2 therapy, blood glucose monitoring, and thermoregulation. Anticholinergics and fasting protocols are also discussed.

This is a FANTASTIC and short episode that is packed with clinical pearls. You won’t want to miss it!

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Veterinary Anesthesia Nerds: http://www.veterinaryanesthesianerds.com/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/store/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Tasha McNerney obtained her CVT in 2005 and has worked clinically in the areas of anesthesia and surgery ever since. Tasha obtained her CVPP (certified veterinary pain practitioner) designation in 2013 and became a veterinary technician specialist in anesthesia in 2015.

Tasha has been a featured speaker on various anesthesia and pain management topics at several international veterinary conferences. Tasha is the author of many articles and blogs on anesthesia and pain management related topics.

In 2013 Tasha created the Facebook group Veterinary Anesthesia Nerds, which has over 65,000 members taking part in education and exchange of ideas from all over the world!

Tasha is crazy and bought a 1920’s fixer upper and is now obsessed with home improvement tutorials on YouTube. She lives in Philadelphia with her husband, son, one perfect cat, and one jerk cat. Trust me that cat is a jerk.

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark:
Welcome, everybody, to The Cone of Shame Veterinary Podcast. I am your host, Dr. Andy Roark, back with my good, good friend, the one and only Tasha McNerney. We are talking about anesthesia and analgesia in itty-bitty kitty cats today. This is super fun. It’s really interesting. I think a lot of us don’t think enough about these types of patients, but we certainly see them. What do you do for a cat that weighs less than one pound? Got you covered today. Guys, this is a great episode. Let’s get into it.

Kelsey Beth Carpenter:
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome back to the podcast. My dear friend, the original anesthesia nerd, the one and only Tasha McNerney. Thanks for being here.

Tasha McNerney:
Thanks for having me again.

Dr. Andy Roark:
Always, always my pleasure. For those who don’t know you, you are a lot of things. You are a wonderful lecturer. You have been the vet tech lecturer of the year at the VMX conference before. I have met you at conferences. Actually, we met in Reno many years ago, and I’ve seen you speak a number of times. You and I have spoken together. We did a Hall & Oates themed track. They gave us a whole track to do something on vet med lessons from Hall & Oates, which I don’t know who signs off on these things, but-

Tasha McNerney:
I know. I don’t know how that got approved when I pitched it, but the fact that they were like, “Yeah, great,” my only regret is that we didn’t do the whole full-on costumes, of you as Oates, me as Hall, and-

Dr. Andy Roark:
I have fake mustache.

Tasha McNerney:
… it could’ve been so good.

Dr. Andy Roark:
I know.

Tasha McNerney:
Listen.

Dr. Andy Roark:
I have a mustache now I could’ve worn.

Tasha McNerney:
I mean, we might need to resurrect this.

Dr. Andy Roark:
Yeah. I agree. So, anyway, we have a history of highs and lows. We’ve made goofy internet videos together. But anyway, you are also a technician specialist in anesthesia, analgesia, and the founder of an enormous Facebook group called The Veterinary Anesthesia Nerds, which also has its own conferences now and things like that. It has really metastasized, if you will, and it’s a force of good in the world. You do great things. Anyway, you are my go-to for in the trenches, on the ground anesthesia, analgesia questions, and I’ve got one for you. Can I ask you about it?

Tasha McNerney:
Of course. Let’s do it.

Dr. Andy Roark:
Okay. This is a case that everybody’s seen, but I just had it. In all honesty, I just had it a week or two ago. So, I got this little black kitten. So, it was about .8 pounds, and it’s just a black domestic shorthair kitty cat, and someone had just found it beside the road, and they brought it in, and they said, “I would like to have this cat and to get it cleaned up and give it a home,” and I said, “I think that’s great, and I want to support that.” As I look at this cat, she has got a big swelling under her right mandible. So, on her neck there’s this big swelling, and I go and I look and there’s a draining tract, and as I squeeze around, I think that there is a cuterebra in there. There is some sort of parasite inside this draining tract. It’s not just infection.

Dr. Andy Roark:
So, I’ve got this itty-bitten kitten, true story, less than one pound, probably four weeks old, and I just am wondering to myself… I don’t want to ruin this cat, fear-free all the way, and it’s sort of like, I want to make sure that I’m keeping this little burger comfortable because this is going to hurt. There’s no way this doesn’t hurt, to have this thing pulled out of your neck, especially if I have to open the tract up a little bit to get to it. So, I just want you to go through with me… Tasha McNerney, talking about a cat this size, anesthesia, analgesia, how do you treat that? Give me some best practices. Help me make sure I’m doing a good job.

Tasha McNerney:
Yeah. So, there’s a lot of things. First off, right off the bat, what I would want to know with this kitten is, especially in the location that you’re telling me, is there any way that we have compromised the airway? We did have a kitten very similar to this come into a practice I relief at, and spoiler alert, you guys, this doesn’t have a great ending, but it had multiple cuterebra, and one of them in the neck area had migrated enough that it had caused a tracheal rupture, and euthanasia was chosen for that kitten just because surgical correction, even with surgical correction and a tracheal stent, might not be… So, again, that’s always going to be in the back of my mind. Has it compromised our airway in any way? If so, we still can work with it.

Dr. Andy Roark:
Thanks for giving me something new to worry about. That had never crossed my mind before, and now I’m like, oh, now I got that to worry about. Thank you for that.

Tasha McNerney:
Well, it’s vet med. There’s always something new to worry about.

Dr. Andy Roark:
Let me tell you something you never even considered that I’ve seen before. Oh, God. All right. Okay. No, I’m onboard.

Tasha McNerney:
All right. So, let’s say-

Dr. Andy Roark:
Note to self.

Tasha McNerney:
Note to self, just make sure that that trachea… Again, you don’t have to go through a full on let’s get a CT, again, unless you’re just feeling really ambitious, but other than that, if you feel like your airway and pulmonary-wise we are okay, all of anesthesia is preparation. I know that a lot of people think that anesthesia is kind of boring in the sense that a lot of these procedures were sitting and monitoring and just writing stuff down. There’s not a lot of movement, fast-paced action. Listen. All of anesthesia is just preparation to make sure that we don’t have fast-paced action once the animal gets onto the table. We want to make sure that we are planning as much as possible, and for a little kitten like this around for weeks old, around a pound in weight, this is really tiny, so we want to plan correctly, and again, a full physical exam as much as we can.

Tasha McNerney:
These little guys are really dependent on heart rate in order to maintain that cardiac output. Remember, we need cardiac output to be maintained because our blood pressure is dependent on cardiac output. So, for these little guys, they kind of come in with that high heart rate. The whole thing during anesthesia is I want to keep that heart rate as close to normal or even a little bit higher as possible because as my heart rate gets lower and lower, or the patient gets bradycardic, that’s going to drop my cardiac output. The reason we care about that is that cardiac output is going to influence oxygen getting delivered to the things that we care about, the liver, the kidneys, the brain, et cetera.

Tasha McNerney:
Also with these guys, the pulmonary reserve is limited, so they can get hypoxic faster. So, these guys, definitely always make sure if you’re giving them any kind of drugs or sedative, it’s in the presence of oxygen, you have supplies ready to go to intubate them. Now, these guys are ones that I’ll tell you sometimes I use them in birds and reptiles, but for these really tiny little guys, I might choose an uncuffed endotracheal tube, an appropriately-fitting uncuffed endotracheal tube, so that way I don’t have to put a tiny tube in and then push that reservoir cuff on the end of a tracheal tube, because too much pressure on these little guys can cause some tissue necrosis in that trachea.

Tasha McNerney:
So, these, I have a selected of not only cuffed, but also uncuffed tubes for them as well. Now, these guys also, everyone’s underdeveloped, so that’s just what you got to on. Their sympathetic nervous system is also underdeveloped. So, that means that drugs that are going to work on the sympathetic nervous system, so again, things like ketamine, telazol, that kind of stuff, those drugs usually will get a sympathetic response, and we see an increase in heart rate and a little bit of increase in cardiac output with them, but we don’t ketamine and tiletamine in these really tiny patients. Again, because that sympathetic nervous system is underdeveloped, they don’t have the same response that an adult or an animal of maturity would have.

Tasha McNerney:
Also, these animals get very hypoglycemic fast. So, before I give any drugs, I want to check a BG and make sure that we’re in range, and I want to be ready to supplement with dextrose as needed. Again, we’re constantly checking EGs. Now, with a cuterebra patient, hopefully they’re not going to be under anesthesia or sedation for a long period of time, but certainly, I have done some amputations on very tiny, tiny little guys where they might be under anesthesia for up to an hour, and we’re every 15 minutes checking BGs on them. Also with these guys, thermoregulation is going to be a big one.

Tasha McNerney:
So, before you get this patient sedation, you want to plan on how are we going to keep them warm, whether that’s a Bair Hugger or whether that is just covering the body in bubble wrap and providing either active or passive warming. You want to have a plan for warming because in these little guys, that larger surface area to body weight ratio means that they’re going to lose heat much faster, and then if you intubate them, you almost always are putting these little guys on a non-rebreather, and remember that that high flow of oxygen from a non-rebreather, it is going to contribute to them getting colder faster as well. So, just be ready with a plan for thermoregulation.

Tasha McNerney:
If you have the opportunity to… If it’s a planned procedure, you know they’re going to come in, again, with the hypoglycemia and et cetera, the fasting recommendations for these guys are no more than three hours, so we want to make sure that they have not been… These are not patients we fast for eight hours or even overnight. We really don’t want to do fasting with these guys. Once we have all of our stuff together, you have your stuff for intubation, you have your oxygen, you know your heat support protocol, all that, if you want to talk about drugs, again, I already mentioned that I probably would stay away from things like ketamine, tiletamine, which is a component of telazol, but maybe I’m going to go with an opioid, and usually the [inaudible 00:10:24] opioids, whatever is your opioid du jour at your clinic, maybe you are a hydro clinic, maybe you are a methadone clinic, again, I always say dealer’s choice when it comes to new opioids.

Tasha McNerney:
I am equal opportunity opioid, so if you want to do hydro or methadone, whatever it is, the nice thing is that it’s reversible, so we just tend to go a little bit lower on our dose, but opioids are pretty safe for these guys. Now, if you give a big dose or you’re giving fentanyl IV, you might see a reduction in heart rate, and again, these guys are really dependent on heart rate, so I always have a dose of anticholinergic drawn up and ready to go for these patients. In some cases, especially in the neonatal, not in this case, but a really tiny brachycephalic patient, because of their high vagal tone, this is the one area of patients where I am going to put glycopyrrolate into their premed to offset any of that reduction in heart rate, and therefore, reduction in cardiac output. So, I always have a dose of anticholinergic.

Tasha McNerney:
Now, some clinics don’t have glycopyrrolate. You might have atropine. So, again, whatever you have at your clinic, just make sure you have a dose of anticholinergic drawn up and ready to go, not over there on a shelf, in the same room with you, but actually calculated, drawn up, ready to go with these. Then the next thing that we consider is if we’re going to put a catheter, if we’re going to intubate them, you can give them an opioid and then a local anesthetic, just a little bit of lidocaine just around the area of the cuterebra to cut those pain signals going to the brain for when you actually have to open and widen it and pop, pull that cuterebra out.

Tasha McNerney:
So, I like a combination of opioids and local anesthetics, definitely some flow by oxygen and ready to intubate as needed. Again, the timing of these procedures, you could make the case that intubation in itself, because it has complications, this might not be warranted, but certainly, if you were dealing with something like an amputation or a longer procedure, you would want to intubate these patients to have control of your airway. If you needed something a little bit more, there’s always alfaxalone, which you could give a small dose of alfaxalone IM. Now, again, with alfaxalone you’re not providing any pain control, and alfaxalone is one of those drugs that if you do use it IM, which is off label in the US, but on label in New Zealand and Australia, if you’re using alfaxalone IM, just remember alfaxalone doesn’t play nice by itself.

