Equine metabolic syndrome (EMS) is an endocrinopathy affecting horses and ponies. It is of primary concern due to its link to obesity, insulin dysregulation, and subsequent laminitis. There are some similarities in clinical signs between EMS and pituitary pars intermedia dysfunction, also known as PPID or Cushing's disease, and some equines may develop both, but they are not the same condition, having different causes and different treatment.
The cells of adipose (fat) tissue synthesize hormones known as adipokines. In humans, dysfunction of adipose tissue, even in cases without obesity, has been associated with the development of insulin resistance, hypertension, systemic inflammation, and increased risk of blood clots (thrombosis). The inflammation produced by these hormones are thought to inflame adipose tissue, leading to the production of more adipokines and perpetuation of the cycle, and a constant low-level, pro-inflammatory state. [1] Although it is suspected that a similar mechanism occurs in horses, further research is needed.
Insulin dysregulation is commonly seen in horses with EMS, and is associated with obesity. This is similar to type II diabetes in humans, where the action of insulin is impaired, despite often elevated concentrations. It is of interest primarily because of its link to laminitis. Horses with EMS will have an increased insulin response after they are given oral sugars, which will cause a subsequent rise in blood insulin levels, or hyperinsulinemia. Hyperinsulinemia results in decreased tissue sensitivity to insulin, or insulin resistance, especially by the skeletal muscle, liver and adipose tissue. Tissue insulin resistance causes increased insulin secretion, which perpetuates the cycle. [2]
There does appear to be a strong link between decreased insulin sensitivity in obese animals; however, it is unknown which syndrome is the cause and which is the result. It is possible adipokines and cytokines made in adipose tissue down-regulate insulin pathways. It is also possible that IR occurs when adipocytes are overwhelmed, leading to the accumulation of lipid within other tissues. When certain tissues that are sensitive to insulin, such as skeletal muscle, develop triglyceride deposits, cellular functions are altered, one of which is insulin signaling. [1]
EMS is also implicated in the development of laminitis. [3] Prolonged IV insulin administration can induce laminitis, [4] possibly due to its effects on blood flow to the foot, [5] changes of glucose metabolism and secondary matrix metalloproteinase activation, [6] or altered cell function within the foot. [7] However, recent research suggests that the situation is more complex, in that "compensated insulin resistance is essentially physiological and health sustaining", and only when this compensatory mechanism fails does laminitis ensue. [8] This may support the argument that EMS is an evolved survival trait. [9]
Ponies and horse breeds that evolved in relatively harsh environments with only sparse grass, the proverbial "easy keeper", tend to be more prone to EMS and insulin resistance. This possibly occurred as a survival mechanism, where the animal would lay down fat during plentiful times, such as the spring and summer, and maintain their weight more easily during the harsh, cold seasons. EMS appears to be more common in Welsh, Dartmoor, and Shetland ponies, Morgans, Paso Finos, Saddlebreds, Spanish Mustangs, and Warmbloods; and may also been seen in Quarter Horses and Tennessee Walking Horses, although is rarer in breeds such as the Thoroughbred and Standardbred. Most horses are 5–15 years of age when they develop laminitis that can be attributed to EMS. [1]
EMS horses tend to become obese very easily, depositing fat in the crest, shoulders, loin, above the eyes, around the tail head, and the mammary glands or prepuce, even when the rest of the body appears to be in normal condition. Some horses may have regional adiposity, and others may even appear normal weight, so obesity is not a definitive clinical sign of a horse with EMS. [1] Horses will be insulin resistant (IR), and may have hyperinsulinemia, have abnormal blood glucose, or abnormal insulin responses to glucose. IR predisposes the animal to laminitis, and horses with EMS may have had previous episodes in their history. [1]
Other signs suggesting EMS include elevated blood triglyceride levels and leptin levels, hypertension, and reproductive changes in mares (an increased diestrus period, and a lack of anestrus). Horses also occasionally show anemia and elevated gamma-glutamyl transpeptidase (GGT) levels. [1]
EMS shares similarities to pituitary pars intermedia dysfunction (also known as equine Cushing's disease), which also causes regional adiposity, laminitis, and sometimes insulin resistance. Treatment and management differ between the conditions, making it important to distinguish between the two. However, both diseases may occur simultaneously; horses with EMS may develop PPID. [1]
| EMS | PPID | |
|---|---|---|
| Age of onset | 5–15 years | 15+ years |
| Clinical signs | Resistance to weight loss | Hirsutism, increased drinking and urination, muscle atrophy |
| Serum ACTH levels | Normal | Elevated |
Source: [10]
Diagnosis is based on history, clinical signs, and diagnostic tests.
