By Laurie Goldstein, September 2015
Please note: This series of articles was written with the needs of kitties with inflammatory bowel disease (IBD) or GI upset in mind. Cats with hyperthyroid or renal insufficiency (chronic kidney disease) can experience actual acid over-production that requires management with antacids; with this use, antacids are treating a by-product of a disease requiring management. With IBD or GI upset of unknown origin, using antacids for nausea or problems with stomach acid pukes is simply masking a symptom rather than treating the problem. Many vets view IBD as a disease that requires symptom management – but, while IBD cannot be cured, using a minimally processed diet, addressing gut dysbiosis (with probiotics, often no antibiotics needed), and by employing anti-inflammatory regimens (often including plant-based digestive enzymes), intestines and other organs impacted by inflammation can heal.
This is Part 2 of a three part series. In Part 1, we discussed how long term use of antacids may raise stomach pH, which can cause:
- bacterial infection, bacterial overgrowth, small intestinal bacterial overgrowth (SIBO),
- bile acid deconjugation (a common and often diagnosed cause of fat malabsorption and chronic diarrhea, distinguished by yellow or green watery stool);
- nutrient deficiencies, notably B12, iron, calcium, zinc, folate, and vitamin D; and
- reduced gastric emptying times. Delayed gastric emptying can result in pain, loss of appetite, feeling full after eating only a little bit, and changes in blood sugar levels.
It is important to note that these are risks, not givens, and that the probability of problems is higher with proton pump inhibitors (like Prilosec (omeprazole)) than with the H2 blockers (like pepcid a/c (famotidine) and Zantac (ranitidine)). Antacids can safely be used short term to stop a cycle of nausea and inappetence; sometimes a few days is all that is needed. If it isn’t, then it is best to identify and address the underlying cause. Obviously, treating the cause is always better than treating the symptoms when possible, and apart from treating stomach ulcers and/or rare hyperacidity, all other uses of antacids simply suppress symptoms. Of course antacids can be used for longer periods, and the H2 blockers have a lower probability of the side-effects occurring compared to the proton pump inhibitors, but such use should only be done with vet awareness and supervision despite the availability of these drugs without prescription.
That said, here in Part 2, we focus on how to identify and address the source of the nausea rather than just suppress the symptoms.
Identifying Nausea and GI Distress
It is quite common to think one’s cat is being “finicky” when the problem is actually nausea. Part of the problem is that there is no one symptom that is specific to nausea, and cats, of course, are well known for hiding any illness or injury if they can.
Any one (or combination) of these symptoms can indicate your cat is feeling nauseous:
- Loss of appetite
- Acting hungry but walking away from food
- Just licking at or sniffing food
- Head hanging over water dish but not drinking
- Vomiting water
- Vomiting frothy foam (bile) (it can be white, yellowish, or tinted red)
- Lip licking or lip smacking (which can be a sign of nausea OR dehydration)
- Eating grass or plants
- Pica, often licking or nibbling plastic, eating plastic plants
- Sitting in a “meatloaf” position (see pictures, below)
- Howling/Yowling (often indicates pain if such vocalizations are not normal in your cat)
- Immediately regurgitating after eating
Of course, most things on this list can have a different cause at their source. This is one of the great difficulties when trying to diagnose and treat cats. Many problems present the same symptoms, and each set of symptoms may indicate a variety of potential problems. No matter the cause, if kitty is displaying any of these symptoms in combination with behavior that indicates she isn’t feeling well, a vet trip is in order. Don’t let paranoia take over, but with cats, a touch of paranoia is better than putting off a vet trip until a problem reaches obviously serious status.
Behavior that indicates any of the above symptoms are related to illness:
- Changes in litter box habits (eliminating out of the litter box)
- Changes in bowel movements or urination frequency
- Changes in social interaction (hiding or not interacting with you or other pets as they normally do; aggression on petting or brushing can indicate pain)
- Changes in activity (lethargy – cats don’t usually slow down much as they age; more activity – this can be caused by hyperthyroidism)
- Changes in sleeping habits
- Changes in grooming habits (greasy or matted fur; dandruff; reduced grooming)
- Changes in vocalization
- Bad breath (this can be related to a dental problem or a GI problem).
Too many times, people, even vets, may think a problem is just “old age,” but that is rarely the case in cats. Remember that cats are usually not fond of change, so when they change in appearance or behavior, there is likely to be a specific cause. We often don’t observe our fur companions closely until they get sick, but it’s helpful to take note of body language now so you’ll know when something isn’t right. It is the same with blood tests. A test done while a cat is healthy supplies a baseline for later. It’s one thing to know what the lab norms are, but just as in people, “normal” varies at times from cat-to-cat. Know your cat’s normal so when kitty is “off” the change in blood values can be identified. A physical exam, blood work, perhaps an x-ray, and/or an abdominal ultrasound will be a part of the diagnostic process.
