VOICE OF THE DIABETIC

VOICE OF THE DIABETIC, published quarterly, is the national news magazine of the Diabetes Action Network of the National Federation of the Blind. It is read by those interested in all aspects of blindness and diabetes. We show diabetics that they have options regardless of the ramifications they may have had. We have a positive philosophy and know that positive attitudes are contagious.

News items, change of address notices, and other magazine correspondence should be sent to: Ed Bryant, Editor, Voice of the Diabetic, 1412 I-70 Drive SW, Suite C, Columbia, Missouri 65203; Phone: (573) 875-8911; Fax: (573) 875-8902.

Find us on the World Wide Web at: (www.nfb.org) and follow the links for "diabetes."

Copyright 2002 Diabetes Action Network, National Federation of the Blind. ISSN 1041-8490

Note: The information and advice contained in VOICE OF THE DIABETIC are for educational purposes, and are not intended to take the place of personal instruction provided by your physician, or by your health care team. Discuss any changes in your treatment with the appropriate health professionals.

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INSIDE THIS ISSUE

AN INSPIRING EXAMPLE

VIRUS LINK TO CHILDHOOD DIABETES

IS IMMUNOSUPPRESSION JUSTIFIED TO ACHIEVE INSULIN INDEPENDENCE?
by Donald Sutherland, M.D., Ph.D.

NFB NEWSLINE NOW NATIONWIDE
by Peggy Chong

METFORMIN WARNINGS

KIDNEY DISEASE: PREVENTION, DIALYSIS OR TRANSPLANTATION
by Ed Bryant

DOCTORS URGE EARLIER DIABETES SCREENING

ORGAN DONATION: THE LIVING OVERTAKE THE DEAD

TEACHING OURSELVES ABOUT DIABETES
by Helen Aldrich

ASK THE DOCTOR
by Wesley W. Wilson, M.D.

COMPLEXITY OF INSULIN THERAPY HAS RISEN IN THE PAST DECADE

INSULIN TYPES: A REVIEW

RECIPE CORNER

YOUR DIABETES CARE SHOULD FIT YOU
by Ann S. Williams, MSN, RN, CDE

CORRESPONDENCE BETWEEN MINIMED AND THE DIABETES ACTION NETWORK OF THE NATIONAL FEDERATION OF THE BLIND
by Ed Bryant

PAYING FOR DIABETES
by Peter J. Nebergall, Ph.D.

BOOK REVIEWS
by Marilyn Helton

BEYOND OUR SENSES
by Chris Kuell

WHAT YOU ALWAYS WANTED TO KNOW BUT DIDN'T KNOW WHERE TO ASK
(Resource Column)

FOOD FOR THOUGHT

AN INSPIRING EXAMPLE

Photo included: Caption: Evelyn Engelhardt

Evelyn Engelhardt, now 81, has had diabetes for more than 70 years. In September 1931, she began to show the classic symptoms of the condition: the thirst, the weight loss... She dropped to 86 pounds, and her parents thought she had a tapeworm.

Her old family doctor figured it out. He checked her urine, and "said she had sugar." But he hadn't ever heard of insulin (it had been out ten years), so he put her on "a real strict diet of gluten bread."

It didn't help, of course. About a year later, in 1932, she went into a "diabetic coma," from the untreated high blood sugars. She was "out cold" for 72 hours. She could have died. Her mother told her they used to call her condition "consumption."

But her aunt knew a doctor at Good Samaritan Hospital, there in Cincinnati, who "knew something about diabetes." Into hospital Evelyn went -- and they kept her there a month. "I got to know the nurses really well," she says.

Evelyn didn't think what she had was all that bad, but her mother did -- and kept her out of school for the next year. During that year, her mother made sure that Evelyn took her three shots of regular insulin (the only kind they had) on time, every day. Evelyn also learned to weigh her food, and to test her urine for sugar, using a test tube and Bunsen burner.

Evelyn notes that once her diabetes was under control, her personality changed. She became president of her high school freshman class. "I was outgoing; I was in all the best groups, you know!"

Now the "gloom and doom" folks, the ones who'd have you wondering how anyone survives the onset of diabetes, would have you certain that a diabetic child in the 1930s would have had a miserable time of it. Not so.

"A bunch of us girls were going to Coney Island (Cincinnati's amusement park), and, while we were there, I went into insulin shock," says Evelyn. "The other girls didn't know about me having diabetes, what it really meant. I said to one friend, 'Do you have a candy bar?' I ate the whole thing, and I came out of it. To this day, she'll say to me: 'I can remember that day, when you had that insulin shock.' She always reminds me of that.

"When I was in high school," Evelyn reports, "I'd love to dance, but when I'd go out on dates, I was a cheap date. I'd have just one highball, and I'd dance away. I remember one night we went out, we went out and had a big eggs and chicken, and I thought 'boy, I'm off my diet," and well, the next morning, I was in trouble -- I had insulin shock."

Like many of us, Evelyn had discovered the power of physical exercise to burn blood sugars. We still face the same risks, but nowadays, we have blood glucose monitors, and if we test regularly, we can see those "lows" coming, and take the necessary action.

Those were the early days; folks didn't know anything like what we do now about taking care of diabetes. Still, Evelyn kept up her diet, her exercise (she loved dancing!) and she prospered. As self-care improved, she adopted the new techniques, like regular blood glucose monitoring.

Evelyn and husband Robby have been married for 56 years, and they have two daughters, now 50 and 46 years old. They have four healthy grandchildren. "It's not the easiest thing in the world to have children when you're diabetic, but it's certainly worth everything I went through," she says.

Now she wants to help children who develop the condition, like she did. "I want to give them hope," she says. They don't seem to have much hope that they're going to live very long. It IS possible, if you take care of yourself."

It hasn't been completely smooth sailing. Lately, she's had some problems with hypoglycemia. "I don't know if it's on account of my age, or what, but I'm having a heck of a time getting that cleared up now. The doctor I have now took me down to almost nothing as far as my insulin's concerned. He is gradually building it up again. I'm taking about eight units less than I was, and it works."

And Evelyn knows how important it is to find a good doctor, someone who fully understands diabetes. "It's working pretty good right now. Finally, I'm not getting these shocks."

She is upset that diabetes researchers have isolated neither cure nor cause for type 1 diabetes. "For as long as it's been known, you'd think they'd have more information. And, they haven't found a cure for it after all these years."

There are many veteran diabetics like Evelyn Engelhardt, and if you ask them how they made it 50, 60, or more years without significant complications, they all seem to say the same thing. Evelyn quotes her daughter, who owns a restaurant: "Mom, you really do take care of yourself. I wish you'd see the people who come to this restaurant, who are diabetic, and think nothing of ordering pie, cake, you know..."

But she never slipped up, and she's gone the distance: more than 70 years with type 1 diabetes. Evelyn Engelhardt is living proof that with diligence, diabetes can be conquered. She is an inspiring example to us all.

She would like to correspond with others interested in diabetes. Write to her: Evelyn Engelhardt, 9191 Round Top Road, Apt. 234, Cincinnati, Ohio 45251-2492.

VIRUS LINK TO CHILDHOOD DIABETES

This story first appeared in BBC ONLINE (www.bbc.co.uk/news), May 24, 2002.

Reprinted with the permission of the British Broadcasting Corporation.

UK scientists have found strong evidence suggesting that diabetes is caused by a virus. The finding raises the possibility of developing a vaccine for the disease.

The researchers have discovered a marked difference between the way the bodies of healthy individuals and those newly diagnosed with diabetes respond to a virus known as Coxsackie B4.

Dr Mark Peakman led the three-year-study at the Department of Immunology at Guy's, King's and St Thomas' School of Medicine. He said: "The implications are clear: if viruses have a proven role in the disease, there is the future possibility of developing vaccines to prevent infection and therefore type 1 diabetes."

Type 1 diabetes is an autoimmune disease in which the body lacks insulin, the hormone which controls the sugar levels in the bloodstream. People with the condition have to inject insulin daily instead.

Serious form

The disease usually begins in childhood, affecting as many as one in 200 people. It is also on the increase. Type 1 can lead to blindness, kidney failure and heart disease in later life.

The cause of the disease is not clear. However, it is most likely to be due to a complex interaction between a person's genes and their environment. Various studies have suggested that a group of viruses could be a trigger, stimulating the immune system to attack and 'kill off' the cells that produce insulin. But until this study the evidence has been indirect and the immune cells involved unclear.

Dying patient

The research team focused on the Coxsackie B4 virus (CVB4), a bug that causes typical viral symptoms and is most commonly found in children. Several years ago, a strain of this bug was recovered from the pancreas of a child dying from type 1 diabetes. Using the genetic code of the virus and the latest DNA technology, the researchers were able to grow key parts of the virus.

They then tested how the body responded to the virus using blood samples from 40 type 1 diabetics who had been diagnosed within the last five months. The team found that CVB4 did stimulate the immune system very readily. However, the response of the diabetics was more pronounced, which suggests that the diabetics had been exposed to the virus in the recent past, or repeatedly over time, and so were already primed to take action.

The research, funded by the UK charity Action Research, is published in the journal DIABETES.

IS IMMUNOSUPPRESSION JUSTIFIED TO ACHIEVE INSULIN-INDEPENDENCE?

by David Sutherland, M.D., Ph.D.
Director, Diabetes Institute for Immunology and Transplantation
University of Minnesota, Minneapolis, Minnesota

(Copyright 2002, by INSULIN FREE TIMES magazine
(www.insulinfreetimes.org), reprinted with permission)

Currently, the only two treatments that sustain life for people with type 1 diabetes are exogenous insulin provided by injections or pumps, and beta-cell transplantation with ongoing immunosuppression. Beta-cell transplantation may be achieved by transplanting the complete pancreas organ or by transplanting the insulin-producing cells alone.

Besides providing the highest daily quality of life possible, a principal objective of today's treatments for insulin-dependent diabetes is to reduce secondary complications, or in the case of a transplant, to reduce the side effects of the immunosuppressive drugs. It is known that the lower the average blood sugar level, the lower the incidence of secondary complications. Unfortunately, other than consistent and sustained perfect blood sugar levels, there is no threshold below which complications do not occur, and attempts to provide such control with current insulin delivery systems give an unacceptable incidence of dangerous hypoglycemic events. Theoretically, a closed loop, insulin-pump system with an insulin secretion rate that is adjusted continuously by an implanted glucose sensor could do so; but a practical device does not yet exist.

Today, only beta-cell transplantation offers the consistent and sustained perfect blood sugar levels that are known to protect against the chronic and acute complications caused by diabetes. To achieve this state, however, a person with diabetes must weigh the risks of surgery and immunosuppression against the risks of insulin treatment, including secondary complications and the relentless burden of modern diabetes management.

For diabetic kidney transplant recipients, the addition of a beta-cell transplant is not debatable: kidney recipients are already obligated to take immunosuppression, so the choice is whether to be a transplant recipient with diabetes, or a transplant recipient without diabetes. Clearly, most people faced with this choice, will choose to be free of diabetes. The long-term success rates for kidney transplants is better if a pancreas is added, whether at the same time as the kidney, or later. The only possible debate for the person with diabetes and kidney failure is whether to choose dialysis to avoid immunosuppression, or immunosuppressive treatment in order to have a successful kidney transplant. Nephrologists routinely advise immunosuppression, and their patients routinely benefit from that advice.

For people with diabetes who do not have kidney disease, the primary benefit of beta-cell transplantation in conjunction with immunosuppression is insulin-independence, just as a dialysis-free state is the principal benefit of immunosuppression for a non-diabetic kidney recipient. Of course, secondary complications of diabetes are also prevented or ameliorated for the beta-cell recipient. In either case, to be dialysis-free or insulin-independent may be worth the price of immunosuppression.

What are the risks of a beta-cell transplant? Even for the surgically invasive pancreas transplant, the mortality rate is less than 1%, and may be lower than the mortality rate caused by insulin-induced hypoglycemia over time. The risk of requiring additional surgery to treat complications following a pancreas transplant is now approximately 10%. The immunosuppressive risk of lymphoma is less than 1%, and the risk of kidney disease progressing because of the side effects of certain anti-rejection drugs is approximately 10%, no higher than the incidence of progressive secondary complications in the intensive insulin treatment arm of the Diabetes Control and Complications Trial (DCCT). In some patients, pre-existing kidney disease may even reverse.

The time has come for diabetologists to view diabetes as nephrologists have viewed kidney disease; internal organ or cellular replacement, even with the need for immunosuppression, can be preferable, for an individual patient, particularly those burdened by an unsatisfactory response to the needle-intensive approach. The rate of insulin-independence for a pancreas transplant alone is nearly 80%; and continued insulin-independence five years post-transplant for transplants done since the introduction of new immunosuppressants in the mid-1990s are greater than 50%. With the immunosuppressants introduced in the mid-1990s, nearly 80% of pancreas-alone recipients have remained insulin-independent at one year, and over 50% are still insulin-independent at 5 years.

When donors and recipients are carefully selected to meet certain criteria, the success rate for islet transplants is approaching that of pancreas transplants. Currently, insulin-producing beta cells are destroyed to such a degree during the islet isolation process that to succeed using islets from a single donor requires using a pancreas from a large donor for recipients with a low body mass index or low insulin requirements.

In order to use the limited number of donors available to achieve insulin-independence in the largest number of recipients, with no more surgery than necessary, a common waiting list and allocation system for beta cell transplants is being implemented; candidates with low body mass index or low insulin requirements will receive islets isolated from the pancreases of donors with high body mass indexes, while those with high insulin requirements will receive a vascularized, whole pancreas organ from pancreas donors with low body mass indexes.

With either technique (whole organ or cellular), if the transplant fails, immunosuppression is stopped. If it continues to function, the side effects of immunosuppression over time have not been shown to occur in greater incidence or severity than the side effects of diabetes. Quality- of-life studies in beta-cell transplant recipients have uniformly shown a preference for immunosuppression over diabetic treatment, and nearly all who lose graft function opt for a retransplant.

Beta-cell transplantation, even with immunosuppression, should be applied to the extent organs are available for the treatment of diabetes. Indeed, the use of immunosuppression to prevent the loss of native insulin-producing beta cells in the pancreas of people with type 1 diabetes with a sufficient mass of cells to still be insulin-independent at the time of diagnosis should be revisited with the modern immunosuppressive agents now available .

NFB NEWSLINE NOW NATIONWIDE

by Peggy Chong

Photo included: Caption: Peggy Chong

Developed by the National Federation of the Blind, NEWSLINE is a free service used by blind subscribers to read newspapers through any touch-tone telephone. Thanks to a one-year grant through the Institution of Museums and Libraries, subscribers in all 50 states, the District of Columbia, and Puerto Rico, will soon be able to access every newspaper that NEWSLINE currently supports. Although NEWSLINE has covered large population areas in over 30 states for the past few years, over half of our country has not been able to access it without calling long distance. As soon as this service is online, any blind person registered for NEWSLINE can dial a new toll-free number, 1-888-882-1629, to access all the newspapers carried on the service.

