Endocronologist (Pediatric) Questions Diabetes Type 1

Should my daughter get a diabetic alert dog?

My daughter manages her type 1 diabetes fine, but I'm just worried about her blood sugar when I'm not around or while she's asleep. I'm thinking about getting her a diabetic alert dog. Do you think that this is a good idea, or a little unnecessary? She's 12 years old.

2 Answers

Diabetes mellitus (DM) is the commonest metabolic disorder encountered in clinical practice. It is the major cause of mortality and morbidity in America Today. As of 2019 there are more than 31 million (10%) Americans with diabetes mellitus. There are also over 85 million Americans with prediabetes. Many of these prediabetic patients will progress in to full blown diabetes in the next decade.
There are two major classes of diabetes. Most patients have type 2 diabetes (90%) and about 5% have Type 1 diabetes. Besides type 1 and type 2 diabetes, there are other forms of diabetes such as gestational diabetes, cystic fibrosis-related diabetes, congenital diabetes and steroid induced diabetes.
Both type 2 diabetes and type 1 diabetes are based on genetic and environmental factors. Type 1 diabetes results from pancreatic islet beta cell destruction by an autoimmune disease. Once more than 80% of islet cells are destroyed by this process the insulin production is insufficient to control blood sugars.
Type 1 diabetes is therefore insulin dependent diabetes. There are about 200,000 (0.24%) of children and adolescents with type 1 diabetes out of 84 million of them. There are one million adults with type 1 diabetes.
The incidence rate of type 1 diabetes is about 40,000 new cases per year in America. Out of these about 20,000 are children and adolescent. There are about 1.3 million people with type 1 diabetes in America. Out of these 200,000 are children with type 1 diabetes.

Type 2 diabetes is usually due to insulin resistance with some an insulin secretary defect. They can be managed with diet and exercise and weight loss or combinations of different oral medications. Type 2 diabetes are therefore insulin independent, though eventually, they will require insulin to control their diabetes.
The incidence rate of both type 2 and type 1 diabetes is increasing at an alarming rate. In the next 30 years over a hundred million Americans will have diabetes. Type 1 diabetes is increasing at an annual rate of 3% in America. By the year 2050 over 600,000 children will have type 1 diabetes.

Diabetes is a chronic illness. Both Type 1 and Type 2 diabetes can be managed well but in most cases they cannot be cured. Gestational diabetes is the exception is it resolves after delivery though, some may precede in developing of Type 2 diabetes later on.
Since diabetes is a chronic disease it caries grave morbidity and mortality. There are acute and chronic complications of diabetes. Acute complications of diabetes are either due to low blood sugars or due to high blood sugars leading to keto acidosis.
The signs and symptoms of hypoglycemia can be very scary. The typical signs of hypoglycemia are as follows: Shakiness, Sweating, palpitations, dizziness, headaches, hunger, irritability or moodiness, anxiety or nervousness. Severe hypoglycemia can lead to stupor, unconsciousness, seizures and death. Chronic exposure to hypoglycemia can lead to long term impairment in executive functioning.
Hypoglycemia develops due to either excess insulin injection, skipped meals, mismatch between the amount of food consumed and the amount of insulin delivered or taking excess oral medications.
Hypoglycemia and hyperglycemia are common in patients with poorly controlled diabetic patients. In America only 30% of diabetic patients achieve reasonable glycemic control.
Acute and chronic complications of diabetes are very common in both poorly controlled type 1 and type 2 diabetic patients. These are also responsible for significant morbidity and mortality.
The chronic complications of diabetes are both microvascular (small vessel) and macrovascular (large vessel) diseases. The microvascular complication has the higher prevalence than the macrovascular complications. Microvascular complications include neuropathy (nerve disease), nephropathy (kidney diseases), and retinopathy (eye disease).
Macrovascular (atherosclerosis) complications cause, cardiovascular disease, stroke, and peripheral artery disease.
Diabetic patients can also develop foot disease that may lead to leg amputation from a combination of nerve disease ( peripheral neuropathy), foot ulcer peripheral artery disease and infection. Therefore combination of microvascular and macrovascular diseases can lead to deadly outcome such as limb amputation.
Chronic hyperglycemia or poorly controlled diabetes with blood glucose excursions will lead to the formation of oxidative stress and many glycation end products that are deleterious to the vasculature. These advanced glycation end-products are highly stable and are not easily degraded.
The excessive deposition of glycation end products are vital in the development of diabetic complications, by increase oxidative stress, and altering the structure and function of certain molecules causing microvascular and macrovascular diseases.
The formation of glycation end products such as HbA1c directly correlates with glycemic control. A reasonable control of diabetes (maintaining HbA1c <7% ) will slow or prevent the formation of these products and the complications of microvascular and macrovascular diseases.

