Diabetes mellitus (DM) is an increasingly common endocrine disease of companion animals. However, owners are still struggling with the management requirements of their diabetic pets (Hamlin, 2010). It is a vital role of the registered veterinary nurse to provide informed advice and effective support to clients with diabetic cats and dogs to maximise quality of life (QoL) of both owner and pet (Scudder et al, 2016).
Diabetes mellitus and quality of life
Owners' feedback is crucial for gaining information on how a pet's DM is being managed at home and its effects on QoL (Reusch et al, 2006). Niessen et al (2012) found that the highest-rated negatively impacting factors of having a pet with DM were related to the owner's QoL rather than the pet's. Furthermore, Niessen et al (2012) found that negative comments regarding support from veterinary professionals came up frequently in the free comments section of their QoL questionnaire, highlighting that long-term support of owners is often being overlooked. In addition, a study by Rothlin-Zachrisson et al (2023) showed that approximately half of owners reported limitations to their daily life as a result of their cat's DM. Aptekmann and Schwartz (2011) found that 31% of owners reported an increase in attachment to their pet associated with the daily management requirements of their DM. This could be seen as a positive result of having a pet with DM, or perhaps these owners feel more attached to their pet as a result of feelings of guilt because they perceive their animal to be suffering.
Management options
Financial factors, the expectations and motivation of the owner, and the support provided by their veterinary practice all contribute to which options clients choose to use to manage their pet's DM (Cook, 2012). Home blood glucose monitoring (HBGM) of diabetic pets has proven invaluable for the long-term management of the disease at home. Hazuchova et al (2018) found that 75% of owners are able and willing to perform HBGM with the right support. Van de Maele et al (2005) found that the main difficulties faced by owners performing HBGM were related to pet resistance, and their main concerns were fear of hurting their pet, lack of confidence with taking blood samples and the costs involved. Furthermore, Van de Maele et al (2005) found that all owners felt that HMBG improved the management of their pet's DM, but there were only nine study participants in total. Knies et al (2022) found that owners were very satisfied with their experience of using continuous glucose monitoring (CGM) on their pet. However, prevalence of complications with using CGM in a group of 20 diabetic cats, including premature sensor detachment, skin reactions and sensor malfunction, was found to be 30% – complications which may be avoided by better owner education (Shoelson et al, 2021).
Nurse-led diabetes clinics provide an invaluable opportunity for owners to seek advice and express any concerns, as well as allowing increased availability of veterinary surgeons, reduced costs for the owner and a sense of fulfilment for registered veterinary nurses (Barry, 2018). However, limited resources mean that this is an unrealistic option for most veterinary practices (Wild, 2017).
Support provided
Failure to monitor QoL of both owner and pet may lead to clients choosing euthanasia because of a lack of support in cases where their pet's DM could be stabilised (Ackerman et al, 2018). Niessen et al (2017) found that at the time of diagnosis, a median of one in ten dogs and cats were being euthanised on request by their owner. Furthermore, Albuquerque et al (2020) found that less than 50% of owners were told about HMBG and how to identify clinical signs associated with uncontrolled DM at the time of diagnosis. In total, 76% of owners agreed that the most useful resource for learning about their pet's DM was online support groups and websites (Albuquerque et al, 2020).
Relevance of research
UK-based research into owner experiences of the support provided to them by their veterinary practice for their pet's DM appears to be lacking. Furthermore, owners' experiences with and awareness of different management options, such as diabetes apps, clinics and HMBG, have not been well researched. The aim of this study was to investigate client perspectives on how support needs to be improved for owners of diabetic pets in the UK in the interest of animal welfare and to meet client expectations. The objective was to investigate owner confidence with the management of their pet's DM, the effects it has on QoL, what they find most challenging, their experiences with different management options, how supported they feel and their suggestions for how support could be improved.
Methods
Survey design
An online questionnaire aimed at owners of pets with DM was designed using the online tool ‘NoviSurvey’. Most questions were multiple choice with single selection answers using Likert or numerical rating scales. A copy of the survey questions can be found in Appendix 1 (available online). All voluntary participants were recruited by posting the survey on relevant closed Facebook groups and by contacting clients with diabetic pets who had opted for marketing emails at the author's place of work. Participants had to be UK-based, aged 18 years or older, and the full-time owner of a cat or dog that has been diagnosed with DM by a veterinary surgeon. Ethical approval was gained from Edinburgh Napier's Ethics Committee before publication of the survey. All responses remained anonymous to ensure confidentiality and data protection.
