In 1674, English physician and anatomist Thomas Willis was struck by the sweet smell and taste of the urine of people with diabetes. He added the word “mellitus”—whose root is Latin for “honey”—to the disease’s name. He eventually devoted a chapter in a book to “the pissing evil” and wrote that the urine of diabetics was “wonderfully sweet as if it were imbued by honey or sugar.”
How did he know? By sipping the sweet golden cocktail himself. (From Willis’s description, you wonder if maybe he liked it a little too much. It sounds like he’s describing a late-harvest Semillon for Wine Spectator rather than someone’s pee.)
Willis wasn’t the first doc to tipple tinkle to make a diagnosis. In fact, he was a latecomer to the notion that diabetes can manifest in sweet-tasting and sweet-smelling urine. But he was English, and relatively recent compared with the others, so he got to give it the name it has today.
He probably didn’t know that in the fifth century BCE, the Indian physician Sushruta had already used the term “madhumeha” (“honey urine”) in a medical treatise to identify diabetes. Sushruta described the urine’s sweet taste and its ability to—are you ready for this?—attract ants.*
In the year 643, Chinese physician Chen Chuan once again noted the sweet taste of urine. And there were other notable physicians who made the same observation.
Back in the day, tasting and smelling urine for disease was commonplace. Luckily for busy medieval doctors, there was a tool called a urine wheel, a zodiac-like diagram associating various smells and tastes and appearances of urine with different diseases. So when physicians noted an odd smell in their patients’ “water,” diagnosing it didn’t require reinventing the wheel; they just had to reach out to their own wheel of misfortune.
Happily for modern-day doctors, tests for diabetes no longer involve their noses and taste buds. But it makes you think: If some people can identify diabetes using their senses, it’s got to be a slam dunk for dogs and their phenomenal sense of smell.
We don’t need to use dogs’ talents to diagnose diabetes since simple tests can do that. Far more valuable is the ability of trained dogs to tell their insulin-dependent humans (type 1 diabetics) if their blood sugar is becoming too low and, in some cases, too high.* Their work, when done well, can mean the difference between life and death. All they ask in return is a favorite toy or treat, and some heartfelt words to the effect of “gooooood dawwwwg!”
Clay Ronk couldn’t get enough to drink. If he wasn’t filling up at the sink, he was pouring something from the fridge—usually lemonade, but he really craved Tang. Even in his sleep, his mother heard him calling out, “Tang, Tang, tangy Tang, Mama!” He was irritable, too. And losing weight. The seven-year-old wet his bed for the first time since he was out of diapers.
This wasn’t how his folks had pictured the end of summer vacation. They figured maybe it was the stress of a new school year, though he wasn’t the kind of kid who got anxious about school. He seemed OK otherwise, so they didn’t worry that much.
A couple of weeks into third grade, the school secretary left a message at his house saying Clay was sick and needed to go home. His mom, Karin, was working nights as a dispatcher for the Ukiah, California, police and fire departments, and had been asleep just a couple of hours when she heard the answering machine go off. You’re kidding. Something’s going around already? she thought as she zombied herself out of bed and drove to school.
The boy she found in the school office seemed like a different child than the one she’d kissed good night before she left for work. His eyes were sunken like a tired old man’s. His skin was gray. The peach fuzz on his face stood out because he was so drawn.
She took him home and tucked him into bed. It was her day off, so she was able to stay home and check on him. A couple of times she found him lying on the floor, barely responding to questions. The next time he’d be back up in his bed. His grandmother came by and was concerned because Clay didn’t seem like himself—even a normal sick version of himself.
That night Clay wanted to sleep in his parents’ room. Karin made him a bed on the floor next to her. He didn’t stir all night. In the morning Karin had a hard time waking him up. This was unusual because Clay was normally an early riser. He didn’t seem to notice his dad, Ken, stepping over him as he got ready for work. Ken tried to play with him to see if Clay was OK enough to go to school. Karin could tell he wasn’t, and told Ken to let him rest.
Karin had to run an important errand and couldn’t leave Clay at home alone, sick, so she brought him with her. She had to help him walk to the car as he leaned against her. Once at the destination, he was unable to get out of the car on his own, much less walk. Karin realized this was beyond the fatigue of a virus. She called the pediatrician and was told to bring him right in.
An “ancient” doctor they’d never seen before hurried into the examining room and told them he was in a rush to deliver breech twins. He pinched Clay’s arm and said Clay was extremely dehydrated, ordered blood work, and sent them on their way.
After the blood draw, they headed home. A couple of hours later, Clay was resting on the couch and watching cartoons. The phone rang. It was the pediatrician. He told Karin that Clay’s lab work had come back and his blood sugar was 870.
“Do you know what that means?”
Karin did, since a good friend had type 1 diabetes. She knew how dangerously high that number was. She felt a rush of panic.
“You need to get him to the emergency room right away. We’ll call ahead and let them know you’re coming.”
Normal blood glucose is about 70 to 130 mg/dL, a little higher after meals. Levels above 300 are considered much too high. Clay’s glucose level, combined with other test results, revealed he was in diabetic ketoacidosis (DKA)—a serious condition that can cause severe dehydration, coma, swelling of the brain, and death.
As soon as Clay and his mother got to the Ukiah Valley Medical Center, Clay’s medical team dived in to try to normalize his glucose level using insulin and intravenous fluids. But his veins had collapsed because of dehydration. Clay was already upset by all the painful poking. When a nurse said they were going to have to put a PICC (peripherally inserted central catheter) line in his neck to get the insulin and fluids in and the blood out for testing, he screamed and writhed and had to be held down.
“Can’t you say it in a language this poor boy doesn’t understand or put the line in his foot?!” Karin said. She asked for the best nurse in the unit. They summoned her, and she inserted the PICC into Clay’s foot without much fuss.
They tested his glucose with a finger prick every thirty minutes, but it wasn’t decreasing the way they’d hoped. The staff decided to send Clay to the University of California, San Francisco (UCSF) Medical Center. Stat. The Ukiah hospital wasn’t set up to deal with this level of diabetic emergency.
Without traffic it’s about a two-hour drive—somewhat faster by ambulance—but in the San Francisco Bay Area there’s rarely a time without traffic. Karin hoped one of the ambulance teams she worked with would be able to take him. Hospital staff told her if Clay’s blood sugar dropped under 499, which was the highest a meter in the emergency room could read, he could go by ground transportation.
Karin phoned work and told her supervisor what she needed. A call went out via radio for the transport. That crew stood by for almost seven hours waiting for his blood sugar to dip below 499, but it never came close.
He needed to go by air. Clay arrived by ambulance at the airport and was transferred to the waiting plane. A doctor and a nurse were aboard, ready to take over his care.
“I can go with him, right?” Karin said. Clay was in and out of consciousness. She couldn’t let him go without her.
The pilot told her that the Cessna 414 could take only another hundred pounds. Karin weighed more. The pilot said there was one way around this if she was bent on traveling in the plane.
“Mom, you’ll have to sign a form that if the plane goes down, we’re not liable.”
That didn’t seem like a good idea. Her son’s blood sugar needed to go down, not his plane. She would drive with Ken. They watched the plane take off. Then they sped to San Francisco, not talking, just trying to get through each interminable minute until they could see their son again.