Readers already using NEWSLINE will find the new expanded service easy to use. Pick up any touch-tone phone, dial the NEWSLINE number, listen to the menu, and choose options by tapping numbers on the phone keypad. Instead of the usual three national papers available each morning, subscribers can read over 50 newspapers, from across the country. Consider how interesting it will be to read the newspaper from a city in which a big story is breaking. In addition, NEWSLINE's non-newspaper features, which are currently available in each area, will now be available with all of the newspapers.

NEWSLINE is available, free of charge, to anyone at least legally blind. To register for this new nationwide service, or to check for updated information, contact the National Federation of the Blind, at the National Center for the Blind in Baltimore, see the NFB's monthly magazine, the Braille Monitor, call the local news option on your local NEWSLINE, or contact a local leader of the NFB in your community, or visit the NFB Web site: www.nfb.org

The NEWSLINE application is a one-page form. Get a copy of the form, fill it out completely, and return it to: NEWSLINE, National Center for the Blind, 1800 Johnson Street, Baltimore, Maryland 21230. Because NEWSLINE service requires a signature, prospective subscribers must acquire or copy a print NEWSLINE application form. A copy may be downloaded from www.nfb.org Forms are often available from public libraries, or may be requested from local leaders of the NFB or from the National Center for the Blind in Baltimore .

NEWSLINE hereby requests all subscribers -- help us to spread the word about this wonderful opportunity. Please help us spread the word to special education departments, teachers, or schools serving blind students, and anywhere else Americans can be found who cannot read the newspapers because of their eyesight. National headlines or local stories, sports, Ann Landers, or letters to the editor and social commentary--there is much that our sighted neighbors and coworkers are enjoying, thinking about, and talking about. Now we can, too.

If you or a friend would like to remember the Diabetes Action Network of the National Federation of the Blind in your will, you can do so by employing the following language:

"I give, devise, and bequeath unto the Diabetics Action Network of the National Federation of the Blind, 1800 Johnson Street, Baltimore, Maryland 21230, a District of Columbia nonprofit corporation, the sum of $_______________" (or "_______________ percent of my net estate" or "the following stocks and bonds:____________________") to be used for its worthy purposes on behalf of blind persons."

METFORMIN WARNINGS

Metformin (Glucophage) is a well-known and widely-used oral diabetes medication. Used alone or in combination with the sulfonylurea Glyburide (the combination is called Glyset), it is a powerful and effective treatment for type 2 diabetes. Used according to instructions, it is reasonably safe.

All powerful medications have potential for side effects; a "harmless" medication would be a powerless one. Metformin is packaged with many warnings, "contraindications," they are called, against using when pregnant, against use in the presence of significant kidney problems, against use of Metformin when a person is a heavy drinker, or when a person has a history of congestive heart failure. These warnings are clear, and some of them are even supplied in bold print, inside a black box, so the prescribing physician will see them and consider them.

Recent findings suggest too often the physician is not paying attention to the warnings. Approximately 25 million prescriptions for Metformin are now written each year; but in a recent study, conducted at University of North Carolina at Chapel Hill, a random selection of 100 diabetics who'd been prescribed the drug found that 22 of these individuals had received it in spite of kidney dysfunction, congestive heart failure, or both conditions. The warnings packaged with the drug had been ignored.

Metformin works well, if you, and your doctor, follow the instructions. Please make certain your doctor is aware of your conditions and your lifestyle - and be sure to discuss with your doctor the risks and side effects of this and other medications. For medications to be safe, everyone must do their part.

KIDNEY DISEASE:
PREVENTION, DIALYSIS, OR TRANSPLANTATION

by Ed Bryant

Photo included; Caption: Ed Bryant

I have a special interest in renal failure, as I have had a kidney transplant for almost 19 years, and I feel great. I know folks who've had transplants far longer than I have, and they're doing fine, too. I hope the following answers some questions.

Prevention Comes First

"I'm sorry, but your kidneys are beginning to fail ..." If you hear those words, what do you do next? Knowing that nephropathy, kidney failure, is a frequent complication of diabetes, do you sit and wait to get worse, or do you act? What can YOU do to prevent, minimize, or slow kidney failure?

The Diabetes Control and Complications Trial (DCCT), a large, long-term, federally-funded study of the relationship between diabetes control and the onset of complications in type 1 diabetics, found that there was a tight statistical link between quality of diabetes control - and ramifications such as heart and blood vessel disease, diabetic eye disease, and diabetogenic kidney failure. The British UKPDS (United Kingdom Prospective Diabetes Study), a similar long-term look at type 2 diabetes, found the same pattern of results. We now know the tighter your control, the less chance you will experience complications. (Note the linkage is not absolute; you can do your best and still face these ramifications, though the statistical risk-reduction is clear.)

The DCCT's findings are not mysterious. High blood sugar causes diabetes complications; and the better job you do of keeping your blood glucose numbers down where they should be, the less your chance of developing conditions such as nephropathy. The importance of this cannot be overstated: Good self-management is the BEST way to cut the risk of experiencing diabetes complications.

There are other things you can do to cut the risk. Some of them come under the heading of "healthy lifestyle." First, don't smoke. Nicotine, the narcotic active ingredient in tobacco, is a vasoconstrictor, raising blood pressure, stiffening capillaries, and making it harder for the kidneys to filter wastes.

Urinary tract infections need prompt treatment, to limit the damage they can do to already strained kidneys. Tell your doctor promptly if you think you have such an infection.

Excessive obesity both raises blood pressure and increases insulin resistance. Keeping your weight at or below your recommended level helps in general, and the resultant blood pressure drop is good for your kidneys.

You need to control your cholesterol, as too much of this fatty substance in your blood overworks (and can even clog up) your kidneys. Diet, exercise, and appropriate medications can lower your cholesterol levels. Consult a Registered Dietitian (RD) for advice.

Heart specialists have known for years that high levels of stress can be damaging. Excessive stress, driving up blood pressure, can harm the kidneys by raising fluid pressure, further straining already weakened filter networks. Stress reduction is part of a healthy lifestyle. Ask your health care team for advice here.

There is a lot of disagreement among doctors over the specifics of what will prevent kidney failure. So much is genetics; more may be environment, or other factors we are not yet aware of. Other than "keep your diabetes under the best possible control, and live a healthy lifestyle," we can offer little advice about prevention. A manual, titled: THE PREVENTION AND TREATMENT OF COMPLICATIONS OF DIABETES MELLITUS, published 1991 by the Centers for Disease Control (and now available on the Web, at: http://www.cdc.gov/diabetes/pubs/complications/index.htm), states: "At present, strategies for preventing diabetic nephropathy must be viewed as limited in their effectiveness, since the exact pathogenic factors responsible for this condition are unknown."

The document continues: "In patients with albuminuria, blood pressure regulation is of critical importance in slowing the progression to renal failure. Other strategies that may slow the progression to renal disease include limiting the patient's protein intake, maintaining good glycemic control, promptly treating urinary tract infections, and avoiding potentially nephrotoxic drugs and radiographic dyes." (Certain dyes used for x-rays of the circulatory system can further harm damaged kidneys.)

As the above quote states, once kidney disease is diagnosed, a great deal can be done to retard its progression, and sometimes interventions such as described above are sufficient to keep the need for dialysis or transplantation well at bay. Current statistics suggest perhaps four out of every ten diabetics may experience measurable kidney disease, though with considerations such as described in this article, many of these individuals should be able to avoid progressing to outright kidney failure, End Stage Renal Disease (ESRD).

If you do your best and still experience kidney failure, it is not time to despair. Whether you choose transplantation, or one of the forms of dialysis, the outlook is good and getting better all the time.

Testing Your Kidney

How is the severity of kidney disease measured? Several tests measure creatinine, a waste product from muscle mass. Although everyone's body produces creatinine, people whose kidneys are failing cannot properly excrete it. One test measures the amount of creatinine in the blood, and the other is "creatinine clearance," a 24-hour urine test. Normal "blood creatinine," for someone with healthy kidneys, is about 0.7 to 1.3. Government guidelines (April 1995) recommend dialysis when the blood creatinine rises to 6 or above (the number rises as you get worse). However, some diabetics will experience kidney failure before that point. There is much variation between individuals who have ESRD, and the actual range for "kidney failure" runs from 3 through 8-but at or above 6, Medicare will pay for dialysis.

"Creatinine clearance" is considered a more reliable test. In this 24-hour urine test, the numbers produced approximately indicate the percent of normal kidney function remaining to the individual (the number goes down as you get worse). The 1995 government guidelines (which relate to Medicare part B eligibility) state they will fund dialysis when the test produces a reading of 15 or less.

Two other tests measure protein spillage into the urine. These are the microalbumin test and the test for proteinurea. The protein albumin is not normally excreted into the urine, and its presence in the urine, in small amounts (microalbuminuria) or larger concentrations (proteinurea) can indicate kidney disease. While not considered absolute diagnostic evidence, a positive finding in either should be immediately followed by further testing, as these tests are very sensitive, and the microalbumin test can detect kidney disease long before the other tests-allowing earlier medical intervention.

Options

Individuals experiencing impaired kidney function, but whose test results indicate they do not yet need dialysis or transplantation, might benefit from two new therapies. The first is regular use of ACE (Angiotensin Converting Enzyme) Inhibitors, commonly used to control hypertension, high blood pressure. Now widely accepted, these ACE Inhibitors have been shown to significantly reduce further kidney degeneration. In FDA Clinicals, the ACE Inhibitor Captopril (trade name Capoten) was given to patients showing early signs of kidney damage. It reduced fluid pressure in the kidneys, and cut in half the rate of kidney failure in its test population. Doctors have since prescribed other ACE Inhibitors, with similar positive results. Note: A diabetic experiencing kidney failure, but whose blood pressure is not elevated, can still use ACE Inhibitors for keeping fluid pressure down in the kidneys. This therapy has been shown to significantly reduce strain on eyes and cardiovascular system as well. Talk to your nephrologist (kidney specialist) about the ACE Inhibitors.

A new class of similar drugs is the Angiotensin II Receptor Antagonists (or ARBs). Teveten, the first member of this class to gain FDA approval, "may be of benefit in preserving renal function in patients with progressive renal disease," researchers state.

Aminoguanidine (Pimagedine) is another possibility. Tests are still underway, but this drug appears to reduce the damage done to the kidneys by excess glucose in the blood (and may reduce diabetic retinopathy as well). Other options are certain to materialize, both for those with impaired kidney function and for those whose kidneys have failed.

End Stage Renal Disease

The damaged kidney may worsen to the point (as described in "Testing Your Kidney," above) where it can no longer carry out its blood-purifying function. Then dialysis or transplantation are necessary in order to preserve life. This is ESRD, end stage renal disease. What are your options then?

There are three options. In hemodialysis, the patient's circulatory system is temporarily linked with a machine that performs the blood-cleansing functions of the human kidney. In peritoneal dialysis (CAPD or CCPD) a tube is inserted into the patient's peritoneal cavity, allowing urine and unneeded fluids to periodically drain from the body. The third option is kidney transplantation, in which a donated kidney is surgically implanted into the patient's body.

According to U.S. Renal Data System (USRDS) figures, more than 392,847 Americans have ESRD, and 168,663 of these kidney patients are undergoing dialysis at this time. In 1995, the last year for which Centers for Disease Control (CDC) figures are available, there were 27,851 new cases of ESRD among persons with diabetes, and 98,872 diabetics were undergoing dialysis or transplantation treatment that year. National Institutes of Health statistics show that 42.9% of all individuals facing dialysis are there because of diabetes, and about 40% of those commencing dialysis or seeking a transplant at this time are diabetic. Some remain on dialysis long-term; others make use of the process while awaiting a kidney transplant. As an aside, before 1970, few diabetic ESRD patients were dialyzed; they simply sickened and died. Those who did dialyze faced a high mortality rate. Medicine has come a long way since then, and the odds have improved with the options. Dialysis techniques have improved substantially since my personal experience with them.

Dialysis

Dialysis is not an "artificial kidney." A person undergoing hemodialysis must be hooked up to a machine three times a week, three to four hours per session. A normal vein cannot tolerate the 16-gauge needles that must be inserted into the arm during hemodialysis, so the doctor must surgically connect a vein in the wrist with an artery, forming a bulging fistula that will better accommodate the large needles needed for treatment.

Like the kidney, a hemodialysis machine is a filter. Where it uses tubes and chemicals, the kidney uses millions of microscopic blood vessels, fine enough to pass urine while retaining suspended proteins. Long-term high blood glucose can significantly damage the kidney's filters, leading to scarring, blockage, and diminished renal function. Diabetes is the leading cause of kidney disease (#2 is hypertension). Long-term diabetics often have cardiovascular and blood pressure problems as well, and the added strain of hemodialysis, with its rise in blood pressure straining eyes and heart function, can be too much for some. The diabetic dialysis patient spends, on the average, 33% more time in the hospital than does the non-diabetic dialysis patient, according to 1999 USRDS figures.

Some patients choose CAPD (continuous ambulatory peritoneal dialysis) or its variant, CCPD (continuous cycling peritoneal dialysis), both of which can be carried out at home, without an assistant. Unlike hemodialysis, which uses a big machine to remove toxic impurities from the blood, peritoneal dialysis works inside the body, making use of the peritoneal membrane to retain a reservoir of dialysis solution, which is exchanged for fresh solution, via catheter, every four to eight hours. CAPD is carried out by the patient, who simply exchanges spent for fresh solution, every four to eight hours, at home, at work, or while traveling. CCPD, its variant, makes use of an automated cycler, which performs the exchanges while the patient is asleep. Although more complicated and machine-dependent, it does allow daytime freedom from exchanges, and may be the appropriate choice for some. Though the risk of infections is heightened (as it is with any permanent catheterization), these two processes have advantages, one being that insulin can be added to the dialysis solution, freeing the patient from the need to inject, and giving good blood sugar control.

Transplantation

Kidney transplantation is a logical alternative for many. It substantially improves a patient's quality of life. Although the transplant recipient must be on anti-rejection/immunosuppressive therapy for life, with the inherent risk from otherwise nuisance infections, a transplant frees the patient from the many hours spent on hemodialysis procedures each week, or from the periodic "exchanges" and open catheter of CAPD, allowing a nearly normal lifestyle. For those ESRD patients who can handle the stresses of transplant surgery, the resulting gains in physical well-being add up to real improvement in quality of life and overall longevity.

An article, published November 1999 in the NEW ENGLAND JOURNAL OF MEDICINE, shows the longevity gains have been major. The average graft survival (how long the kidney remained functional, not the patient) was, from a living donor, 17 years, in 1988. Per 1996 statistics, it is now 36 years. The typical cadaver kidney transplanted in 1988 lasted 11 years, but in 1996, the life expectancy of the organ was nearly 19 years. The study, led by Dr. Sundaram Hariharan, at the Medical College of Wisconsin, funded by the National Institutes of Health, concludes the improvement is largely due to the development of better anti-rejection medications.

In October 1996, a study by Christopher E. Attinger, M.D., and colleagues at Georgetown University School of Medicine, in Washington, DC, reported that diabetics who had a kidney transplant healed twice as fast as those on dialysis, or experiencing chronic renal failure. Alongside the better healing rate, transplant patients' average hospital stay, for treatment of foot wounds, was half as long.

