The Diabetes Action Network of the National
Federation of the Blind
A Support and Information Network
Volume 16, Number 1, Winter Edition 2001
VOICE OF THE DIABETIC, published quarterly,
is the national news magazine of the Diabetes Action Network of the National
Federation of the Blind. It is read by those interested in all aspects of blindness
and diabetes. We show diabetics that they have options regardless of the ramifications
they may have had. We have a positive philosophy and know that positive attitudes
are contagious.
News items, change of address notices, and other magazine correspondence should
be sent to:
Ed Bryant, Editor, Voice of the Diabetic, 811 Cherry Street, Suite 309, Columbia,
Missouri 65201-4892; Phone: (573) 875-8911; Fax: (573) 875-8902.
Find us on the World Wide Web at: http://www.nfb.org and follow the links for
"diabetes."
Copyright 2001 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.
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 290,315+, offers such an outlet. Make your voice heard. For VOICE OF THE DIABETIC advertising information contact: Eileen Rivera Ley National Advertising Sales Manager 804 Hatherleigh Rd. Baltimore, MD, 21212 Phone: (410) 435-3648 Fax: (410) 435-6159 or find us on the Web at: http://www.nfb.org/voice.htm For SUBSCRIPTION information, see the end of this document.
VOICE OF THE DIABETIC is offered absolutely free to any interested person upon request. Readers may receive the publication in standard print, on audio cassette 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 re-mailing. The Post Office requires you place first class postage on any VOICE you mail to others.
Photo: portrait. Caption: MARY RYAN
Mary Ryan, from Westfield, New Jersey, is a Eucharistic Minister, a dispensor of Holy Communion, in the Catholic Church. She is a Licensed Physician's Assistant (PA). A veteran parent, she has raised 30 foster children, and has had three of her own. Forty-seven now, she has had type 1 diabetes for 36 years. She has been using an insulin pump for 20 years, and has been blind from diabetic retinopathy approximately as long. She is a member of the Garden State Chapter of the National Federation of the Blind of New Jersey. She has a lot to say.
I was diagnosed with juvenile diabetes at the age of 11. About two years before, my father had been diagnosed with type 2, adult onset diabetes. Our family had just gotten around to understanding diet and exercise and how important they were, when I became very sick. I lost about 30 pounds in maybe six weeks, and became very lethargic -- with the typical symptoms of type 1 diabetes: excessive thirst, excessive urination, and dramatic weight loss.
It didn't really dawn on my parents what was happening, even though they had experienced my father's adult onset diabetes a short time before. They were really thinking, and worrying, about leukemia!
I had been kind of a chubby girl -- and they got me to the doctor when they realized the weight loss was not a good thing. I just became sicker and sicker. When the diabetes was diagnosed, I was in the hospital for eight days. While there, I learned about diet and exercise, talked to the dietician, and learned how to give myself insulin injections.
Diabetes treatment, back in those days, was very different than it is today. You went to the doctor every two or three months, and had a blood sample drawn, and based on what he found then, the doctor would adjust your insulin dosage. It seems ludicrous to us now, as we know insulin levels change from moment to moment and certainly hour to hour, depending on your exercise and diet, and, for women, your menstrual cycle. Unfortunately at that time, tracking diabetes was not a "state of the art" thing.
After I had juvenile diabetes (type 1) for 16 years, I started to get "floaters" in my vision. These are sure signs of diabetic retinopathy, and I had laser surgery to try and halt the bleeding in my eyes.
I believe the retinopathy probably happened because my blood sugars, in high school and college, were all over the place. I was a brittle diabetic; I had very poor control. Thank God there was no kidney damage, but my eyesight was compromised. But I didn't let it slow me down.
I graduated from college, and went on for 2 1/2 years' training as a Physician Assistant, finished it, and worked for a diabetologist. Then I got married, and was soon the mother of two small children (after a miscarriage first pregnancy).
Our first son was not quite two, and our second was ten months old, when I became totally blind. During my second pregnancy (my first successful one), I was admitted to the hospital nine times, with blood sugars around the 800mg/dl range. That wasn't for lack of supervision -- remember that in 1978, home blood glucose monitoring was almost unavailable.
I was going to the doctor for blood sugars about twice a week, but just as some women, not normally diabetic, become diabetic during pregnancy, with gestational diabetes, a diabetic woman's control can get radically worse during the pregnancy. Most diabetic women do pretty well during the first trimester, but the second trimester, the pregnancy just pours glucose into the system. The uterus becomes gluconeogenic.
After nine admissions to the hospital, we were sure the baby was in jeopardy, but he was born, one month early, by caesarian section. He weighed 6 lbs, 12 oz, pretty good, after what we'd been through; but we thought he had a "VSD," a ventricular septal defect, in his heart. A year later it was discovered he had a much more serious "four-pronged" heart problem, one that would take his life at age 14.
My second diabetic pregnancy occurred about 18 months after the first, and was more typical, in that my control seemed to be better, but my second son was also born a month early, by caesarian section. He weighed 10 lbs, 5 oz, a typical large baby of a diabetic pregnancy. And it was when he was 10 months old that the last of my vision left. I was blind.
At this point, I was working in my diabetologist's office, as a Physician Assistant, instructing young, pregnant diabetic women, telling them what to expect, and what to do, as I had just been through it myself. That was when it was suggested I should try an insulin injection pump, as it would be the best way to save my kidneys and reduce the chance of further complications.
With my husband, I went to the training, to see what using the pump entailed. The criteria were that you had to be highly motivated, had to be willing to really pay attention to diet and exercise, and had to commit to at least four blood sugar tests per day. As home monitoring equipment was finally available to me, this felt like salvation.
The pump sounded like a perfect fit for me. I was a Physician Assistant, and at our practice, we were starting to put patients on the pump. I was used to "selling" the idea to diabetics. I taught them this device could really change their life.
I think I was the fourth person, and the first woman, to go on the insulin pump in the state of New Jersey.
Shortly after I started pumping, with my blood glucose control good and tight for the first time in my life, we started a third pregnancy, and it went perfectly. My health stayed perfect, I tested my blood seven times a day, and the baby (born two weeks premature, by caesarian section again) weighed a healthy 7 lbs, 8 oz. It was an entirely different experience, being pregnant on the pump. The pump helped me avoid the fluctuations that are otherwise an inevitable part of a pregnancy. It provided me good, tight control.
We were so grateful this last pregnancy had gone well, that we wanted to give back, and give thanks to God. We started taking in children, becoming foster parents.
When Brendan, our third son (who's pregnancy went so well) was 13 1/2 months old, we took in our first foster child. I had already been blind for 2 1/2 years -- but fostering seemed like a good idea, since I was at home with three boys under age five anyway. It just kind of took off. We've never put the cradle and bottles away -- we just keep going.
Twenty-two of the 30 foster infants we've taken in have been boys. We have a sign on the door that says "Boys are Us!" My brother calls this place the "testosterone theme park." Our first son, PJ, died at age 14, seven years ago. Our son Tim is a junior at Fairfield University in Connecticut, and our son Brendan is 17 1/2, and a senior at St. Peter's Prep in Jersey City. We also adopted a son, Jason, who was 15 in December.
It's a lot of work. The infants keep me in good shape. Also, I go walking every day, as much as I can. It's important. You have to be committed to your diabetes control -- as the disease can be so deceiving. You think you're OK, maybe you're not feeling great, but you're sure you're OK, and you're not. It's insidious the way it can damage those organs. You have to really be committed to your diet and exercise program.
I would say it's very much a human tendency to be lax not only in diet, but also with exercise; and whether you're on the pump, or using daily insulin injections, you really need to be vigilant. Your self-control and commitment to being as healthy as you can will determine the success of your diabetes control. "Diet and exercise," easy to say, and very difficult to do. You need to work with your nutritionist and diabetologist, and use lots of common sense. I know it took me a long time to understand that immediate gratification, eating that cookie or having that pie, just isn't worth it. If I take something I know I shouldn't have, I start to feel sleepy, sick, or unwell, within half an hour or less, and it's just not worth it anymore. I would say that, especially for parents of type 1 diabetics, if they really feel their child is well- motivated, getting the patient on to the insulin infusion pump, as early as possible, is your greatest ticket to avoiding end organ complications later on. With the pump you have tight control, and you avoid the peaks and valleys. It's all levelled off; you're getting basal insulin in micro-drips 24 hours a day. As I tell patients, it's really as close to achieving a non-diabetic state as we can provide right now.
From the Editor: Mary would be glad to help advise any interested blind person, about using the insulin pump, about child care, or about Eucharistic Ministry. Mary is the only blind person in her area who does such ministry. You may contact Mary Ryan through VOICE OF THE DIABETIC.
by Wesley W. Wilson, MD
Artwork: Medical caduceus
NOTE: If you have any questions for "Ask the Doctor," please send them to the VOICE editorial office. The only questions Dr. Wilson will be able to answer are the ones used in this column. Wesley W. Wilson, MD has retired as an Internal Medicine practitioner at the Western Montana Clinic in Missoula, Montana. Dr. Wilson was diagnosed with type 1 diabetes in 1956, during his second year of medical school. He remains interested and involved in diabetes education for patients and professionals.
Q: I am told I have IGT and that I need to watch it. I know I could develop type 2 diabetes in the future. My question: How much difference do/will my current lifestyle choices make as to whether or not (or when) I go into full- blown diabetes? Can I stave off the Big Day by careful diet and exercise now?
A: You really do need to watch it since your life- style now has a major effect on your future health and your likelihood of developing overt diabetes.
What are your fasting blood sugars now? The level of blood sugar needed to establish a diagnosis of diabetes has recently been changed from 140 or higher to 126 or higher. If your fasting glucose is repeatedly above 126 you no longer have Impaired Glucose Tolerance (IGT) but already have diabetes. The lower sugar level was adopted because we now know that diabetic complications (eye, kidney, and nerve disease) are increased with even slightly increased blood sugar. Numerous studies have shown that the higher the blood sugar level the higher the risk of complication. You should do whatever you can to avoid diabetes and elevated blood sugar levels. Regular exercise and control of body weight certainly can delay the appearance of diabetes. I can t tell you how much benefit there will be since that varies greatly from person to person, but there should be a significant benefit.
Insulin resistance seems an important first element in the development of type 2 diabetes. Exercise and weight loss both decrease insulin resistance and allow insulin to do its job more effectively. I suspect most physicians who treat diabetes have seen persons with flagrant diabetes and very high blood sugars, who reverted to normal blood glucose levels with just weight loss, attention to diet and increased exercise. If you can reverse it with diet and exercise, why can t you prevent or at least delay the appearance of diabetes with those techniques? Development of type 2 diabetes seems to proceed from insulin resistance (with blood sugars controlled by increased insulin production by the pancreas) to exhaustion of the overworked pancreas (with decrease in insulin production), leading to elevation of blood sugar. It seems reasonable to assume that anything we can do to reduce the underlying major abnormality (insulin resistance) should delay the exhaustion of the pancreas and should be recommended to persons at risk of diabetes. This is especially true since diet and exercise have no harmful effects. And you know a hard workout makes you feel better!
More information on the prevention of diabetes will be coming from the Diabetes Prevention Program, which is now underway. This study is designed to see if type 2 diabetes can be prevented with diet and exercise or with the use of several drugs used to treat overt diabetes. While we await the results of that study, it would seem prudent to do the best we can to avoid elevated blood sugars with methods we have.
Dorland's Medical Dictionary defines hypertension as "persistently high arterial blood pressure, generally defined as in excess of 140/90. Why is this dangerous? What does it feel like? What can you do about it?
Even if you don't have diabetes, high blood pressure imposes strain on the eyes, the kidneys, the brain, blood vessels, and the heart. High blood pressure, by itself, increases the risk of stroke, heart attack, and certain types of blindness. The principal symptom of diabetes is hyperglycemia, high blood sugar.
The excess blood sugars of untreated diabetes glycosylate, they bond with any available protein, including capillary walls -- in the blood vessels, in the eye, and in the kidneys. Even without generalized hypertension, it is possible to experience it locally, in the eyes and kidneys. Your doctor can tell for sure.
Add diabetes and high blood pressure, and you have a recipe for trouble -- avoidable trouble. It can hurt you, if you don't take action. You've got to know your BP numbers are elevated, first.
Without testing devices, you can't tell if your blood pressure is high. There is no pain, nothing to tell you "time to get help!" You can "feel fine" and still need action. You need to be tested. Elevated blood pressure is so common that EVERYBODY needs to be tested.
If the doctor finds you have high blood pressure, there are a number of things you can do to bring it down. First, get your diet under control. Eat healthy foods, and in healthy portion sizes. Limit your salt! (Salt raises your blood pressure!)
Second, being sedentary raises the risks of blood pressure, and good, regular exercise cuts blood pressure. Talk to your health care team about an exercise program appropriate for you. Almost anyone can exercise -- there will be activities right for you.
Third, there are a number of blood-pressure-reducing medications. Some of them are appropriate for diabetic use. One class of these medications, the ACE inhibitors, also serves to moderate the localized high pressures that follow diabetic kidney disease. Even if your generalized blood pressure is OK, your kidneys might benefit from the ACE inhibitors. Talk to your doctor.
Fourth, get your blood sugars under good control, and keep them there. Just as high blood sugars lead to glycosylation, helping cause high blood pressure, a sustained period of euglycemia, normal blood sugar, can cut glycosylation, reducing risk of complications like eye disease, kidney disease, nerve damage, and the complications of high blood pressure.
If you have diabetes, remember that although heart complications are the number one killer, there is plenty you can do about it -- if you get involved, and take the necessary action.
by Ed Bryant
Photo: Audio Labelling devices. Caption: The ALOUD Model 100 Audio Labeling
System
Last July, in VOICE, Vol. 15, No. 4, I discussed the pending availability of the new ALOUD Model 100 Audio Labelling System. Manufactured by ASKO Corporation, this new product can best be described as a talking prescription container, something that should interest ANY blind person, or anyone with significant sight loss, who needs to take prescription medications. Here is how it works:
When a pharmacist dispenses your medication, an audio version of the printed prescription label (called an Audio Label ) is also produced, and attached to the medication container. When the Audio Label is placed into your ALOUD replay unit, the Audio Label information recorded by your pharmacist is replayed. As this is a recording, not voice synthesis, any language your pharmacist speaks can be recorded!
Each medication will have its own Audio Label, and can be played over and over, as many times as you like. Any medication dispensed from a rigid container can utilize the system, and the only person who can change the message is your pharmacist, who has a special recorder in the pharmacy. The Audio Label is reusable, so when you need to have your prescription refilled or changed, the message can be changed also and attached to your new prescription.
For years I have been searching for alternatives to sighted identification of insulin vials. There have been a number of partial solutions, but the ALOUD System appears functional with any insulin from any manufacturer, and any language. The current Audio Label is too large to be really practical with insulin vials, especially if the diabetic uses adaptive insulin measuring devices -- but ASKO has been most willing to work with the National Federation of the Blind, and with our NFB Diabetes Action Network, to adapt their system to labelling insulin vials -- and, as no approval from the Food and Drug Administration is necessary, action should come soon.
The ALOUD System is already available through RX Partners Pharmacy, a mail-order and online service based in Pittsburgh, PA -- but only for patients who purchase their medications through that pharmacy.