A roomful of doctors and nurses worked on Clay throughout the night in the pediatric ICU at UCSF. He had been at the edge of the abyss, but by the next afternoon they had pulled him back.
The dramatic beginning of Clay’s life with type 1 diabetes mellitus gave way to a jarringly quiet time. A nurse came into his room with a stack of books on the disease and said Karin and Ken were responsible for reading them while at the hospital. Clay’s blood sugar was coming down, and he was sleeping. They had the time they needed to focus on the flood of information they had to digest in order to keep their son alive.
The next day they got a hands-on education in insulin dosing, insulin injection, blood sugar testing, and everything they’d learned in the books. Ken doesn’t do well with blood and needles, but he tried his hardest for his son.
The life of a type 1 diabetic is an exhausting continual high-wire act where it’s too easy to lose balance. It’s a never-ending cycle of blood testing several times a day, calculating how much insulin to give based on carbohydrate intake and activity level. Too much insulin can be just as harmful as too little, resulting in hypoglycemia severe enough to cause seizures, comas, and death. Even with the latest high-tech options of continuous glucose monitoring (CGM) systems and insulin pumps, nothing is predictable or easy in diabetes. What seems to work one day might tank the next.
Most people who see a type 1 diabetic have no idea what’s going on behind the scenes to keep him or her healthy enough to function. It’s usually an invisible disability, revealed only by a glimpse of a small device attached to someone’s body, or a fingertip blood test done as unobtrusively as possible.
Type 1 diabetes is one of the most common chronic diseases of childhood, although it can start well into adulthood. About forty thousand people are diagnosed in the US each year. But type 1 diabetes accounts for only 5 percent of the more than thirty million Americans living with diabetes, according to the Centers for Disease Control. Type 2 diabetes is far more common.
Unlike type 1, type 2 diabetes can often be controlled by exercise and diet. Well-meaning people frequently tell type 1 diabetics about the right kind of diet and exercise that will halt their disease. But type 1 diabetes is not a lifestyle disease. And there is no cure for it.
Clay’s parents tried not to feel overwhelmed after their crash course. As they drove home with Clay a few days later, they hoped they would not fail their upcoming real-life tests in Diabetes Survival 101.
Shortly after Clay’s eighth birthday, Karin read an article about an organization called Dogs4Diabetics, in Concord, California. The diabetic-alert dogs it was producing seemed like miracle workers. She showed the article to Clay. His eyes grew large.
“Mom, a dog could help me?”
“Yes, I really think so.”
She applied the next day and got an immediate reply saying applicants have to have lived with diabetes for a year. Disappointing, but doable. They waited until the one-year anniversary of his diagnosis and applied again. This time they got an email saying the organization had changed its age requirements, and children had to be a minimum of twelve years old to apply for a dog.
Three more years before they could even try. It seemed like an impossibly long time when every day was a struggle. But they would wait. They knew there were other organizations out there, but Karin had done her research and concluded that Dogs4Diabetics was one of the most respected diabetic-alert dog training and placement organizations in the country. Plus the dog would not cost them anything.
Its founder, type 1 diabetic Mark Ruefenacht, makes his living in the exacting world of quality assurance of precision measurements. He runs a measurement standards laboratory, does contract work with NIST, and consults with scientific and forensic laboratories throughout the world.
In 1999 he began merging his volunteer work for Guide Dogs for the Blind with his professional experience to come up with innovative ways to train dogs to detect hypoglycemia in type 1 diabetics. Once he had figured out the best system, he decided to share it with others. He opened Dogs4Diabetics in 2004.
Given his background of perfecting measurements, it’s no surprise that the organization’s standards are high and read like something out of a statistics course. Dogs4Diabetics kindly supplied me with some basics:
Our standards are based on statistically reliable levels of recorded performance at all stages of training: A dog is not placed until it reaches a minimum of 80% reliability of identification of hypoglycemic scent in training without a diabetic present. A team* is not graduated until it reaches 80% reliability of alerting on low/high blood sugar in most common environments (home, work, school), based on records of all alerts and lows, recorded and reviewed weekly by D4D staff. There needs to be a minimum of 100 data elements (lows/highs) which averages about 6 weeks of records.
In other words, the dogs and people who make it through the program really know their stuff.
It’s difficult to get into the program—Dogs4Diabetics receives a hundred requests for diabetic-alert dogs monthly and can provide only twenty to twenty-five annually. The lucky people who get in have to work hard to graduate. The classes are known for their intensity. And graduating doesn’t mean automatically getting a dog. It’s common to wait for more than a year for the right match.
Clay was fourteen when he was finally accepted into a class. The family had already made reservations for summer getaways and camps, but canceled everything. He and his parents drove nearly five hours round-trip every Saturday and Sunday from the last week of April through the first week in August. Clay was the youngest in the class.
“It was the most difficult thing I’ve ever done,” says Karin. “There was so much emotion we had invested in this, and we worried about the pressures of passing, especially for Clay. I was terrified about us passing. We crammed for the tests together.”
They did pass. And then a new wait began. The wait for a dog. They showed up at every training event and watched as newer students were paired with dogs Clay had hoped to get. It was a heartbreaking process for him, but behind the scenes, trainers were in matchmaking mode, looking for just the right dog for each person.
Almost a year after Clay started at Dogs4Diabetics, the program manager asked Clay if he wanted to take a dog home for the weekend just to see what it was like. He was thrilled, but when he and his mom got there, they learned the dog had a slight injury and they wouldn’t be able to take her. The program manager didn’t want to disappoint them after they’d made the long drive, so she asked Clay if he’d like to take a sweet yellow Lab named Whitley home instead. The tawny girl wasn’t the dog they’d had in mind, but at least Clay would be able to experience having a diabetic-alert dog at home.
That weekend, Whitley alerted to Clay. She moved close to him, sat, and stared at him with her huge brown eyes. It was the same sort of expression a dog begging at the table for a crust of pizza or bit of steak might employ. Once Whitley had Clay’s attention, she licked him on his arms and went into a downward-dog stretch, front end down, hind end up. She was very casual about it, and if they hadn’t known better, they’d have thought she was just getting the kinks out after a nap.
Toward the end of her bow, she dipped her head down and grabbed a durable cloth strip hanging off her collar. The strip is called a brinsel, and Whitley focused her gaze on Clay with the brinsel sticking out of her mouth like a cigar. It’s the ultimate signal from a diabetic-alert dog. Something along the lines of Check your blood sugar because it’s not where we want it, and it’s going down [or up, in some cases] fast.
Clay and his mom couldn’t believe a dog had alerted to him in their house. What they had been waiting for all these years was finally becoming a reality.
This dog who was theirs just for the weekend suddenly became the best dog in the world. They checked Clay’s blood sugar, and it was lower than 70. They rewarded Whitley with what they call a party—loud, loving praise and a high-value treat she gets only when she alerts. Clay drank some apple juice to try to increase his glucose, and they checked again in ten minutes to make sure his blood sugar was rising. If Whitley hadn’t alerted him, he would have dropped even lower before he felt the symptoms, and it would have been harder and taken longer to get his glucose back up.
On Monday they returned Whitley with heavy hearts, not knowing if they would see her again. But when they came back on Thursday, the trainer had a question for Clay: “I wanted to ask you if you would like to take Whitley home and try a temperament placement test with her? If it all works out, she’ll be yours for good.”