"Fifty percent of all kidney transplantations taking place today are into diabetics," states Giacomo Basadonna, M.D., Ph.D., a transplant surgeon at Yale University School of Medicine, in New Haven, Connecticut. He reports that success rates are identical with kidney transplants performed on non-diabetic ESRD patients. "Today," he advises, "average kidney survival, from a living donor, is greater than 15 years."

"Will you survive longer once you get a transplant?" asks Marianna Markel, M.D., Director of Transplant Nephrology at SUNY Health Science Center, in Brooklyn, New York. "If you're a diabetic, it looks like the answer may be yes, perhaps because certain substances which build up in the blood of diabetics (advanced glycosylation end-products) are not removed well by dialysis, and may contribute to a shortened lifespan for diabetic patients on dialysis."

One of the areas where we are seeing rapid improvement is immunosuppressive medication. There is now a generic competitor to Novartis' Neoral (Eon Labs' Cyclosporine Softgel Capsules, USP Modified). The traditional triple mix of immunosuppressants: cyclosporine, prednisone, imuran, is giving way to more targeted medications that may have fewer side effects. Cellcept, by Roche/Syntex, and Rapamycin (Rapamune), by Wyeth/Ayerst, have been approved by the FDA, and a number of others are being tested. The risk of organ rejection is always present, but each new development increases the chances your body will successfully accept the transplant

I and others knowledgeable in kidney transplantation advise you to pick the best transplant center possible. Once you have read their statistics, ask your prospective center the following questions. If they don't answer to your satisfaction, you should consider going to another center.

1. Do you have an information packet for prospective donors and recipients?

2. Can you put me in touch with someone who has had a transplant at your center?

3. What is your "graft survival" (success) rate?

4. Who will my transplant surgeon be? If a fellow or resident, will he/she be supervised by a practicing transplant surgeon?

5. How long have your current surgeons been doing kidney transplants? How many have they done? That your center has 35 years experience with kidney transplants is of little consequence if my surgeon has only done ten in his or her career.

6. What is the average post-operative stay in your hospital?

7. When I come for my transplant, or come back for follow-ups, will there be any affordable housing for me and/or my family? (Ronald McDonald House, or other lodging with discount rates...)

8. How often will I need to come back to the center for follow-ups? Can my nephrologist do the blood tests and send you the results?

9. Can you recommend a nephrologist in my area?

10. Do you have a toll-free number to call for after-transplant information?

11. What is your policy on people with insufficient health insurance? Will you work with an uninsured patient? What will it cost?

12. Are you prepared to satisfy my doubts? Will you show me the documents that answer my questions? Will you guarantee the price quoted?

Transplant Patients Speak:

The following individuals are the real experts. Collectively, they have more than 135 years experience living with a transplant! All of them would choose a transplant again. Although kidney transplantation is not for everyone, and sometimes it doesn't work, it should be given strong consideration.

Ken Carstens, from Minnesota, who received his kidney transplant at Fairview-University Medical Center, in Minneapolis, Minnesota, on September 10, 1975, states, "It's been 26 years now, and I'd make the same choice again."

Karen Mayry, from South Dakota, received her kidney transplant at Fairview- University Medical Center, in Minneapolis, Minnesota, on January 12, 1977. She declares, "I feel great!"

Betty Walker, from Missouri, received her transplant on July 13, 1978, at Yale-New Haven Hospital in Connecticut. In her words: "I was just existing on dialysis; and my transplant gave life back to me."

Lenny Ruygt, from California, received her kidney at Pacific Medical Center, in San Francisco, on St. Patrick's Day, March 17, 1980. She says: "On dialysis, I had no energy at all-I would sleep all but two hours of a day. After my transplant, I felt energized!"

Linda Bingham, from Ohio, who received her kidney transplant at University Hospital in Cincinnati, Ohio, on December 10, 1981, says, "I feel great. I have been given a whole new life."

Ed Bryant, from Missouri, received his transplant on August 9, 1983, at Fairview-University Medical Center, in Minneapolis, Minnesota. He says: "There is no comparison between life on dialysis, and how I've felt since my transplant."

Facts and Statistics

What is the success rate for kidney-transplant surgery? According to the "United States Renal Data System 1999 Annual Data Report," published by the National Institutes of Health, about 75% for a cadaver-donated kidney, better than 90% with a kidney donated by a living relative, with an overall success rate of better than 85%, better than 90% in some centers. UNOS data indicate the averages (based on graft survival, healthy kidney, five years after transplant) are improving. The National Institutes of Health reports that current "graft survival" (donated kidneys successfully functioning in the transplant recipient) rates are approximately the same, whether the recipient has diabetes or not.

What percentage of type 1 diabetics will face ESRD? Current statistics suggest between 20 and 25%, with many factors (genetic, ethnic, lifestyle) taken into account.

Must the ESRD patient be on dialysis before being considered for a transplant? NO! Although some behind-the-times nephrologists still believe so, Fairview-University Medical Center's Transplant Center, which pioneered diabetic kidney transplantation, recommends that once your physician has determined kidney failure is on the way, further delay could be harmful. The more time spent subjecting your body to the toxic excesses of kidney failure and the strains of dialysis, the greater the risk of serious complications like retinopathy and cardiovascular (heart) degeneration.

Your nephrologist should be able to tell you more about your options. For information about kidney transplantation, contact a reputable kidney transplant center (there are, at press time, 245 in the U.S. today), or the United Network for Organ Sharing, 1100 Boulders Park, Suite 500, Richmond, VA 23225; telephone: 1-800-243-6667; Web site: (http://www.unos.org). All UNOS information is available on the World Wide Web, but they will also send you pertinent information, by mail, about transplant centers in your area or nationwide. Contact them at the above address, and ask them for the "kidney transplant package." They also offer the brochure "What Every Patient Needs to Know," and an organ-donor card for you to carry.

For information or assistance with interpreting transplant center data, contact: Health Resources and Services Administration, Bureau of Health Resources Development, Division of Transplantation, OSP, Park Lawn Bldg., 5600 Fishers Lane, Room 7C-22, Rockville, M.D. 20857; telephone: (301) 443-7577; Web site: (http://www.hrsa.gov/osp/dot). This agency also maintains the Web site: (www,organdonor.gov), which offers many useful links and much pertinent information.

Renal failure is not a kiss of death. There are options, and at least one of them will be right for you. Keep your diabetes under good control, and your blood pressure down, to cut the risks-but if it happens (like it did to me), remember that with proper care you stand every chance of living just as long as you would have with healthy kidneys.

More Resources:

American Association of Kidney Patients, 100 South Ashley Drive, Suite 280, Tampa, FL 33602; telephone: 1-800-749-2257; Web site: (www.aakp.org/aakpteam.html). Publishes the quarterly magazine RENALIFE, with articles about dialysis and transplantation.

American Kidney Fund, 6110 Executive Boulevard, Suite 1010, Rockville, M.D. 20852; telephone: 1-800-638-8299. Offers financial aid ($200 limit), provides written and phone information on kidney diseases. Web site: (www.kidneyfund.org).

CVS Procare, (formerly Stadtlanders) 600 Penn Center Boulevard, Pittsburgh, PA 15235; telephone: 1-800-238-7828; Web site: (www.stadtlanders.com). Medication, delivery, and insurance billing; organ transplant recipients receive free express delivery of medication, anywhere in the U.S.A. They offer the book-length document "Waiting For a Transplant," as a free download from their Web site.

Diabetes Action Network, National Federation of the Blind, Renal Failure-Dialysis and Transplantation Support Committee, 1412 I-70 Drive SW, Suite C, Columbia, MO 65203; telephone: (573) 875-8911. Web site: (www.nfb.org/voice.htm). Offers information, encouragement, and support on a person-to-person basis for diabetics. Note: Copies of this article, and others, are available, free, in large print, or on 4-track audiocassette.

Fairview University Medical Center, Patient Education Department, 420 Delaware St. SE, MMC 603, Minneapolis, MN 55455; telephone: (612) 273-3354; Web site: (www.fairviewtransplant.org). Offers THE TRANSPLANT HANDBOOK, prepared for patients facing kidney transplantation. Available in standard print or audiocassette, cost: $12 (print) or $30 (6 tapes). Their Web site offers information on all types of transplant surgery.

National Diabetes Information Clearinghouse, 1 Information Way, Bethesda, M.D. 20892; telephone: (301) 654-3327; Web site: (www.niddk.nih.gov/health/diabetes/diabetes.htm). Provides free and low-cost publications on aspects of diabetes.

National Foundation for Transplants, 1102 Brookfield, Suite 202, Memphis, TN 38119; telephone: 1-800-489-3863; Web site: (www.transplants.org). Advice and instruction on fund-raising to cover transplant costs on any organ.

National Kidney Foundation, Inc., 30 E. 33rd Street, New York, NY 10016;
telephone: 1-800-622-9010; Web site: http://www.kidney.org. Provides services such as: doctor referrals, patient peer counseling, education, medication programs, transportation, and financial services.

National Kidney and Urologic Diseases Information Clearinghouse, 3 Information Way, Bethesda, M.D. 20892; telephone: (301) 654-4415. Provides free information booklets such as #KU-50: "End Stage Renal Disease, Choosing a Treatment That's Right for You," and #KU-134: "Eat Right to Feel Right on Hemodialysis." Two other publications are "dictionaries," of urologic diseases, and of kidney diseases. Contact NKUDIC for availability information. All publications are downloadable from their Web site: (www.niddk.nih.gov/health/kidney/nkudic.htm)

National Transplant Assistance Fund, PO Box 258, Bryn Mawr, PA 19010; telephone: 1-800-642-8399; Web site: (www.transplantfund.org). Helps patients set up fundraising programs to cover transplantation costs on any organ; also offers small emergency grants.

The Patient Travel Service, Fresenius Medical Care, Two Ledgemont Place, 95 Hayden Ave., Lexington, MA 02420; telephone: 1-800-634-6254; e-mail: ([email protected]). Provides referrals and information for dialysis patients wishing to travel anywhere in the world, who need dialysis facilities. Also offers free brochure, On the Road...Again, a how- to guide for arranging dialysis away from home.

PhRMA, Pharmaceutical Research and Manufacturers of America, Publications Department, 1100 15th Street NW, 9th Floor, Washington, DC 20005; telephone: (202) 835-3400; Web site: (www.phrma.org). An industry association, PhRMA publishes a catalog of member companies offering free or low-cost drugs/medications for the indigent, available for download from their Web site.

Transweb: Is an informational Web site that provides an index and links to a great deal of information about transplantation, patient education, donor and recipient issues and other items of concern. Web site: (www.transweb.org)

United States Renal Data Survey, USRDS Coordinating Center, 914 S. 8th Street, Suite D206, Minneapolis, MN 55404; telephone: (612) 347-7776; Web site: (www.usrds.org)

DOCTORS URGE EARLIER DIABETES SCREENING

It's no secret; diabetes in America is growing at epidemic speed. Approximately 90% of all cases are of the "type 2" variety, once called "adult onset diabetes." Type 2 is gradual, ambiguous, and by the time it is diagnosed, can have caused serious damage to eyes, kidneys, and heart. Diabetes can be treated -- if you and your doctor know you have it. Complications can be prevented, delayed, or mitigated -- if they're caught in time.

Many people have a diabetes-like condition known as "Impaired Glucose Tolerance," or IGT, once called "Borderline Diabetes." Authorities are now using the term "Pre-Diabetes," reflecting that in this population, you will find tomorrow's newly-diagnosed type 2 diabetics -- and the sooner they're identified, the sooner they can be treated, to reduce their risk of complications.

Leading US diabetes research and advocacy groups are now recommending screening for "prediabetes." Their recommendations call for physicians to give fasting plasma glucose or oral glucose tolerance tests to overweight people aged 45 years and older, and the same tests for people younger than 45 if they are seriously overweight (a body-mass index greater than 25 kg/m2) with other risk factors, particularly hypertension or a family history of diabetes. Overweight nonwhites are considered at high risk.

Individuals with prediabetic glucose levels need counseling about lifestyle changes that can delay or prevent diabetes (diet, exercise, weight loss). Most of them will probably not need medication, at least for some time. Regular follow-up counseling, encouraging dietary improvement, weight loss and regular exercise appears important in these cases.

For more information, see Diabetes Care. 2002;25, and JAMA (Journal of the American Medical Association): Vol 287, No. 19.

ORGAN DONATION: THE LIVING OVERTAKE THE DEAD

There is a desperate need for donated organs for transplantation. At any moment, hundreds of people are waiting for kidneys, pancreases, livers, corneas, hearts, and lungs. Cadaveric donation (the recycling of usable organs from the dead) allows one donor to help many recipients, and has been the rule; but, there has been a steady increase in organ donation from the living.

In 2001, the number of living donors increased by 13.4 percent, atop a 16.5 percent rise in 2000. However, donations from the dead only rose by 1.6 percent. Last year, there were 6081 cadaveric donors, and 6485 living donors. It is true that one cadaveric donor gives far more (three out of every four donated organs are still cadaveric); but this is the first time living donors outnumbered the dead.

Most living donors donated a kidney. We're born with two, and can do perfectly well with only one. As the surgery gets safer and less invasive, immunosuppressive medications get better, and the need for close genetic match diminishes (you don't need a twin anymore!), healthy folks are choosing to donate to spouses, friends, even employers.

There are risks (as there are with any surgery); but living organ donation is a new option for folks trying to help keep friends and family members alive - and PLEASE consider donating your organs, should anything happen to you.

For more information, see this government Web site: (www.organdonor.gov), or call the National Kidney Foundation; telephone: 1-800-622-9010. A more complete list of resources is published at the end of Ed Bryant's article: "Kidney Disease: Prevention, Dialysis or Transplantation," in this issue.

TEACHING OURSELVES ABOUT DIABETES

by Helen Aldrich

Photo included: Caption: Helen Aldrich

From the Editor: I first heard about Helen Aldrich, an energetic 92 years young, from the Activities Director at her Retirement Community in Florida, who called VOICE OF THE DIABETIC to tell us the story. It seems this very special lady, on her own initiative, had started a program to educate fellow seniors about the history of diabetes (and a lot of folks develop diabetes as they advance in age). I interviewed Helen, and her story reads best in her own words. I will point out that although Helen does not have diabetes herself (many of her fellow residents do), she is legally blind. She is a remarkable woman. Here's her story:

I am 92 years old. I was born October 4, 1909. It was a long time ago, but that's a good month to be born in. Those were good years and much has happened since then, you know. It's an interesting time to live. I was born in Buffalo, New York, and I graduated from South Park High.

A lot people in my family have diabetes. And it's almost tragic the way that things happen because it doesn't seem to come down our bloodline. I tell you, it's not until it hits you that it's really awful.

The first case we had of it in our family was a little eight-year-old nephew. Nobody knew it until much later when they took him to the doctor. He finally died very young. There is hope, now, I know. Medicines are better, and a lot of diabetics can live pretty much a normal life span now - but it depends upon their discipline and dedication to that daily measuring.

Now, where I live, Atria Windsor Woods Retirement Community, in Hudson, Florida, there are maybe 11 or 15 diabetics. I think we were sitting in the stroke group one day and they mentioned diabetes as something we could possibly study. Well, that is what I wanted to do, because it's such a big unknown to so many.

