Category Archives: Diabetes

Numbers Game

Forgive me, interweb, for I have sinned. It has been four months since my last blog post.

I could recite any number of excuses for not posting but the truth is Luka and I were dealing with some challenges that I didn’t want to write about until I had a chance to gain some perspective. I’m happy to say we have emerged from our cocoon of silence and are better for it. I hope to catch up in future posts but first I want to share some cold, hard facts.

In November I started keeping detailed statistics about Luka’s alerts. Every single alert (or missed-alert) was recorded and tallied by day in a spreadsheet. Each alert was categorized as follows:

  • Expected: This means that at the time he alerted I wasn’t surprised. My internal clock that tracks when and what I last ate, level of exertion since, and general trend of the CGMS during that period were consistent with the potential for a low blood sugar. In each case I confirmed with a finger stick and rewarded Luka, ate some Skittles, and recorded the alert on an app on my phone.
  • Unexpected: This means that at the time he alerted I was dubious about his sincerity. The CGMS typically showed me either steady in the 90’s or well above 100. I honestly believed these were false alerts. The meter confirmation of Luka’s diagnosis came as a complete surprise. I have another word for these events: LIFESAVERS. These are the potentially serious episodes that neither technology nor insight could have predicted and, before Luka, would have dropped my glucose to dangerous levels before I caught them.
  • False for attention: I’ll be talking about these more in upcoming posts since this was THE big challenge I struggled with. Suffice it to say that Luka learned that the alerting behavior brought him attention whether I was low or not. This was, in fact, the reason I started keeping such detailed statistics – so that I could measure whether things were getting worse or better as I tried to retrain his behavior.
  • False NOT for attention: These were really interesting and it took me a long time to understand what was going on. In these cases Luka was definitely not trying to get attention but still alerted confidently. More about this and false alerts in general in a future blog post.
  • Missed/Prompted: These were times when I discovered I was low either from a random finger-prick or because the CGMS caught it. In each case I intentionally got close to Luka so he could smell me clearly and eventually he picked up the scent and alerted.

Here are the numbers from the past 80 days:

Total Alerts: 241
Total Expected Alerts: 129
Total Unexpected Alerts: 112
Total Missed/Prompted Alerts: 22
Hit ratio: 92%

These numbers are shocking to me. Luka correctly alerted me to an average of 3 alerts per day. He protected me from 112 potentially serious hypoglycemic excursions missing a low only 8% of the time. I couldn’t be more amazed or grateful for his presence in my life.

To Luka!

Luka

First Alerts

Describe what you see when you look into a kaleidoscope. Twist the end. Describe how the sparkling colors change, patterns emerge and evolve, and symmetry shifts. That’s the task before me as I try to describe my first Wildrose DAD conference.

Several years ago Rachel Thornton, a mom from Mississippi, came up with the idea of training a dog to help her daughter, Abi, manage her newly diagnosed diabetes. She painstakingly laid the groundwork for the rest of us to follow and she leads us still at her invaluable forum DiabeticAlertDog.com. In 2009 she started what has become a yearly tradition: the Wildrose Diabetic Alert Dog Conference, hosted by Wildrose Kennels in Mississippi with whom Rachel works closely. Each conference brings together existing DAD teams, trainers, teams in training, and people looking to find out more about DADs.

For me, it was two days filled with inspiration, disappointment, deeply moving stories, self-doubt, and thrilled exuberance. That’s a lot of emotion packed into 48 hours. My task over the coming days is to unpack and assimilate the experience into a new understanding of this journey I’m on and, hopefully, find a way to express it in this crude instrument called language. This will take some time.

The first story I want to tell is, perhaps, the most important experience I’ve yet had on this journey and definitely the most valuable.