Achieving reasonable glycemic control is therefore the corner stone of preventing acute and chronic complication of diabetes.
Currently various self monitoring blood glucose systems are used to measure to measure the glucose in blood. Self testing blood glucose levels more often will allow a diabetic patient to determine the precise amount of insulin that must be taken for corrections of the abnormal blood sugar or each meal or snacks consumed. Frequent blood sugar testing will also allow a patient to fine tune his/her daily insulin requirement, especially those patients with history of high or low blood glucose levels ( abnormal blood glucose). This will allow administering the appropriate insulin doses.
Self monitoring glucose machines were developed in the 1980. Before the mid 1980's (availability of home-use glucometers), glucose testing was done mostly in the hospitals via clinical-use equipment or the notorious urine testing process. At this time diabetes was poorly controlled and the primary goal of the testing was prevention of hypoglycemia at the cost hyperglycemia. Blood glucose was kept higher to prevent hypoglycemia and chronic complications of diabetes were common.
After the advent of home based glucose monitoring devices management of diabetes, the occurrences of hypoglycemia and chronic complications of diabetes has greatly improved the quality of life of diabetics. Myriads of blood sugar testing devices were invented with better ability to detect the precise blood glucose level. These technologies have advanced so much with tremendous functions and memories, that our understanding of diabetes have advanced m much better. These gadgets use a tiny drop of blood to determine the precise blood sugar level and have memories to perform complex mathematical algorithms..
Insulin and oral medications have also improved tremendously especially in the last 25 years. After the advent of genetic engineering human insulin was produced in the lab using the human insulin gene in a bacteria transfected with human insulin gene using a viral vehicle in the 1980's. There after a plethora of advanced fast acting and long acting insulin's were produced. These insulin's were much better and safer than the beef or pork insulin used before. Oral medications for type 2 diabetes have advanced so much in the last 25 years or so. These technological and pharmacological advances have greatly improved not only our understanding of diabetes but also ameliorated the chronic and acute complications of diabetes.
However, testing blood glucose with self monitoring systems can not achieve the desired goal of HbA1 <7% for all patients with diabetes. After all only 30% of diabetic patients achieve good glycemic control at this time. Testing blood sugars 4-6 times a day will not tell the who story of what the blood sugars are during. Testing at those specific times will only tell you what the blood sugars are at that time. These blood sugars tested at 4 or 6 intervals can not tell us whether there are low or high blood sugars in between or what happens at night time. Intermittent testing blood sugars, say every hour through out day and night will tell as better story to what the blood sugars are doing. Testing 24 times a day may be better but it is not feasible or humanly possible. The next challenge is therefore introducing continuous blood glucose monitoring system (sensors).
In the last 20 years the idea of continuous glucose monitoring systems were advanced. The technology have advanced well that currently there are 4 systems in use in many patients. Medtronic company spearheaded the challenge of the sensor technology followed by Dexcom and Free Style Libre from Abbott and Senseonics Eversense and more.
The sensors have gone through many prototypes (generation) and are now able to function much better and more reliable than before. They are good for blood sugar trends. Some are integrated with the pump and some are not.
They can give an alarm for high and low blood sugars and work continuously for 3-14 days. They have their advantage and disadvantage. If they are used properly they can be a great asset in thwarting low and high blood sugars. With the use of self monitoring blood sugars (testing at list 4 times daily) and the use of these sensors a reasonable blood glucose control can be achieved with lessening or eliminating of symptomatic hypoglycemia and chronic complications of diabetes.
Self monitoring blood systems and sensors are invasive or minimally invasive. They require either pricking the fingers for blood several times a day or inserting the sensing device to the body. This may causes pain and inconvenience and some people with needle phobia or fear they may add more stress and none compliance. It is also important to appreciate that 50 % of the population is none compliant even under the best circumstances. Even with self blood glucose monitoring systems many patients do not test their blood sugars consistently.
The next challenge is therefore to develop non invasive continuous glucose monitoring systems. There are two kinds of none invasive continuous blood sugar monitoring systems.
1) Artificial: Noninvasive sensors.
This concept was over 30 years ago. Many noninvasive technologies have been tried but non of them have been utilized in the patient care. Some of them are in the early stage. Some of the technologies in development are using: Fluorescence technology, electromagnetic sensing, bioimpedance spectroscopy, near infrared spectroscopy, mid-infrared spectroscopy, ultrasound technology, optical polarimetry, Raman spectroscopy etcetera. We will wait until this technology matures to come to clinical use.