Clay and his mom couldn’t contain their emotions, which ping-ponged from tears of relief and joy to giddy laughter.
Clay’s spotless fish tank purred on his desk as the morning sun skimmed through his curtains. He had a mild flu and wouldn’t be going to school that day. He hadn’t set his alarm, and he slept without stirring. It was easy to sleep late in this room, with its carpet the color of a soft bed of fallen pine needles and its tree-green walls. It always reminded him of the places he loved to fish, hike, and camp.
Whitley had been with him for a few months and was already a combination of second mother, nurse, and best friend. She slept curled on her oversized cushion next to Clay’s twin bed. Whitley’s nearness to Clay gave his parents an extra level of assurance. He didn’t have a CGM system yet, so they were hoping Whitley would be able to alert him if he went low while he slept and didn’t realize it.
As Clay slept that morning, Whitley got up and moved to the edge of his bed. No one knows exactly what happened next, but Whitley likely tried to alert to Clay’s blood sugar as she normally would. She sat and stared and probably tried to lick him. Maybe she even bowed with her brinsel. But he didn’t respond. She had never encountered this situation. Usually Clay woke up on his own when he felt his sugar was too low at night.
Whitley knew what she had to do. She jumped onto Clay’s bed and stood over him, paws on his chest, bright pink brinsel in her mouth. She stared so hard it was almost as if she were willing him to wake up.
And Clay did wake up. He felt the weight of her, opened his eyes, and saw her earnest face staring at him, her mouth clutching the brinsel. He knew what he had to do. He doesn’t recall walking to the kitchen, but he found himself there. He pricked his finger to test his glucose level. He registered in the low 40s. He was teetering at the edge of severe hypoglycemia.
He grabbed a Hansen’s apple juice box—the kind with Clifford the Big Red Dog on the package. (It had been his favorite when he was younger, though at age fifteen he wondered if he was getting too old for Clifford.) He gulped down the juice as fast as its tiny straw would allow. As soon as he felt steadier, he tossed Whitley a treat and told her what a good girl she was.
When Clay’s parents found out what had happened, they hailed Whitley as a hero, or something even better. “You are our angel. What a good angel dog you are!” Karin told her. Karin thinks Whitley may have prevented Clay from ending up in a coma, or worse, that morning.
Shortly after that event, Whitley figured out that if Clay wasn’t responding to a blood sugar warning, she should rouse his parents. No one trained her. She just Lassied her way to that realization.
“She has changed everything,” says Karin. “She gives us a peace of mind we never had before. She is literally a lifesaver.”
Whitley has now spent the last four years at Clay’s side. She regularly alerts to his hypos twenty minutes before his CGM device does. His parents trust Whitley more than they trust any machine, no matter how high-tech.
“She is always on it,” Karin says. “This dear girl has saved him so many times over the years.”
Whitley became something of a celebrity on campus during Clay’s high school years. She went to most of Clay’s classes, tucking under desks wherever he went; she was out of the way at the same time she could keep an eye and a nose on him.
The teachers adored her. “I love Whitley. She is the best-trained dog on the planet,” said Ben O’Neill, a teacher in the school’s Scrubs and Extreme Responders programs for students exploring health care professions. “Her devotion to Clay is very moving.”
I attended a few classes at Ukiah High School with Clay and Whitley toward the end of his senior year. As Clay, who was an instructional assistant in an Extreme Responders class, sat listening to Ben, Whitley watched Clay like a mother monitoring her young child on playground equipment. She was attentive, calm, and ready to step in if needed.
Sometimes she used his feet as a chin rest, and he crossed his ankles to support her head. Even if she couldn’t see him, she could smell him—even in her sleep.
Sleeping was the one time Whitley’s presence in class could become obvious to everyone. That day Clay’s econ teacher was lecturing about supply and demand. As he talked, someone began snoring. It wasn’t too loud at first, but the volume quickly increased. I didn’t have to look farther than the floor under Clay’s table for the perpetrator.
The teacher took it in stride. “I’m used to students falling asleep and snoring in my classes, but this is the first year a dog has done it,” he said when he discovered the snorer was under a table, not drooped over it. The students laughed, and Whitley roused for a moment, then settled into a gentler volume.
Whitley’s photo appeared in the school yearbook the last two years of high school, just to the right of Clay’s photo. She attended a senior prom dinner and photo session with Clay and his date. And at graduation, she wore a purple cap, gown, and Hawaiian-style brinsel. She strode on stage with Clay when he received his diploma, and the audience went wild with cheers.
Whitley has gone with Clay and his family on several trips, including a cross-country drive to iconic destinations like the Grand Canyon, Mount Rushmore, and Yellowstone, and a New Orleans river cruise. She accompanied Clay on a graduation-celebration cruise to Alaska. She’s regularly his sidekick on fishing and hiking trips. If she could, she’d always be with him. But sometimes, like when he does EMT training, he has to leave her behind.
The result is hard for Karin to watch. Whitley will sit stoically at their pane-glass door, watching, waiting for Clay to come home.
“She pouts, I’m sure because she’s worried about him, and she misses him, especially when he’s gone for a long time for diabetes summer camp,” Karin says. “It’s heart-wrenching to see her just sitting there.”
Karin and Ken usually manage to distract her after a while and try to help her enjoy her downtime. “We want her to take advantage of just being a regular dog when she has the opportunity,” Karin says.
When I last talked with the family, Clay was a couple of weeks away from starting his freshman year at Butte College. He’s taking nursing prerequisites and hopes to become a nurse or a paramedic. He is already an EMT, thanks in part to his Scrubs training.
He will be sharing a house with three human roommates and one four-legged one, who will go to classes with him, just as she did in high school. Clay was looking forward to this next stage in his life.
“Whitley has given Clay so much self-confidence to be the adventurous person he is, and to face new challenges head-on,” Karin says. “She’ll help Ken and me let go of some of the worry as she helps Clay take on his future.”
It’s clear to anyone who watches Whitley and other successful diabetic-alert dogs that some dogs can do this work and do it splendidly.
But studies show mixed results.
In a study published in Diabetes Therapy in 2016, dogs successfully alerted to perspiration and breath samples of diabetic hypoglycemia (glucose levels between 46 and 65 mg/dL). The samples were placed inside glass jars, and the jars went into open steel cans. There was no human in the room to cue dogs unintentionally. The people doing the study watched from another room via a video camera. When a dog alerted correctly, he or she received a treat from an automatic dispenser that was remotely activated by a trainer.
Most of the seven dogs did well, but there was one named Isabella who dragged the “GPA” down. She detected positive samples only half of the time, while four of her classmates detected positive samples nearly 88 percent of the time. She may have had a pretty good excuse, though.
The testing took place in an Indiana prison, where the dogs were training to become diabetic-alert dogs. At the time of the testing, the prison was having a sewage issue. The stench managed to work its way into the testing room.
Of course, to dogs, sewage is not a stench. It’s a cacophony of fascinating odors that tell stories of the people all around them—stories we can’t read and don’t want to. So it could be that while the other dogs were focused on the task at nose, Isabella was busy reading the sewage.
That distraction didn’t make it into the journal paper. I learned about it from speaking with one of the study’s authors, Jennifer Cattet, PhD, founder of the Indianapolis-based organization Medical Mutts. She and the other authors were encouraged by the overall outcome.