Tasha McNerney:
Alfaxalone needs a buddy. It needs a friend. Now, that friend can be an opioid. That friend can be something like midazolam, but alfaxalone doesn’t go well by itself. When we use alfaxalone IM by itself, you tend to see nystagmus, muscle tremors, which some people mistake for seizures, et cetera. So, that’s why I always say make sure if you’re giving alfaxalone, you’re pairing it with something else, and in this case we would be. We’d be giving this kitten an opioid of some sort. Does that all sound good?

Dr. Andy Roark:
That all sounds good. So, there’s a lot there. That all matches up. I’m frantically taking notes over here. Yeah, that’s really helpful.

Dr. Andy Roark:
Hey, everybody. I’m just jumping in with two lightning-fast updates. Number one, if you have not gotten signed up for the Get Sh*t Done Shorthanded Virtual Conference in October, it’s October 6th through the 8th, you need to do that. If you are feeling overwhelmed in your practice and you want things to go smoother and faster, if you do not want to watch webinars, you want to actually talk about your practice. You want to do some discussion groups, you want to do some workshops where you actually make things and work on things and ask questions as we go along, and have round table discussions and things like that, that’s really going to energize you and help you figure out actionable solutions that you can immediately put into practice to make your life simpler and more relaxed, I got you covered, buddy, but you don’t want to miss it.

Dr. Andy Roark:
Go ahead and get registered. Mark yourself off at the clinic for the time so that you can be here and be present and really take advantage of this. I don’t want it to sneak up on you. I know October seems like a long way away. It’s not. But go ahead. I’m going to put a link down below, and then when registration opens, we’ll let you know it’s open and you can grab your spot. But you do not want it to sneak up on you. Check out our Get Sh*t Done Shorthanded Conference. It’s going to be a great one. The second thing I’m going to tall you about is Banfield. Thank you to Banfield Pet Hospital for making transcripts of this podcast available. You can you find them at drandyroark.com. They are totally free and open to the public, and Banfield supports this to increase accessibility and inclusion in our profession. It’s a wonderful thing that they do. Guys, that’s all I got. Let’s get back into this episode.

Dr. Andy Roark:
Do you have a thermoregulation preference for an itty-bitty like this? Is there something that you think is more effective with something so tiny? I imagine this little speck disappearing underneath a Bair Hugger. You’re kind of hovering over top of the kitten because there’s just so little there. Yeah. Do you have… Give me some advice. Even if it’s just… You said dealer’s choice. Even if it’s personal preference, what do you like for helping maintain body temperature in itty-bitties?

Tasha McNerney:
Yeah. These really tiny ones, I do still think that an active warming as a HotDog or a Bair Hugger or a warm water blanket is the way to go.

Dr. Andy Roark:
Okay.

Tasha McNerney:
Certainly, as you said, we can’t use a regular… Even the small size Bair Hugger blanket this kitten is going to disappear under, but we can… A lot of people, if you have Bair Hugger blankets in your practice, they come with these little plastic inserts, and most of the time people just throw them away. I’m going to tell you, don’t throw them away. Okay? You can actually use the plastic sticky things that come in with it. They come with the Bair Hugger so that you can put the plastic around, and they actually help to seal in the juices as far as the heat goes. But again, most people just throw them away. Don’t. Keep them around because you can stick them longways over your patient, and then you can just finesse the Bair Hugger output or the warm air output underneath this plastic.

Tasha McNerney:
Again, you could use something like bubble wrap as well, and then provide the Bair Hugger underneath that. But usually, I have it on each side. So, I might have a warm water blanket, warm water circulating blanket underneath the patient, and then I might have the Bair Hugger or even a HotDog around it. I will say I’m a fan of the HotDog. What I like about it is that unlike the Bair Hugger, you don’t have to worry about things blowing around your surgical site, and the nice thing is for these really tiny patients, the HotDog does actually make a very tiny size HotDog blanket. It is adorable if you have the chance to see it, but it’s made for hamsters and gerbils, so it’s really tiny, and it will wrap around the patient to provide active warming. So, if you have a HotDog in your practice already and you are dealing with small cats and kittens, I would say invest in one of these because it is really nice to wrap them around, and again, it’s just freaking cute.

Dr. Andy Roark:
All right. I feel good about that. So, I’m feeling good about all of this, honestly. So, up to our procedure, this all makes sense. I can lay all this stuff down. I have everything in the clinic. This is perfect. This is really, really great. Do you have any advice on analgesia post-procedure?

Tasha McNerney:
Yeah. So, for these guys, analgesia post-procedure, hopefully… Here’s the thing. Unfortunately, what you’re going to be dealing with is some inflammation, and we just don’t have, or at least I would say that I would be a little bit uncomfortable giving something that’s four weeks of age a nonsteroidal antiinflammatory. So, with this patient you could consider things like oral transmucosal buprenorphine for analgesia. If you have gabapentin formulated, please note that I’m not saying that gabapentin will be the sole analgesic, but gabapentin can help these patients feel better, provide a little bit of sedation, et cetera. Also, for inflammation, if you have in your practice and you are able to do a session or two before the patient leaves, something like a low-level laser therapy on the antiinflammatory setting is a nice, again, non-pharma adjunct for these patients.

Tasha McNerney:
But really, cats are just amazing in how fast they can bounce back. I think the biggest thing with these little guys is that as long as you’re maintaining their heart rate and their cardiac output, again, which you know what, just means no dexmedetomidine. I know you’re all tempted, and it’s my favorite drug, but in these guys we want to make sure we avoid dexmedetomidine or something like that. But for post, usually these heal up pretty quickly. I like to do laser therapy gabapentin if you can get it compounded so that your dosing would be accurate. It’d be hard to give this little tiny kitten a tablet or a quarter or an eighth of a tablet.

Dr. Andy Roark:
Yeah, yeah. At some point, you’re just kind of scraping powder. Yeah.

Tasha McNerney:
Yes.

Dr. Andy Roark:
That’s no good. All right, perfect. Man, that’s super great. Tasha McNerney, you are amazing. Thank you so, so, so much for being here. Where can people find you online? Where can they learn more if they like to geek out about anesthesia?

Tasha McNerney:
Yeah. So, if you are on Facebook, we run the Veterinary Anesthesia Nerds Facebook group. I always tell people that if you’re not on Facebook, this is not the reason to get on Facebook. If you’ve avoided Facebook this long, I applaud you. You’re probably living the life, man. So, we are on Facebook. We also are going to be having a conference within a conference this year. So, if you are going to or if you’re thinking about heading to Fetch in San Diego in December, the anesthesia nerds are going to be running their conference inside of the Fetch Conference. So, we’re going to have two days of nothing but anesthesia and pain management. We’re doing a regional nerve block wet lab to teach people some more advance ultrasound-guided regional nerve block techniques, and we’re going to do basic nerve blocks as well, but all things nerve block. So, that’s going to be coming out, our links to register for that, pretty soon.

Dr. Andy Roark:
That’s outstanding. Awesome, awesome. Thanks anything for being here. Guys, take care of yourselves. Have a wonderful week, and I’ll talk to you next week.

Tasha McNerney:
Thanks.

Dr. Andy Roark:
That’s our show. That’s what I got for you, gang. I hope you enjoyed it. I hope you got something out of it. If you’re watching on YouTube, hit that subscribe button. If you are listening on the podcast, leave us a review wherever you get podcasts. Tell your friends. That’s how people find out about the show. I really appreciate it. Really appreciate your help. Gang, take care of yourselves. I’ll talk to you soon.

Dr. Lauren Pagliughi joins Dr. Andy Roark to discuss a case that is oh-so-common in veterinary medicine, and oh-so-likely to end badly for feline patients! They are talking about Feline Lower Urinary Tract Disease (FLUTD). They discuss the importance of environmental questions for pet owners, diagnostics (including radiographs), and responsible approaches to treatment in regrade to antibiotic use. Let’s get into it!

This episode has been made possible ad-free by Purina Pro Plan Veterinary Diets!

LINKS

Purina Pro Plan Veterinary Diets: https://www.purinaproplanvets.com/

Indoor Pet Initiative (cats): https://indoorpet.osu.edu/cats

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/store/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Lauren Pagliughi attended Rutgers University for her bachelors of arts and obtained her veterinary degree from Colorado State University. Upon graduation, she completed an internship in Small Animal Medicine and Surgery at Oradell Animal Hospital in NJ. She then joined Absecon Veterinary Hospital, a large general practice in NJ, before joining the Purina family in 2013.

Lauren currently resides in Linwood, NJ serving as a veterinary communications manager for Nestlé Purina Petcare. Spreading passion for advanced nutrition, she supports veterinary teaching hospitals throughout the country and provides technical support for Purina’s sales consultants. She continues to practice as a relief veterinarian in South Jersey. In addition to nutrition, Lauren has a key interest in small animal surgery.

Lauren spends all of her free time with her twin boys Zachary and Felix, and her daughter, Greta. Lauren also enjoys being outdoors mountain biking, surfing, cycling and snowboarding with her children and her husband, Michael. She loves spoiling her lab, Dottie Lou, and her two cats, Cecilia and Daniella. She has a passion for sustainability and helping others to make “green” choices.

Dr. Pagliughi went tandem sky diving 3 times when she was 19 years old in hopes to become certified – that did not happen! She has a passion for high intensity sports, like Mountain Biking and Snowboarding. She has a dream of moving to Costa Rica one day.

EPISODE TRANSCRIPT

Dr. Andy Roark:
Welcome everybody to the Cone of Shame Veterinary Podcast, I am your host, Dr. Andy Roark. Guys, I’ve got a great one today, we are talking about kitty cats being outside the litter box. That’s right, it’s FIC, that’s feline idiopathic cystitis or FLUTD, which is feline lower urinary tract disease. We use both of these terms in the podcast and we use them interchangeably so I just wanted to lay it down up front. I am talking to my friend, the one and only Dr. Lauren Pagliughi and she is walking me through what do we do about these cats. It is a fascinating episode, we talk a lot of behavior, we talk about great questions to ask the pet owners, we talk about setting expectations, we talk about treatment, we talk about nutritional therapy and we talk a lot about diagnostics and just really work these cases up in a very rewarding way. Guys, I hope you will enjoy this episode, let’s get into it. Oh, and this episode is made possible, ad free by Purina Pro Plan Veterinary Diets.

Kelsey Beth Carpenter:
(singing) This is your show, we’re glad you’re here, we want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast, Dr. Lauren Pagliughi, thank you for being here.

Dr. Lauren Pagliughi:
Thanks for having me, Andy. I’m excited to talk about urinary health.

Dr. Andy Roark:
Awesome. Well, I am glad that you’re here. You are a practicing veterinarian, you do some emergency work, you do community work, volunteer work even, you are also a Vet Communications Manager at Purina, which means that you are a nutrition educator in a lot of ways. Yeah. And we were talking just a while ago, you are an avid cyclist and mountain bike as well with three kids, so you stay busy.

Dr. Lauren Pagliughi:
I stay very busy.

Dr. Andy Roark:
I wanted to talk to you today about something that is squarely in your wheelhouse. It is a case that I see a lot and I always like to check myself and make sure that I am doing these cases the way that I should. I’m going to be honest about something that I struggle with as we talk through this. But I want to get your insight on a case that I have, are you ready?

Dr. Lauren Pagliughi:
Absolutely.

Dr. Andy Roark:
Okay. I have a six year old female spayed domestic shorthair named Penelope in room two. She is in for accidents in the house. She is peeing on the couch and peeing on the blankets and the owners are baffled and very frustrated. Now they have had Penelope for a long time, they’ve had her since she was a kitten, this is not a normal behavior for her so I brought her straight in and looked at this and went for a medical examination and evaluation of her and did a sterile cysto and a urinalysis, as well as some blood work.

Dr. Andy Roark:
I don’t see anything of note on the blood work, which is good. I do on her cysto urinalysis, see a lot of blood and some crystals. And so I am looking at this cat and immediately I say, “I don’t see any bacteria.” I expect this is lower urinary tract disease or FIC, but I worry about, is this an infection that I’m missing? Is there something else going on? I just want to work this case up in the best way possible because it’s a common case and I want to get it right. Let me turn this over to you and just say, starting out right here, looking at this case, how do you, Lauren, treat this?