It was early Friday morning. Everyone was sitting in chairs in the meeting center listening to Rachel inspire us with the heart-wrenching tale of her daughter’s diagnosis and early struggles with type 1 diabetes. Brenda, who I interviewed on the blog a few months ago, was sitting about ten feet away. Her diabetic daughter Laura was outside somewhere – out of sight and with all the doors closed. Their DAD, Daisy, lay asleep by Brenda’s feet. (Children with DADs often take breaks from each other and the parents take control of the dog.) Suddenly Daisy stood up, sniffed aggressively at the air and gently placed her paw on Brenda’s leg. Brenda looked down and asks, “Are you sure?” and Daisy repeats the movement. Seconds later, Laura coincidentally entered the room from outside and makes her way to her mother’s side. When she reached Brenda, her mom tells her to check her blood which she does.

You can guess what happened next – a big dog party! Lots of treats for Daisy, lots of praise and petting and Daisy is allowed to hold her beloved tennis ball for a while before settling down.

 

I don’t think I can describe all the emotions I felt. It was an extremely powerful moment and I felt privileged to be able to watch it unfold. I’m not afraid to say I got choked up and even now as I write this on the plane back to Boston I’ve got a sniffle just thinking about it. Prior to this I understood this amazing thing that DADs can do but it was an intellectual understanding – I hadn’t internalized what it meant to people’s lives. I’ll admit my emotional pump was primed that morning when I entered the building and saw an adorable little boy wearing a Superman cape. He couldn’t have been more than three. I said, “Hey Superman,” and as he turned I saw a pump identical to mine attached to his belt, looking absurdly large on his tiny body. The unfairness and cruelty of this disease hit me like a brick, with a deep sympathy for what these parents must experience on a daily basis.

Fast forward to Saturday afternoon. I was in a different meeting room with chairs spread around. Scott and three other trainers were observing Mya to see if they could figure out the source of her anxiety and come up with a plan to help her through it. This particular room was a scary place for her. We can never know what terror she was envisioning in her head but she was obviously distraught which is why we chose that room to observe her – something about the wood floor was not to her liking. Suddenly she started sniffing – no, snorting – very aggressively and walked over to Scott, smelling him all over. Mya then grabbed at the bringsel Scott always has hanging from his belt and tugged until he unclipped it and let her have it. She walked directly to the chair where I was sitting, thrust her head between my knees and dropped the bringsel into my lap, then sat at my feet with her entire rear-end wagging and a look of absolute satisfaction on her face, as if she was saying, “Look what I just did!”

My instinctual reaction was doubt. Over the years I’ve evolved something I can best describe as a subconscious risk meter that is always running in my head. It measures the degree of confidence I have that I know my current level of blood glucose. When I check my blood or eat a meal the risk meter is reset to zero. As time passes the risk meter goes up at a rate that varies with the kind and quality of food I have eaten and my level of physical exertion. This has served me pretty well and is a constantly evolving model. At that moment I felt confident that I was normal or high – it was only two hours since lunch for which I hadn’t needed much insulin and I had recently had a snack. I had checked my glucose only thirty minutes prior and was at a pleasant 98 – right in the middle of my target range of 85-120.

I stood up and checked my Dexcom CGMS and it said I was steady at 80 and had been steady all afternoon – no drama whatsoever. But if I trusted my Dexcom completely I wouldn’t be here – my internal system for recognizing highs and lows is dangerously imperfect and the Dexcom, while useful, has not protected me from some terrifying highs and lows. I pulled my glucometer from my backpack, pricked my finger, and applied a drop of blood. It read 57. I had just experienced my first DAD alert.

I was grateful for the need to praise and reward Mya because it made me focus outside of myself. But inside I felt like a ship tossed in a storm. I so often tell myself that I am in excellent control of my diabetes, and maybe I don’t really need a DAD – maybe I’m pursuing this for the wrong reasons. All doubt evaporated at that moment even as tears came to my eyes. The truth is that my grip on glycemic control is tenuous and hair thin. I work really hard at it – to the point of obsession. I get the best tools, I constantly refine my risk model, I eat very carefully. I was so sure I wasn’t low and I was prepared to tell everyone that this was a false alarm. I hadn’t even considered the possibility that I might be low – certainly not THAT low.

Hello. My name is Dave, and I can’t always control my diabetes.