A lot of seniors get diabetes, but, you know, all these years I've been seeing doctors, and getting tested for things, no one has ever said anything to me about diabetes. Nobody has ever explained about triglycerides (they just say: "oh, your triglycerides are high." - but what does that mean?) or about cholesterol. So what? Why don't they explain these findings -- we need education -- tell us what it means.

When I go to the eye doctor (I'm legally blind), I have never heard anyone ask: "Do you have diabetes?" Someone suggested they don't have to ask you; you write it on your chart. But why don't they talk to us about it? Why are we losing vision? And what do they mean by blurry vision?

We need schooling about these questions, so, with a lot of help, I researched about diabetes, for about three months, and then presented what I'd learned to the residents. I do nothing by myself; there were so many people who helped me with this. Everything we have accomplished, we have done together.

We covered the history of diabetes, as far back as 1500 BC. We talked about what the pancreas is. We talked about Beta cells, and what insulin does to move glucose to the cells. We talked of the need for balance in all things, in protein, in carbohydrate, in fat. We discussed how regular testing of blood sugar tells us what our balance should be.

We talked about stress, how stress can make diabetes worse, and how you need to not have too much of it. And we talked about the symptoms, like dry mouth, constant urination, being thirsty, numb fingers, and more. We tried to cover as many aspects of diabetes as we could.

I haven't done that much. I've only skimmed the surface. I like to talk with people. That's what I like to do. I've been with people all my life who were so interesting and had so much to offer to me. There is so much more to do, to teach ourselves about diabetes.

ASK THE DOCTOR

by Wesley W. Wilson, M.D.
Artwork: Medical caduceus

NOTE: If you have any questions for "Ask the Doctor," please send them to the Voice editorial office. The only questions Dr. Wilson will be able to answer are the ones used in this column.

Wesley W. Wilson, M.D. has retired as an Internal Medicine practitioner at the Western Montana Clinic in Missoula, Montana. Dr. Wilson was diagnosed with type 1 diabetes in 1956, during his second year of medical school. He remains interested and involved in diabetes education for patients and professionals.

Q: After eight years with type 1 diabetes, my son recently died at age 25 from a malignant brain tumor. He'd been taking many medications, including chemotherapy meds, insulin, tegretol, captopril, phenobarbital and others. Could any of these meds, alone of in combination, have caused his tumor to form?

A: Dear concerned, You have my condolences for your son's illness and death. I can understand your wish to know why he developed diabetes, and what caused the brain tumor. It is appropriate to ask if any of the drugs he used contributed to the tumor formation.

Some agents, for example cigarettes and lung cancer, are associated, but the cause of most cancers remains unknown. A few medicines may increase the risk of cancer, but the vast majority of drugs do not. Interestingly, some chemotherapy drugs increase cancer risk, but these agents do so only after prolonged or repeated exposure. I presume the chemotherapy drugs were given to treat the brain tumor -- thus they could not have been responsible for its formation.

Phenobarbital and Tegretol are used to control seizures - and seizures are often seen with brain tumors - so they were probably given after the tumor began. Neither of these drugs, nor insulin, nor captopril have a reputation for causing tumors. I find no evidence that the drugs you listed caused the brain tumor. Age 25 seems inappropriate for cancer, but a three year-old in our church has been troubled by a brain tumor for the last two years.

Type 1 diabetes is perhaps a bit better understood. Some type of immune dysfunction causes an antibody attack of the insulin-producing beta cells of the pancreas, and the ability to produce insulin is destroyed. We used to think that type 1 diabetes began suddenly, but it is now evident there is a slow destruction of beta cells that proceeds for months or years before beta cell destruction becomes so severe that blood sugar rises and insulin must be given. That there is a long period of slow destruction before overt diabetes appears is important, since it allows us to hope that something can be done during this "development stage" to stop further beta cell destruction, and prevent or minimize diabetes. This is very important, since in the British publication LANCET, for Nov. 24, 2001, researchers reported that in a small group of persons with recently diagnosed diabetes, treatment with a peptide halted the progressive destruction of beta cells. This seemed to occur without the general blocking of immune function that causes so much trouble for folks who must take "immunosuppresive" drugs to prevent rejection of transplanted organs such as kidneys. These were folks with outright type 1 diabetes, but the question is: can we detect persons early in the pre-diabetic state and then halt the beta cell destruction?

There are now two reports of persons at high risk of type 2 diabetes treated with ½ hour exercise (walking) daily, and modest weight reduction, who were able to either prevent or delay appearance of diabetes. The weight loss was about 10 pounds for a 200 pound person. Those goals seem easy to achieve, especially since it was so effective in reducing diabetes.

It is an exciting time to be aware of developments in diabetes and it seems we should be ready to block the epidemic of type 2 diabetes now ongoing in the United States and other countries where the living is too easy and too good. I have been heartened to hear U.S. Secretary of Health and Human Services Tommy Thompson kick off a new program that will try to prevent diabetes by encouraging more healthful lifestyles.

I'm sorry to have not answered your questions and hope you will forgive my enthusiasm about new developments that I feel show great promise.

COMPLEXITY OF INSULIN THERAPY HAS RISEN SHARPLY IN THE PAST DECADE

From The Editor: The following is from ISMP MEDICATION SAFETY ALERT, published by the Institute for Safe Medication Practices. While they are concerned with all medications, misdosage of diabetes medications can have especially severe consequences.

PROBLEM: Data derived from scientific research, voluntary reporting programs, and technology used to automate the medication use process clearly show that insulin errors are frequent and cause significant patient harm. There is an unmistakable reason for this. While insulin therapy has always required thoughtful management, over the last decade, its complexity has risen sharply. Here's just a sampling of the error-prone nature of insulin therapy today.

The onset of action for various insulin types varies widely. Depending on the product, the onset may vary from mere minutes to eight hours. This makes the typical time for insulin administration and its relationship to meals confusing. As such, our error database has examples of patients who have developed hypoglycemia because they have not eaten within the required time frame, especially after receiving insulin analogs such as ultra-short acting insulin lispro (HUMALOG) or insulin aspart (NOVOLOG). This also has happened when insulin was ordered according to a standard dosing schedule such as "every morning" or "every evening," not a specified mealtime.

The rule that clear insulin can be given IV has changed. Humalog, Novolog and LANTUS (insulin glargine) are clear, but not indicated for IV use as is regular insulin. Also, clear insulins traditionally have been rapid acting, but Lantus is long acting.

There are close to a dozen different types of insulins and several dozen different brands, many of which have names or packages that look or sound alike. Hospitals have reported a pattern of errors related to confusion between LENTE (insulin zinc suspension) and Lantus, and HUMULIN (insulin, human) and Humalog. For example, after clarification with patients, several bedtime orders for "Lenti" and "Lentis," were changed to Lantus, and an order for "Human Log" was changed to Humulin L. In each case, the house officers who ordered the insulin were unfamiliar with the specific type of insulin that the patient reported taking. It's also easy to mix up insulin vials. We recently heard about a hospitalized patient who sustained profound hypoglycemia after her infusion had been prepared using Lantus instead of regular insulin. A vial of Lantus, which had been left under the hood after preparing syringes for a specific patient, had been mistaken as human regular insulin.

Insulin is available in multiple concentrations (100 units/mL and 500 units/mL). For pediatric use, a 10 unit/mL concentration may be prepared to deliver very small doses. Adding to the risk, insulin syringes only measure the most common concentration, 100 units/mL. One recent error clearly describes the risk of multiple insulin concentrations. Sliding scale insulin was prescribed for an infant with potential doses in tenths of a unit. Pharmacy diluted the regular insulin to 10 units/mL and labeled the vial appropriately. Using a tuberculin syringe, the patient received the correct dose for one week. Then he was given 3 units instead of 0.3 units after a nurse withdrew the dose from a vial of regular insulin, 100 units/mL. Confusion also is possible with premixed products of rapid and intermediate acting insulins offered in varying strengths (HUMULIN 50/50 or 70/30, HUMALOG MIX 75/25). Several errors have been reported when clinicians forgot to include the strength or transcribed the order incorrectly.

It's not uncommon for patients to receive widely variable doses and more than one type of insulin concurrently. Patient confusion between several different insulins, and failure to discontinue previous insulin when switching to a new product, may go unnoticed until patient harm occurs. We recently heard about several errors where patients were hospitalized after taking both Humalog and regular insulin, or Lantus insulin along with twice daily NPH insulin. Over-the-counter availability of most insulins (except some ultra-short acting or long acting products) may contribute to the problem.

Sound confusing? If we as clinicians are confused, imagine how bewildered the patient may be. The examples above, and many more avenues of complexity (e.g., using "u" for unit, improper mixing of insulin products, etc.) leave no doubt that insulin is a high alert drug that is prescribed, dispensed, and administered via error-prone processes and to patients who often are at risk for an adverse outcome if an error occurs.

Insulin therapy is a complex, error-prone process for clinicians and patients. With such complexity, it's not surprising that errors with insulin are frequent and characteristically harmful to patients. As such, this high-alert medication requires special handling.

Obtain an accurate history of insulin therapy from patients and follow-up questions to detect possible confusion between the many look and sound-alike insulin products. Whenever possible, encourage patients or families to bring in the insulin for validation.

Communicate prescriptions clearly using the entire product name and always writing out "units." If a nonstandard insulin concentration is needed, list the concentration and the patient's dose in units and volume. Consider the patient's usual times for meals and specify a clear relationship between insulin administration and meals. Use verbal orders only when necessary and spell back the name to avoid confusion with sound-alike insulin products. Establish a standardized sliding scale for insulin coverage used during illness.

Safely store and dispense insulin. Do not keep insulin vials on top of medication carts or counters, or under pharmacy compounding hoods, as insulin could be confused with heparin, which also is measured in units. Put all insulin back in the appropriate storage area immediately after use. If the concentration of an insulin vial/syringe is not 100 units/mL, apply bold warning labels that clearly state the concentration and explicit instructions for measuring the proper dose in units and volume using a specified type of syringe. Use a single standard concentration for all adult IV insulin infusions. In hospitals, have pharmacy prepare and dispense prefilled syringes for once daily doses of long-acting insulin (e.g., LANTUS). For outpatients, encourage prescribers to order insulin cartridges when appropriate (although insurance coverage may be poor).

For neonates, use insulin 100 units/mL for doses 5 units or greater using a U100 insulin syringe. For doses less than 5 units, have pharmacy prepare and label a 10 units/mL concentration and use a 1 mL tuberculin syringe with 0.01 mL graduations (1 unit equals 0.1 mL). Otherwise, consider IV infusion for insulin delivery.

Require an independent double check of all doses before dispensing and administering IV insulin. Build the double check into daily work processes so it can be accomplished without disruptions. "Smart" infusion pumps with set dose limits also can serve as a double check.

Provide staff with ongoing education about insulin products and methods of delivery. Prepare a chart that lists all insulin products used in your facility. Include generic and brand names; concentration; onset, peak, and duration of action; acceptable routes of administration; time of administration in relationship to meals; appropriate drug delivery devices; and special precautions (e.g., measuring the proper dose, mixing instructions, more frequent patient glucose monitoring). Pictures of the boxes in which insulin is packaged also would be helpful. Post the charts in areas where insulin is prescribed, dispensed, and administered.

Educate patients about their insulin therapy and how to prevent and treat hypoglycemia. Reinforce how physical activity and snacks affect glucose levels and how to handle circumstances such as travel and illness. Ask patients to demonstrate glucose monitoring skills and insulin administration, including measuring the correct dose.

Gauge the patient's response to insulin by obtaining blood glucose levels. For hospitalized patients, the nurse who administers the insulin should perform the glucose testing to avoid potential communication failures. Pay special attention to patients at risk for hypokalemia and hypoglycemia (e.g., people who are fasting or have autonomic neuropathy, those taking potassium-lowering drugs). Patients with renal or hepatic impairment may require reduction in total daily doses of all insulin.

Don't assume there are no problems with insulin therapy at your practice site. Audit health records for episodes of hypoglycemia and hyperglycemia, misuse of the abbreviation "u" in prescriptions, the frequency of verbal insulin orders and so on. Proactively anticipate and address problems with insulin use in both inpatient and outpatient settings through the Failure Mode and Effects Analysis process and by discussing insulin errors that have happened in other practice sites. Don't let down your guard with this high-alert medication, even if problems are not obvious today.

INSULIN TYPES: A REVIEW

Earlier articles have discussed insulin's role in our bodies, what happens when we don't have it, and why some of us have to take it by injection. But all insulins are not the same. How are they different? WHY are they different? And, how can we use their differences to better self-manage?

Insulins are described and subdivided by concentration strength, source, and time of onset/peak. This last category is most critical, but we really need an understanding of all three criteria.

Concentration Strength

All insulins sold in the United States today are of U-100 strength, 100 units of insulin per cc of fluid. But there are other dilutions in other countries, and if you were to encounter one of these (all perfectly usable), and inject your usual volume of insulin, you'd get a different amount of insulin. You'd get the wrong dosage.

Source

At one time, all insulin was produced by laboratory animals, most often cows and pigs. In the last decade, however, American insulin manufacturers have almost completely shifted to use of "recombinant DNA" (rDNA) technology, enabling laboratory production of a close analog to real human insulin. This "human" insulin is said to more closely match our endogenous (pancreatic) insulin.

Although labelled much like "animal source" insulins, recombinant DNA insulins are not quite the same, either in time of onset or in amount of insulin required. Experience shows that any switch between the one and the other must be done with care, and under your doctor's supervision-the types might be different enough to cause you trouble otherwise.

Time of Onset/Peak

The different insulin types: Humalog, Regular, NPH, Lente, Ultralente, Lantus, and the pre-mixes: 70/30, 50/50, and Humalog 75/25, are divided and distinguished by their time of onset and duration. As shown in the chart below, critical questions are:

1. When does this insulin begin to act in my body?

2. When does it reach its peak?

3. When does it fade to insignificance?

NOTE: We're all different! Charts reflect averages-you may well find a given insulin is different for you. Test frequently, keep good notes, and make your own chart!

The chart below is a general approximation, derived from data furnished by all three U.S. insulin manufacturers, Eli Lilly and Company, Aventis Pharmaceuticals, and Novo Nordisk Pharmaceuticals Inc.

INSULIN START PEAK END

Humalog/Novolog 10 min. 1 hr. 4 hr.

Regular 30 min. 2-5 hr. 8 hr.

NPH 1.5 hr. 4-12 hr. 22 hr.

Lente 2.5 hr. 6-16 hr. 24 hr.

Ultralente 4 hr. 8-18 hr. 30 hr.

Lantus 1.5 hr. 2-23 hr 24 hr

70/30 2 hr. 2-12 hr. 24 hr.

50/50 2 hr. 2-6 hr. 24 hr.

Humalog 75/25 15 min. 1-6.5 hr. 18/26 hr.

Where Humalog, Regular, and 50/50 premix have sharp and definable "peaks," the long-acting Lente insulins come on slowly, and have long, flat "peaks," and a slow rate of decline. New Lantus insulin (insulin glargine rDNA) is even flatter, and is meant, like the Lente insulins, to provide "basal" insulin coverage. Discuss your insulin choices with your doctor and your diabetes educator-they will help you find which is best for you.