For information, contact: RX Partners Pharmacy, PO Box 466, Bridgeville, PA 15017-9981; telephone: (866) 332-5683; website: www.rxpartnerspharmacy.com Further information about the ALOUD system can be obtained from: ASKO Corporation, 2 South Street, Stamford, NY 12167; telephone, toll-free: 1-877-732-9227; website: www.askocorp.com
Individuals with severe coronary artery disease face
the risk of vascular blockage, which can lead to angina, weakness, and heart
attack. Traditionally, these folks have received one of two treatments: CABG
(bypass surgery) or PTCA (percutaneous transluminal coronary angioplasty, "balloon
angioplasty"). Diabetes is a major cause of heart disease, and enough diabetics
have undergone one or the other procedure to form a statistical picture of these
procedures' effectiveness.
PTCA uses a catheter, which is inserted into the obstructed vessel from an entry point in the groin, and inflates like a balloon, to dilate the blocked vessel at the point of obstruction, allowing blood to flow past the blockage. CABG, a major operation, involves opening the chest and providing a new channel, or "bypass," for the blood to flow. Both treatments alleviate the effects of coronary artery disease, but neither alters the natural course of the disease.
One might expect the "success" rates of the two procedures to be about the same, or for the less invasive, PTCA, to be better. Beginning in August 1988, the Bypass Angioplasty Revascularization Investigation (BARI), a major study sponsored by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health, compared the effectiveness of the two procedures. Results were surprising.
Using "mortality after five years of follow up" as a yardstick, the BARI study found that for non diabetic patients, both procedures scored equally, with a 9% mortality rate. For diabetics on insulin or oral hypoglycemics (type 1 or type 2), the five year mortality rate following PTCA, the less invasive procedure, was 35%, and the rate for CABG, bypass surgery, was 19%. Although the higher overall mortality rate from diabetic heart disease was not unexpected, the excess mortality with balloon angioplasty had not been anticipated.
Results of the study indicate that bypass surgery should be the preferred treatment for diabetic patients on insulin or oral medications, who have multi vessel coronary artery disease and need a "first coronary revascularization" (first time PTCA or CABG). As the Centers for Disease Control reports that, in 1989, about 48% of all diabetes related deaths had major cardiovascular disease as the underlying factor, these findings are expected to have major impact. Patients were eligible for the BARI trial if they had coronary artery disease with a 50% or more luminal obstruction (as measured by calipers) in at least two of the coronary vessels supplying two or three major coronary territories. They had to have clinically severe ischemia (measurable obstruction to blood flow), and no prior revascularization.
Patients were ineligible, if, for example, they had insufficient angina or ischemia, required emergency revascularization, had left main stenosis of 50% or greater, had a noncardiac illness expected to result in limited survival, primary coronary spasm, or a poor quality angiogram (x ray examination of the circulatory system). All patients accepted for the test received "risk factor modification": help with smoking cessation, appropriate exercise, and diet.
Findings of the BARI study were reviewed on September 13, 1995, by the Data and Safety Monitoring Board, a panel of PTCA experts, cardiovascular surgeons, clinical cardiologists, biostatistics experts and ethics specialists. The board concluded that the differential results of the two treatments, and the unfavorable mortality for diabetics on insulin or oral hypoglycemics, were unlikely to be due to chance. The board recommended to the National institutes of Health that physicians, other health professionals, and the public be promptly informed of the results. On September 21, 1995, the NIH issued a Clinical Alert to Physicians, highlighting the study s findings and recommending appropriate changes in treatment for diabetic patients who present with severe heart disease.
In March, 2000, Researchers from Duke University Clinical Research Institute reported that in spite of the NIH s Clinical Alert, many cardiologists were continuing as before, using angioplasty, stents, and glycoprotein platelet inhibitors, instead of bypass surgery, in spite of the total lack of evidence that these techniques improve outcomes sufficient to overturn the results of the BARI study. The Duke study found that while surgeons wholeheartedly embraced the results of the study, cardiologists (who the patient sees first) were not referring their diabetic patients on to the surgeons!
In summary: The BARI study was a careful comparison of the results of two medical procedures frequently used in response to multiple coronary artery disease. Many "endpoints" were investigated, including: Patients' anginal status, number of diseased vessels, functional status, quality of life, gender, age, race, and presence/absence of diabetes. Although the study considered many issues, its findings for diabetics were particularly significant. The study strongly suggests that if you are diabetic, using insulin or oral hypoglycemic agents (sulfonylureas), and you suffer from multiple coronary artery disease, and if you are at the point of needing a first revascularization, evidence strongly suggests you will fare better with CABG, bypass surgery, than with PTCA, balloon angioplasty, as an initial treatment. If you have diabetes, and need such treatment, discuss your options, and the BARI study, with your doctor, and, if necessary, seek a second opinion.
Anyone who has evidence of coronary artery disease, with or without a prior PTCA or CABG, needs, under close physician monitoring, to aggressively reduce known risk factors, such as smoking cessation, appropriate control of blood pressure and serum cholesterol, and needs to achieve optimal control of their diabetes.
From the Editor: I've had bypass surgery. Several doctors have told me the best way to determine if you have coronary artery disease is with a "routine exercise treadmill test." While you work out, electrical instruments measure your heart rate, heart rhythm, EKG, and blood pressure, and the doctor will note any other symptom you may have. Added together, all the test data give a good picture of the state of your heart.
You can have a normal pulse, and significant coronary artery disease. Diabetics (and non diabetics) can have normal EKGs, too, even in the early stages of a heart attack. One physician told me: "The absence of electrocardiographic abnormalities does not preclude the presence of significant heart disease."
My doctors said that if you have multiple risk factors, like cholesterol, hypertension, smoking, cardiac arrhythmia ("heart murmur"), or a family history of heart trouble (another is the presence of diabetes), you ought to have periodic treadmill checks, to see how your heart is doing. If you've had diabetes for 20 years (IDDM or NIDDM) you could benefit from this test. If heart disease is discovered soon enough, medical intervention can make a difference.
The American College of Foot and Ankle Surgeons (ACFAS) urges all diabetic patients to make sure their physicians check their feet, every office visit, for any sign of ulcerations. Untreated ulcerations and lesions on the feet can lead to infection, and can ultimately result in lower limb amputations. Diabetes is the biggest cause of non- traumatic leg amputation in the U.S.A., with more than 86,000 lower extremity amputations each year.
Most diabetic patients are vulnerable to foot ulcerations caused by poor blood circulation in the lower extremities. Diabetic neuropathy, often causing insensitivity to pain, exacerbates the risk. "Ulcers, the leading cause of foot amputations, are preventable, if the doctors would routinely check patient's feet. It's tragic when there is an amputation that could have been prevented by a two-minute foot exam," states the ACFAS.
Diabetic patients should be checked for nerve sensation, skin irregularities (such as corns, calluses, punctures, and areas of redness), swelling, drainage, fungal infection under the toenails, and foot deformities that might cause ulcer-prone pressure points. If they have bunions, hammertoes, or other deformities, diabetic patients should discuss their treatment options with a podiatric surgeon. The idea is to minimize both present and future infection risks.
All diabetics should have foot inspections at least twice a year, but individuals considered at higher risk should be checked every two to three months, as well as their daily foot self-inspection. Self-inspection is critical, as it doesn't take long for infection to worsen and ulcers to occur.
The American College of Foot and Ankle Surgeons offers a free brochure, Diabetic Foot Problems and Treatments, which is available by calling 1-888-843-3338, or on the ACFAS website: www.acfas.org
by Marc Maurer
Photo: portrait. Caption: Marc Maurer
(Marc Maurer, President of the National Federation of the Blind, delivered the following convention banquet address on July 7, 2000, at the 2000 national convention of the National Federation of the Blind, in Atlanta, Georgia.
This article appeared in the BRAILLE MONITOR, August/September 2000 edition, published by the National Federation of the Blind.)
An essential element of the development of an individual, an organization, or an entire society is its personality, that pattern of traits (emotional, behavioral, temperamental, or intellectual) that gives the entity its unique impact upon the rest of the world. All personalities are a mixture of traits, but at any specific moment one characteristic will be dominant. What a society or an organization is and what it can accomplish are, in large measure, determined by its personality. However, personalities are not immutable--they are constantly being revised, frequently without anybody's awareness that the alteration is taking place. The change need not occur by happenstance; it can be directed.
Alterations in personality come from within. The ability to vary the personality requires the knowledge that it can be done and the determination that it will be. If an increased respect for human dignity and enhanced opportunities are the objectives, then there must be an openness to all facets of learning, from the multiplication table to the most profound philosophical concepts. Some people argue that it is possible to teach facts, but that character cannot be learned. These people believe that a human being is either courageous or not, sensitive or otherwise, gentle or brutal, and that trying to obtain character traits that are not already evident within a personality is futile. Such a pessimistic estimation of the human condition is nonsense. Patterns can be changed, and those who truly learn will come to know that decency and fairness make sense, that there is no such thing as cheating and getting away with it, and that generosity and love are necessary for a good life.
It is said of Michael Faraday, the eminent English scientist of the nineteenth century, that he had greater appreciation of the facts of scientific discovery and took more delight in them than other people because he had a greater depth of understanding than his colleagues. His personality made him aware of wonder. As it is with scientific discovery, so it is with other learning. I am frequently delighted with generosity, not only because of the gift, but because of the spirit of the giver. I am intrigued with the thought that there is a measure of understanding which I have not yet come to appreciate--there are things to know that we have not yet been able to discover. Dr. Kenneth Jernigan, who became President of the National Federation of the Blind in 1968 and served as its principal leader throughout much of his life, often startled me by his decision-making, not so much because of what he did but because of his reason for doing it. What we know is important, but the element that affects our personality more than what we have already learned is what we intend to discover.
So what knowledge have we gained from the time of the founding of the organized blind movement in 1940, and what is it that we plan to learn? From the innocence of our inexperience each of us has at one time or another accepted an assessment of our capacity which is much more limited than is justified. Yet we have learned to question such assessments, and we reject them. We have been told in the past (and sometimes it is repeated even today) that blind people fit a certain pattern--that we possess negligible intellect because our opportunities for education are circumscribed and our channels for learning restricted, that we have indifferent physical capacity because so much of physical movement demands vision, that we experience only limited ambition because the full range of human activity is not available to us, and that our psychological makeup gives us a passive personality with a spectrum of emotion that ranges from somnolence to despair. Is that an accurate description of you and me? Not then; not now; not ever! Those who believe such things should be with us in our thousands tonight. They would learn firsthand that we who are members of the organized blind movement are anything but passive.
We reject the portrayal of a former day. We are reshaping our image and creating a personality that is confident, knowledgeable, unwilling to be taken in by other people's misunderstanding of our capacity, possessing freedom of speech and independence of action, and having sufficient aggressiveness to care for ourselves and our blind brothers and sisters. We do not believe that all learning comes from us, but some does. We are prepared to learn from others; but the blind, too, have something to teach, and we intend to share our knowledge. Nobody else can take our experience and plumb the depths of meaning within our lives--we must do that for ourselves, and we must find a way for the truth of what we learn to become recognized within the broader society. We will discover our innate potential; we will demonstrate it to others; we will insist that it be accepted; and we will never rest until it is. We are the voice of the blind--the voice that will never cease until it is heard.
In 1940, when Dr. Jacobus tenBroek, the brilliant blind professor and scholar of constitutional law, brought together along with him a handful of other blind individuals at Wilkes-Barre, Pennsylvania, to form the National Federation of the Blind, the knowledge we possessed about blindness was comparatively slight; but our belief in ourselves was growing; and our hope for the future was irrepressible. Indeed there was at the beginning little else but hope and belief. Almost 100 percent of blind people were unemployed. Some sheltered workshops existed, but wages were pitifully low and working conditions dismal. Although the hope of a college education sometimes existed, for most of us it was a distant dream. For the vast majority of blind people a job, a home, and the rights and responsibilities of citizenship were out of reach. The Books for the Blind Program of the Library of Congress had been established in the 1930s, but there was little expectation that blind people would use this resource for studious research. The vending stand program had been initiated, but opportunities were few and the pay meager.
However, Dr. tenBroek and those who joined with him at the beginning of our movement had faith and hope. Without Dr. tenBroek's vivid imagination the National Federation of the Blind would never have been formed. As soon as we became an organization, we had to learn to speak independently and to believe in our own capacity for self-governance.
The early years were not easy--there were constant challenges to the right of the blind to speak and act in their own best interest. As Dr. tenBroek said: "The career of our movement has not been a tranquil one. It has grown to maturity the hard way. The external pressures have often been unremitting. We have been counseled by well-wishers that all would be well, and we have learned to resist. We have been attacked by agencies and administrators. We have learned to fight back. We have been scolded by guardians and caretakers, and we've learned to talk back. We have cut our eyeteeth on legal and political struggle, sharpened our wits through countless debates, broadened our minds and deepened our voices by incessant contest. Most important of all, however, we have never stopped moving, never stopped battling, never stopped marching toward our goals.
"We who are blind knew in 1940 that, if we wished to be free, if we meant to gain those inestimable privileges of participation for which we had so long yearned, then we must organize for purposes of self-expression and collective action."
With these words Dr. tenBroek expressed the spirit of the Federation--that spirit which began as we were founded, has continued as a constant within the movement, and persists at this convention and throughout the Federation today. With this fighting spirit the founders of the Federation commenced the arduous task of learning to build a national organization that could stand on its own and speak on behalf of the blind.
In 1952 (when the Federation was 12 years old), Dr. Kenneth Jernigan became active in the movement at the national level. Dr. tenBroek was a philosopher and a theoretician. Dr. Jernigan, who loved Dr. tenBroek and the philosophy he taught, was a builder and an advocate of political action. He expanded Dr. tenBroek's ideas and gave them substance in practical programs within the Federation. By the time of Dr. tenBroek's death in 1968, Dr. Jernigan had created in Iowa the best known program of rehabilitation for the blind in the United States. He did this by incorporating within it that philosophy he had learned from Dr. tenBroek. For his innovative effort in building programs for the blind, Dr. Jernigan received a Presidential citation, and the lives of thousands of blind people were enriched.
Ten years later, in 1978, the Federation secured the National Center for the Blind, a substantial pile of bricks and mortar in what was formerly a rundown section of Baltimore, Maryland. With broken windows, leaks in the roof, antiquated electrical and plumbing systems, and an outdated heating plant, this building required the vivid imagination of Dr. Jernigan to bring its potential into being. Dr. Jernigan gave some of us a tour shortly after the building was acquired. He said, "Here is the conference room; here is the kitchen; this area will be used for the aids and appliances program." There were no interior walls in the areas we were examining; Dr. Jernigan was explaining to us how the building would be--after it had been remodeled. To many of us the whole place seemed like a big, dirty, empty, dreary, cavernous, uninteresting building. However, as was true for the pioneers in 1940, with the inspiration of our leader, Dr. Kenneth Jernigan, we had hope and belief. We needed the space for the programs we were then operating, and we needed even more space for those we would plan to establish. We started the long, arduous task of creating the National Center for the Blind, which is today the nerve center of programming for the blind in our country, the home of the International Braille and Technology Center for the Blind, and the facility in which plans are made to expand educational programs for blind children and to increase the availability of information systems to serve the blind. The National Center for the Blind is a source of pardonable pride for those in the Federation, for we make it what it is. What we know is important, but of even greater significance to our personality is what we hope to discover.
