VOICE OF THE DIABETIC

The Diabetes Action Network of the National Federation of the Blind

A Support and Information Network

Volume 18, Number 3, Summer Edition 2003

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

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

Find us on the World Wide Web at: (www.nfb.org). Our direct Web address is (www.NFB.org/voice.htm).

Copyright 2003 Diabetes Action Network, National Federation of the Blind. ISSN 1041-8490

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

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FREE! FREE!

Voice of the Diabetic is offered absolutely free to any interested person upon request. Readers may receive the publication in standard print, on 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.

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ADVERTISERS

Effective advertising doesn't scream at its audience. It persuades. It sells. The key to cost-effective advertising is making your voice heard where an audience is already listening. Voice of the Diabetic, circulation 322,231, offers such an outlet. Make your voice heard. For Voice of the Diabetic advertising information contact:

Eileen Rivera Ley
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804 Hatherleigh Rd
Baltimore, MD 21212
Phone: (410) 296-7760
Fax: (410) 296-7645

or find us on the Web at:
http://www.nfb.org/voice.htm

For SUBSCRIPTION information, see the end of this document.

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INSIDE THIS ISSUE

LIVING MY DREAM
by Nora House-Petz .....

IT WAS UP TO ME
by Bill Eberly .....

KEEP YOUR FEET HEALTHY
by Kenneth B. Rehm, D.P.M. .....

DIABETES AND KIDNEY DISEASE IN CATS
by Betty Wedman-St. Louis .....

AN IMPORTANT CAUTION .....

THINK VERTICALLY
by Carole McDaniel .....

LETTERS TO THE EDITOR .....

THINKING ABOUT EATING
by Peter J. Nebergall, Ph.D. .....

NEW DIABETES AND BLINDNESS STATISTICS .....

NEW RESEARCH UNDERWAY .....

LAPTOP COMPUTERS AND ELECTRONIC NOTETAKERS FOR THE BLIND: A COMPARISON
by Curtis Chong .....

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

DIABETES EDUCATION FOR ALL WHO NEED IT: INCLUDING EVERYONE WHO HAS DIABETES AND ANY OTHER DISABILITY
by Ann S. Williams, M.S.N. R.N. C.D.E. .....

TALKING MEDICINE IDENTIFIERS .....

QUESTIONS AND ANSWERS .....

NEW NEUROPATHY TREATMENT .....

BOOK REVIEWS
by Marilyn Helton .....

THE SALAD DAYS OF SUMMER
by Robyn Webb, M.S. L.N. .....

RECIPE CORNER .....

CHANGING MY DIET .....

TOWARD CURING BLINDNESS .....

TALKING BLOOD GLUCOSE MONITORING SYSTEMS
by Ed Bryant .....

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

FOOD FOR THOUGHT .....

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LIVING MY DREAM

by Nora House-Petz

Includes photo of Nora House-Petz, wearing her insulin pump.

I'm a body-builder, but I'm legally blind, I'm diabetic, and I use an insulin pump.

I'm from Akron, OH, have two parents, and two older sisters, Lisa and Marsha, and a little brother, Tim.

I've had diabetes for 28 years. I was diagnosed in 1975, when I was nine-years-old. When I was diagnosed, I remember my parents both crying, because back then, they were told that I might manage to live 20 years. So when I turned 20, I was thinking, "boy, getting close to 20 years, I'm supposed to be dying soon."

When I was diagnosed, my mom sat my brother and sisters down and they all had to learn how to give me a shot, test my urine, and understand that when I started getting cranky if I was playing with them, it was time to feed me. And my parents, the way they raised us, is they made me feel special, but we all ate as if we had diabetes, we all ate healthy, we all had snacks. My mother was a nurse, and she was very protective.

My family was very involved. They all participated, they all gave me the shots - my sister Marsha was always very afraid of the insulin needle; but, my sister Lisa and brother Tim, my mom taught them all how to give me my shot. They didn't do it daily, but if I asked them, "could you give me my shot?" they did it. I always tried to do my own shots, but they knew how, too.

My mom always stressed exercise with me, walking, and I was always a walker and a bicycle rider. When I would ride my bicycle, after glucose monitors became available, I would stop half way through, test my blood, and then I would know if I needed to eat a snack.

And then I volunteered for a huge, important diabetes study, the Diabetes Control and Complications Trial (DCCT). I was accepted, and chosen for the "standard" group (rather than the multiple-injection "tight control" group), so all I had to do was keep the diabetes treatment standard, like we did when we were growing up, except I took three shots instead of just two. I got in when I was 18-years-old. In the standard group, you tested your blood sugar three times a day, took two to three insulin injections, and kept your blood sugars anywhere from 200 and under. It wasn't like the tight control group where they kept it at 120-130 and below.

During the DCCT, my diabetes stayed stable, but then I went to the eye doctor, in 1996, for my annual eye exam, and found I had diabetic retinopathy. It was pretty bad, and I am now blind from diabetic retinopathy - one eye is blind and I'm visually impaired in the other. I have had a vitrectomy.

In 1998, I had foot surgery - and it didn't go as well as I would have liked it, so I had to stop my exercise of walking and riding a bicycle. The foot surgery was due to a plantar wart, and when the podiatrist did the surgery to remove it, me being diabetic so many years, somehow it never healed, it took months and months. You live and learn, you know you never let anyone unfamiliar with the diabetic foot touch your feet. That was my first and only mistake - but now I couldn't do the same exercises, the same activities I'd been doing.

I still needed to exercise, so I decided to go into heavy weight training, because in that, I didn't have to use my feet a lot. I don't have trouble walking now, but my left big toe is numb, there's no feeling in it. But I've learned to adapt. I walk with a slight limp, my balance is off a little, but I'm a fighter, I'm gonna beat that, too.

After that foot surgery, and my vision going bad, my husband went out and bought us a tandem bike, a bicycle built for two, and he would stick me on the back of it and we would just ride and ride. My husband, Ralph Petz, and I would cover 20 to 30 miles on the tandem bike and we still do that a lot.

When Ralph and I ride the tandem, he'll say, after about mile ten, "test your blood sugar," and I'll test, and we can still keep riding and I can just do what I need to do. I use the One-Touch monitor.

I realized lifting weights could stabilize your blood sugars the same way as "aerobic exercise," maybe easier, because you don't have to spike the lows. I saw lifting weights was a good form of exercise, and then I started seeing great changes in my body. All my life I always wanted to be a body builder - it was my dream - but I was always told: "You'll never be able to do that because you can't repair your muscles in time," or "not if you have juvenile diabetes," or "because of your blood sugars." I heard every excuse out of every doctor, so about two years ago I decided I was going to try it anyway. So I would walk around saying, "I'm going to be the first blind diabetic body builder." And here I am, getting ready for a competition, it's a dream come true.

Last July, I was trying to start my diet, and I would just bottom out, because I was taking injections and the insulin was already in me. Something had to change.

So my endocrinologist said: "The only way you can really achieve this dream, Nora, is if you get on the insulin pump." So I did it, I got myself a Minimed Paradigm insulin pump. And I make the statement: I can't believe you can have diabetes and feel so healthy. The insulin pump has just changed my whole life. I'm so "normal," it gives me so much flexibility.

I'm really fortunate in that I'm energized but it helps that I've got a lot of people around me I enjoy. I make people understand when I meet them, the first thing out of my mouth (and even growing up in school, I used to stand in front of my classroom and say it) is: "I have diabetes, these are my symptoms and I'm not ashamed I have diabetes." I tell people, "Hey, you can have it, and it's not a curse, it's a positive thing; I'm healthier than the average person because I eat right, I exercise, I sleep right, I do all the things most people ought to do."

The first body-building competition I'll compete in is at West Penn State. It's sponsored by Rick Balbo and it's a national body-building competition (he's the local sponsor of body-building competitions at West Penn State). The second one is NPC Midwest Novice Fitness and Figure Competition, at Indianapolis, and that's sponsored by Michael and Jill Deak. And when I called to sign up for that one, the lady who took my call said she started crying, got chills in her - because four months ago, her 16-month- old baby was diagnosed with juvenile diabetes. She was so happy to hear my encouragement, my "You know, you can do all this."

When she hung up she said, "You were my angel today." That was encouraging.

For body-building, you have to lift the weights to build your muscles up, and that, along with the diet, is how you get that "look": That lean look, those muscles. You are on a very strict diet 16 weeks before your competition. Body builders are trim, fit, and lean.

Weight training is a very good way to stabilize your blood sugars, because as you build your muscle, of course, you lose body fat and it ups your metabolism, so you're always burning energy. I really promote exercise with diabetes, they go hand in hand. and I recommend putting that number one in your life - You'll be healthier.

I'm 5' tall. The key thing is to be very lean for your competition, that's why it's so hard for a diabetic -- you've got to be healthy but really lean.

Body training - I go to the gym five days a week, and spend two hours there. I weigh 110 pounds, I'm short and petite, Mighty Mouse, I think I'm tougher than I look! I just try to be spunky, and with working with dialysis (I've been a dialysis technician for six years), my patients say: "how do you do this?"

My father goes to the gym with me a few times a weeks to check on me. I have a very supportive family, and I think if you have supportive people around you it makes it a lot easier to cope with the disease.