There are a number of insulins not charted above. Some are "buffered insulins" (from both Lilly and Novo Nordisk), and there is a special U-400 insulin from Aventis. These are strictly for use in insulin pumps, and should not be used for any other purpose! There are also insulins not available in the United States (or not yet available), such as the complete line of Hypurin animal-source insulins manufactured by CP Pharmaceuticals of Great Britain, and other insulins encountered in other parts of the world.

Avoid Rigid Thinking

The most accurate chart will still be imprecise. Short-term, things will vary because diabetes, like life itself, is like riding a surfboard-no one can control all factors! Novo Nordisk says it best, on their chart: "The time course of action of any insulin may vary in different individuals, or at different times in the same individual. Because of this variation, time periods indicated here should be considered as general guidelines only."

Long-term, things will vary because your body is not the same from one decade, or one year, to the next. Your chart will need regular updating. Use it as guide, not gospel.

Mixes and Mixing

Although users of the insulin pump generally take only short-acting insulin, most insulin-using diabetics employ a mix of faster and slower insulins, to provide best control. The idea is to let the fast insulins (Regular or Humalog) cover meals, and let the longer-acting types (NPH, Lente, Ultralente) cover the period between meals. There is quite an art to insulin mixing, as you must consider diet, exercise, injection frequency, total insulin volume, ratio of slow-to-fast insulins, general health (including other medications you might be taking!), and your own unique intangibles. NOBODY is exactly "average."

Some folks employ commercially-prepared "pre-mixes," like "70/30" (70% NPH to 30% R). While these pre-mixed insulins provide a convenience (precise and consistent mixing) they also come with a liability: What if, to achieve optimal control, your best mix, right now, is 68/32, or 75/25? And what if tomorrow, due to variations in your diet, activity level, and general health, it's 60/40 or 81/19? You can't make fine adjustments with a pre-mixed insulin-you're stuck with the mix the doctor gave you-and for some, that means less than optimal control. Yes, you can vary your total dosage, total volume, and injection frequency; but, as the different insulins are really there for different purposes, adjusting insulin with a pre-mix can be like scratching an itch-with a sledgehammer. There can be consequences. You can get better control of your diabetes by mixing your own insulins.

A Caution

The insulin manufacturers report that certain insulin types should not be mixed; these could have dangerous consequences. The Lente insulins, long-acting insulins, should never be combined with intermediate-speed NPH insulin. Chemicals in the NPH would alter the Lente or Ultralente, turning it into an approximation of fast-acting Regular insulin! Mix those two, and you'll have a very different result than you might expect! Also, notes supplied with new Lantus insulin state: "Lantus must not be diluted or mixed with any other insulin or solution, as it may result in a delayed onset of action."

Be sure to talk to your doctor about appropriate and inappropriate insulin combinations.

Adjusting Insulin

People's bodies, and their insulin needs, change. Not only by the year, the month, or the decade, but, to achieve the best possible control, you may choose to vary your dosages by day, linking them to results of your blood glucose monitoring. To preserve optimal control, you will need to adjust your insulins, to compute, draw up, and inject different amounts and mixture percentages. Some folks, working with the full potential of "tight control," use a sliding scale, adjusting their insulins every day, in close step with their diet, exercise, and blood glucose test results. The rewards of their discipline-greatly reduced chance of complications-can be great.

Once you realize the role played by the different types of insulin, and how you can optimize your control by utilizing the most appropriate blend, right here, right now, you're well on the road to staying healthy. Knowledge is power!

Blind diabetics, and those losing vision, need to adjust insulin as well, and the technology to do so is available: Tactile insulin measuring devices like the Count-A-Dose enable reliable non-visual insulin measurement and mixing. Lack of sight is no bar to good control!

The Count-A-Dose (Two models, 1cc and ½cc "Low-Dose" model, using B-D syringes) from Medicool (of Torrance, CA), is available from the National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, M.D. 21230; telephone: (410) 659-9314. Cost is $40, either size. The Materials Center is open 8:00 am to 5:00 pm EST, weekdays.

RECIPE CORNER

Artwork included: fruit and vegetables.

This issue, recipes are from Last Minute Meals for People with Diabetes, by Nancy Hughes. Copyright 2002, American Diabetes Association. Reprinted with permission.

FAMILY-STYLE VEGETABLE BEEF SOUP

This soup freezes well. Try freezing it in 1-cup servings so you can pop it in the microwave for a quick lunch.

Ingredients:
1 lb. lean ground beef (96% fat-free)
2 14.5-oz cans stewed tomatoes
2 cups fresh or frozen diced green bell peppers
1 10-oz pkg frozen mixed vegetables
2 cups water
1 Tbsp worcestershire sauce
3 Tbsp ketchup
½ tsp salt
1/4 tsp black pepper

Instructions:
Heat a Dutch oven over high heat. Add beef and cook for two minutes, or until no longer pink, stirring constantly. Add tomatoes, peppers, mixed vegetables, water, and worcestershire sauce. Bring to a boil, reduce heat, cover tightly, and simmer 20 minutes. Remove from heat, stir in ketchup, salt, and pepper and let stand 5 minutes, uncovered, to develop flavors. Makes 9 one-cup servings. 132 Calories, 3g Fat, 34mg Cholesterol, 490mg Sodium, 14g Total Carbohydrate, 2g Fiber, 5g Sugars, 14g Protein. Exchanges: 1 Carbohydrate. 1 Lean Meat.

SPRING GREENS WITH RASPBERRY SPICE VINAIGRETTE

It's easy to combine salad dressing ingredients in a jar rather than whisking in a bowl. The dressing blends easily, with less mess and effort ... and you can store any unused dressing in same jar.

Ingredients:
1 oz sliced almonds (1/3 cup)
1/4 cup raspberry vinegar
3 Tbsp honey
1/4 tsp ground ginger (optional)
1/4 tsp ground cinnamon
1/4 tsp salt
4 cups prepackaged spring greens
1 cup mandarin oranges or sliced strawberries or blueberries

Instructions:
Heat a 12-inch nonstick skillet over medium-high heat. Add almonds and cook 4 minutes or until just beginning to turn golden, stirring frequently. Remove from heat and cool completely. Meanwhile, in a jar, combine vinegar, honey, ginger, cinnamon, and salt. Cover with lid and shake vigorously until well blended. Place greens in a salad bowl, add salad dressing, and toss gently. Top with fruit and almonds and serve immediately. Makes four 1/4-recipe servings. 117 Calories, 4gm Fat, 2gm Protein, 21gm Carbohydrate, 156mg Sodium, 2gm Fiber, 0 Cholesterol. Exchange: 1-½ Carbohydrate, ½ Fat.

CHICKEN AND VEGETABLES WITH ONION SAUCE

Only one pot to wash for this easy meal!

Ingredients:
5 4-oz boneless skinless chicken breast halves, rinsed and patted dry
1 1-lb bag frozen stewing vegetables
1 10.5-oz can condensed French onion soup

Instructions:
Heat Dutch oven over medium-high heat. Coat with cooking spray, add chicken, and top with vegetables and soup. Bring to a boil, cover tightly, reduce heat, and simmer 20 minutes or until carrots are tender. Remove chicken and vegetables with a slotted spoon and place in serving bowl. Increase to high heat, bring pan drippings to a boil and continue boiling one minute or until the liquid measures ½ cup. Spoon sauce over chicken and serve. Makes five 1/5-recipe servings. 194 Calories, 2gm Fat, 65mg Cholesterol. 570mg Sodium. 12gm Total Carbohydrate. 2gm Fiber. 6gm Sugars, 28gm Protein. Exchanges: 1 Starch, 3 Very Lean Meat.

WARMED SHORTCAKES WITH ORANGE'D STRAWBERRIES

This is the perfect summer dessert.

Ingredients:
4 cups sliced strawberries
3 Tbsp sugar, divided
½ tsp orange zest
Juice of medium orange
2-1/4 cups reduced-fat biscuit baking mix
1 cup fat-free plain yogurt
1/4 cup reduced-fat margarine
1 cup fat-free whipped topping (optional)

Instructions:
Heat oven to 425 degrees F. In a 1-gallon zippered plastic bag, combine strawberries, 1 Tbsp sugar, orange zest, and orange juice. Seal tightly, releasing any excess air, and press gently to mash some of the strawberries in order to thicken the mixture slightly. Set aside. In a medium mixing bowl, combine baking mix, yogurt, margarine, and the remaining sugar. Stir until well blended. Spoon the batter onto a nonstick baking sheet in 8 mounds, and bake 10-12 minutes or until lightly golden. Place shortcakes in individual bowls, spoon ½ cup strawberries over each shortcake, and top each with 2 Tbsp whipped topping, if desired. Makes eight 1-shortcake servings. 203 Calories, 6gm Fat, 1mg Cholesterol, 482mg Sodium, 36gm Carbohydrates, 3gm Fiber, 14gm Sugars, 5gm Protein. Exchange: 2-½ Carbohydrate. ½ Fat.

SPARKLING FRUIT SMOOTHIES

Try freezing this recipe in ice-cream goblets and serving
it as dessert.

Ingredients:
3 cups cold chopped melon or strawberries
1 medium banana
½ cup frozen orange-pineapple concentrate
1 12-oz can sugar-free ginger ale
Instructions:

Blend all ingredients until smooth. Makes four 1/4-recipe servings. 159 Calories, 0gm Fat, 0mg Cholesterol, 27mg Sodium, 37gm Total Carbohydrate, 4gm Fiber, 28gm Sugars, 2gm Protein. Exchanges: 2-½ fruit.

YOUR DIABETES CARE SHOULD FIT YOU:
Making Insulin Action Times Work for You

by Ann S. Williams, MSN RN CDE

This column focuses on providing information to help people make their diabetes care fit their needs and their lives.

One of many technical advances in diabetes care over the last several years has been the release of several new types of insulin. This has opened many possibilities for new insulin regimens that match people's needs more closely than the old ones did. Now, people often find they can have both better diabetes control and greater lifestyle freedom. In other words, many people are finding that they can literally "have their cake and eat it too."

Normal Insulin Secretion

To understand ideas about the newer insulin delivery patterns, let's look first at normal insulin secretion in someone who does not have diabetes. The main purpose of insulin is to stimulate the body's cells to take in glucose (the form of sugar that is dissolved in the blood, the major source of fuel for the body's cells). A second purpose is to signal the parts of the body that store glucose, like the muscles and the liver, to keep it stored -- in other words, not to release it into the bloodstream.

In someone who does not have diabetes, the pancreas normally secretes a small amount of insulin 24 hours a day, seven days a week, even when the person does not eat. This background insulin is known as "basal" insulin. It is necessary because the body's cells need to take in glucose all the time, even when the person is totally relaxed or even asleep.

After all, the cells need to burn glucose for the energy they need just to stay alive. Furthermore, the insulin signal that tells the muscles and liver to keep the stored glucose in storage is also important. If that signal was not there, the stored sugar would be released when it's not needed, and the blood sugar would rise too high.

For most people, the basal insulin need is relatively steady throughout the day, at somewhere between 0.5 - 2.0 units. But some variation throughout the day is also normal. For example, many people need a little extra basal insulin during the early morning hours, and a little less basal insulin during exercise. When the pancreas is working properly, it adjusts for these variations and produces the exact amount of insulin the body needs, just when the body needs it.

When a person eats something that contains carbohydrates (starch or sugar), digestion begins immediately. The first carbohydrates to enter the stomach are broken down into glucose, which makes the blood sugar begin to rise in just about 10-20 minutes. In a person who does not have diabetes, the pancreas works a little like a thermostat. A thermostat senses cold and responds by turning on the heat. The pancreas senses a rise in blood sugar and responds by secreting insulin. When insulin made by the pancreas enters the body, it acts very quickly to lower blood sugar. If the person eats only a little carbohydrate, the pancreas puts out only a little insulin; if the person eats a lot of carbohydrate, the pancreas puts out a lot of insulin. And, just as a thermostat turns off the heat when the temperature returns to normal, the pancreas stops secreting insulin when the blood sugar returns to normal.

Insulin Types and Action

Now let's look at the action times of insulin most commonly used in the United States. The following list gives basic information about each major type of insulin, from the fastest and shortest acting to the longest acting. (It does not include animal-source insulin or Ultralente, which are seldom used in the United States.)

Type: Rapid
Insulin: Humalog (Lispro)
Begins working: 15-20 minutes
Peaks at: 1-2 hours
Ends working: 3-4 hours

Type: Rapid
Insulin: Novolog (Aspart)
Begins working: 15-20 minutes
Peaks at: 1-2 hours
Ends working: 3-4 hours

Type: Fast
Insulin: Regular
Begins working: 30-60 minutes
Peaks at: 2-3 hours
Ends working: 6-7 hours

Type: Intermediate
Insulin: NPH
Begins working: 2-4 hours
Peaks at: 6-10 hours
Ends working: 14-16 hours

Type: Intermediate
Insulin: Lente
Begins working: 3-4 hours
Peaks at: 6-12 hours
Ends working: 16-18 hours

Type: Long-acting
Insulin: Ultralente
Begins working: 4-6 hours
Peaks at: 10-16 hours
Ends working: 18-20 hours

Type: Long-acting
Insulin: Lantus (Glargine)
Begins working: 2-3 hours
Peaks at: Almost no peak
Ends working: 18-24 hours

All these different types of insulin have been used in multiple combinations, and every combination seems to work well for someone. In general, when designing an insulin regimen for an individual, you're trying to get the blood sugar as close to normal as possible without too much hypoglycemia (low blood sugar), without too much inconvenience, and at a cost the person can afford.

Making Insulin Work For You

Now let's think again about normal insulin secretion. Natural human insulin secreted by a pancreas is very rapid-acting insulin. If we think about the insulin described above, the closest we could get to the way the body actually produces insulin would be to deliver tiny amounts of rapid insulin (Humalog or Novolog) throughout the day, and then to give larger amounts with meals, to match the carbohydrate in the meal. Following are three commonly-used insulin regimens, and some discussion about how well they match the body's needs.

All-rapid insulin in an insulin pump: An insulin pump is designed to work very closely to natural insulin secretion. It is programmed to give tiny amounts of rapid insulin throughout the day, and the pump user then triggers larger amounts (bolus) at mealtimes. Unfortunately, unlike a pancreas, the insulin pumps currently available do not automatically sense the blood sugar and give the right amount of insulin. Instead, people who use insulin pumps learn to adjust the amount of insulin the pump delivers throughout the day (the basal insulin), and to give themselves the right amount of insulin with food (the bolus insulin), and to adjust for unexpected high blood sugar. If the basal insulin need varies throughout the day, they can set the insulin pump to give different amounts at different times. In other words, they learn to "think like a pancreas." This allows them to eat what they want when they want, to not eat if they don't want to, and to adjust the insulin to exactly what they need in any situation. Properly taught and adjusted, an insulin pump can come very close to normal insulin secretion, and give excellent blood sugar control with little or no hypoglycemia. Using an insulin pump does require extra work, and some inconvenience: frequent blood sugar checking, calculation of insulin for each meal, the constant presence of the pump itself, and the need to fill the pump with insulin and change the tubing at least every three days. People who like using insulin pumps generally say that the inconveniences of pump use are small compared to the increased freedom in eating times, and the feeling of well-being they have with better blood sugar control. However, not everyone feels those inconveniences are small, and using an insulin pump can be very expensive for people who don't have insurance coverage. (Editor's Note: For years, many blind diabetics have successfully used insulin pumps.)