The Dexcom never even alerted. The alarm is set to go off at 75. If I set it any higher I get so many false alarms that I start to ignore it. I chewed some glucose tablets and ate some gorp that I always keep handy and my glucose quickly recovered. The graph on the Dexcom showed not even a blip – it was a perfectly straight line like nothing had happened at all. The fact that in just 30 minutes I had dropped from 98 to 57 tells me that, had Mya not alerted, I would probably be in the 40s before the CGMS caught wind of the low and finally alerted me. What if I was in the middle of the woods, alone on a long hike? It could happen. It *has* happened.

 

This is the first gift bestowed upon me by the 2013 Wildrose DAD conference: resolve. I resolve that next year I will return to Wildwood with my own DAD where, for two days, my journey will merge with the journey of others like me and I will return home fulfilled and inspired.

There are so many more stories to tell from the weekend: meeting and spending time with Mya, getting a chance to meet and talk with DAD teams I only knew through Facebook, working with Scott and other trainers to understand Mya’s anxiety. There is much to tell – stay tuned!

Waffle Time!

I have found that people make all kinds of assumptions about me when they find out I have diabetes. Their assumptions are typically based on what they’ve heard from other diabetics either directly or indirectly. And often their assumptions are wildly inaccurate for one simple reason: my diabetes is not your spouse’s diabetes, nor your friend’s diabetes, nor the diabetes of the person you see every other week at your book club. We all have different bodies, and we all have varying levels of insulin production and resistance ranging from none to some to lots. Likewise we all have different metabolic, digestive, and adrenal systems so we each react differently to foods, levels of exertion, and stress all of which affect glycemic control.

These assumptions and tendencies to paint all diabetics with a common brush sometimes lead to comical moments when they are challenged. I frequently enjoy an inner chuckle when I inspire a double-take by eating food that most people assume is off limits due to my inhibited pancreatic function. I can almost hear people running through the list of possible explanations in an attempt to quell the cognitive dissonance between what they assume about my disease and the seemingly reckless pile-o-carbs I am busy devouring. Usually they settle on some variation of “I guess he’s not as careful about his diabetes as he claims to be.”

Often people comment that they didn’t think I was allowed to eat “that” and I usually respond with a polite comment about how there are many foods I cannot eat but this particular food I’ve figured how to eat safely. That usually elicits more questions to which I respond with a detailed description of carb counting, how fat affects digestion rate, how I can bolus insulin to cover digested carbs, and how I follow some meals with exercise to increase insulin absorption. Hopefully by the time I’m done I’ve convinced them that a) I really *am* careful about my diabetes, b) that some of their assumptions about diabetes may be flawed, and c) that being diabetic is a lot of work.

A diabetic suicide note? Nope, just waffles, real Vermont maple syrup, and walnuts. Plus a handful of chocolate chips thrown in that melt deliciously in the precious honeycomb-like indentations that make a waffle so much more than just a pretty pancake.

Here’s a real-life example. A friend we had invited over for brunch recently saw me tucking in to one of my favorite breakfast (or anytime!) foods: WAFFLES. He had the aforementioned reaction and I explained how I had spent months of Sunday mornings trying to figure out how I could safely eat this delicious morning (or anytime!) treat. Here is the magic formula that works for me and almost definitely will not work for other diabetics:

For starters I make the waffles using Trader Joe’s Multigrain Pancake batter mix. This is crucial because the extra fiber in the wheat slows down digestion.

Next I make sure every bite of waffle includes a bite of walnut. I’m nuts about nuts so this is easy for me and I sometimes mix it up with pecans instead which work just as well. The high fat and fiber content in the nuts further slows down absorption of the carbohydrates (which also explains why I can easily eat ice cream and, in the summer, do so almost daily. Ok, not just in the summer.)

For a drink I’ve had to limit myself to tea or water. I desperately crave milk with my waffle but repeated failed experiments have proven that even the fast acting insulin I inject from the pump can’t keep up with the speed that the milk’s carbs get digested.

Ok – so that’s the expense side of the balance sheet. Let’s talk credits. For a 8 inch waffle as pictured I shoot up for 75 grams of carbs with a 60/40 split over two hours. What this means is that the pump will deliver 60% of the insulin immediately then trickle the remaining 40% over the next two hours.