Survey questions
The survey consisted of 24 questions including the species of the pet, how long ago the pet was diagnosed with DM, whether owners had experience with using certain management options including HBGM, CGM, insulin pens, diabetes apps/diaries and diabetes clinics, where they found out about these options and whether they improved the management of their pet's DM (Appendix 1, available online). Participants were asked to rate how challenging they found the management requirements of their pet's DM, including insulin injections, taking blood glucose (BG) readings, time commitments, financial commitments, having an understanding of the disease and worry about their pet's wellbeing/QoL, and how confident they felt with managing the disease overall. Further questions asked how DM affects QoL of both pet and owner, and whether owners had ever considered rehoming or euthanasia because of their pet's DM. Finally, owners were asked how supported they felt by their veterinary surgeon/nurse with their pet's DM, and how they think this support could be improved.
Data analysis
Data were analysed using Microsoft Excel. Qualitative responses to open-ended questions were manually categorised according to main themes, and the frequency at which each category came up in answers was also provided. All uncertainties are given as standard errors of the mean.
Results
Data analysis was carried out on a total of 99 valid responses. Respondents were able to withdraw from the survey at any point before submission in accordance with ethics committee requirements. Partially completed survey responses were still included in data analysis, provided the respondent had given consent.
Demographics
Out of the 99 respondents, 64% were dog owners and 36% were cat owners. Most participants had recently diagnosed pets, with 66% having been diagnosed within the last 2 years.
Management options
For all the management options asked about in this survey, most participants had heard about them elsewhere rather than from their veterinary practice (Figure 1). The advantages and disadvantages of different management options given by owners in the optional comments section of these questions is summarised in Table 1.
Table 1. Summary of the advantages and disadvantages of different management options as given by participants in the optional comments section
| Management option | Advantages | Disadvantages |
|---|---|---|
| Home blood glucose monitoring | Allows hypoglycaemic episodes to be identified quickly | Time consuming |
| Fewer vet visits | ||
| More accurate insulin dosing | ||
| Better understanding of the effects of different foods on blood glucose | Negatively affects pet–owner bond | |
| Helps with achieving remission in cats | ||
| Gives owners a sense of control | ||
| Continuous glucose monitors | Allows 24-hour monitoring of blood glucose | Malfunctioned and gave inaccurate data |
| Helpful for charting blood glucose to identify trends | Unreliable for lower blood glucose readings | |
| Allowed food/insulin alterations | Requires vet visits to fit | |
| Less stressful than repeated blood glucose tests | Expensive | |
| Good for reactive dogs | ||
| Peace of mind for owner | ||
| Insulin pen | Good for needle-phobic owners | Only useful for large doses |
| Easier for owners with arthritis | Concerns about accuracy – does not allow micromanaging | |
| Less stressful for both owner and pet | Not useful if animal is unstable and insulin dose varies | |
| More portable and easier to dispense | There is always a small amount of insulin left in the pen | |
| Smaller needle so less painful | ||
| Easier if someone else taking care of pet | ||
| Diary/app | Allows trends to be identified | Not useful or necessary if animal's diabetes mellitus is stable |
| Allows data to be shared with vet | Freestyle Libre app designed for humans with diabetes mellitus | |
| Can create blood glucose curves at home | Some apps are not user friendly | |
| Allows info such as insulin dose, medications, food intake, appetite and demeanour to be recorded and monitored |
HBGM was the most used management option asked about in this survey, where 77% of participants have had experience with it, most of whom (72%) strongly agreed it improved management of their pet's DM (Figure 2). The next most frequently used method was diabetic diaries or apps, which 63.4% of respondents had experience with, and 52% of whom strongly agree it improved management of the disease. The optional comments section highlighted that a lot of owners use paper diaries or online spreadsheets to monitor their pets' DM. The apps mentioned included the Royal Veterinary College (RVC) Pet Diabetes App and the Freestyle Libre app. In total, 28% of owners had used CGM, most of whom (54%) strongly agreed it had a positive effect on the management of their pet's DM. 20% of participants had used an insulin pen for their pet's DM – 32% of whom answered ‘strongly agree’ to whether it improved management. Just 15% of participants have attended diabetes clinics, while most (82%) have not been offered this option by their practice. Only 3% answered that they would prefer not to. Most of those who have attended them (79%) either agreed or strongly agreed it improved management of their pet's DM.
