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VOICE OF THE DIABETIC

The Diabetes Action Network of the National Federation of the Blind
Diabetes Support and Information
Volume 19, Number 3, Summer Edition 2004

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VOICE OF THE DIABETIC, published quarterly, is the national 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) our direct Web address is: (www.NFB.org/voice.htm)

Copyright (c) 2004 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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FREE! FREE!

VOICE OF THE DIABETIC is offered absolutely free to any interested person upon request. Readers may receive the publication in standard print, on audiocassette for the blind, or in both formats. To begin receiving the VOICE, please complete the subscription form (or a facsimile), found at the end, and mail it to the editorial office.

Please Note: We have a special bulk-mailing permit that we use to ship the VOICE to you at low cost -- it does not allow for free remailing. The Post Office requires you place first class postage on any VOICE you mail to others.

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Here’s the new front cover page for the VOICE.

Includes photo of Karen Mayry with the following overprinted on the photo: U.S. Senate Honors Karen Mayry.

RESEARCH UPDATE: CHEMICAL MAY HELP PREVENT TYPE 1 DIABETES

WHAT TO EXPECT FROM AN EYE EXAMINATION
Advice from Dr. Paul Chous

DIABETIC FOOT PAIN
Dealing with Neuropathy

MEDICARE PRESCRIPTION DRUG BENEFIT
Exploring the New Drug Discount Cards

INSULIN BASICS: THE REASONS BEHIND THE RECOMMENDATIONS

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ADVERTISERS

Effective advertising doesn't scream at its audience. It persuades. It sells. The key to cost-effective advertising is making your voice heard where an audience is already listening. VOICE OF THE DIABETIC, circulation 334,725, offers such an outlet. Make your voice heard. For VOICE OF THE DIABETIC advertising information contact:

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or find us on the Web at:
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For SUBSCRIPTION information, see the end of this document.

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INSIDE THIS ISSUE

INSULIN BASICS: THE REASONS BEHIND THE RECOMMENDATIONS
by Ann S. Williams, MSN, RN, CDE

NOT JUST WAITING FOR A CURE

DIABETIC FOOT PAIN
by Kenneth B. Rehm, DPM

THE SLEEP SENTRY, A NEW HYPOGLYCEMIA ALARM
by Ed Bryant

AMERICA'S JOBLINE

MEDICARE PRESCRIPTION DRUG BENEFIT
by Peter J. Nebergall, Ph.D.

A POTENTIAL FOR TROUBLE: ERRORS IN REFILLING THE MINIMED 2007 INSULIN PUMP

YOU CAN'T POSSIBLY FAIL
by Deborah Robinson

LETTERS TO THE EDITOR

CUT THE RISK OF HEART ATTACK

ASK THE DOCTOR
by Chris Corsi, M.D.

WHAT TO EXPECT FROM AN EYE EXAMINATION
by Paul Chous, OD
WHAT IS MACULAR DEGENERATION?

CINNAMON?

US SENATE HONORS KAREN MAYRY

AN INTERNET ALTERNATIVE

DIVING
by Terri Uttermohlen

NEW DRUG SHOWS PROMISE IN NEUROPATHY TRIALS
by Ed Bryant

SUMMER FOOT CARE

RECIPE CORNER

BEYOND STATISTICS: A WEIGHTY PROBLEM
by Peter Nebergall, Ph.D.

HEALTHY HOME COOKING
by JoAnna Lund

RESEARCH UPDATE: CHEMICAL MAY HELP PREVENT TYPE 1 DIABETES

DIABETES SELF-CARE -- WHEN YOU'RE BLIND
by Ed Bryant

INJECTING INSULIN THROUGH CLOTHING

RESOURCE ROUNDUP

FOOD FOR THOUGHT

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INSULIN BASICS: THE REASONS BEHIND THE RECOMMENDATIONS

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.

This month's column contains general information about insulin. I have received quite a few questions lately about why people are supposed to do particular things when drawing insulin and giving injections. So here are answers to those questions, organized into three general topics: storing, drawing, and injecting insulin.

This is definitely not everything there is to know; these are just the questions I have been asked most often.

Storing insulin

Q: Why am I supposed to store insulin in a refrigerator?

A: Insulin is a protein dissolved in water. (You can think of it as something like a soup broth.) Like any other protein, it can spoil. Keeping it cold helps to keep it from spoiling.

Q: What will happen if the insulin starts to spoil?

A: Bacteria growing in it will break down the protein. The insulin will not poison you or make you sick. It just won't work very well. If this happens to you, your blood sugar would be higher than you expect, even though you have given your injection in the right amount at the right time.
Q: How cold does it need to be?

A: Insulin you are not using should be kept between 36 degrees and 46 degrees Fahrenheit. If it gets colder than that it can freeze. If it gets warmer than that, it will be good for a while, but eventually it will start to break down.

Q: I have been told it's OK to keep a bottle of insulin I'm using at room temperature. Is this really OK? If so, why?

A: Yes, the standard recommendation from all the insulin manufacturers is that a vial of insulin you are using can be kept at room temperature for up to 28 days. Room temperature is defined as between 59 degrees and 86 degrees Fahrenheit. This works because all the standard insulin preparations have preservatives in them -- which will keep the insulin good for a while, but eventually stop working. Bacteria begin to grow in the insulin, and start breaking down the protein.

Many people say injections of insulin are more comfortable when the insulin is not cold. Also, many people find it easier to get rid of air bubbles when the insulin is room temperature. If these factors don't matter to you, and you prefer to keep your insulin in the refrigerator, that is fine.

Q: I live in a hot climate, and I don't have air conditioning. Can I still keep my insulin at room temperature?

A: If your room temperature goes above about 80 degrees Fahrenheit, you would be safer to keep your insulin in the refrigerator.

Q: I use an insulin pen. I have heard I should keep my pen at room temperature for only two weeks. But insulin in vials can be kept at room temperature up to 28 days. Why?

A: The insulin manufacturers did experiments with insulin pen cartridges, and found some kinds of insulin began to spoil sooner in pen cartridges than in vials. So, insulin in pens and cartridges now have different recommended storage times. To find out the recommended storage time for the pen or cartridge you use, ask your pharmacist, check the package insert, or check the manufacturer's web site. (See below for the Web sites and contact phones for all three insulin manufacturers.)

Q: I'm storing my insulin at room temperature. I don't use up the whole vial in 28 days. What should I do with the extra insulin, and why?

A: All the insulin manufacturers recommend throwing out the rest of the insulin in the vial, because they cannot guarantee the insulin is still good.

Q: What would happen if I kept using insulin past 28 days at room temperature, or past the expiration date on the box?

A: Your insulin might still be good after the expiration date on the box, or after 28 days at room temperature, but it's not guaranteed to be good. I know some people who don't have health insurance and have to pay out-of-pocket for all of their insulin do continue to use insulin past the recommended times. Generally, for the first few days, nothing much happens. Then, a time comes when the insulin does not control their blood sugar very well, and it's hard to find a dose that works. This happens because the insulin is spoiling. When they measure a certain number of units of insulin, there is actually less active insulin in the syringe, and no one can be sure exactly how much active insulin is left.

I do NOT recommend using insulin past the recommended times. If you feel you need to do that, you will have the best chance of keeping your insulin good if you have kept it refrigerated. You should also know that Lantus insulin and the rapid insulins (Humalog and Novolog) spoil faster than Regular and NPH insulin.

Q: I can't afford to throw out insulin, and I don't want to have unpredictable insulin action. What can I do?

A: All the insulin manufacturers have patient assistance programs to help people who need insulin and cannot afford it. You can find out more information about exactly how each company's program works by checking their Web sites, or going to www.helpingpatients.org, the Web site of the drug industry association PhRMA; telephone: (202) 835-3400. You will need to ask the doctor who prescribes your insulin to help you get signed up for one of these programs.

Drawing insulin

Q: When I was first taught how to use NPH insulin, I was told to roll the vial between my hands ten times before drawing the insulin. Why?

A: Certain types of insulin: NPH, Lente, and Ultralente insulin, look cloudy in the vial. They look cloudy because particles of insulin are not fully dissolved. When the insulin bottle or pen sits still for a few minutes, the particles of insulin settle out, and fall to the bottom of the container. Before you draw the insulin, you need to gently mix it up so the whole bottle has the same concentration of insulin all the way through. If you carry prefilled syringes, and they have any of the above "suspension" insulins in them, you'll need to gently agitate them, too, for the same reason. Otherwise, you would get different concentrations of insulin when you draw the clear part than when you draw the part that contains the settled particles.

Rolling the insulin between your hands is a good way to mix insulin in a vial without making a lot of little bubbles in the insulin itself. If you shake the insulin and mix in a lot of bubbles, they will not hurt you. But you might end up with little bubbles of air in your syringe, and that would mean you would not get your full dose of insulin.

Q: When I started using an insulin pen with an NPH mixture, I was taught to mix the insulin by rolling the pen ten times, and then pointing the pen up and down ten times. Is this really necessary? Why?

A: Research has shown that insulin in pens is a little harder to mix than insulin in vials. There are no air pockets to help the mixing process. When people roll the pens in their hands, the insulin can still have layers that are not completely mixed. But there is a tiny glass ball that rolls back and forth when the pen is pointed up and down. By doing this ten times, you may be sure all the layers of insulin are thoroughly mixed.

Q: When I was taught how to draw insulin I was told to inject air into the vial before I drew insulin out. Why?

A: The rubber stopper on the top of the vial does not let air through. When you're taking insulin out of the bottle, you need to put air into the vial to replace the insulin. If you don't do this, each time you draw out some insulin, you are building up a little bit of vacuum in the vial. After a while, it actually gets hard to pull the insulin out. And if you let go of the plunger, the vacuum in the bottle pulls the plunger back in.

Q: Why don't I have to inject air into my insulin pen before I use it?

A: Pens work in an entirely different way than syringes. The insulin never gets drawn from one container into another. Instead, there is a little plunger inside the insulin chamber in your pen. When you set the dose on your pen, you are setting how far forward this plunger will move. When you deliver the dose of insulin and the plunger moves forward, the space that holds insulin gets smaller. There is no need for air to fill up any of the extra space.

Q: I used to mix NPH and Regular insulin. Now I am taking Lantus for basal insulin, and a rapid insulin with meals. I have been told I should not mix them in one syringe. Why?

A: The action time of Lantus insulin changes when it is mixed with any other insulin. You end up with some mixture of long-acting and short-acting insulin, but the mixture is unpredictable. So the manufacturer of Lantus recommends it should not be mixed with any other type of insulin in the same syringe.

One easy way of making sure you don't mix Lantus with any other insulin is to take the Lantus with a vial and syringe (no Lantus pen cartridge is yet available), and take the other insulin with a pen.

Q: I have been told not to mix Lantus with another insulin, but I have been also told I can give my Lantus injection at the same time as one of my rapid insulin injections. Won't they mix themselves in my body?

A: As long as the Lantus and other insulin are not mixed together in a syringe, or given in exactly the same spot on your body, they will not change each other's time of action. What this means is if you give these injections at the same time, you should give them in different syringes, and in different spots on your body.

Injecting Insulin

Q: I started using insulin recently, and was told to be careful to not inject into the same spot over and over again. Why?

A: If you use the same spot repeatedly, your body reacts by creating changes in the fatty tissue just under the skin. It can either cause the fat tissue to deteriorate, and create a pit under the skin; this is called lypodystrophy, or it can grow a little extra fat tissue there, and create a lump just under the skin; this is called lypohypertrophy. Either one of these will change the absorption time of insulin. Also, many people don't like the way these lumps and pitting just under the skin look.

Q: When I started taking insulin years ago, I was told to rotate the sites for injection between my stomach, my thighs, my buttocks, and my arms. Recently, a diabetes educator told me to inject into my abdomen only. Why have the recommendations changed?

A: There are two reasons the recommendations have changed. First, we now know a lot more about insulin absorption. We now know the absorption of insulin is fastest and most predictable, when injected into the abdomen. So, for example, insulin injected into the buttocks might be absorbed slower than you expect. On the other hand, insulin injected into the arms and thighs is injected near some large muscles. When you use those muscles, the blood flow increases there. If this happens while the insulin is being absorbed, it speeds up the absorption rate. You might then have an unpleasant surprise -- low blood sugar!

Secondly, modern insulin is more pure than older insulin. This means there are fewer problems from injecting in the same area repeatedly.

Q: I'm using my abdomen only for my injections, and I inject four times a day. Do I still need to rotate where I give the injections?

A: Yes. As long as you give each injection about an inch away from the last injection, it's far enough away to prevent problems.

Q: I keep forgetting where I last injected. How can I keep track?

A: One system that is easy to remember is to draw an imaginary line vertically through your navel. Then draw another imaginary line horizontally across your stomach through the navel. Now you have four rectangles on your abdomen. Draw two more imaginary vertical lines to divide all the rectangles in half. Now you have eight areas that are approximately squares. Starting on one side, assign a square for each day of the week. Inside each square, use the top right hand area for the morning injection, the top left hand area for the noon injection, the bottom right for the evening injection, and the bottom left for the bedtime injection. Use the middle of each square, or the extra square, for any extra injections you might have to give.

Q: I have been told to pinch up some skin and fat, to be sure I don't inject insulin into a muscle. What would happen if I injected insulin into a muscle?

A: It would probably hurt. More seriously, the insulin would probably be absorbed very rapidly. You would have more chance of having a serious episode of hypoglycemia, or low blood sugar.

Q: Some people say you should inject insulin with the needle at a 45 degree angle, and others say you should just push the needle straight in at a 90 degree angle. Which is right?

A: Either one can be right. The idea is that you want to inject the insulin into the tissue just under the skin. Most people have enough fat in the areas used for injections that it's fine to inject straight in (90 degrees), and it's a little easier. Insulin needles are short enough that they don't reach in too far. But for small children, or thin adults, there might not be much space between the top of the skin and the muscle underneath. These people can be more certain of injecting into the right place by holding the needle at a 45-degree angle to the skin. Another choice would be to use shorter insulin needles, which would then allow them to use a 90-degree injection angle.

Q: Sometimes I can feel a bump right under my skin right after an injection. What is that?

A: It means you injected the insulin too close to the surface of the skin. The insulin is probably sitting in between the layers of the skin. This can happen if you're trying to do an injection at a 45-degree angle, but you actually use even less of an angle.

The insulin you just injected will be absorbed into your body, eventually. But there is not good blood circulation this close to the surface of your body, so it could take a long time to be absorbed. Meanwhile, you might have higher blood sugar for a while. To prevent a repeat of injecting the insulin between the layers of the skin, you should inject at a 90-degree angle, or use a shorter needle. This will allow you to use a 90-degree angle without any problems.

Q: When I was first taught how to give insulin injections, I was told to wipe my skin with alcohol before giving the injection. Now my diabetes educator has told me I don't need to do that. Why?

A: Wiping the skin with alcohol was a medical ritual everyone assumed we needed to do. But until a few years ago, it had really never been tested. When it was tested with careful research, we learned most people do not get higher rates of infection if they give insulin injections without wiping the skin with alcohol, as long as they bathe at least once a week, and the skin is basically clean. This works for several reasons:

1. Wiping with alcohol does not sterilize the skin. It only cleans the top layer of skin. You can get your skin just as clean by washing it with soap and water.

2. Insulin needles are small and slick. They are not good carriers for bacteria.

3. Most people keep the areas of the body they use for injections covered by clothing most of the time, so they are generally kept clean.

If the area you'd inject has been exposed, and has gotten dirty, say, for example, you have been wearing a bikini and rolling in the dirt, or if you have spilled something wet over an injection site and it has soaked through your clothes, you definitely should clean the site before giving an injection. You can either wash with soap and water, or wipe the area with an alcohol wipe. But if your skin is basically clean, you don't need to use alcohol routinely.

Q: How can I contact the insulin manufacturers?

A: Their web sites and customer service numbers are:

Aventis: Web site: www.lantus.com; Customer service number: 866-452-6887.

Eli Lilly: Web site: www.lillydiabetes.com; Customer service number: 800-545-5979.

Novo Nordisk: Web site: www.novonordisk-us.com; Customer service number: 800-727-6500.

