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Diabetes alert dogs provide ‘safety net,’ emotional comfort
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Diabetes alert dogs cannot replace routine glucose testing or tools for people with diabetes. On paper, diabetes dogs are clearly inferior to continuous glucose monitoring and have a high rate of false-positive alerts. However, for those who might feel overwhelmed or alienated by their disease, these service dogs provide something less quantifiable: enjoyment, additional security and love.
“They do a lot for the emotional side of type 1 diabetes,” Becky Causey, dog trainer and owner of Causey Labradors and Training LLC, told Endocrine Today. “It’s nice to have a companion that doesn’t judge, is just always there to listen and snuggle. The emotional toll can sometimes be significant ... and having that built-in emotional support dog, in addition to the other tasks these dogs are trained to do, is really nice.”
Diabetes alert dogs are specifically trained to detect fluctuations in blood glucose and alert the person with type 1 diabetes to a sizeable decrease. According to Causey, these dogs are particularly useful as a “safety net” for people with hypoglycemia unawareness.
“They’re especially good for people who live alone,” Causey said. “The dog is someone else to help you catch those lows. If you live with other people, chances are your parent, spouse or child can let you know when you seem a bit off. People who live alone don’t have that luxury.”
Dog vs. machine
Evan Los, MD, assistant professor of pediatric endocrinology at East Tennessee State University, conducted a study on diabetes alert dogs as part of his fellowship training in Portland, Oregon. He had heard a great deal of anecdotal validation but found very few studies in the medical literature. He designed an exploratory study to determine the dogs’ reliability for alerting to hypoglycemia.
“It was a small study with eight participants who had type 1 diabetes,” he said. “They already had their own dogs who were trained specifically to detect low blood sugar.”
Five of the dogs were Labrador retrievers or Lab mixes, one was a border collie, one a St. Bernard, and one a golden doodle. The dogs had been trained for 6 to 24 months (median 10 months).
Study participants or a parent completed surveys regarding hypoglycemia unawareness, perceived dog dependability and value.
Los and colleagues evaluated the reliability of the dog alerts compared with capillary blood glucose testing and masked CGM, with hypoglycemia defined as blood glucose level less than 70 mg/dL.
Researchers found a high level of satisfaction among dog owners (8.9 on a 10-point Likert-type scale) and a significant amount of confidence (7.9/10) in the dogs’ ability to alert them to hypoglycemia, which was their primary reason for obtaining a trained dog.
Los and colleagues found that during hypoglycemic events, spontaneous dog alerts took place at 3.2 (95% CI, 2-5.2) times the rate of alerts that occurred during euglycemia (70 mg/dL to 179 mg/dL). Regarding sensitivity, 36% of all hypoglycemic events (n = 45) prompted timely alerts by the dogs. The dogs had a positive predictive value of 12% for hypoglycemia, due to inappropriate alerts.
“It turned out the dogs alerted to almost everything, one of which was low blood sugar,” Los said. “They did alert to 36% of all low blood sugars, including some low blood sugars the people didn’t know they were having.”
However, for the 30 events noted by CGM and dog alert, CGM would have alerted sooner than the dog 73% of the time (median 22-minute difference).
Los said despite the dogs’ high false-positive rate, the fact that they alerted more frequently during an event than during euglycemia indicates some discriminatory skill.
“They were alerting more during low blood sugars than during normal blood sugar, timewise, so they probably are able to detect low blood sugar, but they’re also not very good at telling the difference between low blood sugar, high blood sugar, falling blood sugar or rising blood sugar,” he said. “Essentially, the dogs could tell you something is going on that you should pay attention to, but they aren’t great at telling you exactly what it is.”
Los said he is currently planning a follow-up study, for which recruitment will begin soon.
“I’m trying to figure out how, if these dogs can really do this, how are they doing it,” he said.
Despite the dogs’ abilities, rapidly evolving technology will likely only widen the gap between dog and machine, Los said.
“CGMs are now starting to automate insulin delivery in insulin pumps, and some sensors are talking to each other,” he said. “Obviously, a dog can’t tell your insulin pump how much insulin to give. So as all these devices are more and more connected, dogs will never be part of that loop — but I think they will always be a thing.”