The open-ended question asking owners what other options they use to manage their pet's DM received 61 responses. Table 2 shows a summary of the other management options used by participants and the frequency at which they came up in open-ended answers.
Table 2. Table displaying a summary of the other management options used by participants, and the frequency at which they came up in open-ended answers (n=61)
| Management option | Frequency |
|---|---|
| Online support groups | 12 |
| Dietary changes | 10 |
| Urine test strips | 5 |
| Spreadsheets | 3 |
| Doctor's Best B12 capsules (for symptoms of diabetic neuropathy) | 3 |
| Online carbohydrate calculator | 3 |
| Specialist vet/nurse | 3 |
| Smaller needles | 2 |
| Medications | 1 |
| Monitoring | 1 |
Challenges
Figure 3 shows the mean ratings given by owners for certain management factors on a scale of ‘1–5’, where 1 is ‘not at all challenging’ and 5 is ‘extremely challenging’. This study found the factor that participants rated as most challenging when managing their pet's DM was ‘worry about your pet's wellbeing/QoL’, which 42% rated as a ‘5’ (mean rating 3.9±0.2). This was followed by ‘financial factors’ which 32% rated as ‘5’ (mean of 3.6±0.2), ‘time commitments’ which was rated a ‘5’ by 30% (mean of 3.6±0.2), and ‘having to stick to a specific routine’ which 29% rated as a ‘5’ (mean 3.4±0.2). Managing concurrent conditions had a mean rating of 3.2±0.2, taking BG readings had a mean rating of 2.5±0.2 with 27% of participants rating it as ‘1 – not at all challenging’, and ‘having an understanding of the disease’ had a mean rating of 2.7±0.2. The least challenging factors included ‘resistance from your pet, eg with injections’ which was rated ‘1 – not at all challenging’ by 51% (mean of 1.9±0.2) and ‘giving injections’ which was rated ‘1’ by 46% (mean of 2.0±0.2).
Quality of life
When asked on a scale of 1–5 (where ‘1’ is ‘not at all confident’ and ‘5’ is ‘very confident’) how confident they are with managing their pet's DM, 65% gave a rating of above 3. Only 3% gave a rating of ‘1’ and 3% gave a rating of ‘2’ (Figure 4). However, in response to how much they thought DM worsens their pet's QoL on a scale of 1–5 (where ‘1’ is ‘not at all’ and ‘5’ is ‘severely’), 31% gave a rating of above 3. In comparison, when asked the same question about how much their pet's DM worsens their own QoL, 34% gave a rating of above 3 (Figure 5). Most participants (82%) had never considered rehoming or euthanasia because of their pet's DM, 16% answered ‘occasionally’ and just 1% said ‘often’.
Support
This study found that half of participants (52%) either agreed or strongly agreed that their veterinary nurse/surgeon supports them with the management requirements of their pet's DM (Figure 6). However, a quarter of participants (26%) either disagreed or strongly disagreed. The optional open-ended question asking how support can be improved received 70 responses. Table 3 shows a summary of the main themes in these responses, and the frequency at which they came up in open-ended answers.
Table 3. Table displaying a summary of the support improvements suggested by participants, and the frequency at which they came up in open-ended answers (n=70)
| Support improvement | Frequency |
|---|---|
| More informed and up-to-date advice | 33 |
| Reduced costs | 13 |
| Better dietary advice | 12 |
| Better advice at time of diagnosis | 10 |
| Treatment protocols and more consistency with advice/vet being seen | 8 |
| More support for HBGM/CGM | 7 |
| Offer clinics and make efforts to connect owners | 6 |
| Alternative insulin | 2 |
| Do not just suggest PTS/rehoming as best option | 2 |
| Better advice for identifying complications | 2 |
| Use data sharing apps to reduce need for vet visits | 1 |
| Specialist vet/nurse | 1 |
| Provide handouts | 1 |
| Less emphasis on BG curves | 1 |
| Ask owners for feedback | 1 |
CGM, continuous glucose monitoring; HBGM, home blood glucose monitoring; PTS, put to sleep; BG, blood glucose
Discussion
This survey was designed to investigate owners' perceptions of the support provided to them by their veterinary practice for the management of their pet's DM, and how this might be improved. Although half of participants agreed or strongly agreed that they felt supported by their veterinary practice, a quarter either disagreed or strongly disagreed. Furthermore, the most common response given to the open-ended question asking how support could be improved was ‘more informed and up-to-date advice’, which came up in almost half of responses. This highlights the need for action by the UK veterinary profession to improve support for owners with diabetic dogs and cats.