My trainer, Scott Buxton, I met when I was 20-years-old, so he grew up with me. Then he got into body building, so he knows a lot about diabetes and when I'm getting low. With this diet, it's very hard to diet for the competition, so he starts me out carefully. A lot of body builders take the carbohydrates out of their diet - but what we've done is keep the carbohydrates in, but they're "clean" carbs; and so at the same time I'm losing my body fat, I'm not starving or getting low. He's very careful, in the training we have, that if I train my arms one day, the next day I'll do my legs, and then we rest. We have rest days after hard days, so my muscles can repair themselves in order to train again. Being a diabetic, it takes extra days when we're training so hard, and he's very good at that.

But what's a "clean carb?" Clean carbs are: dried oats, baked potato, rice, etc. No sugar is allowed, but I can have three strawberries a day. In general I have a very good, healthy diet. I understand when you're going on a body-building diet, it's carbs, vegetables, and protein, and I understand that because I grew up that way. So I don't have to give up ice cream and everything else "normal" people eat, because I never ate it anyway. Well, we would get to sneak ONE OREO, or as mother would call it, a diabetic slice of cake. And you didn't get your bread or fruit for dinner if you had a cookie or cake. I remember growing up and counting, and my mom weighing my food, and taking this away or that away if I wanted this or that. But it worked!

You get what you give out of life. If you have a dream, just make your diabetes number one and you can achieve any dream. I put my diabetes first, I give 110%. You can achieve any goal you really set for yourself. If you keep your diabetes in control, you can do anything, by checking your blood and doing what you have to do. Just look where I am, living my dream.

Nora House-Petz
[email protected]

Anyone who wants to e-mail Nora about exercising or body building, that's all right.

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IT WAS UP TO ME

by Bill Eberly

Includes photo of Bill Eberly.

I was born on September 25, 1921, in Toledo, Ohio. In 1928, I developed all the symptoms of diabetes. Excessive thirst and wetting the bed were the most obvious. I spoiled more mattresses for my mother and dad than you can shake a stick at. Finally they took me to the doctor; my uncle, Dr. Karl Eberly, who was a physician in Fort Wayne, Indiana. He quickly determined I was a type 1, insulin-dependent diabetic.

After a week or two of closely regulating my insulin and diet, Uncle Karl walked me through the diabetes ward at a local hospital. Remember, this was 1928. He said, "Billy, if you take your insulin, exercise, and eat the proper diet, you can avoid this; you can have a productive life," as he took me down a ward of diabetic patients who were blind, had gangrene, and had feet and legs amputated. It made a lasting impression on this seven-year-old.

I had always wanted to be a professional baseball player, and I got lots and lots of exercise playing baseball and softball. During my growing-up period, I had a newspaper route, cut lawns, and did other things to raise a little money.

I was taking one or two shots of insulin each day, contingent upon how I felt and what exercise I got. Of course blood glucose testing, the only real way to tell where your sugars are, would be decades in the future.

In any event, I went to high school, then graduated from the University of Toledo, in 1943. Ineligible to serve in the armed forces because I was diabetic, I went straight into Major League baseball -- not as a player but an administrator. In early 1944, I had an interview with President of the Brooklyn Dodgers, Branch Rickey. He's in the Baseball Hall of Fame; he's a famous baseball executive (and by the way, his son, Branch, Jr., has diabetes, as I discovered during my final interview). I asked him for a job -- and I got it.

I started work with the Dodgers, and was associated in various business activities, from February, 1944 through August, 1953. I was a scout, a minor-league business manager, and troubleshooter for the franchise. I worked with their "farm teams, "and in 1950, became "concession and promotion manager" for all 24 Dodger farm teams.

Jackie Robinson was the most famous baseball player I met. He was with the Dodgers. He's in the Hall of Fame. He was the first black player, he broke the color-line the first time. Branch Rickey, the man who hired me, signed him.

In 1953, I left the Dodgers, and joined the Milwaukee Braves. They were a big-league ball club in the National League. They'd just been moved from Boston to Milwaukee. I was the business manager. I stayed with them until 1965, when they moved to Atlanta. Yes, I have two World Series rings, one from the Dodgers, one from the Milwaukee Braves -- 1947 from the Dodgers, and 1957 from the Milwaukee Braves.

One little incident during my time with the Dodgers: I was arrested in a Buffalo, New York Railroad Station, in about 1949 or so, for taking my insulin shot in the men's room. I finally proved that I was diabetic, and that the syringe contained insulin rather than cocaine.

Since 1966, I have been a financial consultant with various firms on the New York Stock Exchange, and I am currently associated with Smith Barney.

As an avocation, I give a baseball talk: "The Evolution of the Big League Baseball Business," to civic and business groups. This keeps me in touch with our national pastime. And, I'm a frequent speaker at diabetic educational and fund-raising functions.

I now take four shots of insulin a day. Three of them are Humalog, one before each meal. I take a shot of Lantus, before I go to bed. I would guess my total number of insulin injections has been somewhere above 70,000.

Even today, I have a lot of hypoglycemia, so I test my blood sugar eight times a day. Back in the old days, testing your blood was a major problem. You had to go to the doctor and they would draw out blood, and send it to the lab. It could take days to get a result. (Editor's Note: That's why, for decades, urine testing was the rule; it was less accurate, but more or less immediate -- there were no home blood glucose monitors 'til the late 1960s.) I used "test tapes" to check my urine for sugar.

The old "reusable" insulin syringes were like ice picks. You had to sterilize and check them, which was not very pleasant. Diabetes self-care is far better today, with the new devices, testing equipment, and so forth.

I'm grateful to Drs. Best and Banting, who developed insulin, to the diabetes associations, to the dedicated research teams that develop new procedures and products to make diabetes care more productive and less painful. Here I am, 81-plus-years-old, having taken over 70,000 insulin shots, I test my blood glucose six to eight times a day, and I am still working full time.

I'm one lucky guy. I know I've "beaten the odds," to stay healthy so long, 75 years as a brittle type 1 diabetic, but, though part of it is luck, much of it goes back to the support I've had all these years -- loving care from parents, empathy with brothers and sisters, wives, and children. All have helped me learn how to do things right, and helped me keep on doing them. And, Uncle Karl's remarks helped me tremendously, as he meant to do, by getting my attention, and making clear it was up to me to take my insulin, eat right, and exercise. And I never forgot the lesson.

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KEEP YOUR FEET HEALTHY

by Kenneth B. Rehm, DPM

Includes photo of Dr. Rehm.

Dr. Rehm, head of The Diabetic Foot and Wound Treatment Center, in San Marcos, California, gave the following as the keynote address at the 2002 annual conference of the Diabetes Action Network of the National Federation of the Blind. The conference took place on July 6, 2002, at the annual convention of the National Federation of the Blind, in Louisville, Kentucky.

I am a podiatrist. I specialize in the treatment of diabetic foot problems. How many people here are diabetic?

Why do we talk about the diabetic foot? What is so special about the foot? What happens specifically because people have diabetes? Four things happen in the foot because of diabetes. One is nerve problems. We call that neuropathy. Neuropathy happens because of circulation problems around the nerve, and also because the covering of the nerve is a fatty, sugary substance that can be damaged by diabetes. When your blood sugar goes up and down, the covering of the nerve can be altered, interfering with that nerve.

There are actually three types of nerve problems we want to pay attention to. There are nerve problems that alter our sense of feeling and we call this sensory neuropathy. There are nerve problems that cause our nerves to our muscles to misfire, and this causes muscle weakening: motor neuropathy. The third type of nerve problems we have to pay attention to are in the autonomic nerves. These are the automatic nerves that go to the kidneys, heart, other organs that function automatically. Basically if these three areas of nerves have problems, we can experience muscle and joint problems. We can lose the ability to tell whether or not we are walking correctly.

We also get circulation problems. Diabetic people get a kind of hardening of the arteries behind the knee and below the knee. Some researchers call it "small vessel disease."

The next thing that happens is frequent infections. If your blood sugars are up then we have what is called immunopathy, a cluster of problems relating to diabetes' effect on the immune system. We can get athlete's foot, and other nuisance infections, more frequently than people who do not have diabetes.

There are many different ways these problems can manifest in a given individual.

People can experience: Numbness and puffy feeling, numbness and lack of feeling, feeling like a foreign object is present, feeling like feet are on fire, sharp pain in toes, "leathery" feeling, pain in feet coming up calves, hard-to-heal blisters, loss of bone mass, loss of hair on legs, loss of flexibility (can be the feeling of flexibility and it could be real loss of flexibility), feeling of weakness, lack of strength, altered mechanics of the foot, bones collapse, dry feet, chronic fungus in the toe nails, and cramping of the calves. That's a lot of problems, from diabetic feet.

We are going to talk about prevention because prevention is an important part of every step of the game. Prevention requires certain steps. The way we walk and the way we move are very important. This is one of my points in the "Keep Your Feet Healthy Programs."

Just as an aside, I have a product called Toesease. I developed this stuff because of folks like the lady who can't take any of the fungus medication that the drug stores offer her because of her medical situation. I developed Toesease to clean off the fungus and bacteria, and to soften the skin and nails. Then you use the cream to condition the skin, to make it more elastic, so the skin moves when you walk instead of staying stiff and developing calluses. This is a very important point; I see the need for it all the time.

Swelling is because of possible circulation problems. High blood sugar can be one cause of swelling. Neuropathy is not a big cause of swelling, but diabetic nephropathy, kidney disease, can be, so you need to remain vigilant.

So, a lot can happen to the foot in diabetes. We have the nerve problems, the neuropathy, the sensory neuropathy; people feeling like their feet are numb or asleep. They also can have hyperesthesia, which means that the foot can feel asleep and at the same time when you touch it, it is overly sensitive, and that is called paradoxic neuropathy. Some people lie in bed and the bed sheets hurt their feet -- and at the same time their feet are numb.