Dr. Lauren Pagliughi:
Great question. So these are common cases that we see in practice and they are frustrating. They’re right up there with the derm cases that we see on a regular basis because they’re often chronic in nature. A lot of the times a cat that presents for inappropriate urination will present again for the same issue because of some risk factors they might have. So I usually backpedal a little bit and just try to empathize with the owners. I don’t know if you’ve ever had a pet urinate in your house somewhere that is difficult to clean. I have a neighbor actually who is going through this right now with her cat, it urinated on her couch and it essentially ruins the furniture. And you love your pet, but believe it or not, this is one of the most common reasons that cats are surrendered to animal shelters. So it’s a big problem, not just for the owner, but for the pet as well and for their quality of life.

Dr. Lauren Pagliughi:
And I think there’s this misconception that there’s always a behavioral component. Sometimes there is a behavioral component, but often together with the owners, we can come to some type of solution. So I think that off the bat, it’s really important to discuss with your owner and to help them understand that how they’re feeling and how frustrated they are and that you want to help them find a solution for their pet and for their own household so their own household isn’t getting ruined at the same time. I think also even before going right into diagnostics, which is absolutely something that needs to be done in all of these cases, I think trying to determine if there is a behavioral component or if it’s more of a medical problem that’s causing this inappropriate urination. So getting some more information about the environment, about how many cats are living at home, about just the temperament of that cat in general.

Dr. Lauren Pagliughi:
So is Penelope what the owner would describe as a scaredy-cat? I have a scaredy-cat. I have two cats in my office right now sleeping, two geriatric little old ladies and one is scared of her own shadow and I wouldn’t be surprised if she was a FLUTD cat at some point in her life. Thank God she isn’t. But knowing that can help you understand if they fall into the category of cats that are at risk for lower urinary tract signs, which is the new name for FLUTD. And also, is the cat obese? What is the environment like at home in terms of litter box maintenance? Are there a bunch of kids running around? I have three little kids, it’s a stressful environment for cats in my household as well. So understanding all of that prior to jumping into diagnostics is really helpful because you’re going to need all that information anyway.

Dr. Lauren Pagliughi:
You did the right thing first and foremost in getting the urinalysis, it’s really hard to make this diagnosis without having all the different pieces of the puzzle. And I say the pieces of the puzzle because lower urinary tract signs or FLUTD are multifactorial. So all that environmental stuff we just talked about, underlying medical conditions, a potential stones or urinary tract infection, things that we can treat will be hopefully found out through diagnostics and then just individual response. So every cat’s going to be different and the same treatment plan might not work for every single cat. And the owners play a really big role in the treatment of cats with FIC, of cats with lower urinary tract signs of any sort.

Dr. Lauren Pagliughi:
And I can pick on my own self, early on as a vet I probably didn’t involve the owners as much as I needed to. They play a huge role because they’re the ones managing them on a day to day basis. As vets all we can do is prescribe food and maybe medication to help them if it is a medical cause of the signs that we’re seeing. But beyond that, we’re not doing a whole heck of a lot. So it’s really up to the owner to be on the same page, right there with us in part of that treatment plan to really get down to the bottom of what will help to reduce these signs and hopefully eliminate them and make that pet feel better.

Dr. Andy Roark:
Talk to me a little bit about what it means to partner with the owner at this phase? And you say we didn’t include them as much as you wished that you had, help me understand what that looks like in your mind? What you do differently now than you did earlier in your career?

Dr. Lauren Pagliughi:
Yeah. So I think the longer I’ve been a vet, I lost to my own dogs last summer and just experiencing pet ownership myself. When you’re a brand new vet, you may have had your pets growing up, you may have a young cat or young dog, that was me for a long time. And I think experiencing different ailments in your own pets helps you empathize a lot more so with pet owners. If you have, God forbid, a dog that seizures, you’re going to really empathize with someone whose pet suffers from idiopathic epilepsy. Or if you have a cat with inappropriate urination, you’re really going to empathize with these owners that come in. So regardless of if you’ve gone through that, I think it’s important to try to find that empathy first. And that really helps with that communication, they’re going to trust you more because you understand how they’re feeling, you’re validating what they’re going through.

Dr. Lauren Pagliughi:
And then once you’re on that same page together, I think it’s getting that commitment from the owner of, “Hey, Penelope’s mom, I want to help Penelope. And these are the tests that we’re going to do to help figure out if there’s something medically that I, as your vet, can treat. And here’s all the things that we’re going to do together and I’m going to help you do at home so that we can address all these other factors that might be increasing the risk of Penelope having FLUTD or having potentially FIC, whatever diagnosis we get to over the course of examining her and doing all of her test. But Penelope’s mom, if I can’t get you on the same page, we’re going to have a really hard time getting her symptoms to go away and we’re going to have a really hard time getting her to feel better and having good quality of life and we’re going to have a really hard time preventing your furniture from getting peed on.”

Dr. Lauren Pagliughi:
So I think it’s getting that buy-in so important. And we can say that for so many different diseases that we treat in veterinary medicine. I always think of doing an elimination diet trial and using a hypoallergenic diet or an elemental diet that you really need that buy-in from the owner, you cannot just send that bag home, you’ve got to make sure that they can absolutely commit, 110%. And the same goes for FLUTD. And I’ll talk about, if we get some time on this podcast, about some good resources that owners can use to help to modify that environment at home, to really reduce stress in these guys.

Dr. Andy Roark:
Yeah, definitely. Let’s jump back to the diagnostic process here. So I really like your behavioral, environmental approach asking about stressors, things like that, that totally makes sense. I said, “Blood work looks good, I’m seeing a lot of blood and some crystals and things in the urine.” For you, when you look at this, do you ever have a question about this being a urinary tract infection or the benefit of antibiotics to it? That’s the thing I said at the beginning, I said, I wrestle with this. I’ll be honest, I want to be a good steward of antibiotics, I also struggle and go, “Well, what if I’m wrong and I tell them we’re going to approach this to FIC, but there’s a bacterial infection?” Do you ever have that concern and how much confidence do you have as you approach these?

Dr. Lauren Pagliughi:
So the good thing is in Penelope’s case, you already got a urinalysis and you got it via cysto. So you have urine that you can hold aside and you can send off for culture, if you decide you want to go that route. The fact of the matter is that young and adult cats have a very low risk of a urinary tract infection, it’s 1% to 2% of cats. If they become more geriatric and have concurrent diseases like diabetes or renal disease, then their likelihood of having UTI goes up a little bit. But you already mentioned that Penelope is six years old, she’s otherwise healthy, her blood work was all normal so the likelihood of her having a UTI is very low.

Dr. Lauren Pagliughi:
So the problem with just… And I’ve done this, again, I will raise my hand and slap my own hand, I’ve given many a cat coming in because you feel like these owners come in and you want to help them and you don’t want to send them home with nothing, you want to try something, whether it be pain medication or antibiotics. And then sometimes you give this stuff and then you’re like, “Did it help?” Maybe that is what helped and so you go down this road of doing something that probably is doing more harm than we really realize.

Dr. Lauren Pagliughi:
So we know that some of these longing-acting antibiotics like Convenia, when they’re necessary, they’re absolutely great. But when they’re not necessary, they’re probably wiping out a lot of the important micro flora in the GI tract of these guys, which can impact their immune system and lead to dysbiosis down the road. And we don’t want to do that unless we have a really good reason to give antibiotics. So I say, when in doubt, do not give antibiotics and if you are really suspicious of a UTI, then send off a culture. Absolutely, there’s no harm in doing that and then you’ll know for sure.

Dr. Andy Roark:
Okay. That I completely makes sense to me. I like that a lot. I like the idea of talking about the culture just to cover our bases. Then I still feel like I’m doing things. You mentioned giving them something like pain management medications. And I do think that, that’s important and honestly, that scratches a lot of itch for me, as far as feeling like I need to do something and I want to help this cat right now. Can you talk a little bit about pain management, supplemental approaches to this? And so we’ve moved in and we have our culture and we can confirm that there’s no infection and things like that. And so it seems like we’re moving down the course of treating this as a FLUTD cat, let’s go ahead and start talking about comfort first, how do you approach that and what do you communicate to the owners?

Dr. Lauren Pagliughi:
So the research is iffy out there as to whether or not cats really do better on pain therapy or not in these cases. So some vets will feel really comfortable using something like Buprenorphine. You want to be pretty careful with NSAIDs and make sure that there’s no renal insufficiency or anything like that because we don’t want to be causing any renal issues with pain medication. Really my go-to is trying to get that urine really dilute and trying to get them to actually pee more so that we can continue to flush that bladder and reduce stress by doing this multimodal environmental modification that the owner is super involved in. So doing things to reduce stress and as we reduce stress, then a lot of the times these cats overall feel better. But pain, typically it is the veterinarian’s choice of what they feel comfortable to use safely in their patients. But Buprenorphine’s pretty well tolerated by cats and pretty rare contraindications to using a drug like that, but just be careful with the NSAIDs in these guys.

Dr. Andy Roark:
Okay. Let’s talk about stress reduction. So we started off with environmental questions and we talked about things that are possibly affecting Penelope at home, things like that. Maybe they have some, they don’t, but we’re going to talk about alleviating that stress and then where do you go from there?

Dr. Lauren Pagliughi:
Yeah. So we could talk about different supplements, Calming Care is a probiotic that can help reduce anxiety in cats. But I think before going down that road of considering supplementation or anxiolytics, really diving into that environment. It’s no different than a person who might need to start a medication to help with their stress and what’s going on in their lives. But if all those stressors are still there all the time and you’re doing nothing to modify your environment, it’s going to be a lot harder to feel better. It’s no different for our pets. So there’s a good website through Ohio State called the Indoor Pet Initiative, you could just Google it and you can find it very easily and there’s some really great resources on there. They follow the N+1 rule with essentially everything that is in the cat’s life. So if you have two cats, you should have three to four litter boxes and you should have multiple places for them to eat and drink and multiple places for them to perch or lay around or wherever they’re comfortable.

Dr. Lauren Pagliughi:
And most households are not set up like that for their cat. So those are some really easy things that owners can do to modify their environment and to make the environment less stressful for that cat. Also, trying to identify the stressors in the house. So if you have a skittish cat, what is causing that stress right now? I mentioned earlier that my cat share my office with me and that’s for several different reasons. They did not grow up around my children, my children came later. They do not like my puppy, they are stressed as can be when they are not in my office. They prefer to have this as their space, they have their little cat tree over in the corner and they can come and go as they please out of the room, but nobody else comes in here except for me.

Dr. Lauren Pagliughi:
So not every cat is going to be a kid person, not every cat… Or kid cat, I should say. So understanding your pet and trying to adapt more to them, I mean, they are cats, they rule the world and rather than trying to have them adapt to us. And I think that’s really important to think about. Other things that can help to reduce stress is pheromones so Feliway diffusers or Feliway spray can help to reduce stress in some cats so that’s always a good thing to think about.

Dr. Lauren Pagliughi:
And then, like I mentioned, once we have that environmental component really nailed down, then maybe considering things like Zylkene or Calming Care or potentially some anxiolytics, if you want to go down that road. But I think addressing the environment is so important and I would say maybe the most important part of the puzzle, that and diet, to really address these guys. And I think that part’s often missing or the owners aren’t realizing what an important role they play and think that there might be just a magic diet or a magic pill that will take care of all the problems their cat’s having, but they really have to be invested in getting their pet to feel better.

Dr. Andy Roark:
Yeah, that’s really interesting. I don’t think I’ve really processed how much getting the pet owner on board with that part of it probably means. So that’s something I’m going to have to think a little bit about as far as, have I been impressing this on pet owners enough? And probably not. So that all makes sense to me and it tracks along. Walk me through your approach from a treatment standpoint? Let’s just say that we have a spouse who’s going, “Look, I need this cat to stop peeing on my [inaudible 00:18:34] now.” And I think we’ve all seen those cases where this cat is one person’s cat and the other person in the house tolerates the cat and now they are really having a hard time. That’s real stress that people have to manage.

