When I picked up Pooh Bear* for his walk on Tuesday, I immediately noticed something was off. His left eyebrow, usually bushy, was sparse, as if he had done a face plant and scraped the fur off in the process. Pooh’s parents had noticed the change too and headed to the vet for a diagnosis. The unusual location of the spot, over his eye, made the possibility of a hot spot unlikely. Hot spots can form in response to any kind of irritant but grow and linger when the dog scratches and licks the area. Without a monster tongue or ultra flexible paws, Pooh would have trouble getting enough leverage to create a full on hot spot on his eyebrow. Pooh’s dad’s money was on Demodex and the vet confirmed his suspicion. Little Pooh was suffering from an infestation of mites!
Demodex, a form of mange, is a genus of tiny, parasitic mites that feed on the skin cells and oils found in hair follicles. There are a number of different species which can infect mammals of all kinds (including humans) but demodex canis is the type most commonly found on domestic dogs. Many veterinarians believe that all dogs have a certain number of demodex mites living on their skin and most will never develop a full-blown infestation. But some dogs have fewer of the natural antibodies that help to defend them against demodex and may develop skin lesions in response to nutritional or environmental stress or an otherwise compromised immune system. Demodex is also common in newborn pups with undeveloped immune systems that may be infested by mites living on the mother’s skin when suckling. Despite popular belief, it is demodex does not seem to be hereditary, passed from mother to fetus.
Demodex infestations can be localized, like the single spot above Pooh Bear’s eye, or more generalized and found in multiple spots on the body. Localized infections are easier to resolve and may even do so without any veterinary intervention (however, adult on-set demodex may signify a more sreious underlying cause such as hypothyroidism, adrenal gland disease, or even cancer so it is important to take your pup to the vet to have him checked out). More wide-spread infestations may require closely clipping your dog’s fur, regular dips in benzoyl peroxide and Amitraz (a miticidal treatment), and possibly antibiotic therapy.
It is uncommon (though not impossible) that canine demodex will infect humans and, because demodex mites are likely present on all dogs, there is little risk that a healthy dog that comes in to contact with one suffering from a demodex infection will develop an infection of his own. To eliminate any real risk to others, though, keep your dog away from young puppies and older or sick dogs while he is suffering from a demodex infestation.
Ginny was my last Muttville foster and my first dog adoption since sweet, shy Sage – a Shepherd mix – spent a brief 18 months in my life in 2003. Volunteering for Muttville for nearly two years, I knew what to expect when adopting a senior dog and over the four months of our foster relationship, I had the opportunity to learn her health limitations. My biggest concern in giving Ginny a forever home was whether she had any internal issues that were, at this point, invisible – cancer, kidney disease, heart problems. But her blood work was clean. Ginny had other health issues, of course. She was deaf, she limped significantly in her hind legs, but neither issue seemed to bother her much and if these relatively superficial issues didn’t bother her, they didn’t bother me either.
About six weeks after officially adopting her, Ginny’s mobility issues became more serious. It became harder for her to get up, she became exhausted more easily on her walks and she panted heavily in the night. X-rays showed that Ginny had fused vertebrae in her neck and a lesion that had formed in the area. Her shallow hip sockets accounted for her strange, limping gait. Painkillers, muscle relaxants, and later, steroids, helped to bring Ginny back to her normal self. She began playing with her ball again and she rejoined her doggy buddies in her 3-day a week afternoon walking group.
Tuesday was a good day. Ginny scarfed her breakfast and dinner, greeted me with playful excitement when I returned from work, and relished the smells on her walks. That night, Ginny was tired. She slept soundly on the living room floor until bedtime. But in the middle of the night, Ginny became restless. I let her out to do her business and when she returned, her violent shaking and rapid breathing frightened me. About 30-minutes after, she settled down in another room (unusual but not alarming) and presumably fell asleep.
When I awoke the next morning, it was with surprise. Ginny, despite her inability to hear, always knew the second my feet hit the floor and would attempt to herd me to the kitchen for breakfast. This morning, she didn’t move. When I went to wake her, I found her with her eyes open, shaking, and panting. I offered her water and she turned her head. Super food-driven dogs like Ginny will only refuse treats if they are under severe stress or in deep pain so I brought her a couple. She ate them but took no pleasure in the act. I carried her in to the kitchen to prepare her breakfast. She took a couple of bites and then dropped her head. When I carried her outside to do her business, she took the opportunity, but could hardly stand or move her back legs. Later, she vomited several times.