And there is dry skin. Neuropathy can affect the nerves that go to the sweat glands -- so we get dry feet. We also build up callus quicker. The bones can collapse because of the neuropathy in the bones -- they get a little more calcified, and we can't feel when we walk, so we walk off balance, creating pressure on joints and bones. If we could feel what was going on, if we didn't have neuropathy, we wouldn't be walking that way.

When someone has high blood sugar, some of that blood sugar can accumulate in the joints. The combination of the blood sugar and the joint material is called glycosylation. This can make our joints stiff.

When the nerves to the muscles are affected, motor neuropathy, there is loss of flexibility in their feet. What happens next is the muscles, affected by neuropathy, can get weakened, and can atrophy. The most common muscle affected can be found if you put your hand below your knee, on the right side, with your right hand on the outside. That is called the anterior tibia muscle -- and it is enervated by what we call by the anterior tibial nerve. Sometimes that nerve gets weak, and the result is, when we stand up and walk, we bring our foot up, and as we want to swing our foot to get down to the ground we have to slightly pick our foot up. That is the muscle that helps us pick our foot up. So people who get this type of neuropathy can't pick their foot up so quickly. They shuffle a little bit. They can stumble.

The body is a pulley system, and we have to have balance. For example, if we have back problems, we strengthen our stomach. If one part of the body is weakened, we have to strengthen the opposite set of muscles to help it. If, at the front of the body, muscles are weak, then the back of the leg muscles can become tight. Remember, I said we shuffle? The front of the body muscles get weak, the back of the body muscles get tight, and as we are taking a step, we want to bend our ankle over - but the body says, "oops, we can't do that," so it cheats. How do we cheat? We become more flat footed than we should. This helps break down our feet. We can't complete a normal walking cycle; we have to grab with our toes, that gives us crooked hammer toes.

If you take your fingers, curl them up, and push them up with your other hand, you'll see what I mean. Now what happens is the ball of your hand, otherwise the knuckles of your hand on the bottom the plantar surface, palm surface become down, don't they? It's like your foot becoming flattened. If the fingers go up, the palm goes down. Ok, here we are walking with our muscles being affected by diabetes--walking on the ball of our foot, because our toes cramped up. This way of walking pounds it, and that is why we get the calluses we mentioned. When the calluses are rubbed raw, and we don't feel it because of our neuropathy, we get blisters that we don't feel. If the blisters become infected, sometimes our high blood sugars lessen our power to heal that infection.

What happens in the diabetic foot? Again, nerve problems: sensory neuropathy, motor neuropathy and autonomic neuropathy. What are the results? We see numbness, burning, dry skin, muscle weakness, calluses and cold, burning feet. This is how it shows up clinically. This is what the people tell the doctor. What happens because of these symptoms? Orthopedic problems, walking wrong. We get the foot pushed aside, and we get hammer toes and bunions. Then we have walking problems because of the feet being crooked, and then we get hammer toes and then we get ulceration. We get other skin problems - because of rubbing, shearing, and calluses. You see how the neuropathy plays in? It is not clean cut; you can have one problem like calluses, but it can be due to several different causes. All these things happen in the foot: neuropathy, circulation problems, and muscle problems and all kinds of other stuff.

My goal is to have everybody understand what they are dealing with. When something is too confusing, or too complex to comprehend, then we don't want to deal with it. We say, "Oh well, it will go away." If we have a clear picture, however, then we are motivated to help ourselves. We are all a bunch of denial people.

Four words are important when we get a diabetic problem: treatment, management, rehabilitation and prevention. We have to go through these stages. You get a blister - we treat it. If you have neuropathy - we manage with it. We are going to talk about it.

Rehabilitation: so we have a broken bone, or a flattened arch. How do we rehabilitate from that? How do we build the muscles? Then prevention. Prevention, by the way, is the best possible treatment. Did you ever think about that? It is so much more a problem once we get a complication. I see people smoking, I see people doing this and that. And I ask myself (don't get me wrong I am not perfect), something about human nature. If we know what is good for us, why don't we do it? Why don't we act in prevention mode? Because we are human.

What is the most important element of prevention? Everyone here knows the rules to good health. It is nice to say we are "going to exercise," but don't we have to be motivated? That is the biggest stumbling block, motivation - wanting to care for yourself, enough to do it. Number one in importance is mental conditioning, before anything else. You have to want to take the appropriate steps.

The thing with mental conditioning in diabetes, or any chronic disease, I found out interviewing patients (I do a lot of writing and research and all that type of stuff), is the biggest problem with mental conditioning in any chronic disease like diabetes or vision problems or cancer or whatever it is, one day we are Bill Smith or whatever our name is. We like ourselves, well lets just say we are satisfied with ourselves. We have our routine down. We are doing our thing. I like myself. I want to protect myself. I am Bill Smith. Then someone gives you a label, there at a doctor's office. You have cancer, or whatever it is. And that drops you like a lead balloon. You don't want to be Bill Smith number two. You want to be Bill Smith number one. I will take care of Bill Smith number one. I don't want to take care of Bill Smith number two. I don't want to. I want to go back to being Bill Smith number one, but I am Bill Smith number two. Hey, the hell with him. It is like "I don't want to be this guy."

We know when you control diabetes, when you control your blood sugar, when you eat right, you can control a lot of the complications. We just have to like ourselves enough to care do it. The alternative is diabetic denial.

If the very first thing is prevention, its first component is mental conditioning. The second thing is physical conditioning. So, once I am feeling (mentally) good, when I am feeling good, I am going to exercise. I am going to swim. I am going to do whatever it takes to keep my blood flowing, and my whole body in shape. By the way, it feeds back to the emotions. Doesn't it feel good after you have exercised?

Exercise also feeds the body. So then we say, "Ok, what do we need to do next?" You don't have to run marathons, just be in the ballpark. Do something. Then do it a little more. It is just the act of doing something, getting into the habit of doing it, is more important then what you are doing. The fact that you are getting out there and making it part of your life is what matters.

#1. Mental conditioning
#2. Physical conditioning
#3. Know and practice a "keeping your feet healthy program"

What does this last part mean? It means you keep your feet clean, keep your feet warm, and keep your feet protected with the right shoes and socks. I see so many people going barefoot. I saw a patient of mine with very brittle diabetes, and he was mowing his lawn barefoot, I swear. Keep your feet safe. Keep your feet free from excess moisture. Keep your feet conditioned and free from excess dryness. You need that skin to be supple and move when you move it, so it doesn't stay stiff, and so it does not cause calluses.

Some people sweat an awful lot because of their neuropathy, instead of getting dry skin. Keep your feet free from excess dryness because that is the other end of the spectrum. Never put your socks and shoes on when you are still wet from a shower. Now, by the way, I hope none of you have any of these problems. If you control your diabetes, you should not have these problems, but that is the whole point, prevention is the best treatment.

So, going on with the "Keeping Your Feet Healthy Program." Keep your feet and toenails trimmed. There are a lot of ingrown toenails. The biggest problems, the biggest infections, can stem from those ingrown toenails. Keep your feet working, with exercise, because you are breaking those adhesions up I told you about, that happen when the high blood sugars mix with the joints. Wiggle your feet. Exercise your feet. Stretch your feet. Stretch your legs. The tightness in the calf we talked about, that is exactly just what it is. Stretch, move, and if you can't do it on the sidewalk, do it in a pool. Keep your feet balanced when walking.

See a professional for your foot care. Most professionals offer both shoes and custom inserts because the foot is moving within the shoe, and the shoe and the foot move together, so we have two different units moving. You need good shoes, but you also may need something inside the shoe to help balance your feet, so they don't rub.

There are three types of dangerous rubbing that can occur. First is shearing. If you put your hand on top of your other hand and rub it real fast, that is friction, but if you let it stick a little bit, so the skin on the outside stays still while the bones move, that is shearing. The third type of rubbing is pounding. Pounding is direct pressure. We have to protect ourselves from each one of these three types of pressure. These pressures can cause the blisters, which cause the infections, which cause the ulcerations, which cause other bad things. My job is to prevent these things.

Virtually all amputation is 100% preventable. That is the good news. Which brings that and me to the next point in the Keep Your Feet Healthy Program: keeping your feet in check. I have had other patients whose heels touch the sheets and they get deep bad ulcers on their heels. What does the nurse do? They put a foam block under their heels. This protects the heel against pounding, but it does not protect against the other two types of pressure.

In the hospitals the patient must stay aware, as they may not have all the answers. The point in the Keep Your Feet Healthy Program is to keep your feet in check. Everyday either you, or have someone else, inspect your feet. What should you look for? Hot spots, blisters, sore and painful areas, cuts, cracks, dryness, red, hot, swollen; all the things we have talked about. Keep your feet in check.

Should you have your doctor check your feet? Every time you go. This is an interesting point. I am 56-years-old, and I go to the doctor for a physical every two or three years if there is nothing wrong. My doctor has never, ever inspected my feet. What, the feet aren't part of the body? He checks my throat, he checks my eyes, but not the feet. The feet must not be part of the body. I am here to tell you that the feet are part of the body. So when you go to your doctor ask them to check your feet. Raise your hand to let me know if your doctor does not check your feet. I am telling you that 50 to 60% of you have your hands up -- your doctors are not checking your feet.