Other Sources:

DIABETES ACTION NETWORK ARTICLES book: Contains useful articles like "Blind Diabetics Can Draw Insulin Without Difficulty," "Insulin Types: A Review," "Insulin Measurement Devices," and 20 more, available free in large print or 4-track audiocassette from the Materials Center, National Federation of the Blind, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314; Web site: www.nfb.org

See also accompanying article in this issue: "Diabetes Self Care -- When You're Blind" -- more good information about drawing and injecting insulin.

Do you have questions about your diabetes care? If you would like your question answered in a future column, please contact me, Ann S. Williams, c/o the Voice editorial office.

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NOT JUST WAITING FOR A CURE

At best, diabetes can be unpleasant and inconvenient. Taking good care of yourself, "good diabetes self-management," is not a lot of fun. We all know of people who ignored their self-care "because they didn't feel bad," only seeing the error of their ways when the permanent damage they were doing to themselves with those high sugars reared up and bit them.

But for all those folks, there are as many others "waiting for a cure." Now we'd all like a cure for diabetes; but, while you're in the lifeboat, waiting to be picked up, are you rowing and bailing, or are you just enduring, waiting for medical research to deliver you from your tribulations?

If you're just waiting, you're doing yourself damage.

A cure for diabetes, in some form, is going to happen. But, we can't say quite when, and those diabetics who will be in the best shape to benefit when it arrives will be the ones who've done the most to minimize its complications. They will be the ones who ate wisely and sparingly, tested their blood often, and took their medications on time.

Will you be one of them?

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DIABETIC FOOT PAIN

by Kenneth B. Rehm, DPM

Includes photo of Dr. Kenneth B. Rehm, DPM

Diabetes is one of the most common reasons people seek relief for painful feet. With diabetes, four types of foot problems may arise in the feet.

Nerve Problems due to Diabetes

The most common contributor to diabetic foot pain is a nerve problem called Peripheral Neuropathy. This is where the nerves are directly affected by the disease process. There are basically three types of peripheral neuropathy: sensory, motor, and autonomic neuropathy.

A large percentage of pain diabetic patients complain of is due to sensory neuropathy. This can show up as "sensitive pain," where the amount of pain is not proportional to the amount of insult that is causing it. For instance, just touching the skin or putting a sheet over your feet in bed could be painful. This can be present at the same time as numbness in the feet. Sensory neuropathy symptoms can include burning, tingling or a stabbing pain.

Relief is foremost on someone's mind when painful neuropathy has raised its ugly head. The first thing to do is to check your blood sugar for the past several weeks to see if there has been a trend toward high blood sugar (Editor's Note: The A1c test is traditionally employed to determine this, and should be repeated about every three months.) Persistent high blood sugar can contribute to this type of pain.

Massaging your feet with a diabetic foot cream, or using a foot roller, often takes the edge off the pain. Vitamin B preparations are often recommended; and there are a variety of prescription medications that do work. Using cushioned, supportive shoes and foot support inserts is always needed to protect the feet from the pounding, rubbing and irritating pressures that contribute to neuropathic pain.

Motor neuropathy can contribute to another painful diabetic condition. The nerves to the muscles become affected by the disease process. This makes the muscles feel weak and achy. Some of the first muscles to become affected are those in the thigh; other common muscles include the shin muscle and the small muscles of the feet. When motor neuropathy is present, walking imbalances can result. These can cause increased rubbing of the foot in the shoe, inflammation of the skin, increased callous formation, and pain.

Helping yourself against the ravages of motor neuropathy involves correcting those walking imbalances with supportive shoes and foot support inserts. Foot exercises, massage and using foot rolling devices are excellent ways to help keep those muscles and joints from becoming stiff.

Keep the muscles working and the joints moving!

Autonomic neuropathy affects the nerves to areas that are not under our conscious control. The sweating mechanism is altered -- so the person who suffers with this condition may have thickened, dry cuticles and nails; as well as dry, stiff, cracked skin -- which is subject to a buildup of thicker calluses with more pain. Bacterial and fungal infection could be more likely; an additional source of pain and concern.

Daily use of toenail oil and conditioning foot cream made specifically for diabetic foot care can play an essential role in preventing these problems.

Circulation Problems

Circulation problems in the feet may cause intense pain, even though the feet may feel numb to the touch. This is due to the effect of high blood sugars on the arteries, capillaries and veins. Arteries feed fresh blood away from the heart. This fresh blood nourishes and provides oxygen to the tissues. The blood enters and leaves the tissues through capillaries and goes back up to the heart to get refreshed with oxygen and nourishment by way of the veins.

The arteries most commonly affected are those behind the knee and the calf. These arteries are subject to the same fatty deposits that most people have, however, the process can be accelerated in diabetes. These fatty deposits thicken the walls of the arteries, and may develop calcium deposits. Blood flow to the feet could then be partially or totally blocked. Because the tissues are starving for oxygen, this can be an extremely painful process. Such pain is often described as though the feet are in a vise, and are being strangled.

The capillaries are known to get thickened and stiff from diabetes -- thus not as efficient in delivering oxygen and nutrients to and from the tissues.

The veins can get swollen and painful. This happens when the arteries cannot handle the blood flow, and little channels are created to direct the blood over to the veins instead of trying to push the blood through closed arteries. Sometimes there is more blood than the veins can handle. They become so full that the valves become broken. Blood then pools in the feet and legs and can leak out into the skin, creating ulcerations, which can be very painful.

With the approval of your medical doctor, support hose, exercise, massage, physical therapy, medications and various surgical procedures can be used to improve the circulation.

Muscle & Joint Problems

Muscle and joint problems in the diabetic patient are a frequent source of discomfort and pain. The muscles are affected by diabetic neuropathy, circulation problems and atrophy. The tendons (attachment of the muscle to the bones) may become stiff and contracted due to the walking imbalance associated with peripheral neuropathy.

This walking imbalance forces the foot and joints to move in ways that are not healthy and that Mother Nature never intended. In addition, they may stiffen in this bent position because of the excess blood sugar combining with the proteins in the joints. This is called diabetic glycosylation of the joints.

This, combined with the normal imbalance all people, including non-diabetics, are subject to, can lead to stiff hammertoes, bunions, spurs, and tiny fractures with dislocation of the bones (called Diabetic Charcot Deformity). These problems can be sources of pain, infection, ulceration and major medical concern.

With consent from your foot healthcare provider, foot rollers, massage and specially made shoes and inserts might be the best way to deal with these muscle and joint problems.

Frequent Infections

Diabetic persons become more susceptible to bacterial, fungal and yeast infections due to medical and nutritional changes that takes place in the body.

Bacterial infections show up in areas on the foot that become irritated, ulcerated or injured. The signs of a bacterial infection include redness, swelling, warmth, pain and tenderness as well as the presence of pus. (Editor's Note: Blind diabetics can detect foot infections by touch, and, in some cases, by smell.) This kind of infection can either be on the skin, called cellulitis, or can spread to the bone. When infection has spread to the bone it is called osteomyelitis. It is interesting that even though a diabetic may have numbness in their foot, they could sometimes feel pain when they have a bacterial infection. When a diabetic suddenly develops pain while their feet are numb, it could be a sign that an infection is present -- and a health care provider should be contacted without delay.

Fungal or yeast infections in the foot commonly occur as athlete's feet or fungal toenails. Athlete's feet can cause the skin to become blistered, scaly, red, inflamed and painful. A bacterial infection can occur on top of this because the irritated skin serves as a good place for germs to thrive. Fungal toenails can become very thick, powdery and ingrown. These thick nails can leave debris under the nails and cause severe irritation to the skin surrounding the nails. They can even become ingrown with callused nail grooves. This can cause infection to the areas surrounding the nail and is a source for medical concern.

In order to maximize a person's ability to fight off infections, think strengthen the immune system. This comes from good blood sugar control, moderate exercise, good nutrition and supplements, if recommended by your health care professional. Fungus can make the skin raw and fungus toenails can become thick, irritating, painful and infected with bacteria. Self-inspection and daily maintenance of the skin and nails is essential to prevention. Once your toenails or skin on the feet become infected with fungus, it is important to treat it right away to prevent ulceration and bacterial infection. Medications prescribed by your foot healthcare professional are recommended, but various over-the-counter and home remedies have found success. The use of tea tree oil, sesame oil, garlic, grapefruit seed extract, and galberry root soaks are among them.

It is important to note that not all diabetics can detect the pain of these problems -- and therefore should have their feet visually and manually inspected every day. Be Prudent, Be Cautious and Follow the Rules of Good Health!

From the Editor: Dr. Kenneth B. Rehm, DPM, is a podiatrist whose practice is limited to the diabetic foot. He is the medical director of the Diabetic Foot and Wound Care Center, in San Marcos, California; telephone (760) 744-6226. Along with expert care and instruction, he offers several products he has developed for the diabetic foot. Originally from Cleveland, Ohio, Dr. Rehm graduated from California College of Podiatric Medicine in 1976, and has been in practice for more than 25 years. Consulting Editor to Podiatry Management magazine, he is also an active lecturer, and has been keynote speaker for our Diabetes Action Network’s annual meeting

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THE SLEEP SENTRY: A NEW HYPOGLYCEMIA ALARM

by Ed Bryant

The Sleep Sentry was introduced in the Winter 2004 edition of the VOICE. I am a type 1 insulin dependent diabetic, and I purchased the Sleep Sentry so I could evaluate it. I am pleased with the watch-like device, but please be cognizant that it is not for everyone.

NOTE: Parts of this article are from the instruction manual, included with each unit.

Diabetes brings the risk of hypoglycemia, low blood sugar. Most often the result of imbalance between food, exercise, and medications, a "hypo," a low blood sugar reaction, can cause disorientation, unconsciousness, and sometimes, the need for an ambulance.

The Sleep Sentry is intended to warn type 1 diabetics of a hypoglycemic reaction, low blood sugars, occurring while they are asleep. It is actually designed to monitor the temperature and moisture level of the skin; symptoms normally associated with insulin reactions. If it does not detect one of these symptoms, if a low blood sugar reaction occurs without them, the alarm will not sound, and it will probably be of no use to the diabetic.

Remember, the alarm is intended to awaken the user, if there has been a temperature drop, or if it is detecting increased perspiration. The alarm does not directly indicate hypoglycemia. If the alarm goes off, and, after checking your blood sugar, you find it is in the normal range, the alarm could have been triggered by its wrist band being too loose, by an extreme change in the room temperature, or if the user perspires excessively or exhibits a drop in skin temperature for reasons other than hypoglycemia, as examples, fever, menopause, or as a side effect of medications.

Diabetes Sentry Products tells me the Sleep Sentry was successful, in initial clinicals 90 percent of the time, in detecting hypoglycemia. The 10 percent failure rate was generally attributed to user error. Some people do not wear the device during the daytime because they sweat more then, which can trigger a false alarm. If you have concerns about undetectable low blood sugar, you might wear the device during the day, as a precaution. Again, the Sleep Sentry is intended for a type 1 diabetic, but can be worn by type 2s as well, to warn them of hypoglycemia.

There is a condition called hypoglycemia unawareness, in which the diabetic loses the ability to tell that s/he is going down, and the next sound you hear may be a siren. What many of us need is a device to warn us we are getting low when we cannot tell for ourselves -- sufficient to warn us to act before we are so far into the hypo we can’t help ourselves.

The Sleep Sentry uses three type #357 button cell watch batteries. This device has only one tactile button on top, which is used for controlling the alarm, and the ON/OFF button.

NOTE: The FDA has approved this device for nighttime use.

After evaluating the Sleep Sentry, I recommend it, because the alarm will detect symptoms of hypoglycemia.

The Sleep Sentry costs $399, shipping included, and may be ordered from: Diabetes Sentry Products, Inc., 1200 Dupont St., Suite #1D, Bellingham, WA 98225; telephone: 1-866-270-5675; Web site: www.sleepsentry.com.

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AMERICA’S JOBLINE

Blind job-seekers have traditionally been at a disadvantage, as few job vacancies have been widely posted in accessible format. How were you supposed to find out about the position? Too often, you never did. But the National Federation of the Blind, the largest organization of blind people in the United States, has acted, developing technology to access and search computer database files with a standard touch-tone telephone. Now anyone can access a million or more current job listings, free of charge, by telephone. To access America’s Jobline, simply dial: 1-800-414-5748.

For the user (someone looking for employment), America’s Jobline is instantly available, 24 hours a day, providing all job announcements in a high quality synthesized speech format. The system provides callers the ability to search America’s Job Bank (sponsored/administered by the U.S. Department of Labor and state workforce-development agencies), allows job seekers to create and store in the system personal job-search profiles (electronic resumes) for use in quickly locating vacancies for which they are qualified; and allows users the option to retrieve, if they wish, only the new and relevant job listings posted since the last call, or all previously saved announcements.

With America’s Jobline, the user enters a search profile into the system, using a standard touch-tone telephone keypad, in response to spoken menu choices. To try Jobline yourself, call: 1-800-414-5748. NOTE: Not all states currently subscribe to Jobline; the list changes frequently -- contact the NFB (410-659-9314, in Baltimore) if the above 800# does not work in your area.

America’s Jobline was created to help:

* Persons who do not have or cannot use standard computers, who now have a convenient and easy-to-use alternative means to obtain job information; and

* Persons who cannot see or cannot read standard video display terminals, who now have prompt audio access, without expensive adaptive equipment of their own.

What are these jobs? Where do they come from? America’s Job Bank, the database Jobline searches, is the set of jobs listed with the U.S. Job Service, the world’s largest job database. At any given time, there may be a million or more open positions in there, catalogued by region and job type. If you are an employer, and you post a job vacancy with U.S. Job Service in your state, blind users of America’s Jobline can now access that job as soon as it is entered. To learn more about America’s Job Bank, go to ww.ajb.org or contact your local Job Service or state workforce-development office. To learn more about America's Jobline, contact: National Federation of the Blind, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314; Web site: www.nfb.org

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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 Diabetes 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.

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MEDICARE PRESCRIPTION DRUG BENEFIT

by Peter J. Nebergall, Ph.D.

Includes photo of Peter J. Nebergall, Ph.D., with cat

There has been a great deal of reportage about the "new Medicare Prescription Drug Benefit. "What is it? How do you get it? Is it an improvement over what you already have?

The last question is most important. If you are of retirement age, or disabled, and eligible for Medicare, you may qualify for this service. If you don't have any prescription drug coverage (or any medical benefits at all -- and there are millions of us), something is better than nothing -- but how much better? It depends. Note: If you receive a prescription drug benefit under Medicaid, Tricare, FEHBP, or any private program, you may not be eligible. If your household income is above $16,862 (but you otherwise qualify for Medicare), you cannot receive the $600 per year subsidy, but can purchase the card.

The Medicare Prescription Drug Benefit is now very much a "work in progress." The "card" became available in June, but is officially "temporary," scheduled for replacement in 2006 -- though we don't know what with. First day to enroll was May 3, 2004. The "rules" are still being fine-tuned. Expect change, and expect the "advisors" to be confused. The "Sign-Up Information Sheet," available for download from the Medicare Web site, is a humongous 34 pages long -- and every paragraph has its list of notes and exceptions.

On paper, it sounds good, at first. Purchase of a Medicare-approved "discount card" will entitle one to 25 to 30 percent discount off list price for prescriptions. People in the lowest income ranges are eligible for a $600 per year prescription subsidy.
As it stands, there are problems. Right now, there are private, low-income drug discount cards (from drug manufacturers Pfizer and Eli Lilly) offering a better deal, with somewhat less stringent income eligibility requirements. Plus, the issuers, the drug companies, allow you to purchase more than one card -- and Medicare does not. It appears, if you are eligible, Medicare will fund your card -- but only one card, under Medicare's rules, and, whether from one of the drug companies or a pharmacy chain (there are a lot of choices), you're locked there for the year (though you may purchase other non-Medicare cards). Choose wisely. For more information, updated almost daily, you might call Medicare: (1-800-633-4227), or inspect their Web site: www.medicare.gov/medicarereform

The Medicare Web site is supposed to allow "comparison shopping" for the best price on prescription medications, but within hours of its establishment, a number of suppliers were quoted (New York Times, May 4) as saying the prices attributed to them were erroneously high. Look for rapid adjustment of the prices quoted on this site, and, if you can, wait a while before you buy in -- give them a chance to get some of the bugs out.