During the 1980s the Federation continued to develop programs at the National Center for the Blind; served as an instrument to bring harmony and cooperation among agencies and organizations in the field of blindness; established rehabilitation centers in Louisiana, Colorado, and Minnesota; created the National Organization of Parents of Blind Children along with FUTURE REFLECTIONS, the magazine for parents and educators of those children; started VOICE OF THE DIABETIC, the largest circulation magazine dealing with blindness in the United States; increased the emphasis on Braille literacy for blind children and adults; and sought methods for financing the programs we had been operating and those that were coming into being.
The dreams and efforts of the 1980s laid the foundation for a decade of astonishing progress during the last ten years of the century. In this short span of time, the Federation has established the International Braille and Technology Center for the Blind, produced and distributed over four million Kernel Books (18 of them now in circulation, and the nineteenth to be released later this year), conducted four international symposia on technology for the blind, and instituted the NEWSLINE(r) for the Blind Network and AMERICA'S JOBLINE Network--which provide greater quantities of information to blind people over the telephone than have previously been available in all recorded history. As the decade was nearing its end, we embarked upon what is perhaps the most ambitious effort we have undertaken from the time of our founding--the creation of the National Research and Training Institute for the Blind--a facility that exists today only in imagination, but which will be constructed in the early years of the twenty-first century.
Dr. Jernigan was a builder. He became the director of programs for the blind in Iowa in 1958, which, under his leadership, were recognized as the best in the nation. In 1978, 20 years later, he founded the National Center for the Blind and began the work to put it into shape. Twenty years thereafter, in 1998, within only a few months of his death, he formulated the concept of the National Research and Training Institute for the Blind and had the plans drawn for its construction. Building this facility will demand from us a change in our personality. We must adopt the belief that we can stimulate major financial investment in programs and ideas of our own creation. When we have raised the funding to establish the research institute, we must find a way to attract and stimulate the most imaginative researchers.
Much research is conducted involving blindness. The vast majority of it is centered on locating cures for diseases of the eye. Of the percentage that remains, much is directed toward alleviating the supposedly stressful and dismal condition of those who are blind. Almost no research is conducted in the realms that we find of interest. When the National Research and Training Institute for the Blind has been built, we must put the facility to use. It will not be enough to expand what we are already doing; we must dream of programs that do not exist.
In the mid 1970s we assisted Dr. Raymond Kurzweil in his work of inventing a reading machine. It was, at that time, so outrageously innovative that most people believed it could not be built. Even we wondered. The electronic scanner, which was a necessary part of the device, is now standard office machinery. Dr. Kurzweil's machine was the first, but today there are a number of reading machines available at a low enough price that many, many blind people can afford them. The invention was helpful for the blind, but it also benefited the larger society. The machines will continue to drop in price and increase in capacity. This change in technical ability occurred within 25 years.
What is it that we want to build which, in our wildest imaginings, could be constructed for the blind? What programs can be imagined to offer literacy both for blind adults and for the children who are now in school? What teaching methods can improve mobility for the blind, and how can we inspire increased confidence? How long will it take to devise a personal vehicle that we can operate? What is the best method for persuading the shapers of American thought--filmmakers, university teaching programs, outlets in the news media, and others--to portray blind people in the way we know them to be, rather than as helpless, foolish, or inconsequential? What is the best way to give blind people access to the written word whether it is in print or in electronic form? How can education for blind children be stimulated? These questions arise from our dreams of a brighter tomorrow. We intend to use our institute to answer not only these but dozens of others.
Today, as we raise the funds and make the plans to create the National Research and Training Institute for the Blind, I have heard it said that research should be left to the researchers, that the blind should stick to matters of special interest to the blind--Braille, lessons in the activities of daily living, teaching blind students to operate equipment for the blind, and the like. Research (if it is to be effective) must explore realms that are highly complex, rigorously demanding, and technically innovative. Sometimes it is not so much said as implied. Why do the blind need a research institution? Surely the universities can do it at least as well as or better than the blind can.
To those who believe that we who are blind are incapable of the intellect, the skill, and the dedication to conduct our own research in our own way, I say this: we have the capacity to learn, but we can also teach. We have a resource that none of you possess; we have the experience of tens of thousands of blind people collected in one place and represented by a body of literature which has produced more independence and self-reliance for the blind than any other. Our point of view will not be yours; our results will not be yours; and our contributions will not be yours. We are prepared to learn, but we also have something to teach. Ours is a vibrant and an aggressive personality.
In creating the research institute, we make a leap of faith. Is there a fundamental reason that the unemployment rate for the blind should hover in the neighborhood of 70 percent? We say emphatically, no! Is there some kind of a physical limitation that keeps the Braille literacy rate for blind children in the neighborhood of 10 percent? The answer is equally emphatic and exactly the same, no!
A new direction must be found. We, the organized blind of the United States, have decided that we will find it. This determination has become an element of our personality. We are the voice of the blind--the voice that will never cease until it is heard.
Is there really a need for a different kind of research and a new institution to study the problems of blindness? If you doubt the urgency, consider this: The M.D.'s WELLNESS JOURNAL from the Whitaker Wellness Institute, winter 2000 edition, carries an article entitled "Save Your Vision NOW!" Some excerpts from this article are instructive. They say: "It's true--we're all slowly going blind. The miraculous transformation of light into nerve impulses, which your brain sees as color, shape, and depth, eventually wears out your eye. It is called age-related macular degeneration (AMD). . . .While this condition is universal to everyone, it's one of the most terrifying threats to your health, independence, and enjoyment of life as you age."
[I interrupt to ask whether blindness necessarily must be terrifying. If it is not correctly understood, it certainly can be. However, with thorough understanding and proper training, the "terrifying threat" can be reduced to a physical nuisance. Furthermore, have we who are blind lost our independence or the capacity for the enjoyment of life? But back to the article.]
It continues: "Without your vision, you can't drive, you can't work, you can't read, you can't see your grandchildren or a movie. You can't easily travel, shop for yourself, or remain independent. For heaven's sake, you can hardly walk into the next room or around the block without difficulty!"
[Once again I interrupt. Although those who are newly blinded are sometimes quite timid in asserting independence, is this description at all accurate for the blind? Do we work, read, shop, walk around the block, or attend the theater? Of course we do all of these things and many others. But there is more of the article.]
While you can't stop this process [it continues], you can surely and dramatically slow it down so that you keep your vision in reasonable shape for as long as you live. . . . Numerous studies have shown certain antioxidants protect your retina from free radical damage. . . . The gentle herb which dramatically improves vision. . . was discovered by World War II British pilots who ate it and reported much better night vision! Works by improving blood flow to your eyes."
These statements come from the M.D.'S WELLNESS JOURNAL. They do not specify the gentle herb that so dramatically increases night vision, but other reports I have gathered tell me that it is a nutrient in the unpretentious, humble carrot. How many blind children have been told to eat their carrots because they are good for the eyes? For all I know, it may be true, but the story did not start with science. It began with deception and trickery.
It is said that during World War II the British invented the first radar. With this device operators could see enemy airplanes in the midst of clouds and fog or even in the dark. Unless the Germans were led to believe that a program to enhance the vision of British pilots had been instituted, they would inevitably come to the conclusion that a technological development, such as radar, had been discovered. British intelligence knew it was important to prevent the Germans from seeking to discover new scientific apparatus. Radar gave the British air force a distinct advantage over the Luftwaffe.
Those in British intelligence made it appear that they inadvertently permitted German spies to discover that the British airforce had embarked upon a campaign to feed massive quantities of carrots to the pilots because, they said, this diet dramatically increased their night vision. It was all done in an effort to mislead the Germans to prevent them from learning that a scientific breakthrough had been achieved. Although carrots are undoubtedly good for you, I can report that I have consumed substantial quantities without producing a noticeable difference in the quality of my vision.
Whitaker's journal exaggerates beyond all reason the limitations of becoming blind. In most cases blindness is not an advantage, but Dr. Whitaker's description is out of proportion. He says blind people can't work, can't read, can't travel easily, can't shop unaided, can't remain independent, and can't walk around the block or into the next room without difficulty. Every single one of these assertions is a lie! Yet they are dressed up to make it appear as if they are part of scientific research. They are issued by a health institute and written by a doctor. Two of his many statements have an element of truth. Those of us who are blind can't see our grandchildren in the same way that sighted people do, and we can't drive an automobile. However, coming to know our grandchildren, caring for them, nurturing them, loving them, taking them to the zoo, and having the other experiences that grandparents find so dear are part of daily activity for the blind.
Then there is driving. Blind people do not drive cars. However, with a little planning and ingenuity, we are mobile.
Many people think driving is of the utmost importance. Take my son David, who is 19, for example. He is sighted, and he believes that driving a car offers him not only independence of movement but status among his peers as well. He has persuaded me to buy a car for him to drive. I even ride in it occasionally if he doesn't have it off somewhere inaccessible to me.
He probably would not believe me if I told him, but I am more mobile than he is, even though I am unable personally to drive an automobile. Most of the time I get where I want to go with minimal inconvenience to me and to others. This is the test of mobility. I am older and more experienced than my son, and I have more ready cash available to me. Even though he drives the car, I exercise more freedom of movement than he does.
Dr. Whitaker was not researching blindness, but a cure for a disease of the eye. In doing so, he portrayed the prospects for the blind as nothing less than tragic. His portrayal comes from a former time, and it is without understanding and without depth. We reject it. We will not permit misunderstanding and false information to determine our future. We will challenge the dismal summation of the doctor and replace it with an image of competence and success. We are the voice of the blind--the voice that will never cease until it is heard.
As Federation members know, the primary problem blind people face is one of misunderstanding. The misunderstanding comes in different guises. Sometimes our methods for doing things are not comprehended; sometimes our capacity for performance is not appreciated; and sometimes the misperception involves the importance of our doing anything at all. The loss of eyesight requires blind people to use alternative techniques to do the same things sighted people do with vision. Some modifications to the environment are necessary to permit blind people to compete successfully. This is especially true in handling information, which is frequently presented visually.
One of the major providers of information is America Online (AOL). Officials of this company have said that their product is unique and beneficial. However, they have systematically refused to consider building the AOL system in a way that would permit the blind to get at the information. Why? Some people would argue that they have never thought about the question. But of course they have had every opportunity to think about it. Blind people have complained about the inaccessibility of AOL for years. The attitude of AOL seems to have been that the blind do not have enough to contribute to AOL or to society as a whole to make an alteration in their system worth serious thought. Most of the time, when the matter has been raised, they have told us to wait or to seek access to their information through somebody else's technology or to get our knowledge from another provider or to forget it. AOL officials are not against the blind; they just don't think we are worth the time and effort it would take to give us the same access that other people have. To AOL the blind are objects of charity--not customers, people for whom things are done--not contributors, in a word inconsequential.
When we the blind had been forced to conclude by the actions and attitude of AOL officials that their perception would not change, we took measures to protect our own interests and secure our future--we brought suit against them in the federal court. They may believe that the blind are inconsequential, but we do not share this opinion, and we also have something to teach.
Compare this attitude to one exhibited by a man in Montana, Pat Schildt, who has decided to do something for us--he has designed a special toilet for the blind. I confess that this one took me by surprise. Blind people do not have a different physical form from the sighted. What could possibly be done, I wondered, to make a toilet more effective or easier to use for the blind? I speculated that Mr. Schildt may have thought blind men would be unable to aim for the proper spot. Perhaps, I thought, he had devised a funnel attachment which would make the aiming unnecessary. However, this is not the case.
An article which appeared in the Tuesday, April 25, 2000, edition of the MISSOULIAN describes the genesis of this product as follows: "[Pat] Schildt realized that people with disabilities, particularly people with limited vision or no vision, often were frustrated by having to hunt for the most basic things--like toilet paper dispensers."
Schildt said, "They [blind people] don't know if the seat is wet or if it's dirty, if there is toilet paper or where it is--or, if it is there, how to get it out of its container." Schildt's solution, which he has named the Hygienic Toilet for the Blind and Physically Challenged, is a stainless steel toilet with covered toilet paper dispensers attached to each side of the bowl. I kid you not; you can read it in the paper.
Why do people come up with such crazy ideas? Why do information-providers refuse to consider including the blind? The answer is simple. They do not believe blind people are in the same class with the rest of humanity. They think that being blind sets us apart from others, that we are different, unable to make substantial contributions, unimportant. The attitude is not one deliberately to belittle the blind. It would be better for us if it were. Rather it is to assign blind people to a role so insignificant that our problems are never considered, our presence is never desired, our contributions never sought, and our abilities never observed. However, this attitude, although at one time almost all-pervasive, is waning, and those who hold it are fewer than they once were. What has occurred to cause this transformation? How has the personality shift come into being? It is through the efforts of the organized blind movement--through the activities and spirit of the National Federation of the Blind. In the past we were the unheard minority, but that must and will change. We are the voice of the blind--the voice that speaks with an insistent cadence--the voice that will never cease until it is heard.
The public misconceptions about blindness are not confined to the sighted. Blind people, being a part of the public, also share them. When these misconceptions are repeated by the blind, they have the appearance of substance even when there is none. An article which appeared in the WASHINGTON POST on June 9, 2000, depicts a stark, tragic, unrelenting world of misery as described by a man who became blind within the last few years. Entitled "A World Darkened by Despair," this article says in part, "I was walking to my car the other day [says the reporter, Courtland Milloy], when a blind man named John Sterling called out, 'Am I on Third Street?' He was indeed. Right smack dab in the middle of it, with traffic bearing down on him. The least I could do was offer him a ride home, which he gladly accepted. Turns out that Sterling needed somebody to talk to almost as much as he needed to get out of the street. In fact, he confessed, he sometimes deliberately walks in the streets--either to get attention from sympathetic passersby or in hopes of actually getting hit by a vehicle. `Being blind is so boring,' he told me. `Sometimes you just get tired of waking up to face the same old thing, nothing, every day. Sometimes, I just want to walk right out in front of a bus and end it all.'"
[Or get a free ride home with a passing newspaper reporter along with a dollop of sympathetic press. I confess that this last thought was not in the WASHINGTON POST, but it does seem to come to mind. What a distorted and dismal picture. Blindness, according to Sterling, offers no hope. Life itself may not be worth living for the blind, he tells us, and he tells us in the WASHINGTON POST. But we are not through with this news feature.]
Sterling insisted [continues the article] that he needs a job, anything to do besides sleep all day. And he is not alone. About 20,000 blind people live in the Washington area, and, despite the booming economy and low unemployment rate, 70 percent of working-age blind people are without jobs. `There are a lot of blind people in our area, but how many do you see?' Sterling asked. `That's because they stay indoors all day, mostly sleeping or talking on the telephone, trying to keep from feeling that nobody cares,' he said.
[I interrupt this article to point out that the people who should care the most about the blind are the blind themselves. Somebody else cannot achieve independence for us. Somebody else cannot win our freedom. We must gain these things through our own efforts or be without them. Do our sighted friends and neighbors care? Of course they do. Growing numbers are joining with us in the effort to bring self-reliance to the blind, and we are glad to welcome them. But charting the course of our lives is not their responsibility; it is ours. However, there is still more in the WASHINGTON POST.]
"About a year ago [continues the article], Sterling completed an eight-month mobility training course for the blind. But he still bumps into fences and parked cars, stumbles along cracked sidewalks, and occasionally falls. `Basically I paid $4,000 to learn how to tap the ground with this stick,' he said. `See, with this stick, I go zigzagging all over the place. I walk twice as long to get half as far.'"