Long-acting (basal) and rapid (bolus) insulin: The next closest to normal insulin secretion involves using two kinds of injected insulin: Lantus for the basal insulin, with a rapid insulin (Humalog or Novolog) with meals. Lantus insulin lasts in the body for about 24 hours, and has no peak, so it can make a very good basal insulin. And since the rapid insulins go into the body very quickly, they can be given right before a meal, and adjusted to cover the exact amount needed for that meal. This insulin regimen is so close to the way insulin is given with a pump that it is sometimes called "the poor man's pump." It involves the work of learning to adjust the insulin for meals and for high blood sugar, and in turn allows the freedom of eating as much or as little as the person wants, or even skipping meals. Many people are able to get excellent control with this pattern, without the expense of a pump and the inconvenience of wearing a pump all the time. This combination of types of insulin does have a few disadvantages, though. With Lantus insulin, it is impossible to vary the basal insulin throughout the day, so people who need that variation would not get quite as good control as with an insulin pump. The person must inject insulin, on average, four or more times a day: rapid insulin whenever eating a meal or a carbohydrate-containing snack, and a separate Lantus injection, because Lantus cannot be mixed with any other insulin. (Lantus is usually given at bed time.) Also, since both the rapid types of insulin and Lantus are still relatively new, they are more expensive than the older types of insulin.

Intermediate and short-acting mixture: Before Lantus and Humalog became available, the choices in injected insulin were less like normal insulin secretion. Generally, most people in the U.S. used some combination of a short-acting insulin (Regular) and an intermediate-acting (Lente or NPH) insulin. A typical regimen would be to take a mixture of these two insulins about 1/2 hour before breakfast, counting on the short-acting insulin to cover the blood sugar rise from breakfast. The intermediate-acting insulin would provide for both the basal insulin need through the day, and also its peak mid-day would cover the insulin need for lunch. A second injection of a mixture about 1/2 hour before suppertime would provide rapid insulin to cover the supper need, and the intermediate-acting insulin to cover the overnight basal need. (More recently, people often use a combination of intermediate and rapid insulin in the same way; but rapid insulin can be given right before a meal, making the timing of the injection a little easier.) This insulin regimen has the advantage of being simple, not requiring the mental arithmetic of figuring out doses, only requiring a minimum number of injections, and not being very expensive. But, it has the disadvantages of not being very precisely adjusted to a person's need, and not allowing much flexibility in eating. For example, once the intermediate insulin is injected in the morning, it will peak a few hours later whether lunch is ready or not. If the person does not eat enough food at the right time, a dangerously low blood sugar can be the result. This is usually not a problem for people who keep regular schedules and do not mind having to eat about the same amount every day. But for people who want flexibility it can feel too rigid.

What is right for you? These are only a few of the possible insulin regimens. How can you decide what is right for you? The following questions can help point you in the right direction:

1. Is excellent control of your diabetes important to you?
2. Do you want to have flexibility in when you eat and how much you eat?
3. Have you had a lot of problems with frequent episodes of low blood sugar?
4. Are you willing and able to pay attention to your diabetes (checking your blood sugar and giving yourself insulin) before eating every meal?
5. Are you willing and able to learn carbohydrate counting and the simple mental arithmetic to adjust your own insulin doses to your need?
6. Do you have good insurance coverage or adequate financial resources for insulin, diabetes equipment, and diabetes supplies?
7. Is a simple diabetes regimen important to you?
8. Are the timing and amounts of your meals regular, with little change from day to day?
9. Have you been able to get easy control of your blood sugar with relatively little effort?
10. Would paying attention to your diabetes at every meal be difficult for you?
11. Do you have little or no insurance coverage, and not much financial resources for insulin, diabetes equipment, and diabetes supplies?

If you answered "Yes" to Questions #1-#6, you should probably consider using an insulin pump, or a Lantus and rapid insulin regimen. If you answered "Yes" to Questions #7-#11, you should probably consider using a combination of intermediate and regular or rapid insulin. If your answers didn't divide up so evenly, then you'll need to consider closely what is most important to you.

No matter what you answered to these questions, it is important for you to be aware that you have many possible choices. It is best if you can discuss these choices, and other choices too, with a diabetes educator or physician who knows about the full range of possibilities. That will give you the best chance of figuring out an insulin regimen that will fit your individual needs, and allow you to live your life to the fullest.

Readers: Do you have questions about how to make your diabetes care fit your life? If so, please send them to the Voice editor, and I'll answer in a future column.

CORRESPONDENCE BETWEEN MINIMED AND THE DIABETES ACTION NETWORK OF THE NATIONAL FEDERATION OF THE BLIND

By Ed Bryant

There are now 17 million diabetics in the United States. The number of people who are both diabetic and blind (or dealing with significant sight loss) has been estimated as high as two million. We know that for insulin dependent diabetics, in most cases the insulin pump provides the best, tightest, and most "normal" blood sugar control; precisely what diabetics need to maintain health and avoid complications. For many, the insulin pump is a good thing.

We know that almost since the insulin pump was invented, several decades ago, resourceful blind diabetics have used it. Pumps have improved, in accuracy, reliability, and ease of use, and blind diabetics continue to use them - even though their controls are too often sight-dependent, as are their instruction manuals.

Several companies make insulin pumps for the United States market. Medtronic Minimed (formerly Minimed) has the biggest share of that market. On several occasions I've suggested the pump manufacturers make their products more adaptive (voice synthesis, better audio prompts and warnings, more tactile controls). I've also worked for a long time on something simpler - the preparation of audiocassette instructions for blind pump users.

One would think, from the manufacturer's point of view, this would be no big deal. You find a few blind diabetics who already use your pump, and use their expertise to teach other blind users how to do the same - and incidentally, you sell more of your pumps. Right?

Well, it didn't work that way. I communicated with Mr. Ray Hoese, of Medtronic Minimed's Marketing Department. On the phone, he sounded interested, and asked me for the names of blind pumpers who'd like to volunteer to help make such a tape.

I gave him his list. That was in April of 2000.

He didn't do anything. In September of 2000, I inquired of the volunteers how the project was going - and received the following reply. I should point out that the writer, Donna Balaski, Executive Director of Connecticut's Board of Education and Services for the Blind, is herself a trained medical professional, who lost her sight to diabetes.

September 26, 2000

Dear Ed:

I spoke to Mr. Hoese twice. The first time, it was difficult to get hold of him; and the second time, he said they were busy with some pump project, and that I would be a good resource for the "blind pumper's audio project," and that when they were ready to start, he would call me. Guess what - it has been some time, but no call. I called him once, just after convention (NFB Annual Convention, in July of 2000), but never a return call.

I must admit to you that I am rather disappointed in Minimed, since they also gave me a long history (a bunch of empty promises) about making the pump more accessible, and easier to tell when the low battery alarms go off. I should also let you know that Minimed shipped my supplies to the wrong location several times, gave away my pump when it was in for repairs, sent me a replacement pump, and recalled the replacement pump when they sent the wrong model without operating instructions. I had to contact the district sales manager (who'd sold me my pump) when it got out of hand. So, if all of my experiences are any indication...

Warmest regards,
DB

Without any luck, I tried to reach Mr. Hoese. My calls were not returned, and neither did I receive any response to the following (e-mailed) letter:

October 10, 2001

Dear Ray:

Some time ago, we talked about the blind diabetics who use Minimed insulin pumps, and their need for audiocassette instructions specifically tailored for non-sighted use. At that time you suggested it would be helpful if blind pump users contributed to the making of such an instructional tape.
I provided you with the names and addresses of several blind pumpers who expressed an interest in volunteering, in helping you make such an instructional audiocassette. Were you able to make contact with any of them? One of them, Donna Balaski, has been in touch with me.

Please let me know. Your company builds an excellent product, and though many blind individuals already use it, I am certain many more would follow, if the learning process were made more accessible to them. Such a project would not merely be a convenience to blind pump users, but could substantially help increase your company's sales to a population that needs your product, and is fully capable of using it safely and well.

Most sincerely,
Ed Bryant
President
Diabetes Action Network
National Federation of the Blind

I've continued trying to reach the man. No response. I find this hard to understand. In VOICE, Vol. 15, No. 2, April 2000, I presented the stories of a number of blind diabetics in the article: "Many Blind Diabetics Successfully Use Insulin Pumps." In the next VOICE, Vol. 15, No. 3, July 2000, I provided still more information, publishing the articles: "The Evolution of Insulin Pumps," "I've Gotten Attached to my Insulin Pump," and "Medicare Will Pay for Insulin Pumps." But we can't do it all. We know the insulin pump is a good idea for insulin-dependent diabetics, blind or sighted, and we know many blind diabetics already successfully use pumps. We've put that information in front of you, the readers, and we've put it in front of the pump manufacturers. You can lead a horse to water, but you can't make him drink ....

In the next VOICE OF THE DIABETIC, I will gladly print any correspondence from Mr. Hoese, or from Medtronic Minimed, regarding this issue.

PAYING FOR DIABETES

by Peter J. Nebergall, Ph.D.

Photo included; Caption: Peter J. Nebergall

The Problem

About a year ago, a widely-publicized international study ranked American health care 37th in the world, principally because it was not "universal," or "single-payer," as in nearly all other developed countries. One of the survey's authors observed: "Poor health is the biggest producer of new poverty in the United States." Our doctors and hospitals may be very good indeed, but our "safety-net" has holes in it - and if you have diabetes, you've probably found a few of those holes already.

The direct medical costs of diabetes in the U.S.A. (the money we pay the doctor, the hospital, and the pharmacist) run about 44 billion dollars a year, according to the U.S. Centers for Disease Control. That works out to $4000 dollars per diabetic per year -- above and beyond our already high general health costs and fees. That's a hardship for a lot of people -- especially if you receive an hourly wage, and don't have a fantastic "benefits package."

If you're old enough or sick enough to qualify for Medicare, you'll have found it covers a lot, but not everything. If you have private insurance, it may or may not be adequate for your needs, and the HMOs, desperate, drowning in red ink, are cutting back wherever they can. Millions of people have no prescription coverage, or no medical coverage at all. How do we pay for what we need -- now? Although we can't address "paying for the doctor" today, there are options, if you need some help paying for your diabetes medications.

Paying for Medications

Outside of Medicare, Medicaid, and private insurance, there are a few alternatives to paying list price out of pocket -- maybe more than you think. Drug manufacturers Pfizer and Eli Lilly offer "discount cards" for individuals eligible for Medicare (SSI or SSDI) who meet their income requirement (less than $18,000 individual or less than $24,000 family) and who have no other prescription drug coverage. These cards allow a user to purchase a month's supply of any of the issuer's products, for a low set fee ($12 to $15 per med per month). Naturally, a drug company's card will only help you with products distributed by that drug company.

There are several others, but the private "subscriber" cards generally offer only small discounts, and some of them (according to a recent U.S. government. survey) may not offer any discount at all. If your meds are from Pfizer or Lilly, these cards look best from here:

PFIZER ("the Share Card")

Effective March 1, 2002, holders of this card can purchase a 30-day supply of any listed Pfizer prescription product, for a flat fee of $15 each. For many drugs, this is a major discount. As Pfizer makes both type 2 diabetes medications and other drugs that treat common diabetes complications, this news should be of great interest. The Pfizer Share Card can be used at retail pharmacies, such as CVS and WalMart. Look for more pharmacies to join the program. For more information, or to receive an application, telephone: 1-800-717-6005, or see the Web site: (www.pfizerforliving.com)

ELI LILLY ("LillyAnswers Card")

Similar to the above, includes many diabetes medications. contact Lilly at 1-800-545-6962.

The PhRMA group, for medication assistance

The pharmaceutical industry has a tradition of providing medications free of charge to physicians whose patients might not otherwise have access to necessary medicines. Members of the Pharmaceutical Research and Manufacturers of America (PhRMA), an association of drug manufacturers, have created a directory listing each participating manufacturer, and the products that manufacturer has decided to list. Eligibility rules vary between manufacturers, and all prescription medications are not included, nor are all drug manufacturers members of PhRMA. Still, the association's patient assistance program (which does include insulin, oral diabetes medications, and cyclosporine) is a useful safety net. PhRMA's directory is in fact quite extensive.

Transfer of prescription medications is regulated by many laws. Upon approval, medications are shipped to the prescribing physician. For information, and a copy of their Directory of Prescription Drug Patient Assistance Programs, physicians should contact: PhRMA, 1100 Fifteenth Street NW, Washington DC, 20005; telephone: (202) 835-3400. Alternatively, the directory may be downloaded from their Web site: (www.phrma.org).

Web site: Diabetes-Meds.Org

Diabetes-Meds.Org (www.diabetes-meds.org) is a Web site designed as a clearing house to link doctors and needy patients with the appropriate drug-company program for free or low cost medications. Although this service is NOT tied to Medicare eligibility, its income limitations are the same as those for the Pfizer and Lilly discount cards (Less than $18,000 single or less than $24,000 family).

Prescription Drug Help

If you have prescription medications, and you can't afford them, you may know a number of manufacturers provide free medications -- but the problem is finding the right one, and then completing the paperwork. If you qualify (low income, no prescription coverage), The Health and Wellness Educational Center will help you find your necessary prescription medications, and will help with the paperwork. Contact: (205) 652-6557.

MEDICARE has its own consumer Web site: (www.medicare.gov), offering a prescription drug assistance program that searches online for public and private programs that offer discounted or free medications.

Conclusion.

Is it "Your money or your life?" No. It's not that bad. There are options. If you do the legwork, if you meet the income guidelines (which are pretty reasonable, when you do the math), there are alternatives out there. It may take you some time, but they're out there.

What should we be doing? We should be joining the rest of the world, with a national health service, guaranteed basic access, and price controls on basic medications. Initiatives like Pfizer's SHARECARD are commendable, but they are stopgaps, and the companies know it. "Until the Administration, Congress, and the states design an appropriate, high-quality, long-term solution ... we are bridging the gap," says Pfizer.

Here's hoping Pfizer's competitors, and the government, quickly follow their example.

BOOK REVIEWS

by Marilyn Helton

Greetings Readers, and welcome to the July issue of Book Reviews! I hope most of you have geared down to a more leisurely pace, and can indulge in some interesting summer reading.
Response to my survey about what you want to see reviewed in this column was ranged from veteran diabetics wanting more information on complications of the disease, to the newly diagnosed, seeking information on what foods to eat and how to cook them.

Almost all wanted more books on coping with the stress of living with diabetes, and more reading material having a motivational/spiritual focus. I've concluded that I should continue to review a variety of books on diabetes, with an emphasis on the newest ADA guidelines for nutrition, prevention and complications of the disease.