We as consumers must be assertive with our healthcare. You cannot depend on anyone any more. I know, in California, our healthcare system with all the HMOs and PPOs and they don't pay for this and they don't pay for that, and they are putting so much pressure on the doctors to see so many patients, money issues, and this is covered and that is not, we have to be proactive. We have to tell the doctor, "Will you look at my feet? I need an arch support, will you refer me?" You have to take the lead. You are responsible for knowing your own healthcare. Please be proactive, work on prevention - the steps that I have designed of mental conditioning, and physical conditioning can really keep your feet healthy.

Massaging your feet is an absolutely great idea. You combine the action of conditioning with the cream, taking care of the dryness as well. Massaging helps the circulation, and with diabetics who have swelling, it can reduce that swelling. There are creams made especially for the diabetic foot. You should look for them when you go to buy diabetes products. Make sure it is for the diabetic foot.

Again, with the Keep Your Feet Healthy Program, keep your feet clean, dry, wear proper shoes, keep your feet safe, keep your feet free from excess dryness or wetness, keep your toenails trimmed, keep your calluses trimmed, exercise, keep your feet balanced when walking, and keep your feet in check, with a professional, and by yourself. This is the basis to keeping your feet healthy.

After his address, Dr. Rehm took questions from the audience:

There was a question about special pillows for sore, painful diabetic feet, pillows small enough to be packed in a suitcase and carried by a traveler. I know of one: The Heelivator, It wraps around the foot and keeps it protected. It's a great item. Contact me, Dr. Kenneth Rehm, at The Diabetic Foot and Wound Treatment Center; telephone: (760) 744 6226, in San Marcos, California, 92069.

For those of you who cannot take some of the antifungus medications, and need to treat your feet topically (I did mention my product, Toesease) I've heard of using Vick's Vapo-Rub on your feet. I saw a press release about it - but I have no personal experience either way.

Everybody buys shoes; short of going to the podiatrist, how do you know which kinds of shoes are best for your diabetic feet? You want good cushioning, to protect against the pounding. You want a good heel counter, for support. You want a wide toe-box, with lots of room for your toes. A little arch support is great too. It has to have a good shank, which is the upper part, to support the top of your foot - but not too tight. They can have laces (lace shoes stay on better than loafers), but they could also be velcro. And, avoid shoes with uppers made of man-made materials - they don't breathe as well as leather, and can cause problems.

Includes graphic: picture of a shoe with lines to the following explanations:

1. Cushioned heel counter top. Heel counter reinforced to prevent bending of shoe - more supportive of foot and ankle.
2. Added depth to accommodate orthotics.
3. Flared heel puts wider distribution of pressure on the heel and foot. Formula: force/area = pressure.
4. Metatarsal rocker bottom - less pressure on metatarsal heads.
5. High and wide toe box allows room for toes without squeezing.
6. High vamp - with easy velcro straps. Accommodates swelling in feet and arch support height.

And of course the shoe should be leather, and seamless - as seams can irritate skin. Shoe should allow removable orthotic inserts.

Your socks should be of natural material. Nylons and artificial materials do not let the foot breathe. And many fabric dyes can harm the foot. A white sock is best. Choose a sock without seams.

You want to dry your feet, after washing them, but I've heard of people using hair dryers to do this - and this is not a good idea. Hair dryers are very hot, and I've met people who literally burned their feet, by trying to dry them with a hair dryer. If you have neuropathy, and some numbness, you may not even know you did it. I cannot recommend hair dryers. Bathing your feet in overly hot water is dangerous, for the same reason. Some of us can't tell anymore, that the water is too hot, so we leave our feet in - and can be seriously burned.

It is important to make sure your feet are dried, but you need to minimize friction, while using a towel. Better to pat your feet dry. Then wait, perhaps half an hour, before putting your shoes on.

One thing about numbness: When a non-diabetic foot feels numb, we feel that it is numb. The pathway from foot to brain is working, telling us the foot is numb. In a diabetic with neuropathy it is possible that the pathway is also numb, damaged by diabetic neuropathy, so we don't know, we don't perceive, the foot is numb - and then we don't take action.

What if you have edema on your feet? What do you do? Though there are some conditions for which an Ace Bandage is appropriate, this is not one. Instead, in such a case I'd like you to get a doctor's prescription for support hose, rated at about 10 to 15 mm of Mercury. At this rating, you're not squeezing off any circulation. More than 25mm of Mercury, the traditional "rating" for support hose, means that you may clamp off the circulation. You don't want to do that.

Where do you find support hose? Every state's different. Some wheelchair companies, or medical supply companies, will have support hose; other states, you'll find it at the pharmacy. You, the patient with dry skin on your feet, never debride it, or cut it yourself. When you go to the doctor, and it's scaley, if he wants to use cream to help debride it, or to snip off loose, dead skin, OK. Don't you do it. But, conditioning that skin, keeping it moist, on a daily basis, will auto-debride the area. Keep it moist and soft.

If you're going to use a "pumice stone" to remove dead skin, even if you're sighted, you can't really see the area, and it would be better to have someone else do it. They can keep a closer watch than you can. Some doctors use a "Dremel Tool" with a soft sanding stone, to do the same thing.

If you have swelling in your feet, any time you have the chance to massage it, it's the best.

Don't put lotion or cream between your toes. You can use oils, but not creams - creams are lotions which dry.

Sometimes, some of us will have dry, cracking skin on our feet and lower legs, and it can get extremely painful - to the point of restricting mobility. This is linked to the circulation problems we experience as diabetics. I would suggest talking to your doctor about support hose. And, every time you can, you keep your feet elevated. Put them up in a chair.

Portable whirlpools may not be a good idea for diabetic feet. Your feet are hanging down (and they should be elevated), we can't tell the temperature, sometimes, and we can't tell how clean the whirlpool is. If we can monitor the temperature (ask someone else!), we can be sure the whirlpool is absolutely clean, and we limit the time, to 10 minutes, no more than 15 minutes, I don't see anything wrong with it then. Otherwise, its not a good idea. Keep close watch; less might be enough for you as an individual. And always check with your doctor.

If you are diabetic, you need a diabetic foot doctor, who you'll need to see regularly.

Thank you, and I really hope I've been able to help.

NOTE: Dr. Rehm's speech, titled: "Diabetes, Neuropathy, and the Feet," is available on normal-speed audiocassette, for $2 per copy, from: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314, Web site: www.nfb.org

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DIABETES AND KIDNEY DISEASE IN CATS

by Betty Wedman-St. Louis

Includes photo of Chrissy the cat.

Diabetes doesn't just strike humans. It is a metabolic disorder that can affect pet members of your family, and it can be just as life-threatening to them. Two years ago, I began noticing the classic symptoms of diabetes in my cat, Chrissy, but I didn't react to them, because who ever heard of diabetes in cats! The empty water bowl just meant that she was more thirsty, or maybe I had forgotten to fill it before leaving for work. The extra use of the litter box was shrugged off because "all that water had to come out." Lethargy was just a sign of her aging, or boredom.

All during this time Chrissy, a beautiful long haired, silver and white Persian, would leave me "messages" on the bed where I slept. The urine pools that soaked through the bedspread, blankets, and sheets got pretty annoying, and I would punish her for them. The vet assured me this was probably "a behavior problem."

Then one day I asked myself why would a beautiful, well groomed, smart cat, with no competition for love and attention, have such a behavior problem? The next time there was an accident on the bed, we headed straight for the vet's office.

Chrissy's blood glucose was 471. Her cholesterol was 238 (normal = 70 to 180), triglycerides 122 (normal = 18 to 115), and protein 1+ on urinalysis. Those results looked like those of many newly diagnosed type 2 diabetes cases I see in my work as a diabetes educator. Oral medication was not an option, the vet said, so we began a regime of intermediate-acting insulin twice a day. It took a lot of brushing and reassurance to establish a routine of insulin administration, without lots of hissing and growling.

Within four months, a random blood glucose test was 201, and Chrissy's hyperlipidemia was history. But within three weeks, we were in the vet emergency room with anorexia, lethargy, and abnormal liver function. X-rays and a CAT scan indicated an enlarged fatty liver, possibly caused from neoplasm/tumor cell growth. Weekly antibiotic therapy was initiated when I would not agree to "put her out of her misery." Through a combination of traditional and alternative medicine, Chrissy made a remarkable recovery-dropping her liver ALT from 2839 on August 27, to 158 by September 21!

Regular monthly visits to the vet continued, despite Chrissy's protesting-just like many humans. Every time she saw the carrier container come out, she'd hide in the bath tub. But, the vet failed to advise me of a doubling of her creatinine, and marked elevation of her amylase on November 6. We were too impressed with her liver enzyme improvement, and the management of her blood glucose. Consequently, by December 24, Chrissy was a very sick cat. By January 3, with a creatinine of 11.6, BUN 207, and blood glucose of 481, I was again told to consider euthanasia.

Knowing Chrissy was a fighter and wanted to live, we began a seven day regime of antibiotics, and lots of love. Her creatinine dropped to 4.6 within eight weeks, and she started regaining her weight. By May, Chrissy's creatinine was stable at 3.1 to 3.9, and her blood glucose at 180-205.

Knowledge about cat nutrition has helped us maintain Chrissy's well-being. Like many humans, she takes vitamin supplements fortified with the antioxidant alpha-lipoic acid. Since cats do not convert beta carotene to Vitamin A (like many humans who have hypothyroidism), her supplement drops contain all the fat soluble alphabet (Vitamins A, D, E, K) needed for immune health. Also, cats, unlike humans, do not convert ultraviolet rays into Vitamin D when they are in the sun, so a supplement with a significant amount of Vitamin D was selected. Taurine is also a critical amino acid for feline well-being, so a capsule is added to Chrissy's wet food daily.