Most participants reported that they felt confident with the management of their pet's DM, which may be as a result of most participants being members of online support groups and, therefore, likely to be highly committed owners. However, responses also showed that DM worsens QoL of the owner just as much as it worsens the perceived QoL of the pet. These findings support those of Niessen et al (2010), who found that nine out of ten of the factors reported by owners as having the most negative impact were related to the owner's QoL rather than the pet's. Furthermore, the most challenging factor for owners that this study identified was ‘worry for pet's wellbeing/QoL’ which agreed with Niessen et al (2012). This emphasises that owners experience anxiety associated with their pets' DM and therefore need more consistent support. Most participants had never considered rehoming or euthanasia because of their pet's DM, despite the perceived negative impact on QoL. Rothlin-Zachrisson et al (2023) found that the most common reason for owners of cats with DM opting for euthanasia was that they did not want to see their pet suffer (53%). It would be useful to gain more insight from owners as to what they think defines a good or bad QoL for their pet.
‘Financial factors’ and ‘time commitments’ were the next most challenging factors as rated by participants in this survey. Furthermore, ‘reduced costs’ was one of the most common answers given to how support could be improved. This was consistent with a study by Aptekmann and Schwartz (2011), who found that 89% of responses indicated that costs were the primary reason for owners opting to not have their animals treated. Owners should be encouraged to use the free management options available to them such as diabetic diaries or apps, which 52.5% of participants strongly agreed improved the management of their pet's DM. In comparison, factors in this survey related to insulin injections were not considered particularly challenging, with ‘resistance from your pet, eg with injections’ and ‘giving injections’ rated as the least challenging. This suggests that it is the overall commitment of having a pet with DM that owners perceive as challenging, rather than the individual daily tasks involved. These results may also suggest that most participants had pets with stable DM at the time of survey completion. The raw data for responses to this section can be found in Appendix 2 (available online).
This study found that most participants had heard about all the management options from a different source to their veterinary practice, suggesting that veterinary professionals may not be offering a broad range of choices to these clients. However, it should be noted that most participants were members of support groups on Facebook and are therefore individuals who are more likely to do their research and actively seek out alternative options. In addition, 35% of participants had pets that had been diagnosed within a year of completing the survey and so may have not had the chance to attend many appointments at their veterinary practice or try many management options for their pets' DM. The management options asked about in this survey proved largely beneficial, with most participants who had used HBGM, CGM, diabetes diaries/apps and diabetes clinics answering ‘strongly agree’ to whether it improved management of their pet's DM. More support with HBGM and CGM was a suggestion seen in 10% of open-ended responses to how support could be improved. Furthermore, this survey identified the advantages and disadvantages of these management options from the perspective of the owners who are using them (see Table 1). This is vital information for introducing these options to clients, particularly those with newly diagnosed pets, and guiding them with their use (Souza et al, 2022). A future survey aimed at veterinary professionals asking about their motivations for offering certain options may prove useful.
In response to being asked what other management options owners used, online support groups were the most common answer (Table 2). This was unsurprising as a result of the way in which most participants were recruited. However, this study highlighted that these support groups are a lifeline for many owners and play a crucial role in management of the disease as a way of helping to build confidence by using the knowledge and experience of others. This supports results from a study by Albuquerque et al (2020), who found that 76% of participants agreed that websites and online forums were the most useful source of information when learning about their cat's DM. Furthermore, when asked how support could be improved, some participants suggested that the veterinary profession should be encouraging these groups as a way for owners with diabetic pets to connect with each other. However, the potential for the spread of false information within these groups should not be overlooked. In addition, owners should not be turning to these sources because of the failure of their veterinary practice to provide effective support. Forums that are moderated by veterinary professionals would be an ideal resource, but also an unrealistic time commitment for most practices. Providing owners with diabetes handouts, reliable resource links and starter packs would be an effective alternative. This would also address participants' requests for ‘better advice at the time of diagnosis’ in open-ended answers. The point of diagnosis is a critical time for providing support to ensure that appropriate treatment decisions are made to reduce clinical signs early, in the interests of animal welfare (Tardo et al, 2019).