Note: Vomit that looks like coffee grounds means there is active bleeding in the stomach, often from ulcers. This is an emergency, and you should get kitty to your vet or an emergency vet as soon as possible. Red tinged vomit indicates ruptured capillaries in the esophagus and is usually from the irritation to the throat from vomiting. This is of concern if it happens frequently, but again, a vet check is always best.
Meatloafing: comparing comfortable positions with those indicating nausea
The every-day meatloafs
There are four basic “meatloaf” positions. The first two pictured here are normal, every-day positions; the final two are indications your cat feels sick and/or is in pain.
Happy, relaxed, not nauseous. Not necessarily relaxed, this pose says “this is my spot.” But it doesn’t indicate nausea.
The nauseous/in pain meatloafs
Looks uncomfortable, possibly in pain, Clearly uncomfortable, sitting forward on head down. haunches, in pain, sometimes with head down, eyes squinted.
Treating Nausea and Vomiting: Food
Apart from using medicine (prescription or over-the-counter) there are three basic components of treating GI problems in your cat: food, supplements, and water. We also address hairballs, a common cause of nausea and vomiting in cats.
Food issues that can cause GI problems: What is fed, How it is fed, and When it is fed.
What Kitty is Fed
Cats are obligate carnivores. Their natural diet consist of small prey animals. Some argue they naturally consume carbohydrates because of the stomach and intestinal contents of the prey. An examination of the diet of feral domestic cats (that have access to very little human food or garbage) found the stomach contents of prey provide very little in the way of carbs: just 2% of the diet on an energy basis. This author notes that the contents of the stomach and intestines are, for the most part, predigested. Thus feeding our cats a species-appropriate (low carb, grain-free, meat-and-organ based) diet can be the difference between a sick kitty and a healthy kitty. Some food companies and vets maintain that cats can metabolize carbs, which they can. But there is a big difference between “can” and “should.” Also, there remains a question of at what point carbs become a problem. For those that want to stick with commercial diets, a food that contains 40% carbohydrates (usually measured on a dry matter basis, a downloadable carb calculator in Excel is available, here) is simply not going to be a good long term choice. When making food choices, bear in mind that vets that embrace our kitties as the obligate carnivores they are, but are not anti-carbs in their diet, usually suggest no more than 20% of the diet be carbs. There is no research to indicate one way or another whether that level of non-meat based ingredients will take a toll on your kitty’s organs over time or not. One thing is clear: the physiology of a cat indicates they are not intended to derive much energy or nutrition from grain-based foods or intake of carbohydrates. Feed low carbs.
If cats were in charge of the pet food industry, cat food instructions would likely read, “remove mouse, rabbit or small bird from freezer: thaw and serve.” Anything else is 1) for our convenience, 2) due to our access to feeding resources, or 3) due to the cost of feeding. When our cats get sick, we need to learn how to best balance our time and resources with their needs. So please know that:
- Grains can cause nausea and vomiting.
- Non-grain carbohydrates such as peas can cause nausea and vomiting. This is tricky, because many Limited Ingredient Diets contain peas to raise the protein level and lower the cost. Anecdotally, we’re finding more and more IBD cats reacting to the peas in the food.
- Otherwise high carb foods can cause nausea and vomiting. Many “grain-free” foods simply replace grains with non-grain starches. The problem? Carbohydrate ingestion does not trigger the same gastric secretion as meat-based proteins. A high carb diet can raise stomach pH, leading to improperly digested protein and/or delayed gastric emptying, contributing to nausea and/or vomiting.
- A carb “red flag:” Meat is high in methionine, an amino acid used by many companies as a urine acidifier. If the synthetic version, “DL-methionine” is supplemented, especially if you find it towards the top of the supplement list in commercial food ingredients, alarm bells should go off; this is an indication the food does not contain protein primarily from meat or that the food is otherwise high in carbohydrates. Those carbs make the entire GI system, not just the stomach, too alkaline, and this can lead to various issues, among them urinary tract health problems and the formation of crystals. Natural methionine is found in meat, one of the reasons a meat-based diet naturally targets the proper pH in cats.
- The many thickeners in most commercial canned foods can cause nausea, vomiting, and GI irritation. Thickeners and gelling agents include carrageenan, xanthan gum, guar gum, locust bean gum, cassia gum, agar agar, tapioca, potato starch, and wheat gluten. This list is not complete, but these are common additives for thickening and gelling. Any or all of them can cause stomach upset and nausea.