Such are excerpts from the article that appeared in the WASHINGTON POST, and one wonders how to respond. Sterling's description of his experience and the despair he feels may be his honest appraisal, but the assessment is not accurate. There are blind people who have given up, but the great majority have not. There are those who have accepted the assertion that blindness means the end of productive living, but most of us know this is wrong. The educational programs of the Federation are having an impact, and employment opportunities for the blind are expanding. Sterling has caused his description to be printed in the paper, and his view of blindness will help create the disadvantages and erect the barriers that the rest of us must confront. However, his voice is not the only one. We have also learned to speak, and we have an abiding hope and faith. Blindness need not be tragic, and we will not permit this description to go unchallenged. We are the voice of the blind--the voice that speaks with an insistent cadence--the voice that will never cease until it is heard.
Every year we receive many thousands of letters from blind people. Some of these tell of the tragedy that misunderstanding and lack of information cause. Here are parts of one such communication. The language is stark. The exclusion is total. The injuries to the spirit of this blind person are still raw. This is what she says:
"Let me tell you what Magoo and related things did to me. I remember, with agonizing clarity, the pain, humiliation, suffering, and fear--yes, fear of my childhood. I was called `Blinky,' `Missus Magoo,' `Four Eyes,' and other hurtful names. I know the sound of hatred. I remember what the rocks felt like as they hit my face. I remember the taste of my own blood. I remember that at each new school the first thing I did was search for hiding places! My favorite school was the one that had a coal chute. When the bell went, I would dash for the hiding place trying to get there before the bullies could grab me.
"Since this was the Fifties and Sixties, the heyday of Magoo and long before sensitivity issues, there was no recourse. Teachers and principals would tell me, `Just stop annoying the bullies,' or `Ignore them.' Let me ask you. . . how do you ignore a circle of children, standing around you while you feel around on the ground to find your glasses, which are under the foot of one of the biggest kids? How do you pretend not to be bleeding?
"I now know that the reason my grades were so poor was that I could not concentrate on learning. I was in a war zone. My ability to work is damaged due to faulty learning."
The woman who wrote this letter was hurt physically by the rocks, but what bruised and twisted her spirit was the constant apprehension--the fear that she was alone and friendless in a hostile world. She did not know of the National Federation of the Blind, and we did not know of her. In the 1960s we were smaller and less powerful than we are today, but we would have offered support and comfort. We cannot change the past, but we are absolutely committed to a brighter future. Frequently children (especially blind children) do not possess the experience or training to protect themselves. Blindness is a particularly visible characteristic which is sometimes employed to divide blind people from the rest of the group. Often the only reasonable alternative available to a blind person is seeking assistance from others to establish a secure environment--to shift the emphasis away from fear and toward the exercise of independent choices. We know that blind children are vulnerable, and we will take steps to protect them. Because there is strength in numbers, because the power to belittle the blind diminishes when we face it together, we have formed our vehicle for collective action--we have established the National Federation of the Blind.
We, the organized blind movement, have decided to alter our personality so that the role of insignificance that was once assigned to the blind is swept away and replaced with a character that is bold, assertive, self-confident, joyous, and successful. To do this, we must change ourselves. We must believe that the alteration can occur, and we must insist that it come into being. It is your responsibility and mine. Will we succeed? Will we set the standard for pioneering a new image of blindness? Will we find a way to build for the blind of this generation and the next programs that do not yet exist? You know the answer as well as I--you know the spirit of the Federation--you know our absolute, unshakable, unbendable determination to achieve first-class citizenship within society. The personality of freedom cannot be brought into being by a single human being, by a handful, or even by a multitude; it must be shaped by the entire movement--it must be created by you and me. I will not ask of you what I myself am not willing to give, but I will not hesitate to ask. Our movement needs all the best within us--our imagination, our love, our dedication, our shared commitment, our belief in ourselves and each other.
The mechanisms of our movement change, but the fundamental purpose remains the same. Sometimes we achieve our objectives through letter-writing campaigns, sometimes by marching in the streets, sometimes by confrontations, sometimes by educational symposia, sometimes by creating a literature of hope and belief, sometimes through actions in the courts, and sometimes by designing our own research facility. However, though the method may shift, the objective does not--it is the complete, unhampered, total independence of the blind. In this year of new beginnings, as the 1900s cease to be, we look to the future and wonder what the decades ahead will bring. The specific details may be obscure, but the direction is abundantly clear. The future belongs to us.
The doctors can tell us that we cannot live independently; the computer specialists can deny us access to information; the inventors can assert that we are unable to find the toilet paper; and the newspapers can print that some of us think it would be better for us to jump in front of a bus. In the long run such arguments are of no significance. They cannot stop us, for we will not let them. We will form our personality to fit our own image, and we will keep on marching--never quitting, keep on battling--never stopping, keep on living our independence--never altering our irrepressible spirit. Whatever the challenges, we will meet them. Whatever the obstacles, we will surmount them. Whatever the costs, we will pay them. We will not be ignored or stifled or intimidated--and we will prevail. This is our determination; this is our personality; this is the National Federation of the Blind! Come: join me, and we will make it come true!
by Ed Bryant
Photo: portrait. Caption: Ed Bryant
Diabetes mellitus, by definition, is inability to properly process blood glucose. The untreated, out of control diabetic has abnormally high blood sugars, and the diabetic who wishes to keep his or her blood sugars down in the normal range uses diet, exercise, oral medications, and/or insulin to get them there. For whatever reason, sometimes the sugars dip too low, and hypoglycemia results.
A "hypoglycemic reaction," also called an insulin reaction, insulin shock, or low blood sugar reaction, occurs when blood glucose drops to a point where the individual becomes confused and disoriented. At what point a person is "low" varies; some health professionals say any blood sugar level below 70mg/dL is hypoglycemic, while others put the "trigger point" at 60mg/dL. Individuals vary, and hypoglycemia can affect both insulin dependent and non insulin dependent diabetics, though type 1s are more at risk. Safety is paramount. Talk to your doctor about where your sugars should be running, to keep you safe.
Prevention is the best treatment for low blood sugar reactions! Though the personal "threshold" varies, and some folks can function with their blood glucose down at levels that would leave others disoriented or unconscious, if your sugars stay up in the 70 to 110mg/dL range, a hypoglycemic reaction won't happen. Although exactly what is "normal" for a diabetic in good control varies between individuals, the point is to provide yourself a healthy range, while ensuring a margin of safety against "hypos." "Tight control" means doing the best possible job of keeping your blood sugar fluctuations under control it doesn't mean continuously staying below normal range.
Don't just wait for symptoms of a "low" to clue you in all that shakiness, sweatiness, and confusion; too often a reaction comes on without much warning. Frequent blood glucose monitoring is the best way to warn yourself of impending hypoglycemia. By observing your patterns of low blood sugar, by learning how much medication, exercise, and sustenance your body needs, you can make the changes necessary to prevent a reaction. Remember that meters are imperfect they can vary by 10% either way, and an indicated test result of 70mg/dl may in fact be closer to an unsafe 63mg/dl. Home blood glucose monitoring is not an exact science to be safe, test often, learn your individual "normal" range, and keep your sugars in it, as best you can.
Although every effort should be made to prevent hypoglycemia, almost every diabetic, especially those who use insulin, will occasionally experience a reaction. Common causes include straying from the prescribed diet, taking too much insulin or oral medication, not eating the proper amount at the proper time, or doing vigorous exercise, especially at an unplanned time. Sometimes a "low" comes on for no apparent reason at all. Alcohol and certain drugs (certain sedatives, sleeping pills, and the "beta blockers") can also lower blood sugar and bring on a reaction. Individuals practicing strict "tight control," holding to a low blood glucose level, increase their risk of hypoglycemic episodes. Although the long term benefits of tight control are great, some individuals may need to relax their numbers a bit, trading higher glucose meter readings for an increased margin of safety. THE GOAL SHOULD BE TO USE THE TIGHTEST CONTROL THAT IS RIGHT FOR YOU.
Symptoms vary between people; learn what yours are when you "get low." Studies suggest a diabetic's awareness of his or her hypoglycemia is a learned response, is taught, and can be improved by more education. There's no substitute for your glucose meter, but "when I feel like this my blood is doing that" is a good line of defense. The old saying "know thyself!" makes sense here. Once you recognize the symptoms, you can take quick action to correct the condition.
Symptoms of low blood sugar reaction can be divided into two general stages. The first stage, usually occurring early in a reaction, can include shakiness, sweating, nervousness, fast pulse, dizziness, headache, and pale skin color. These symptoms may appear suddenly. The second, more advanced stage of hypoglycemia, includes mood/behavior changes, confusion, poor coordination, and difficulty in speaking. If you think you might be going into a reaction, have a snack, some simple carbohydrate, now. Better safe than sorry.
Next to prevention, the best way to treat a low blood sugar is to "nip it in the bud." To do so requires that you realize it is happening. Many diabetics have learned to recognize a reaction by the way they feel. For example, I have learned to recognize that at the first sign of a "low," I feel a kind of inner shakiness, although it is not physically visible to anyone around me. Although difficult to describe, it is a sensation I have learned, and recognize as an early sign of low blood sugar.
Note: Some people have "hypoglycemia unawareness," and cannot sense when a reaction is coming on, or even that a reaction is in progress. There may be few initial symptoms, or they may fail to recognize them. By the time symptoms manifest, these individuals may be too disoriented to help themselves. These folks should be particularly careful to keep to their insulin and eating schedules, and to monitor themselves for low blood glucose levels. (Note: Studies suggest a long period of euglycemia normal blood sugar achieved by tight control, may restore some ability to perceive a "low.") When such persons experience a reaction, it may appear at the "second stage," with disorientation, confusion, or even loss of consciousness. A diabetic in this condition, while still conscious and able to swallow, needs sugar immediately. CAUTION: DO NOT FORCE ANYTHING DOWN THE THROAT OF AN UNCONSCIOUS PERSON IT CAN BE ASPIRATED INTO THE LUNGS!
Simple Carbohydrates/Sugars
Doctors and Diabetes Educators recommend The Rule of Fifteens -- 15 grams of
simple sugar, immediately by mouth and every 15 minutes after, until hypoglycemic
symptoms have cleared, and blood glucose has returned to normal range. People
vary -- learn what's best for you, but note: -- taking more won't bring your
sugars up any faster! Below are listed examples of simple sugars in appropriate
quantity:
Several companies make similar "glucose gel" products.
NOTE: Sugar-free, "low-cal" products provide no benefit in treating a "low," and the fat in high-fat "sweets" (like candy bars) can slow the absorption of sugar!
What should you do then? Once symptoms of the low have cleared (use your blood glucose monitor to be sure), if your next meal is scheduled within 30 minutes or less, be sure you eat on schedule. If it ll be more than 30 minutes, you should have a snack, more substantial food, to cut the risk the hypoglycemia will reoccur. Food containing complex carbohydrates, such as fruit, crackers, or a lowfat peanut butter sandwich, should be taken. Skim milk is particularly ideal, as it contains both a simple sugar, lactose, and proteins. The complex carbohydrates in the foods listed above enter the blood more slowly than does refined sugar, but their effects endure, helping re establish euglycemia, proper blood glucose level. Don't overtreat -- don't gorge yourself here! You need to eat but if you keep "stuffing it in," you may drive your blood sugar up above 300 or more! Eat ENOUGH to re establish euglycemia, and then STOP. If a glucose meter is available, use it. (Note: The Diabetes Control and Complications Trial suggested that diabetics who had experienced a reaction stood a 50% risk of another within 24 hours, and a 25% risk of another in the next 24 hours.)
If a diabetic "misses the signals," if, for whatever reason, no action is taken to bring the blood sugars back up, the reaction will progress. The diabetic may shake or sweat. When someone asks if something is wrong, the response may be, "There's nothing wrong," or "I'm all right." Confused, the diabetic may ask the speaker to repeat himself, or may state that the question was not understood. A person undergoing a low blood sugar may appear distant, meditative, unusually quiet, "in another world." He or she may stop conversing, or might respond very slowly to questions. Some may become uncooperative or belligerent, spewing obscenities at the offer of assistance. The diabetic experiencing a "low" may seem intoxicated. Unfortunately, every year a few diabetics, thought by police to be drunk, are jailed overnight "for drunkenness." Before morning, their untreated low blood sugar reactions can lead to brain damage, even to death.
I strongly recommend that all diabetics wear medical information jewelry, either a bracelet or necklace, and carry a medical information card with them at all times. I wear a bracelet, and my card is in my wallet. Such information, available at most pharmacies, alerts law enforcement and emergency personnel that the bearer is diabetic, and is subject to low blood sugar reactions. Because hypoglycemia is easily, quickly and inexpensively treated, wearing a medical ID might help prevent an expensive and unnecessary trip to the emergency room.
The diabetic should inform friends and fellow workers about low blood sugar reactions. Relate symptoms and remedies. Tell friends and fellow workers: "When in doubt, give me something with sugar in it."
Occasionally a type 2 diabetic will experience a low. If the individual is taking the oral medication acarbose (trade name Precose), alone or in conjunction with a sulfonylurea, table sugar will not be an effective treatment for hypoglycemia. Oral glucose tablets or lowfat milk are recommended.
When a diabetic is unconscious due to a low, many physicians recommend an injection of glucagon, a prescription drug. It acts rapidly and causes the liver to release stored glucose directly into the blood stream. After an injection, the diabetic should regain consciousness within 10 to 30 minutes. Expect a lot of variation no two diabetics, and no two reactions, are the same.
After giving the injection, apprise the diabetic's physician of the situation. The glucose released after a glucagon injection burns off rapidly. To prevent recurrence of the reaction, it is important for the diabetic to take some food, especially complex carbohydrates. Glucagon may make some diabetics nauseated (there is a risk of vomiting turn the patient's head to one side and guard against choking). Some individuals may need to wait 20 to 30 minutes after glucagon is administered before having any food. Incidentally, glucagon is expensive, but I recommend all diabetics keep glucagon emergency kits on hand. Unmixed glucagon keeps without refrigeration (mixed glucagon must be used or discarded within 48 hours).
There seems to be no medical consensus regarding how much time should elapse before emergency help is sought. However, if a diabetic is not cognizant after two rounds of sugar or two injections of glucagon, emergency medical help should be summoned.
A diabetic walks a thin line between high and low blood sugar. To keep diabetes under control, he/she must follow the recommended diet and exercise, and must take the proper dosage of medication, on time. DON'T OBSESS OVER "TIGHT CONTROL." YOUR GOAL SHOULD BE TO USE THE TIGHTEST CONTROL THAT IS RIGHT FOR YOU. Keep to your schedule it's your first line of defense. If and when you experience a reaction, the best way to ensure your safety is to know how to bring yourself out, keep the tools close at hand (glucose tablets, cake icing, gel, or sugary liquid, if consciousness is present; glucagon if it is not), and tell your family, friends, and co workers what to do when you cannot help yourself. Discuss these issues! A hypoglycemic reaction is an emergency situation, and should be treated quickly to restore normal blood glucose level. Plan, prepare, and be rewarded!
In VOICE Volume 13, No. 4, I reviewed the surprising development of inhaled insulin, insulin taken into the lungs instead of injected beneath the skin. At that time I explained that inhaled insulin works, you do get blood glucose reduction, but the problem has been to moderate the dose, so as to allow consistency and reduce chance of hypoglycemia.