I'm extending my invitation for your continued reading requests, and I'm open to all suggestions. In the meantime, here's your summer buffet of "food for the mind."

* * * * * * * * *

NUMB TOES AND OTHER WOES: MORE ON PERIPHERAL NEUROPATHY, by John A. Senneff.

A sequel to John Senneff's Numb Toes and Aching Soles: Coping with Peripheral Neuropathy, (c) 1999, NUMB TOES AND OTHER WOES is jam-packed with new information for thousands of diabetics who suffer from peripheral neuropathy (PN), a debilitating nerve disorder.

The book begins with a wonderful tribute to John Senneff's work and achievement. In his preface, Richard D. Marks, Jr., M.D. (who also suffers from PN), states, "This new book will become my textbook and should be for every patient, caregiver or teacher of peripheral neuropathy." When you read Dr. Marks' poignant personal journey with PN, it will make you think long and hard about your own diabetes control and the possible consequences of a complication such as peripheral neuropathy.

In Numb Toes and Other Woes, Senneff narrows his focus to the many forms of treatments for providing pain relief. This detailed compendium of new information includes:

* Pain medications including antidepressants, anticonvulsants, antiarrhythmics, antispasmodics, and topicals.

* Current thinking on other medical therapies such as nerve blocks, H-Wave, PENS, TENS and ALTENS.

* Updated information on nutrient supplementation (vitamins and other natural substances can make a BIG difference!)

* Fresh insight on how exercise, magnets, acupuncture, hyperbaric oxygen, biofeedback, hypnosis and a host of other alternative and complementary strategies can work together to help relieve pain.

* And finally, how experimental therapies such a neurotrophic factors, gene therapy, stem cell technology, biologic mini-pumps and nerve disablement may offer significant treatment possibilities.
Numb Toes and Other Woes is a sobering yet inspiring new look at some of the unusual neuropathies and novel causes, drug causes, neuropathic pain, selection of a doctor and patient assistance, complementary and alternative strategies, as well as traditional medications and forms of pain relief. Highly recommended reading for all those suffering from peripheral neuropathy.

* * * * * * * *

DIABETES NUTRITION A to Z, WHAT YOU NEED TO KNOW ABOUT DIABETES NUTRITION-SIMPLY PUT, by Lea Ann Holzmeister, RD, CDE, and Patti B. Geil, MS, RD, FADA, CDE.

This book is the first reference available based on the American Diabetes Association's new 2001-2002 nutrition guidelines. Author Lee Ann Holzmeister was part of the team that established the new guidelines, bringing a variety of updated concepts about diabetes into the twenty-first century.
Topics focus on alcohol, carbohydrate counting (oh, how I wish everyone on the old "exchange" system could learn how to count carbs -- it really simplifies your nutritional life), diabetes medications, fast foods, food labels, gestational diabetes, the glycemic index (so very important in making your carbohydrate choices), herbals and supplements, "New Wave" nutrition, obesity, restaurant dining, travel, vegetarian diets, weight control, and more (there's more?).

Alphabetized listings provide the reader with quick and easy access to any subject, and the thorough, up-to-date information is a bonus for the newly diagnosed diabetic. If you're the type of reader who wants "more" on the subject, the resource lists, book titles and Web site references included at the end of most of the topics are extremely helpful.

I've reviewed hundreds of cookbooks and many, many books on diabetes for several years now, and Diabetes Nutrition A to Z is one of the most comprehensive sources of nutritional information presented in the simplest format. Whether you're looking for information on alcohol or vitamins, eye disease, nutrients, nerve damage or prevention tips, they're all packed into this 188-page book! Great for the newly diagnosed as well as those of us who thought we'd "read it all." Highly recommended.

* * * * * * * *

THE OTHER DIABETES -- LIVING AND EATING WELL WITH TYPE 2 DIABETES, by

Elizabeth Hiser, MS, RD.

Did you know that more often than not, type 2 diabetes is characterized by too much rather than too little insulin? We are insulin-resistant, where type 1s are insulin-deficient. When my own M.D. gave me a C-peptide test, I was astonished to find that I had a system fully capable of producing large amounts of insulin. In fact, nine out of ten cases in the US are type 2 (once called "adult-onset") diabetes, which typically starts out with high insulin levels.

By now, most of us know the drill: Excess calories and a sedentary lifestyle are major contributors to type 2 diabetes; insulin resistance is the hallmark of the disease; and losing excess weight combined with regular exercise is necessary to avoid the most lethal complication of type 2 diabetes -- early death from heart disease.

Elizabeth Hiser, a health writer and one of the founding editors of EATING WELL MAGAZINE (a favorite of mine which is now out of publication), offers the reader a consumer guide to type 2 diabetes by debunking "quick-fix" diets that don't work, and "just thinking about exercise" more than actually doing it (did someone call my name?)

In The Other Diabetes, Hiser reviews the latest findings on fats, fiber, carbohydrates, alcohol and supplements, as well as recommending the optimal plan for controlling diabetes through a Mediterranean-style eating pattern, which she calls the Good Fat Diet. This eating pattern is based on extensive research supporting the fact that a diet rich in the monounsaturated and omega-3 fats is ideal for controlling both diabetes and heart disease. I've recently switched to the newer, more simplified carbohydrate counting for controlling my own diabetes, and was pleased to see that Ms. Hiser has included a section on this method.

Given the author's background in nutrition, there are many excellent recipes which fill the second half of the book. The "Breakfast Cakes" recipe, which incorporate nuts, cereal, buttermilk, and fresh (an orange) and dried fruits (apricots) is just one of the recipes which we'll be sharing in the Cinnamon Hearts Spring Recipe Sampler.

"The Small Meals And Snacks" chapter is designed for busy people on-the-go. Quick-and-easy breakfast recipes, ideas for brown-bag lunches and a variety of snacks emphasize take-along food that is good for you and helps to keep you from becoming so hungry that you "lunge at the next glazed doughnut you happen by." "Salads And Vegetable Dishes, Meat-Free Entrees, Almost Vegetarian Entrees, Poultry and Seafood Entrees," and delicious "Treat Yourself" desserts round out the recipe sections of The Other Diabetes.

Treat yourself to this terrific book, readers. How can you go wrong with recipes from a very popular food magazine editor? Recommended summer reading.

* * * * * * * *

101 TIPS FOR AGING WELL WITH DIABETES, by David B. Kelley, M.D., (c) 2001 by The American Diabetes Association.

Aging well and staying healthy is a challenge for everyone, and aging well and staying healthy when you have diabetes is even more challenging! 101 Tips For Aging Well With Diabetes is one of the newest books in the best-selling series of self-care books published by The American Diabetes Association. It's designed to answer the most common (and sometimes uncommon, yet essential) questions about how the maturing process can be affected by diabetes.

Written in a straightforward question and answer format, this uncomplicated book explores in detail such questions as:

* Am I alone with my diabetes?

* Why aren't my new diabetes pills lowering my blood glucose?

* What is causing my leg pain?

* Why has my wife's/husband's personality changed since she/he developed diabetes?

* Why would I learn to count carbs?

* Am I too old to exercise, and what kinds of exercise are best for me?

* How do I manage my diabetes when I am sick?

* What precautions do I need to take if I live in a nursing home?

An easy-to-reference book, 101 Tips For Aging Well With Diabetes gives maturing people who have diabetes the guidance to improve their lifestyles. Very good reading.

Marilyn Helton, a type 2 diabetic since 1993, is the publisher of Cinnamon Hearts: The Art of Living A Winning Diabetic Lifestyle, a positive-power online E-zine for diabetics and their families. Visit the Cinnamon Hearts Web site: www.cinnamonhearts.com

BEYOND OUR SENSES

by Chris Kuell

Photo included: Caption: Chris Kuell

From the Editor: This article first appeared in the BRAILLE MONITOR, January/February 2002 Edition, published by the National Federation of the Blind. Reprinted with permission.
From the MONITOR Editor: Chris Kuell is a blind freelance writer from Danbury, Connecticut; First Vice President of the NFB of Connecticut; and Director of Legislative Affairs for the affiliate. Although he has a Ph.D. in Chemistry, he now writes articles dealing with blindness--accessibility issues, Braille literacy, and positive attitudes--as well as other nonfiction articles and short stories. He is married; has two children; and enjoys spending time gardening, working on the house, playing with his kids, and experiencing the great outdoors.

"We do not understand what this means--to `see.'"

"Well, it's what, what things look like," Meg said helplessly.

We do not know what things look like, as you say," the beast said. "We know what things are like. It must be a very limiting thing, this seeing."

"Oh no," Meg cried. "It's the most wonderful thing in the world."

"What a very strange place your world must be," the beast said. "That such a peculiar-seeming thing should be of such importance."

From A WRINKLE IN TIME by Madeleine L'Engle

As we closed one millennium and opened the next, the media reminded us exhaustively of the many medical and technological advances made by humankind in the last 100 years. This progressive wave of knowledge and achievement is so impressive that we could spend the next hundred years debating which inventions were the most important. But what really fascinates me is the manner in which knowledge is expanded, being built up from a foundation of basic understanding, one brick at a time, individual advancements contributing mortar and stone to discoveries that alter the structure of our lives.

Prior to the last 150 years or so, human beings relied on our senses to examine, investigate, study, analyze, and understand the world around us. By using sight, sound, taste, smell, feel, and movement, people developed a crude picture of the inner mechanisms that govern life processes. When certain phenomena could not be explained by the science of the times, they would be understood through witchcraft, superstition, and hauntings from the spirit world. Our former need to turn to the supernatural to explain basic natural phenomena illustrates the limitations of our biological detectors.

In order to draw a better picture of nature, we have had to move beyond the power of the senses to acquire knowledge about the physics, chemistry, and biology that make our world work as it does. Thus scientists have spent the last century developing highly refined instruments so that we might better scrutinize our cosmos. The progressive wave of the twentieth century swept in antibiotics and antiviral agents, revolutionary transportation, satellites, computers, the Internet, microwave ovens, and digital technology. Each and every milestone in discovery and technology was presaged by incremental scientific advancements. The invention of better, more precise instruments allowed us to develop new theories about our Earth and its inhabitants. Gaining new knowledge and theories made humankind yearn for even deeper understanding, and we built still better and more sophisticated devices. Technologies such as the electron microscope, the mass spectrometer, the gas chromatograph, the nuclear magnetic resonance spectrometer, and computerized telescopes have allowed us to see things from the sub-units of our universe to objects far beyond our galaxy. Modern instrumentation allows human beings to transcend our senses, transforming data into information that can be used by our minds first and our senses later.

For example, mathematicians have developed an equation that describes the sound of rain as it falls on the ocean's surface. Using sophisticated microphones 60 feet underwater, Dr. Jeffrey Nystuen, a University of Washington oceanographer and research team member for NASA's Tropical Rainfall Measuring Mission, collects acoustical data resulting from the sound of the drops hitting the surface and the bubbles being formed underneath. With these data he can deduce the size of the raindrops, the amount of rainfall, and ultimately the progress of climate change.

Cancer research and treatment have been forever altered by the use of magnetic resonance imaging technology (MRI). An MRI machine uses a nuclear magnetic resonance spectrometer to produce electronic images of specific atoms and molecular structures in solids, especially human cells, tissues, and organs. MRIs are so precise that they can be used to find the tiniest of clusters of cancer cells deep inside a patient's brain. However, it should be noted that the doctor does not see the cancer. Rather the doctor interprets a three-dimensional graphical representation of what the human eye could never see in a live patient.

Is anyone in the modern era unfamiliar with Doppler radar? Every local weather station uses this powerful tool to see the weather patterns. How many homes now boast a carbon monoxide detector? Our senses prevent us from detecting this silent, deadly gas, but our technology frees us to learn of its presence.

We live in an era in which our understanding of the world is not limited to our biological connections to that world. Instrumentation and technology that greatly surpass our human senses are commonplace today. Yet the most specialized instrument and the data it records are rendered meaningless in the absence of the most important sense of all--common sense. Our brains and our ability to think logically are the only mandatory link to all the progress humankind has made in the past hundred years. Anyone can see more deeply into the nature of life by putting his or her brain to work; eyesight is not necessary.

Like the beast in L'Engle's A WRINKLE IN TIME, I, too, wonder why we put such importance on sight and the other senses. After all, appearances can be very deceptive. It is far more important to understand what things are like than what things look like.

WHAT YOU ALWAYS WANTED TO KNOW BUT DIDN'T KNOW WHERE TO ASK
(Resource Column)

Artwork: Hand pulling a book from a shelf of books

Inclusion of materials in this publication is for information only and does not imply endorsement by the Diabetes Action Network of the NFB.

Correction

In the last issue of the VOICE, Volume 17, No. 2, April 2002, we carried an short piece about the FlexSite Diagnostics' A1cAt.Home test kit. In that piece, the company's phone number was listed incorrectly. The correct telephone number is: 1-877-212-8378.

Diabetes Supplies

American Diabetic Supply, Inc., will ship your diabetes supplies to your door. They handle all insurance claims and provide free delivery. Folks with Medicare and/or private insurance (no HMOs) may receive supplies at no further cost. For information, contact: American Diabetic Supply, Inc., 400 S. Atlantic Ave., Suite 108, Ormond Beach, FL 32176; telephone: 1-800-453-9033.

Adaptive Computing Equipment

Freedom Scientific is a powerhouse adaptive equipment maker for the blind and visually impaired computer user. A union of Arkenstone, Blazie Engineering, and Henter-Joyce, Freedom Scientific offers screen magnifiers, talking attachments (voice synthesizers) for your computer, Braille printers and much more. Whether you need adaptive software or hardware, check them out: Freedom Scientific; telephone: 1-800-444-4443; Web site: (www.freedomscientific.com)

Consider Lantus Insulin

LANTUS (Insulin Glargine Rdna), from Aventis Pharmaceuticals, is very different from the "rapid acting" insulins types you hear so much about today. How is this insulin different? LANTUS is a very slow insulin. The company describes it as a "long-acting basal insulin ... providing a relatively constant profile with no pronounced peak, and a glucose-lowering effect for over 24 hours." Company literature states LANTUS is for once-a-day administration, at bedtime, to treat adult patients with type 2 or type 1 diabetes, who require "basal" insulin.

LANTUS is a recombinant dna insulin analog specifically formulated to provide a long, flat response. Because of its special formulation, LANTUS cannot be mixed in a syringe with any other insulin, so if you wished to take it with Regular, Humalog, or Novolog, you'd have to take two injections. LANTUS insulin is available now. To find out more, contact: Aventis Pharmaceuticals; telephone: 1-866-452-6887; Web site: (http://www.lantus.com)

Full Service Diabetes Supplier

DS Medical Supply is a full-service supplier with a catalog of more than 55,000 items, dealing with diabetes, its complications, and many other medical supplies, delivered to your home. Diabetes products range from glucose monitors by Bayer and LifeScan, and the AccuChek VoiceMate talking glucose monitor, strips, lancets and other supplies, to diabetic orthotics/foot care items, and much more. They accept Medicare, private insurance, some HMOs, and, in most states, direct or crossover Medicaid. Contact: DS Medical, 2105 Newport Place, Suite 600, Lawrenceville, GA 30043-5561; telephone: 1-800-722-2604, Web site: (www.dsmedical.com)

Easy Diabetic Cookbook

If you want to prepare healthy diabetic meals, but find most cookbooks just too complicated, you need Linda Coffee and Emily Cale's THE DIABETIC 4 INGREDIENT COOKBOOK. There are over 200 recipes, in all food categories, with complete nutritional and exchange information, each one using four ingredients. The book costs $9.95 (+$2.95 shipping), from: Coffee and Cale, PO Box 2121, Kerrville, TX 78029; telephone: 1-800-757-0838.