- Food/ingredient sensitivities can cause nausea and vomiting.
- Food allergies can cause nausea and vomiting. Grains are a common culprit. A frequently-fed protein can be the cause.
- Kibble is often a culprit. Whether it is problem ingredients, the highly processed nature of kibble, or its impact on stomach pH and motility (due to being free-fed no matter the quality of ingredients – see Hairballs, below), simply removing kibble from the diet provides relief in many cats.
How Kitty is Fed
- Raise the dishes. Cats normally eat sitting or standing so their throat is at the same height or lower than the stomach. If kitty does have problems with acid reflux, raising the food and water dishes to head-height (while sitting up or standing) can resolve this problem. In Part 1 we discussed how acid reflux is not caused by excess acid; it is a problem with muscle tone in the lower esophageal sphincter, the valve that is meant to prevent stomach acid from rising into the throat. By keeping the head elevated and letting gravity work, the raised dishes keep the stomach acid in the tummy. Once there is food in the stomach, the acid is put to work.
- Slow kitty down. When a cat eats too fast and regurgitates as a result, this is almost always when kitty is being fed kibble. Rather than put a rock or ball in the dish to slow down kitty, please just stop feeding kibble. If kitty manages to wolf down food so fast they regurgitate canned, homecooked, or raw food, then portion out smaller amounts and extend meal time to numerous smaller meals over 10 or 15 minutes vs one plop of food in a dish left out for 10 to 15 minutes. (And bless you for having adopted a formerly abused cat or kitty rescued from a hoarding situation, as this is behavior displayed most often by cats in those situations. Feral cats that almost starved usually slow down pretty quickly on their own once they realize food is provided regularly. Please don’t underrate the importance of emotions and psychology in cats. Please take the time to treat the whole kitty, and that’s more than just the body).
When Kitty is Fed
- Feed smaller, more frequent meals. Two meals a day is not ideal for cats. Their systems are geared toward eating more frequent smaller meals (as in the wild they hunt small prey). Add a meal as late as possible before you go to bed. Reducing the length of time between the last meal of the day and the first meal of the next day often stops overnight bile pukes.
- Feed a freeze dried meat treat to kitty when you get up, and/or prior to bed, and/or in the middle of the night, and/or prior to meals. The anticipation of food gets the gastric juices flowing. Giving kitty a protein-based meat treat that puts those gastric juices to work can stop the morning (or overnight) bile pukes, and can stop the regurgitation of the morning meal. In some cases, a middle of the night treat will resolve pre-breakfast vomiting better than any medicine. For those making a trip to the bathroom in the middle of the night, taking the time to give kitty a treat can improve your cat’s morning – and yours as well. If bile pukes happen during the day, or meal regurgitation is a frequent occurrence, feed kitty a few small bites of freeze-dried meat treats as needed, when you get home from work, or about 10 to 15 minutes before each meal to see if that resolves the problem. Pure Bites, Whole Life, and Grandma Lucy’s are popular brands of single-ingredient meat treats made in the USA.
- Stop free-feeding and move to timed meals. (Better yet, stop the kibble). In cats, indigestible solids (such as hair) are the last items to leave the stomach. They are forced out of the stomach only by the strong peristaltic waves created by hunger pangs. If kitty is never hungry, motility is impaired and waste material does not move through kitty’s system properly. Obviously this can cause nausea, and a belly full of hair or improperly digested food can cause a loss of appetite as kitty feels full. (For transition tips and how to help kitty understand the concept of meal time, please see Transitioning to Timed Meals OR New Food)
- For more on the timing of meals for kitty, please see How often should you feed your cat?
Hairballs are by far the most common cause of nausea, inappetence and vomiting in cats. And yet hairballs are NOT normal. I know, it’s news to many. But a healthy cat does not normally have anything other than an occasional hairball, and tossing a hairball more than twice a month in long-haired cats and more than once every two months in short-haired cats can be indicative of GI disease. A study published in 2014 found that 99 of 100 cats examined for chronic vomiting – including tossing hairballs – had GI disease. Of those 99 cats, 50 had some form of cancer, and 49 had some form of inflammatory bowel disease. Many may still joke about hairballs, but hairballs are NOT a joke.
A primary symptom of hairballs is regurgitating undigested food hours after eating. Prior to this point, kitty feeling full and seeming “picky” about eating can be a subtle sign of hairballs:
- Cats with hairballs often seem “picky” but otherwise fine: they don’t necessarily display any signs of nausea other than wanting to eat but not eating;
- Kitty regurgitating the meal undigested hours after eating is often hungry immediately, and displays no other behavioral signs of illness.