Research has continued, following several lines of inquiry. Inhale Therapeutics, of San Carlos, California, has developed both an aerosol-type inhaler device and a technique of micro-encapsulating insulin that allows it to penetrate deeply into the lungs. Their delivery system, and the special dry-powder insulin it requires, are currently in Phase III clinicals.
On December 15, 1999, Inhale Therapeutics was issued U.S. Patent No. 5997848, for their method of delivering inhaled insulin. One should note that their proprietary "deep-lung" delivery technique should function with a variety of (previously injection-only) medications, and that the syringe's days may be numbered.
On June 14, 2000, the company reported on new data provided by its manufacturing partners Pfizer and Aventis Pharma, who have been testing the inhaleable insulin they manufacture on patients for the last 30 months. The data showed HbA1c results remained stable across the test period, and that long-term use of inhaled insulin did not pose any "black-lung" type threat to the lungs.
How are they doing? There are a lot of hoops to jump through, on the way to getting a new medication accepted by the Food and Drug Administration. It can take years. Inhale has come a long way. They have a patent. They may well succeed -- but they aren't there yet.
Andaris, the competing British firm mentioned in my earlier article, has been purchased by Quadrant Healthcare PLC, with the new "Quadrant Group" focusing on inhaled and orally-delivered pharmaceuticals of all types. Watch for them.
California-based Aradigm Corporation is another player, and their AERx oral insulin administration system is currently in Phase II clinicals. Aradigm claims their product, which produces a fine aerosol mist, produces glucose control comparable with a dose of Regular insulin taken 30 minutes before mealtime. Data to support this assertion were presented at the 2000 annual meeting of the American Diabetes Association.
UK-based Provalis PLC, a subsidiary of Cortecs International, is following a different path, working to develop Macrulin, an oral, rather than inhaled insulin formulation, one that can pass through the digestive tract and "go active" in the intestines. Data appear promising, but Provalis is being circumspect with the release of information, and will say only: "More news about Macrulin will be released in late 2000."
There are many other players. Whoever is first to develop a reliable alternative to injected insulin will be able to cash in big time, for the demand will be tremendous.
When will it happen? Frank Vinicor, MD, MPH, Director of the Division of Diabetes Translation at the Centers for Disease Control, speaking at the 1999 annual meeting of the Diabetes Action Network in Atlanta, Georgia, stated: "I suspect within a year or two, you'll see major studies, and probably within three years or so you'll begin to see some availability. There are very practical issues to work out ... but the initial results are very positive."
Stay tuned.
From the Editor: Last issue, VOICE Vol. 15, No. 4, we asked Where s the Glucowatch? The Glucowatch Biographer is the almost-noninvasive blood glucose monitor we last reported as close to final approval, having been accepted by its Advisory Committee at the Food and Drug Administration. At that time, we noted final FDA approval is usually a formality, once these hurdles are past. But, as Dr. Russell Potts, Vice President for Research of CYGNUS, the GlucoWatch s manufacturer, pointed out, it is impossible to tell when the government will get around to doing something. The FDA has not yet sent CYGNUS the appropriate certificate.
On a related point, in the above article I expressed concern that the Glucowatch did not yet incorporate speech compatibility. I said Dr. Potts had not returned my calls and letters about this matter. On November 9, Dr. Potts called me, and discussed the Glucowatch, its future, and the possibility of making it adaptive for blind individuals. He apologized for not responding sooner, and said he and his company were anxious to get it out to consumers, and gain their "real world" feedback. "We have every intention of expanding its use," Dr. Potts said, "including for use by people who are sight-impaired." He stated Cygnus had to launch the basic meter before contemplating subsequent products, but their intention was to do so in the not too distant future.
For more information about the Glucowatch and its availability, contact: CYGNUS, Inc., 400 Penobscot Drive, Redwood City, CA 94063-4719; telephone: (650) 369-4300; fax: (650) 599-2503; website: www.cygn.com
ISMP MEDICATION SAFETY ALERT, the newsletter of the Institute for Safe Medication Practices (ISMP), warns health professionals that poorly written orders for the oral diabetes medication Avandia (rosiglitazone) can look like Coumadin (warfarin). Both drugs are available in 4mg oral tablets, increasing the likelihood of a mix-up.
The newsletter reports of specific mix-ups, and details one case where the pharmacist first misread the prescription, and then, inspecting the document, realized Coumadin would be inappropriate to this patient. As misdosage with either medication could cause grave danger to a patient, ISMP suggests that all prescription orders should include the medication's purpose. Also, nurses and pharmacists must clarify the drug's purpose prior to dispensing the medication.
For further information, contact: ISMP, telephone: 1- 800-324-5723; e-mail: [email protected]
by John Walsh, PA, CDE and Ruth Roberts, MA
(Editor's Note: The authors mention many texts in this article -- and all are either pages on their website, or publications available for purchase at The Diabetes Mall. Reprinted with permission.)
See also Can Humalog Handle The Heat? and Users' Reports
Humalog is a fast-acting insulin that gives users greater flexibility and better blood sugar control. Produced by Lilly and released in 1996, this insulin offers a quicker action time than the original Regular insulin, developed in 1921. With its higher peak activity and shorter working time, users report that their eating can be more spontaneous, their control is improved and they feel better.
Although Lilly has not applied for FDA approval to use Humalog in insulin pumps, the majority of pumpers in the U.S. have already switched and appear to be very satisfied. Novo-Nordisk is planning the release of their fast-acting Novolog or aspart insulin into the U.S. market following the anticipated FDA approval late in 1999. They may also seek FDA approval for pump use for Novolog.
Like Regular, Humalog is used to cover meals and snacks. Most meals create a rise in the blood sugar for only a short period, normally two to three hours for most foods. Regular insulin takes 30 minutes to begin working, does not peak until three to four hours after the injection, and continues to lower blood sugars for six to as much as eight hours. Humalog, on the other hand, begins working in 10 minutes, peaks at one to two hours and is gone in about 3 and 1/2 hours.
The great advantage of Humalog is that it can be taken as you begin eating, rather than 30 to 45 minutes earlier, required of Regular, because it matches the "action time" for most meals. For mothers of small children and for those on the go, this is a tremendous advantage. Rather than having to anticipate when the next meal might begin, those who aren't sure when the next meal might begin and those feeling ill can simply wait to bolus as they begin eating. Kids who are picky eaters can be given a bolus after they actually finish the meal with little loss of control.
Humalog simply matches meals better, lowering the blood sugar at the same time the food is raising it. Blood sugars at one to two hours after eating do not spike as they often do with Regular, and by the end of the second hour the blood sugar is often close to its starting point. This shorter action time gives Humalog a cleaner action pattern meaning the action of the last meal bolus is gone before the next meal begins.
More important for many, there is no residual bolus activity before going to bed and fewer nighttime reactions. Humalog leaves your body more quickly so you don't have residual insulin causing low blood sugars in the late afternoon or in the middle of the night. With Humalog you're better equipped to stop blood sugars spiking between meals, and you're no longer exposed to the overlapping build-up of Regular boluses.
Humalog's clearly defined action time makes it easier to troubleshoot problems. For information on how to determine the number of carbs covered by each unit of Humalog, see the 500 Rule in the POCKET PANCREAS. Humalog is also excellent for lowering high blood sugars. Its faster action means that less time is spent at high blood sugar levels, and less residual insulin is left to trigger low blood sugars later. For information on how to safely lower highs, see the 1800 Rule, also in the POCKET PANCREAS.
These rules work when someone has their basals and boluses set up correctly and has tested their doses to make sure their total daily insulin dose is correct.
Test often. Test your blood sugar often to determine how Humalog works best for you. As you start using Humalog, it is wise to test before eating, two hours after eating, and any time you experience unusual symptoms. Test often and use special caution when lowering high blood sugars.
Covers food differently. The great advantage of Humalog is its convenience. Although a 10 to 20 minute lead time is ideal, boluses can be taken with the first bite of food with very good post-meal control. Of course, its quick action means that you must not delay eating! If the pre- meal blood sugar is high and eating is delayed to allow the blood sugar to drop, the food must be eaten at the time planned to avoid a low blood sugar.
Foods with a high glycemic index that raise the blood sugar quickly, like cold cereals or a scone for breakfast, are easier to cover with Humalog. However, low glycemic carbohydrates like pasta al dente or a bean burrito which digest more slowly can present some problems, such as hypoglycemia occurring before these foods completely digest. For these rare foods with a low GI, the bolus may be split. Take half before the meal and the second half an hour or two after eating, or use a square wave bolus or raise the basal rate temporarily. Another option is to give an injection of Regular to better match these slow carbohydrates.
|
Total Daily Insulin Dose
Covered by One Unit of Humalog
|
Approximate Grams of Carb
|
|
20
|
25
|
|
25
|
20
|
|
30
|
17
|
|
35
|
14
|
|
40
|
13
|
|
50
|
10
|
|
60
|
8
|
|
Total Daily Insulin Dose
|
Estimated Point Drop per
Unit of Humalog
|
|
20
|
90 mg/dl
|
|
25
|
72 mg/dl
|
|
30
|
60 mg/dl
|
|
35
|
51 mg/dl
|
|
40
|
45 mg/dl
|
|
50
|
36 mg/dl
|
|
60
|
30 mg/dl
|
|
75
|
24 mg/dl
|
|
100
|
18 mg/dl
|
Meals with a high fat content may also occasionally be best covered by taking a split dose of Humalog, or taking the whole dose after the meal is eaten to better match the slow digestion of these meals. And, of course, if your blood sugar is low or on the edge of low at mealtime, eat the meal and then take your bolus afterwards.
Treat lows differently. Because of Humalog's fast action, fast carbs are recommended when you need to treat a low blood sugar. Glucose tabs, honey, or candies with dextrose like Sweet Tarts work best. Low blood sugars usually occur within three to 3 and 1/2 hours of a bolus. Obviously, if a low blood sugar occurs one or two hours after a bolus, more carbohydrate will be needed to raise the reading back to normal, than if the low happens three or four hours after the bolus. At three hours, a small amount of carbohydrate (10 to 20 grams) is usually all that's needed to remedy the situation.
Another great benefit of Humalog is that fewer lows are experienced during the night. People often needed a bedtime snack when using Regular in their pump to avoid a low during the night. In contrast, Humalog can be used at dinner with little need for a bedtime snack if the nighttime basal is correctly set.
Many research studies have reported that insulin boluses remain the same when people switch from Regular to Humalog. However, there are several reasons to be alert for changes that are likely to be needed in insulin doses. Because meals are covered more precisely with Humalog, often less insulin is needed to cover them. On the other hand, Humalog's shorter bolus action time may require a higher basal rate during the day. With Humalog, we recommend that the basal rate make up 50% to 60% of the total daily insulin dose.
In research on Humalog's biologic activity, two of six studies found that Humalog was as much as 10% more active than Regular in lowering blood sugars, while the other four found its activity was identical to Regular. So be alert if a unit of Humalog seems to go farther than a unit of Regular. Any change in insulin doses should only be attempted after discussing them thoroughly with your physician.
Many pumpers using Humalog report they need slightly less insulin through the day. Some find boluses may need to be reduced as much as 10 to 25%. Basal rate amounts generally don't change, although some find they need to raise the basal rate in the late evening and early nighttime hours because they used to rely on Regular's long action to work into the nighttime hours.
With Humalog's greater speed, basal rate changes are made closer to the actual time they are needed. For instance, on Regular, if the basal rate is raised at 2 a.m. to offset a Dawn Phenomenon, raising the basal rate might be delayed until 3 a.m. on Humalog.
For safety's sake, do not use the suspend feature with Humalog for exercise or low blood sugars. If you forget to take it out of suspend, you can quickly end up with high blood sugars. Because of its short action time, blood sugars typically begin to rise 60 to 90 minutes after the insulin is suspended, unless a bolus was taken recently. Another reason to never use suspend is that insulin which is static in the infusion line encourages clogging.
Always take Humalog by injection at the FIRST high blood sugar reading over 300 mg/dl (17 mmol). If any delivery problem occurs with Humalog in your pump, blood sugars can start to rise within 60 to 90 minutes, and ketoacidosis can begin in 4 to 5 hours. If a SECOND reading taken 90 to 120 minutes later is still over 300 mg/dl, take Humalog by injection and change out the reservoir and infusion set.
Results from 23 clinical research studies using Humalog in Europe, Canada and the United States were reported at the 1997 American Diabetes Association meeting in Boston. Our analysis of these studies found positive results in four areas when comparing Humalog with Regular:
Other results in individual studies were also positive. In one study, two people who had hypoglycemia unawareness regained warning symptoms of a low blood sugar. In a study of adolescents, incidents of nighttime hypoglycemia decreased.
The subjects in most of the research studies above were type 1's on long-term intensive management who had good control with HbA1cs in the 7s or 8s before using Humalog in the study. But one study followed people with "brittle diabetes" with erratic blood sugars and high HbA1c's. On switching to Humalog from Regular, their diabetes improved in all four areas listed above. Another study using people with type 2 diabetes also reported these improvements and the subjects had no weight gain.
Some people have noticed unexpected high blood sugars with Humalog and report that Humalog may deteriorate faster in hot weather than Regular. Control problems can certainly occur for other reasons such as incorrect basals and boluses that do not match the body's need for insulin. But Humalog appears to be less stable than Regular and more likely to lose activity, especially when exposed to heat. Test often and if your insulin does not appear to be having its expected effect, check for particles in the bottle and open a new bottle.
When Humalog goes bad, it does so quickly. Blood sugars may be fine one day and high the next. If blood sugars are unexpectedly high for any reason, check for particles, usually one or two large floaters, or several small crystals in solution or on the sides of the bottle. Always start a new bottle if you have any doubts.
In summary, the overwhelming majority of pumpers who have tried Humalog have gladly stayed on it. Most have been impressed by improvements in their control and in the convenience of taking their insulin when they eat. Fewer lows at night and improved HbA1c reports are a few of the benefits pumpers have experienced with Humalog, and many report that they feel better on this fast insulin.
For more information on Humalog and many other areas of intensive management, carbohydrate counting, glycemic index, proper insulin doses, exercise with control, pregnancy, complications, etc., get PUMPING INSULIN and the POCKET PANCREAS by John and Ruth, or STOP THE ROLLERCOASTER by John, Ruth, and Lois Jovanovic-Peterson, MD. Order these books online at (http://www.diabetesnet.com) or call The Diabetes Mall at (800) 988-4772 (011-1-619-497-0900) to order your copy.
Copyright (c) 1997, 1999 by Diabetes Services, Inc.
By Brooks Kent
The following was the keynote address delivered at the annual seminar of the Diabetes Action Network, on July 3, 2000, as part of the annual convention of the National Federation of the Blind, held in Atlanta, Georgia.
I'm Brooks Kent. As President of the Atlanta Association of Diabetes Educators, I'd like to welcome you to our city. I 'm a nutritionist and dietitian by trade. It's a fantastic career for somebody whose passion is food! Food is one of the ways that we celebrate life. In the beginning, when babies cry, we feed them. Throughout life, we celebrate all of our holidays around food. At the end, when someone dies, we take food to the family. What happens when we are told that we have to change the very way that we eat that many of the foods we most enjoy are limited to us?
It' s hard to make the changes that are so necessary for our health. Fortunately, many of the recommendations for people with diabetes have changed. We no longer ban sugar from the diet. It isn t the poison that we once thought it was. We know that, with careful planning, all foods can fit. The latest dietary guidelines have been produced and released. These are known as THE DIETARY GUIDELINES FOR AMERICANS 2000. Notice that they are not just for people with diabetes or with chronic heart disease. They are for all Americans, in order to make us healthier and stronger, and better able to enjoy the lives we lead.