2) Natural sensors: Using pets especially diabetes alert dogs: Dogs have been used for many purposes. including as guide dogs for the blind persons, mobility assistance dogs, psychiatric service dogs hearing dogs and blood sugar alert dogs.
Dogs have special smell potential. Dogs have 30 million smell receptors called olfactory receptors. Their brain have a bigger are for processing smell. They can smell 1 part in trillion. They may follow a sent about 40 feet underground. They can detect things from over 10 miles a way. They can smell up to 200,000 times better than humans.
Using this special smell ability they can be utilized as diabetes alert dog. Dog will be selected for this service based on their motivation and willingness to serve in this capacity. The first dog to serve in detecting hypoglycemia was in 2003. In 2009 a dog was recruited to assist in a type 2 diabetic patient. There are three kind of dogs suitable for this purpose. They are golden retrievers, poodles, & Labrador dogs. Currently there are several dogs in that capacity specially for type 1 diabetic patients.
They are trained for about 6 months with the sample of the patients low and high blood sugars. The training is based on reward system. Every time the correct identification of the desire blood sugar level in obtained the dog gets reward to do more. The dog has also to bond with the patient well for this to happen. Extensive training is very important for a successful out come.
Dogs are not machines. They have feelings, attachments and sentiments. They can not work 24 hours a day like a machine. They need enough sleep of about 12 hours a day. They also need to relieve themselves of their urine or feces at least 3 times a day. They also need to be loved and cared continuously. The dog need to bond well with the patient. They need to eat well and they should rest and have a play time. A dog will not be in service while sleeping at tight.
Trained dogs can detect the sent of low or high blood sugars. What they smell no body knows. Some say some chemicals called Isoprene?. Once they detect high or low blood sugars they alert the patient by paw tap, licking, nose tap, placing paws on partner’s shoulders, or laying their head on partner’s knee.
Diabetes alert dogs are not cheap. They cost between 15-20 thousand dollars. And they require an additional maintains money and time including several veterinary visits several times a year.
The accuracy of detecting high or low blood sugars are not exactly know. There is no standardized commercial guide lines in use of diabetes alert dog.
Diabetes alert dogs may work well in alerting high and low blood sugars but only during the time they are working (8-10 hours a day). They may also be good company for some patients.
In summary frequent blood glucose testing is the most important aspect of monitoring diabetes. Having sensors will greatly improve diabetes control and prevents extremes of blood sugars and may prevent acute and chronic complications of diabetes. The desired HbA1C i of <7% can be achieved in most diabetic patient utilizing frequent blood glucose testing and using sensors. Use of diabetes alert dog will be an addition to a better management of diabetes. It should not be a replace to the frequent blood sugar testing or the use of the various continuous monitoring systems. When dogs are sleeping or not working the parson will be covered the continuous glucose monitoring systems in addition to frequent testing of the blood sugars.
Going back to your daughter: Your daughter have type 1 diabetes. She need insulin to control blood sugars. Inappropriate insulin doses or missed or smaller meals may lead to low blood sugar. Fluctuations leading to high or low blood sugars are also worrisome. Maintaining reasonable blood sugars on daily basis and HbA1c <7.5 is advisable. You can achieve this by checking blood sugars several times a day and using one of the continuous glucose monitoring systems. A diabetes alert dog will be an addition to these but not a replacement. If you can afford the dog and you have good amount of time to take care of the dog and if your daughter is fond of a dog having an additional natural sensor will be a good asset to have. You also have to appreciate that the dog may alert for low or high blood sugars but the dog can only do this for certain time of the day. He has to sleep at list 12 hours a day and is not going to alert you at night. He is going to sleep just like you. The sensors, which ever you choose will alert you 24 hrs a day 7 days a week if you use them properly. Of course you have to check blood sugars several times a day as well. So the dog is an addition to these gadgets but not replacement. Some of the sensors such as Dexcom G6 and the Medtronic's G670 have special application and behave like artificial pancreas. They can stop insulin delivery when blood sugar is low and give more insulin when the blood sugars are high. They will also alert you when the blo0od sugars are higher or low.
So the answer to your question is if you have the means, the time and devotion, there is no reason why you shouldn't have a diabetes alert dog. It will strengthen the safety of you daughter in managing her diabetes.
Good Luck

The concept sounds really good and I have seen some case reports in newspapers about this. However, I have not seen evidence-based clinical studies showing that they are better than having a continuous glucose monitor (like Dexcom) that alerts about hypoglycemia episodes overnight. To my knowledge, there are not scientific studies approved by the American
Diabetes Association that supports their claims.