Equine metabolic syndrome
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Equine metabolic syndrome (EMS) is an
endocrinopathy Endocrinology (from ''endocrine'' + ''-ology'') is a branch of biology and medicine dealing with the endocrine system, its diseases, and its specific secretions known as hormones. It is also concerned with the integration of developmental events ...
affecting
horse The horse (''Equus ferus caballus'') is a domesticated, one-toed, hoofed mammal. It belongs to the taxonomic family Equidae and is one of two extant subspecies of ''Equus ferus''. The horse has evolved over the past 45 to 55 million y ...
s and
ponies A pony is a type of small horse ('' Equus ferus caballus''). Depending on the context, a pony may be a horse that is under an approximate or exact height at the withers, or a small horse with a specific conformation and temperament. Compared ...
. It is of primary concern due to its link to obesity, insulin dysregulation, and subsequent
laminitis 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. Sever ...
. There are some similarities in clinical signs between EMS and
pituitary pars intermedia dysfunction 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 c ...
, also known as PPID or
Cushing's disease Cushing's disease is one cause of Cushing's syndrome characterised by increased secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary (secondary hypercortisolism). This is most often as a result of a pituitary adenoma (speci ...
, and some equines may develop both, but they are not the same condition, having different causes and different treatment.


Pathogenesis

The cells of
adipose Adipose tissue, body fat, or simply fat is a loose connective tissue composed mostly of adipocytes. In addition to adipocytes, adipose tissue contains the stromal vascular fraction (SVF) of cells including preadipocytes, fibroblasts, vascular ...
(fat) tissue synthesizes hormones known as
adipokines The adipokines, or adipocytokines (Greek ', fat; ', cell; and ', movement) are cytokines (cell signaling proteins) secreted by adipose tissue. Some contribute to an obesity-related low-grade state of inflammation or to the development of metabolic ...
. In humans, dysfunction of adipose tissue, even in cases without obesity, has been associated with the development of insulin resistance,
hypertension Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high bl ...
, 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. Although it is suspected that a similar mechanism occurs in horses, further research is needed.


Insulin dysregulation

Insulin dysregulation is commonly seen in horses with EMS, and is associated with obesity. This is similar to
type II diabetes Type 2 diabetes, 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, ...
in humans, where the action of
insulin Insulin (, from Latin ''insula'', 'island') is a peptide hormone produced by beta cells of the pancreatic islets encoded in humans by the ''INS'' gene. It is considered to be the main anabolic hormone of the body. It regulates the metabolism o ...
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 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 metabol ...
. 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. 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.


Laminitis

EMS is also implicated in the development of
laminitis 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. Sever ...
. Prolonged IV insulin administration can induce laminitis, possibly due to its effects on blood flow to the foot, changes of glucose metabolism and secondary
matrix metalloproteinase Matrix metalloproteinases (MMPs), also known as matrix metallopeptidases or matrixins, are metalloproteinases that are calcium-dependent zinc-containing endopeptidases; other family members are adamalysins, serralysins, and astacins. The MMPs b ...
activation, or altered cell function within the foot. 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. This may support the argument that EMS is an evolved survival trait.


Breed and age predisposition

Ponies and horse breeds that evolved in relatively harsh environments with only sparse grass, the proverbial "
easy keeper Easy may refer to: Arts and entertainment Film and television * ''Easy'' (film), a 2003 American romantic comedy film *''Easy!'', or ''Scialla!'', a 2011 Italian comedy film * ''Easy'' (TV series), a 2016–2019 American comedy-drama anthology ...
", 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 Welsh may refer to: Related to Wales * Welsh, referring or related to Wales * Welsh language, a Brittonic Celtic language spoken in Wales * Welsh people People * Welsh (surname) * Sometimes used as a synonym for the ancient Britons (Celtic peop ...
,
Dartmoor Dartmoor is an upland area in southern Devon, England. The moorland and surrounding land has been protected by National Park status since 1951. Dartmoor National Park covers . The granite which forms the uplands dates from the Carboniferous ...
, and
Shetland Shetland, also called the Shetland Islands and formerly Zetland, is a subarctic archipelago in Scotland lying between Orkney, the Faroe Islands and Norway. It is the northernmost region of the United Kingdom. The islands lie about to the no ...
ponies, Morgans,
Paso Fino The Paso Fino is a naturally gaited light horse breed dating back to horses imported to the Caribbean from Spain. Pasos are prized for their smooth, natural, four-beat, lateral ambling gait; they are used in many disciplines, but are especially ...
s,
Saddlebred The American Saddlebred is a horse breed from the United States. This breed is referred to as the "Horse America Made". Descended from riding-type horses bred at the time of the American Revolution, the American Saddlebred includes the Nar ...
s,
Spanish Mustangs The Spanish Mustang is an American horse breed descended from horses brought from Spain during the early conquest of the Americas. They are classified within the larger grouping of the Colonial Spanish horse, a type that today is rare in Spain. ...
, and
Warmblood Warmbloods are a group of middle-weight horse types and breeds primarily originating in Europe and registered with organizations that are characterized by open studbook policy, studbook selection, and the aim of breeding for equestrian sport. ...
s; and may also been seen in
Quarter Horse The American Quarter Horse, or Quarter Horse, is an American breed of horse that excels at sprinting short distances. Its name is derived from its ability to outrun other horse breeds in races of a quarter mile or less; some have been clocked at s ...
s and
Tennessee Walking Horse The Tennessee Walking Horse or Tennessee Walker is a breed of gaited horse known for its unique four-beat running-walk and flashy movement. It was originally developed as a riding horse on farms and plantations in the American South. It is a ...
s, although is rarer in breeds such as the
Thoroughbred The Thoroughbred is a horse breed best known for its use in horse racing. Although the word ''thoroughbred'' is sometimes used to refer to any breed of purebred horse, it technically refers only to the Thoroughbred breed. Thoroughbreds are c ...
and
Standardbred The Standardbred is an American horse breed best known for its ability in harness racing, where members of the breed compete at either a trot or pace. Developed in North America, the Standardbred is recognized worldwide, and the breed can trace i ...
. Most horses are 5–15 years of age when they develop laminitis that can be attributed to EMS.