Dr. Andy Roark:
Walk me through your steps and even a timeline of what do you generally start out with? When do you have them come back or call you with updates? Help me go through your steps? And I want to understand timelines too because I don’t want to jump in and it’s easy to do everything at once and go, “We’re going to do Calming Care and we’re going to do diet and we’re going to do a new water bowl and a fountain that gets them to drink.” And you can do all the things at once and it can be really overwhelming, but you can also not take this seriously enough and then there’s a lot of tension at home. And this is the number one reason that cats end up in shelters and that sticks with me and haunts me and I go, “I really don’t want to not seem motivated here.” So how do you balance those things and what does your timeline look like?

Dr. Lauren Pagliughi:
Gosh, timeline is going to be so individual, Andy, that’s a hard one because every cat’s going to be so different. And I mean, I always like to be positive, but if you have a cat that’s coming in, that’s urinating inappropriately and it’s one of 10 cats in a household, gosh, I mean those are really challenging cases. And sometimes we don’t get to the bottom of those, sometimes we can’t find a solution in every single situation. But again, I think opening that line of communication and setting realistic expectations are so important with our owners, we need to set realistic expectations. The cat, Penelope might urinate on the couch again before we get to the bottom of this and we might not stop it entirely, but we’re going to do our darnedest to try. And we’re going to see if we can find a solution, whether it be medical or behavioral or environmental or whatever it may be so that we can stop her from doing this.

Dr. Lauren Pagliughi:
But again, I think we need that buy-in and we need that realistic expectation. And timelines make me nervous because giving an owner a timeline and we can’t predict exactly how every patient’s going to respond. So giving a timeline to an owner I think we’re going to be shooting ourself in our foot if we don’t stick to that timeline. So I think if we backtrack a little, we’ve had this great discussion with Penelope’s mom, we get her on board, we talk to her maybe about some solutions to trying to get that urine smell out of the couch or maybe we just cover it for now or come up with some solutions. Maybe the cat is happy, confined to one room where she could put some perches in and a bunch of litter box and keep her away from some of the other things that stress her out.

Dr. Lauren Pagliughi:
A lot of the times people think that cats won’t like that, some really do, some actually like that change of environment. Some cats want to be able to go outside, I mean, sometimes that is a big stressor for them, maybe they started as an indoor, outdoor cat or an outdoor cat and then they got moved in. So really digging down as a vet to try to understand what changed in that cat’s life or what is happening that is creating stress for that cat, that’s making this cat now do this, if that’s the cause. So then as you mentioned, you did blood work, which is really important because there’s lots of things that can cause cats to urinate more or inappropriately. So we want to make sure that we don’t have any renal insufficiency or anything else going on, diabetes. And then the analysis, you mentioned that there were a lot of crystals and a lot of blood.

Dr. Lauren Pagliughi:
So hematuria is pretty commonly seen with FIC cats. So idiopathic cystitis, our favorite word is vets for when we don’t know what causes something. So just unknown inflammation in the bladder, blood is often what we see there. But it is important to realize too, that when we do a cysto or we palpate the bladder, we can cause iatrogenic hematuria. So sometimes just spontaneous nutrition can help us to know if that is real or not. So asking the owner if they see blood when they’re looking at the couch or wherever the cat’s urinating inappropriately or in the litter box. And then the crystals I do want to mention, because I think crystals haunt veterinarians. They see them, they want to treat them, they don’t feel right to see them on a urinalysis, but they can be very normal. And there’s a lot of different studies looking at disillusion with some Purina diets where normal cats had crystals and crystals were not very predictive of stone type.

Dr. Lauren Pagliughi:
There’s an interesting study that showed, I think, 28% of urine samples form crystals just from sitting out on the counter or going in the refrigerator. So just forming outside of the body in the urine. So I like to use the pun, “Take it with a grain salt.” Don’t fixate in on the Crystalluria. On the flip side, it’s really important to think about taking a radiograph as well. The number two cause of lower urinary tract signs in cats are stones. And we so often skip that because FIC is the most common, but stones are still common enough that shooting two of you radiographs of the abdomen to look for stones is super important. And it’s not enough to just do an ultrasound because you can miss things on an ultrasound, especially urethral disease, you can miss with an abdominal ultrasound.

Dr. Lauren Pagliughi:
So x-rays are so easy to do and most stones that we see in cats are going to be radio-peg and you’re going to see them on there. And that’s going to be a treatable disease, whether by surgery or with disillusion, if it’s a Struvite Stone. Then once we have all that information, we talked about antibiotics, I wouldn’t do antibiotics. We talked about pain controls, the cat seems uncomfortable, the cat’s meowing out, crying out, it seems to have strange area. Yeah, I think pain therapy is important to consider, lots of different modalities for pain therapy so whatever floats your boat there is a bet. And then diet, gosh, we saved the best for last, diet’s super important. So multimodal environmental modification and diet really, in my opinion, are the two most important things that we could potentially do to help these guys.

Dr. Andy Roark:
That makes a ton of sense. Help me set expectations for the pet owners. So when they come in and this is very individualistic and I don’t really know how long it’s going to take to see resolution of signs and that really depends a lot on how much of an impact that can make on the cat’s stress and things like that. How do you talk to pet owners about that? When they say, “When is this going to get better?” What language do you use?

Dr. Lauren Pagliughi:
Yeah. Gosh, it’s really important to stress that it’s so individual and that praising them and giving them kudos for being there, for helping their pet, helping them understand that Penelope, in this example, is not doing it out of spite, I hate when owners say that. Our pets are funny and they have funny little personality quirks, but I don’t think they’re intelligent enough to do it out of spite. So helping them to understand that there’s a medical reason or behavioral reason that your cat’s doing this and that can also help them to be a little bit less frustrated and a little bit more empathetic to their own pet’s problem. And then beyond that, I try not to really, again, set that timeline per se, I try to get those treatments on board.

Dr. Lauren Pagliughi:
So getting them fully on board with multimodal environmental enrichment, getting that pheromone spray, adding litter boxes, getting them to drink more. So a lot of different ways to get them to drink more, we can do a canned urinary diet, they can add in a hydration supplement like Hydra Care, they can try water fountains, extra water bowls around the house, adding water to the dry food. And then getting them on board with a therapeutic urinary diet. So urinary diets, namely they’re formulated to get the cat to drink more water, to increase urine volume. And as we increase urine volume, they urinate more frequently and they can flush out some of these inflammatory mediators that are in their bladder and help to reduce their symptoms.

Dr. Andy Roark:
Awesome. That’s super helpful. Are there any final pearls of wisdom that you would put forward in approaching these cases? Are there any common pitfalls that you see people falling into, any tricks that are commonly missed?

Dr. Lauren Pagliughi:
Yeah, absolutely. I think that on one side inappropriately treating for UTIs that aren’t really there, treating Crystalluria that’s not causing symptoms, crystals don’t typically cause symptoms. Those would be the cat that doesn’t need to be treated like a FLUTD cat. Then you have your true FLUTD cat that again, I think the common pitfalls is not getting the owner on board. We need to get the owner on board to get these cats to resolve, to get these cats to feel better and to stop urinating appropriately. And getting the buy-in on a diet and getting the buy-in on what they need to do and change at home, I think is most important. And then checking in, I think you mentioned timeline a couple of times and I know that owners want to know that there’s a light at the end of the tunnel and that’s where keeping that open line of communication can really help.

Dr. Lauren Pagliughi:
Checking in with them on a weekly basis, “How’s Penelope be doing this week? Let’s bring her back in a few weeks and check a urinalysis and see if her urine has less blood or is a little bit more dilute or whatever it may be.” Or maybe we don’t do that, maybe we don’t stress her out by bringing her in and we just monitor some of those clinical signs at home and we let the owner know what to look for and how to manage that. So yeah, I think not treating what doesn’t need to be treated is really important, misuse of antibiotics is a pet peeve of mine, just treating crystals that aren’t a problem is a pet peeve. And then forgetting the importance of the owner’s role in the treatment of these cats and diet, we’ve got to get them on a urinary diet to really get that urinary environment so that these cats aren’t having as many issues.

Dr. Andy Roark:
What is your favorite resource or resources for people who want to learn more about FLUTD and managing FIC?

Dr. Lauren Pagliughi:
Sure. So the Purina Institute actually has some really good resources on Centre Square now. So Purina Institute is product-agnostic, you won’t find any product info on there, but there is a whole nutrition resource portion of the website now called Centre Square, it’s C-E-N-T-R-E. And if you just type in urinary in the little search bar, you’ll find a whole bunch of different articles and you can actually send those to your clients, you can email them and print them out. And these are written by veterinarians so it’s a really good reputable source. And then earlier I mentioned that Indoorpet.osu.edu, that is a really great resource for all that environmental enrichment and probably the most important thing that the owners can be doing at home. So there’re tons of resources on there that are really owner driven.

Dr. Andy Roark:
That’s fantastic. Awesome. I’ll put links to those in the show notes as well. Dr. Lauren Pagliughi, thank you for being here, I really appreciate your time.

Dr. Lauren Pagliughi:
My pleasure, Andy. Thanks for having me.

Dr. Andy Roark:
And that is our episode. Guys, I hope you enjoyed it, I hope you got something out of it. Thanks again to Dr. Lauren Pagliughi for being here, thanks to Purina Pro Plan Veterinary Supplements for making this episode possible. Guys, I hope to talk to you again soon. Be well.

Dr. Dottie Laflamme, a board certified veterinary nutritionist, joins the podcast to discuss a peer-reviewed article she first-authored earlier this year: Evidence does not support the controversy regarding carbohydrates in feline diets. She and Dr. Roark discuss the controversy, the role of carbohydrates in feline digestion and disease pathology and management, and finally, the pros and cons of feeding a wet vs dry commercial food.

You can also listen to this episode on Apple Podcasts, Google Podcasts, Amazon Music, Soundcloud, YouTube or wherever you get your podcasts!

LINKS

Evidence does not support the controversy regarding carbohydrates in feline diets: https://avmajournals.avma.org/view/journals/javma/260/5/javma.21.06.0291.xml

Purina Institute: https://www.purinainstitute.com/

Tufts University Vet Nutrition: https://vetnutrition.tufts.edu/

AAVN: https://aavnutrition.org/

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/training-tools/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Dr. Dottie Laflamme received her DVM, MS in ruminant nutrition, and PhD in nutrition and physiology, all from the University of Georgia. She completed her clinical nutrition residency as an ALPO Postdoctoral Fellow in Clinical Nutrition. Dr. Laflamme is a Diplomate and past-President of the American College of Veterinary Nutrition. She is an author on over 200 scientific and technical publications; and has been a speaker at a number of veterinary, research, and continuing education programs worldwide. She worked for Purina (first Ralston Purina, now Nestle Purina) in the Research and Development Department from 1990 until her retirement in 2015. Her research focused on therapeutic nutrition, especially obesity management, and geriatric nutrition. She currently works as an independent consultant. Dottie lives in the Blue Ridge Mountains of western Virginia.

EPISODE TRANSCRIPT

This podcast transcript is made possible thanks to a generous gift from Banfield Pet Hospital, which is striving to increase accessibility and inclusivity across the veterinary profession. Click here to learn more about Equity, Inclusion & Diversity at Banfield.

Dr. Andy Roark :
Hey guys, if you’ve listened to this podcast for any time at all, how much I care about keeping pet care accessible to pet owners and how much I hate when people don’t have the resources they need to take care of their pets or staff included.

Dr. Andy Roark :
Guys, if you are here, you are probably pretty hardcore about pet healthcare. Figo Pet Insurance helps you and your clients prepare for the unexpected so that you never have to make the tough choice between your pets health and your wallet.

Dr. Andy Roark :
Whether these pets are eating out of the trash or diving off of furniture, pets don’t always make the best decisions, we know that, but with Figo, you can and pet owners can. Designed for pets and their people, Figo allows you to worry less and play more with customizable coverage for accidents, illness and routine wellness.

Dr. Andy Roark :
To get a quick and easy quote, visit figopet.com/coneofshame. That’s F-I-G-O-P-E-T.com/coneofshame. Figo’s policies are underwritten by Independence American Insurance Company. Welcome everybody to the Cone of Shame Veterinary Podcast. I am you’re host, Dr. Andy Roark. Guys, I am here with my friend Dr. Dottie Laflamme today.