Immediately upon completion of the feast I get on my exercise bike and work up a sweat for 48 minutes while watching an episode of Breaking Bad (this is crucial – other shows simply can’t compete).

This is what works for me. Occasionally my glucose will gently break 150 over the next four hours as I digest my yummy breakfast but generally settles back down within range pretty quickly.

Now reading this you might think to yourself that an industrious diabetic might be able to figure out how to eat *anything*. This is definitely not true. There are many foods that, try as I might, I simply can’t figure out how to enjoy without sending my glucose skyrocketing. Among them are pizza, pasta, and any kind of sugary drink. I honestly thought waffles were going to end up on that list and it is only recently that I can say I have really figured out how to eat them safely. And boy am I glad I did!

A Sober Reminder

This post on Scott Johnson’s blog describes his experience passing out from hypoglycemia and is a sober reminder of the risk we face every day. His description of how he felt just before passing out sounds all too familar:

I felt off as I walked to the bathroom. By the time I got to the front hallway I lost all logic and couldn’t read the signs to figure out which bathroom was which.  Stumbling through the hall and bouncing off of the walls, I pushed through the front door of the restaurant and reached for an outside wall.

I’ve been there more times than I care to count. Fortunately I have not (yet) gone the next step into unconsciousness and hope I never do. Thanks for reminding us, Scott, of the seriousness of this dangerous game called insulin therapy.

SPI Belt

Diabetes is a constant challenge. You have to deal with medication, exercise, diet and don’t forget stress, which wreaks havoc on glycemic control. If you use insulin then you also have to manage injections or a pump, carb-ratios, basal rates, correction boluses… it’s enough to drive a PWD insane. But these challenges do not speak of the one that drives me nuts day after day. I’m speaking of course of HOW TO CARRY ALL THIS STUFF!

You ladies have your handbags and, although I’ve been accused of carrying a man-purse from time to time, usually I like to travel light with my hands and shoulders unencumbered. My pump is typically clipped to my belt or waistband. Yeah, it looks a little geeky and most people assume it’s a pager so I’ll only deduct 10 fashion points for it. My Dexcom receiver goes in my pocket which bulges unnaturally but is not much worse than my iPhone so I’ll only deduct 15 fashion points for that. Ok – now what exactly am I supposed to do with my glucometer and associated accessories?

My miniscule One Touch Ultra glucometer came with a cheap nylon case with a velcro strap that is supposed to fit onto my belt. Have any of you ever actually worn this on your belt? In my book it clocks in at about minus 1000 fashion points. What if I’m wearing pants that don’t allow for a belt or a bathing suit which has neither belt nor pockets? And take a look at that fine half inch strip of velcro on the One Touch’s case – yeah, that’s gonna hold up to me chasing after my six year old son whose independent spirit I find simultaneously infuriating and endearing.

This problem has vexed me for years and after a nasty low during an unexpectedly long hike in the woods sans meter and glucotabs I decided to actually spend some time solving it rather than just complaining about it. Meet… the SPI Belt. (SPI = Small Personal Items).

The SPI Belt is designed and marketed towards runners and athletes who, I guess, wear those super lightweight shorts and have no place to carry their keys and ID. (Wouldn’t know about that personally.) It consists of a simple stretchable belt with a zippered pouch in the middle – like a fanny pack but really small and discrete. The pouch is made of absurdly stretchy material and holds far more than it appears capable of. So stretchy is the pouch that if worn empty you might not even notice it. It can easily fit my glucometer, test strips, lancet, and a tube of GlucoLift tablets with room to spare. If I really wanted to stretch it I’m sure I could fit my keys and cell phone as well but I suspect it would lose its streamlined shape and start to resemble an unsightly bulge like I’m shoplifting avacados.

Zipped tight with glucometer, tube of glucose tabs, lancing device, meter, and bottle of test strips.

Holds everything!

So how does it fare on the fashion test? Not too bad if I may say so myself. It doesn’t stand out and actually looks kinda sporty. As if maybe when I’m not cruising the aisles of my local Lowe’s I might be running the route of the Boston Marathon just for fun (guffaw!). SPI Belts come in multiple colors and I got mine for a cool $20 at my beloved Amazon.