Training methods
Although the exact mechanism of diabetes alert dogs’ ability to detect glycemic changes is not understood, the training methods are straightforward, Los said.
“They are trained the same way a dog would be trained to pick up on drugs or bombs or sniff out people in earthquakes,” he said. “They teach them that a certain smell is what they should be paying attention to.”
Many alert dogs are highly trainable breeds known for excellent olfactory abilities. Causey, who works with Labrador retrievers, said dogs are trained on different smell exposures indicative of hypoglycemia.
“They’re trained on different items — some are training on sweat samples from a [person with] type 1 [diabetes] while they’re having a low [blood glucose event], and some are trained on saliva samples also taken during a hypoglycemic event,” she said. “Some are actually just training by being physically in the presence of the person during the low.”
Causey said all these exposures seem to work equally well, but sweat samples can be problematic in cases in which a person with long-duration type 1 diabetes no longer exhibits sweating when glycemic level is low. Because hypoglycemic unawareness is one of the main motivations for people with type 1 patients to seek out a service animal, dogs trained to detect a physical response the person no longer has may fail to achieve the main goal.
“That’s the reason the vast majority of trainers use saliva samples,” she said. “I don’t have a number, but I’d guess it’s close to 75%, because saliva samples are something the person is always going to have access to.”
Causey said the training takes about 18 months. The dogs are taught to detect the scent of hypoglycemia in a variety of different settings to ensure the dog will not be distracted by a loud or heavily populated environment. Causey said she uses a reward-based training system, as do most modern trainers.
“The dogs are simply taught that when they’re smelling this particular odor, they’re getting a reward and lots of praise,” she said. “You do that often enough with a puppy, and the puppy eventually can’t look for anything but that smell. It becomes a game to them.”
When to recommend a service dog
Given the advantages and disadvantages of a diabetes alert dog, endocrinologists may not know when to recommend one to a patient. These dogs may benefit a person who values the emotional support and is prepared for the responsibility of owning one, Causey said.
“People have to have realistic expectations of what it is like to own a dog and own a service dog. Service dogs have slightly different rules and guidelines for their behavior vs. pet dogs,” she said. “There’s also the responsibility of being out in the world with a service dog and having to tell people, ‘No, you can’t play with my dog, or pet my dog.’ It really can be an added stress and added amount of attention.”
Causey said she would be most likely to recommend a diabetes alert dog to someone with hypoglycemic unawareness, who lives alone and who does not use CGM.
“I do have a lot of clients who have both CGMs and diabetes alert dogs, though,” she said.
Anyone with an allergy to dogs should not be advised to use a diabetes alert dog, Causey said, adding that there “is no truly hypoallergenic dog, just those that produce less dander and shedding.”
Moreover, diabetes alert dogs are not covered by insurance and can be expensive — usually thousands of dollars.
“Vet bills can also be expensive; monthly flea, tick and heartworm preventives and food can be expensive,” Causey said.
Although diabetes alert dogs lack the precision of CGM, their potential value to quality of life should not be dismissed, Los said.
“Really, what’s fun about diabetes? You get to poke your finger, you have to watch what you eat, you’ve got to take shots and worry about your blood sugar,” Los said. “Yet, maybe having this mutual or positive diabetes partner that can say, ‘Hey, I love you no matter what — let me check your blood sugar,’ then maybe diabetes isn’t so bad. There may be positive things other than just blood sugar detection that these dogs are doing.” – by Jennifer Byrne
Reference:
Los E, at al. J Diabetes Sci Technol. 2017;doi:10.1177/1932296816666537.
For more information:
Becky Causey can be reached at 1092 Kearneysville Pike, Kearneysville, WV 25430; email: wvcauseys@frontiernet.net.
Evan Los, MD , can be reached at 408 North State of Franklin Road, Suite 31B, Johnson City, TN 37604; email: losea1@mail.etsu.edu.
Disclosures: Causey reports she is owner of Causey Labradors and Training LLC. Los reports no relevant financial disclosures.