Dr. Andy Roark :
She is a boarded vet nutritionist. She’s retired. She’s only doing research and things now. She’s not affiliated with any company. As she mentions at the end, she had done some work on Purina CenterSquare, which is a public educational resource that everybody can check out.

Dr. Andy Roark :
It’s really good. But yeah, she’s fantastic and she’s just talking about carbohydrates and cats based on an article that she published earlier this year. Guys, let’s get into it.

Kelsey Beth Carpenter:
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to the Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark :
Welcome to the podcast, Dr. Dottie Laflamme. Thank you for being here.

Dr. Dottie Laflamme:
Thank you. My pleasure.

Dr. Andy Roark :
Oh, it’s always a pleasure to talk to you. This is the second time we’ve gotten to chat and I loved the first time. And so anyway, I’m glad to have you on the podcast. You are a boarded veterinary nutritionist and you had an article earlier this year in the Journal of the AVMA called Evidence does not support the controversy regarding carbohydrates in feline diets.

Dr. Andy Roark :
And I just wanted to get on and unpack that a little bit with you because obviously we get a lot of questions in the exam room and there’s a lot of questions about cats and carbs and there’s a lot of internet discussion of that topic. So I just wanted to pick your brain a little bit and get into that. Can you start by just sort of laying down what is the controversy with cats and carbohydrates?

Dr. Dottie Laflamme:
Great, and it’s probably a multifold controversy, but I think the essence of it is that some veterinarians and a lot of cat owners perceive that carbohydrates are either inappropriate for cats or downright detrimental, and by our title, what we’re really saying is that’s not really true and nothing is quite as clear cut as A equals B, or this is not good under any circumstances.

Dr. Dottie Laflamme:
The truth is there could be if you select circumstances where carbohydrates may not be appropriate for cats, but for the most part, and hopefully we can talk about lots of the details of that. For the most part, there’s absolutely nothing wrong with cats eating carbohydrates if they’re properly processed and part of a nutritionally balanced diet.

Dr. Andy Roark :
Okay. Well, talk to me a little bit about kind of the role that carbohydrates play in feline nutrition.

Dr. Dottie Laflamme:
Okay. Well, if we think about food stuffs, whether we’re talking about cats or whether we’re talking about ourselves or any other creatures, okay, there are three what are called macronutrients because they’re in there in large quantities. There’s three macronutrients that provide 100% of the energy that our body uses.

Dr. Dottie Laflamme:
Those macronutrients are proteins, fats and carbohydrates. Our bodies, and that includes the cats, can derive energy from any of those three. In fact, they get more energy from fat on a gram per gram basis. On a weight basis, they get more than twice as much calories from fat as they do from carbohydrates or proteins.

Dr. Dottie Laflamme:
So we need to keep that in mind when we’re formulating diets or looking at what we’re feeding because how many calories do our cats need? There’s a lot of fat cats out there. That said, the benefit of carbohydrates in the diet is it is a source of calories that the cat can use.

Dr. Dottie Laflamme:
Now there’s other benefits to it as well. For example, if a cat is being fed a low carbohydrate diet, they will actually take protein and break down the proteins in order to make glucose, which is a carbohydrate. It is a sugar which can come from the carbohydrate, but it can come from protein.

Dr. Dottie Laflamme:
So if you’re not giving them enough carbohydrate in the diet, they’re going to break down protein that could otherwise be going to support lean body mass and protein synthesis and use that for energy.

Dr. Andy Roark :
Okay. Tell me a little bit about cat carbohydrates in the wild, because I think that’s where a lot of this comes from, right? Is cats obligate predator or obligate carnivore? You say, what carbohydrates are they eating out in the wild? And I think a lot of people want to replicate the traditional evolutionary diet of cats.

Dr. Andy Roark :
And so I think that’s a question that I kind of have is to say, well, what is normal for sort of cats in the wild? How do they survive in a landscape that doesn’t have-

Dr. Dottie Laflamme:
Let’s start by defining what we mean by a carbohydrate. The most common perception of that is meat eater, but that’s not quite correct. A carnivore is an animal eater, a prey eater. So they are going to eat basically all of that prey. And so that includes the stomach contents, the intestinal contents, as well as all the musculature, all the bone, all the organs, all the byproducts.

Dr. Dottie Laflamme:
So all of that is consumed by the predator, whether that’s a cat or a dog or wolf or bear or whatnot. So they’re getting more than just meat when they do that. So given that one of the, let’s look at the statistical perspective first and then the practical. Two different studies have looked at a cat in the wild eating prey and other foods that it can get to.

Dr. Dottie Laflamme:
How much carbohydrate are they actually eating? One study showed it was really low. It was about two and a half percent of the calories. A different study showed it was actually a little bit higher. It was about 15%. And let’s put that in perspective of nursing kittens and how much carbohydrate does a cat put into its milk and its about 15 to 25%.

Dr. Dottie Laflamme:
So there’s a fair bit of bit of carbohydrate that’s naturally present in the diet. So it’s not that cats don’t want carbohydrates, but it’s often said, “Well, you won’t see dogs or cats in the wild going out and grazing on a wheat plant.” Well, that’s true, but cats and wild animals in general are opportunistic in what they eat.

Dr. Dottie Laflamme:
So they eat what they can get, and if what they get is enough to keep them alive and allow them to reproduce, then the species will survive. So the feral cat diet, if there is nobody feeding them, there’s no kibble being fed generally has somewhere between five and 15% carbohydrate in and those wild cats survive.

Dr. Dottie Laflamme:
But what’s the average lifespan of feral cats? It’s something like two or three years. It’s relatively short compared to the 15, 20 plus years that we want our pet cats to live. So they could survive on that, but is it optimum nutrition? I think there’s no evidence to support that conjecture.

Dr. Andy Roark :
Right. And that fits with the conversation we have about dogs and wolves. And people say, “Well, my dog [inaudible 00:08:56] a wolf face and the average wolf die at age four.” So yeah, it’s a standard. I personally understand where people come from. They look at cats and how they’re sort made and designed and say, “Well, I want to feed something that fits with what they are and who they are.”

Dr. Andy Roark :
That all makes sense to me. When we talk about, I don’t feel like we get nearly as much pushback on this from dog owners or about dogs as we do about cats. How unique are cats and how they use carbohydrates? I mean, is cat digestion of carbohydrates fairly similar to dogs or humans, or are they pretty unique in how they break down used carbohydrates?

Dr. Dottie Laflamme:
Well, the short answer is both. Assuming we’re talking about properly processed carbohydrates. Because I have to say, if we’re talking about any kind of carbohydrate starch, think about sources of carbohydrates like rice and wheat and other grains and potatoes and things like that.

Dr. Dottie Laflamme:
We wouldn’t eat bowl of raw rice or a raw potato because that’s not digestible, but we cook it. We bake our potatoes, we boil our rice, whatever it might be. So if we’re talking about properly cooked carbohydrates, cats can digest them essentially as well as dogs.

Dr. Dottie Laflamme:
There’s one study that they made a bunch of different diets, different grains and they fed them to cats and then they made very, very similar diets and fed them to dogs. And the carbohydrate digestibility for all the different diets, dogs and cats was well over 90%. So cats really don’t have any trouble digesting carbohydrates.

Dr. Dottie Laflamme:
That said, there are some unique features about cat metabolism. They don’t have the enzyme amylase, salivary amylase that we have, so we actually start breaking down carbohydrates while it’s still in the mouth. Cats don’t have that, but neither do dogs. So it’s not absolutely unique to cats, it’s just there are some species differences.

Dr. Dottie Laflamme:
There are other digestive enzymes, pancreatic amylase, different enzymes that are produced within the digestive tract that cats have less of compared to dogs, but then there’s other enzymes that they actually have more of. They also lack the taste receptor for sweets.

Dr. Dottie Laflamme:
And there’s a number of other things, the way they actually metabolize glucose from the bloodstream, there’s an enzyme that’s required for bringing that, what shall we say, trapping that glucose into the cell. It’s a glucokinase and cats don’t have specifically glucokinase, but they have hexokinase in abundant quantities.

Dr. Dottie Laflamme:
And the hexokinase works in the same way that the glucokinase does. It just works a little slower. So cats are very similar and yet they’re different. And because of these differences, they do tend to process blood glucose a little bit slower than dogs do, for example, but that’s also consistent with the way cats normally and naturally eat.

Dr. Dottie Laflamme:
They eat a lot of small little meals, up to 20 meals a day. So they’re getting a small amount at a time compared to the way dogs in the Wildwood, which is to eat large quantities all at once. So it’s consistent with their metabolism. Bottom line, there are some differences, but a lot of similarities.

Dr. Andy Roark :
No, that’s good to know. Are there advantages and disadvantages to a low carb diet for cats?

Dr. Dottie Laflamme:
Assuming we’re talking healthy cats, not diabetic cats. But healthy cats, the advantage to a low carb diet is there, let me put it this way, there’s absolutely no evidence of a benefit to a low carb diet for a healthy cat. The potential disadvantage is, as I was mentioning earlier, if you… Okay.

Dr. Dottie Laflamme:
Cats need calories just like we all do, and they come from protein or carbohydrates or fats. By definition, when you remove one of those macronutrients, the sum of the total, you have to see the other two increase. So a low carbohydrate giant generally is higher in fat and higher in protein and higher in calories because fat has more calories than carbohydrates. Okay.

Dr. Dottie Laflamme:
So the disadvantage of a low carbohydrate diet is the resulting diets tend to be higher in calories. And because obesity is a major issue in cats, there’s actually a greater risk for obesity in cats fed high fat diets. So there’s no specific advantage.

Dr. Dottie Laflamme:
And the only real disadvantage is that calorie thing. So if you’re feeding a low carbohydrate diet because you want to, there’s no harm to the cat as long as they’re being fed the right amount of calories, but there’s no advantage either.

Dr. Andy Roark :
Hey everybody, I’m just jumping in with two lightning fast updates. Number one, if you have not gotten signed up for the Get Shit Done Shorthanded Virtual Conference in October, it’s October 6 through the 8th. You need to do that.

Dr. Andy Roark :
If you are feeling overwhelmed in your practice. If you want things to go smoother and faster. If you do not want to watch webinars, you want to actually talk about your practice. You want to do some discussion groups.

Dr. Andy Roark :
You want to do some workshops where you actually make things and work on things and ask questions as we go along and have round table discussions and things like that, that’s really going to energize you and help you figure out actionable solutions that you can immediately put into practice to make your life simpler and more relaxed.

Dr. Andy Roark :
I got you covered, buddy, but you don’t want to miss it. Go ahead and get registered. Mark yourself off at the clinic for the time so that you can be here and be present and really take advantage of this. I don’t want to sneak up on you. I know October seems like a long way away. It’s not, but go ahead.

Dr. Andy Roark :
I’m going to put a link down below and then when registration opens, we’ll let you know it’s open and you can grab your spot, but you do not want it to sneak up on you. Check out our Get Shit Done Shorthanded Conference. It’s going to be a great one. The second thing I’m going to tell you about is Banfield.

Dr. Andy Roark :
Thank you to Banfield the Pet Hospital for making transcripts of this podcast available. You can find them at drandyroark.com. They are totally free and open to the public and Banfield supports us to increase accessibility and inclusion in our profession.

Dr. Andy Roark :
It’s a wonderful thing that they do. Guys, that’s all I got. Let’s get back into this episode. Let’s take this a little bit into a medical context and start to say, can you talk to me a little bit about clinical practice and carbohydrates?

Dr. Andy Roark :
I mean, I immediately think of cats with diabetes, things like that. Are there medical instances, cases that we commonly see where we want to pay attention to carbohydrate intake specifically where they can be detrimental or beneficial?

Dr. Dottie Laflamme:
Sure. And here’s where we’re kind of… Okay. Let’s talk specifically about diabetes first and then maybe a couple of other circumstances. So in the face of diabetes, cats are already unable to process glucose properly. And so it accumulates in the bloodstream.

