Unwitting heroes: With training, dogs come to aid of diabetics

This article reprinted from the Contra Costa Times.

By Sara Steffens, Staff Writer
Sunday, September 23, 2007

On the first night home with her new dog, Sara Outler awoke to an urgent face-licking.

It wasn't time to get up yet. But Tahiti, a 21/2-year-old black lab, knew something her owner didn't: Outler, who has type 1 diabetes, was suffering from dangerously low blood sugar.

As the product of the rigorous training program at the Concord-based nonprofit group Dogs for Diabetics, Tahiti was just doing her job. She knows the distinct smell of hypoglycemia means it is time to warn her owner to get a glass of juice.

Even in the middle of the night, she will abandon her snoozing to warn of the smell -- "it's like bacon to people," Outler said -- persistently licking her owner's face or, failing that, jumping onto the bed to awaken her.

Three months later, Outler and Tahiti remain paired on a trial basis. The dog sleeps in Outler's bedroom and accompanies her everywhere she goes, including the store and to Mervyn's headquarters, where Outler manages the color office.

"It's just that extra sense of security because I don't always feel my lows," said Outler, 34, who lives in Oakland. "It's really comforting to know that there's something else there as a backup."

No one knows exactly what dogs are smelling in a person with hypoglycemia, said Mark Ruefenacht, founder of Dogs for Diabetics.
But the canines are unflaggingly accurate, correctly recognizing low blood sugar more than 90 percent of the time, he said.

Ruefenacht, a diabetic who works in forensic metrology, discovered this ability by accident. As a volunteer with Guide Dogs for the Blind, he brought a black lab puppy named Benton along on a business trip to help socialize the dog.

One evening, Ruefenacht ate a chocolate doughnut, injected extra insulin and went to bed alone in his hotel room, forgetting to check his blood sugar.

That night, Benton insisted on waking him up. "More than likely, I had a seizure and it alarmed him," Ruefenacht said. "But it sparked the idea."

In the past three years, Dogs for Diabetics has placed 20 other medical alert dogs in the homes of Northern California residents with type 1 diabetes. The group's first trained dog, Armstrong, still lives and travels with Ruefenacht.

Dogs and follow-up services are free to clients of the nonprofit organization. But each canine costs $25,000 to train.

"As we do more dogs, we expect that to go down," said program director Carol Edwards.

As one of only a handful of programs of its kind across the country, Dogs for Diabetics struggles to raise enough money to meet the demand.

Already, the group gets so many requests that it is unable to maintain a public phone number and routes all inquiries through e-mail instead.

For each dog the group is able to place, an additional 100 applications go unfilled.

"Everyone I've talked to has been really excited about it," said Cynthia Shane Smith, director for the Greater Bay Area branch of Juvenile Diabetes Research Foundation International. "We're very impressed with what they've been able to do."

People with type 1 diabetes, which used to be called juvenile diabetes, can no longer produce insulin. So they must inject insulin throughout the day, using either a syringe or an external insulin pump, to counteract the food they eat.

Diabetics test their blood frequently to gauge its sugar levels so they can tell whether they are using the correct amount of insulin.

It is a constant struggle for balance: High numbers can lead to long-term complications, including blindness and loss of limbs. But lows can be even more dangerous, causing disorientation and, eventually, seizures, comas, brain damage and even death.

Lows can follow even minor changes, such as exercising more, eating slightly less or injecting more insulin than usual, said Jeannie Hickey, a diabetes educator who works with Dogs for Diabetics.

And some unexplained lows are just the nature of the disease.

"Many times there's no real answer," Hickey said. "That's part of the frustration of having diabetes."

Dogs not only provide security and comfort to people struggling to control diabetes, but they also don't nag or judge, Hickey said. "There is something there to be on your side and let you know when things go wrong because otherwise it can be scary," she said. "A burden shared is half as much."

The work is rewarding for dogs, too, who get to spend the whole day with their humans, Edwards said.

"Dogs have a natural ability to want to take care of you, to comfort you when you are sick," she said. "If you're home for the day feeling like crap in bed, even a dog that's usually bouncing off the walls will come and curl up with you. It's the same impulse."

Dogs' sense of smell is far superior to humans', said Eranda Rajapaksha, a veterinarian and animal behavior resident at the UC Davis School of Veterinary Medicine.

Dogs not only have more olfactory receptors than people, they also have a vomeronasal organ that helps them smell.

"They lick the air or the surface they want to smell, and then that substance is mixed with saliva," helping them to identify it, Rajapaksha said.

That's why dogs can smell other animals at long distance, find bodies or detect traces of drugs or bombs. Research published in the British Medical Journal in 2004 proved that dogs also can smell cancer, a skill that may someday lead to advances in human detection.

"When we use a dog to sense something, it's a very noninvasive way of doing it, which is a huge advantage," Rajapaksha said. Like all dogs, medical alert canines tend to be attuned to human behavior and body language, said Rajapaksha, and they likely supplement their smelling ability by noticing subtle factors such as heavy breathing or increased heart rate.