The nonexistence of a single, universal, meaningful drug discount card, is, like the nonexistence of drug price controls or universal health care, a statement of political will -- or lack of same.

A major problem is that the Medicare card's promised discount is "25 to 30% off list," and many drugs, especially at popular discount pharmacies, are already priced well below "list" -- so Medicare card users who have been using already-existing discount plans or private cards, and switch, may pay more, not less, per prescription, than they have been paying. I recommend you make a list of your medications, find out what you have been paying, and ask if you've been paying list price, or some discount. You are responsible for checking whether or not the Medicare card would reduce your expenses -- there is no guarantee. And, as the sign-up literature warns you: "A company can change its discount drug list and the discount prices at any time."

Another problem, immediately obvious when you try to study this new benefit (and you HAVE to study it, if you want to save any money with it) is the incredible complexity. It's too much like Form 1040, folks, WAY TOO COMPLICATED for anyone but a benefits professional to understand -- and the people who need help also need plain-language simplicity. There are 73 different "Medicare-approved" cards already; here it fails utterly.

Unlike the abortive Clinton attempt at national health care, "joining up" in this program is not mandatory. If you already have satisfactory pharmaceutical benefits, you can keep them. If you have a private card (not "Medicare Approved"), you can continue to use it (and note, all discount cards are not and will not be "Medicare Approved.") If you want to keep "traditional" Medicare instead, with its Part A and Part B, you are free to do so. You have to choose what will be best for you, and there's a lot of detail to master before you can make an "informed choice."

The great significance of this program is not its generous benefits -- they aren't. In fact, the new plan is a chaotic, complicated mess. It's just that, for the first time, the wall has started to crumble; the old puritanical resistance against any "socialized medicine" at all has finally failed. I see this hesitant first step as a "door-opener," helping prepare our Neanderthal lawmakers for (eventually) a meaningful, single-payer, price-controlled, national health service.

For that, and perhaps that alone, it is commendable. Now, let's go get to work on a real one!

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A POTENTIAL FOR TROUBLE: ERRORS IN REFILLING THE MINIMED 2007 IMPLANTABLE INSULIN PUMP

From the Editor: Medtronic Minimed makes an implantable (surgically implanted under the skin of the abdomen) insulin pump. This pump's insulin supply is refilled by injection -- and if the patient misses the target, they risk giving themselves a massive peritoneal injection of highly concentrated insulin. The following is reprinted from ISMP MEDICATION SAFETY ALERT, Vol. 9, No. 6, March 25, 2004, Published by the Institute for Safe Medication Practices. Reprinted with permission.

Obesity may be a factor when refilling implantable pumps. We heard from several readers in response to our January 15, 2004 article on errors when refilling an implantable pump. One pharmacist, who preferred to remain anonymous, told us that her organization had three adverse reactions related to refilling Medtronic [Minimed] implantable pumps. Patient obesity played a role in each. During refill, she believes, the needles became disengaged from the ports, and the medication was accidentally administered subcutaneously. She felt the method described in our newsletter, of injecting small amounts of the drug, and periodically pulling back and checking the appearance of the injection fluid, might have prevented some of these events. Each patient exhibited a local reaction from the narcotic, which alerted staff to the problem. The patients were quickly transferred to the emergency department, but no one suffered significant harm, due to rapid actions by the staff.

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YOU CAN'T POSSIBLY FAIL

by Deborah Robinson

Includes photo of Deborah Robinson

I was born on March 18, 1947 in Winchester, Mass. My parents lived in Wakefield. I think I was born there only because there was no hospital in Wakefield at the time.

I was diagnosed with diabetes at 16. It came on sudden and severe. I was extremely thirsty and couldn’t get enough to drink. I remember being at the Joslin Clinic, the famous clinic in Boston. I was diagnosed first, and then I went there for instruction.

My diagnosis was fairly easy. It was so obvious. I had a neighbor, a little girl, who was also diabetic. When we were out playing, I was in charge of keeping an eye on her, so I was used to having something sweet on me to counter an insulin reaction. I was pretty knowledgeable about it. It wasn’t a big surprise.

When I was young, the syringes were hideous. They were re-usable, and had to be boiled after each use. They were glass, and the needles were big enough that you had to clean out the inside of them with a little wire and then you boiled those, too. You even had a stone to sharpen them on. It was nothing like today.

When I was diagnosed, there were no home blood glucose monitors to test with; we tested urine. We put the urine in a little tube, dropped in a tablet, and looked at the colors. I had a lot of orange, which meant I had high blood sugars.

They now have blood glucose monitors, ones you can have at home, but now I have one that’s better for me, because now I can’t see. Now, I use the Accu-Chek Voicemate. It’s a really nice one.

My sugars bounced around a lot. As a child and adolescent, I had more insulin reactions than I had later on. Now, I’m more apt to be high. At the Joslin Clinic, I was taught to be a little on the high side to avoid going too low.

Unfortunately, I let it go to far. It was extreme, too high for too long, and I got some complications. Even after the first year, I noticed my feet would get numb, as early as that, and my fingers, too. I was about 17 or 18 then.

I had problems with my pregnancies, too. Not gestational diabetes, it was onset by that the time. Just with carrying children I had toxemia. I know you can have that without diabetes. I put on a lot of water weight. It all wound up okay in the end.

I do have huge triglyceride problems. I also have MS (multiple sclerosis.) I started having vision problems early, but at first the MS was causing it. The diabetes didn’t start affecting my eyes until much later, but diabetes made me lose my eyesight. The MS, you know, made me legally blind when I was young -- but I still had sight. I didn’t have reading vision, and I couldn’t recognize faces unless they were really close; but now I’ve lost my sight completely, and one eye had to be removed.

My diabetes has led to several other complications. I had retinopathy, but I also had a type of glaucoma called rubiosis. I’d never heard of it. It was an ordeal. Within a year after the doctors removed the one eye, the other eye went.

I have a heart problem too. In fact, depending on what doctor I’m talking to, he’ll blame that on the diabetes, too. It’s called sinusnode function. This problem has just started in this past year. I kept passing out, like seven times within six weeks. I thought this was odd. I thought I was having insulin reactions; but it turned out to not be that at all. I had no warning. I’d just collapse. The last time it happened, I cracked my scalp open on the bathtub. So, they put me on a Holter monitor, and discovered it was my heart. They put me in the hospital to have a pace maker put in. Either my heart stops, or it races like mad. As soon as I got that over, I felt a lot better. Neuropathy can affect the heart, too.

There’s something else I was born with. It is associated with diabetes, especially nowadays since doctors know more about it. I have something called celiac disease.

This is more common among type 1 diabetics than anyone else, but you don’t have to have diabetes to have celiac. It is common enough that the diabetes clinics nowadays screen all children for it.

My younger boy, Tom, has celiac disease too. At the time, I didn’t know that’s what you called it. It’s really a hereditary, genetic problem. My grandmother had it as well; and I’m finding out, years later, a lot of my first cousins have it.

Celiac is an intestinal malabsorption syndrome, and it means you basically can’t have gluten, which means: wheat rye, barley, oats, or any of the chemicals in food that translate to gluten -- like MSG, modified food starch, etc. Also, you usually have a problem with lactose as well, you know. What a pain in the neck that is. You know, it really messes things up for the diabetic. It causes diarrhea.

I was sick with it all my life and nobody knew what it was. I got mis-diagnosed with everything from Chrone’s disease, to spastic colon. Nobody really knew, and it was very easy to figure out, because you could get a biopsy.

I collect funny incidents. My whole life has been one big ha-ha. I just thought of a beaut. I remember one time when my husband was still alive, there was a bee in the house, and I just happen to be allergic to bee stings, one of those reactions where your throat swells up. Well, this thing had landed on a window shade in our bedroom. I thought, “Oh my goodness. I gotta get rid of this thing.” Well, I stood up on the bed and the end of the bed is right near the window. Right about then, I started to have a reaction, an insulin reaction.

It came on like gangbusters, so I thought, “Oh no. This is terrible.” So, I just grabbed the window shade, pulled it down slightly, and let it fly. The shade rolled the bee up in it. We were all laughing like crazy.

I didn’t move that window shade for six months until it was a crispy critter. My two boys, Jason and Thomas, were killing themselves laughing.

They're all grown up and married now. Jason is 36 and has a 14-year old son. Thomas is 33.

They also call me the squirrel lady. I love squirrels, and even though I can’t see them now, I can hear every little move. I know just which one is which because of the different weights. I can hear them come up my steps to get the peanuts. I’ve got names for them. One is called Baby, and another one is called Gus. We even had one we named Boo-Boo because the poor thing, he lost his hair. I don’t know whether he chewed it off, or whether he got into some insulation somewhere or what, but he had a bare back. He used to throw his tail over his backside to keep warm. We called him Boo-Boo also because there was something wrong with his jaw, and he couldn’t eat the peanuts. So, we gave him peanut butter sandwiches. He actually survived the whole winter on that.

Squirrels are sweet. I even have a hat with patches of leather on it and I call it my squirrel hat.

I think the Voice is a wonderful publication, and my physicians really enjoy getting it. I always save one for the doctor himself, and with his permission put the rest on his office table where his magazines are. He says: "Oh goody. My patients, they grab them up. They go like hot cakes."

They’re usually completely gone when I go there the next time. I guess all his patients really like them. It’s really informative, so how could they not?

I'd like to tell people that I know everyone’s different, but I think it would be prudent to keep on top of your blood sugars daily, keeping as tight control as possible. Some people seem to squeak by, never having any problems, and they’re not even taking care of themselves. Then, there are others who get tight control, and have everything go wrong. You can’t possibly fail by taking care of yourself. If you just let it go, then you got nobody to blame but yourself. I’m presently in a program to get the pump, and I haven’t got it yet because I have to really get my A1Cs down lower.

I just know that any diabetic, on insulin especially, can feel the difference when they're under better control. It’s something you cannot take a vacation from. It’s there whether you want it or not, and it’s something you have to learn to live with.

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LETTERS TO THE EDITOR

Includes artwork: quill pen and ink pot

November 6, 2003

Please continue to send your publication VOICE OF THE DIABETIC to my home. Since 1999 my diabetes has been under good control. I was not aware of your pamphlet until I read a copy at my eye doctor’s office while waiting for an annual checkup.

Thank you for these informative articles which help me relate to other diabetics and their insight as the disease affects their lives.

Mrs. Teresa A. Pavy
LaSalle, Illinois

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November 7, 2003
The new format of the Fall edition of the VOICE OF THE DIABETIC is outstanding.

The information provided in all issues is of great importance to me and my family.

Thank you for keeping us informed on the new changes going on in the diabetic world.

I learn more from the VOICE OF THE DIABETIC than any other newsletter; the stories are very inspiring and very true.

My donation is on its way - a Christmas gift for me!!!

Thank you very much,
Joe Rodriguez
Arlington, Texas

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November 8, 2003

Your paper is great. It has so many interesting stories about people with diabetes, besides all the educational facts we can all use. I am anxiously waiting for the next issue that will help us find ways to prevent it.

Thank you,
Joyce Novey
Crystal Falls, Michigan

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November 24, 2003

I saw your paper for the first time recently, and it got rave reviews from both staff and patients at our clinic. We would love to become a distribution site for the paper; we need about 50 copies each quarter.

The clinic name is Fulton County ADTC and is located at 425 Langhorn, SW, Atlanta, GA 30310. The telephone number is (404) 346 8365.

Sincerely,
Robin M. Johnson, MD, Chief of ADTC
Fulton County ADTC
Atlanta, GA

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November 25, 2003

I’ve been a diabetic for 55 years. I’m a ranger’s wife and (need) any help I can get for my supplies.

My husband picked up VOICE OF THE DIABETIC at an eye clinic. It is very informative, and I want first-hand information on new equipment to monitor and inject my insulin.

Thanks for a good publication.
Darlys Hofer
Meadow, South Dakota

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November 25, 2003

Yes, I would like to continue getting the VOICE OF THE DIABETIC in paper and tape form. Thank you, I love it - I came across it at my hospital.

Ruth Bost
Hickory, NC 28602

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December 4, 2003

Thanks for sending the VOICE OF THE DIABETIC. Our support group enjoyed the issues very much. We wanted to do something, so we passed the hat at our monthly meeting in November and I am sending you a check for the amount received.

I believe your publication is much needed and is very helpful for the diabetic to control their problem. All we need many times is for someone to show us the way and have confidence in us. Your publication does that.

Again, let me say thanks,
Windol W. Robbins
Bowie, TX

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January 16, 2004

We would like for you to add us to your mailing list; we have approximately 50 patients who are diabetic. I found your magazine at a pharmacy; it’s a GREAT magazine for diabetics. Please mail to the address above.

Thank you,
Trenda Robertson, CA
Steffen Chiropractic
Gladstone, Missouri

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CUT THE RISK OF HEART ATTACK

For more than a generation, Americans have lived with the widespread, well-publicized fear of having a heart attack. Coronary heart disease (CHD) is our leading cause of death. We know we are all at risk.

Where do these deadly events come from? Is it our heredity? Is it "race-based?" Was it just "bad luck?" What can we do to cut our risk of having a serious cardiac event?

There has been a lot of guessing.

Although hearing your doctor say: "You've just had a heart attack" has seemed like a bolt from the blue for many individuals who couldn't imagine they'd be "tagged," upon closer examination, in a large majority of cases, conventional warnings of increased risk were present -- but no one thought to look. Medicine is that way; to get the right answers, you have to ask the right questions, and opportunities to head off heart disease were missed.

What are the right questions? First, the basics:

* Do you have hypertension? (high blood pressure, defined as BP >130/80, strains the heart and raises risk of CHD.)

* Is your diabetes in good control? (HBA1c<7; higher numbers raise risk of CHD.)

* Do you smoke? (cigarette smoking substantially raises risk of experiencing a dangerous "cardiac event.")

* Is your cholesterol elevated? (keeping your numbers down in the "normal" range, by diet, exercise, and medications, substantially reduces risk of CHD.)

A recent study of 122,458 patients, published in ENDOCRINE TODAY (Vol. 2, No. 4), suggests that in 85 to 90 percent of cases, these "traditional risk factors" were present. Where such factors are found, the researchers suggest lifestyle change as the single most potent intervention. And note, you and your doctor have to find them -- which means regular physical exams can save your life.

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ASK THE DOCTOR

by Chris Corsi, M.D.

Includes art: 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 (our regular writer) will be able to answer are the ones used in this column.

Christopher M. Corsi, M.D., our guest writer this issue, is an endocrinologist at Western Montana Clinic, in Missoula, Montana.

Q: I am a diabetes educator, working with a lot of older, “maxed-out” type 2 diabetics, who are either now injecting insulin, or should be. From what I have read about new Lantus insulin, it looks ideal for my clients. What do you think? What can you tell me about Lantus?

A: Becoming “maxed-out,” no longer receptive to oral diabetes medications, is an increasingly common problem. Type 2 diabetes is considered to be a “progressive disease, and recent evidence suggests the reason for this progression may be declining Beta cell function in the pancreas, resulting in reduced insulin secretion. Investigators are looking at new ways to treat patients, earlier in the course of their disease, with hopes of preserving this Beta cell function. If their research is successful, fewer patients will need to progress to insulin therapy.

When should someone switch from oral diabetes medications to insulin injection? When the oral meds can no longer keep the blood sugars down in the safe range. We used to do this when the patient showed persistent hemoglobin A1c levels over 8%, but now, endocrinologists and diabetologists are often initiating insulin therapy when hemoglobin A1c levels are over 7.0-7.5% on two successive measurements. There is, of course, a reasonable resistance on the part of many patients to move on to insulin, due to injections -- but it is important that, once insulin is needed, it should be initiated promptly, to avoid increasing the risk for long-term diabetes complications.

This is where Lantus insulin comes in. In most patients, Lantus has at least a 24-hour duration of action. Thus it can be used once a day, a much more acceptable situation (than multiple daily injections) for patients just getting used to the idea of needles. In many cases, a single injection of Lantus each day can allow patients to achieve their target A1c levels.

Beginning such therapy, physicians will often continue some of the oral medications, removing them at a later date. There may be advantages to continuing “insulin sensitizers” like Actos, Avandia, and Glucophage. Eventually, oral medications may be removed from the program.