Dr. Dottie Laflamme:
They’re glucose intolerant and insulin resistant, so they have a hard time clearing the glucose out of the bloodstream. And so feeding large amounts of glucose or carbohydrate to a cat that’s diabetic is going to cause an undesirable increase in glucose in the bloodstream.

Dr. Dottie Laflamme:
So two of the ways to get around that, of course, is to feed less carbohydrate, so there’s less being released into the bloodstream. And the other is to feed it in frequent small meals so that the total amount of carbohydrate going into the bloodstream, even in diabetic cats is not as much the issue, it’s the inability to clear it out.

Dr. Dottie Laflamme:
And so it’s because of the difference between the different glucose transporters, the insulin dependent and non-insulin-dependent. So the non-insulin-dependent such as glute one will still be able to process enough glucose to keep the cats cells fed, but the insulin independent and the glute four is the one that’s not working properly, so they can’t process as much.

Dr. Dottie Laflamme:
So I think the bottom line is like the consensus opinion is that limiting carbohydrate intake in the face of diabetes is a positive thing.

Dr. Dottie Laflamme:
The other conditions where carbohydrates or carbohydrate sources, in other words grains, are raised up as possible issues is in the face of GI disease and food sensitivities, the food allergies and food sensitive, whether that’s the skin related issues or GI related issues, that seems to be more of either a misperception or a rarity as opposed to a commonality.

Dr. Dottie Laflamme:
The reason I say that is if you look at the, but the published statistics, feline allergies to grains are extremely less common compared to feline allergies to various animal proteins.

Dr. Andy Roark :
That makes sense. I mean, that tracks, again, kind of with what we see with dogs as well as sort the push to the grain free foods and things like that. And a lot of people come with the idea that they’re hypoallergenic where they’re good for food allergies and things, and veterinarians have wrestled with that for a long time.

Dr. Andy Roark :
Help me understand what we can expect with carbohydrates in your average sort of commercial cat food, for example? So we talked about feral cats being at five to 15% carbohydrate in their diets. What do we see? Is there a sort of recognized standard in modern pet food or high quality pet food? Yeah. And how much variance is there?

Dr. Dottie Laflamme:
Okay. Really, really good question. There’s big differences on average between dry foods and wet foods like canned foods and pouched foods that in general, the wet foods are lower in carbohydrates compared to the dry foods. And part of that is based on the ingredients used.

Dr. Dottie Laflamme:
Part of it is the fact that normal cooking and processing of dry foods actually requires a certain amount of carbohydrate in the diet in order to form the kibble. It’d be like trying to make bread without gluten or without flour, really need to have that in there.

Dr. Dottie Laflamme:
So if we look at what’s average in the US at least, the average amount of carbohydrate in wet foods is well under 10%. Whereas in dry foods, it’s somewhere in, I don’t know, about 35% plus and minus on average.

Dr. Dottie Laflamme:
The review that we did, the paper you had referenced, one of the things we looked at was all of the published literature where they were looking for adverse effects for carbohydrates, and at what level do you start to see adverse effects?

Dr. Dottie Laflamme:
And the studies basically found no adverse effects with the possible exception of diets that were about 50% of the calories coming from carbohydrates. And at that level, first of all, at that level, the protein in the diet is really low. So the first challenge you would have is that the diet would no longer be nutritionally balanced.

Dr. Dottie Laflamme:
It would have not enough protein in the diet. In that study that used that kind of diet, they did see unusually high serum glucose levels. And in some cats, they also saw GI upset, diarrhea and so forth.

Dr. Dottie Laflamme:
So that’s the kind of risk you might be looking for. But the biggest risk, if you’re talking about that much carbohydrate in the diet, the biggest risk is there’s not going to be enough room to have enough protein in the diet.

Dr. Andy Roark :
Given the difference that we see in carbohydrate levels between dry and wet foods, just in their compositions as we sort of talked about, do you have a preference of wet versus dry food when feeding cats? Are you one of those wet food cat people or are you a mixture person? Or how does that affect your thinking? And if so, how?

Dr. Dottie Laflamme:
That’s a really great question and I really need to unpack it because the first part of that is carbohydrates and the other part of that is water, wet versus dry. So from a carbohydrate point of view, here’s really the way to look at it. Cats need nutrients, not ingredients. Okay.

Dr. Dottie Laflamme:
And they don’t require a dietary source of carbohydrates. And the reason they don’t is that carbohydrates are so important to the cat that the body has its own mechanism for creating carbohydrates, in other words, for creating glucose. Okay.

Dr. Dottie Laflamme:
So the body absolutely has a requirement for carbohydrate. Either they’re going to make their own or they’re going to get it from the diet. And so if we’re looking at carbohydrate in the diet, then the body can use that and it doesn’t have to create its own, which means it can spare protein.

Dr. Dottie Laflamme:
And I think that’s a significant benefit to the higher carbohydrate diets within a nutritionally balanced diet. Okay. So from a nutritional perspective, I think there’s no real advantage of a dry food versus a wet food or a wet food versus a dry food as long as it is nutritionally complete and balanced.

Dr. Dottie Laflamme:
Not all foods are, so that’s just an important thing to keep in mind. But assuming that they are, from a nutritional perspective, there’s really not an advantage one over the other. Now let’s talk about wet food. There are pros and cons to wet food.

Dr. Dottie Laflamme:
Some of the pro is that you’ve got a lot of water there, and that is some cats need that extra water either because they don’t naturally drink enough or because they happen to have a health condition like urolithiasis or kidney disease or something where they need that extra water, I’m going to say forced on them. They need that extra water.

Dr. Dottie Laflamme:
So that’s where wet foods are really beneficial. The other advantage of wet foods, because they come in small cans, especially if you give them the little tiny cans, there’s relatively few calories because it’s mostly water.

Dr. Dottie Laflamme:
And so feeding wet foods might make it easier for cat owners to control the calorie intake and would help them potentially in managing their cats weight. And I’m saying that potentially because it’s not an absolute for sure. That’s really the advantage of wet only in my perspective.

Dr. Dottie Laflamme:
One of the advantages of dry, since we’re doing a comparison, one of the advantages of dry is it does provide a better oral care benefit. It helps to keep the teeth cleaned longer, not that it’s a replacement for dental care, but it does reduce plaque and tarter and oral disease compared to wet food.

Dr. Dottie Laflamme:
So if you’re comparing 100% dry versus 100% wet, those are kind of the benefits. The advantage of the mix is that you get the dental benefit of the dry, and then feeding your variety of wet foods gives you a chance to feed a variety without totally changing the diet up.

Dr. Dottie Laflamme:
That said, if you’re really trying to feed wet food for the purpose of forcing the cat to consume more water, you almost have to go to a completely 100% wet food diet because if it’s 50%, the cat fully compensates and drinks water or doesn’t drink water as it needs.

Dr. Dottie Laflamme:
So one of the things we have to think about, whether we’re talking about wet food, dry food, carbohydrates, protein, whatever, cats are very adaptable. And no matter what you’re trying to do to them, they’ll adapt based on their own physiology.

Dr. Andy Roark :
Yeah. On their own willful desires often is what it seems, right?

Dr. Dottie Laflamme:
Exactly.

Dr. Andy Roark :
Dr. Laflamme, thank you so much for being here. I really appreciate you coming in and making time to talk with me.

Dr. Dottie Laflamme:
My pleasure. And if you ever happen to get more questions, let me know.

Dr. Andy Roark :
Oh, I will let you know for sure. One last question. Do you have favorite resources for people that are interested in feline nutrition? What’s at the top of your list?

Dr. Dottie Laflamme:
There’s a couple of good websites. One of them, I have to admit it, I helped with the formulation of that as a consultant for the Purina Company, and that’s Purina Institute CenterSquare.

Dr. Dottie Laflamme:
It’s a great resource for veterinarians as well as for them to share with their clientele. Tufts University has a great website also with good nutrition information. I don’t have that address for you right now, but-

Dr. Andy Roark :
I’ll pull it and I’ll put it in the show notes for people who want to find it.

Dr. Dottie Laflamme:
Okay. Those are a couple of great ones right there as well as the aavn.org website, the American Academy of Veterinary Nutrition.

Dr. Andy Roark :
That’s outstanding. Great. I’ll put all those links in the show notes. Thank you again for being here. Guys, everybody take care of yourselves. Have a wonderful week. And that is our episode. That’s what we got for you. As I said, have a wonderful week everybody.

Dr. Andy Roark :
If you love this episode, write me a review, wherever you get your podcast. Anywhere that it says, rate this podcast, you just rate this podcast. And if you don’t like the episode, then just maybe wait until next week and see what you think before you write a review. I don’t know. Just think about it for a while before you do that. Anyway, guys, take it easy. I’ll see you later on.

What role can nutrition and probiotics play in addressing behavior problems? Probably more than you think. Dr. Ragen McGowan, Ph.D. joins Dr. Andy Roark to discuss the link between the gut and the mind, how Purina’s new Calming Care supplement has been shown to help dogs and cats, and what expectations veterinarians can have (and set for clients) for working with these products.

This episode has been made possible ad-free by Purina ProPlan Veterinary Supplements!

LINKS

Purina Pet Expertise: https://www.purina.com/articles

Purina Pro Plan Vet Direct: https://www.proplanvetdirect.com/pro-plan-veterinary-diets/cat-dog-supplements

Dr. Andy Roark Exam Room Communication Tool Box Course: https://drandyroark.com/store/

What’s on my Scrubs?! Card Game: https://drandyroark.com/training-tools/

Dr. Andy Roark Swag: drandyroark.com/shop

All Links: linktr.ee/DrAndyRoark

ABOUT OUR GUEST

Ragen is the Senior Manager of the Global Pet IoT, AI and Digital Solutions Group at Nestlé Purina leading work to generate pet behavior and wellbeing insights. She has over 20 years of experience in animal behavior research, the last 13 of which have been with Nestlé Purina using a holistic approach incorporating behavior, physiology and endocrinology to quantify affective states and temperament in dogs and cats. With this knowledge she aims to create products that cater to different behavioral needs of pets and to better understand and quantify the human-animal bond from the pet’s perspective. Ragen earned B.S. in Zoology, a B.A. in Foreign Language and Literature and a PhD in Applied Ethology from Washington State University in Pullman, Washington. Her PhD research focused on Contrafreeloading behavior, a phenomenon whereby animals choose to work for food even when the same food is freely available, in grizzly bears, laying hens and laboratory mice. In addition, Ragen worked on other projects examining play behavior in piglets and children and means to reduce problem behaviors such as cannibalism in laying hens. Prior to joining Nestlé Purina Ragen held a post-doctoral research position in the Section for Ethology and Animal Welfare at the Swedish University of Agricultural Sciences in Uppsala, Sweden. Her post-doctoral research focused on the study of emotionality in dogs. Specifically, she explored new methodology to objectively evaluate positive emotions in animals. This included using Cognitive Bias and Contrast to measure emotional states and studying the ‘Eureka Effect’ (emotional reactions to learning) in dogs. She is now bringing this knowledge of animal behavior and emotions into the digital space to better connect owners with their pets. Ragen has a passion for sharing her vast knowledge of pet behavior and the human-animal bond. In addition to speaking at a variety of events for Purina, she serves as a reviewer for several scientific journals and is a contributing scientific expert for scientific congresses, roundtables and podcasts. In addition to her passion for animals, Ragen is also an avid dancer and has been an instructor of ballroom dance for many years. Ragen is based in Saint Joseph, Missouri where she lives with her husband, two children and two giant rescue dogs, Luna and Perry.

EPISODE TRANSCRIPT

Dr. Andy Roark:
This episode is made possible ad-free by Purina Pro Plan veterinary supplements.

Dr. Andy Roark:
Hey everybody. I am Dr. Andy Roark, and welcome to The Cone of Shame veterinary podcast. Today, I am talking to my very special guest, Dr. Regan McGowan, about probiotics and their use in anxiety and behavioral problems in dogs and cats. Is it possible to use a probiotic to affect pet behavior to make pet owner lives easier? We get into it, we talk about what is out there and how it works, and what expectations are set. This guys, is a great episode. I got a lot of stuff out of this. I’m going to be changing up maybe my multimodal approach to behavior consultations. And I just found this to be super useful. I hope you will too. Let’s check it out.