To address hairballs in our cats, it is best to:
- Stop free feeding and feed timed meals (addressed above)
- Stop feeding kibble (feed canned, cooked, or raw food – food with moisture)
- Feed species-appropriate food (low carbohydrate, no grain foods, addressed above)
- Forget the petromalt or petroleum-based hairball products. It is best to address hairballs by treating the underlying problem: GI motility. If a species-appropriate, moist food fed in timed meals does not resolve the problem, please see Hairballs: Species-Appropriate Treatment
Identifying Food-related Problems
When there is nausea or vomiting, if kitty is diagnosed as having Inflammatory Bowel Disease and/or Pancreatitis, then food sensitivities/allergies need to be ruled out as a cause. Many traditional vets recommend “Novel proteins,” “Limited ingredient diets,” “Allergan-free diets” or “Hydrolyzed protein diets,” many of these being prescription diets. The problem? This approach is the equivalent of throwing spaghetti at the wall to see what sticks, and many of these foods have a poor ingredient list for long term use. It is much, much simpler to stop ALL commercial food and feed kitty a simple, meat-only bland diet short term. Think of it as plain chicken soup for a person with the flu.
The Bland Diet. If your cat is frequently nauseous or vomiting (or has diarrhea and parasites have been ruled out), consider stopping ALL food and treats, and feeding a bland diet (even better if with a novel protein) for a week or two (less in young kittens). In cats, this is either a prepared meat-only baby food or a meat you poach at home. This bland diet is NOT nutritionally balanced and is for SHORT TERM USE ONLY. But just as drinking only chicken stock does not hurt us while we have the flu, eating just plain cooked meat will not harm your cat for a few days or few weeks. It is immensely helpful in quickly identifying if the food they’ve been eating is causing the problem.
In the U.S. the best baby food option is Beechnut or Goya as they are made with the water the meat and bone are cooked in (and then the bone is removed). This is the “broth” in the ingredient list. No, it is not seasoned with anything. Neither brand uses corn starch as a preservative (Gerber does). Consider using the turkey as your kitty has likely had less exposure to this protein vs chicken. The stage I, meat-only baby foods contain no spices or seasoning.
If poaching a meat at home, it is important to include the water in which the meat was poached as part of the meals. The meat can be fed shredded in some of the broth, or the broth and meat can be blended together. Consider using boneless pork, as this is very likely a “novel” protein for your cat.
Kitty won’t eat it? Try a different protein. If the nausea was severe, you may have to assist feed your cat for a day or two to give the bland diet a chance to settle the tummy. If problems continue or worsen, try a different meat before giving up. Cats are very strong creatures, but also idiosyncratic, as most kitty companions know very well.
Make and feed bone broth as a supplement to the bland diet. Bone broth is both nutritionally dense and yet extremely easy to digest. It is very healing and very soothing. In fact, you may need to feed bone broth for a day before kitty feels like eating the bland diet on her own. (Caution: Do not let your cat eat only bone broth for more than a day, and if your cat has liver disease, has been diagnosed with Inflammatory Bowel Disease or pancreatitis, do not let them go without food for more than 12 hours at most. Cats need close to their full complement of daily calories to prevent a liver disease caused by not eating, called hepatic lipidosis or “fatty liver.” The treatment for fatty liver is food. So best just to ensure kitty gets all they need in the first place). For bone broth instructions, see Dr. Becker’s video or transcript (if a chicken allergy is suspected, make the broth with bone-in turkey or pork or beef. There is no need to cook the larger bones to complete mush). Susan Thixton of Truth about Pet Food has written up a nice piece on the benefits of bone broth, though I do recommend following the instructions of the two-stage process that uses meaty bones as described by Dr. Becker, and keeping out some of the meat broth from Stage I before continuing to Stage 2. Some cats do not like the stage 2 broth. That’s fine, the meat broth is also very nourishing and soothing.
Has kitty improved on the bland diet? Then you know food is the problem. At this point, you MUST think of food almost as a medicine: food is the key to your cat’s health and happiness. Food can help heal or hinder the well-being of your cat. You can start trying different commercial canned foods, or you can just go straight to a commercial raw product for a minimally processed, fresh food option. Of course, making homemade fresh food where you control the ingredients is an option. It is more than just offering meat, but it isn’t rocket science. And we are here to help: the resources on this website and of course there is the associated Facebook group.
Do not be surprised: Kitty may not like the food you make. Yes, this is disappointing, of course! But if all I’d ever eaten was dry cereal or canned stew, I probably wouldn’t like a salad or fresh fruit. It looks weird, has a strange texture, the temperature is likely different. So if kitty doesn’t take to the food right away, you need to give kitty time to transition. They will come to like, even love the food. They just need time. Transition help is available here.