One major hesitation, affecting both patient and physician, is the fear of hypoglycemia. Patients starting insulin therapy, it is feared, are more likely to experience low blood sugar. Lantus insulin appears to cause less hypoglycemia, especially in the middle of the night, the time when a hypoglycemic event is most feared.

When Lantus insulin first became available in the United States, recommended dosage was at bedtime. Recent studies suggest a single dose given in the morning might be better. Of course, insulin dosage needs to be tailored to the individual patient, and then titrated (adjusted) over time, in order to reach and maintain blood glucose targets. The best measurement of the effectiveness of Lantus therapy is the morning blood sugar.

There are times when a single injection of Lantus will not provide adequate blood sugar control. This most commonly occurs in a patient who has large increases in blood sugar following meals (postprandial hyperglycemia.) If this is happening, it is important to provide a “peak” of insulin action to cover those post-meal “spikes.” For instance, if a patient consumes most of his/her carbohydrates at supper time, the blood sugar will often go high after that meal. It may then be appropriate to add a quick-acting insulin at supper. If this problem (“spikes”) is occurring after all meals, a more detailed insulin program might be necessary. Sometimes, a mixed insulin (70/30 or 75/25) at breakfast and supper time will provide some peaking of insulin with each of these meals.

Lantus particularly shines in type 1 diabetes, where it is used as a “basal” insulin. In such a program, a short-acting insulin (Regular, Humalog, or Novolog) is also given with each meal, based on the blood sugar and the amount of carbohydrates going to be consumed at that meal. This is a very precise way to control blood sugars; it can be used in patients with type 2 diabetes who have need of insulin -- but of course these patients must be willing to take on the work of multiple injections and calculating doses. As usual with diabetes, patients are never exactly alike, and programs need to be tailored to their individual needs.

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WHAT TO EXPECT FROM AN EYE EXAMINATION

by Paul Chous, MA, OD, Doctor of Optometry

Now that we have considered the various kinds of diabetic eye disease, the treatments available for each, the results of clinical research, and some recommendations for avoiding or minimizing eye complications, let’s discuss the elements of a thorough diabetic eye examination.

It is unlikely that any two eye doctors (or any kind of doctors) will conduct an examination in exactly the same way. Procedures, techniques and explanations that work well for one health care provider may not work for another, and vice versa. Here, it is simply my aim to describe and explain the fundamentals of an eye exam that will allow you to ask the right questions and assess the thoroughness of your examination experience.

All eye examinations should start with a detailed case history. Patients often ask why so much general health information is required for an eye examination, and the answer is really quite simple: Because the eyes are connected (via the blood stream and nervous system) to every part of the body, and because the eyes and vision are affected by many general health conditions, medications, and genetic influences which are shared by or inherited from your family members.

Diabetics, in particular, should be asked about how long they have had diabetes, the specific medications they are using for diabetes treatment, the previous diagnosis of any diabetes complications (eye, kidney, nerve or vascular), the frequency and range of home blood glucose readings, the most recent home reading, and the results of their last glycosylated hemoglobin test.

The answers to these questions will give the eye doctor a good sense of overall diabetes control and the likelihood of finding eye complications. The patient’s responsibility is to know the answers to these very important questions.

After conducting a case history, the patient is typically asked to read the eye chart wearing any corrective lenses previously prescribed. This is not a test, nor anything to be embarrassed about if the letters are unclear. Guessing is absolutely allowed, as the true definition of visual acuity is the smallest letters that can, just barely, be identified correctly.

The results allow the doctor to gauge just how far off the prescription might be, or the effects of any eye diseases (cataracts, diabetic retinopathy, keratopathy, to name just three of many possibilities) that will be uncovered in subsequent parts of the eye exam.

A test of stereopsis (stereo vision, or the ability to see three-dimensionally) may be given, which precisely measures depth perception and helps evaluate how well the two eyes work together. Color vision testing also may be performed. In my experience, this is an important test, as academic research (including a study in which I participated while in optometry school) shows that diabetic retinopathy can cause short wave length (tritan, aka blue/yellow) color vision defects. In fact, some researchers believe subtle, acquired color vision deficiencies may precede the earliest stages of diabetic retinopathy by months to years.

I have consistently uncovered blue/yellow color vision deficits in long-standing diabetic patients without ophthalmoscopically detectable retinopathy, primarily through use of short wave length automated perimetry (SWAP), a sophisticated visual field test that isolates function of the retina’s blue/yellow cones (S-cones).

The patient’s pupil reactions should be evaluated by shining a bright light into each eye. This checks the neurological integrity of the connections between the optic nerve and the brain, and many optic nerve diseases (including advanced glaucoma and ischemic optic neuropathy) may be first detected this way. Many diabetics are found to have sluggish pupil responses, and this suggests some degree of autonomic neuropathy affecting Cranial Nerve III.

The patient also is asked to follow a moving target with her eyes only, which allows the doctor to evaluate the function of the six extra-ocular muscles and assess any possible paresis or double vision from diabetic nerve palsy.

A test of peripheral vision may be given, which may be as simple as detecting the number of fingers the examiner is holding up, or as sophisticated as a computerized visual field test that more precisely determines the extent and sensitivity of a patient’s peripheral vision in relationship to thousands of other patients (a normative database). All patients, diabetics included, should have their visual field checked by professional examination regularly, as visual field loss can be very subtle until severe damage has occurred (as in glaucoma). Such testing also represents the least expensive and invasive technique for assessing the integrity of the entire visual pathway (from eye to brain) and uncovering much serious neurological disease.

At some point, the patient will be refracted, the process through which a new eyeglass prescription is determined (“tell me which lens choice is better, choice #1 or choice #2"). No part of an eye examination is probably more frustrating to patients than this test: Oftentimes, neither of the two choices is clear, or both choices look identical. Take heart -- this is entirely normal; the test intentionally forces the patient to pick between crummy choices or choices that look virtually the same. Also, no one answer counts very much at all. The examiner is looking for consistency and will show the same choices repeatedly (even though you may not be aware of it!). When the test is completed, the prescription almost always is correct, and vision will be as clear as the patient is capable of seeing. If the doctor is a sub-specialist, such as a retina or glaucoma sub-specialist to whom your regular eye doctor has referred you, refraction may or may not be done.

Several points about refraction should be of particular interest to diabetic patients. Changes in blood sugar can have a dramatic impact upon your prescription, so it is important you and the doctor know if your overall blood sugar control is good (as reflected by recent HbA1c testing), and if your blood sugar level the day of the eye exam is high, low or relatively normal (as reflected by home blood glucose testing that day). Dramatic prescription changes may be the result of poor glycemic control, which should be corrected before getting a new eyeglass or contact lens prescription.

Diabetics sometimes have more difficulty than usual discriminating between the various choices presented during refraction. This may be due to loss of contrast sensitivity from keratopathy, cataract, or retinopathy. (I personally prefer to perform a specialized test of contrast sensitivity on all diabetics.) Decreases in nearsightedness, or increases in farsightedness, especially in one eye more than the other, are often signs the patient has diabetic macular edema and should alert the patient and doctor to this possibility.

All patients should have their eyes examined by a slit lamp, a specialized microscope that gives the examiner a highly magnified view of the eyes. The patient places her chin on a chinrest, and a bright (slit of) light is shined on various parts of the eye, including the cornea and conjunctiva, the iris, the lens, the anterior vitreous, the tear ducts and the eyelids. This allows the doctor to detect any sign of diabetic cataract, keratopathy, abnormal blood vessel growth on the iris (the cause of neovascular glaucoma) or blood cells that might signal vitreous hemorrhage. A fluorescent dye may be dabbed into the eyes, which is especially useful for detecting keratopathy of the corneal epithelium. Measurement of intraocular pressure (tonometry) also may be performed with this instrument, a similar hand-held device, or a machine that blows a puff of air at the cornea. Examination of the eye’s internal drainage canal, with a specialized, mirrored contact lens, may also be performed at the slit lamp microscope.

Eye drops should be placed into the eyes that dilate the pupils. Drops typically take 15 to 30 minutes to work, cause blurred vision and make patients more sensitive to light. Once the pupils are dilated, the internal eye is examined once again with the slit lamp microscope, very powerful hand-held lenses, or other instruments which allow the doctor to visualize the posterior vitreous, optic nerve and retina in considerable detail. A combination of techniques and instruments is often used to ensure completeness. Use of the slit lamp microscope to view the retina and optic nerve is very important, because the doctor is able to use both eyes to examine the patient in stereo (3-D), a feature which is critical for assessing diabetic macular edema, as well as optic nerve cupping from glaucoma.

The eye doctor may recommend other tests depending upon the patient’s particular diagnosis, including retinal or optic nerve photographs to document baseline findings and subsequent changes, more sophisticated visual field testing, or a retinal dye test called fluorescein angiography (a fluorescent dye is injected into the vein of a patient’s arm, and travels to the blood vessels of the retina which are photographed, allowing the doctor to evaluate retinal circulation).

After all tests have been completed, the eye doctor should explain the findings and treatment recommendations to the patient in understandable detail, and ensure the patient’s questions are answered. Sometimes, the patient may be referred to an ophthalmic sub-specialist for further evaluation.

At the conclusion of the eye exam, every patient should know her diagnosis, be informed of various available treatment options as well as the doctor’s recommended treatment plan, the prognosis for her condition, and exactly when she should have an eye examination again.

For the diabetic patient, special emphasis is placed on those findings pertaining to diabetic eye disease. The doctor should discuss the need for prescription lenses, including any changes in prescription, particularly as those changes relate to diabetic cataract or retinopathy. The patient should be advised as to the presence or absence of any eye muscle abnormalities due to diabetic cranial neuropathy, as well as the presence or absence of diabetic keratopathy, cataract, glaucoma or other optic neuropathy, and retinopathy or other retinal abnormality.

If diabetic eye disease (or any eye disease) is detected, the doctor’s recommendations and treatment plan should be explained in detail (written instructions are ideal), the next appointment date should be established (always one year or less) and a letter describing the patient’s eye exam findings should be sent promptly to each of her doctors. All of the patient’s questions should be encouraged and answered, and the doctor’s availability to answer future questions firmly established.

It is the eye doctor’s professional and ethical responsibility to be thorough, knowledgeable, and caring, and to know her limits if there is some aspect of a given patient’s care with which she is not totally familiar and comfortable. Consulting with a diabetic patient’s other health care providers, or referring that patient to another eye doctor who has more experience with a particularly unusual or difficult problem, are not signs of inexperience, but of excellent professional judgment.

I will close this discussion with some key questions that I believe every patient with diabetes should ask her eye doctor:

Questions to Ask Your Eye Doctor

1. Do you have a lot of experience with diabetes and its various effects on the eyes?

2. Do you (or do other doctors in your practice) have any special interest in diabetic eye disease?

3. Do I have any signs of diabetic eye disease? Do I have any cataract, glaucoma, corneal problems, retina problems or eye muscle problems that are being caused by diabetes?

4. Has my eyeglass prescription changed significantly? If it has, is it likely caused by poor blood sugar control?

5. If I don’t have any diabetic eye disease, when do you want to see me again?

6. If I do have diabetic eye disease, how do you recommend we manage or treat it? When do you want to check my condition again? Are you experienced with the surgical or laser treatment of diabetic eye disease? If my condition worsens, will you refer me to a sub-specialist?
7. Do you have any recommendations on how to avoid or reduce eye complications from diabetes?

8. Will you send a report of your diagnosis and recommendations to my other doctors? Would you like me to ask my diabetes doctor to send you a report of her findings and recommendations?

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WHAT IS MACULAR DEGENERATION?

Although diabetic retinopathy is the biggest producer of blindness in working-age Americans, it is certainly not the only one, and, as people grow older, they become more at risk for other sight-destroying conditions, whether they have diabetes or not. One of the most common is age-related macular degeneration (AMD).

The macula is the central part of the retina, the area of light-sensitive cells most capable of sharp focus -- the part we most often use to see. When it weakens, when it is damaged, we may be unable to read, to distinguish one face from another, to use sight for our daily tasks. And, there is no cure for AMD.

There are two types of AMD, called "dry" and "wet." "Dry" AMD causes a steady degeneration of the cells of the macula, with corresponding gradual loss of acute vision. The presence of dry AMD raises the risk of the more virulent "wet" type.

Similar to proliferative retinopathy in some respects, "wet" AMD causes the growth of tiny, fragile blood vessels where they don't belong, in this case just beneath the retina. As with retinopathy, these vessels frequently rupture and bleed -- in this case into the retinal tissue, causing sudden and severe vision loss at the center of the field of vision. Because of the location of the "bleeders," laser surgery is less successful as a treatment than with retinopathy.

The best thing you can do with age-related macular degeneration is avoid it. Wear sunglasses when the sun is bright, don't smoke, keep your blood pressure and cholesterol within healthy normal ranges, and avoid obesity. New research suggests a diet rich in vegetables and fruits can help, as can a regular use of a good multi-vitamin supplement.

And, have regular eye examinations. It's a good idea!

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CINNAMON?

The online newsletter DIABETES IN CONTROL recently reported researchers from University of California at Santa Barbara are investigating cinnamon's potential utility in diabetes control. It seems the substance has a certain chemical similarity to insulin, and in mouse-based tests, some benefit was observed.

These tests are not complete; data are preliminary, and human clinicals have not been undertaken. DIABETES IN CONTROL published an un-attributed, somewhat irresponsible speculation that cinnamon is "a natural version of insulin that could be used by diabetics who require injections but cannot afford them." Such statements beg for abuse by the snake-oil crowd.

What might cinnamon be good for? UCSB researcher Professor Don Graves reports it has "insulin-like activity,” and might also "potentiate the activity of insulin." He states this second quality "could be quite important in treating those with type 2 diabetes."

Bottom line: In early studies, in mice in the U.S. and on a small number of human subjects in Pakistan, "promising results were observed." The article notes the 30 Pakistani subjects had type 2 diabetes," NOT the type 1 which is normally controlled with insulin -- so describing cinnamon as an "insulin substitute" is premature, to say the least. Cinnamon, or perhaps one or more of its chemical components, might one day prove useful against type 2 diabetes, and against its chief component, insulin resistance. For now, we don't know enough, tests are not complete, so keep taking your prescribed medications -- it's too early for a mad dash to the spice shop.

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U.S. SENATE HONORS KAREN MAYRY

From The Editor: (speaker is Senator Tim Johnson from South Dakota)

CONGRESSIONAL RECORD, Washington, Thursday, April 8, 2004:

Mr. Johnson: Mr. President: I stand today to recognize an individual who is a dedicated advocate for the blind in this nation, and especially in my home state of South Dakota.

Karen was raised in Hibbing, Minnesota. The second of five children, she learned at an early age to cope with people's afflictions. Her brother Robert was born with Down's Syndrome. It was from this early exposure that Karen gained some of the beliefs that would carry over into later life. At age eleven, Karen herself was diagnosed with type 1 diabetes, the disease that was to define the rest of her life.

In 1965, Karen married her long-time love, Marshall. While living in Tacoma, Washington, where Marshall was to finish out his military obligation, Karen found a job teaching in the Clover Park school system. In her first year on the job, she experienced her first hemorrhage in her right eye, which resulted in complete vision loss in that eye. Because of her love of educating children, she remained on the job teaching, despite experiencing a traumatic physical ailment.

Marshall and Karen moved to Denver, Colorado, after his military obligation was fulfilled. While in Denver, Karen lost still more of her vision, and for all purposes became "totally blind," then underwent eye surgery in the hope of restoring some vision to her right eye.

The surgery was deemed a cosmetic failure. It was also at this time that Karen discovered she was beginning to experience renal failure.

In 1969, Karen and Marshall moved to Rapid City, where she was hired as a Juvenile Probation Officer. She remained at this position for six years, until her renal failure had progressed so much that she was unable to continue her duties. As she experienced kidney failure soon after, her loving brother David offered one of his kidneys. After many months of complications delaying the surgery, the transplant was successful. Three weeks later, she left the hospital, and her kidney functions have remained excellent for the past 27 years.