Glucose levels alone are insufficient to diagnose EMS. Many EMS horses will effectively compensate their insulin response even with insulin resistance, maintaining a blood glucose within normal limits, although usually at the high end of normal. Other factors, such as stress, feeding, inflammation, or administration of α-2 agonist drugs such as xylazine and detomidine, can falsely raise blood glucose levels. [1] [11] [12] Horses with persistent hyperglycemia may have type II diabetes. [13]
Insulin normally increases after feeding, as well as secondary to cortisol (stress) and epinephrine (pain), so measurement should be avoided if any of these conditions are present. Actively laminitic horses should therefore not undergo testing until their pain and stress have been adequately controlled. Additionally, resting insulin levels may not be increased in all animal with EMS. For these reasons, dynamic tests are recommended for the diagnosis of EMS. [1]
Measurement of fasting insulin concentration involves giving a horse a single flake of hay, low in non-structural carbohydrates, at 10 pm the night before testing. [14] Blood being drawn the following morning, usually between 8 and 10 am. [1] Both insulin and glucose blood levels are measured. Hyperinsulinemia suggests insulin resistance. This test is easy to perform, but is less sensitive than the oral sugar test. [15] It is best used in cases where risks of laminitis make the oral sugar test potentially unsafe. [2]
The oral sugar test also requires giving the horse only a single flake of hay at 10pm the night before the test. The following morning, karo corn syrup is given orally, and glucose and insulin levels are measured at 60 and 90 minutes after administration. Normal or excessively high insulin levels are diagnostic. However, equivocal test results require retesting at a later date, or performing a different test. A similar test is available outside the US, in areas where corn-syrup products are less readily available, where horses are given a morning meal of chaff with dextrose powder, and blood insulin levels are measured 2 hours later. [16]
Dynamic testing for insulin has higher sensitivity test than fasting insulin concentration, because insulin resistance may only become evident when challenged by hyperglycemia. [1] There are various tests available for measuring changes in insulin concentration. They usually require a similar fasting protocol as the fasting insulin test.
The main goals of treatment involve methods to induce weight loss. This may be accomplished through dietary changes, exercise, and medical management.
Dietary management involves reducing both the digestible energy levels and the total non-structural carbohydrate (NSC) level of feed. NSC include starches, single sugars, and fructans, whereas cellulose and hemicelluloses are structural carbohydrates. [18] High NSC levels cause a glucose and insulin spike following feeding, and may worsen insulin resistance. Current recommendations for NSC levels are less than 10% of the diet on a dry matter basis. [1]
Pasture is often eliminated from the diet, since digestible energy levels from grazing are not easily measured and pasture carbohydrates can trigger laminitis. [19] It may be introduced back into the diet following improvement of insulin sensitivity. In horses with mild insulin resistance, this is often the case once obesity is resolved. [1] However, pasture access should be restricted to those times of day when grass NSC levels are lowest, such as early morning, and never following a frost, which stresses the grass and results in accumulation of water-soluble carbohydrates. [20] Horses are best managed by only allowing short grazing periods—less than 1 hour since they can rapidly ingest grass, [18] or confining them to a limited turn-out area or by use of a grazing muzzle. Horses with severe IR, that have recurrent laminitis, are not recommended to return to pasture.
Hay low in NSC is provided in place of pasture. Ideally, hay should be tested and purchased based on known NSC levels, only using hays less than 10% NSC. Hays higher than 10% NSC may be used, but it is recommended to soak it for at least one hour before feeding in cold water, which can help reduce NSC levels, [21] although this method is not always a reliable way to adequately drop them to acceptable levels. [22] Obese horses are usually fed hay at a level of 1.5% ideal body weight, which may be dropped to 1% of body weight if no weight loss is realized after 30 days. However, feeding less than 1% of body weight in forage is not recommended, since secondary problems such as hyperlipemia and stereotypies can occur, and insulin resistance may actually be worsened. [1]
Removal of concentrates from the diet may be sufficient to produce weight loss in obese horses. Hays are often low in vitamin A, vitamin E, copper, zinc, and selenium. [1] A vitamin and mineral supplement is added to the diet to ensure adequate nutrition. Ration balancers, which are low in calories but offer protein, vitamins, and minerals, are often recommended. [1]
Exercise has been shown to improve insulin sensitivity in humans with metabolic syndrome. [23] Increased exercise is therefore recommended in horses with EMS, assuming laminitis does not restrict activity levels. Current recommendations include 2–3 sessions a week, of 20–30 minutes of work, with gradual increase in duration and intensity. [1]
Medical management is usually reserved for horses that do not adequately respond to diet and exercise alone. The two most commonly used drugs for EMS are metformin and levothyroxine sodium.