As to making your own food, there are many ways to do this: cooked or raw; chunky meat and organs with bone-in meals (called “prey model raw”); an easy properly balanced vitamin premix added to meat or meat and liver. You may wind up wanting to move to prey model raw if feeding ground, or you may want to buy a grinder to manage making bone-in homemade ground. You may want to move to raw from cooked. There are no right answers here, these are all decisions of personal choice based on your lifestyle and your cat’s tastes and needs. None are particularly difficult; some approaches require investment in kitchen equipment. But when food is the problem, making one’s own and transitioning kitty with a slow introduction is often much easier in the long run than getting back on the food merry-go-round.
Do be aware, if you begin making homemade, it is important to include at least three proteins in rotation so that your cat does not develop a protein allergy/sensitivity and so that kitty does not reject the food due to boredom. Yes, even in your cats with IBD, these different proteins can be alternated at every meal, or every day, or every week. They do not need to be fed months at a time. Many kitties, once on raw, prefer the variety when offered more frequently.
Finally, it bears repeating: feeding a homemade diet is not just offering up meat. Cats need the minerals from bone and the dense nutrition in organs, and these need to be fed in proper proportion. Far too often we see people feeding just meat thinking they are doing something great for kitty, but this is a recipe for disaster. Here we’ve pulled together a list of approaches and recipes that are nutritionally balanced. All are simple and straightforward. They range from needing a grinder that can handle bones, to simply needing a food scale.
Homemade food resources that are nutritionally balanced:
Bone-in ground raw: www.CatNutrition.org by Anne Jablonski, who helped Dr. Pierson of develop her homemade ground diet (below). Requires a grinder than can handle bone unless eggshell is used as a bone replacement.
Easy homemade food that can be fed ground OR chunked, raw or cooked (uses eggshell instead of bone): Click here. Does not require a grinder, but does require a food processor.
Of course, Catcentric has many complete and unique resources for prey model raw feeding. Does not require grinder or food processor.
Partial cooked ground (many follow the recipe raw): www.catinfo.org – Making Cat Food, written by Dr. Lisa Pierson, DVM. Requires a grinder that can handle bone unless eggshell is used as a bone replacement.
As with people, in cats food is very frequently the root cause of nausea and vomiting (and for those with it, their diarrhea). Medicine is not the best answer when food is the problem. Medication is an important tool, and has its proper time and use. But altering what, how, and/or when we feed is often all that is needed to make kitty feel better. Feeding fresh food where we control the ingredients is sometimes needed, but in this author’s opinion, always preferable. Our cats are obligate carnivores. Their physiology is “designed” to have a low stomach pH and to eat primarily meat (bone and organ). Our cats are descended from desert animals and while some may drink water, cats do best when fed a moist diet, better yet, a fresh food diet. In many instances, identifying a problem ingredient can be difficult, and it is easiest to help our kitties feel better by simply getting off the commercial food merry-go-round. Transitioning is not always easy, but there are many tricks, tips, guides and resources to help. Persistence ALWAYS pays off. The road to good health is not a race, it is a journey.
…and I didn’t plan on this, but it turns out this discussion of the role of food in nausea and vomiting is much longer than anticipated! We will have to cover supplements and water in Part 3. (Funny how everything seems to become more complicated when we talk about cats, especially when we try to do the best we can with what we know and what we have… and what we can continue to learn if we talk openly and listen closely).
And a shout out with thanks to Forrest D. Poston for the thoughtful input.
Funaba et al 2003. Effects of a high-protein diet versus dietary supplementation with ammonium chloride on struvite crystal formation in urine of clinically normal cats, Am J Vet Res, Aug; 64(8):1059-64 (2003).
Funaba et al 2004. Evaluation of dietary carbohydrate on formation of struvite crystals in urine and macromineral balance in clinically normal cats, Am J Vet Res Feb::65(2):138-42 (2004).
Norsworthy et al 2013. Diagnosis of chronic small bowel disease in cats: 100 cases (2008-2012), J Am Vet Med Assoc, Nov 15;243(10):1455-61 (2013).
Plain English summary, by Gary Norsworthy, DVM for Veterinary Practice News, January 2014: Chronic Vomiting in Cats isn’t Normal After All.
Plantinga et al. 2011. Estimation of the dietary nutrient profile of free-roaming feral cats: possible implications for nutrition of domestic cats, British Journal of Nutrition / Volume 106 / Supplement S1 / October 2011, pp S35-S48.
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