“Our results demonstrate that DADs [diabetic-alert dogs] are able to identify Hypo and be trained to alert to its presence,” their paper stated. “The results reported here take canine glucose sensing to a new level of sophistication.”
But a year later, researchers from the Oregon Health & Science University published a paper in the Journal of Diabetes Science and Technology that evaluated the reliability of eight diabetic-alert dogs (or, as the authors wrote with a touch of snark, “so-called diabetes alert dogs”) working under real-life conditions with their people. It concluded that there was a high false-positive rate and that continuous glucose monitoring often detected hypoglycemia before a dog.
“The current study,” the authors wrote, “helps define the clinical utility and limits of DADs and balances the often sensational reports of DADs in the popular press and social media.”
Ralph Hendrix, a longtime Dogs4Diabetics staff member, says he’s glad the study acknowledged dogs can detect hypoglycemia, but points out some issues his organization has with the study: Dogs are usually trained to identify rapidly changing blood sugar. They don’t wait until the person is already low. Ralph and others I spoke with also wish the study had weeded out poorly trained dogs or handlers instead of relying on patients’ statements on their satisfaction with their dogs.
The study’s lead author, pediatric endocrinologist Evan Los, MD, wasn’t entirely negative about the possibility of dogs as reliable alerters. He told NPR, “Although it appears CGM outperformed trained dogs in this study, it is intriguing that dogs were able to detect some hypoglycemia. Perhaps understanding what factors impact dog reliability could help optimize dog performance.”
Those who keep an eye on the literature suggest trying to standardize the training and abilities of diabetic-alert dogs used for future studies. They also hope to see the numbers of dogs in studies increase. A study reported in Diabetes Care (by some of the key researchers in the Oregon study) used only three dogs and concluded, “Trained dogs were largely unable to identify skin swabs obtained from hypoglycemic T1D [type 1 diabetic] subjects.”
Researchers at the University of Virginia used a larger number of dogs in a study published in 2017. The results showed high variability in the results from the eighteen dogs—all Labrador retrievers bred, raised, and trained by the same organization. The accuracy of dogs alerting to low blood glucose ranged from 33 percent to 100 percent. In other words, some dogs were really good at it, others not so much.
The authors called for larger trials that can help sort out the “factors influencing the complexity of DAD accuracy.”
This would be helpful to this increasingly popular doctor dog specialization. Most organizations training these dogs are well-meaning. But the accuracy and reliability of their dogs, and the training given to their people, sometimes falls short. If quality studies can suggest best practices, that could translate to increasingly better generations of these diabetes specialists.
That doesn’t necessarily mean cookie-cutter training. There’s more than one way to create a top-notch diabetic-alert dog.
Young Luke Nuttall and his diabetic-alert dog, Jedi, have a partnership as successful as Clay and Whitley’s, but their beginnings couldn’t have been more different.
Jedi was three days old when he first smelled the scent of diabetic hypoglycemia. A trainer had thawed out a sample of saliva on a cotton ball from a type 1 diabetic with low blood sugar. With gloved hands, she rubbed it on his mother’s belly. As the tiny black Lab and his siblings enjoyed the delectable taste of mother’s milk, they also breathed in the scent of hypoglycemia.
This continued until they were weaned. Sometimes the trainers bottle-fed the pups. But even then, they were exposed to the scent, thanks to a little piece of the saliva-soaked cotton placed on the side of the latex nipple closest to their noses as they snortled in the puppy formula.
Later, when the pups played games with people, a prized toy was always paired with the scent of a diabetic low.
It’s not like playing Mozart for your newborn in hopes your baby will be smarter. Trainers who use this early-scent-exposure method say it can have a marked effect on pups when it comes to ease of training.
“They learn to associate the smell of low blood sugar with something really good,” says Crystal Cockroft, founder of Canine Hope for Diabetics, which supplied Luke with Jedi. “It becomes something they’re always wanting to find, something they know deep down.”
Jedi hadn’t been born when Luke was diagnosed with type 1 diabetes at only two years old. The toddler had been under the weather. He was lethargic, itchy, crying through the night, and had an insatiable thirst. At one point he woke up screaming and gulped six baby bottles of water until he fell asleep from exhaustion two hours later.
He was going through diapers at an alarming rate—a red flag to his mom, Dorrie, who teaches child development at Pasadena City College. She took him to the doctor, who ran some tests and gave them the bad news.
The intensive, round-the-clock work of keeping Luke alive after his diagnosis became crushing for Dorrie. Luke was the youngest of three boys, and between working and parenting, Dorrie was already busy nearly 24/7. She was desperate for anything that would help ease the load.
When she learned about diabetic-alert dogs, she imagined how one could come into their lives and make things as close to normal as possible. Dorrie and her husband searched for an organization that would provide a young child with a dog. There weren’t many. They found one across the country that promised a dog would solve their problems and claimed 100 percent alerting rates for high and low blood sugars. Dorrie checked out their dog graduates and found a couple who were doing good work. The Nuttalls sent in $2,000 as a down payment for a $22,000 puppy.
But while they waited, Dorrie learned about problems with some of the dogs. That they weren’t reliable. That they arrived as puppies and the organization expected families to train them from scratch, with almost no support. That even those families that managed to train the dog to occasionally alert ended up with fearful or aggressive dogs. Some families were suing.
This was not what Dorrie needed. She knew she couldn’t get the deposit back. A couple grand was a lot of money for them, but they couldn’t take the chance on a dog who might make life harder.
Dorrie continued searching for a better organization. A year after Luke’s diagnosis, she found Canine Hope for Diabetics, which was only about seventy-five miles from their Glendale home. Crystal told her the organization didn’t normally provide dogs for young children, and gave her a much more realistic view of what to expect from a diabetic-alert dog. She told her how much work a dog would be, that training never stops, and that no dog alerts to every low or high.
Canine Hope was putting out only four or five dogs a year and spending a great deal of time on each dog. Dorrie didn’t want to wait for a trained older dog. She wanted the chance to train the dog herself, with the support of the organization.
She knew it would take time, and probably more training expertise than the family could muster. The Nuttalls had three dogs already, and those guys didn’t even know how to sit on command. How could they train a diabetic-alert dog? But there was something about this idea that spoke to her. She was determined they would work hard and succeed.
Crystal had done a puppy placement like this once before, and it had worked out well because the family was “100 percent dedicated.” She saw the same qualities in Luke’s family. She picked a sturdy black pup she sensed would be a good match for Luke: The pup had a great nose, a strong drive to work for food, and was calm enough not to get flustered by the chaos of a family with small children and other dogs.*
The Nuttalls, self-described Star Wars nerds, knew what they were going to name Luke’s partner: Canine Hope’s Master Jedi Knight, or Jedi, for short.
Crystal told Dorrie there was no guarantee. At worst, Jedi would be a great pet. He joined the family when he was twelve weeks old.
Jedi proved to be an enthusiastic, talented student. A typical Lab, he was as food-driven as Crystal had described. And since he’d been exposed to the scent early on, it was easy to get him to show that he smelled a diabetic low by offering a small reward for certain actions.
“He will do anything for a piece of kibble or slice of tangerine,” Dorrie says.