Tonight, I m going to go over these brand new dietary guidelines. Has anybody here seen them? Have you noticed how they have changed? I think these guidelines make a good basis for all of us as we learn how we can eat a healthy diet. I m sure there will be questions you ll want to ask as we go along.
The first guideline concerns weight. Uncle Sam actually wants you to take out the tape measure and measure your waist. Anything over 35 inches for women and 40 inches for men is considered a risk factor. How many of us can say that we re under those figures? Did you know that it's the first 10 or 20 pounds that will make the biggest difference? When I first started diabetes education, I d constantly encourage people all the time about "getting down to your ideal body weight." We now know that getting rid of that little abdominal pouch, just a few of those extra pounds around the middle, will take us a lot closer to our blood glucose targets.
The second guideline addresses physical activity. How are you doing with that? Are you physically active? Are you doing pretty well? Do you know how much exercise is recommended as good, physical activity? Actually, the recommendation is 30 minutes daily, of moderate physical activity. But what does the word "moderate" mean? "30 minutes of moderate activity" actually means something like walking two miles in 30 minutes. Have you ever tried to do that? That s pretty intense! So it's going to take some effort on everybody s part to get out and do a little more exercise.
For those of you who find it difficult to exercise outside, that s okay. There are plenty of exercises that can be done in a chair. Would you like to try a few right now? The first thing I m going to ask you to do is put your hands on your shoulders. Now, lift them up as high as you can go. Stretch those fingers out. Now, curl your fingers in. Go back down to touch your shoulders. Let s do it to the count of ten. We ll go up on one, down on two. Ready? One, two, three, four, five, six, seven, eight, nine, ten.
How do you feel now? Do you feel any better? Just that little bit of exercise gets your heart pumping, doesn t it! Remember that following the guideline for exercise is something that we all need to do. We know that exercising is vital for our health.
How many of you are familiar with the food guide pyramid? Did you know there is a different one for diabetes? It differs in several ways from the one for the general public? One example is cheese, which is normally listed in the dairy group with milk and yogurt. On the diabetes pyramid it is now in the meat group. This is because cheese doesn t have very much carbohydrate. When you have diabetes, cheese acts more like a meat than like a dairy product. The beans which are typically in the meat group are very high in carbohydrates, so we ve moved them over to the starch and grains group. And what about potatoes, corn, peas, and the winter squashes like hubbard, acorn and butternut squashes? Those indeed are vegetables, but we group them as starchy vegetables because of their starch content.
Now, somebody tell me where to put a tomato? I'm sure you made an A in biology if you said tomatoes were fruit; but, when you have diabetes, you count your tomato as a vegetable.
Another way to use the pyramid is as a guide for the number of servings for a day. For instance, for people with diabetes, the number of servings for grains, starches and beans is six servings or more. For members of the general public, it goes as high as eleven servings , which would be appropriate for a 2800 calorie diet -- a little high for most of us. Most women, especially those desiring weight loss, need somewhere around 1600 calories each day.
Did anyone hear about the report that was published a month ago, on the effect of fiber in managing your diabetes? For a long time, we've thought fiber was a major player in controlling diabetes and now the research substantiates it. Any time you add fiber to your diet, it is beneficial. This does not mean your white rice is off limits ( you re only going to get two more grams of fiber if you use brown rice instead), but we d like for you to increase the fiber intake in your diet at every opportunity. Adding fiber is something you want to do very slowly, while incorporating extra water. Do not try to do it all at once.
Now, let me give you a list of words to look for on labels, words that should be first on the list of ingredients you look for. These are words like brown rice, bulgur (a cracked wheat), also look for graham flour, whole grain corn, oatmeal, popcorn, pearl barley, whole oats, rye or whole wheat.
We have excellent evidence now this will help all of us. There was a study published by the American Dietetic Association in 1998, the DASH Diet Study. The "Dash" diet actually stands for "dietary approaches to stop hypertension." Most people who have diabetes are also at very great risk for hypertension, so one of the things we d like you to do is to find other ways of controlling your blood pressure. The DASH Study indicates one of the best ways is to eat eight to ten servings of fruits and vegetables every day. That s right! Eight to ten! Along with that, we d like you to eat two servings of low-fat dairy products. Now, that s a lot of fruits and vegetables. How many fruits do you think I could include in that, if I am helping you with your diabetes? Not a whole bunch! So, you ll have to eat lots and lots of vegetables. We ve also found that all of those fruits, vegetables and dairy products can decrease your blood pressure as much as we could with medication. it's pretty impressive how your diet can make that much difference.
How many of you were out in the Atlanta heat today? Here, it's not a good idea to take chicken salad on a picnic. Just make sure you keep things clean, make sure your food is properly refrigerated and that you keep your food safe.
One of the things about low-fat and low-carbohydrate foods is that they protect our kidneys as well as our hearts and arteries. I have a particular passion for protecting people s hearts! I don t want you all to have the same heart problems I have, so I d like to see you all decrease the amount of fatty foods in your diets, and increase the number of beans and legumes that you include. This can be tasty as well as healthy.
We all know, but we need to remember, that sugar is not now considered to be the poison it used to be for people who have diabetes. On the other hand, sugar can present a problem, because it is a very concentrated form of starch or carbohydrate. What's more, it fills us up, and keeps us from eating foods that are much more nutritious, that would benefit us. It's important to moderate the amount of sugar you consume. Did you know that for the general population soda pop is the number one source of added sugar? That is followed by sweets and candies, cookies and cakes, fruit drinks and fruit "ades." I can t tell you how many kids think that these fruitopias are the way to go!
Again, the main purpose of this guideline is to combat hypertension; but there are also a lot of other things about salt we really don t understand. We think there may be some problems with salt we don t even know about yet. While not everyone who has diabetes is salt sensitive, you are much more likely to be "salt-sensitive" if you have diabetes. In Japan, where they have a very healthy diet, we find a much higher incidence of stomach cancer, and we think it has something to do with their high intake of sodium. A high intake of sodium is also a contributing factor to the formation of kidney stones. There are lots of reasons to watch the amount of salt you have in your diet.
There s that wimpy word, moderation, again! Moderation means one drink per day for women and two drinks per day for men. We know a healthy diet can be had which includes alcohol, and some studies have shown that alcohol may actually lower the incidence of cardiac disease for people who have diabetes. However if it's one drink per day for women and two drinks per day for men I don t want ya ll to save up all your drinks for Saturday night!
The new dietary guidelines are now available to everyone. There is a lot of other information in them besides the ten guidelines I have shared tonight. Actually, it is a 39-page booklet, which can be obtained by calling (202) 418-2312. it's also on the Internet through the U.S. Department of Agriculture. Let me give you that website also. It is www.usda.gov/cnpp. Or, you can just go to the USDA web site and ask for "dietary guidelines," and the search box will take you there.
Isn' t it true that when you use canned tomatoes in cooking the serving amount is different than when you use fresh tomatoes?
Actually, when we use tomatoes or anything that is pre- cooked, we should decrease the portion size. If you take a fresh tomato, it would take almost the entire tomato to give you one serving of the same vegetable, raw. What happens when you cook the tomato or the vegetable? It shrinks as it cooks. Are you still getting the same amount of tomato or onion, for example? A smaller quantity will give you the same amount in the serving size. So, we ask that you cut back on the amount in your servings of cooked vegetables.
In that same vein, what about your green leafies? I have a question for all of you. Green, leafy vegetables, are they "free foods"? No, they are not free foods. We do have to consider them as part of the daily diet. We can add a green, leafy vegetable to any meal or snack without having to worry about it, but it does contain carbohydrate, and has to be counted.
What about catsup?
Catsup has both sugar and salt. Catsup labels will tell you there are between four and five grams of carbohydrate in each tablespoon, which would mean one tablespoonful is a free food. Beyond that, however, if you are a six-packet catsup person, you ve just added two carbs to your diet.
Can you say something about Splenda?
Splenda (sucralose) is a wonderful, new artificial sweetener, on sale mid-September. I tasted it at the American Dietetic Association meeting last year. It has been approved for pregnancy as well as all types of diabetes. Anyway, it tastes just like sugar, and it can be used in cooking, which you can t do with the aspartame products. Some people don t like Sweet n Low, which we have been using for cooking. Splenda can be used in cooking and it is teaspoon for teaspoon at the same ratio as you would use sugar. You can also bake with it. You have to order it and I will give you the phone number to use. It is (800) 777-5363. it's a wonderful sweetener, and it's going to add a lot of choices for a lot of people.
There' s been a lot of publicity about testing of aspartame.
The artificial sweeteners have probably been tested more than anything else that we put in our mouths. They' ve gone through many, many clinical trials to determine their effects on people. There are so many things going around about these artificial sweeteners right now but I would say that moderation is the word for all of these things. I have heard a lot of negative things about aspartame, but none of them have been supported through scientific evidence or research. Aspartame was checked very, very carefully before it was released onto the market and approved for use. It is considered to be a safe product. If you are hesitant about using aspartame then choose another sweetener. Remember, though, that it does give you a lot of flexibility that you might not have otherwise. It gives you the satisfaction of having some sweetness in some products that you might not otherwise be able to enjoy.
Don t try to cook with it, though. Has anyone ever tasted a diet soda after it has been left outside in the sun all day at the filling station? Isn' t it horrible? That is because aspartame is made from protein, and protein "denatures," breaks down, with heat.
I live in Indiana and it's been a test market for Splenda.
Yes, Splenda is in some things that are on the market right now such as Log Cabin Syrup and in the reduced-calorie, Ocean Spray Cranberry Juice Cocktail.
I think someone also asked about fructose, the product called "Fifty/Fifty." What is fructose? It' s a sugar made from fruit. It' s the same thing that we get in orange juice. I d be very cautious about using Fifty/Fifty. I normally teach people to look at the total number of carbohydrates rather than just the amount of sugar that is contained in a food product. If you just look at the amount of sugar included, it can be very deceiving. After all, a carbohydrate is either a starch or a sugar. Our bodies don t care where the sugar comes from. They don t care if it's from a sugar or a starch. By looking at the total carbohydrate count, the amount of starch and sugar in your diet is already figured for you.
I teach everyone I instruct how to count carbohydrates. It is a very simple thing to do. All you have to do is know the amount of carbohydrates in the amount of food you are eating. If you are on an insulin pump, it's the only way that we can teach you to manage your diabetes. To use the pump effectively, you have to learn carbohydrate counting. Anyone who has been using the EXCHANGE LIST to manage their diabetes can easily learn to count carbohydrates. All you need to know is how much carbohydrate you are getting in each meal, and keep that consistent throughout the day. If you are on insulin, you obviously can have a little more flexibility in how much Regular or Humalog insulin to inject, by counting carbohydrates. If you are not on insulin, carb counting is an excellent way to control your diabetes with diet.
Carbohydrate counting is very simple and you can easily fit it into your meal plan. All of the starches and sugars that you want to include in your diet can be included if you don t overdo the carbohydrate intake at any one particular time. How many of you are doing carbohydrate counting? For those of you that have not learned to do it, I would suggest you talk to somebody on your diabetes management team. It will give you the freedom to eat a lot of foods you thought were off limits.
Someone asked me about eating rice bran. The bran from the rice, or any grain, is where the fiber is found. Any time you can add more fiber to your diet, it will improve your blood sugar control. Another form of bran would be something like Metamucil. Again, you want to be very careful and increase your intake of fiber slowly. You want to drink lots of water. Don t overdo it. You ll have a lot fewer friends if you go at it too hard.
One more thing about carbohydrate counting. Most people who are trying to control their diabetes with diet do not have a problem with what they eat. Rather, they have a problem with how much they eat. That is what makes the difference.
by Ed Bryant
Recently, the authors of the Diabetes Control and Complications Trial (the "DCCT Group") published an article titled "Retinopathy and Nephropathy in Patients with Type 1 Diabetes Four Years after a Trial of Intensive Therapy," in the February 10, 2000 NEW ENGLAND JOURNAL OF MEDICINE.
Background: The DCCT and its British equivalent, the United Kingdom Prospective Diabetes Study (UKPDS) proved that for patients with diabetes mellitus, intensive therapy, "tight control" (meant to achieve near-normal blood glucose and glycosylated hemoglobin concentrations), significantly reduces the risk of diabetic complications, as compared with conventional therapy. To test whether these benefits persist, the authors "compared the effects of former intensive and conventional therapy on the occurrence and severity of retinopathy and nephropathy for four years after the end of the Diabetes Control and Complications Trial." Note: Participants in this study were all type 1, insulin- dependent diabetics, but the UKPDS' findings strongly suggest the same will be true for type 2 diabetes.
Methods: At the end of the DCCT (1993), the patients in the conventional- therapy group were offered the chance to switch to intensive therapy, and all patients' care was transferred to their own physicians. The occurrence of diabetic retinopathy was evaluated in 1208 of these patients during the fourth year after the DCCT ended, and nephropathy was evaluated with urine specimens obtained from 1302 patients during the third or fourth year, approximately half of whom were from each treatment group.
Results: The difference in the median glycosylated hemoglobin (HBA1c) values between the conventional-therapy and intensive-therapy groups during the years of the DCCT (average, 9.1 percent and 7.2 percent, respectively) narrowed during the follow-up (median during four years, 8.2 percent and 7.9 percent, respectively). Nevertheless, the proportion of patients with worsening retinopathy, proliferative retinopathy, macular edema, and the need for laser therapy, was lower in the intensive-therapy group than in the conventional-therapy group. The proportion of patients who had raised urinary albumin was significantly lower in the intensive-therapy group.
Conclusions: The reduction in the risk of progressive retinopathy and nephropathy that comes from "tight control" of blood sugars persists for at least four years, despite increasing hyperglycemia.
by Nicholas Wilson
Tandem cyclist Julia Werner is one the premier blind athletes in the world. She was the United State Association of Blind Athletes(USABA) 1998 Female Athlete of the year, the 1998 World Time Trial Champion, the 1998 World Sprint Champion, a silver and bronze medalist at the 1996 Atlanta Paralympic Games (the elite competition for disabled athletes), and the World Record Holder in the Flying 200m Sprint Time Trial(12.82 seconds). She completed a 942-mile bike ride in October from Raleigh, NC, to Chicago, IL, and now she is preparing for the 2000 Sydney Paralympics, which will take place in Sydney, Australia, two weeks after the Olympics.
At what age did you lose your sight?
I began to lose my sight progressively from the age of 24 for about a year. The doctors said my vision would get better, and I stopped speed skating because I didn't want to take the chance of hurting myself. I didn't drive, I didn't do anything. My vision didn't get better, though and it put me into a nasty funk for about two years. I'm not totally blind however. Take two dinner plates and imagine they have dents in the center. I have some peripheral vision, but it's pretty bizarre.
Explain the psychological phases of losing vision?
Most people agree there are about three phases: denial, anger, and acceptance. At first you don't believe it's happening to you, you try to prove that you can do everything you used to do. I remember being on a boat with some friends one day a long time ago thinking to myself: "How can I take it back? I'll do whatever I can to get my vision back..." But this logic is a waste of time. Once you accept blindness, you realize, Why did I waste all the time denying it or being angry? But it's a necessary process. Eventually you grow out of it, try new things, and ACCEPT difficulty.
Have sports helped you along after blindness?