By the time I took Ginny to the vet, she was paraplegic – unable to move her hind legs. She had lost significant function in her front legs. The vet believed she slipped a disk in her spine but couldn’t be certain without an MRI, technology that most neighborhood veterinary offices don’t have. Given her age and mobility issues, and we had to act fast; Ginny was in severe pain. Our options were limited. The first was to put Ginny on heavy morphine and keep her immobile for 6-8 weeks (i.e., in a crate) to hope that the slipped disk would adhere to its new position with scar tissue. If the disk acted as we hoped, Ginny might be able to walk again. More likely, she would regain some function in her legs and would need to be partially carried with a sling to keep most of her weight off of her legs. But even if she regained some function, Ginny would inevitably find herself back at the vet as her spine deteriorated and her pain increased. She would take morphine daily and would move around less and less. The second option was to put Ginny to sleep now, gently, and spare her from additional pain.
I chose the later. Ginny passed away a little before 11am on July 5, 2012.
Everything about this little dog in my life took me by surprise. Ginny came to me severely underweight, missing large patches of fur, covered in scabs. At her death, Ginny was soft and fluffy, her skin was clear, and her belly was soft. Ginny didn’t know any obedience when she arrived. By the time she left me, she had learned to sit, down, roll over and shake using hand signals. She walked by my side when off-leash and came to me when I motioned to her. Her initial fear of the car had dissipated to comfort and even joy. She was playful and loved to tug on her plush ball and chase it around the living room, giving goofy growls and barks. She was a constant scavenger; I’ve never seen a dog so good at finding “food” on the street or in the park. She had a spirit of a dog half her 12 years. She adored her walks and greeting dogs at the dog park.
And I adored Ginny. I often marveled at how much love I had for this silly little dog and how quickly it had developed. I loved being with her and regularly begged off of outings with friends or left early from events to go home to be with her. For eight short months, Ginny was the light of my life.
The other day I got the wonderful news that one of my clients is adding a new baby to their family…a human baby, this time. Cricket*, their first “child,” has grown in to a sensitive four-year old terrier with lots of energy, tons of love to give, and some anxiety in new situations.
Sadly, some dogs never adjust to a new baby in the home and desperate parents have no choice but to surrender their pet. Cricket’s mom and dad adore their fur baby and would be absolutely devastated to give him up – even if it was a last resort to protect their human baby – so we want to make sure that he is as prepared as possible for the upcoming change. Ultimately, there is no way to simulate a new baby in the house but exposing Cricket to some of the scents, sounds, and other changes he will experience will help him to adjust to the real thing.
Babies are loud and for a dog with a history of sound sensitivity like Cricket, it’s important to get them used to the cries and gurgles that will become a part of daily life. Buy a c.d. (or make a playlist) of baby sounds – crying, cooing, laughing, etc. – and play it (loudly) daily. Give your dog a stuffed Kong to munch on while the c.d. plays so he forms happy associations with the noises. The first several times you play the c.d., do so while you are home with your dog so that if he is frightened, you can reassure him. As he becomes accustomed to it, give your dog a Kong and press play before you leave the house.
Sudden noises, such as a baby’s cry in the middle of a quiet night, which can be particularly frightening to a dog. Single out a couple of specific noises that a baby may suddenly make, play them at random times without warning. Gather a handful of treats and when you press play, throw a shower of treats over your dog. This will teach him that a sudden cry means that great things will happen!
There are all sorts of new smells that you will bring home with your new baby. Expose your dog to baby powder or other products you will use regularly on your little one in the months before the birth by using it on your own skin and allowing your dog to sniff you. Play games with him while smelling of the baby so that he will form happy associations with these scents.
When the baby is born but before he is ready to come home, ask your partner or a friend to take a blanket or piece of clothing that the baby has been wrapped in or worn home to your dog so he can sniff it at length and get used to the new human scent.
Your dog will have to get used to the fact that you will holding or otherwise paying attention to the baby a huge percentage of the time. A person holding a baby, or carrying one in a pouch or pack, can look like a distorted monster human to a dog. Buy a life-size babydoll and practice holding and carrying it around at home, as well as simulating other common activities like changing a diaper or bathtime. Show the baby to the dog but treat the doll the way you will your real baby – don’t let your dog lick it or get close enough to jump up on it. Put the babydoll in a stroller and practice walking your dog with the baby stroller, too!