Whenever she tested Luke’s blood sugar—up to a dozen times a day—she made sure to bring little Jedi. “He’s low! He’s low!” she’d exclaim when Luke had hypoglycemia. For high blood sugar readings, she’d enthusiastically say, “He’s high! He’s high!”
With occasional intensive training weeks at Canine Hope, Jedi was able to show he recognized the scent of Luke’s lows at six months old. He’d smell Luke running low and run to the fridge for a treat, knowing he was due for a reward. The family found this adorable and endearing. By the time Jedi was a year old, he was alerting consistently to Luke’s lows. Soon after, Jedi could reliably alert to Luke’s highs.
Jedi’s alert for low blood sugar is like Whitley’s. But instead of showing Luke the alert, he goes to Dorrie. He stretches with his front end down and hind end up, and grabs a brinsel—either the one on his collar or one she always has hitched to her belt loop. When Dorrie wants to know if it’s a low or high, she’ll ask Jedi. If it’s low, he’ll bow again. If it’s high, he’ll give Dorrie a high-five with his paw.
The body language couldn’t be clearer, she says. Jedi is remarkably accurate and doesn’t overalert. And he’s only improved with age.
“No dog catches absolutely everything. But Jedi’s alerts beat the meters and CGMs almost every alert. Especially after almost six years,” Dorrie says. “Once in a great while we get an alert to something we can’t figure out—very rare or maybe it’s me. I get low blood sugars sometimes. But usually it’s just an early alert way before the meters catch it.”
She says Jedi usually beats the meters by fifteen to twenty minutes, allowing Luke to avoid big lows and highs. Since getting Jedi, Luke no longer reaches the point where he passes out. His A1C level, which reflects his average blood glucose levels over the past three months, is usually around 5.5, with a standard deviation in blood sugar of 28 mg/dL. These are excellent values, on par with a person without diabetes.
Luke doesn’t have to be near Jedi to alert to him. During training he responded from the distance of a football field away when the wind was blowing in his direction from Luke. And at home, Jedi can be inside and smell Luke having a blood sugar issue when he’s outside playing with friends.
Jedi has alerted to thousands of highs and lows. “He makes us all a little more relaxed, a lot more happy,” Dorrie says. “He makes everyone feel loved. He’s not just another tool against diabetes. He’s an extremely special part of our family.”
Jedi starts the night in Luke’s room, then moves to his parents’ room after his first alert of the night. But that doesn’t stop him from waking up to Luke’s lows or highs. His parents’ bed is a testimony to Jedi’s nocturnal alerting: The baseboard is covered in scratches from his nails as he tries to rouse them.
Dorrie has a popular blog and Facebook page about Luke and Jedi. People come to her to try to find out more about getting a diabetic-alert dog. Despite how much Jedi has done for their family, she says she spends most of the time telling people they should think twice about getting a dog.
“People are like we were, desperate, looking for something to make life easier. A good dog is an amazing help, but it’s not just a machine on autopilot that will be the answer for busy families,” she says.
She doesn’t want anyone to get ripped off, or to get in over their heads. She tells those who contact her how much work dogs are. She explains that dogs will wake up parents at night, when monitors might not, so they often get less sleep, not more. And there’s poop and walking. And constant training and reinforcement.
She lets them know that yes, Jedi has saved Luke’s life, and she’s grateful for Jedi every day. But a dog isn’t the magic answer. The work, day and night, of having a child with type 1 diabetes doesn’t disappear when a dog walks into your life, she tells them.
You can feel her exhaustion in a blog post from Valentine’s Day 2018:
Every single night before bed I test his blood sugar. That is about 2,340 nights that I’ve found my sleeping child’s hand under the covers and pricked his finger to get a drop of blood big enough to get a reading.
2,340 nights that I’ve looked at a number and decided what I needed to do next. What alarm to set, what dosing to adjust, how much insulin or glucose to give with full understanding that my decisions directly impact him.
2,340 nights I’ve made decisions a pancreas should make, or maybe next in line doctors, without a meticulous degree and through trial and error I’ve decided what to do next, I’ve considered his exercise his recent patterns his dinner and nutritional contents to decide how much insulin his body will need.
2,340 nights I’ve set alarms, plugged in equipment, inserted pumps and needles.
2,340 nights I’ve thought of families and children who do not have supplies or insulin or life expectancies longer then a year.
2,340 nights I’ve wandered through my dark house searching through supplies and doing calculations in my head wondering how many people would support us in our fight for a cure if they knew what diabetes really was. I’ve wondered how compassion could be lost for so many that go through so much because their diagnosis has the word “diabetes” in it.
2,340 nights I’ve prayed for a cure and thanked god for the science and miracles that have kept him here with us.
2,340 nights . . . that will be forever for Luke unless there is a cure.
#weneedacure please help us tell the world it’s time.
People have been training dogs to alert to diabetes for a couple of decades, but dogs have been freelancing for far longer. When I was a kid, my parents told me about their friend’s little dog who would scratch at her leg at odd times. It annoyed the woman until she realized the dog was doing this shortly before she started feeling “off” from her diabetes. Once she understood what her dog was trying so hard to tell her, she listened, and ended up with far fewer distressing episodes of low blood sugar.
Companion dogs have surely been sensing changes in the odors of their people way before my childhood, but the science didn’t start looking at this phenomenon until relatively recently.
A case study published in BMJ (formerly the British Medical Journal) in the year 2000 reported with charming enthusiasm that some pet dogs provide “a novel alarm system that can detect hypoglycaemia before the patient notices any symptoms and that operates robustly in a uniquely, patient friendly fashion.”
The authors reported on three pet dogs, two of whom routinely detected the hypos of their companions and “then undertook further corrective action by waking them to eat—thus going further than any available glucose sensor.”
The study’s conclusion may have inspired some early diabetic-alert dog training: “An extended healthcare role should now be considered for man’s (and woman’s) best friend. Research is urgently needed to determine whether dogs can be trained to recognise and react to early signs of hypoglycaemia. Hypoglycaemia alarm dogs could provide an important aid to patients with poor awareness of symptoms, particularly those prone to nocturnal episodes or who live alone.”
And it’s not just dogs. It appears there are some talented doctor cats out there as well. In 2011 a Queen’s University Belfast researcher reported on five people whose cats woke them up when they had hypoglycemia. One particularly determined cat with chronic arthritis in her paws managed to get past her pain to scratch at the bedroom door until she woke up her person. In all cases of kitty alerts, their people checked their glucose and found they were very low. The researcher concluded that “other species, such as the cat, may also have a role to play in the detection of certain underlying physical ailments.”*
And there was this unintentionally amusing proviso: “Whether this species offers the same ease of, or degree of flexibility in, training [as dogs] is still unknown . . .”
For now, dogs who sniff out diabetic highs and lows probably don’t have to worry about job security.
A study of 212 insulin-dependent diabetics with pet dogs found that almost two-thirds of the dogs often reacted to their hypoglycemic episodes. They barked, cried, licked, nuzzled, jumped up at them, and stared at them. A few sensitive souls showed fear—trembling, moving to another room, and/or hyperventilating.
The most promising finding was that one-third of the diabetics said their pet dogs reacted before they were aware of their own low blood sugar. People like my parents’ old friend would not be surprised by these findings. And neither would a diabetic doctor I visited in his office about ninety minutes north of San Francisco.