Following the successful kidney treatment, she was approached by representatives of the National Federation of the Blind to become a member. The philosophy of the NFB matched her own; one of independence, and the abilities of blind persons -- if given a chance. Soon after joining, she became active that same year, and was elected NFB State President, a quite remarkable achievement.

Karen Mayry is the long-time president of the South Dakota Federation of the Blind. For many years, she has provided tireless advocacy for the blind residents of South Dakota and for the disabled population of the state. Under her presidency, the state affiliate has grown to five local chapters. She has proposed and lobbied for, and had legislation passed, which bettered the lives of blind South Dakotans. She has testified before the Senate, investigating transportation for the handicapped, and has annually made trips to our nation's Capitol to lobby for issues of importance to the blind of the country.
She is dedicated to advocating issues of importance, and she is committed to breaking down the structural and attitudinal barriers that impact the blind and disabled community in South Dakota. Her list of organizations is vast, and her accomplishments and awards are countless.

Despite various physical ailments in recent years, Karen refuses to be sidelined, and continues her stalwart advocacy. Her vitality and energy are commendable, and her advocacy and education over the years on issues affecting blind and disabled individuals have proven very successful. She works hard to educate and advocate for the Americans with Disabilities Act, which helps promote the skills and talents of the blind, and educated the business community about the importance of hiring individuals with disabilities.

South Dakotans with disabilities have many fighters in their corner, and Karen Mayry is one of their most ardent advocates. Karen doesn't mince words with elected officials. I, for one, have appreciated her frankness and candor over the years. Her insight is valuable on important issues, not only on matters directly affecting blind residents, but also on issues vital to all South Dakotans, disabled and non-disabled alike.

As residents of my state prepare for the annual South Dakota Federation of the Blind Convention in Sioux Falls, I take this opportunity to congratulate and commend Karen Mayry for her many years of outstanding advocacy work for the blind. I applaud her dedication and commitment, appreciate her advocacy, and wish her the best in her own individual battle to come. I look forward to continuing my work with Karen, concerning issues of importance to the blind and disabled citizens of South Dakota. It is with great honor that I share her impressive accomplishments with my colleagues.

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AN INTERNET ALTERNATIVE

Many blind people use computers to access the Internet. They make use of Braille keyboards, speech synthesizers, and other special adaptive equipment -- and they do it very well. But like all things, accessing the Internet can be a challenge, even for many of the sighted. What if you're blind, and emphatically NOT a computer whiz? What if you don't even own a computer?

InternetSpeech, Inc., working in partnership with the National Federation of the Blind, now offers netECHO, a telephone-based means to access Web sites or read email without a computer. Once you sign up, you can use any telephone. That's all you need. A clear, easy to understand, synthesized voice will read the material you select.

What does it cost? There are two plans. Program A costs $12 a month, and allows unlimited use, but the access number you'll dial will be in the 408 area code. If you have a cell phone, with free national calling, this may be your best bet. Program B costs $21 a month, but provides a toll-free 800 number to call -- which would be better if you're calling from home. There'll be a one-time setup charge of $20, to create your account, either program.

Many blind people have trouble accessing the Internet -- but by no means is this program limited to the blind. Anyone who wishes to access the Internet by phone can make use of this service. Contact: InternetSpeech, Inc., 6980 Santa Teresa Blvd., Suite 201, San Jose, CA 95119; telephone: 1-877-312-4638 or (408) 360-7730; Web site: www.internetspeech.com

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DIVING

by Terri Uttermohlen

Includes photo of Terri Uttermohlen

This article appeared in the BRAILLE MONITOR, April 2004 edition, published by the National Federation of the Blind.

From the MONITOR Editor: This charming story will make you yearn for Caribbean islands and tropical breezes. It appeared in To Reach for the Stars, the 25th in the Kernel Book series of paperbacks we publish to educate the public about blindness. It begins with President Maurer's introduction:

When Terri Uttermohlen considered the possibility of fulfilling her long-held dream of diving in the sea, her blindness was not what she feared. What she worried about was whether she would find an instructor willing to work with her. Here is the delightful story of her adventure:

Jacques Cousteau, the French oceanographer and inventor of the Aqua-Lung, has always been a hero of mine. When I was a kid, I used to dive vicariously by watching him on television. The fish and other sea life brought to me by his camera fascinated me. I also admired the younger French divers as they fell backwards into the sea -- clad in wetsuits, masks, fins, and tanks. It seemed like magic to me to be able to enter another world so close, and yet so different, from the one inhabited by those of us dependent on air for our survival.

It may not surprise you then to find that I wanted to try diving on a recent trip to a small island in the Caribbean on my belated honeymoon. My husband Jim and I planned the trip for months. Though we had both traveled out of the country several times before, it would be our first trip alone together. Jim and I are blind, a circumstance that led us to some unusual speculation about how we would be received and what techniques we would use to maximize the freedom and pleasure we would have on our trip.

After much Internet research, planning, shopping, and contemplation, we still had many questions as we took off from the Madison, Wisconsin, airport. Would our inadequate French be enough to help us get around? Should we carry our canes in the water the first time we went in? Did we have enough money for all the shopping and fine dining we were hoping to do? Would dive shops freak out at the idea of a blind person wanting to dive in the sea?

We had been on the island two days when I ran into Sebastian, a small man from Paris who ran the activities desk at our hotel. "Is there any way I can help you with water sports?" he asked us after pointing out a bench for us to rest on while waiting for our tour guide.

"I would like to scuba dive," I said boldly, anticipating an argument.

Instead he responded, surprised but willing, "I can help you arrange that."

Reassured this dream might be realized, I told him I would call the dive shop later to set something up.

On Tuesday, I stood nervously in front of the activities desk wearing a sarong, my swimsuit, a hat, and enough sunscreen to grease a car. My transportation to the dive shop arrived, and we were introduced. Mark, my instructor, drove us across the island, over a steep, poorly graded road to the hotel that housed the dive shop. We conversed a little on the way. His English was fairly good, and he seemed only a little nervous about my blindness.

When we arrived at the pool, Mark showed me the fins, mask, regulator, and tank. He was a good instructor and explained step by step what he wanted me to do. He held my hand and said I should squeeze his hand twice if I was having a problem and once if I was okay. He taught me how to inflate my tank vest using a valve to control buoyancy.

The first time into the pool he had me simply place my face in the water and breathe through the regulator. Since I made it around the pool a couple of times successfully doing that, he guided me deeper and deeper until we touched the bottom of the pool.

Finally he asked me to sit on the bottom. My only challenge was, being well blessed by Mother Nature and an abundance of fine Wisconsin cheese in my diet, I had trouble swimming below the surface. Some weights solved that problem, and I soon sat cross-legged on the bottom until Mark signaled me to rise. Lesson over, Mark said we could dive the next afternoon in the sea. I was pleased to have passed the test and even more pleased that he had relaxed considerably with me.

The next afternoon I stood on the warm boards of the marina, trying to squeeze my ample Midwestern flesh into a wetsuit. I succeeded in stuffing myself into my new skin and handed Mark all of my land clothes for safekeeping. I reached for my cane and discovered it had taken a walk with the curious eight-year-old son of the dive shop owner while I was occupied with the wetsuit. It was quickly retrieved. Finally equipped for my adventure, I clambered into the boat.

The tropical sun beat upon me as I rested on the bench at the back of the boat. I was the only American on board. As the dive boat moved into the harbor, its roundly inflated sides pulsing with the impact of the waves, I sat and listened to the French-speaking voices around me. Was I really there? I felt as if I had been transported into the Jacques Cousteau films I used to watch on TV. I sat hoping I would enter the water before the commercial break.

The ride to the dive spot was brief. Mark and I waited on the boat while the other divers and their instructor made their splashes into and under the waves. While I waited my turn, I let the French conversation between Mark and the mother of a particularly young diver pour over me like sun-warmed wine. I could understand only a bit and instead focused my drowsy mind on imagining the scene around me.

Eventually the others returned, and I donned the fins, re-zipped the sausage wrapping, put the mask on, and jumped off the side of the boat into the warm Caribbean. Mark swam to me and helped me put on the tank and the weights.

Because of the wetsuit, the weights had to be very tight on me before they would stay where they were intended. The first attempt had them sliding almost immediately to encircle my thighs. Since I had no aspiration to emulate the swimming style of a mermaid, I suggested we try again. After much giggling on my part, we finally successfully put them around my waist.

Being cautious, Mark repeated the exercise of the pool. First we swam around the boat with my face in the water, making sure I was comfortable breathing through the regulator. I reassured Mark several times by squeezing his hand once in response to his questioning squeeze that I was okay. I was far better than okay, but we hadn't worked out a signal for "wow!" Eventually we began to descend in the water.

My first impression of the dive was Mark's reassuring hand in mine, the bubble of my breath rising from around my face, and the sun-warmed water surrounding me. We slowly descended to the bottom. As we swam, I ran my hands along the surface of the coarse sand of shell fragments. I hoped Mark would warn me if I were about to grab one of the Caribbean's less friendly residents.

As we swam, Mark would tap my right arm when he wanted to guide my hand to show me things. I touched rocks bearded with algae, a tiny closed clam, and a conch shell that I believe still encased the conch. I saw sea plants that looked like firmly planted garden weeds and beautiful slime-oozing strands of tall sponges shaped like kielbasa. Mark placed my hands on coral, stubby sponges, and sea fans. One type of sea fan made of fuzzy finger-wide tendrils seemed to pull itself away from my touch. Another type had wide, rigid leaves that didn't move at all.

I was amazed when I touched coral. This variety was a hard globe with a pattern of lines and swirls incised into the surface. After touching the coral, my arm began to burn. I pointed to it, but of course Mark was unable to explain at the time that it was fire coral. Instead, he squeezed my hand to ask, "Are you all right?" Since the burning was minor, I squeezed back reassurance, and we swam on.

Finally I noticed my tank was emptying of air. My throat was dry from the regulator, and I knew my time under the sea was almost over. Mark gave the signal, and we rose. On the surface of the water Mark told me he had been surprised a moment before by a three-foot-long Great Barracuda. The fish barely noticed us and swam peaceably around ten meters from us. Mark had forgotten that I wouldn't see it and was momentarily afraid I would panic. Had I sensed fear from him, I might have been afraid, but my trust by then was absolute.

We swam back the short distance to the boat. Mark removed my tank and handed it and my weights to the other instructor. I handed up my goggles and asked if I should remove the fins. Mark responded, "As you like."

Next came the least graceful moment of the excursion. As I said earlier, I was stuffed into the wetsuit. The boat was round, rubber, wet, and about four feet above the water. There was no ladder or rope to hold onto. In my younger days it would have been relatively easy to pull myself up onto the boat. These are not my younger days, however, and years of heavy computer use have left my hands and arms weak.

I stretched my arms up to grasp the upper side of the boat. Helpful hands pulled on me like a Thanksgiving wishbone. Mark pushed from below. I was laughing and out of breath, so I could not explain that the men pulling on my arms were making it impossible for me to help myself get into the boat. After much pulling, pushing, squealing, and laughter on the part of the slim Europeans who surrounded me, I was finally able to say, "Let me try." Thus I finally flopped aboard, relieved and a little embarrassed.

As we made the short, bouncy trip back to the marina, Mark handed me a small, beautiful snail shell. Of all the shells I had examined when diving, this was the most perfectly formed. He presented it to me as a keepsake. I inquired to make sure no one was occupying the shell. I didn't like the idea of evicting a small creature from the water. Nor did I relish the possibility of that same creature emerging into my hand to register its complaint at the rude treatment.

I could not express my thanks to Mark for understanding and respecting my desire to experience the sea. He said he had really enjoyed the experience. After we arrived at the dock, Mark helped me peel off the wetsuit. (Without his aid I would have needed a shoehorn and about a quart of WD-40.) I threw my clothes on over my swim gear, and we drove back to my hotel. When I returned, I found Jim contentedly sunning himself on the beach.

The rest of our honeymoon trip was wonderful--romantic and sun-filled. We arrived home after an endless day of cancelled flights and plane malfunctions. As soon as we arrived, we unpacked to ensure everything had traveled safely. In the bottom of one of the suitcases I found the perfectly formed, delicate, gray and white shell. I marveled at the beauty of the shell and the fact that I had finally lived that long-held dream of being under the sea.

Thank you, Jacques. Now you are even more my hero.

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NEW DRUG SHOWS PROMISE IN NEUROPATHY TRIALS

by Ed Bryant

Includes photo of Ed Bryant

One painful diabetes complication is neuropathy, nerve disease. Most frequently manifesting in the feet and legs (see "Diabetic Foot Pain," by Kenneth B. Rehm, DPM, in this issue), the condition can cause burning, itching, stabbing, indescribable agony, or even complete numbness. Neuropathy can seriously impact quality of life. It can be disabling.

Although there are a number of ways individuals cope, with varying success, these treatments and medications have been applied "trial and error," with little scientific support for such use. No medication has yet been approved by the Food and Drug Administration (FDA) for treatment of diabetic peripheral neuropathy (DPN, the most common form), but that fact is about to change.

Pregabalin, from Pfizer, has successfully completed all its clinical trials, and is currently under FDA review for this use and others (though when the FDA will act is not known). To date, it has been studied in more than 10,000 patients, and in randomized controlled trials -- far more extensively than the FDA requires. Dr. Russell Portenoy, M.D., one of the researchers who tested the drug, who I interviewed on June 8, said: "Pregabalin is the most extensively studied neuropathy medication in history. Definitive data prove that it works for DPN, and the expectation is that it will be coming on the market as the only one FDA-approved for this usage."

"No drug is a panacea," says Dr. Portenoy, Chairman, Department of Pain Medicine and Palliative Care at Beth Israel Medical Center in New York City, "so we'll need many weapons in this fight, but Pregabalin will be an important new weapon. There's no evidence that it does anything for the neuropathy; it's not a cure for the neuropathy; it's a treatment for the pain. This is going to be a widely used, and good, drug for the pain, but in no way a panacea, no drug is."

Dr Portenoy is right; it's an exciting new development. Stay tuned; we'll let you know when Pregabalin becomes available.

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SUMMER FOOT CARE

It's summertime, and people are heading outdoors, they'll need to take care of their feet. Flimsy sandals, "flip-flops," and no shoes at all are the rule. Folks will be swimming and wading, in the pool and at the beach. Of course people with diabetes will be there with everyone else. People are enthusiastic: having fun, playing sports, enjoying their leisure -- and putting their feet at risk.

Many diabetics have diminished tactile sensation in their feet. They may be less aware of a blister, a cut, or an infection, and in the summer, without the protection of good footgear, they are at increased risk. Diabetes is the single greatest cause of lower extremity amputations -- and they stem from runaway infections left untreated because, being diabetics, with diminished pain reflexes in our feet, we didn't notice them in time.

This summer, keep your feet! Keep your blood glucose down in the "normal" range (below 126mg/dl). Do this with regular exercise, proper diet, and attention to your medications. Wear properly-fitted shoes, even indoors -- and make sure they are constructed of materials that "breathe" (many man-made "leather substitutes" may look stylish, but they can trap sweat and encourage foot infections). Ask your podiatrist for advice here.

If you're going to wade at the beach, check out the "water shoes" available at local dive shops. Barefoot is not a good idea for anyone; it's too easy to find a piece of broken glass the hard way.

Be sure to inspect your feet; blisters, calluses, cuts, splinters, "athlete's foot," and "thrush" infections can cause trouble. Take action promptly -- see your podiatrist before small problems get big. Enjoy, but take precautions.

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RECIPE CORNER

Includes drawing of fruits and vegetables

This issue's ethnic recipe specialties were all provided by Dave Griffith, of London, Ontario, Canada.

Kartoffelsalat (Hot Bavarian Potato Salad)

Ingredients:
4 potatoes, red skin, scrubbed but not peeled
1 bay leaf
4 peppercorns
1 red onion chopped
(For the dressing):
1/4 cup finely chopped onion
2 slices back bacon, chopped
1 tsp celery seeds
2 tbsp vinegar
2 tbsp water
2 tsp oil
1/4 cup chopped radish
2 tbsp chopped parsley
Fresh ground black pepper

Instructions:
Cook potatoes in boiling water with the bay leaf and peppercorns for 25 minutes our until tender. Slice potatoes into salad bowl and discard bay leaf and peppercorns. Add chopped red onion.