After blindness, I relied on sports at a very deep level -- as a validation of my ability. I want to do any sport, and I believe that I can; but I've had to redefine and to redevelop skills to make things happen. My vision is 7 o'clock in both sides, I get nasty headaches, but sports have helped my physical and mental health. I remember seeing a blind skier when I was a little girl and it blew my mind. I couldn't understand how it was possible. But now I realize I can do just about anything, like ride a tandem bike 942 miles.
Talk about the ride(Sydney Optimal Awareness Ride that Julia finished with her tandem partner Natalie Kelly).
We rode over 100 miles on some days alongside a full support vehicle, two Subaru cars, one driven by an Australian guy who got in two hours before the start. He had to suck down cups of coffee, learn to drive a manual on the wrong side of the road, and shift with his right hand while flipping CDs. He was great. We had a car in the back and a car in the front to protect us from traffic. Some days we slept in the back of a friend's camper truck when there was no other place to sleep. The first five days it was pouring rain, and at the end of the day we were covered in rain water, road oil and truck dirt- - we looked like we had just been dragged through a hole. One day, Julia said, "Let's make a stop at the hardware store." I said, "Why?" She said, "So we can buy a drill, and make holes in our shoes for drainage."
How did you get so involved in sports?
I was very depressed for quite a while. I didn't get out, I felt sorry for myself. Years later, I found a group of people (blind) who said, "I think I can." This group, the United States Association of Blind Athletes (USABA) connected me with all kinds of great people and events, like the Ski Spectacular, where 500-700 blind people ski, up in Breckinridge. The ratio of blind to sighted is like five to one on the slopes! I never knew this existed.
I found out about cycling camp through some of my ski events, though at the time I didn't have a bike or a partner. I ended up renting a bike right before the camp, and riding with a pilot who flew from California, whom I'd never met in my life. I loved it, and when they asked me my goals, at the end of the camp, I said: "I want to be a paralympic cyclist. I want to ride in Atlanta."
Athletics shouldn't end after high school, not just for the blind, but for anybody. People don't have to give sports up. You just have to search for ways to keep doing what you love to do.
Have you ever been scared to ride?
Yes, when I went to a race called the Burley Championships. My partner couldn't make it, and I had to ride with a replacement rider who was very emotional. He swore and screamed at everybody and I was like, "Oh my God, I'm on a bike with a crazy person." I was very scared, but I was determined to do the race. We ended up crashing, but we both got back up. I could have quit then, but I had come a long way and I really wanted to do the race, even though this guy had a few spokes missing. We finished the race, but I would never ride again with this rider or someone I didn't trust. This rider was accustomed to single racing, and tandem takes a heck of a lot of responsibility. The higher level of impairment, the more trust you need to have in your partner.
When did you start riding with Natalie?
This summer. She made two appearances at the Olympic Trials as a single rider, but had never ridden tandem before. We got on a bike together and it just felt right -- EVERYTHING: the way we sat, the way we pedaled... It's very important to be as close to unison and flawless as possible. You don't want to be fighting with your partner. We went to the Frisco EDS Superpose (velodrome track), where they have a 45-degree bank, and Natalie looked at it and said, "Oh no!" She didn't want to deal with a bank that steep, but I thought we should give it a try, at least, and we did. That track was so fast it was like putting a marble in the bathroom sink. We did fine though. We have the same build: short and stocky, and it helps because otherwise you have to overcome the physical differences of someone who isn't built like you.
Do you think it's more difficult psychologically to acquire loss of vision or to be born with it?
That's an interesting question. I would say losing it later in life, because you go down so deep that you think you can never come back up. You still want to do the things that you used to be able to do, but you have to adjust. Our society is so sports- based that you can feel like disability doesn't have a place, but you have to do something that gets you out. A kid is going to jump and land on his head, but that's what kids do. I ski, ride, run, and I'm a mother. The worst disability is close-mindedness. There aren't any dumb questions, even something like, you know: "Do you dream in color or black and white?" You have to force yourself to try new things and not be afraid to fail.
by Marilyn Helton
Here is some more material well worth your consideration.
The American Diabetes Association has updated and revised their COMPLETE GUIDE TO DIABETES, including new information on drugs, insulin regimens, health care and insurance issues, and diabetes in the workplace. Including thousands of proven tips from doctors, nutritionists and other health care providers, it also has informative segments on how to deal successfully with the emotional aspects of diabetes, including denial, anger and depression.
I'm particularly impressed with the much-needed, often overlooked topics discussed in Chapter 14, aptly titled "Diabetes in the Real World." Ask yourself this: Before you were faced with diabetes, did you know much about it? Most people don't. One of the tasks that comes with having diabetes is educating others in the workplace, the schools, and our society about what you (as a diabetic) need to live well with diabetes.
Chapter 14 discusses situations such as dealing with shift work and erratic hours (so dear to my heart and so hard to manage), travel, eating on the run, job hunting, and discrimination. Did you know that there's even (diabetes) discrimination in the military? An eye-opener for me. Also included in this real world chapter is an excellent section on diabetes at school, including numerous tips on how to prepare your diabetic child for school, educating his classmates and teachers about diabetes, your public school rights and sample forms for guidelines for caring for your diabetic child in school. You can copy these forms for the school nurse, teacher and your child's file, personalizing them for your child's individual needs.
This book is a good reference guide which will answer almost any question you have about living with diabetes. Make sure you're up to speed on the latest information on the new chapters on diabetes and the family (how to balance it all) children, and day care. It's all here in THE AMERICAN DIABETES ASSOCIATION COMPLETE GUIDE TO DIABETES, 2nd Edition, 1999, $23.95.
Here it comes again . . . My old nemesis, the big "E" word (exercise). I'm still struggling with commitment to a definite plan, and have really appreciated reading THE HEALING POWER OF EXERCISE, by Linn Goldberg, MD, and Diane Elliot, MD.
Did you know that exercise can reduce your risk of developing glaucoma, slow down (and even reverse) aging; and, rather than being harmful, exercise is actually good for your joints even if you already have arthritis? Exercise is now part of the treatment for degenerative joint disease.
What an eye-opener, excuse-reducing epiphany this book has been for me! (Don't tell anybody but I'm beginning to suspect I've just plain been lazy where exercise is concerned.) For the diabetic with type 2 diabetes (commonly a result of obesity and a sedentary lifestyle), there's no question about it: Exercise is not only necessary -- it could make the difference between life and death. At the very least it's essential to successful control!
Fascinating and informative medical sidebars, step-by-step photos, and detailed advice will get you motivated to start exercising and stay exercising for life! If you want to increase bone health, find relief for arthritis and back pain, lower your risk of developing certain cancers, treat diabetes, heart disease, and fight depression, consider THE HEALING POWER OF EXERCISE, by Linn Goldberg, MD, and Diane L. Eliot, MD, copyright 2000, John Wiley & Sons, $17.95.
Marilyn Helton, type 2 diabetic since 1993, is the publisher of CINNAMON HEARTS --THE ART OF LIVING A WINNING DIABETIC LIFESTYLE, a positive-power online e-zine for diabetics and their families. You can find more of Marilyn's book reviews, articles and recipes online at: http://diabeticgourmet.com, www.fabulousfoods.com, www.practicalkitchen.com, or Cinnamon Hearts website: http://members.xoom.con/cinnhearts/
If you start the day with a typical American-style breakfast of bacon and eggs plus buttered toast, you could be getting nearly a day's worth of fat, saturated fat, cholesterol and sodium, and taking in over 1,000 calories. To make your breakfasts healthier, use fat-free egg substitute, skip the butter, and choose fresh fruit instead of side dishes like bacon, high-fat sausage, or hashed brown potatoes.
Healthy breakfast choices include fresh juice, cereal, toast with jam, low-fat or nonfat yogurt with fruit and low- fat waffles, pancakes and muffins. If you can't get along without the taste of butter, try fat-free margarine it's amazingly rich-tasting.
Multigrain waffles served with sugar-free maple- flavored syrup are a delicious way to start your day. This low-fat breakfast is full of flavor, fiber and vitamins.
Ingredients:
Instructions:
In a bowl, combine flour, cornmeal, oats, baking powder, Butter Buds, baking soda, Morton Lite Salt Mixture and sugar substitute. In another bowl, mix egg with buttermilk. Pour liquid into dry ingredients. Stir enough to moisten evenly. Heat an electric waffle iron on medium-high heat, then spray heavily with nonstick spray. Evenly spoon in 1/4 of batter. Close lid and cook for about 4 minutes. Lift out waffle, respray iron heavily with nonstick spray and repeat process with remaining batter. Serves 4.
Per serving: 113 cal. (20% from fat); 6.1g protein; 2.5g fat (0.75g sat.); 17.2g carbo.; 384mg sodium; 56mg chol.; 2.15g fiber. Exchanges: 1/2 low-fat milk, 2/3 bread.
Ingredients:
Instructions:
Add apple juice, maple flavoring, Butter Buds and cornstarch to a small saucepan. Stir well to dissolve cornstarch. Cook over medium heat, stirring constantly, until thickened. Stir in sugar substitute. Syrup may be refrigerated for up to one week. Serves 6 (3 tablespoons per serving).
Per serving: 25 cal. (2% from fat); 0.03g protein; 0.06g fat (0.01g sat.); 6.2g carbo.; 1 mg sodium; 0mg chol.; 0.08g fiber. Exchanges: 1/3 fruit.
From the DELICIOUSLY HEALTHY FAVORITE FOODS COOKBOOK by Suzi Castle. Available in most bookstores, or by sending $18.90 (14.95 + $3.95 S&H) to: Health Cookbooks, Dept. M, 3520 McCourry Street, Bakersfield, CA 93304.
Artwork: Fruits and vegetables
Send your great food ideas to the editor. Your recipes will be evaluated by dietitians, and if necessary, adjusted to make them more diabetically appropriate. Then he gets to taste them...
by Sally A. York
(Editor's Note: Sally serves on the national Board of the Diabetes Action Network of the National Federation of the Blind.)
This is a hearty and healthy salad with a fresh, wholesome taste. You may vary the herb seasonings according to your preference.
Ingredients:
Instructions:
Place the corn, olives and cucumber in a serving bowl and mix well. In a small bowl, combine the sour cream, mayonnaise, vinegar, mustard and spices, and mix well. Gently stir into the vegetables. Scatter the tomato pieces on top of the salad. Cover and chill for at least two hours before serving.
Makes 6-8 servings. Per serving: 161 calories (62 calories from fat), 6gm total fat, 0gm saturated fat, 0.7mg cholesterol, 719.9mg sodium, 3.8gm protein, 25.6gm total carbohydrate. Exchanges: 1 1/2 starch, 1 fat.
from The California Avocado Commission (www.avocado.com)
Ingredients:
Instructions:
In a large bowl combine the olive oil, vinegar, basil, green onions, sundried tomatoes, and half of the California avocado.
Toss ingredients well so they are evenly coated with the oil and vinegar. Cook pasta in boiling water for six minutes or until "al dente." Drain pasta and pour in salad bowl with the other ingredients while the pasta is still hot. Toss together and serve immediately, using the remaining California avocado as a garnish on top of the pasta.
Serving Suggestions: Serve with 2-3 oz. of lean meat and additional steamed vegetables for a complete main meal.
Makes six servings. Per serving: 402 calories, 11gm fat, 1.6gm saturated fat, 1.6gm polyunsaturated fat, 6.7gm monounsaturated fat, 0mg cholesterol, 20mg sodium, 66gm total carbohydrate, 4gm dietary fiber, 7gm sugars, 12gm protein.
Exchanges per servings: 3 bread, 1 vegetable, 2 fat
from Dave Griffith of London, Ontario, Canada
Ingredients:
Instructions:
Mix the bread crumbs and paprika together. Brush the turkey with the oil and coat with the breadcrumb mixture. Bake at 350F for 30 minutes. Saute the garlic in a little oil and then add the tomatoes, onions, oregano, olives, parsley, and wine. Heat and simmer for five minutes. Place turkey fillets on the serving plates and spoon the sauce over the turkey, and top off each with a tbsp. of the crumbled feta cheese.
Makes 4 servings. Per serving: 9gm carbohydrate, 26gm protein, 7gm total fat, 199 calories. Exchanges: 3 lean meat, 1/2 carbohydrate.
Correction
The following recipe was carried in VOICE OF THE DIABETIC, Vol. 15, No. 4, Fall 2000. At that time, it incorporated errors. Here they have been corrected.
Ingredients
Instructions
Preheat the oven to 400 F. Combine sugar, salt, flour and baking powder. In a separate bowl, combine the liquid ingredients. Make a well in the center of the dry ingredients, and add the liquid ingredients and the blueberries. Mix with a fork until it forms a loose batter.
Lightly coat a muffin pan with nonstick cooking spray. Spoon the batter into the pan, until the cups are 3/4 filled. Bake for 18 20 minutes, or until the tops are golden brown and the centers are firm.
Makes 12 servings. Serving size: one muffin: Per serving: 227 calories; 65 calories from fat; 7gm total fat; 1gm saturated fat; 19mg cholesterol; 193mg sodium; 37gm carbohydrate; 4gm protein. Exchanges: 2 starch, fruit, 1-1/2 fat.
Artwork: Hand pulling a book from a shelf of books
Inclusion of materials in this publication is for information only and does not imply endorsement by the Diabetes Action Network of the NFB.
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 with 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.
DIABETIC SPECIALTY PRODUCTS
If you have diabetes, you may need alternatives to some commonly used items, like cough medicine (most are full of sugar!), or a good moisturizing skin cream, for the dry skin so many of us have, especially on our feet. Health Care Products offers all of the above.
DiabetiDerm skin moisturizer, available in cream and lotion, uses many natural ingredients, and is made without a petroleum base.
Diabetic Tussin is a line of cough syrups, formulated for diabetics without sugar, sodium, alcohol, fructose, sorbitol, codeine, or dye.
These items are available in most major drug and discount stores. For information, contact: Health Care Products, telephone: 1-800-899-3116; or at their website: http://www.diabeticproducts.com
READING MACHINE
There are many ways to cope with the problems loss of vision brings to reading. There are optical reading machines, where you scan a printed page into computer memory, from where it is then read by a synthesized voice. Now there is another alternative: the L&H MagniReader.
This device combines CCTV magnification with an optical reader. The MagniReader magnifies text or graphics up to 36x on screen, and reads it aloud, in a clear voice. You can use either or both modes.
To find out more about this reading machine, contact: Lernout and Hauspie Speech Products USA, Inc., Kurzweil Educational Systems Group, 52 Third Avenue, Burlington, MA 01803; telephone: 1-800-894-5374; website: http://www.lhsl.com/educationad/votd
DIABETES INFORMATION IN BRAILLE
Although diabetes is the biggest cause of new blindness in working-age Americans, and there may be as many as two million Americans coping with both diabetes and serious vision loss, diabetes information in alternative format has been in short supply. Now there is a source for diabetes articles in Braille.
The Braille Group of Buffalo's diabetes collection includes:
Note: They expect to add more titles to their Braille list, so contact them for a full catalog and availability, and spread the word to your Braille-using friends who have interest in diabetes. As these materials are offered at a fraction of real cost, the Braille Group asks for a doctor's certification that the recipient is a Braille-reader either with diabetes, or caring for someone with diabetes. Call them for more information.