Metformin is a drug used in humans for type II diabetes, and has been shown to improve insulin sensitivity and reduce output of glucose by the liver. [24] However, it has low bioavailability in horses, [25] and does not appear to affect insulin sensitivity at doses that are commonly used. [26] Its current mechanism of action in horses is thought to be a reduction in intestinal glucose absorption, and therefore postprandial glucose levels, when it is given before meals. [27]
Levothyroxine, a T4 analogue, improves insulin sensitivity and weight loss in horses. [28] After desired body weight has been reached, horses are slowly weaned off the drug. Although it does not appear to produce signs of hyperthyroidism in horses, [29] safety of long-term usage has not been evaluated. [1]
Polycystic ovary syndrome, or polycystic ovarian syndrome (PCOS), is the most common endocrine disorder in women of reproductive age. The syndrome is named after cysts which form on the ovaries of some people with this condition, though this is not a universal symptom, and not the underlying cause of the disorder.
Metabolic syndrome is a clustering of at least three of the following five medical conditions: abdominal obesity, high blood pressure, high blood sugar, high serum triglycerides, and low serum high-density lipoprotein (HDL).
Insulin resistance (IR) is a pathological condition in which cells either fail to respond normally to the hormone insulin or downregulate insulin receptors in response to hyperinsulinemia.
The glucose tolerance test is a medical test in which glucose is given and blood samples taken afterward to determine how quickly it is cleared from the blood. The test is usually used to test for diabetes, insulin resistance, impaired beta cell function, and sometimes reactive hypoglycemia and acromegaly, or rarer disorders of carbohydrate metabolism. In the most commonly performed version of the test, an oral glucose tolerance test (OGTT), a standard dose of glucose is ingested by mouth and blood levels are checked two hours later. Many variations of the GTT have been devised over the years for various purposes, with different standard doses of glucose, different routes of administration, different intervals and durations of sampling, and various substances measured in addition to blood glucose.
Hyperglycemia is a condition in which an excessive amount of glucose circulates in the blood plasma. This is generally a blood sugar level higher than 11.1 mmol/L (200 mg/dL), but symptoms may not start to become noticeable until even higher values such as 13.9–16.7 mmol/L (~250–300 mg/dL). A subject with a consistent range between ~5.6 and ~7 mmol/L is considered slightly hyperglycemic, and above 7 mmol/L is generally held to have diabetes. For diabetics, glucose levels that are considered to be too hyperglycemic can vary from person to person, mainly due to the person's renal threshold of glucose and overall glucose tolerance. On average, however, chronic levels above 10–12 mmol/L (180–216 mg/dL) can produce noticeable organ damage over time.
Ketosis is a metabolic state characterized by elevated levels of ketone bodies in the blood or urine. Physiological ketosis is a normal response to low glucose availability, such as low-carbohydrate diets or fasting, that provides an additional energy source for the brain in the form of ketones. In physiological ketosis, ketones in the blood are elevated above baseline levels, but the body's acid–base homeostasis is maintained. This contrasts with ketoacidosis, an uncontrolled production of ketones that occurs in pathologic states and causes a metabolic acidosis, which is a medical emergency. Ketoacidosis is most commonly the result of complete insulin deficiency in type 1 diabetes or late-stage type 2 diabetes. Ketone levels can be measured in blood, urine or breath and are generally between 0.5 and 3.0 millimolar (mM) in physiological ketosis, while ketoacidosis may cause blood concentrations greater than 10 mM.
Type 2 diabetes (T2D), formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urination, fatigue and unexplained weight loss. Symptoms may also include increased hunger, having a sensation of pins and needles, and sores (wounds) that do not heal. Often symptoms come on slowly. Long-term complications from high blood sugar include heart disease, strokes, diabetic retinopathy which can result in blindness, kidney failure, and poor blood flow in the limbs which may lead to amputations. The sudden onset of hyperosmolar hyperglycemic state may occur; however, ketoacidosis is uncommon.
Metformin, sold under the brand name Glucophage, among others, is the main first-line medication for the treatment of type 2 diabetes, particularly in people who are overweight. It is also used in the treatment of polycystic ovary syndrome. It is sometimes used as an off-label adjunct to lessen the risk of metabolic syndrome in people who take antipsychotics. Metformin is not associated with weight gain and is taken by mouth.
The blood sugar level, blood sugar concentration, blood glucose level, or glycemia, is the measure of glucose concentrated in the blood. The body tightly regulates blood glucose levels as a part of metabolic homeostasis.