Today, Chrissy still takes her insulin injections twice a day, but at a much reduced dose, since her hypoglycemic episode in June. Like many type 2 diabetes patients, too much insulin caused excessive hunger, and weight gain. Once I cut back on her insulin, a normal weight was achieved with no further evidence of hyperlipidemia.

What is the lesson? Education is the answer. Once we learned what was really going on, and paid attention to all the test results, we were able to save my cat, and restore her to good health.

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

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

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AN IMPORTANT CAUTION

Herbal, homeopathic and other "alternative" forms of health care are growing in popularity. Frustrated with the slow pace and incomprehensible jargon of mainstream scientific/medical research, many folks turn to the folk medicines of India or China, or to the hippie traditions of the New Age Movement.

Some of the "herbals" used by these faith-based traditions may well prove efficacious - eventually, but until they are thoroughly and honestly tested, major caution is advised. Recently, there have been several cases in which the contents did not match the label. In one case, violations were so severe that the Government of Australia shut down the manufacturer (Source: BBC online).

The second case, reported by Reuters (Feb, 21), concerns several concoctions marketed as "Chinese Herbal Diabetes Treatments." It seems one diabetic patient experienced severe hypoglycemia after using one such product, and handed samples over to the authorities, who analyzed the contents. The "herbal medication" in fact contained the sulfonylurea Glyburide and the weight-loss drug Phenformin, both prescription medications, and both un-named on the label. As it is a crime to dispense prescription medications while calling them something else, and another to dispense them without prescription, the authorities tested further, and found five different "diabetes medications" with dishonest labels and illegal contents.

Please recognize the importers of "alternative" medications may not operate under the same laws, scrutiny, or sense of responsibility as the mainstream prescription drugmakers. It is now a matter of legal record that some of these firms have lied about the contents. It's your body; be certain what you're putting in it.

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THINK VERTICALLY

by Carole McDaniel

Includes photo of Carole McDaniel.

I was born in Rowan County, Kentucky, right outside of Morehead, in the foothills of the Appalachian mountains. I was 14 years old when I was diagnosed with type 1 diabetes. Of course I had all the usual symptoms -- but I didn't know what they meant, and I got sick, very sick, and my stomach was hurting. I ended up in the hospital, which was about 65 miles from Morehead, on Thanksgiving day. They put me in the pediatric ward.

At first, the doctors thought I had appendicitis. It took a few days for them to check my blood sugar, and then, of course, they found it: I had diabetes.

I know some doctors, especially back then, could be pretty negative, but mine did it right. He said that although most diabetics (at that time) did not live long lives, if I took care of myself, I would have a better chance of survival. What he was saying was positive; take care of yourself and follow your diet. He told me it was up to me.

So, from that very day, I did what I was supposed to do. I watched the diet, and I took the insulin. And it was very difficult at first. One doctor I had said: "Now, Carole, you will have to give your own insulin shots before you can leave the hospital." They gave me an orange to practice on.

It was really scary when it came time to give myself shots. The first one was in my leg, my right leg. I remember that quite well. I was taking Regular insulin, three shots a day. I did that for approximately four years.

At the age of 18, the doctor had me enter the hospital (Morehead now had a hospital) to switch my insulin. He replaced my three shots of Regular per day with one shot of Lente. My doctor was wonderful and supportive. He understood how important it was for me to continue, as close as possible, an everyday "normal" routine. He also knew how important exercise was to me. When I was in the hospital, I asked him if I could go outside, to the parking lot, and play badminton for exercise. He agreed. I asked my mother to come with me. It was right at shift change, and I told the nurse on duty, but she forgot to let the others know, so they put out an alert, when they found me gone. They were wondering, "Where did she go?" And I came dragging in with my mother, badminton rackets in hand. They were just a bit upset, but I told them my doctor had given me permission.

The doctor just switched me back to a multiple-injection schedule, about a year ago. I take four shots a day now. Sometimes it takes five injections, if my sugar does go up high. Then I'll take Humalog to cover the higher sugar level. I'll take Humalog insulin before each of my three meals, and then at bedtime it's the Lantus.

My doctors have learned that, after having diabetes 46+ years, I'm very aware. I attend a diabetes support group, and I read a lot about the latest research. In fact, I am the liaison for the support group, and I work closely with my diabetes educator. The doctors tell me: "You know what you're doing. Do what you need to do." And I do it.

This is a funny story. When I was a junior at school, a new girl moved into town and we became friends. She didn't know I was diabetic - I thought she knew, but she didn't. She would hear me say to one of my friends, "Well, I've got to take my shot," or sometimes I would say, "Well, I've got to go shoot myself." I noticed she was suddenly not as friendly to me as she had been, because she had been a real good friend. I think she heard that I was taking shots, and she thought I was "shooting up" or something. I thought, "I've never taken a drug in my life!" Anyway, we have laughed about that many, many times.

Now, because of my diabetes, I have autonomic neuropathy and diabetic gastroparesis. One of the problems that I'm having is, although I eat what I'm supposed to, and I take my insulin like I'm supposed to, I really don't have all that much control anymore, because of the unpredictable way my food empties into my stomach. Sometimes it will metabolize faster, and sometimes a lot slower. Sometimes when I eat, my blood sugar jumps really high, and sometimes it goes really low, and then I can experience hypoglycemia.

Some of my friends, when they're around me, can tell when I'm too low. They'll say, "Carole, you're getting loony toons. You need to eat." I've been very blessed. I've had good people around me. I have really close friends, and the support of my mother and father. There's something else I think diabetics should do. Let all of your friends, associates, and everyone around you know what to do if you have low blood sugar symptoms. That's something I think is very important. I educated everyone I was around. And they were so sweet (no pun intended). Every one of them kept something around for me, in case I spaced out: peanut butter, orange juice, a candy bar. But now the diabetes educators say you really shouldn't eat peanut butter, or a candy bar, to treat hypoglycemia, because of the way they are metabolized. Too much fat; too slow. "Use orange juice instead," they say. So I don't do the peanut butter anymore. But I love peanut butter!

I've been an educator all my life. I taught high school, grades 9-12. And I worked basically with special needs children and teenagers. They had physical, mental and emotional challenges for the most part. But I also taught regular Business classes. I majored in Business and Special Education.

I'm "retired" now, but all that means is I'm doing a lot of volunteer work instead. I haven't quit working. I'm still very physically active as well. I think that's very important; it helps you control your diabetes. As an educator, I have traveled the state of Kentucky, conducting trainings on dropout prevention, developing self-esteem and humor.

My interest in Special Education has led me into working with victims of child abuse and spouse abuse. I've done a lot of work in this area, and I'm still at it. I speak at civic clubs, schools, and churches, regarding safety for children.

I do a lot of fun things too. I enjoy dancing and I taught dance classes. I love to do crafts and I like to do woodworking. I have a workshop. I even design many of my own clothes, hats, and jewelry.

I believe whatever comes your way, just face it. Accentuate the positive, and have a really good attitude about things. I would suggest you watch your diet and medications; get your exercise and rest. And, work with your diabetes support team: doctors, pharmacists, diabetes educators and dietitians.

One of the things I've learned, and I use this in a lot of my talks, is self-esteem. Sometimes I have a horizontal day, a flat day. I want a vertical day, going up, really positive. There may be days we don't feel as well, but that isn't any reason not to enjoy yourself, have a sense of humor about things, and laugh a lot. Think vertically instead of horizontally. For example, back in 1983, I had a double mastectomy. I don't know if you remember the movie "E.T.," but E.T. had sort of a bony, flat chest. Well, the first time they took the bandages off and I looked at myself, I used E.T. as my crutch to make it a vertical day. I'm a Christian person, so I've always said "This, too, will pass" and "it will work out." Sometimes people have diabetes plus something else. But, again, it all goes back to the way you think.

So, stay positive, think vertically, and take care of yourself.

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LETTERS TO THE EDITOR

January 22, 2003

I work with the Free Medical Clinic of Mayes County, Inc., and was wondering if we might receive the publication Voice of the Diabetic. A large percentage of our patients are diabetic, or are in the high-risk group for diabetes and I believe this would be of help to them. I see where it might be possible to receive multiple copies; if that is true may we have 25 copies? We will distribute them to our clients.

In His service,

Sharon K. Pilant

Pryor, Oklahoma

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January 23, 2003

Yes! I wish to continue to receive Voice of the Diabetic! This publication is the only source I receive that keeps me updated and informed of the diabetic community, and current diabetic information currently available.

I'm appreciative of your efforts on my behalf, and on behalf of other diabetics.

Sincerely,

Craig E. Mendenhall

Amarillo, Texas

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January 25, 2003

Always look forward to the Voice of the Diabetic, as you have so many good articles for all of us including me, naturally. I do want to remain on your mailing list. Keep up the good work!!

Also, I just passed my 71st year of living with diabetes as of December, 2002. Praise the Lord for all His help ... and the many others along the way!! Thank you!

Sincerely yours,

Helen L. Olson,

Hallock, Minnesota

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January 26, 2003

I have both mental (emotional) as well as physical problems in coping with diabetes. So far, the Voice has helped me learn there are many other people with diabetes and they have some of the same problems I do. I've also been given a lot of general information. I read/re-read most stories and I really enjoy the Voice. Please keep up the great diabetic information, and I'm anxious to get my next issue!

Your new friend,

Julia Farris

Birmingham, Alabama

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January 30, 2003

Just started receiving them the[Voice] last fall. Thank you! What a wonderful service for our diabetic patients.