Kelsey Beth Carpenter:
(singing) This is your show. We’re glad you’re here. We want to help you in your veterinary career. Welcome to The Cone of Shame with Dr. Andy Roark.

Dr. Andy Roark:
Welcome to the podcast, Dr. Ragen McGowan. Thanks for being here.

Dr. Ragen McGowan:
Thank you so much for having me.

Dr. Andy Roark:
Oh, it is my pleasure. You are super cool. For those who do not know you, you are… So first of all, you’re a PhD. You have a PhD in applied ethology for those who don’t know not me, because I totally know. I completely have this nailed down. What is ethology?

Dr. Ragen McGowan:
Ethology is the study of animal behavior. It’s sort of the animal counterpart to psychology on the human side.

Dr. Andy Roark:
Love it. So you have a PhD. Actually, your postdoc work is in studying emotionality in dogs, which I thought was super awesome and cool. You also are the senior manager at the global pet Digital Solutions Group, I’m paraphrasing that, from Nestlé Purina. You do all the pet wearables, devices, data collection, artificial intelligence, you’re all up in all of that stuff. So you are a PhD behaviorist who runs the digital section at Purina. I think that’s fascinating. I love also, in your free time, you instruct ballroom dancing just as a flare.

Dr. Ragen McGowan:
Just for fun.

Dr. Andy Roark:
Exactly right. Just an accent. I love it. So thank you, thank you, thank you for being here. I want to talk to you today about behavior. I want to talk to you a little bit about anxiety. I want to talk to you about nutritional therapeutics and things like that. And this is something that I have been really excited about for a long time. The reason is because I see a lot of anxious pets, both cats and dogs. They look different when they come in. But I think anxiety and nervousness, high strung pets, I think a lot of us see that.

Dr. Andy Roark:
And I think a lot of us also see pushback from pet owners to traditional therapeutics when it comes to managing anxiety and managing neuroses and things like that in pets, especially in cats. I really think this is a tough thing in cats because people don’t want to give their cat sort of traditional medications. I think the ask is really high. But even in dogs, I still think that there’s a lot of pushback on, my dog doesn’t need to be on medications, or I don’t want to do this, or I don’t want to put him on anything.

Dr. Andy Roark:
I’m certain there is a general idea that something that is nutritional, something that is a probiotic, something like that, that doesn’t fall in people’s mental categories in the same way. And they seem much more open to trying things of that nature. And so I wanted to learn more about that. And that’s really an area of interest for you and area of study. And so I wanted to lay all of that down and say, let’s start with dogs and cats. Talk to me just generally, about anxiety presentation in dogs and catalogs. And then, how nutrition might interact with the ability to alter that behavior and that anxiety.

Dr. Ragen McGowan:
Sure. So anxiety is a big problem in dogs and cats. And often, pet owners might not realize that their pet is anxious. I’ll be talking in many different scenarios out to the general public and I’ll be mentioning behaviors that are attributed to anxiety, and people will come up to me afterwards and just say, “Oh my goodness, you’ve just blown my mind. I didn’t realize that my pet was showing me all these anxious behaviors until you described them.” So some of that is the more micro behaviors. So for dogs, the lip licking, the yawning, the avoidance of gaze, just the general presentation of uneasiness in many different situations.

Dr. Ragen McGowan:
For cats, some people think it’s just normal for a cat to be hiding under the bed all the time and never come out. People will come over and be like, I didn’t even know you had a cat except I saw a litter box, because I never met your cat. But actually, that can be a sign of anxiety in cats. So just helping people to realize this. So when they come to us with questions around this, first we say, okay, clear out any medical reasons that might be causing these kinds of behavior. If you’ve got that clean bill of health from your vet, then let’s try to think about what else you might be able to do or what the triggers might be in the environment that are causing your pet this anxiety.

Dr. Ragen McGowan:
But you’re right that people are resistant to pharmaceuticals. Behavior modification can go a long way, but that’s a lot of work. It takes dedication from the pet owner and a lot of training and consistency and routine, and it’s not a one stop save all thing. It takes a lot of work and catering specifically to the pet.

Dr. Ragen McGowan:
Nutrition is often overlooked as a contributing factor to help address behavior problems. But when you think about it, all of the nutrients that we’re taking into our bodies, those are actually the precursors for all of the hormones and the neurotransmitters that actually regulate your behavior. So altering your diet to manipulate the availability of all these precursors, the things that your body needs to make these hormones and neurotransmitters, that can actually help mitigate behavior issues. So there really is something to that old adage about having a gut feeling about something, because your gut and your brain, they’re actually directly linked and connected through what’s called the gut-brain axis.

Dr. Andy Roark:
So gut-brain axis is really interesting. I’ve actually been reading a lot about that in human nutrition recently. There’s a couple different books that have come out fairly recently on treating things like anxiety, depression, things like that in people. There’s more and more research about the gut-brain relations. I wanted to mention real quick, one of the things that really turned me on to the idea of working with therapeutics to lower stress and anxiety in dogs is, when we talk about training… When you have an anxious dog, people will jump up and say, “Oh, you need to train them, you need to train them.” Training a pet that is dealing with anxiety who is anxious, it’s not easy, because they’ve already got so much tension and now you’re working with them. And even if you’re low stress, everything gets easier if you can reduce the stress and anxiety that pet is having. And then do the training. And I say that because that’s a mistake I’ve made early in my career.

Dr. Andy Roark:
Terry Curtis, who’s a vet behaviorist, talked me out of it a couple years ago. Because what would happen, I’ll just be honest about what I did, is I would talk to people and they would have an anxious dog or cat, and I would sort of present pharmaceuticals and they would say, “Oh no, no, I don’t do that,” and I’d say, “Okay, well let’s try some training then.” And what would happen is they would go away and they would do some training and it wouldn’t get better and it would get worse. And then they would come back and they were tired and they’re frustrated. And now we’re throwing drugs at the problem, but they’re already kind of tired of trying to train. And she really convinced me that working together with nutrition or with therapeutics and the training together. Lower the stress, do the training, and then you can even, like if you’re using pharmaceuticals, you may be able to lay off of those later on, because you’ve done the training now and it was effective. Anyway, I just always like to point that out.

Dr. Ragen McGowan:
For sure. We call that the multimodal approach. Not one thing is really going to solve everything. It’s about getting the pet in the right frame of mind. With appropriate socialization, we can give pets the skills that they need to cope with stressors that come their way, but if they have an underlying anxious temperament, they’re always going to have that underlying anxious temperament, just like people. You can learn how to deal with a situation and not be overstressed by it, but you’ll still have that underlying level of anxiety. So if we can treat that to get pets in a better frame of mind, then they’re more responsive to that behavior modification, it’ll stick with them, and they’ll actually start to improve in their behavior. But until you can get them over that hump, it’s really, really difficult. Whether that’s a nutritional intervention or pharmaceutical intervention together with the behavior modification, that’s where you’re really going to make those big steps, and really be able to celebrate even the little baby steps that you get your pet through so that they can cope more with the stressors around them.

Dr. Andy Roark:
Give me a basic 101 level understanding of nutritional therapeutics in behavior and pets. We talked a little bit about the relation of the gut and the mind. There’s a number of different products out there that are nutritional or nutriceutical or things like that. Help me understand a little bit about how this works. What is important in using these products effectively, and are they all effective? What should I be looking for in products like this?

Dr. Ragen McGowan:
Yeah. This is sort of a tricky question, because you really need to find products where there’s good data behind it, and that’s hard to assess. And we know that there’re many studies out there that show there’s a large placebo effect. People are so emotionally drained with dealing with their anxious pet, that they’re really looking for any solution that will give them even a tiny bit of relief. They’re very quick to say, “Oh, this must be helping,” because they notice some subtle change, so we know there’s a huge placebo effect. So look for products where there’s really good data that shows not only behavioral effects, but even a step further, physiological effects, that show that you’re actually reducing the stress response. And this is the approach that we take to get over that placebo effect or only relying on behavior changes or indicators that are visible on the outside, we’re also looking for invisible changes on the inside.

Dr. Ragen McGowan:
We take that holistic approach, where we’re taking both behavioral and physiological measures. And by physiological measures, this could be something like hormones like cortisol, it could be physiological responses like changes in heart rate or respiration rate or body temperature. Pairing those together with behavioral changes, then you really get a good picture of the impact or the efficacy of some of these nutritional solutions. Now, there’s a handful of things out there where there is published data, but for the most part, there’s very little. So when you’re researching a product, make sure it’s coming with some data behind it, some solid claims that are on the product there. And I can give you an example of a probiotic that we’ve developed at Purina, if you’d like that.

Dr. Andy Roark:
Mm-hmm. Sure, yeah. Of course.

Dr. Ragen McGowan:
It’s the Calming Care probiotic. This is a specific strain of bifidobacterium longum. It’s important to remember, probiotic, by its name, means that it has a positive biological impact on the animal or human, whoever it might be that is consuming it. But not every probiotic is the same. They’re very, very strain specific. So when you’re researching probiotics, you want to make sure that you’re identifying one where there’s good data behind that specific probiotic for whatever the claims are. So we assessed this strain of bifidobacterium longum in a population of anxious Labrador Retrievers, and later in cats.

Dr. Ragen McGowan:
For the dog study, we took a population of 24 Labradors that had been previously assessed and characterized as being anxious. And because every dog, every pet, we all know is an individual, just like every person is an individual, we use every pet as their own control, knowing that their baseline physiology and their baseline behavior will be different. So every dog served as their own control, participating in two phases where they had both this probiotic treatment and a placebo treatment. All the caretakers were blind to the study, so they didn’t know what the dogs were eating. They just knew these are dogs that have been having anxious issues, they show anxious behavior, but they didn’t know what the treatments were. It looks the same to them. It was just sprinkled upon their complete and balanced diet that they get every day from a little sachet.

Dr. Ragen McGowan:
For six weeks, we fed the dogs with the supplements, and then we had a three-week washout phase, and then they switched treatments. So every dog got both treatments again. This way, everything was controlled for. Then we looked across the six-week feeding time and their day-to-day normal responses to any type of anxiety inducing stimuli that they came across. So this could be, we live in the Midwest, so maybe it was a thunderstorm. Maybe they’re going for their vet exam. Maybe they’re going to get groomed or have a bath, or maybe they’re out for a walk and something surprising is happening to them. We looked at their just normal day-to-day change in behavior across the whole feeding period. Then at the end of each feeding period, we actually subjected them to a formal anxiety test, where we looked for non-social, social, and separation anxiety. This was things like bringing them to a novel room, which we know can be stressful for some anxious pets.

Dr. Ragen McGowan:
In that novel room, we had music playing, and then we would suddenly turn off the music. That’s what we call the sudden silence effect, similar to if you were in a grocery store or a mall or something, usually there’s background music playing. You don’t really notice it until it turns off, and then you become vigilant and you’re like, “Wait a minute, something changed. What happened? Oh, the music stopped.” So we look for that vigilance in our pets as well. And then surprising objects. So it could be a novel object, like a motorized car that drives out from a corner, or a panel opens up from the ceiling and a balloon falls out, novel noises, something they’ve never heard, like an elephant call or a chimpanzee, just to simulate strange noises that pets might hear out in their environment. Then we had a stranger come in, always with a mask on, their eyes covered, so the dogs couldn’t read their intentions. This could be similar to like a contractor coming to your house, wearing their hard hat or equipment, or trick-or-treaters. And then we left the dog alone for a short period of separation in this novel environment, so we could see their response to separation.

Dr. Ragen McGowan:
Throughout, we were measuring their physiology. We had little cardiac monitors on them so we could measure their heart rate and heart rate variability. We also took saliva samples before and after the test, to be able to look for their cortisol or stress response. And then we also tracked their behavior throughout. And what we found, is that during that six-week period, the dogs that were supplemented with the probiotic, the bifidobacterium longum, BL999, they showed much more calm behavior. They showed reductions in anxious behavior like excessive barking or jumping or spinning or pacing. They were less reactive going out and about at the grooming stations or for their veterinary exams or meeting strangers out on walks, compared to themselves, remember when they were on the placebos. We’re always comparing the dog to themselves. And we also found a physiological response. They showed improvement in their cardiac response, with reduction in their heart rate, increases in heart rate variability, and reductions in circulating cortisol. So overall, they were in a more calm, less reactive state.