If you have friends with babies or young children, invite them over for a visit. Ask your dog to sit calmly with you and your guests and give him a Kong or treats to keep him busy while they are present.
The reality of bringing home a new baby is that you simply won’t have as much time to spend with your dog. Even though your natural inclination may be to spend more time with him now to make up for the change, it is actually better for your dog to begin spending less time with him in the months preceding the birth. This will help to mitigate the realization that new baby = less time with mom and dad.
Bringing home baby
It’s very important that your first actual interaction between your dog and your baby is a good one so go slowly. With mom having been in the hospital for a few days, let her greet your dog without the baby – he will be excited to see her! Have someone else take the baby in to the other room while mom calmly gives your dog love and treats.
After mom’s initial greeting, sit somewhere comfortable with baby and dog and reward him for being calm. If possible, have a friend or relative introduce your dog to the baby the very first time while you sit with him and give him affection. Also shower him with treats or give him a Kong to make him happy around the baby.
As time passes, be sure to give your dog some one-on-one attention each day. Since dogs are creatures of habit, try to establish a routine that is as similar as possible to the pre-baby one (make changes in your dog’s routine pre-baby to anticipate those that will come when the baby arrives). Above all go slowly and be patient; never force your dog to be around the baby if he is not interested. As things settle down over time, so will he, and you will have one big happy family!
When Ginny began to have more trouble than usual standing about three weeks ago, we visited the vet. She was diagnosed with nerve damage in her spinal cord – a condition that would continue to deteriorate with time. Unusual in a 30lb dog under ten years of age, the vet believed she may in fact be more like 10-12 years old, instead of the 8-9 years she was identified as several months ago. We were given a prescription for a ten-day course of non-steroidal anti-inflammatories and asked to call with an update when the medication was complete.
I called Dr. Leyba at San Francisco Pet Hospital first thing in the morning on Monday and arranged to bring Ginny in the following day. When I returned to pick up my girl that afternoon, Dr. Leyba sat me down for a long discussion. From his previous examination, the doctor believed he would find the issue in the lower spine or hips of my little dog. He ordered x-rays but after close examination, saw nothing unusual; spacing between the vertebrae was wide and even. He extended his search further up her spinal column towards Ginny’s head and there, in her neck, he found the issue among three cervical vertebrae. Whether from past injury or a deformity, two of these small but vital bones had grown to compensate for the problem so that they are now almost fused together. A third vertebrae, not yet fused to the others, is separated by only a thin gap.
Spinal injuries – whether in the neck or back – can have a major impact on mobility. In Ginny’s case, the muscles around her fused vertebrae are likely stressed and causing spasms that are giving her significant pain and affecting her ability to rise from laying down. The doctor prescribed muscle relaxants and steroids to bring down her level of pain and strengthen her movements and discussed our choices.
There is no easy fix here. Surgery is an option but, as Dr. Leyba told us, as with any neck or spinal surgery the procedure is painful, recovery long, and improvement not guaranteed. Management may be the more appropriate choice in a dog of Ginny’s age, but management won’t actually change anything – it will simply help to keep her as comfortable as possible for as long as possible. In Ginny’s case, Dr. Leyba recommended several things, some of which we were already doing:
– Walking Ginny only with a harness, not with a collar so as not to put pressure on her neck.
– Carrying Ginny up flights of stairs.
– Decreasing Ginny’s activity. Walking is still a great option for her but should be done in shorter bursts of 15-30 minutes. Ginny’s not a rough-houser or ball player, but if she was, we would have to cut that out.
– Giving Ginny Glucosamine to help her bones and joints.
– Keeping Ginny at the proper weight.
– Continuing steroids for Ginny after her initial course is over. We will likely begin at a pill every other day but this will increase in frequency as she ages.
Eventually, Ginny’s pain will become so severe that she will need daily opiates and, when those no longer help, the time will come to consider putting her down. Dr. Leyba feels confident that Ginny still has a couple of good years left if we pay close attention and do everything we can to keep her comfortable. Sadly, this is always a hazard of adopting a senior dog but I do not regret my decision. As when Franny came to me as a hospice dog, I am honored to give Ginny the best life she can have over her remaining years.