Sue Waggoner

St. John's South Barry Coventry Hospital

Cassville, Missouri

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February 4, 2003

Keep up the good work. This paper has more valuable information than many medical magazines/journals. The latest advances in diabetes are so interesting.

Thank you,

Jane Malone

Evansville, IN

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February 6, 2003

I think Voice of the Diabetic is a truly helpful and interesting aid to help us in taking care of our diabetes. I don't throw mine away, and when I have a problem I am able to go back through the previous issues for the information. I am grateful for the Voice and think Mr. Ed Bryant has done a wonderful job and hope he has a great retirement (Editor's Note: We appreciate the comment, but I am not retiring. I am only stepping down as President, but not as Voice Editor). Please thank him for the job he has done and we hope the new President has great success.

Sincerely,

Margaret R. Wilson

Clearwater, Florida

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January 27, 2003

Great magazine. Keep up the good, positive work!

Allison Stefanou

Kennesaw, Georgia

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February 6, 2003

I routinely offer these to our patients, or diabetes support group, as well as distribute to offices affiliated with our hospital. We are a fairly large hospital, so I distribute a lot in the lobbies. Thanks for sending them. And if you send me more, I will be glad to distribute them. They are great informative papers.

Thanks,

Linda W. Johnson, R.N.

Frye Regional Medical Center

Hickory, North Carolina

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February 6, 2003

I love your newspaper. God bless you for it, it's so insightful and enjoyable to read. I look forward to each and every issue.

Thank you,

Lula Mae Nelson

White Plains, New York

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THINKING ABOUT EATING

by Peter J. Nebergall, Ph.D.

Includes photo of Peter Nebergall with cat.

What is the role of food in your life? For most of us, food is far more than sustenance. Mealtime is far more than "filling up at the pump;" it is a time of "communion," between family members, friends, and comrades. For so many of us, eating is indeed "ritual behavior." Social and cultural "rules," rather than "need," dictate what you eat, and how much of it.

But what about when you have diabetes, or Impaired Glucose Tolerance (IGT), or are merely overweight, and wish to do something about it? Those "rules" can and often do get in the way of good self-management.

Many restaurants offer "traditional farmer's breakfasts" (eggs, sausage, pancakes, perhaps biscuits and gravy), and many people eat the same at home. We are re-affirming our "traditional-ness," our connection with our ancestors, with these foods ... Right? But these breakfasts are huge, monstrous blasts of carbohydrate meant to sustain ten or more hours of hard physical labor behind the plow.

We eat like our great-grandparents, but we don't work like them -- and we have the nerve to wonder why we're getting bigger? There are plenty more foods, of all types, ready and willing to put weight on our middles.

America is a land of plenty. "People want to move to a country where the poor are fat," says immigrant writer Dinesh D'Souza, but he's talking about famine, not type 2 diabetes. There is more food to go around, here, than anywhere else, and for most of us, more food than we know what to do with. And we overeat.

I submit it is not simple ignorance, nor greed, that causes so many of us to routinely overeat. Rather, it is that we are following the rules our parents and fellows taught us -- rules for which the annual Thanksgiving and Christmas food binges are merely extremes. "Are you full yet?"

We need to question those rules. Is it possible to have a "celebration" without eating to bursting? Can one eat less without feeling "deprived?" Here are a few hints:

1. Fresh foods taste better than "junk" or "convenience" foods, and organic foods taste better than "factory." Last Thanksgiving, we had an organic chicken instead of too much turkey. We ate less.

2. Fast foods (better termed "junk food," because that's what they are -- JUNK) are so carb-loaded and high-calorie as to destroy any chance of good self-management. To eat such -- is to overeat. Best you don't go there.

3. Count your calories. Counting carbohydrates is necessary for good tight diabetes management, but before you get there, you need to get your total diet under control, and most of us eat far more than we can burn off. Remember, a sedentary adult male needs only 1800 calories a day -- and more than that will show up on your scale, your waistline, and your meter's screen. If you count calories (like they do in Weight Watchers), you'll learn portion control, and you'll learn to eat smaller portions.

4. Consider taking up new group activities that do not directly involve eating, and thus a new set of "rituals." Watching football at the "sports bar" -- is about eating. Coaching your boy and his friends -- is about doing. "Hanging out at the pizza parlor" is about eating. "Going dancing" is about doing. If you are trying to lose weight, doing something is vastly better for you than watching something -- and you know, you might lose a few pounds from the doing.

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NEW DIABETES AND BLINDNESS STATISTICS

The U.S. National Institutes of Health (NIH) collects statistics on all manner of diseases and health conditions, in order to track both extent and evolution of public health problems. The National Eye Institute and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) have collected quite a few regarding diabetes. Here is a pertinent sample of the most current diabetes statistics:

Today, an estimated 17 million Americans have diabetes, and 5.9 million of them have not yet been diagnosed. This figure is climbing. Each year one million Americans age 20 and older are diagnosed with the condition. Diabetes is the sixth leading cause of death in the U.S., and the NIH stresses these stats are under-reported and incomplete.

Heart disease is the leading cause of death among diabetics, who are two to four times as likely to experience cardiac events as are non-diabetics. Statistics for diabetes and risk of stroke are the same (diabetics two to four times as likely as non-diabetics), and about 73 percent of diabetic adults either have high blood pressure (greater than or equal to 130/80 mm Hg) or use prescription medication for hypertension.

More than nine million Americans are visually impaired; 5.3 million of these from diabetic retinopathy. Diabetes is the leading cause of new blindness among Americans

age 20 to 74 years, causing 12,000 to 24,000 new cases of blindness each year.

Diabetes is the leading cause of treated end-stage renal disease (ESRD), accounting for 43 percent of new cases. In 1999, the last year for which we have complete statistics at this time, 114,478 diabetics underwent dialysis or kidney transplantation, and 38,160 diabetics began their treatment for ESRD.

NIH statistics report 60 to 70 percent of diabetics show detectable neuropathy, nerve damage. Results can include numbness or pain in extremities, difficulty with digestive processes, and other problems. Severe neuropathy can contribute to diabetic foot complications, and is a major contributor to lower-extremity amputations. More than 60 percent of non-traumatic (meaning not caused by explosion, accident, or act of violence) lower limb amputations occur among people with diabetes.

Poorly controlled diabetes leads to an increase in dental/periodontal problems, and poorly controlled diabetes during pregnancy can imperil the baby in many ways.

Type 2 diabetes (more than 90 percent of all cases) is closely associated with "lipid abnormalities," which manifest most often as dangerously high cholesterol -- with all the risks that brings.

Statistics are not "inevitability." They are not "fortune-telling," but merely measures of past performance, not absolute predictors of the future. If you have diabetes, the best way to minimize the risk of any of its complications is to "do as the doctor ordered," to tightly control your blood glucose. It works -- and we have the statistics to prove it.

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NEW RESEARCH UNDERWAY

The U.S. National Institutes of Health (NIH) is studying the best strategies to treat and prevent diabetic cardiovascular disease (CVD) in three trials: Look AHEAD, ACCORD, and BARI2D. As CVD is the leading cause of diabetes-related deaths (65 percent, two to four times higher than non-diabetic adults) this research is of vital importance.

We all grasp that it is beneficial for someone with type 2 diabetes to not be carrying excess weight, but until now, no study had been done to quantify the benefits of voluntary weight loss. The NIH is conducting the largest clinical trial to date to examine the long-term effects of voluntary weight loss through decreased caloric intake and increased exercise.

Five thousand obese type 2 diabetics will participate, and will be "followed" by the researchers for up to 11.5 years. For more information, about the Look AHEAD trial, telephone: 1-866-552-4323, or visit their Web site: www.lookAHEADstudy.org

Although several major studies have shown us the strong link between "tight,"

intensive control of blood glucose and the lowered risk of diabetes complications, there has been no definitive study of the link between tight control and reduced risk of cardiovascular disease events in type 2 diabetes. the ACCORD (Action to Control Cardiovascular Risk in Diabetes) study is designed to compare current practice guidelines with tighter control, and will involve 10,000 type 2 diabetics, including those judged at high risk of cardiac events. Volunteers will be treated and followed from four to eight years. For more information on ACCORD, visit their Web site: www.accordtrial.org.

Some years ago, the BARI (Bypass Angioplasty Revascularization Investigation) studied the question of whether balloon angioplasty or bypass surgery were better, more successful, for type 1 diabetics with severe coronary artery disease. It was found that although for cardiac patients without diabetes, the less invasive balloon angioplasty had a higher success rate, type 1 diabetics had better luck with conventional bypass surgery. The BARI2D trial picks up the question for 2800 type 2 diabetics, and also seeks to examine the effect of the two surgical procedures on a population divided between conventional and "tight" (A1c below 7) control. For information, contact the BARI2D Web site: www.bari2d.org.

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Voice DISTRIBUTORS NEEDED

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

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

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LAPTOP COMPUTERS AND ELECTRONIC NOTETAKERS FOR THE BLIND:

A COMPARISON

by Curtis Chong

(This story appeared in the April 2003 BRAILLE MONITOR, published by the National Federation of the Blind.)