Clinical signs

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. 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 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. Sever ...
, and horses with EMS may have had previous episodes in their history. Other signs suggesting EMS include elevated blood
triglyceride A triglyceride (TG, triacylglycerol, TAG, or triacylglyceride) is an ester derived from glycerol and three fatty acids (from ''tri-'' and ''glyceride''). Triglycerides are the main constituents of body fat in humans and other vertebrates, as w ...
levels and leptin levels,
hypertension Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high bl ...
, and reproductive changes in mares (an increased diestrus period, and a lack of anestrus). Horses also occasionally show
anemia Anemia or anaemia (British English) is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of hemoglobin. When anemia comes on slowly, th ...
and elevated
gamma-glutamyl transpeptidase Gamma-glutamyltransferase (also γ-glutamyltransferase, GGT, gamma-GT, gamma-glutamyl transpeptidase; ) is a transferase (a type of enzyme) that catalyzes the transfer of gamma-glutamyl functional groups from molecules such as glutathione to ...
(GGT) levels.


Differentiation from pituitary pars intermedia dysfunction

EMS shares similarities to
pituitary pars intermedia dysfunction 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 c ...
(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.


Diagnosis

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. Horses with persistent hyperglycemia may have
type II diabetes Type 2 diabetes, 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, ...
. 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. 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. Blood being drawn the following morning, usually between 8 and 10 am. Both insulin and glucose blood levels are measured.
Hyperinsulinemia 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 metabol ...
suggests insulin resistance. This test is easy to perform, but is less sensitive than the oral sugar test. It is best used in cases where risks of laminitis make the oral sugar test potentially unsafe. 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. Dynamic testing for insulin has higher sensitivity test than fasting insulin concentration, because insulin resistance may only become evident when challenged by
hyperglycemia 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 ...
. There are various tests available for measuring changes in insulin concentration. They usually require a similar fasting protocol as the fasting insulin test. * A glucose tolerance test requires IV or oral administration of a sugar. Multiple blood draws are then performed to measure blood glucose and insulin levels over time. The area under this curve is the best indicator of insulin resistance, but it may also be evaluated just based on the peak value and time to return to baseline. *The combined glucose-insulin test requires less time to perform than the glucose tolerance test. It involves a baseline blood draw, followed by an IV injection of dextrose, and then an injection of insulin. Blood glucose is measured every 10–15 minutes over the course of 2.5 hours. Samples are evaluated for time to return to baseline blood glucose levels, and insulin blood concentration. Elevated insulin concentration suggest insulin resistance. Rarely, this test can result in hypoglycemia, which requires administration of IV dextrose to correct.


Treatment

The main goals of treatment involve methods to induce weight loss. This may be accomplished through dietary changes, exercise, and medical management.


Diet

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. 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. Pasture is often eliminated from the diet, since digestible energy levels from grazing are not easily measured and pasture carbohydrates can trigger laminitis. 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. 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. Horses are best managed by only allowing short grazing periods—less than 1 hour since they can rapidly ingest grass, 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, although this method is not always a reliable way to adequately drop them to acceptable levels. 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 A stereotypy (, or ) is a repetitive or ritualistic movement, posture, or utterance. Stereotypies may be simple movements such as body rocking, or complex, such as self-caressing, crossing and uncrossing of legs, and marching in place. They are ...
can occur, and insulin resistance may actually be worsened. 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. 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.


Exercise

Exercise has been shown to improve insulin sensitivity in humans with metabolic syndrome. 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.


Medical management

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 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. ...
and
levothyroxine sodium Levothyroxine, also known as -thyroxine, is a manufactured form of the thyroid hormone thyroxine (T4). It is used to treat thyroid hormone deficiency (hypothyroidism), including a severe form known as myxedema coma. It may also be used to tr ...
. 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. However, it has low
bioavailability In pharmacology, bioavailability is a subcategory of absorption and is the fraction (%) of an administered drug that reaches the systemic circulation. By definition, when a medication is administered intravenously, its bioavailability is 100%. H ...
in horses, and does not appear to affect insulin sensitivity at doses that are commonly used. 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. Levothyroxine, a T4 analogue, improves insulin sensitivity and weight loss in horses. After desired body weight has been reached, horses are slowly weaned off the drug. Although it does not appear to produce signs of
hyperthyroidism Hyperthyroidism is the condition that occurs due to excessive production of thyroid hormones by the thyroid gland. Thyrotoxicosis is the condition that occurs due to excessive thyroid hormone of any cause and therefore includes hyperthyroidism ...
in horses, safety of long-term usage has not been evaluated.


See also

*
Henneke horse body condition scoring system The Henneke horse body condition scoring system is a numerical scale used to evaluate the amount of fat on a horse's body. It was developed in the early 1980s by Don Henneke at Texas A&M University with the goal of creating a universal scale to ass ...


References

{{reflist Syndromes in horses