Some nights Ginny wakes me up with heavy panting. Occasionally she gets to her feet and wanders in to the kitchen to gulp water and then returns to bed. But last night she lay there for hours, panting. Maybe she’s just feeling too lazy to get up, I thought. I grabbed a bowl of water and offered it to her. She drank a bit then turned her head away. A little later, the panting began again and she drank a little more water. But the panting continued. This is unusual; her nighttime panting is usually brief and easily quelled.
Panting is normal in dogs and usually comes after exercise or in excessive heat. Panting is also a common sign of stress and it can indicate chronic illness such as congestive heart failure, Cushing’s Disease, or respiratory disorders. Franny, my beautiful fospice dog who passed away with cancer in November, had Cushing’s. She would pant at night, too, but Franny drank ridiculous amounts of water, Ginny doesn’t. She also doesn’t display any of the other common symptoms like hair loss (on the contrary, Ginny just keeps getting fluffier) or a pot-bellied appearance. While heart failure is always a possibility, Ginny had a series of blood tests done a little over a month ago and there was nothing unusual. Respiratory failure often leads to heavy breathing throughout the day and Ginny rarely pants at unexpected times other than over night.
Heavy panting may also accompany an injury or pain. This is what concerns me. Since Ginny arrived in my home, she has dragged her back leg. It’s a stiffness that doesn’t seem to bother her – she limps a bit but enjoys walks – and manipulating her leg doesn’t cause her to flinch. But the last week or two I have noticed that Ginny’s leg has become more stiff. She has more trouble getting up and takes longer to get a “normal” gait. This change, combined with last night’s panting, may indicate that Ginny’s pain has increased. Ginny topples over quite a bit and has lately missed a occassional stair and slid backward down a couple of steps. Whether she does this because of pain or she has inadvertently increased pain, I’m not sure, but I do know that sudden behavior changes often indicate a health problem. So what next? A visit to our friendly vet!
When I first told my best friend Serena that I was going to become a foster parent for Muttville Senior Dog Rescue she literally laughed in my face saying “there’s no way you’ll be able to give up a dog!” Two years later, I am proud of the nearly one dozen dogs for whom my home has provided a safe haven before passing on to their forever families (or, in the case of my darling Franny, passing out of this world). But last week, Serena’s prophecy finally came true; I found a dog I couldn’t give up.
In dog rescue terms, a foster family that ends up adopting their charge is called a “failed foster” – good for the pet, bad for the organization who depends on foster families to rescue dogs from shelters with low resources and high euthanasia rates. Over the last couple of years I’ve run in to a number of people who have told me they “used” to foster or “tried” fostering but just couldn’t let go of the dog they were supposed to care for “temporarily.” I completely understand this. I’ve fallen in love with every single one of my foster dogs – gentle Cassie, spunky Layla, loveable Arkie… And the longer they stay, the harder it becomes to imagine your life without them. I still regret giving up Debbie, the toothless ten pound Pomeranian that lived with me for four months.
But there is something about Ginny that is different. She came to me as a skinny, frightened creature. She had big patches of scabs on her back and stomach and a ratty, hairless tail. Deaf, missing half an ear, and dragging her right hind leg, if you had told me three months ago that this was the dog for who would be my fostering kryptonite, I wouldn’t have believed you. But Ginny has blossomed over the months in to a fluffy and charming little lady. She now knows several commands (taught using hand signals, of course) and is even learning to enjoy the car, a thing she first feared. Ginny is far from perfect – we will be managing her on-leash reactivity issues for the rest of her life – but the thought of her soulful brown eyes looking up at some other guardian just broke my heart… Completely by accident Ginny found her forever home.
I failed this time around, I admit, but if my past record is any indication, I have a dozen more dogs to look forward to fostering in the future!
Thanks to popular culture, the concept of dominance in dogs has become widespread. Your dog won’t come when you call? Well he must be dominant. Your dog always sleeps on the bed? He’s showing you he’s dominant. You dog rushes ahead of you when you open the front door? Dominant.
But dogs, as individuals, are not “dominant”. Dominance is not a personality characteristic (as in, my dog is energetic and dominant), it is found in relationships between individuals. By definition, dominance refers to an individual’s ability to take charge of or influence others but to be dominant requires the presence of those other individuals; I can’t just walk around by myself being dominant.