The patient examination rooms at the Sutter Pacific Medical Foundation in Santa Rosa, California, contain all the usual trappings: a state-of-the-art computer, tongue depressors, an otoscope, gauze, boxes of examination gloves, a red biohazard wall bin, a shiny reflex hammer, and other tools of the trade. The rooms used by Steve Wolf, MD, have one extra feature: a dog bed.
Every day a medical assistant checks which rooms the family medicine doctor will be using and sets up a dog bed in each one—usually tucked against a wall next to the computer where Dr. Wolf types in patient information, a few feet away from the patient.
Dr. Wolf, now fifty, has been dealing with his own type 1 diabetes since two weeks before he took the Medical College Admission Test (MCAT) that would help determine if he’d be going to medical school. He had been feeling miserable for weeks, with fatigue and weight loss and extreme hunger and thirst. He chalked it up to a bout of bronchitis mixed with the stress of preparing for the exams.
On the day of the MCAT, he walked into the testing room with a couple of gallons of water and an ice chest jammed with food, and was trying to fit it under his desk when the proctor approached him. The proctor firmly told him that he could only bring two pencils and his ID. All food and drink needed to be left in another area. He could eat and drink during breaks.
He ran out to his stash at every chance and slammed down food and chugged as much water as he could, then continued the test. By the time he was down to the last twenty-five or so questions of a section, his bladder was competing with his brain for attention.
Two days later, he was diagnosed with type 1 diabetes.
Since then, he has used every tool at his disposal to help him manage his condition. He started using insulin pumps when they were the size of a paperback* and tries to keep up with the latest technology for pumps and for monitoring his glucose levels.
But there’s something else in his arsenal that most diabetics don’t have. Something with no digital readouts and dials and doohickeys: Kermit, his deeply devoted diabetic-alert dog.
The yellow Labrador retriever was slated to be a guide dog, but every time the trainers at Guide Dogs for the Blind put the harness on him, he froze and wouldn’t move. A guide dog who can’t wear a harness has to find another career. Kermit ended up with Dogs4Diabetics, the same organization that trained Whitley.
Kermit isn’t Dr. Wolf’s first foray into the world of diabetic-alert dogs. In the early 2000s he had a boxer named Graham who somehow trained himself to alert to Dr. Wolf’s hypoglycemia. Graham would paw his leg and whine at certain points throughout the day, and it didn’t take long for Dr. Wolf to realize what Graham was doing. He encouraged his dog to continue alerting by giving him love and attention every time he alerted.
Graham saved his life on a few occasions. One time Dr. Wolf was sleeping and his blood sugar dropped into the 20s. He is sure it would have been “the big sleep” if Graham hadn’t been fiercely determined to wake him up. His recollection of the event is hazy because of his condition at the time, but he remembers Graham barking in his face on the bed and eventually rearing up on his hind legs and body-slamming him.
“I thought maybe he was telling me about a robber, but first I checked my blood sugar and realized I was in trouble,” he says.
He had fruit snacks and a juice box close at hand and had barely finished them when he noticed Graham was already curled up on the bed, mission accomplished.
After Graham passed away in 2010, Dr. Wolf couldn’t think about getting another dog. About a year later, though, he was shopping at Costco and ran into someone with a diabetic-alert dog. He struck up a conversation and found out that the dog was trained at Dogs4Diabetics, which was located only about sixty-five miles southeast of where he lived. He applied the same week, was accepted quickly, and began the rigorous program.
The trainers there had to be especially choosy when selecting a dog for Dr. Wolf. He has an active lifestyle involving outdoor sports, so the dog had to be high-energy. At the same time, the dog also needed to be calm and gentle enough to sit through a doctor’s encounters with patients, including newborns and the elderly. And the dog needed to be able to greet patients and welcome their attention, if there was attention, while still remaining focused on Dr. Wolf’s glucose levels.
When Kermit got through training, they knew he was the dog for Dr. Wolf.
Kermit goes almost everywhere with his man. When Dr. Wolf walks into an examining room to meet a patient, Kermit walks right in with him. The doctor introduces him, then it’s “Go kennel!” Kermit finds his bed and lies down for the duration. When the appointment is over, he and Kermit walk side by side back to Dr. Wolf’s office—colleagues in the war against illness.
During Kermit’s early days visiting patients with Dr. Wolf, he was reluctant to alert. “He could see I was conducting business and didn’t want to interrupt,” Dr. Wolf says. “I had to encourage him when I could see he was fighting the urge to alert.” The doctor carries dog food with him whenever he visits a patient with Kermit in case he has to reward him.
As important as Kermit is to his well-being, Dr. Wolf doesn’t always bring Kermit with him when he’s doing medical procedures. Until recently Dr. Wolf delivered babies. Kermit would be in the nearby call room or at the nurses’ station while Dr. Wolf was helping bring new life into the world. But sometimes Kermit would get up and scratch on the call-room door or try to pull away from the nurses’ station. When that happened, someone would knock on the delivery-room door and let Dr. Wolf know what Kermit was doing so he could check his blood sugar. Sure enough, Kermit usually had a reason to be concerned.
One of the few times Dr. Wolf doesn’t bring Kermit into an examination room at Sutter is when his staff informs him the patient is a heavy smoker; he’s concerned about the scent interfering with Kermit’s sense of smell. He’d also respect the wishes of someone who is allergic to dogs, but in all his years as a family practitioner, he’s run into only one patient with this allergy. She said it was OK to bring Kermit in, though, and she ended up petting him because she couldn’t resist. (She washed her hands immediately.)
Only a few patients have expressed a fear of dogs. Kermit seems to know, and usually goes straight to his bed and doesn’t try to get a pat or a hug. Dr. Wolf believes that Kermit, like other dogs, has a sixth sense about people who are scared and gives them space. But if someone is seriously fearful, he respects the fear and leaves Kermit in his office or with a staff member.
While I was spending the afternoon with them, Dr. Wolf got called to a room to do a laceration repair. He could have taken Kermit in, but instead left him in his office with me, with the door open.
I thought I would keep Kermit company and we’d be grand old friends while Dr. Wolf was out. After all, Kermit and I had already enjoyed playing with his favorite toy—a red lobster with googly eyes. And he seemed to like my ear rubs, leaning happily into them while I was talking with Dr. Wolf earlier.
Besides, dogs love me, and this dog would surely rather hang with me than just wait for Dr. Wolf.
I overestimated my curb appeal.
After a minute or two of halfheartedly playing with Mr. Lobster and me, and not seeming all that interested in belly or ear rubs, Kermit took his place on his green bed under Dr. Wolf’s desk and peered out the door down the hall. He lay there staring with tender brown eyes, waiting. He was a picture of patience. And he looked concerned, like someone in a hospital waiting room gazing in the direction they imagine their loved one is having surgery.
I took a few bites of my sandwich, and he didn’t give it a sideways glance. When I came back from washing my hands, he didn’t seem to notice me passing in front of his field of vision. He looked right through me as if I were invisible.
I clearly didn’t have a ghost of a chance with Kermit while he kept vigil for Dr. Wolf. We waited for him together, with only the low thrum of the office ventilation system and the patter of April rain to break the silence.