In a non-stick skillet, cook the bacon, chopped onion and celery seeds over medium heat for 2 minutes or until the bacon is nearly crisp. Stir in vinegar, water and oil; bring to a boil for 30 seconds. Pour over potatoes. Sprinkle with radish, parsley and pepper to taste and toss together.

Serve while still warm.

Makes 6 servings. Per serving: 117 calories, 5g total fat, 0g saturated fat, 1mg cholesterol, 2g protein, 16g carbohydrate, 42mg sodium, 447mg potassium.

Spanyakopita (Spinach Pie)

Ingredients:
2 eggs, lightly beaten
1 cup low-fat cottage cheese
1 cup shredded low-fat mozzarella
1 tbsp minced fresh parsley
1 tsp canola oil
8 oz thinly sliced fresh mushrooms
2 tsp fresh lemon juice
1/4 tsp freshly ground pepper
10 oz chopped fresh spinach
1/8 tsp freshly grated nutmeg
1 tbsp fresh minced chives
1/4 cup fresh minced dill

Instructions:
Pre heat oven to 350 F. Mix eggs, cottage cheese, mozzarella, and parsley together and set aside. Heat oil over medium heat in a skillet. Add the mushrooms, lemon juice, and pepper, and sauté until mushrooms are cooked. Add spinach and nutmeg, cover and sauté for 1 minute. Remove cover and continue cooking until spinach is cooked. Remove from heat and add chives and dill. Add vegetables with egg and cheese mixture and pour into a nine-inch pie pan. Bake for 25-35 minutes, or until the top is lightly browned on top.

Serves eight. Per serving: 96 calories, 4g carbohydrates, 9g protein, 58mg cholesterol, 5g total fat.

Souvlaki

Ingredients:
6 garlic cloves sliced in half
1 cup chicken broth
1 tbsp olive oil
1 sprig fresh thyme
4 sprigs fresh rosemary
4 tbsp fresh lemon juice
salt and fresh ground black pepper
1 lb lamb shoulder, trimmed of all fat and cut into 1" cubes
4 bamboo skewers soaked in water for at least 1 hour (or invest in some metal ones)
4 pita breads cut in half and opened to form pockets
1 medium red onion coarsely chopped
2 coarsely chopped tomatoes

Instructions:
Combine lamb, garlic, broth, oil, thyme, rosemary, lemon juice, and salt and pepper. Stir well and marinate overnight in the fridge, covered. Divide the meat evenly and thread on skewers alternating with pieces of garlic.

Grill or broil for 6-8 minutes while basting with the left-over marinade and turning frequently (the meat, that is).

Warm pita and place two halves on each plate along with a skewer of meat. Place meat in pitas and add the chopped onions and tomatoes. Top with tzatziki, yoghurt sauce. What yoghurt sauce? Well hang on, and I'll tell you)

Makes 4 servings. Per serving: 337 calories, 36g carbohydrates, 21g protein, 51mg cholesterol, 12g total fat.

Yoghurt Sauce, "Tzatziki"

See? I told you not to worry!

Ingredients:
1 cup non-fat plain yoghurt
2 tbsp fresh lemon juice
2 finely minced large garlic cloves
1/4 cup fresh mint

Instructions:
Combine all ingredients in a small bowl and serve. Gee, that was an easy one!

Per tablespoon serving: 9 calories, 1g carbohydrate, 1g protein, 1mg cholesterol, 0.1g total fat.

Dave's What am I going to do with all these strawberries? Dessert

Ingredients:
2 cups frozen sliced strawberries
3 tsp sweetener
4 tbsp plain no-fat yoghurt (60 mL)

Instructions:
Slice strawberries and spread on wax paper and place in freezer. When frozen take out and put into food processor with sweetener. Grind until strawberries are granular then add yoghurt. Process until smooth. Adjust yoghurt and sweetener to suit your tastes. This is a nice fresh desert to have on a hot day.

Makes 2 servings. Per serving: 11.5g carbohydrates, 2g protein, 0g fat, 54 calories.

Notes: For a "grownup version," you might add 1.5 ounces of white rum and you have a frozen strawberry daiquiri dessert. If you do, the calorie count goes from 54 to 129 calories. The other values remain the same. Remember that alcohol can lower your glucose values though.

You can freeze all the strawberries you want and just put them in a freezer bag and take out what you need when you need it. I think this will work well for other fruit, such as raspberries, mangos, peaches just to name a few.

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BEYOND STATISTICS: A WEIGHTY PROBLEM

by Peter J. Nebergall, Ph.D.

I just encountered two similar articles, and the problem they discuss is serious. The first, in the excellent online weekly DIABETES IN CONTROL, used statistics from the National Center for Health Statistics, a division of the U.S. Centers for Disease Control, to underline the problem of obesity in the United States. The second, from the English paper the TELEGRAPH, made a similar presentation for England. The English obesity stats are bad; the American ones are worse. We are a fat people, and our children are increasingly following in our footsteps.

Type 2 diabetes occurs, becomes overt, when two factors occur together. The first is genetic: an inherited predisposition to insulin resistance. The second is environmental: an unhealthy lifestyle. If you have the gene (and millions do -- there's nothing we can do about it), but you eat healthily, stay fit and remain active, diabetes will probably stay in its closet. But a combination of genetic trait and couch potato lifestyle will likely bring your diabetes out into the light -- and you don't want this.

The English article, published October 10, highlights how an increasing number of children as young as six years old (8.4 percent) are now clinically obese. If these children carry the gene for diabetes, their odds on developing overt type 2 diabetes shoot way up (and this is precisely why we no longer call type 2 "adult onset diabetes" anymore.)

The English writers highlight inactivity. As the UK follows the American trend, transiting from a culture of doers to one of watchers, adults cease regular exercise. Children learn from their parents ...

This is a medical problem, but it is as much a cultural one. It is the job of government, church leaders, cultural leaders, mentors and parents, to foster healthy habits in the young. When they don't, when WE don't, laziness bubbles to the top, and we call it "convenience ..." Right.

The American article, looking at very similar statistics, focused on diet as problem. Food is abundant here, and we eat 'til we're full. We OVER-eat, far past our biological needs. Our 27 percent increase in type 2 diabetes (since 1997) and "lifetime risk" of now one in three (a projected one in three Americans born this year will become diabetic) is in large part due to stuffing our faces. And our children watch us eat.

We can't fight the gene for type 2 diabetes -- we haven't even identified it yet. What we can do is recover a sense of physical values, and treat our bodies as if someone had given us a Ferrari to drive: Feed it properly, keep it in good tune, and treat it wisely. What an idea.

The obesity crisis both articles highlight is solvable -- not by our doctors, or by far-off researchers in white lab coats -- but by us -- and our weapons are both diet and exercise. It's up to us to show some respect for our bodies, move them more, and stop stuffing our faces. Our children will follow our lead. Yes, the doctors can give us medications, but we can, we must, solve this problem ourselves.

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HEALTHY HOME COOKING

by JoAnna M. Lund

Includes photo of JoAnna M. Lund

Welcome back into my kitchen where the cooking is easy and the food is both healthy and tasty! I have more cooking tips to share with you and a couple of recipe makeovers I’ve done for fellow readers. Hope you enjoy!!!

Shortcakes and other such fruit desserts are in full demand right now. Here’s an easy way to extend the flavor of purchased whipped topping so you can enjoy the flavor of whipped topping without the guilt. Blend together 3/4-cup plain fat-free yogurt and 1/3-cup nonfat dry milk powder. Add 1/4-cup Splenda or any sugar substitute to equal 1/4-cup sugar and 1/2-teaspoon vanilla extract. Mix well to combine. Gently fold in 1 cup of Cool Whip Lite or Free. Use as you would any whipped topping. The texture is almost a cross between marshmallow cream and whipped cream. This makes enough to mound high on a cream pie or to generously spoon over strawberry shortcake. What we’ve done for the same size serving is increase the calcium greatly and cut the oils of the whipped topping in half! Store in the refrigerator just as you would purchased whipped topping.

As the warm weather is only going to get warmer, I want to share a quick way to make lemonade that tastes just like homemade -- the kind your grandmother used to make. Use a purchased sugar-free dry lemonade mix, such as Crystal Light or Country Time and prepare it according to the package directions for two quarts. Slice 1/4 of a lemon into tiny pieces -- and be sure to leave the skin on and the seeds intact! Pour two cups of the liquid lemonade into a blender and add the lemon pieces. Cover and process on BLEND for 60 seconds or until the lemon almost -- but not quite -- disappears. Pour this mixture back into the pitcher, mix well, and serve in tall glasses filled with ice. When anyone asks, “you went to all the trouble to make real lemonade?”, be sure to flick a few drops of water on your forehead and reply, “yes I did. And if you’re nice to me, I’ll do it for you again tomorrow!”

You can easily make a “square pie” without having to make a graham cracker crust. This also is a great stand in for a purchased pie crust and is handy to know when supplies are short and drive time to the store is long. Simply line a 9-by-9-inch cake pan with nine (2-1/2-inch) graham crackers. Use whatever you have, be it regular, chocolate or whatever. Then, evenly spread a can of pie filling (Lucky Leaf No Sugar Added Cherry Pie Filling comes quickly to mind) over the top. Cover with foil and refrigerate. Allow about two hours for the moisture to work down to the crackers and form its own magic crust! This eliminates both the work and calories of the pie crust and still makes eight generous servings.

Low-fat cooking sprays are one of the wonders of the cooking world. I use olive oil-flavored spray anytime I’m cooking Italian, Greek or Mexican. And I use butter-flavored, not only for cooking, but also to coat hot ears of corn and for a quick spritz on air-popped popcorn. Regular-flavored can be used for general cooking. And, they’ve recently come out with a flour-coated cooking spray, ideal for baking. Now, if those manufacturers could only create both bacon- and caramel-flavored cooking sprays, we’d have it made!

The next time you want to enjoy a fruit shake with some pizzazz, just combine soda water and unsweetened fruit juice in a blender. Add crushed ice. Blend on HIGH until thick. Refreshment without guilt!

Did you know in most recipes that call for egg substitutes, you can use two egg whites in place of the equivalent of one egg substitute or 1/4-cup of substitute? Simply break the eggs open, use the white and toss the yolk away. I can hear some of you already saying: “but that’s wasteful!” Just look at the cost of the egg substitute package (that usually has the equivalent of four eggs in it) and then look at the price of a dozen eggs, in which you’d get the equivalent of six egg substitutes. Now, what’s wasteful!?!

Fat-free mayonnaise -- It’s creamy and it does work in binding salads together. But, because most of the flavor came from the fat, and now there’s no fat, we have to think of new ways to put some life back into it. A few of the methods I use (not all at the same time, of course) are: add prepared or Dijon mustard; add prepared horseradish sauce; add lemon juice and sugar substitute; add salsa; add chili or taco seasoning mix. Let your imagination have fun. What have you got to lose? Only calories and fat grams. What do you have to gain? Lots of flavor without lots of fat!

Now for our Recipe Makeovers

CM of IL, sent me a wonderful main dish to lighten up. I loved this healthy version I came up with, but as Cliff (my truck drivin’ husband) doesn’t care for broccoli, when I prepared it for him, I substituted a (15-ounce) can of cut green beans instead. But, don’t let his opinion keep you from trying this, because the broccoli is a great addition!

Chicken and Broccoli Alfredo

Ingredients:
1/2 cup chopped onion
1-1/2 cups chopped fresh or frozen broccoli, thawed
1-1/2 cups diced cooked chicken breast
2 cups cooked fettuccine noodles, rinsed and drained
1 (10-3/4-ounce) can Healthy Request Cream of Chicken Soup
1 (2.5-ounce) jar sliced mushrooms, undrained
1 (2-ounce) jar chopped pimiento, undrained
1/4 cup Land-O-Lakes no-fat sour cream
1/2 cup grated reduced-fat Kraft Parmesan cheese
1/8 teaspoon black pepper

Instructions:
In a large skillet sprayed with butter-flavored cooking spray, saute onion and broccoli for 6 to 8 minutes. Stir in chicken and fettuccine. Add chicken soup, undrained mushrooms, and undrained pimiento. Mix well to combine. Fold in sour cream, Parmesan cheese, and black pepper. Lower heat and simmer for 5 minutes or until mixture is heated through, stirring occasionally. HINTS: (1) 1-1/2 cups broken uncooked fettuccine usually cooks to about 2 cups. (2) If you don't have leftovers, purchase a chunk of cooked chicken breast from your local deli and dice when you get home. (3) Chopped reduced-fat ham instead of chicken also works well.

Serves four (1-1/4 cups each.) Each serving equals: 264 calories, 4 gm fat, 25 gm protein, 32 gm carbohydrate, 575 mg sodium, 4 gm fiber; Diabetic Exchanges: 3 meat, 1-1/2 starch, 1 vegetable.

NA of CO, asked me to whip one of her favorite desserts into shape. After one bite of my version, you just might be saying, "Ooh la la!" By the way, my version was less than half the calories, fats and carbos, so maybe we should shout Ooh la la again!!!

French Apple Streusel Pie

Ingredients:
3 cups (6 small) cored, peeled, and sliced cooking apples
1-1/2 teaspoons apple pie spice
1 cup Bisquick Reduced-Fat Baking Mix
1/2 cup + 2 tablespoons Splenda Granular
1/2 cup fat-free milk
2 eggs or equivalent in egg substitute
1 tablespoon Land-O-Lakes no-fat sour cream
1/4 cup chopped pecans
4 teaspoons I Can't Believe It's Not Butter light margarine

Instructions:
Preheat oven to 325 degrees. Spray a 9-inch pie plate with butter-flavored cooking spray. In a large bowl, combine apple slices and apple pie spice. Evenly spoon mixture into prepared pie plate. In same bowl, combine 3/4-cup baking mix, 1/2-cup Splenda, milk, eggs, and sour cream. Mix well until blended. Spread mixture evenly over apple slices. In a medium bowl, combine remaining 1/4-cup baking mix, remaining 2 tablespoons Splenda, and pecans. Add margarine. Mix well, using a pastry mixer or fork until mixture is crumbly. Evenly sprinkle crumb mixture over top. Bake for 40 to 50 minutes or until a knife inserted near center comes out clean. Place pie plate on a wire rack and let set for at least 15 minutes. Cut into 8 pieces.
HINT: 1 teaspoon ground cinnamon, 1/4 teaspoon ground nutmeg, and 1/4 teaspoon ground ginger may be used in place of "apple pie spice."

Serves eight. Each serving equals: 146 calories, 6 gm fat, 4 gm protein, 19 gm carbohydrate, 233 mg sodium, 2 gm fiber; Diabetic Exchanges: 1 fruit, 1 fat, 1/2 starch

I hope you enjoyed our time together in the kitchen. Remember, if you'd like me to revise one of your family favorites, to make it healthier, send your request to: JoAnna Lund, C/O VOICE OF THE DIABETIC, 1421 1-70 Drive SW, Suite C, Columbia, MO 65203. Also, be sure to visit my Web site at www.healthyexchanges.com for more "common folk" healthy recipes to try. Until next time . . .

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DIABETES SELF-CARE -- WHEN YOU'RE BLIND

by Ed Bryant

All diabetics need to take care of themselves: test their blood, monitor their diet and exercise, and take the appropriate medications at the appropriate time. If you have type 1 diabetes, you'll need to draw up and self-administer insulin injections -- whether you can see or not. Thousands of blind diabetics successfully meter their blood glucose, accurately draw up their own insulins, and both safely and reliably perform all the other day to day tasks of diabetes self-management, without sighted aid.

Talking blood glucose monitoring systems

There are many different home blood glucose monitors on the market today. Although their "operating drills" vary, and they use different test strips, almost all of them require sight to read the results. The National Federation of the Blind Resolution 97-12 calls upon meter manufacturers to make their machines speech-compatible. Most still aren't.

A few monitors either talk (they have a voice synthesizer and speaker inside them) or are speech-compatible (they couple easily with one or more commercially available voice synthesizers). With these, a blind person can hear the results of his/her test -- but these machines vary in ease of operation, only one of them being fully adapted to independent blind operation.