Let’s apply this concept to some beloved friends. Take Lassie, Rin Tin Tin, the Taco Bell Chihuahua and Spuds Mckenzie, the Bull Terrier spokesman for Budweiser in the 80’s. On their own, these dogs are noble (in the case of Lassie and Rin Tin Tin, at least), loveable, and obedient. Now put all four of them in to an empty room for 24-hours with only one food dish delivered 12 hours in to the experiment. It is highly likely that one or more of these dogs will dominate the others in order to eat as much of the food as possible but I’m not sure I could place a reliable bet on which dog that would be. That’s because in this specific context, Lassie may be the first to get to the food and protect it from the others or Spuds McKenzie might bully the others and fight them off. Does that mean Lassie or Spuds are dominant dogs? No. It means that in this specific context, one dog gained the upper hand and wielded power over the others in order to get what it wanted. In this context that dog “dominated” the others. Dominance in dogs is based on a loose hierarchy that may be established when two or more dogs interact. But this is an unstable and constantly shifting hierarchy. Let’s go back to our empty room. What if we suddenly throw two more dogs – Goofy and Pluto – in to the mix (ok, I realize these are not actual dogs, but bear with me here…)? Suddenly, the relationship that was established among our original four dogs changes to take Goofy and Pluto in to account. Even if Lassie acquired the food before, now it may be Pluto who is the most adept at securing resources for himself. Does this mean Lassie is a submissive dog? No. It just means that in this new context she is no longer the individual with the power.
If a dog can never be described as “dominant” how did this idea of a dominant or alpha dog become so entrenched in modern-day dog training? The concept was first developed by Austrian animal behaviorist and Nazi Party member, Konrad Lorenz, in 1949. Lorenz made many contributions to the understanding of dog behavior, but he was also highly influenced by the times in which he lived when dominance and submission applied to dictators and peons, to violent victors and overcome nations. Lorenz’s theory of canine dominance and submission closely mirrored these historical patterns of human action: submissive dogs will roll over (literally and figuratively) under the aggressive leadership of a dominant dog. In the relationship between humans and dogs, he believed, humans are dominant and should express that dominance any way necessary, including through physical means.
Over the following decades, the concept of dominance became standard in dog training and generations of dog owners were taught that the only way to produce an obedient dog was through punishment that proved the dog owner had the power. After the identification of “pack leaders” in the 1970s, research on wild wolf packs was used to support the theory. Unfortunately, this was a case of interpreting the data to fit the theory instead of the other way around. Wolf packs are family groups which are naturally led by wolf moms and dads. Just as in human families, when offspring mature, they leave to go and begin families of their own, they do not stick around to challenge their parental figures for leadership status. “Leaders” emerge in the pack not because one is more dominant or aggressive than another, but because parents must take charge over their children to keep the whole family happy and healthy.
Free ranging dog packs (when they form packs, which is not a given as in the wolf world) differ from wolf packs in that individuals may not have familial ties. But even in this case, dogs fail to establish and cede all power to one “leader.” Instead, as shown in research by Roberto Bonanni (2010), adult individuals take turns in the leadership position according to which dog can contribute most to the pack at any given time. In the pack he studied, Bonanni witnessed at least half of the dogs taking the “lead” at some point (with six individuals in regular rotation at the head of the group) according to which dog could make the strongest contribution to the pack’s welfare in any given context.
So if the idea of canine dominance is invalid, and establishing yourself as the “alpha” in your relationship with your dog is unnecessary and, in many cases, cruel, how should we approach dog training? Luckily, there is not only an alternative, but one that has been proven to be more effective in training dogs. This method – positive-reinforcement training or reward-based training – is in many ways the polar opposite of training that uses physical dominance, pain, and intimidation as a tool. In positive-reinforcement training, the dog is rewarded with something it loves (food, toys, or even praise) when it does something good. This basic tenet opens up tons of possibilities for training a dog to do something positive to replace a behavior you dislike (instead of punishing the “bad” behavior) and for shaping a dog to do fun tricks. Instead of instilling fear in your dog which may lead or exacerbate aggression, reward-based training (in both operant and classical forms) can decrease fear, build a dog’s confidence, and strengthen the human-canine relationship.