Months later (in Kermit time), Dr. Wolf returned from the procedure down the hall. Kermit stood up and waggled a greeting that seemed to be both joy and relief, all the while looking at his face intently. If he could talk, he would likely say something along the lines of Thank goodness you’re back! You don’t know how I worry about you when I can’t be near you!
Not that Kermit needs to be close to Dr. Wolf to sense he’s heading for trouble. Kermit has accurately alerted when he was outside and Dr. Wolf was inside—as Jedi has with Luke.
“The most impressive [time] was when I was at a friend’s house watching the Super Bowl,” Dr. Wolf recalled. “Kermit was outside being a dog, playing with his best dog friends. At some point we heard kind of a knocking at the back door of the house. It was Kermit pawing at it to tell us he wanted to come in. My friend let him in and Kermit came right over to me and alerted. I was dropping low and I had no idea.
“He’s the best sensor,” he said. “I trust Kermit implicitly.”
Kermit had been dozing next to his toy lobster as we spoke, but when he heard his name, his ears kicked up and his eyes instantly opened.
“It’s OK, Kermit, I’m just talking about you, not to you,” Dr. Wolf reassured him and smiled.
Dr. Wolf continued. “My dog is more accurate than my sensor. Dogs can alert within five seconds of a drop because you’re already breathing and sweating out the scent from the liver,” he said. “The best sensors currently measure interstitial glucose [the fluid between cells] every five minutes and average the measurements over thirty minutes. So sensors can be thirty minutes behind real-time change in blood glucose. Dogs are almost immediate.
“Plus, beyond their alerting, dogs have intangible benefits for diabetics, like getting us out for exercise, decreasing isolation and depression. A diabetic-alert dog has the combination of being able to save your life at the same time as giving unconditional love.
“All this fancy equipment I have can fail. Technology is susceptible to battery problems, a transducer can come loose. The transmitter of my current pump isn’t working without a good signal. I can lose a connection. Kermit never loses connection.”
But Kermit and other well-trained alert dogs are not infallible. When Kermit accompanied Dr. Wolf to New Orleans, he wasn’t catching his lows. It turned out he was panting so much from the heat that his nose wasn’t at its most efficient.* Dr. Wolf got around this by having Kermit lick his skin so he could taste and smell his sweat.
Another time that Kermit’s nose didn’t work was during the wildfires that decimated giant swaths of Santa Rosa in 2017. Kermit couldn’t smell Dr. Wolf’s lows or highs, and didn’t alert for the three days he was in the fire zone. Dr. Wolf was concerned about the toxic smoke permanently damaging Kermit’s nose, so he had a friend who lived farther away pick him up and keep him until the smoke cleared.
It’s not just environmental factors that can make a medical alert dog less efficient. Without constant reinforcement of their training, their skills can get rusty.
And dogs do cheat.
Dogs who alert are godsends, but they’re not always angels. If there’s a faster way to get a treat, many will take the quickest path to the reward until told otherwise. In my years writing about dogs who use their nose to save lives in war, or protect presidents, I’ve heard all kinds of stories about cheating dogs. Some dogs figure that if they get rewarded when they appear to smell an explosive, they may as well act like they smell explosives as much as possible.
It’s human nature.
Kermit doesn’t cheat. Not really. But on occasion, when he’s being talked about, he’ll alert. To give him the benefit of the doubt, this may be because Kermit is used to giving demonstrations of his skills. During demos, Dr. Wolf talks about Kermit and calls on him to show what an alert looks like. Kermit is probably like the Far Side comic dog, hearing “Kermit blah blah Kermit blah blah blah.” When there are enough “Kermit blah blah” statements, he may know a request to alert is coming up. Sometimes he jumps the gun.
I watched Kermit alert for real partway through our afternoon together. He stood up and casually dipped into a downward-dog position while staring at Dr. Wolf. Kermit has been trained to grab his brinsel after he does his downward-dog, but the bow-and-stare method is shorthand he and Dr. Wolf understand.
Kermit, like many diabetic-alert dogs, alerts to a blood glucose level drop of 10 percent or more within a ten-minute period. Dr. Wolf checked his glucose level: 182 mg/dL. We talked for twelve minutes and checked again: 106 mg/dL, a big drop.
“GOOD BOY! Nice!” Kermit’s tail lobbed back and forth. “Now he gets a treat and I get a treat,” he told me.
He gave Kermit a few pieces of chicken jerky and looked for a snack for himself. An extra desk next to his computer was covered with food: a bag of tangerines, a plastic container of chocolate-covered blueberries, and a paper plate with an orange, a lollipop, a big red pear, and an apple. A metal cabinet above his desk was like a mini-mart for diabetics, with a neat line of canisters containing cookies, dried figs, chocolate-covered sea salt caramels, jelly beans, and an assortment of other foods that can rapidly stop a drop or treat a low. It may sound like junk food, but it’s essential to consume a relatively simple sugar that can be absorbed quickly.
He downed a handful of Jelly Belly jelly beans, and we continued talking. In a few minutes Kermit stretched and bowed and stared again. “Are you really alerting?” Dr. Wolf checked his blood sugar. It had increased and seemed to be on an upward trajectory.
Kermit took another bow. He was like an actor coming out for one more curtain call when most people have stopped clapping. Kermit, though a highly skilled medical alert dog, is still a Lab. And as we’ve already seen, Labs tend to be food-motivated. Kermit occasionally tries to get an extra treat by alerting after an alert. Dr. Wolf changed the subject, and the bowing stopped.
A medical assistant popped her head in the door and told Dr. Wolf a patient was waiting. He checked a pocket to make sure he had some treats in case Kermit alerted in the examining room. Kermit looked at Dr. Wolf and looked at me, then back at Dr. Wolf. I could almost hear Kermit thinking.
You’re not gonna leave me with her again, are you?
“Let’s go!” he told Kermit as he strode out of the office. Kermit wagged and joined him for their next appointment.
“What do you call a diabetic-assistance dog in Rome?”
“I don’t know.”
“Very rare! Ha-ha!”
So begins a conversation with Italian dog trainer Paolo Incontri. It’s a cool November morning, and we’re sitting at an alfresco table of a café across the street from the Colosseum. We couldn’t get much closer to the Colosseum unless we were in it.
Cigarette smoke from a table of boisterous Italian men in black suits floats relentlessly to our table. Paolo gives them the best glare he can and waves his hand in front of his nose, but it’s not getting the message across. So Valentina Braconcini, founding president of L’Associazione Italiana Cani d’Allerta Diabete (IACAD), walks over and asks them to keep it down and to blow their cigarettes away from our table.
She’s petite but packs a punch. She returns to our table, and they pipe down and puff in the opposite direction until they get animated again, which takes all of about ninety seconds.
“This is one thing that would keep me from giving someone a diabetic-assistance dog,” Paolo says, nodding in their direction.
“Loud people?” I ask.
“No, smoking. Smoking is bad for the dogs. They can’t smell the diabetic changes.” (Kermit would concur.)
Paolo is founding partner and national training manager for the association, which he began under a different name in 2015. He’s sixty-one, with a shaved head, a tight goatee, and wire-rim glasses. A soft wool coat and a scarf keep the chill off his slight frame.