At this time, there are three meters adapted for speech available in the U.S.A. The oldest is the LifeScan Profile. Speech-enabled rather than talking, the Profile, without modification, couples to a number of commercially available "talk boxes." LifeScan is, I believe, phasing out the Profile, but many remain on warehouse shelves. If you already have a Profile, you can plug it into a talk box, and it will work.

The Profile is an accurate machine, but its "hanging drop of blood" test strip can be difficult, for blind or sighted, to use. It was the best in its time, but some features, even with a "talk box" attached, require sighted aid.

LifeScan's SureStep is a newer and simpler meter, with a touchable test strip, and a large-print screen. To get it to talk, you'll need to buy a Digi-Voice speech module, available from Science Products, of Southeastern, PA; telephone: 1-800-888-7400.

Note: Neither LifeScan meter is supplied with audiocassette instructions, and though their Digi-Voice talk box modules are, those instructions (from Science Products) cover only voice box operation.

My personal favorite is the Roche Accu-Chek Voicemate. A true talking meter, it incorporated the proven Accu-Chek Advantage meter into a system that speaks the instructions and results, and (for users of Eli Lilly and Co. insulins) tells you the insulin type (R, NPH, Humalog, etc.). A Spanish-speaking Voicemate is available. The meter has many advanced features, and its touchable Comfort Curve test strip requires less blood, helps a blind tester find the proper location on the strip, eliminates the need to clean blood off the meter, and does away with the cumbersome and difficult "hanging drop of blood." The meter's "code key" (one is packaged with every vial of test strips) is easy to use without sight, and completely eliminates the need for sighted aid each time you start a new vial of test strips. Each Voicemate comes with an instructional audiocassette -- the only adaptive meter to do so. The Voicemate is the only talking meter available at this time that can be operated 100 percent by a blind individual, without sighted aid -- PRESERVING INDEPENDENCE.

The Voicemate is not without problems. Most serious is the meter's occasional inability to distinguish between low blood sugar and not enough blood on the strip. To resolve this and other issues, our Diabetes Action Network is working with the manufacturer, Roche Diagnostics. See Voice, Volume 18, No. 4, Fall 2003 edition, article titled: "Correspondence Regarding the Accu-Chek Voicemate Talking Blood Glucose Monitor." This is available on our Web site: www.nfb.org/voice.htm

The Voicemate can be ordered through most any pharmacist. Its catalog number is: #2030802, at Roche Diagnostics (#3040208 for the Spanish-speaking unit); telephone: 1-800-428-5076. Roche's Customer Service telephone number is: 1-800-858-8072. The Voicemate is also available through the National Federation of the Blind Materials Center; telephone: (410) 659-9314, for $475, the lowest price on record.

Medicare

Medicare recognizes home blood glucose monitors as "Durable Medical Equipment," and coverage is provided for diabetics, under Medicare Part B. Glucose meters without audio output have one specification on the "Fee Schedule" (EO607), and glucose meters with voice synthesis, or add-on voice boxes for home blood glucose monitors, have another (E2100), available to diabetics who are at least legally blind. Be sure to use the correct specification, and to follow all guidelines for reimbursement. For further information, call Medicare's main telephone, 1-800-633-4227, and ask for "Durable Medical Equipment."

Drawing Up Insulin

Once you know how much insulin you should take, you need to reliably "draw it up" (measure it), and then administer it. At this time, all insulins must be injected through the skin, via syringe, insulin pen, or insulin pump. Blind diabetics successfully use all three methods.

Although government regulations require all insulin pens to be sold with the warning: "Not for use by blind individuals without sighted aid," properly trained blind diabetics have used them successfully for years. The different pens, both "pre-filled" (disposable) and reloadable models, from Novo Nordisk, Owen Mumford, Eli Lilly, and Disetronic, are all somewhat tactile, and one may be right for you.

The biggest weakness of any insulin pen is the inability to mix your own insulins. You either use one of the few insulin pre-mixes already prepared (like "70/30"), or else you use two different pens, and take two shots. The pen may be convenient, but it is not that precise.

Many blind diabetics successfully use insulin pumps. Although pumps are expensive, complex, fragile, and not equipped with speech, several have sufficient audio cues that motivated blind pumpers can and do use, successfully and independently. There are many more pump manufacturers selling in the United States that there were a few years ago, and a product from Minimed (U.S.A; 1-800-646-4633), Disetronic (from Switzerland; U.S. phone: 1-800-280-7801 -- and look for them to return to the U.S. Market around the end of 2004), Deltec (from the U.K.; U.S. phone: 1-800-826-9703), Dana Diabecare (from Korea; U.S. phone: 1-866-342-2322), Animas (U.S.A.; 1-877-937-7867), or Nipro (from Japan; U.S. phone: 1-888-651-7867) may suit you. New, easier to use machines are arriving all the time. Hopefully, one of them will be designed to ease blind use.

Most of us, however, are going to keep it simple, and use the syringe. Now people with normal vision use their sight to judge when they have drawn the correct amount of insulin into the syringe. Does a blind person have to have a sighted person fill their syringes? No.

There are two devices that allow a blind individual to insert a syringe, attach the insulin vial, and then, using tactile and audio cues instead of sight, reliably draw up an accurate insulin dose. The best of these is the Count-A-Dose, once made by Jordan Medical, now manufactured by MediCool. The current model (the 1cc size is no longer available) utilizes the 50-unit, .5cc BD syringe. With the Count-A-Dose (available from the NFB Materials Center for $40; phone: 410-659-9314), a blind diabetic can reliably draw up and mix insulins, in the same syringe, without seeing them -- or asking someone else to do it for them. The Count-A-Dose is an excellent choice; many blind diabetics have used it for years. Audiocassette instructions are included.

A simpler, less-expensive device is the Canadian-made Syringe Support, available in the U.S. through the Cleveland Sight Center's Eye-Dea Shop; (216) 791-8118, extension 278. It costs $26, and lacks definite audio cues, but has sufficient tactile indicators that most could use it -- except that, to mix insulins, it is necessary to remove vials from the device, unlike the Count-A-Dose. Note: Cleveland Sight Center can create an instructional audiocassette for you.

To learn more, consult the following articles: "Blind Diabetics Can Draw Insulin Without Difficulty," "Many Blind Diabetics Successfully Use Insulin Pumps," and "Talking Blood Glucose Monitoring Systems." These, and 20 others, make up the book titled DIABETES ACTION NETWORK ARTICLES, available free in large print or 4-track audiocassette, from the Materials Center of the National Federation of the Blind, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314; email: [email protected]; Web site: www.nfb.org

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INJECTING INSULIN THROUGH CLOTHING

Ever since Semmelweis, Lister, and Pasteur, doctors and nurses have been taught to follow sterile antiseptic technique, especially where a medical procedure (such as an injection) breaks the skin. Thus those diabetics who must daily inject insulin have been taught to remove clothing, alcohol-swab the injection site, and otherwise preserve maximum cleanliness. But some authorities state such precautions are unnecessary. How clean is clean enough? There has been much argument.

The American Diabetes Association's professional journal Diabetes Care (Vol. 20, No. 3, March 1997) published the results of a study by Doris Fleming, MSN, RN, CS, CDE; James Fitzgerald, PhD; George Grunberger, M.D.; Scott Jacober, DO, CDE; and Melissa Vandenburg, BSN, RN, CDE, in which 50 insulin-using diabetics performed injections both by traditional antiseptic techniques and through a single layer of clothing. Was there any significant difference, either in diabetes control, or in side effects such as nuisance infections?

The researchers were thorough. All participants had a skin assessment, A1C, and leucocyte count before the test, at the 10-week point (halfway), and again at completion. Problems, benefits, type of clothing (from nylon to denim) and other comments were recorded by the subjects in an "injection log."

Over the 20-week period, approximately 13,720 injections were performed by the participants. None of the subjects experienced erythema, induration, or abscess at injection sites. Neither the glycosylated hemoglobin levels nor the leucocyte count differed between the conventional or the experimental (through clothing) injection regimens. During the injection-through-clothing phase of the study, participants' logbooks recorded only minor problems, such as small bloodstains or bruising. Subjects reported that insulin injection through clothing offered benefits such as convenience and saving time.

The researchers' conclusion: "It is safe and convenient to inject insulin through clothing."

From the VOICE Editor: I have made many injections through my clothing, without problems. However, I would recommend you do this only if you and your clothes are clean. I note that if you are on immunosuppressive therapy (or otherwise immune-compromised), you might need to be more cautious of infection, and avoid this practice. Also, needles, in the name of pain reduction, are getting ever smaller and more fragile, and some of the smallest/shortest may be inappropriate for such use. I saw the above study was also noted in New England Journal of Medicine's newsletter HEALTHNEWS (March 1997).

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RESOURCE ROUNDUP

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

New Test For Diabetes

The principal component of type 2 diabetes is insulin resistance, in which the body does not effectively use its own insulin. As type 2 almost always features a slow, gradual onset, it can be difficult to diagnose until the patient has had it some time -- and by then, its high blood sugars will have done some damage. It is important to detect diabetes as soon as possible, and promptly begin the necessary lifestyle changes to control it.

Isodiagnostika, a Canadian corporation, announces Diatest, a non-radioactive, breath-based test for insulin resistance. The test, which is not a substitute for blood glucose monitoring but a means to detect insulin resistance before blood sugars climb above the euglycemic "normal" range, simply requires the patient to breathe into a sample tube, which is then analyzed. The patient is never exposed to radioactive materials.

For information, contact: Isodiagnostika, Inc., 5120 75th Street, Edmonton, Alberta, Canada, T6E 6W2; telephone: 1-888-487-9944; Web site: www.isotechnika.com

Important New Web site

PhRMA is the U.S. pharmaceutical industry's trade association. For a number of years, PhRMA and its 48 member companies have sponsored programs providing free prescription medications to low- income patients of all ages. Their publication, the Directory of Prescription Drug Patient Assistance Programs, is available from: PhRMA, 1100 Fifteenth Street NW, Washington DC 20005; telephone: (202) 835-3400. Alternatively, the directory may be downloaded from their main Web site: www.phrma.org

PhRMA's new interactive Web site is designed to be faster, more convenient, and more user-friendly, for doctors and low-income patients looking for specific medications. Go to: www.helpingpatients.org

New Insulin

Apidra, Aventis' new rapid-acting insulin analog, has been approved by the Food and Drug Administration for distribution in the United States. Joining the company's successful Lantus (long-acting insulin analog), Apidra, with an action profile (time of onset, peak, and finish) similar to that of Lilly's Humalog and Novo Nordisk's Novolog, will bring some competition to the field. It should be on pharmacy shelves shortly.

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, ext. 200; Web site: www.americandiabeticsupply.com

High Tech Medical ID

We have been asked to announce: MyVoice ID is more than just a medallion. Other "medical IDs" identify you, or cue the authorities to visit a database, but MyVoice ID speaks. Pager-sized, it allows the user to record vital information, like name, address, contact numbers, blood type, allergies, required medications, and pre-existing medical conditions. The device sells for less than $40. Contact: Support Systems Product Development Corporation; telephone: 1-866-667-5768; Web site: www.myvoiceid.org

Healthy Cookbooks
JoAnna Lund writes healthy cookbooks. They are simple, “common folks” recipes, and all contain both complete nutrient counts and diabetic exchanges. There are three titles: Fast, Cheap, and Easy; Grandma Jo’s Soup Kettle; and Fresh From the Hearth. Price is $10 each, or $25 for all three. There is no shipping charge. Contact: Healthy Exchanges, PO Box 80, DeWitt, IA 52742; telephone: 1-800-766-8961; Web site: www.healthyexchanges.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 Accu-Chek Voicemate talking glucose monitor, strips, lancets and other supplies, to a broad selection of diabetic orthotics/foot care items, and much more. They accept Medicare, private insurance, some HMOs, and, in most states, direct or cross-over Medicaid. Contact: DS Medical, 2105 Newport Place, Suite 600, Lawrenceville, GA 30043-5561; telephone: 1-888-724-4357 , Web site: www.dsmedical.com

New Diabetes Resource List

The Diabetes Action Network of the National Federation of the Blind now offers the 2004-2005 edition of Diabetes Resources: Equipment, Services and Information, our comprehensive list of resources for diabetics. Diabetes Resources is our compilation of companies and individuals offering products and/or information to help diabetics, especially those who are blind or are losing vision, self-manage their diabetes. The list contains many subject categories, including: Insulin Measurement Devices, Insulin Syringe Magnifiers, Insulin Injection Systems, Diabetic Foot Care, Blood Glucose Monitoring Systems, Insulin Pumps, Products for the Blind, Food and Diet, Literature and Information, Distributors of Diabetes Equipment and Supplies, and Medication Assistance.

Blind diabetics can and do accurately draw up insulin, monitor blood glucose, and perform the other tasks of independent self-management. By using alternative techniques and products, they can continue being independent, and control their diabetes as efficiently as do their sighted peers. Limitations are usually self-imposed--often all that is needed to overcome negative thinking is simply to know where to go for information.

DIABETES RESOURCES: EQUIPMENT, SERVICES, AND INFORMATION (2004-2005 Edition) costs $5 per copy, and is available in Braille, large print, and 4-track audiocassette, or you can access it on the NFB Web site: www.nfb.org/diabres

Please order from: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314. Note: the NFB Materials Center is open weekdays 8 a.m. to 5:00 p.m. Eastern time.

New Canine Insulin

It is truly the height of irony. Dogs gave us the very first insulin (Banting and Best, 1921), but it has taken more than 80 years for us to formulate an insulin for diabetic dogs. As animal-source insulin gave way to human analogs, veterinarians had to use insulins less than fully compatible with their animal patients. As there are millions of dogs out there, and 1 in 200 American dogs may develop diabetes, there is a market indeed.

Enter Vetsulin, from Intervet, of Millsboro, Delaware. Derived from porcine sources, used in 20 countries, it will be available via veterinary prescription shortly. Note: It is insulin, and pet owners who accidentally inject themselves would face the real danger of hypoglycemia.

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 (including MAGic 9 software, which both magnifies up to 16x and speaks the words on the screen), 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

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: 1-800-713-7062.

Relief

Many diabetics suffer from dry feet. It "goes with the territory." They hurt, they itch, they dry out and crack, and you need to do something about it. Sometimes neuropathy, nerve inflammation, in your feet can really drive you 'round the bend. But Steuart Laboratories offers help. Steuart's Foot Cream, with Melalenca Oil, is excellent for dry diabetic feet. Steuart's CNS Liposomes offers relief from neuropathy; also good for back, muscle, and joint pain. Prices (2-oz. jar): $9.25 plus shipping for the Foot Cream; $19.80 for the CNS Liposomes. Contact: Steuart Laboratories, PO Box 297, Harmony, MN 55939; telephone: 1-800-210-9665; Web site: www.steuartlabs.com

Diabetic Products

Health Care Products makes many over-the-counter medications and supplements for diabetics, including DiabetiSweet sugar substitute and DiabetiDerm skin cream (with L-Arginine) for the feet. Find these products in the diabetic section of Eckerd, Osco, Sav-on, Target, GNC, and other retailers. For information, contact: Health Care Products, 369 Bayview Avenue, Amityville, NY 11701; telephone: 1-866-263-9003; Web site: http://www.diabeticproducts.com

Fund-Raiser

We have been asked to announce: Jackie Mahone-Tyson, from Sacramento, California, has a catalog sales business. Her wares include garden and yard ornaments, furniture for house and patio, patriotic items and Africana. Portions of any profits will be donated to the Diabetes Action Network. Contact: Jackie or Karen, 4433 7th Avenue, Sacramento, CA 95820; telephone: (916) 731-7114.