Gestational diabetes is a condition in which a woman without diabetes develops high blood sugar levels during pregnancy. Gestational diabetes generally results in few symptoms; however, it increases the risk of pre-eclampsia, depression, and of needing a Caesarean section. Babies born to mothers with poorly treated gestational diabetes are at increased risk of macrosomia, of having hypoglycemia after birth, and of jaundice. If untreated, diabetes can also result in stillbirth. Long term, children are at higher risk of being overweight and of developing type 2 diabetes.
Diabetes is a chronic disease in cats whereby either insufficient insulin response or insulin resistance leads to persistently high blood glucose concentrations. Diabetes affects up to 1 in 230 cats, and may be becoming increasingly common. Diabetes is less common in cats than in dogs. The condition is treatable, and if treated properly the cat can experience a normal life expectancy. In cats with type 2 diabetes, prompt effective treatment may lead to diabetic remission, in which the cat no longer needs injected insulin. Untreated, the condition leads to increasingly weak legs in cats and eventually to malnutrition, ketoacidosis and/or dehydration, and death.
Laminitis is a disease that affects the feet of ungulates and is found mostly in horses and cattle. Clinical signs include foot tenderness progressing to inability to walk, increased digital pulses, and increased temperature in the hooves. Severe cases with outwardly visible clinical signs are known by the colloquial term founder, and progression of the disease will lead to perforation of the coffin bone through the sole of the hoof or being unable to stand up, requiring euthanasia.
Hyperinsulinemia is a condition in which there are excess levels of insulin circulating in the blood relative to the level of glucose. While it is often mistaken for diabetes or hyperglycaemia, hyperinsulinemia can result from a variety of metabolic diseases and conditions, as well as non-nutritive sugars in the diet. While hyperinsulinemia is often seen in people with early stage type 2 diabetes mellitus, it is not the cause of the condition and is only one symptom of the disease. Type 1 diabetes only occurs when pancreatic beta-cell function is impaired. Hyperinsulinemia can be seen in a variety of conditions including diabetes mellitus type 2, in neonates and in drug-induced hyperinsulinemia. It can also occur in congenital hyperinsulinism, including nesidioblastosis.
Specific dynamic action (SDA), also known as thermic effect of food (TEF) or dietary induced thermogenesis (DIT), is the amount of energy expenditure above the basal metabolic rate due to the cost of processing food for use and storage. Heat production by brown adipose tissue which is activated after consumption of a meal is an additional component of dietary induced thermogenesis. The thermic effect of food is one of the components of metabolism along with resting metabolic rate and the exercise component. A commonly used estimate of the thermic effect of food is about 10% of one's caloric intake, though the effect varies substantially for different food components. For example, dietary fat is very easy to process and has very little thermic effect, while protein is hard to process and has a much larger thermic effect.
Isomaltulose is a disaccharide carbohydrate composed of glucose and fructose. It is naturally present in honey and sugarcane extracts and is also produced industrially from table sugar (sucrose) and used as a sugar alternative.
Equine polysaccharide storage myopathy is a hereditary glycogen storage disease of horses that causes exertional rhabdomyolysis. It is currently known to affect the following breeds American Quarter Horses, American Paint Horses, Warmbloods, Cobs, Dales Ponies, Thoroughbreds, Arabians, New Forest ponies, and a large number of Heavy horse breeds. While incurable, PSSM can be managed with appropriate diet and exercise. There are currently 2 subtypes, known as Type 1 PSSM and Type 2 PSSM.
An easy keeper, easy doer, or good doer is a horse that can live on relatively little feed. The opposite of an easy keeper is a hard keeper, an animal that is prone to be too thin and has difficulty maintaining adequate weight.
Pituitary pars intermedia dysfunction (PPID), or equine Cushing's disease, is an endocrine disease affecting the pituitary gland of horses. It is most commonly seen in older animals, and is classically associated with the formation of a long, wavy coat (hirsutism) and chronic laminitis.
Obesity is defined as an abnormal accumulation of body fat, usually 20% or more over an individual's ideal body weight. This is often described as a body mass index (BMI) over 30. However, BMI does not account for whether the excess weight is fat or muscle, and is not a measure of body composition. For most people, however, BMI is an indication used worldwide to estimate nutritional status. Obesity is usually the result of consuming more calories than the body needs and not expending that energy by doing exercise. There are genetic causes and hormonal disorders that cause people to gain significant amounts of weight but this is rare. People in the obese category are much more likely to suffer from fertility problems than people of normal healthy weight.
Serpin A12 is a glycoprotein that is a class A member of the serine protease inhibitor (serpin) family. In humans, Serpin A12 is encoded by the SERPINA12 gene.