"The bond between humans and dogs is a big factor here," he said. "It is very important that these dogs go to a person who is caring for animals."

Each medical alert dog undergoes three to four months of professional training that is similar to techniques used with narcotics dogs and cancer-sniffing dogs.

First, a dog learns to recognize the scent of low blood sugar, then to "alert" to the smell by holding a soft tube called a bringsel in its mouth. Finally, the dog learns to warn a particular person of the smell.

Dogs can smell so well that trainers use gloves when handling scent samples so they don't inadvertently transfer trace amounts on their bare hands.

"What they can perceive, we can't imagine," lead trainer Blancett Reynolds said.

Learning is helped along by frequent offerings of Bac'n Bits, chicken crumbles and soft salmon jerky, alternated to keep the dogs from getting bored.

The dogs -- black and yellow labs donated by the San Rafael campus of Guide Dogs for the Blind -- clearly enjoy the challenge, prancing into the training room with their eyes bright as they take turns learning to hold their bringsel or identify scents.

As "career change" animals, they were bred for service temperament and trained extensively, but they showed minor traits that made them unsuitable for guiding the blind.

"We had one guide dog that didn't want to walk a straight line through a puddle, it wanted to walk around and keep its paws dry," Ruefenacht said. "That's unacceptable for a guide dog."

Medical alert dogs also must be fairly uninhibited, willing to eschew the service-dog commandment to always keep "four on the floor."

They also need what Edwards refers to as "a work ethic" -- a willingness to make decisions and think through problems, instead of merely obeying commands.

"I have to be able to get that dog wound up fairly easily and excited about something," Edwards said.

When screening career-change dogs, she will sometimes take a handful of kibble and throw it into the tall grass to see how the dog reacts.

A dog with good medical alert potential will sniff happily until he finds each piece -- proving both his food motivation and his interest in using his nose to solve problems.

Meadow, a 3-year-old yellow lab, has been living since December in the Santa Rosa home of Sheila Hakel.

Three of Hakel's four children -- ages 7, 9 and 11 -- have type 1 diabetes.

When one has low blood sugar, the dog is often the first to know. "She'll come alert on me, she jumps up on me or crawls across my lap," Hakel said. "She gets too excited to tell me which one sometimes."

The signal warns Hakel and the children to stop for a blood test, which often winds up being followed by a glass of juice to raise their blood sugar.

At first, when the test numbers showed the children in a safe range, Hakel wondered whether Meadow was simply mistaken. But she has learned to retest all three children 20 minutes after the dog's alert, and she usually finds one has dropped dramatically.

"I would love to think that she's a brilliant dog and knows that she could be saving their lives, but what I really think is she thinks, 'There's that smell, gotta tell Mom, I'm going to get a treat,'" Hakel said. "We tell her 'What a good girl,' (and) she gets all squirmy and excited."

Ozzie, a 3-year-old black lab likely to graduate from Dogs for Diabetics in January, is still perfecting his alerting.

He has no trouble recognizing when his person, 11-year-old Katelyn Grubich, has low blood sugar, but his response varies. Sometimes he correctly holds the bringsel in his mouth; other times, he sits attentively before Katelyn or paws her gently.

If Katelyn falls low while riding her bike in front of their Concord home, Ozzie will sit in the yard and stare intently at her, wagging his tail -- behavior Katelyn's mother, Christa Halstead, has learned to watch for.

Since the dog's arrival in February, "I feel more at ease, definitely," Halstead said. "I hope that eventually she'll be able to go off to college with him."

For now, Ozzie attends sixth grade with Katelyn at Walnut Creek's North Creek Academy, serious and dignified in his service vest. Other students quickly learned not to treat him like a pet or play games with him, Katelyn said.

At home, the dog follows her from room to room, sleeping alongside her bed and "giving lots of kisses."

Katelyn adores the dog, her mother said, and he returns the affection tenfold. "She gives him 100 percent of his care, feeds him, cleans up after him. She's everything to him."

Usually content to snooze at her feet as Katelyn finishes her homework, Ozzie rose from his recline on a recent afternoon to pace the living room, whining.

When Katelyn got up to test herself, she confirmed what Ozzie already knew -- her blood sugar reading had fallen dramatically since her return home from school.

So the two went to the kitchen together, where Katelyn punched open a juice box and Ozzie gobbled his prized reward: a small piece of salami.

Then he collapsed on the floor, wholly content.

"This is the highlight of his day," Halstead said, smiling. "It's like, 'Kid's low, yeah!'"

How to help
Dogs for Diabetics needs donations and volunteers to expand its assistance-dog program in Northern California. Find out more at http://www.dogs4diabetics.com. Tax-deductible contributions may be made online or by mail. Send checks made out to Dogs 4 Diabetics to 1647 Willow Pass Road No. 157, Concord, CA 94520-2611.

This article reprinted from The Contra Costa Times.