<Disclaimer> I do not work for SPI Belt, Amazon, or GlucoLift and I did not receive any compensation for this blog post.

I, Robot

That’s me in the middle, dressed up for Halloween. Circa 1977

Sometimes I feel like a robot. Like when I insert the test strip, prick my finger, apply blood, wait (5…4…3…2…1…) then promptly remove the test strip without paying attention to what the meter says. I’m on autopilot, having repeated this ritual so many times that I almost forget why I’m doing it in the first place. Then I remember, “oh yeah, I’m diabetic”.

Sometimes I feel like a robot. Like when I prepare the same meal I eat every weekday for lunch and my lips move automatically as I silently count out exactly 16 crackers then add up the carbs in the orange, cottage cheese, and 5 chocolate almonds. My calculation always produces the exact same number yet I mindlessly count the carbs every time – I can’t help myself.

Sometimes I feel like a robot. Like when I slide the cgms out of my pocket and check my number every time I stand up to walk to a meeting or go to the bathroom. I secretly brush my fingers against it hundreds of times a day just to make sure it is there. It has become the touchstone of my disease.

Sometimes I feel like a robot. Like when I sit down to dinner with the family, everyone excited to tell the tales of their day, and I have to ask everyone to wait and not talk for a minute while I consult and caress my holy trinity of medical devices: glucometer, cgms, and insulin pump, ensuring they have given their blessing for the food I am about to eat.

 

I’m aware how bizarre these rituals are, how synthetic they make me feel. I recently took a forced 2 month vacation from cgms when my Dexcom transmitter gave up the ghost and I wanted to wait for the new G4 to come out. It felt liberating to have one less device to carry, one less numeric statistic over which to obsess. Undoubtedly my glycemic control was far worse with many more highs and lows, like trying to steer with my eyes closed. I’ll continue to use my cgms even after Mya arrives, but one of the things I look forward to with a diabetic alert dog is that she’ll be so much more organic than the other tools I use to manage this disease. She’ll be a tongue-lolling, desperately-excited-ball-chasing organic partner who eats dog food instead of batteries.

 

Know your HbA1c / Pre-Diabetes

This post is really for my non-diabetic readers. If you are diabetic you are all too familiar with your HbA1c, or A1C as we commonly abbreviate it.

<DISCLAIMER>I am not a doctor and you would be a fool to make medical decisions based upon anything you read online including in this blog. 

When people find out I’m diabetic they typically have lots of questions about the disease. One of the questions/comments I get a lot goes something like this “my doctor says I’m pre-diabetic but I don’t know what that means or what I’m supposed to do with that information.”

Odds are they are hearing this from their primary-care physician (PCP) who is looking at a fasting glucose result which is where the problem starts. The problem is twofold. Part one is that – with all due respect to generalists, internists, and family-practitioners – they typically don’t know much about diabetes besides what they were taught in med-school. I don’t mean to sound harsh but the misinformation I’ve heard from my own PCP and what I hear other people’s PCPs tell them is frightening. In my experience their information is either out of date or too generalized to give them an informed understanding about diagnosis and treatment. So step one if you’ve been told you are pre-diabetic: get yourself to a specialist, aka an endocrinologist.

Step two: demand an HbA1c blood test and ask for the specific result, not just the doctor’s interpretation. The fasting glucose test, in my opinion, is fine for detecting the possibility of diabetes but is useless for diagnosis and treatment. The fasting glucose test measures your stable blood glucose (bg) at one point in time, typically first thing in the morning. The problem is that for some people this can be perfectly normal even though they are experiencing dangerously high spikes in glucose after meals and, as it turns out, it is the spikes that do most of the damage. The HbA1c test uses a clever trick to assess a 3-month average of your glycemic profile from a single blood sample and it is, in my opinion, the gold standard by which diabetes should be diagnosed and monitored.