From the MONITOR Editor: Are you struggling to decide between buying a laptop computer and an electronic notetaker? Curtis Chong, who is now the director of field operations and access technology at the Iowa Department for the Blind, has compiled a very useful list of pros and cons for both of these electronic wonders. In his job, Chong is responsible for internal information technology, vocational rehabilitation, independent living, and all programs dealing with access technology, including the department's Project Assist program, which provides tutorials to run software with specific versions of various screen-access software. Here is his distilled wisdom and experience on this important subject:

Blind people often need portable electronic devices to perform such tasks as notetaking, dealing with e-mail, word processing, appointment management, and so forth. Traditionally the solution has centered on off-the-shelf laptop computers equipped with screen-access technology or specialized devices for the blind, often referred to as notetakers or PDAs (personal data assistants). This document attempts to provide a concise list of advantages and disadvantages for each class of device to enable potential buyers to make a more informed decision.

Laptop Computers

Off-the-shelf laptop computers running Windows function very much like desktop computers, except they are smaller and more portable. Braille, talking, or magnification screen-access technology can be added to this class of computer. As a rule, refreshable Braille displays are not built in, but portable displays can be obtained and connected. Synthesized speech is generated through the laptop's sound card; an external speech synthesizer can be attached if necessary.

Advantages of Laptop Computers

* Laptops are fully functional computers, able to run the same software as a

desktop computer. In fact they can replace a desktop computer.

* Technical support for laptop computers is widely available and not restricted to a vendor selling blindness products.

* A typical laptop will have gigabytes of hard disk space and hundreds of megabytes of random access memory - significantly more than a typical PDA for the blind.

* Laptops can read and burn CDs.

* If the user knows how to operate a desktop computer, little additional training is required to use a laptop.

*When using a laptop, it is much easier to exchange files with other people.

*Laptops can more easily be connected to devices such as scanners or printers, and the technical support required for such connections is not limited to a specialized vendor selling products for the blind.

*With appropriate software (e.g., ZoomText or MAGic), enlargement of information on the display is possible.

Disadvantages of Laptop Computers

*All of the components to make a laptop usable by a blind person are generally not available from one source. Typically the laptop is acquired from one dealer, and the access technology comes from one or two companies, depending on whether a Braille display is involved.

*Laptops have a relatively short battery life (typically five hours).

*It takes minutes to boot up a laptop computer, 30 seconds if resuming function from a sleep or hibernation mode.

*Laptops are typically heavier and bulkier than PDAs for the blind.

*Laptops do not provide direct Braille keyboard input - that is, a person who knows how to enter Braille but who cannot type would not be able to use a laptop without QWERTY keyboard training.

*Selecting and then attaching a refreshable Braille display to a laptop requires some technical knowledge and support from specialized vendors.

*It is relatively difficult to use a connected refreshable Braille display with no speech running - that is, laptops are harder to use by people who are deaf-blind.

Personal Data Assistants for the Blind

These devices are often referred to as "notetakers," although the actual note-taking function is a relatively small fraction of what they can do. They are truly personal data assistants. Devices which fall into this class include Braille 'n Speak, Type 'n Speak, Braille Lite Millennium (or 2000), Type Lite, BrailleNote (and VoiceNote), and PAC Mate. The Braille 'n Speak, Type 'n Speak, and VoiceNote do not have refreshable Braille display capability. The PAC Mate currently being shipped does not either, but plans have been announced to produce PAC Mates with built-in refreshable Braille displays.

Advantages of Personal Data Assistants for the Blind

*All accessibility is built in. There is no screen access software to buy.

*Because they are designed for the blind, it is much more likely that documentation and training materials will be available in alternative formats.

*Start-up time is very rapid. It takes seconds to get back into a file.

*Battery life is much better than a laptop. Twenty-plus hours is typical.

*Typically a PDA for the blind is smaller and more portable than a laptop.

*The PDA for the blind and accompanying accessories can be purchased from a single vendor.

*No additional effort or technical knowledge is necessary to get the Braille display to work when it is part of the unit.

*Generally, Braille displays can be used without speech running.

*Direct Braille input is possible.

Disadvantages of Personal Data Assistants for the Blind

*PDAs for the blind have no visual display. Display magnification is simply not an option.

*When using a PDA with direct Braille-input capability, one has to be concerned about forward- and back-translation issues, if files are to be exchanged with sighted classmates, friends, or co-workers. Though the promotional literature may make this seem easy, in reality the user must have a minimal knowledge of the issues involved with Braille grade translation.

*Formatting material for visual use requires attention to details that a laptop user need not worry about. This is especially true for PDAs for the blind with direct Braille-input capability.

*PDAs for the blind cannot read or create CDs.

*Sharing files with classmates, friends, and co-workers is not as simple as it is when using a laptop. In most cases files created in the format native to the PDA are not easily read with mainstream technologies.

*PDAs for the blind cannot run off-the-shelf applications which, on a laptop, have a good chance of working with nonvisual access technology. They certainly cannot run the full-function Microsoft or Corel Office suites.

*Technical support must be supplied either by the vendor or by someone trained by the vendor. PDAs for the blind are not well understood or supported outside of the blindness field.

*PDAs for the blind are not equivalent to laptop computers. They possess less storage and processing power, and are not designed to be a primary method for information processing and exchange. While many laptops have more than 512 megabytes of random access memory, even the largest PDA for the blind has only about 100 megabytes. A laptop can contain more than 40 gigabytes of hard disk drive storage capacity, whereas a PDA for the blind might today support a mini-disk drive with about five gigabytes.

So there you have it. No one answer is right for everybody, and no single choice can meet anyone's every need. Here, at least, are the issues that will help people make the most informed decisions for themselves.

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ASK THE DOCTOR

by Wesley W. Wilson, MD

Includes Art: Medical Caduceus

NOTE: If you have any questions for "Ask the Doctor," please send them to the Voice editorial office. The only questions Dr. Wilson 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.

Question: I'm 67 years old, and have been type 2 for more than 30 years. My diabetes educator suggests that it might be time for me to consider using some insulin at night. He says oral diabetes medications eventually fail, and he thinks I'm getting close to that point. Why would the pills I've taken for years now need to be replaced? How do I determine whether or not I need to start injecting insulin?

Answer: Type 2 diabetes is a complex disease and questions as to its cause, its course, and the best treatment remain. Despite these uncertainties, some parts of the "type 2 puzzle" are clear. Persons who are likely to develop type 2 diabetes show "insulin resistance," that is they require more than the normal amount of insulin. It's interesting that persons with risk factors for type 2 disease such as family history of type 2 and who are overweight have higher than normal levels of blood insulin. This insulin resistance puts an increased work load on the beta cells of the pancreas, which may eventually stop working. Type 2 diabetes then, seems to result from the combination of insulin resistance and a decreased ability to produce insulin. When that occurs, blood sugar rises, and that's what we call type 2 diabetes.

Big American and Danish studies have recently shown that modest reduction in diet, and modest exercise, in persons who are at high risk of diabetes, can cut the rate of diabetes by 50%. Even though genetic factors are important, our life style has a lot to do with development of type 2 disease. Exercise and weight loss reduce insulin resistance and sometimes seem able to revive the beta cells of the pancreas, or at least give them a rest.

During my years of practice, it was great to see someone with newly found diabetes and high blood sugars, drop the sugar into the "normal" range by just following their diet plan and starting a regular daily exercise program - something as simple as 30 minutes of walking daily.

Several studies, especially the United Kingdom Prospective Diabetes Study (UKPDS), have now conclusively shown that elevated blood sugar is associated with development of microvascular complications. These complications are the cause of eye, kidney and nerve problems so frequently seen in persons with diabetes. More importantly, there is now proof that reduction of blood sugar is able to prevent or delay or slow down progression of these complications. Another finding in the UKPDS was that with passage of time, type 2 diabetes is harder to control, requiring more medicine. This is probably due to the progressive failure of the beta cells - and is probably what your diabetes educator is alluding to - and sometimes the end result of this failure is the need for insulin injections.

Type 2 diabetes is not a stable disease, and therefore we must follow it and make adjustments as things change. This can mean adjusting lifestyle, adjusting medications, or even starting to use some insulin - it depends on your circumstances.

I'd advise you to be aware of your blood sugars and Hemoglobin A1c (HbA1c) and although it's easy for any of us to get in a groove, especially after 30 years, and think about the foundation of our treatment of type 2 diabetes. Can you get in some walking, gardening, or golf every day? Can your diet be "tuned up," and could you lose a little weight? Sometimes those things can make a big difference. The target should be to keep the sugar as near normal and the HbA1c below 7%. If it takes insulin to do that, it's worth the effort to stay healthy.

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Including Everyone Who Has Diabetes and Any Other Disability

Last year, the Board of Directors of the American Association of Diabetes Educators (AADE) accepted and published the new "Position Statement on Diabetes Education for People With Disabilities." This action makes AADE the first of the national diabetes organizations in the United States to officially affirm as a matter of policy that people who have disabilities have a right to receive reasonable accommodations for their disabilities in both the process and the content of diabetes education. This is good news for people with disabilities, who often have not had full access to the particular tools, techniques, and information they need for fully independent diabetes self-management.

What does this position statement mean to readers of the Voice of the Diabetic, many of whom are blind? This article summarizes what the position statement says, gives an example, and also gives a few of my own thoughts about how people with disabilities can use the position statement to get the services they need.

If you want to read the full text of this position statement, you can find it on AADE's Web site at: http://www.aadenet.org/PublicAffairs/PositionStatements/positionstateindex.html.

Click on "Diabetes Education for People with Disabilities".

What does the "Position Statement on Diabetes Education for People With Disabilities" say?