New Hypoglycemia Alarm

Diabetes brings with it the risk of hypoglycemia, low blood sugar. Some of us need some help. What many of us need is an alarm, a device to warn us we're going low, when we cannot tell for ourselves. There is now such a device -- FDA approved. Diabetes Sentry Products, from Bellingham, Washington, offers the Sleep Sentry, a wrist watch-sized device that sounds an audible warning whenever the wearer’s blood sugar drops too low. Not a blood glucose monitor, this noninvasive device meters changes in body temperature and sweat consistent with hypoglycemia, and sounds a warning in time for you to take action. Completely noninvasive and continuous, the Sleep Sentry costs $399, shipping included, and may be ordered from: Diabetes Sentry Products, Inc., 1200 Dupont St., Suite #1D, Bellingham, WA 98225; telephone: 1-866-270-5675; Web site: www.sleepsentry.com

Diabetes Supplies

Do you get tired of having to "shop around" for your various diabetes items? "Go to this place for these; to that place for those ..." Do something about it. Check out diabetesstore.com, the leading online source for discount diabetes products. Contact them by telephone: 1-800-891-9399; or Web site: www.diabetesstore.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 new and improved DIABETIC 4 INGREDIENT COOKBOOK. There are almost twice as many recipes as before, 350, in all food categories, with complete nutritional and exchange information, each one using four ingredients. The book costs $19.95 (+$3.50 shipping), from: Coffee and Cale, PO Box 2121, Kerrville, TX 78029; telephone: 1-800-757-0838;Web site: www.fouringredientcookbook.com

I'd Like To See Them Make:

A talking insulin pump. This would be simple. We know that if you can display it on a screen, it can go to a speech box. They're cheap. What're you folks waiting for?

Lantus insulin in a pen cartridge. Self-explanatory.

More good diabetes instruction materials on cassette. We receive piles of new diabetes texts, many of excellent quality. Publishers, blind people need this information, too!

Glucose monitors, talking and otherwise, that let you know when enough blood is on the strip -- not just when you just wasted one. This can be done.

More next time. Got some ideas? Send them to VOICE OF THE DIABETIC.

Medical Equipment and Supplies

Specialty Shoes and Diabetic Supplies, Inc., from Beaumont, Texas, is a one-stop supplier for your diabetes needs. They stock blood glucose meters, strips, lancets, vacuum erection devices (for diabetic impotence), other diabetes care items, and, of course, specialty pedorthic footwear. They accept Medicare, Medicaid, Blue Cross, Blue Shield, and private insurance. Contact them at: SSDS, 229 Dowlen Road, Suite 15A, Beaumont, TX 77706; telephone: 1-877-817-7737; email: [email protected]

Diabetic Foot Products

The following products were specifically designed by Dr. Kenneth B. Rehm, DPM, to help treat diabetic conditions of the human foot.

* DiabetiCream: $30 (plus S&H) for a 4-oz. tube. Apply to clean, dry feet, to help alleviate dryness and cracking. Use with massage will help circulation.

* ToeSoak: $20 each (plus S&H). Foot shampoo.

* ToesEase: (foot and toenail cleaner) $20 (plus S&H) for an 8-oz. supply

All these products are available from: The Diabetic Foot and Wound Treatment Center, 1529 Grand Avenue, Suite C, San Marcos, CA 92069; telephone: (760) 471-8637; Web site: www.thediabeticfoot.com

NFB-NEWSLINE® for the Blind

The National Federation of the Blind’s NEWSLINE® is an electronic publication of major daily newspapers, specifically tailored for blind and visually-impaired readers. NFB-NEWSLINE electronically "reads" all of each day's edition, which is immediately made available via modem to the local distribution centers. Users listen to the articles they choose, read to them in a synthesized voice. The reader is free to jump between articles, sections, and publications, and to pick the speed of reading to suit their needs. There is no subscription fee, and NFB-NEWSLINE is not the Internet, so no computer is necessary to use it, just a touch-tone telephone. Service is available to any person at least legally blind. There is no charge.

For further information, contact: NFB-NEWSLINE®, National Federation of the Blind, 1800 Johnson Street, Baltimore, MD 21230; telephone: 1-888-882-1629.

Diabetes Literature from NFB National Center

The National Federation of the Blind maintains an extensive literature collection, with free materials on many subjects, including diabetes, available in a variety of formats. The diabetes articles are available, in large print or on 4-track audiocassette, in a single volume titled: Diabetes Action Network Articles, or singly, in large print. These are free of charge.

The Materials Center also has a supply, in Braille and on 4-track audiocassette, of the new ADA Exchange List for Meal Planning, 2003 Edition. In Braille, price is $10; on tape, $2.

The Materials Center also offers “Diabetes, Neuropathy, and the Feet,” an audiotape by Dr. Kenneth B. Rehm, DPM. Recorded on normal (music speed), this tape costs $2 per copy.

To order, or to request a complete NFB literature catalog, contact: NFB Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314. You may also order by email: [email protected] The Materials Center is open 8:00 a.m. to 5 p.m., EST, weekdays.

New Email Diabetes List

Our Diabetes Action Network now offers its own ‘listserv,’ [email protected] Although its primary focus is on blindness and diabetes, any and all discussions concerning diabetes are welcome. We welcome topics like: diet, devices, healthcare, diabetes control, and how to improve the Voice of the Diabetic. Remember, please do not give any direct medical advice, unless you are a medical professional. Membership is free, and open to all.

There are two ways to sign up. You can go to the following Web site: www.nfbnet.org/mailman.listinfo/diabetes-talk or you can sign up by email, by sending a message to: [email protected] and putting “subscribe” in the subject line.

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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.

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FOOD FOR THOUGHT

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; their inclusion does not imply endorsement by the Diabetes Action Network of the NFB.

New Urgency to Kidney Test

For decades, doctors who suspect their patients have kidney damage have tested for albuminuria (protein in urine), a reliable indicator of such damage. These tests have improved in sensitivity and predictive power (allowing quicker intervention to save kidneys and preserve health), and the current microalbuminuria test is far more effective than its ancestors -- though not enough diabetics are receiving it.

Nephropathy, kidney failure caused by diabetes, is not uncommon, and can lead to End Stage Renal Disease (ESRD), a serious complication forcing the patient into dialysis or kidney transplantation to preserve life. The quicker nephropathy is detected, the better the chances of avoiding ESRD.

Now there's another reason to get tested. Data presented at the International Society of Nephrology's symposium in New York, in June 2004 (co-sponsored by the National Kidney Foundation) show a solid link between measurable albuminuria and impending cardiovascular disease. "Microalbuminuria is a marker for existing inflammatory vascular disease ..." said one presenter.

As with kidney disease, and diabetes itself, so with cardiovascular disease: it is far better to discover the condition quickly, and take corrective action, than to wait until big, spectacular "events" make the diagnosis obvious. "High-risk patients, such as those with metabolic syndrome, diabetes, renal insufficiency, or hypertension, should be screened for microalbuminuria," said one of the researchers at the symposium.

What does this mean? If a simple urinalysis can predict a heart attack a long way off, isn't it a good idea? Talk to your doctor about the microalbuminuria test and what it means for your health.

Kidney/Pancreas Transplants
by Ed Bryant

Have you had a kidney or pancreas transplant? If you've received either, alone or as part of a kidney-pancreas set, I'd like to hear from you. How long have you had it? How has it affected your life? Contact me, Editor Ed Bryant, with your comments at: VOICE OF THE DIABETIC, 1412 I-70 Drive SW, Suite C, Columbia, MO 65203; telephone: (573) 875-8911; email: [email protected]

Diabetes Fact

It appears diagnosed diabetics make up 6 percent of the American population -- however they account for 15 percent of the annual health care cost. As "baby boomers" age, and as their children sit in front of TV and computer screens munching junk food, these figures are expected to rise.

Exercise or Viagra?

A significant proportion of diabetic men over age 50 suffer from erectile dysfunction (ED). Many of these men treat their ED with Viagra or its new equivalents, Levitra and Cialis. Researchers in Cologne, Germany, recently performed an interesting experiment.

Half the men in the study, all men with ED and mild to moderate circulatory problems, followed a targeted exercise program. The other half took Viagra. Three months later, 74 percent of the men on Viagra reported better erections, but the figure was 80 percent for the exercisers.

The researchers, who presented their findings at the European Association of Urology, say their data support the hypothesis that physical conditioning may help prevent or relieve ED, when such is caused by circulatory insufficiency.

The findings do not suggest any link between exercise and ED caused by neuropathy, but some researchers suggest that as circulatory damage co-occurring with generalized peripheral neuropathy may be the most common cause of "diabetogenic" erectile dysfunction, exercise may be a worthwhile option to consider.

Continuous Glucose Monitor

Medtronic Minimed is about to offer the Guardian, an FDA-approved continuous glucose monitor worn like an insulin pump. The device's sensor hooks to the abdomen with a catheter, and reports to a pager-sized receiver. The device has programmable alarms for "too low," and "too high." By no means "noninvasive," the Guardian must be calibrated by a conventional fingerstick test at least once every 12 hours.

The Guardian isn't on the shelf yet (as of press date), but will be offered at a "promotional price" of $999. Medtronic states "no release date yet." For more information, telephone: 1-800-646-4633, or visit www.protect-my-child.com or www.minimed.com

New Talking Meter

Roche Diagnostics is working on a replacement for the Accu-Chek Voicemate at this time, VOICE OF THE DIABETIC has learned. High-level sources at Roche confirm the work is underway, and that the meter may be unveiled sometime in 2005. Further details unavailable at this time; stay tuned.

A Different Kind of Insulin Pump

Starbridge Systems, of Swansea, Wales, is developing an insulin patch that contains a micro-pump. Described as looking like "a cross between a credit card and a first aid plaster" (Band-Aid, to speakers of American), the patch will contain a tiny pump, meant to be cheaper and easier to use than current pager-sized insulin pumps. Insulin infusion will be continuous, and controllable by the patient. The pump will be disposable.

The British National Endowment for Science, Technology, and the Arts has just awarded the company £140,000 to develop a prototype, "hopefully by the end of the year." Stay tuned.

Blood Pressure News

The American Diabetes Association (ADA) has lowered its "trigger point" recommendations for high blood pressure in individuals with diabetes. The new guidelines (as reported in Diabetes in Control Newsletter for March 30, 2004) are "no higher than 130/80." A number of recent major studies, including the United Kingdom Prospective Diabetes Study (UKPDS), have demonstrated improved outcomes, including reduced risk of stroke, when diabetics are given lower blood pressure targets, and then appropriate blood pressure medications are prescribed to achieve them.

As one class of blood pressure meds, the "ACE Inhibitors," are also effective against established diabetes complications like nephropathy and retinopathy, this is timely information. Talk to your doctor.

Can I Eat That?

Sugar is a carbohydrate. Your body needs a steady supply of carbohydrates, to maintain energy and life. What it doesn't need is an overdose. Your body needs quality protein, the equivalent of about three ounces of meat per day. It doesn't need an oversupply. And, your body needs a steady, small, supply of fats. Too much, and too little, are equally dangerous.

Twenty five hundred years ago, Greek physician Hippocrates of Kos taught that balance, moderation in diet and lifestyle, coupled with regular healthy exercise, was the best way to deter disease and ensure longevity. For diabetics, his advice is still current.

Free Internet Resource

Hundreds and thousands of doctors, hospitals, merchandisers, and NGOs (not to mention the U.S. Government) have Web sites dealing with diabetes. Their information ranges from excellent to awful. One of the most thorough, accurate, and comprehensive diabetes sites we've seen (www.mendosa.com) is also the work of a private citizen. If you have access to the Internet, and have a question about diabetes, go take a look.

The question I had was about computer programs to help diabetes management. With some of these, you key in your blood sugar test data by hand, and the computer will keep track of how you are doing. Other programs allow you to download directly from your glucose monitor. Some use Windows platforms; others are written for the Mac. Some are independent products; others are offered by specific monitor manufacturers. Some are "graphical," others allow reliable access to screen readers for the blind such as Jaws or Window-Eyes. Some are purchasable; some downloadable "shareware;" others are available free. The mendosa.com Web site had 48 pages of information about what must have been several hundred such programs, current and obsolete.

Skimming other sections of the site (he has many), it appears such information overkill is the rule; Lord knows how many thousands of pages he has on that site -- but they're all useful. Pay him a visit -- and learn something.

Islet Cell News

Islet cell transplantation, to replace nonfunctional pancreatic Beta cells and restore insulin function, probably represents an eventual cure for type 1 diabetes. However, there have been two big problems to overcome.

Most published research has focused on surmounting rejection, autoimmune attack against the new, transplanted islet cells. There's progress here. But, there's another issue: Where do we get enough islet cells to transplant?
It apparently takes up to three (human) cadavers to produce enough viable islets for one transplant, and xenotransplantation (use of animal islets, most often from the pig) still has a lot of unanswered questions, as does the use of human stem cells. Where else can we turn?

Researchers at University of Florida College of Medicine have given us another option. Working with laboratory rats, they successfully persuaded bone marrow cells to produce "clusters," structures resembling islet cells -- and these new structures produced insulin, and several other hormones normally provided by the pancreatic Islets of Langerhans.

Are they new islet cells? The researchers aren't sure, but they note the clusters, transplanted into diabetic mice, lowered their blood glucose from 550mg/dl to about 200mg/dl, and kept it stable there for three months.

Given time, this technique could become a useful tool in the treatment of human diabetes.

Another Reason for Good Face-to-Face Diabetes Education

The health Web site www.diabetesincontrol.com reports an estimated 90 million Americans "lack sufficient reading and math skills to understand basic health information and navigate the U.S. healthcare system."

More than most, diabetes is a patient-managed condition. To thrive, a diabetic MUST have access to quality health information, and it MUST be delivered in a manner he/she can understand. Thus the tendency of too many educated, privileged medical professionals to deliver their information in obscurantist highbrow verbiage makes things worse. It can cost lives.

Many Americans can't read. Others can't read well, or at a level sufficient to keep up with their doctors. Diabetes affects all of us, regardless of our literacy level -- and the answer is obvious -- plain, simple, clear instruction, in print and face to face. It is our obligation to explain diabetes care in ways our readers, listeners, and clients can understand.

Accessible Magazines

The Smithsonian Institution, America's national museum, publishes a number of magazines about history and technology (such as SMITHSONIAN, and AIR AND SPACE). Blind and visually impaired subscribers can now receive these magazines on audiocassette as well as standard print, for the normal subscription fee. For information on the Smithsonian's Accessibility Program, telephone: 1-888-783-0001.

Reversing Neonatal Diabetes

Children diagnosed with type 1, insulin dependent diabetes, at or before six months of age, can sometimes have their diabetes reversed, if they are given sulfonylureas, medications normally prescribed for non-insulin dependent, type 2, diabetes. It sounds unlikely, but it seems the sulfonylureas, given in time, to children who have a genetic defect, to the K-ATP potassium channel, may restore their insulin secretions. The doctors point out the time window for this therapy is short, and not all type 1 diabetes is caused by this particular defect -- but this could be very good news for many young children and their parents. Sources: BBC Online, and Diabetes In Control, Issue #206, May 5, 2004.

New Numbers for Pre-Diabetes

In past issues, we've discussed how the old classification for people with an elevated, but not quite "diabetic," blood glucose, Impaired Glucose Tolerance (IGT), is now to be called "Pre-Diabetes." This change is because about half the people with this condition go on to type 2, and because some of the high sugars will do damage even before the sugars reach the "diabetic" range. The idea is to diagnose quickly and take action ASAP.

As the "cut" or trip-wire for a diagnosis of diabetes has been revised downward (from 140mg/dl to 126mg/dl), more people have been diagnosed, many who'd not have been "diabetic" under the old standards. IGT has been revised downward as well, to a fasting plasma glucose higher than 110mg/dl.

The newest statistics suggest 18 million diabetics in the U.S., and perhaps 41 million individuals with IGT, double the old predictions. More people are diabetic -- but we're also doing a better job of finding them.

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. Note: Attempting to play VOICE tapes (or any other tapes recorded for the Blind in NLS format) on a conventional music-speed tape player will yield only incomprehensible "chipmunk sounds."

The VOICE is also available, free, by email, distributed quarterly. Go to: www.nfbcal.org/listserv-signup.html to sign up. Periodically we receive requests for the VOICE in Braille or large print. It is not available in either of those formats at this time.

All a subscriber needs to do, to switch from standard print to tape, or to receive both formats, free of charge, is contact us at the VOICE OF THE DIABETIC Editorial Office.

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 334,725 VOICE readers could benefit from your story.

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

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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. It is outreach publication emphasizing 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 [ ] both
and physically handicapped
(recorded at slower-than-
standard speed of 15/16 IPS)

To receive VOICE OF THE DIABETIC by email, go to: www.nfbcal.org/listserv-signup.html. (NOTE: If you want a print or tape copy as well, send this form to the VOICE office).

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

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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