Contact: the Braille Group of Buffalo, Jill Pariso and Sue Kahn, 4660 Sheridan Drive, Buffalo, NY 14221; telephone: 1-800-561-8253; fax (716)633-8952; e-mail: [email protected]
DELIVERED TO YOUR DOOR
Homed Pharmacy Services will deliver your diabetic supplies to your door. If you have Medicare, and/or private insurance, your supplies may come at no cost to you. Homed handles all insurance claims, and delivery is free. For more information, call Homed Pharmacy Services; telephone: 1-800-226-7212; fax: 1-800-381-9929.
DIABETES SUPPLIES
Inverness Medical Corporation carries a full line of discount-priced diabetes supplies, including: Dex-4 glucose tablets, skin cream, and Excel test strips for the Glucometer Elite monitor. The company also markets the Monoject line of insulin syringes and lancets. Many Inverness (formerly Can-Am) products are also sold as "house brand" at major pharmacy chains. Their low price in no way compromises their high quality.
For information, contact: Inverness Medical Corporation, 200 Prospect Street, Waltham, MA 02453; telephone: 1-800-461-7448.
HUMALOG INSTRUCTION
Eli Lilly's Humalog insulin is powerful and efficient, but its responsiveness demands attention and understanding. GETTING STARTED WITH HUMALOG is an instructional audiotape that takes you step by step through issues like dose change, timing with meals, pregnancy, children and adolescents, intensive therapy, and how to achieve the most benefit. The 90-minute tape also contains several case studies. Written and delivered by Betty Brackenridge, MS, RD, CDE, and Kris Swenson, RN, CDE, it is priced at $14.99, plus $1.50 shipping, and is available from: Learning Prescriptions, 1520 W. Warner Road, Suite 236, Gilbert, AZ 85233; telephone: (602) 426-1965.
DIABETES SUPPLIES
Diabetic Supply Distributors, Inc., helps you save four ways with your diabetes supplies:
Contact: Diabetic Supply Distributors, Inc., PO Box 1820, Laurel Springs, NJ 08021; telephone: 1-800-962-8098.
NUTRITION SUPPLEMENT
Your insulin or oral diabetes medications are only part of your diabetes self-management. Although food supplements do not replace your medications, and the U.S. Food and Drug Administration has not evaluated their efficacy to prevent or treat any disease, a healthy diet is important, and research is continuing on the role specific supplements may play in controlling diabetes. AlphaBetic Multi-Vitamin Supplement is a food supplement formulated for the special needs of diabetics. A blend of vitamins, antioxidants, and minerals, it is available in sugar-free caplets. Contact: Abkit, Inc. New York, NY 10128; telephone: 1-800-226-6227; website http://www.alphabetic.com
TREAT MALE IMPOTENCE
For men who've had diabetes many years, one possible ramification is impotence, the inability to sustain an erection. This can be treated in a number of ways, but the least invasive is vacuum therapy.
The Vet-Co Vacuum Therapy System for male impotence is FDA-approved, safe, non-invasive, and easy to use. For information, call: Coast To Coast Home Medical; telephone: 1-800-330-6316.
PRODUCTS FOR THE BLIND
Freedom Scientific is the new corporation created out of the union of Arkenstone, Blazie Engineering, and Henter- Joyce. Its products include adaptive computer programs such as JAWS (Job Access With Speech), the Blazie line of talking and Braille-display computers, the Arkenstone reading machines -- and more. For information, contact: Freedom Scientific; telephone: 1-800-444-4443; website: www.freedomscientific.com
INSULIN PUMPS AND SUPPLIES
MiniMed is one of the world's leading manufacturers of insulin pumps -- those precision microdevices that are the closest thing to an artificial pancreas we have. If you are an insulin-dependent diabetic, talk to your doctor about pump therapy -- you might find the MiniMed 508 pump right for you. If you need pump/infusion supplies, Minimed offers a complete line. Minimed also offers (for doctor's use) the Continuous Glucose Monitor -- which can precisely chart three days' sugars, as an aid to establishing better control. And Minimed has the (still investigational) 2007 Implantable Insulin Pump. For information contact: MiniMed, Inc., 18000 Devonshire Street, Northridge, CA 91325-1219; telephone: 1-800-646-4633; website: www.minimed.com
FULL SERVICE DIABETES SUPPLIER
D & S Medical Supply is a full-service supplier with a catalog of more than 55,000 items, dealing with diabetes, its complications, and many other medical supplies, delivered to your home. Diabetes products range from glucose monitors by Bayer and LifeScan, and the AccuChek VoiceMate talking glucose monitor, strips, lancets and other supplies, to diabetic orthotics/foot care items, and much more. They accept Medicare, private insurance, some HMOs, and, in most states, direct or crossover Medicaid. Contact: D & S Medical, 2105 Newport Place, Suite 600, Lawrenceville, GA 30043-5561; telephone: 1-800-722-2604, website: www.dsmedical.com
TALKING BLOOD GLUCOSE MONITOR
Based on the proven Accu-Chek Advantage meter, the Roche Diagnostics Accu-Chek Voicemate provides the following: Clear, high-quality speech synthesis, talking the user through preparations, test procedures, and results, without the need for sighted assistance; an "insulin vial identifier" which reads Eli Lilly insulin vials and speaks their type, as a safety aid in tactile insulin mixing; a new, improved, "touchable" test strip -- the Accu-Chek Comfort Curve (no more "hanging drop of blood" needed!); no meter cleaning required; and a tactile "code-key" system for programming test strip codes. The Voicemate is the most "blind-friendly" talking glucose monitor available today, and the only one whose regular operations require no sighted assistance at all.
The Voicemate comes with an adjustable over-the- shoulder carrying case, with meter, voice box, battery, adapter cord, 10 Comfort Curve strips, earphone, insulin check-vial, manual and quick-reference guide (in print), and instructions on audiocassette. The meter (catalog # 2030802) can now be ordered through any pharmacy (suggested retail price $495-525). To do so, have your pharmacist contact Roche Diagnostics, 9115 Hague Road, Indianapolis, IN 46250; telephone: 1-800-428-5074. For direct purchase, and a price below $500, contact any of the following retailers: BeyondSight, Inc. Littleton, CO: 303-795-6455 ($498); Independent Living Aids, Inc. Plainview, NY ($495): 1-800- 537-2118; or the National Federation of the Blind Materials Center Baltimore, MD ($475): 410 659-9314.
TALKING COMPUTER
The VoiceNote, from HumanWare, is a laptop note- taker/organizer for blind individuals and those losing vision. It combines the familiar MicroSoft WINDOWS CE operating system, and standard computer keyboard, with voice access. You can create MS Word documents, access your e- mail, transfer documents to and from a standard PC computer, use your VoiceNote as a speech synthesizer for another computer, and access a number of planning and scheduling tools. For more information, about the VoiceNote or other products, contact: HumanWare, 6246 King Road, Loomis, CA 95650; telephone: 1-800-722-3393; website: www.humanware.com
HEALTHY SUPPLEMENT
Many people believe that "free radicals," chemicals produced by conditions such as diabetic high blood sugar, are dangerous. This line of thinking says that if such oxidants are controlled, health will be improved. Experimenters have isolated "antioxidants" such as alpha- lipoic acid, which they believe raises insulin sensitivity in persons with type 2 diabetes. Glucotize, by MRI, is a "timed release" formulation of alpha-lipoic acid, meant for oral use in association with your regular diabetes medications. NOTE: It has not been approved by the Food and Drug administration. For information, contact: Medical Research Institute, 1001 Bayhill Drive, Suite 204, San Bruno, CA 94066; telephone: 1-888-448-4246; website: www.lipoic.com
DIABETES SUPPLIES
When you need it, you need it. When it's time to test, when it's time for medication, you need it already there. Diabetic Care Center will ship your diabetes supplies to your door, and they do the paperwork. No forms, no trips to the pharmacy. Medicare and most private insurance accepted. Call the Diabetic Care Center, telephone: 1-800-633-7167; website: http://www.diabeticare.com
Artwork: Dancing fruits and vegetables
We invite blurbs and tidbit articles for inclusion in this column. Materials received may be edited and used as space permits. Products and services included in this column are for information only and do not imply endorsement by the Diabetes Action Network of the NFB.
THANK YOU! THANK YOU!
To all of you who responded to our recent donations drive, an enormous THANK YOU! It costs more than $300,000 per year to publish VOICE OF THE DIABETIC, the principal communication tool of our Diabetes Action Network. Through the generosity of the National Federation of the Blind, we offer subscriptions without charge; but our advertising income covers only a portion of production costs, so we depend on YOU, our readers, to help us keep on carrying our message to more diabetics, family members, health professionals, and individuals with an interest in the condition. As our circulation has now grown beyond 286,000, our need for your assistance grows more acute. Twice a year we send out requests for donations. To those of you who responded--Thank You again!
RESEARCH STUDY
Physicians with Southeastern Clinical Research are seeking individuals with chronic renal insufficiency (CRI) and anemia (low number of red blood cells, for possible participation in a research study (these individuals must not be receiving dialysis therapy). Individuals who have both these conditions together will experience frequent fatigue and weakness. The clinical trial will determine whether an investigational medication improves the quality of life for study participants. All study-related care will be provided at no charge, including physical exams, lab tests, and the study medication. Financial compensation is also provided to those who take part. For information, contact: Southeastern Clinical Research; telephone: (423) 778-6947.
DIABETES VACCINE?
Last September, the journal NATURE MEDICINE reported that researchers from Yale University School of Medicine in New Haven, Connecticut, believed they were on target to eventually develop a vaccine against type 1 diabetes. Dr. Susan Wong and her colleagues at Yale think they have identified the cause of type 1, and that they have found an antigen, a substance that stimulates autoimmune response against insulin-producing pancreatic cells. Although so far this reaction has only been studied in specially-bred type 1 diabetic mice, the researchers believe they can recover sufficient information pertinent to human type 1 diabetes to enable formulation of a diabetes vaccine "possibly within a decade."
FLU SHOTS
The U.S. Centers for Disease Control reminds people with diabetes to get their flu shot! Influenza and its complications kill an average of over 25,000 Americans each year, and diabetics are three times more likely to die from these infections. We encourage you to use this ounce of prevention this winter. Take action, and stay well!
TAX HELP
For assistance with completing your year 2000 tax forms, you can telephone the Internal Revenue Service, toll-free: 1-800-829-1040; website: www.irs.ustreas.gov/prod/forms_pubs
WEB SEARCH ENGINE
By its own reckoning, the U.S. Government maintains 27 million different web pages! It can be a full-time job just finding the official information you need but now the U.S. Government has its own search engine: www.FirstGov.gov
PAIN MEDICATIONS AND DIABETES
If you have diabetes, what about those "over-the- counter" pain medications: aspirin, acetaminophen, ibuprofen, and other "NSAIDs"? Are they safe?
It turns out they are "safe," in that they don't affect your blood sugars either way, but there are other considerations. First, if you have any degree of kidney failure, from your diabetes or otherwise, the action of these medications will be altered. Talk to your doctor before using them.
Second, if you are taking any of the sulfonylureas, common oral diabetes medications, these NSAIDs interfere with their action, possibly causing a hypo. Be careful!
NEW WEBSITE
Eli Lilly and Company now sponsors the website: www.lillydiabetes.com
Significant features of this site include the "tracking tools," graphs and charts to help the diabetic chart HbA1c test results, Blood pressure test results, and a "height and weight index" to help with calculation of body mass index, a ratio widely used to help determine ideal weight.
The site also includes product information, test results and success stories, as well as news releases about Lilly's many fund-raising activities. Check it out!
HEAR YE, HEAR YE, A RAFFLE
The Diabetes Action Network of the National Federation of the Blind reaches out and provides support and information to thousands of people. Because it costs to operate this valuable network and to produce the VOICE OF THE DIABETIC, we must generate funds to help cover these expenses. Our Diabetes Action Network has elected to hold a raffle, which will be coordinated by our division treasurer, Bruce Peters.
THE GRAND PRIZE WILL BE $500! The winning ticket will be drawn, and the winner's name announced, on July 6, 2001, at the banquet held during the annual convention of the National Federation of the Blind.
Raffle tickets cost $1 each, or a book of six may be purchased for $5. Tickets may be purchased from state representatives of our Diabetes Action Network or by contacting the VOICE Editorial Office, 811 Cherry Street, Suite 309, Columbia, MO 65201; telephone: (573) 875-8911. Anyone interested in selling tickets should also contact the VOICE Editorial Office. Tickets are available now! Names of persons who sell 50 tickets or more will be announced in the VOICE.
Please make checks payable to the National Federation of the Blind. Money and sold raffle ticket stubs must be mailed to the VOICE office no later than June 10, 2001, or they can be personally delivered to Raffle Chairman Bruce Peters, at this year's NFB convention in Philadelphia, Pennsylvania. This raffle is open to anyone age 18 or older, and the holder of the lucky raffle ticket need not be present to win. Each ticket sold is a donation, helping keep our Diabetes Action Network moving forward.
NFB SCHOLARSHIP PROGRAM
Photo: portrait. Caption: Peggy Elliott
The National Federation of the Blind will award $125,000 in scholarships this year. Individual scholarship amounts range from $3,000 to $10,000, and the competition is open to any legally-blind individual who will be a full-time, post-secondary student in Fall 2001.
All 30 scholarships are merit-based, and most are unrestricted. Entries will be judged on the criteria of academic excellence, financial need, and service to the community. The committee making the award decisions will be composed of blind citizens with distinguished academic and community backgrounds from across the country.
The scholarship winners will be presented their awards in July, at the 2001 convention of the National Federation of the Blind, in Philadelphia, Pennsylvania. The NFB will also pay all expenses of scholarship winners to attend the convention.
The National Federation of the Blind is an organization dedicated to creating opportunity for all blind persons. With more than 50,000 members, it is the largest organization of blind citizens in existence, and it awards more scholarships to the blind than does any other group or organization. Recipients of Federation scholarships do not have to be members of the NFB.
Applications for the 2001 NFB Scholarship program must be received by March 31, 2001. Scholarship winners will be notified by June 1. We receive approximately 500 scholarship applications each year, so don't delay! Anyone interested may request as many application forms as needed from:
BOARD MEMBERS
The Diabetes Action Network of the National Federation of the Blind.
HERBAL CAUTION
Herbal medications and "botanicals" are as powerful as many prescription medications, cautions the American Optometric Association, and they can have serious side effects. Although these medications may be "natural," they are not harmless.
Herbs reported as (or suspected of) causing ocular problems include Black Cohash, Ginseng, Bilberry, Kava Kava, St. John's Wort, and a combination, marketed to "fight cellulite," containing Gingko Bilboa, Grapeseed Extract, Sweet Clover and Iodine.
Many herbals are harmless; some are probably beneficial. What is important is to remember they are medicines, and thus need to be reported to the doctor. Certain medicines interact with other medicines, and can have unpredictable side effects. It is vital your doctor know all the medicines you are taking -- including the ones you bought at the health food store.
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 in NLS format) on a conventional music-speed tape player will yield incomprehensible "chipmunk sounds."
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 290,315 VOICE readers could benefit from your story.
For information and article submission guidelines, contact: VOICE OF THE DIABETIC, 811 Cherry Street, Suite 309, Columbia, MO 65201; telephone: (573) 875-8911.
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, 811 Cherry Street, Suite 309, Columbia, MO 65201; telephone: (573) 875-8911, fax: (573) 875-8902. NOTE: Please provide a phone number so we can reach you.
END of VOICE OF THE DIABETIC, Volume 16, Number 1, Winter 2001 Edition