With positive-reinforcement training’s record of incredible results in obedience and behavior modification, there is absolutely no reason to use intimidation to train your dog. Really, wouldn’t you rather have your dog love to work for you than fear your presence?
A few weeks ago I go an email from Bethany*. Her family had recently added a new canine member, Chloe*, and she was looking for a little guidance in furthering her training. At the age of three, Chloe had never been housebroken or taught basic commands so we set to work turning her in to a tiny, obedient ball of white fluff. A few sessions in to our training, Bethany asked if I knew anything about the peach colored stains developing under her eyes, on her paws and on her rear end. Though I was used to seeing this discoloration on white dogs, I had to admit that, no, I didn’t know anything about the staining. So, to the internet I went for a little research on the topic.
Discoloration on a dog’s coat is often caused by a yeast infection called Ptyrosporin or “red yeast” that develops from tears and saliva – though other possible causes include the oxidation of saliva or artificial dyes from foods and toys. This discoloration is most common in dogs with white coats but any dog can have excessive tearing if the eye sockets are too shallow, hair grows too close to the eye, or tear holes (puncta) become blocked due to inward turning eyelids or previous eye infections or damage that causes scar tissue. Some dogs – especially short-nosed breeds like Pekingese and Maltese – are more susceptible to these eye issues.
In the case of blocked tear ducts, there may be surgical options that can improve the drainage around your dog’s eyes but those dogs with shallow eye sockets are, unfortunately, stuck with them. In any case, minimizing irritation and discoloration is an option. Keeping hair short around the eyes can help, so can keeping the eyes clean. Your vet may prescribe antibiotics to reduce or eliminate tear stains but going this route could be dangerous if the bacteria forming the stains becomes drug resistant. If the cosmetic issue is paramount for your pup, there are a number of tear stain removers on the market. Carefully wiping the stains with hydrogen peroxide may also help to whiten the area.
If your dog is impacted by the staining of red yeast, check with your vet before beginning a whitening routine to rule out damaged tear ducts that may be further irritated by harsh products.
Every dog is different and it can take some time to get to know the quirks of each individual. The first week I walked Lambie*, I was taken by her sweet, plucky nature but I was also concerned by an odd characteristic that seemed to come and go. As Lambie walked, particularly the faster she moved, she lifted her back leg. The action happened every few seconds – Lambie lifting her leg up, putting it down, and lifting it up again – and it was intermittent, occurring a few times during an hour-long walk. Having just met Lambie, I became concerned that she may be experiencing pain or have something prickly stuck to her paw but after checking her paw several times and manipulating her leg to see if she flinched or yelped, it seemed nothing was wrong.
I debated whether to talk to Lambie’s dad about it but, the more I thought about it, I began to recall other dogs in which I had seen this strange leg lifting action. Paku, the five-pound Chihuahua that temporarily resided in my home lifted one of his back legs up while running around the house or when he was let outside to do his business. Bertie*, a lovely Shiba Inu that brightens my world three days a week will lift up a leg while she runs at top speed down the stairs towards her building’s front door on the way to a walk.
In many cases, this action is caused by a luxating patella or “trick knee;” as the dog moves, the knee cap slips out of its socket. A luxating patella is most common in small breed dogs with weak ligaments, tendons or muscles and in dogs with a narrow or shallow kneecap groove. You may see a trick knee in one leg or two and there are different degrees of severity. The first grade – the lowest one – is when the kneecap can be moved by a vet but won’t slip out-of-place on its own. The second grade – the level that seems to be affecting Lambie – is a kneecap that occasionally slips (luxates) back and forth as the dog moves. Grades three and four may regularly cause pain through chronic lameness (grade three) or a kneecap that has permanently slipped to the side (grade four).
If your dog doesn’t seem to be experiencing pain, grades one and two probably aren’t causing any major problems. It may be a good idea to keep an eye on your dog’s movement and get the knee(s) checked out every couple of years by your vet to make sure pain doesn’t develop. If there is pain, your vet may prescribe a non-steroidal anti-inflammatory medication (steroidal meds have been proven to negatively impact the immune system and cause serious side-effects) which will not fix the problem but will help your dog to feel better. In very serious cases, your vet may recommend surgery. To help keep your dog’s condition from progressing, supplements such as Glucosamine may help; so may keeping your dog trim, his exercise moderate, and his diet high quality.