Diabetes clinics would be an ideal solution for the issues highlighted in this study, where 78.6% of those who have attended them answered either ‘agree’ or ‘strongly agree’ to whether it improved management of their pet's DM. Only 3.2% of participants answered that they would prefer not to attend them, showing that there is high demand for these clinics and likely to be a high attendance rate. In the optional comments section, participants said diabetes clinics are useful for getting more in-depth information targeted to DM and allow opportunities to ask questions and voice concerns. Other participants said they only attend their practice for 6-month prescription-only medication checks for their pet's insulin, and some expressed a lack of trust for their vet and feel they are more capable on their own with managing their pet's condition. Nurse-led clinics would allow treatment protocols to be put in place while also individualising support and ensuring continuity of care, which were also examples of improvements suggested by participants (Table 3). This will also strengthen the client–practice bond and build the owner's trust (Ackerman, 2018).
Humans with DM who attend practices with specialist nurse practitioners have been shown to receive better care compared to from physician-only practices (Ohman-Strickland et al, 2008). However, most participants (81.7%) reported that they have not been offered the option of diabetes clinics by their practice, highlighting that most practices are not using their registered veterinary nurses effectively. The evident lack of support identified in this study could drive practices to have a dedicated registered veterinary nurses for the role, thus also increasing job satisfaction for registered veterinary nurses. Another suggested improvement was that a specialist registered veterinary nurse could provide owners with immediate support by phone or email, as well as during appointments.
Limitations and future studies
This survey was designed in a way that was biased towards owners who are particularly committed by asking questions about a broad range of management options. Therefore, the results highlighted issues that veterinary professionals may have overlooked. However, this may mean that results do not accurately reflect the requirements of all owners of diabetic pets, where an owner who would rather do the bare minimum to manage their pet's disease may feel overwhelmed by being offered several management options. This is likely to lead to reduced client compliance and poor animal welfare as a result (Bennett, 2002). This highlights the need to individualise advice based on the owner's lifestyle and expectations, and the pet's treatment requirements (Lewitt et al, 2015).
Owners acting as proxies for pets in QoL assessments affects the reliability of results (Spofford et al, 2013). Data on the pet's clinical signs, BG readings, fructosamine measurements and the incidence of complications including hypoglycaemia and diabetic ketoacidosis are required to better assess QoL of the pet (Souza et al, 2022). Future studies may also include owners who have previously owned diabetic pets which are now deceased, and those who opted out of treatment for their animal's DM. However, these owners are likely to be difficult to recruit.
Some participants in this study also reported difficulty with the sliding-scale numerical rating questions when completing the survey on a smartphone, which may have prompted some respondents to exit the questionnaire prematurely. As mentioned previously, a future study aimed at veterinary professionals asking about what management options they offer to owners and their motivations for doing so would prove useful.
Conclusions
Overall, this study has shown that having a diabetic pet comes with significant financial and time commitments, often at the expense of the owner's wellbeing and QoL. Furthermore, many owners do not feel supported by their veterinary practice with the management of their pet's diabetes and feel the need to seek out other sources of information. This study identified that veterinary professionals need to make efforts to remain informed with evidence-based advice on DM to provide the best support for owners. Improving owner support will inevitably result in better patient welfare by ensuring the disease is managed effectively at home. Registered veterinary nurses are well placed to implement diabetes treatment protocols while also providing individualised care during clinics and consultations. Future studies which recruit a broader range of owners as well as research into the veterinary professional perspective will help gain more insight into where support is lacking and the implications for QoL.
KEY POINTS
- Veterinary professionals should not be overlooking the effects that having a pet with diabetes mellitus (DM) has on the quality of life (QoL) of the owner.
- Motivated owners should be offered a broad range of management options for their pet's DM, while also being made aware of the free options that are available to them.
- Advice should be tailored to the expectations of the owner and the clinical needs of the pet to ensure the disease is managed effectively at home, where better owner support will inevitably result in better patient welfare.
- Online support groups are a valuable resource for owners of diabetic pets to connect with others but should not be their only option because of a lack of support from their veterinary practice.
- Regular nurse-led diabetes clinics will improve support by providing an opportunity for evidence-based advice and continuity of care from specialist registered veterinary nurses.