There’s something about him this morning that reminds me of the “job” he had for several years before devoting himself full-time to training dogs: Paolo had been a Buddhist monk.*
He traveled to Nepal and Sri Lanka, helping the poor, but spent most of his time as a monk in Italy. “The romantic vision people have about monastic life doesn’t correspond to the truth,” he says. “It is a simple life to be lived among the people and not in some kind of cave or a monastery on top of a mountain.”
Paolo has one of the more interesting and indirect career paths of anyone I’ve met in the dog world: Before he was a dog trainer or a monk, he’d had a long career in Italy’s Arma dei Carabinieri—a national police force older than the country of Italy.
Dogs have been part of his life ever since one followed him home before Christmas when he was a young boy. “I’ve always been able to communicate with dogs,” he says in his excellent English. “I feel like I am a translator of human language and dog language.”
He had been working as a trainer on and off, but in 2010, he felt a calling to work with dogs on a more regular basis. When he learned about diabetic-alert dogs, he was drawn to the idea that they can save lives. He thought it would be especially helpful to train dogs for children with diabetes.
“I always wanted to find the halfway point between helping the sick and working with dogs,” he says. He got some training in diabetic-scent detection from an American organization and started working with families.
Paolo believes it’s important to custom-make a relationship between a dog and a person or family. He explains it in his poetic manner: “One size does not fit all. Every family is different. Everything has to be in the mind, heart, and hands of the trainer from the beginning, as a tailor that first helps choose the most suitable fabric, then takes the measurements, then starts the work, then he checks and corrects and eventually you wear his work.”
There aren’t many diabetic-alert dogs in Italy. Paolo hopes that will change so anyone who really needs a dog will be able to get one.
For now, Paolo is helping families see if their own pet dogs can be transformed to become reliable diabetic-alert dogs. He looks for certain characteristics—calm yet inquisitive dogs who enjoy easy and fun scent-detection games he sets out for them. Then he works with the family and the dog, using positive reinforcement, never stressing the dog. “It must be great fun for them, or it’s not going to work,” he says.
He and Valentina are making plans to train specially bred litters of puppies for this work once the group gets a more robust library of diabetic hypoglycemic scents and a little more funding.
“We want to help as many people get good, reliable dogs for diabetic assistance as we can,” Paolo says. “There’s such an unmet need in Italy. People and the government don’t understand what these dogs do. We want to help families suffer less, and children be healthier, and Italy learn about medical alert dogs as service dogs.”
The pain of having a diabetic child is the same everywhere in the world. Several months after we met at the Colosseum café, Paolo put me in touch with a family he’d been assisting in the southern city of Reggio Calabria, located in the toe of the Italian boot.
“When we were told our son had diabetes, I stopped breathing,” said Lidia Calabro, whose son Matteo was diagnosed with type 1 diabetes at the age of six. “I also stopped thinking about how I felt. I just had to be his support and learn how to handle insulin, measure blood sugar, get over my fear of needles, and at the same time give him courage. It was such a sad feeling for him that he was going to be affected by this terrible disease for the rest of his life.”
She said Matteo is intensely curious, and that his mind “was in turmoil for days after his diagnosis.” One day he walked up to her and her husband and said, “Mamma, Papà, I must have a dog for my diabetes. I saw in a documentary that some dogs can help people with diabetes.”
They had a miniature schnauzer named Frida. When they found out about Paolo, they contacted him.
“Paolo warned us that it would not be a walk in the park. You put your personality into play, you put on the field emotions, skills, motivation, patience, hope, frustration, uncertainty, and a thousand other things, and you have to manage them. It is not easy, but it is very worth it.”
A few months later, Frida is alerting to Matteo’s hypos with an accuracy that thrills the family. When she senses something is off, she runs to Matteo and pokes him with her nose. Paolo’s interpretation of what she is saying: Something is wrong inside of you. Listen to me! If Matteo doesn’t acknowledge her the first couple of times, she licks and wags and does anything to get his attention. Then she runs to get his parents or grandmother and pokes at them and runs back to Matteo. They check his blood sugar. The whole time her tail is a blur of wagging. She loves this game.
And it gets even better for Frida when Matteo’s glucose monitor shows he is too low or high. “Brava, Frida! Brava!” the parents, grandmother, or Matteo—or all four at once—enthusiastically tell the little dog. She gets a treat or two as a reward.
“We love this exciting, exhausting, and beautiful experience,” Lidia explained. “Frida is Matteo’s greatest, most helpful, precious, faithful, and loving friend for life.”
Paolo told me that during his years as a monk, he felt exceptionally happy when helping people but that his work with dogs and diabetics has proven even more fulfilling. “It is a joy to watch how dogs can reach across species so gently and tenderly and transform lives. We don’t know exactly how they’re doing it, but we don’t really have to know, do we? It’s working.”
Of course, some of us just can’t help wondering exactly how they do it . . .
Before it became clear that scent is how most dogs seem to alert to diabetic events, researchers also postulated that body language, tremors, more rapid breathing, or changes in behavior or demeanor might be the ways some dogs sense trouble with blood sugar. It wouldn’t be surprising if these also play a role since dogs are so attuned to how we act and look, but they seem to be secondary to scent.
The authors of a 2008 case report in the Irish Journal of Medical Science broached an unusual idea. They suggested a dog alerting to hypoglycemia could be picking up on “energy wave changes in a person’s electrical and/or magnetic fields.”
The BMJ case report on the three dogs also offered an unorthodox possibility: “We are attracted by the notion of the ‘sixth sense’ with which dogs are commonly credited, but acknowledge that this will need to be substantiated by further research.”
The idea of dogs being able to use intuition or energy-wave detection might be kind of cool and heartwarming. But at this point, at least, it’s not terribly scientific.
The best explanation to date is that dogs are detecting the volatile organic compounds in exhaled breath that change with large fluctuations in blood sugar. A 2016 report from the University of Cambridge and University of Oxford used soft-ionization mass spectrometry to measure VOCs in breath. The researchers found that the common breath VOC isoprene rose significantly during hypoglycemia. But there was no correlation between isoprene and other levels of blood sugar. And it was the only VOC they found that greatly increased during hypoglycemia.
The authors wrote that they didn’t know how hypoglycemia could cause an increase in isoprene. But they did suggest that measuring breath VOCs like isoprene might one day be a noninvasive alternative to finger pricks for monitoring diabetic blood glucose changes.
It would be pretty convenient if diabetics could, say, blow into a tube and check their VOCs for accurate and real-time glucose levels. But would this put dogs out of business? Maybe one day—if technology like this gets ridiculously good and easy to use.*
But as much work as it can be to keep diabetic-alert dogs in top form, they have so much more to offer than their alerts. Studies list numerous psychosocial benefits of diabetic-alert dogs, including significant improvements in quality of life, decreases in anxiety about hypos or hypers, decreases in visits to the hospital, and greater independence.
Then there are the intangibles that studies aren’t really designed to describe. They’re like the benefits most people derive from their pet dogs, only perhaps even more intense because of the life-and-death element: The sense of having a devoted partner who is always looking after you. The unconditional love of someone who keeps you from grave danger. An understanding soul who lifts your spirits when your condition feels overwhelming.
No machine could ever do that. Most people can’t even manage it.
These qualities aren’t unique to diabetic-alert dogs. Most people who depend on their service dogs treasure the caring, loving nature of their dogs—even if they can’t always express how they feel about their canine caretakers . . .