Treating Neuropathy

Diabetic neuropathy can be a particularly challenging complication, producing everything from itching and burning to extreme pain and numbness. It's inconsistent; what treatments help one person may not help another. You need expert medical advice from a neurologist trained in this field. If you live in New York or New Jersey, contact Dr. Bello, telephone: (718) 437-5001. If you live in Illinois or Indiana, contact Dr. Ungar: telephone: ( 219) 210-6353.
Diabetic Supplies On Line

Pharmacist Bryan Luna, Rph, offers diabetes supplies, including glucose monitors, on line at (www.diabeticsupplies.com) . This convenient Web site is simply laid out, and can be accessed in large print, too. For those without the internet, telephone: 1-877-787-7543. They will file your Medicare, Medicaid, and private insurance forms. Free product catalog; 30-day money-back guarantee.

Talking Blood Glucose Monitor

Based on the proven Accu-Chek Advantage meter, the Roche Diagnostics Accu-Chek Voicemate provides the following: Clear, high-quality speech synthesis, talking the user through preparations, test procedures, and results, without the need for sighted assistance; an "insulin vial identifier" which reads Eli Lilly insulin vials and speaks their type, as a safety aid in tactile insulin mixing; a new, improved, "touchable" test strip -- the Accu-Chek Comfort Curve (no more "hanging drop of blood" needed!); no meter cleaning required; and a tactile "code-key" system for programming test strip codes. The Voicemate is the most "blind-friendly" talking glucose monitor available today, and the only one whose regular operations require no sighted assistance at all.

The Voicemate comes with an adjustable over-the-shoulder carrying case, with meter, voice box, battery, adapter cord, 10 Comfort Curve strips, earphone, insulin check-vial, manual and quick-reference guide (in print), and instructions on audiocassette. The meter (catalog # 2030802) can now be ordered through any pharmacy (suggested retail price $495-525). To do so, have your pharmacist contact Roche Diagnostics, 9115 Hague Road, Indianapolis, IN 46250; telephone: 1-800-428-5074. For direct purchase, and a price below $500, contact any of the following retailers: BeyondSight, Inc. Littleton, CO: 303-795-6455 ($498); Independent Living Aids, Inc. Plainview, NY ($495): 1-800-537-2118; or the National Federation of the Blind Materials Center Baltimore, M.D. ($475): 410 659-9314.

Talking Computer

The VoiceNote, from HumanWare, is a laptop note-taker/organizer for blind individuals and those losing vision. It combines the familiar MicroSoft WINDOWS CE operating system, and standard computer keyboard, with voice access. You can create MS Word documents, access your e-mail, transfer documents to and from a standard PC computer, use your VoiceNote as a speech synthesizer for another computer, and access a number of planning and scheduling tools. For more information, about the VoiceNote or their many other products, contact: HumanWare, 6246 King Road, Loomis, CA 95650; telephone: 1-800-722-3393; Web site: (www.humanware.com)

Diabetes Supplies

When you need it, you need it. When it's time to test, when it's time for medication, you need it already there. Diabetic Care Center will ship your diabetes supplies to your door, and they do the paperwork. No forms, no trips to the pharmacy. Medicare and most private insurance accepted. Call the Diabetic Care Center, telephone: 1-800-633-7167; Web site: (www.diabeticare.com)

Diabetic Products

Health Care Products makes many over-the-counter medications and supplements for diabetics, including DiabetiSweet sugar substitute and Diabetic Tussin sugar-free cough syrup. Find these products in the diabetic section of Wal-Mart, Rite Aid, Walgreens, and other retailers. For information, contact: Health Care Products, 369 Bayview Avenue, Amityville NY 11701; telephone: 1-800-899-3116; Web site: (www.diabeticproducts.com)

Change Your Ways

Good diabetes management is a lifestyle. Although doctors can prescribe medication and recommend changes, sometimes "changing your ways," adapting/adopting a healthy lifestyle, can be a lot of work -- for there is so much to learn.

The NEWSTART Lifestyle Center offers 12- and 18-day in-house, physician-supervised intensive education programs, that emphasize permanent lifestyle changes designed to help the participant lose weight, maintain health, and adopt healthier habits in nutrition, cooking, exercise, and stress management. Contact: Weimar Institute; telephone: 1-800-525-9192; e-mail: ([email protected])

Full Service Diabetes Supplier

Access Diabetic Supply promises free delivery, no paperwork, and free in-home training in the use of blood glucose testing devices. Your private insurance is welcome, and they accept Medicare, too. They offer free blood glucose monitors to folks who sign up. Check them out on line: (www.diabeticsupply.com) or call: 1-800-276-5712.

Diabetic Food Exchange List

The 1995 EXCHANGE LISTS FOR MEAL PLANNING is now available in Braille (74 pages) and on audio cassette. This publication, the result of a joint effort of the American Diabetes Association and the American Dietetic Association, reflects the current emphasis on total carbohydrate intake, rather than restricting specific sugar types. Users find its orientation simple, and its meal plans flexible. Although it is only one of several ways to manage diabetic food intake, the "Exchange List" has been proven to work reliably and well, and will continue to play a pivotal role.

To purchase, make tax deductible checks payable to: National Federation of the Blind. Cost: Braille $10, cassette $2. Order from: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, M.D. 21230; telephone: (410) 659-9314.

Free Diabetes Literature

The National Federation of the Blind maintains an extensive literature collection, with free materials on many subjects available in a variety of formats. The articles listed below make up one part of the collection, the "diabetes" category:

"Arthritis and Diabetes: A Common Association," "Blind Diabetics Can Draw Insulin Without Difficulty," "Can I Eat Sugar?," "Cardiovascular Health: Bypass May Be Better for Diabetics," "Check Your Hemoglobin A1c I.Q." "Diabetic Eye Disease," "Diabetic Peripheral Neuropathy," "Diabetics, Don't Give Up on Braille," "The Emotional Side," "Finger-Sticking Techniques," "How I Went Blind...And Then What," "Hypoglycemia - Low Blood Sugar," "Insulin Measurement Devices," "Insulin Types: A Review," "Keeping Your Feet," "Kidney Disease: Prevention, Dialysis, and Transplantation." "Male Sexual Dysfunction," "Many Blind Diabetics Successfully Use Insulin Pumps" "New Dietary Guidelines for Diabetes Management," "Oral Diabetes Medications Update," "Talking Blood Glucose Monitoring Systems," and "What Is Diabetes Mellitus?"

A volume of these articles is available in large print and four-track audiocassette for the blind (all the diabetes articles together), titled: "Diabetes Action Network Articles"). Both formats are free of charge. To order, or to request a complete NFB literature catalog, contact: NFB Materials Center, 1800 Johnson Street, Baltimore, M.D. 21230; telephone: (410) 659-9314. You may also order by E-mail: ([email protected]). The Materials Center is open 8:30 pm to 5 pm, EST, weekdays.

FOOD FOR THOUGHT

Artwork: Dancing fruits and vegetables

We invite blurbs and tidbit articles for inclusion in this column. Materials received may be edited and used as space permits. Products and services included in this column are for information only and do not imply endorsement by the Diabetes Action Network of the NFB.

Be a Chef

Stars and important people are more and more enlisting the services of a "Personal Chef." If you've ever been interested in this profession, you should know the U.S. Personal Chef Association (USPCA) is holding summer training programs. Each five-day session will teach participants how to prepare individualized/customized meals for their clients, in their clients' home, and package them in ways that allow reheating at the client's leisure.

For information, contact: USPCA, 481 Rio Rancho Blvd., NM 87124; telephone: 1-800-995-2138; Web site: (www.uspca.com)

Treat IGT

Many people exhibit some, not all, of the symptoms of type 2 diabetes. Their condition has been described as "Impaired Glucose Tolerance" (IGT) and recently as "pre-diabetes," because perhaps half of them will progress to full type 2.

What do you do, if you have IGT? First, you work on lifestyle changes: better diet (and less of it), regular exercise, stop smoking, cut stress. Then, if you need it, there is now a medication, Starlix (nateglinide), from Novartis Pharmaceuticals.

Starlix stimulates secretion of endogenous insulin, and, in recent studies, proved useful for people who show delayed primary insulin response (a common symptom of IGT). Studies are continuing, but Starlix is available for prescription now.

For information, contact: Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, NJ 07936-1080; telephone: (973) 781-5970; Web site: (www.novartis.com).

To Our Readers

To hold down costs, both the VOICE and many of our divisional mailings are sent via "bulk mail." When we have your current address, this works very well; but when we don't, the Post Office throws the VOICE away, or returns it to us with a hefty "postage due" attached. They do NOT automatically forward bulk mail!

If you move, please let us know promptly. If the VOICE doesn't follow you to your new address, we may not have your new address. Don't miss a single issue.

Obesity and Type 2 Diabetes

Consider obesity. "Overweight" can come from a number of causes, separately, or together in the way we call an "unhealthy lifestyle." If you are genetically predisposed toward type 2 diabetes (NIDDM), and an astonishing number of people are, being overweight and sedentary can greatly increase your chance of developing the disease.

Years ago, before the age of convenience devices, convenience foods, television and couch potatoes, most people's lifestyle (hard manual labor!) kept them physically fit. Few but kings had the opportunity to be "lazy," an opportunity now provided to all by our many household devices. We use our "conveniences" instead of our muscles, and we are not looking after our diet, or our exercise. Too often, we pay for it.

Being overweight by itself does not cause diabetes. There are many overweight people with perfectly normal blood sugars and A1C tests. But if you are genetically predisposed toward insulin resistance, impaired glucose tolerance, and type 2 diabetes, a fit and healthy lifestyle is the best thing you can do to keep the wolf from the door. And, if you already have type 2, the same lifestyle choices are the best thing you can do to treat it.

VOICE Formats

VOICE OF THE DIABETIC is offered in two formats: standard print, and 15/16 ips audiocassette, "talking book" speed. Anyone who is currently receiving the VOICE in print, and having difficulty reading it, may receive it on cassette at no charge. VOICE tapes require the special tape player available free to the legally blind from Regional Libraries for the Blind and Physically Handicapped, which can be obtained by telephoning the National Library Service at: 1-800-424-8567.

Periodically we receive requests for the VOICE in Braille or large print. It is not available in either of those formats at this time.

Articles Needed

If you have diabetes, are a family member or friend of a diabetic, or a health professional with an interest in diabetes, we invite you to submit an article for publication in the VOICE OF THE DIABETIC.

Our philosophy regarding diabetes is positive. Do you have an inspiring, enlightening story? We, the Diabetes Action Network of the National Federation of the Blind, seek to show people they are not alone, and do have options, regardless of diabetic complications. If you have experienced ramifications, others, who may be facing the same side-effects, could benefit from what you have to say.

Perhaps you have not experienced complications--your unique insight, coping strategies, and lifestyle can still inspire others. Are you a relative, a friend, or a health professional? More than 308,723 VOICE readers could benefit from your story.

For information and article submission guidelines, contact: VOICE OF THE DIABETIC, 1412 I-70 Drive, Suite C, Columbia, MO 65203; telephone: (573) 875-8911.

WHAT DO YOU THINK?

We are a membership organization, dedicated to the public service of informing our readers about diabetes, its complications, and the best ways to cope with it. Our job is to help show all of you that, regardless of your current state of health, what you've endured, or what you fear might happen, NO diabetic is alone; ALL have options.

How are we doing?

You, the reader, are the expert here. What do you like? What could we improve? How could we better carry our message of empowerment for all diabetics, blind or sighted?

Contact us at:

VOICE OF THE DIABETIC
Diabetes Action Network
National Federation of the Blind
1412 I-70 Drive SW, Suite C
Columbia, MO 65203
Fax: (573) 875-8902
e-mail: ([email protected])
We really need to hear from you.

SUBSCRIPTION/DONATION FORM

The VOICE OF THE DIABETIC is a quarterly magazine published by the Diabetes Action Network of the National Federation of the Blind (NFB) for anyone interested in diabetes, especially diabetics who are blind or are losing vision. An outreach publication, it emphasizes good diabetes control, diet, and independence.

Donations are gladly accepted and appreciated. Contributions are not only tax deductible but are needed to keep the VOICE and the Diabetes Action Network moving forward to help people with all aspects of diabetes.

Members of the NFB Diabetes Action Network enjoy priority services and unique benefits such as a continuous free subscription to the VOICE, automatic access to committees covering all aspects of diabetes, free counseling concerning all facets of blindness and diabetes, as well as access to diabetics who have experienced complications.

The VOICE is free to any interested person upon request. Each subscription costs the Diabetes Action Network approximately $20 per year. To help defray publication expenses, members are invited, and nonmembers are encouraged, to cover the subscription cost.

To begin receiving the VOICE, please check one:

[ ] I would like to become a member of the NFB Diabetes Action Network and receive the VOICE OF THE DIABETIC. (Members are entitled to special benefits.)

[ ] I would like to receive the VOICE OF THE DIABETIC as a nonmember. (Nonmembers are encouraged to pay the institutional rate of $20/one year; $35/two years; $50/three years.)

Send the VOICE in (check one):

[ ] print [ ] cassette tape for the blind and physically handicapped(recorded at slower-than-standard speed of 15/16 IPS) [ ] both

Optionally check this box:

[ ] I would like to make (or add) a tax-deductible contribution of $__________ to the Diabetes Action Network of the National Federation of the Blind.

PLEASE PRINT CLEARLY

Name:_____________________________________________________
Address:__________________________________________________
__________________________________________________
City:_______________________ State:______ Zip:__________
Telephone: ( )________________________

Send this form or a facsimile to:

Voice of the Diabetic
1412 I-70 Drive SW, Suite C
Columbia, MO 65203
Telephone: (573) 875-8911
Fax: (573) 875-8902

Please make all checks payable to:
NATIONAL FEDERATION OF THE BLIND

VOICE DISTRIBUTORS NEEDED

Since the VOICE is now offered free, our Diabetes Action Network will provide extra copies to anyone wanting to help spread the word. We will gladly send from five to five hundred-plus copies each quarter to be used as free literature. Medical facilities can order as needed for patients. Individuals can usually place copies of the VOICE in libraries, pharmacies, hospitals, doctors' offices, or other public locations.

Diabetes education is essential. Anyone who distributes the VOICE will be helping people with diabetes, and their families, to learn about the disease and its ramifications; to learn that they have options; and that their world is far greater than whatever "limits" may be imposed by the disease. If you would like to help spread the word by distributing the publication, please contact: VOICE OF THE DIABETIC, 1412 I-70 Drive SW, Suite C, Columbia, MO 65203; telephone: (573) 875-8911, fax: (573) 875-8902. NOTE: Please provide a phone number so we can reach you.