Dr. Ragen McGowan:
So from both a behavior perspective and a physiological perspective, we could see that the dogs were in a more positive emotional state when they were supplemented with the probiotic versus a placebo. And again, always using themselves as their own control because you can’t really compare dog A to dog B because they’re going to have different responses, so within themselves, we could see this significant difference. And that was just from feeding this probiotic that really brought to life the power of nutrition and that gut-brain communication, how we can actually manipulate behavior by modifying what we’re feeding our pets.

Dr. Andy Roark:
That’s amazing. I will tell you, my dog has watched lots of Stephen King, and so a balloon through the ceiling and a man in a mask coming in, you’d have to [inaudible 00:16:02] him off the wall. He would be pretty stressed. So, all right. Tell me a bit about cats, because I think selling pet owners on traditional pharmaceuticals in cat anxiety, one, I think they’re less likely to believe it when I tell them, “Hey, this sounds a lot like anxiety.” I think cats show less and owners are less believing that their pet has a problem. And then two, I think that the reticence to intervene with a therapeutic is much higher in pet owners. They are much less likely to take steps traditionally in cats. When you talk about, well, there’s a medication and their eyes just kind of glaze over, and they immediately think about how awful it’s going to be. Talk to me about the study in cats, please.

Dr. Ragen McGowan:
Sure. You’ve just said it all with cats there. So one, it’s hard to get people to admit their cat is even showing anxiety, or to teach them what to look out for, that their cat might be anxious. So again, looking at those behaviors in their day-to-day routine, and what the cats are doing, and kind of tracking how they’re responding. So if you have strangers coming to your house and your cat disappears, and they never know you have a cat, that could be a sign that they’re anxious. Or if your cat’s eliminating outside of the box, if all health reasons have been cleared and it’s not a urinary or kidney issue going on and your cat’s still eliminating out of the box, it could be a sign of anxiety.

Dr. Ragen McGowan:
The thing with cats is, they’re so highly sensitive to changes in their environment, just based on their natural history of being territorial and being predators, they’re really keen on even subtle changes in their environment. So for your cat, just changing something like the litter box that you’re using, or rearranging your furniture, these could be stressors and actually lead to anxiety for them. We actually use that as the model to test whether the same probiotic, this BL999, could show efficacy for helping cats with anxiety.

Dr. Ragen McGowan:
We used a model of switching housing environments for cats. We took groups of cats and moved them between different housing types, and again, assessed both their behavior and their physiology. And we found, again here, that cats that were supplemented with the probiotic, that bifidobacterium longum that’s in Calming Care, they were able to much better cope with the stress of moving between housing environments, shown by lower cortisol, reductions in anxious behavior like pacing back and forth, and really increase social ability. So seeking out more contact from the observers that were involved in the study. And also, even being more willing to do vulnerable things in front of people, like eliminate. Like urinate and defecate in front of people. Whereas usually, that’s something that would be hidden away for an anxious cat. So even with the cats, looking at slightly different behaviors than we would for the dogs, using a little bit of a different model, we were able to really show that this probiotic can have a positive impact for them as well.

Dr. Andy Roark:
Very nice. I think that’s awesome. Let me ask you about communicating expectations. This is always a big thing for me, especially when I’m talking about behavior, because behavior with clients is challenging. It’s a lot of handholding, there’s a lot of communication. Oftentimes I’m trying to set realistic expectations with pet owners, because that’s where I get blown up all the time in the exam room. They’ll come in and they’re expecting a magic switch and this to be fixed, and I’m trying to get them to understand what progress looks like and things like that.

Dr. Andy Roark:
So let me start by giving you two questions. One, if I’m talking to a pet owner and I’m like, hey, I want to try this calming probiotic. And this is as I’m talking through what the expectations are and why I want to recommend it and say, I want to try it. And they say to me, “How long will it be before I start to see signs?” I’m pretty impressed, honestly, that your study length was six weeks. That seems like a minimum to me. If you’d said, how long is it before you start seeing benefits? I would’ve said six weeks, just as a gut reaction, if you will. Talk to me about speed with which we start to see changes in behavior, and then the magnitude of those changes. Because people are going to say, “How much of a difference am I going to see?” So help me set those expectations.

Dr. Ragen McGowan:
Yeah. These are great questions. It’s important to remember that every pet is an individual. This is why we’re using pets as their own control. But out in the real world, just the same with pharmaceutical interventions, you’ll have some pets that might show response slightly ahead of others. But in general, at that six-week mark, that’s where we saw a statistical significance. So that’s where the group effect, we had enough pets that were showing such a response that we would get statistical significance. That means for some pets, earlier than that, you’ll start to see signs. For other pets, it might be slightly longer. But in that six-week range, that’s right on par with something like fluoxetine or some of these other pharmaceutical interventions where you’re expecting at least four to six weeks of that loading period before the physiology is changing enough that it’s starting to manifest in actual behavioral changes.

Dr. Ragen McGowan:
Here, again we were looking not only at those behavioral changes, but the physiological changes. So we can say that, yeah, at that six-week mark, we are seeing statistical differences with the pets between when they’re on the placebo and they’re on the supplement. Telling pet owners that though, they want an immediate solution. They also want something that, they know something stressful is going to happen and they want to give it to their pet and it works instantly. And here we’re telling them, “No, this is a nutritional solution, so it takes time for your body to change, the physiology to change enough that actually that ladders up to a change in behavior.” So just giving them that perspective that it’s not an instant change, and there’re few things that are instant changes. And as far as magnitude, again, there’s going to be a lot of individual variation there, but really looking out for subtle differences and also asking the people around you. So anecdotally, we’ve heard from multiple people that said, “You know, I didn’t really think it was helping my dog. The dog’s behavior wasn’t changing dramatically in my mind until I had a neighbor come over, and my neighbor said to me, what is going on with your dog? Your dog never lets me pet them. Your dog always barks at me. And now your dog is right here by my side and I’m petting them, what happened?”

Dr. Ragen McGowan:
So sometimes you’re with your pet every day and you’re not noticing those changes until you get in a context and someone else alerts you like, “Wait a minute, your pet’s acting differently, what’s going on?” And that’s when you start to realize, hey, there’s something here, this is helping. But again, it’s part of that multimodal approach. Just by feeding the probiotic, doesn’t mean you shouldn’t also be doing the behavior modification, encouraging your pet, providing your pet that confidence to get through those more stressful encounters, working hand in hand with your veterinarian. Because perhaps you’re also layering on pharmaceutical interventions together as part of this plan, to really cater to what is needed for that individual pet, because every pet is individual.

Dr. Andy Roark:
Talk to me a little bit more about acute stressors. To be honest, I was kind of surprised when you tossed out thunderstorms and things like that, as areas where you found this to be particularly beneficial. I guess in my mind, when I’d thought about nutritional intervention, I was thinking of low-level anxiety, just general neuroticism, things like that. I think back to the 4th of July and the fireworks and things like that. To me, I’m kind of surprised. I tend to think more along the lines of, again, pharmaceutical things like that, for that level of acute fear coming on. What’s the research like on nutritional therapies in those cases?

Dr. Ragen McGowan:
Again, it’s not going to be that light switch goes off, now your dog’s not reacting to thunder or fireworks anymore, but again, part of our discussion before getting them in that better state of mind to be able to handle the stressors coming their way. So if you have your anxious pet that in the past, they’ve been reactive to these things. You’re starting them on a nutritional intervention. Now it’s been weeks that they’ve been on this. You’re also still preparing them. So if it’s 4th of July and you know they react to fireworks, you’re not out there outside while fireworks are going on. You’ve created a calm space in your house, you’ve provided them things to distract them, you’ve set all that up, you will likely see that your dog is responding better than they have in years past. Where those other, the behavior modification, the preparing them, wasn’t working as well, now you’re saying, “Oh, it is taking the edge off.”

Dr. Ragen McGowan:
You’re right. If you’re looking for that acute response of really bringing the dog down from that panic or stress, then that’s more of a sedative situation, a pharmaceutical intervention. Here, we’re lessening overall the reactivity. You have pets that have extreme fear responses, all the way to pets just being hypervigilant or hyper reactive. In both cases, we’re bringing them in a better frame of mind to cope with that. But it’s still part of the approach that you’re building into your routine. So it’s not the one solve everything silver bullet, it’s just part of everything else that you’re already doing with your pet.

Dr. Andy Roark:
And that totally makes sense. It goes back to what we talked about before, about being multimodal. I would much rather use less sedative. You know what I mean? And not completely have to gork the dog or cat out, because they’re in a better place. That totally makes sense. Again, I was just a hundred percent thinking back to, I want to have clear expectations here so that I can speak about this and get clients on board. And I can also gauge my therapeutic plan, so that… You want to get as close to ideal as you can, just because the trust of the client is in you. And if you try things and they don’t feel like they see any sort of a benefit, it can be much harder to keep them on board and keep them trying. So I really like that idea of, this is part of a multimodal approach and I go, great, that helps me make my plan and figure out where I need to put these things.

Dr. Andy Roark:
Are there any final pearls that you have in using, whether it’s probiotics or other nutritional approaches to behavior, are there best practices? Are there words of advice that you would give? Time of day for feeding, time of starting treatments, anything like that?

Dr. Ragen McGowan:
Again, just building it into the routine that you already have for your pet. So not stressing them out by making this one extra thing. The beauty of the probiotic, for instance, we’re not asking you to switch their diet. We’re not asking you to have to pill them or anything. It’s literally sprinkling on top of the food, it’s actually in the digest carrier that pets love, so they’re eager to eat it up. Just making it as seamlessly a transition into your routine as possible, and then taking the time to let it work. So really waiting at least that six weeks before you’re giving up, because a lot of people, they’ll try it for three days and they want to see something happening and if nothing’s happening, then they give up. So just encouraging them to continue to build it into their routine, keep it going, and then make that judgment. And just as part of that multimodal approach. So you can’t give up doing the behavior modification that you’ve been trying, or maybe wean them completely off the pharmaceuticals they’re on, but it’s that balance. And I think in working in partnership with their veterinarian, they should be able to strike that balance.

Dr. Ragen McGowan:
And for some pets, it does make a dramatic difference relatively quickly. We’ve seen pets that become much more easy going and less dramatic about their responses. For other pets, it’ll be very subtle changes that you’re seeing. But it all is important because at least we can see, even if it doesn’t manifest fully in the behavior you’re seeing, internally, physiologically, it’s helping with their stress response. You don’t want your pets in that chronic stress, because it can lead to all sorts of other immune issues and things going on. It might even be that their stress before was manifesting in something visceral like digestive upset or obsessive licking or self-injurious behavior. So look out for things like that too, like if their coat is improving because they’re no longer licking so much, or the redness between their paws is going away. There’s all these other indicators that could show, actually you’ve taken that mental load off and they’re much less stressed, even if it’s not hugely apparent in their reactions to big events happening in their life.

Dr. Andy Roark:
That makes tons of sense. We always want to celebrate pet owners. When something is working, I want to be able to say, “Look at this, look how much better this is.” And that totally makes sense. So yeah, the licking and chewing, and just those types of behaviors, yeah, that absolutely makes sense. Where can people get more information online? Where can they learn about the studies that have been done? Yeah, where can they read up?

Dr. Ragen McGowan:
Yeah. If you go to purina.com/expertise, there’s information there. And also, if you go to the Pro Plan Vet Direct website, you can learn a lot more about Calming Care.

Dr. Andy Roark:
That sounds awesome. Guys, I’ll put links to that down in the show notes. Dr. Ragen McGowan, thank you for being here. I really appreciate your time and energy. Thanks for sharing your knowledge.

Dr. Ragen McGowan:
My pleasure. Thanks for having me.

Dr. Andy Roark:
And that is our episode. Guys, I hope you enjoyed it. I hope you got something out of it. I know I certainly did. Thanks again to Purina Pro Plan veterinary supplements for making this episode possible. Gain, be well, and I’ll see you next week.