But don’t just take my word for it, take a look at this study, or if you prefer, the less technical summary. Here’s the punchline:

Glycated hemoglobin (HbA1c) outperformed blood glucose as a predictor of cardiovascular disease (CVD) and all-cause mortality and had similar predictive accuracy for diabetes, data from a large cohort study showed.

Ok, so you’ve got your HbA1c. What does it mean and what exactly is pre-diabetes? Officially, an A1C below 5.7% is considered normal, 5.7-6.4% is prediabetes, and 6.5% and above is diabetes. So if you are in the high-fives (ha, down low, too slow!) or low sixes does that mean you are fine and have nothing to worry about? Sadly not.

The fact of the matter is that any A1C above normal (5.7) increases your risk of diabetes related complications. Take a gander at this chart from the aforementioned study (fear not the statistics and technical terms – I’ll explain it all shortly):

These four charts describe the risk of various hazards associated with levels of glycated hemoglobin – the thing that is measured by the HbA1c test. Charts B through D are the really interesting ones that show, respectively, the risk of coronary heart disease, stroke, and death. In each case the increase in risk starts pretty early – in the mid 5’s – and climbs appreciably well before reaching 6.0.

This excellent article on diabetes and eye disease has this to say about HbA1c:

 

So what does this all mean? It means that pre-diabetes is simply the short range where the risk curve starts to climb. It does not mean that being pre-diabetic is nothing to worry about and can be safely ignored.

Know your HbA1c.
See an endocrinologist.
Let’s be safe out there.

The Joy of Lows

Meter showing 42 mg/dlI was woken this morning by the telltale feeling of dread that typically accompanies my middle-of-the-night lows, but not the usual cold sweats. The meter tells the tale though – 42 mg/dl. Oh, and look at that nightly average of 55. That’s skewed a little by the fact that this is my next-to-the-bed meter that typically only gets used before I go to bed, in the morning when I wake up, and in the middle of the night if I wake up suspecting I’m low. Meters are so cheap these days that I keep one within arms reach at all times – I’ve got at least 6 meter stashes including one in each car, one in the kitchen, one in my backpack, one at work, etc. But I digress.

Unless you’ve experienced severe hypoglycemia you don’t know what hunger is. In an attempt to save itself, the body produces a voracious desire to consume anything that looks remotely edible. As much as I hate the high risk and damage to brain cells that these episodes impart, I’ve learned to find their silver lining.

This is the one time I can eat whatever I want without counting carbs or figuring out how much insulin I’ll need to cover it. It’s a thrilling moment when I open the pantry and let my eyes gaze upon the bounty before me, knowing I can devour whatever I like without guilt. Indeed, thanks to the fogbank that hypoglycemia puts me in I often stand there, gently swaying in the mental breeze, while suffering a long moment of stupefying indecision as I let my eyes taste each bag or box of starch or sweetness.

This time I started off the feast with a big glass of concord grape juice. This is officially “my” bottle in the house because I love the stuff and miss it dearly from my childhood. Needless to say I usually can’t drink anything with sugar so this is off limits except when I need a quick boost of glucose. Trader Joes Dark Chocolate Covered Pretzels provide the main course which mixes nicely with the grape juice and guarantees I’ll wake up with an interesting flavor in my mouth in the morning. I finish it off with a healthy bite of Jello which thoroughly fails to satisfy.

Ok, disaster averted. Now back to bed where I’ll lie awake for an hour waiting for the adrenalin to burn off.

Well THERE’S your problem!

Most mornings my meter greets me with a comforting number in the 90s, occasionally breaking 100 but not much more. So I was quite disheartened the other day to see 136 staring back at me. Hmmm… I did have a small bowl of ice cream while watching Major Crimes with the family (verdict: not as good as The Closer but worth watching) and, although I’m usually pretty good at bolusing for ice cream thanks to the delayed-absorbtion impact of all that fat, perhaps I misunderestimated. Still – 136 was fairly disturbing and gave me a hint it was going to be one of “those” days.

I ate my usual breakfast and took my usual bolus and SWAGged a correction for the overage. I fully expected an hour later to be back in range. But no. 185. WHAT THE FORK! Ok, now I was pissed. Time for some serious rage-bolus action.

This pattern repeated itself throughout the day. Even though I reduced my carb intake and did 40 minutes on the bike I could not seem to get my number under control. When I rang the bell after dinner at 220 even though I took an absurd quantity of insulin I decided this was no normal some-days-your-glucose-just-won’t-behave kind of day.

Pump settings normal? Check. Big air gaps in the tubing? Nope. There was only one thing left to check: the infusion site. It “felt” fine laying flatly against my skin. I had no choice but to pull it, violating my obsession with stretching how long I can go between site changes.

I could almost hear hear Jamie saying “well there’s your problem” through his walrus-styled mustache. The cannula was kinked back on itself and clearly never punctured the skin. So where was all that insulin going that I had been shooting all day? I’ll never know.

How I Got Here, Part 2

In part one I gave I gave a not-so-brief summary of my diabetes diagnosis, struggles with hypoglycemia, and how the idea of a diabetic alert dog entered my consciousness. This post will pick up where that one left off and explore how I went from thinking about a DAD to eventually committing to buying one from a trainer.

Having gotten the green light to explore a DAD I started educating myself about them and service dogs in general. DADs are a relatively new phenomenon and there are few good authoritative sources. There have been a number of high-profile stories in the media about how these dogs are helping children and adults and this has led to some misleading and potentially harmful misconceptions; some of which are being spread by what are, in my opinion, unscrupulous trainers looking to make an easy buck.

I spent hours reading websites and forums and having in depth discussions with trainers about their programs. As I expected this turned out to be the easy part of the process. I’m an engineer so I’m very analytical by nature and after long consideration was able to make some important decisions, the first of which was that I would buy a trained dog rather than train my own. While I liked the idea of training a puppy of my choosing which would save considerable money I decided that it’s a bit like home dentistry – it’s not terribly complicated but the stakes are high. Considering the role a dog would come to play in my life and the high level of obedience and focus I feel is necessary this decision ended up making itself.

The second important milestone was narrowing the list of candidate trainers to two: Scott Smith  or Mary McKnight at Service Dog Academy. Both Scott and Mary exude a dedication to their craft and a deep understanding of how dogs learn garnered from years of training. In the end I settled with Scott primarily because he was geographically closer and seemed to always have a free minute to answer questions which I deemed critical for post-sale support which I will surely need.

The most difficult barrier I had to get through ended up being in my head. Diabetes is one of many invisible disabilities. Besides the insulin pump clipped to my belt, you would never know I have a chronic disease that threatens my long and short term health. Being accompanied by a service dog wearing a vest that reads “Service dog. Do not pet” is a bit like waving a neon sign over your head saying, “I have something wrong with me and I can’t cope on my own.” Some people will stare, some will politely ask questions, some will ask not so politely and others will try to stop me from entering their business with my “pet.” (Service dogs are allowed to accompany their trainers into public establishments under the Americans with Disabilities Act.)

Thus, the decision to get a DAD is also a decision to become an advocate for diabetes and service dogs in general, and an active defender of my rights and the rights of other service dog teams. My anonymity and strong preference toward privacy will be threatened on a daily basis. This was a pretty big pill to swallow and while I’ve made peace with the idea I’m still pretty terrified at the thought of it.

On top of all this I realized that having a dog with me 24/7 is a bit like caring for an infant. Everything takes much longer and you have to haul around lots of extra gear. Getting in and out of the car takes longer. I need to think about toileting schedules all day. A dog requires lots of exercise so I’d be taking walks at least three times a day with lots of energetic playtime in between. Dogs need brushing, and petting, and cuddling… wait this is starting to not sound so bad.

The truth is that for all the challenges I will face having a new constant companion, there will be many benefits that are hard to quantify but can make a profound difference in quality of life. One day I came across this post on TuDiabetes. Terry’s eloquent words resonated within me and helped clear the fog that mired my decision. Don’t misunderstand: I know that life with a DAD will not be all rainbows and unicorns. There will be times when I will question my decision and there will be times when I want to give up. But I also believe that a DAD will help reduce the risk I face from hypoglycemia and otherwise improve my life in ways I can’t predict.

And that’s how I got here.