To understand exactly what the position statement says, it's important first to clearly define what we mean by "disability". The position statement uses a definition very similar to that used in the Americans with Disabilities Act: "an impairment that substantially limits one or more major life activities." For a person with diabetes, both diabetes education and the activities of diabetes self-management, like monitoring blood glucose, drawing insulin, inspecting feet, and exercising, are part of that person's major life activities. So any impairment that substantially limits a person's ability to participate either in diabetes education or in diabetes self-management activities is a disability. Examples of disability include, but are not limited to: amputation of all or part of a limb, blindness, deafness, low vision, learning disabilities, numbness or stiffness in the hands, mental retardation and developmental disability, partial or complete paralysis of a limb, and serious mental illness.

This definition focuses on function, not on specific numbers or techniques that measure abilities (like visual acuities and fields), and not on the source of the disability. So, for example, anyone who has a condition that makes it difficult to read print, or to see lines on a syringe, has a disability, whether that person is legally blind or not. And anyone who cannot use standard diabetes equipment because of low vision or numb fingers has a disability, and should receive accommodations in diabetes education, even if other parts of that person's life are not affected.

The core intent of the position statement is contained in these two sentences: "The AADE recognizes the special diabetes education and care needs of people with disabilities. The Americans with Disabilities Act requires that diabetes educators provide reasonable accommodations for people with disabilities in response to their particular individual needs."

In other words, all diabetes educators are required to provide reasonable accommodations for people with disabilities in order to make diabetes self-management education accessible and usable. Furthermore, they are required to provide diabetes self-management education equivalent to the education provided to people who do not have a disability.

The position statement is quite specific about two aspects of the responsibilities of diabetes educators. First, it states "Disabilities do not necessarily preclude effective diabetes self-management. People who have disabilities and diabetes are usually capable of caring for themselves when they are provided with appropriate, adaptive diabetes self-management education, tools, and techniques." This means if a person has a disability that makes it difficult or impossible to use a standard diabetes tool, like a syringe or a blood glucose meter, or a standard technique, like visual foot inspection, a diabetes educator working with that person is required to teach them how to use adaptive tools and techniques for those tasks.

The position statement further states, "People who have disabilities should receive diabetes education that is equivalent to that received by people without current disabilities. Disability per se should not be a barrier to the pursuit of desirable levels of glucose control." This means ALL diabetes self-management knowledge areas and skills normally provided to people without disabilities should also be provided to people with disabilities. The education should cover all the content areas listed in national standards. Furthermore, intensive management should be just as available to disabled people as it is to non-disabled people.

An Example

Let's look for a minute at how this position statement would affect a real person I know. I'll call him Carl (not his real name).

When I first met Carl, he was 54 years old. He had lived with type 1 diabetes for 32 years. He said most of that time, he had not had good diabetes control. His vision had been measured at 20/250 in his right eye, and 20/200 in his left. He told me his vision fluctuated a lot, depending on his blood glucose levels. At its best, he could read a little bit of very large print, and at its worst he could barely see at all. He had some neuropathy in his hands, and he had an old foot injury that left him with a right-sided limp. He had to wear a special shoe on that foot.

Before his vision loss, he had worked in a factory, and lived alone. Now, he was living with his brother and sister-in-law, and none of them were happy with this arrangement. "But," said Carl, "what can I do? I have to have someone draw my insulin for me." His sister-in-law is drawing his insulin for him every time he needs it. He is using a 70/30 mixture of NPH and regular insulin, given twice a day.

Let's consider what the "Position Statement on Diabetes Education for People with Disabilities" requires me, as a diabetes educator, to do for Carl. First, as I would for anyone without a disability, I should find out how much Carl knows and what he does in all the major areas of diabetes self-management - medications, monitoring, nutrition, exercise, prevention and screening for complications, and stress management. While I am doing this assessment, I should also ask Carl about how his disabilities and his life situation affect what he does in each of these areas. For example, we already know someone else is drawing his insulin. Is Carl doing his own blood glucose monitoring? Is he getting any exercise or physical activity? Is he inspecting his feet? How is he dealing with the stress of having a disability, of having diabetes, of losing his job, and of living with his brother?

I should also think about how Carl's disabilities affect the diabetes education process. I usually give print handouts to people who have good eyesight, to help them remember the things we have discussed. But I already know Carl won't be able to use my standard print handouts, so I have to think about what kind of handouts Carl would find useful. He might be able to use large print, but because he cannot read large print when his vision is at its worst, he might prefer to have his handouts on audiotape, or on a computer disc. (I am not including Braille as a possibility here because Carl has not yet had blindness rehabilitation services, so he has not yet had a chance to learn Braille.) The best way for me to find out what sort of materials would be best for Carl is simply to ask him what he would prefer.

Once I have assessed Carl's situation thoroughly, I would be ready to plan his care. A reasonable plan for Carl might include the following adaptive techniques:

* A talking blood glucose meter he could use independently.

* A way to measure and give his insulin nonvisually, perhaps using a tactile tool like the Count-a-Dose or an insulin pen.

* Up-to-date nutrition teaching, with reference materials in a format Carl can use.

* Planning for a safe and appropriate form of exercise. Because Carl has a foot injury, I might refer him to a physical therapist to help with this.

* Nonvisual foot inspection, using his hands and his sense of smell.

* Audiotaped stress management exercises, such as relaxation and imagery.

* All handout materials on audiotape.

* If using a videotape as part of Carl's diabetes instruction, I would sit near him and describe visual portions of the video to him.

In addition, because I know Carl realizes his diabetes control was not good in the past, I should discuss with him the pros and cons of a more intensive diabetes regimen. I should give him enough information to decide whether he would like the flexibility and greater control of using multiple injections or an insulin pump. Of course, the decision about whether to actually pursue intensive management should be made in cooperation with his doctor. But I have a responsibility to make sure Carl has enough accurate information about the treatments, tools, and techniques available so he can decide what he wants to choose for himself.

What Does This Position Statement Mean To You?

If, like many readers of Voice of the Diabetic, you are blind or otherwise disabled, this position statement could help you get the diabetes education you need. Suppose, for example, you are blind, and you worked with a diabetes educator four years ago. At that time you were never offered any ways of monitoring your blood glucose independently. Or suppose that five years ago you went to a diabetes education class, and you found the experience very frustrating. Maybe you wished you could have take-home materials, because there was too much information to absorb all at once; but the take-home materials were only available in print. Or maybe the class used a lot of videos, and although you could hear the soundtrack, some of the important information you need was shown visually on the screen, and not in the soundtrack. Or, suppose you would really like to try using an insulin pump. But you have hesitated to ask for this, because you think that your diabetes educator and your doctor will tell you can't do that since you are blind. This position statement applies to exactly these sorts of situations.

Your first task will be to find a diabetes educator to work with. Your doctor, or other people with diabetes, may be able to tell you about diabetes educators who are available in your area. It's good to get a referral this way, since a referral from someone you know might give you some idea of the educator's skills and reputation. Your doctor, in particular, may also have information about which local diabetes educators are covered by your health plan. But if you're having trouble getting a referral to a diabetes educator from people you know, AADE has a referral line through which you can get the names and contact information for diabetes educators in your area. The phone number is 800-TEAMUP4, or 800-832-6874. Or, you can check the AADE Web site at: http://www.diabeteseducator.org/FindAnEduc/index.html

Once you have found a diabetes educator and made an appointment, I would suggest that you prepare carefully for your first visit. You should be ready to tell your educator what kinds of adaptations would help to make the diabetes education meaningful to you. You don't need to know ahead of time which adaptive tools you want to use, but it will help if you know you want to try adaptive tools, say for insulin drawing and blood glucose monitoring. And it will help a lot if you can tell your educator what format will work best for you in handouts. It's also a good idea to let your diabetes educator know you are aware that AADE has a Position Statement on Diabetes Education for People with Disabilities. You might find it helpful to tell your educator where to find a copy of this position statement.

You might consider asking your educator if she or he has any experience working with other people who have your disability. It's probably true many diabetes educators will be a bit anxious when they first encounter a person whose situation they don't understand. But in my experience, most diabetes educators are glad to have a chance to improve their skills and learn how to serve their patients well. So if your educator has no experience with your disability, you might want to offer to help educate your educator about your disability and how it affects you. If you don't feel you can do this, you could tell your educator about organizations, like the National Federation of the Blind (NFB), that could provide accurate information about your particular disability. (Contact the NFB at: 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314; Web site: http://www.nfb.org) You could also suggest your educator talk with other diabetes educators who have more experience with your disability. (Since 1987, AADE has had a Visually Impaired Persons Specialty Practice Group. These educators often share techniques with their colleagues who are working with a visually impaired person or blind for the first time.)

Thinking this all through ahead of time, and sharing it at your first meeting with your diabetes educator, will help you get what you need. If, in spite of your preparation, your educator balks at providing reasonable accommodations for you, a polite but firm reminder of the position statement should go a long way toward assuring you get what you need. Both the position statement and the Americans with Disabilities Act clearly state you have a right to reasonable accommodations. But if you're still having trouble getting needed accommodations, remember the old adage, "You catch more flies with honey than vinegar." You can remain firm about your needs, and helpful in pointing out how your diabetes educator can best serve you, without being harsh or rude. If you are in a difficult situation, it might help you to remember the professional you are dealing with today will probably meet other disabled people in the future, and the memory of the encounter with you will affect how those other people will be treated.

If you have done your best to explain your needs, and you are still not getting reasonable accommodations, you could simply "vote with your feet." Find a new diabetes educator who is more willing to accommodate you.

Since the Position Statement on Diabetes Education for People With Disabilities is relatively new, it is likely that right now many diabetes educators do not know how to provide reasonable accommodations for people who have even common disabilities. However, the more people with disabilities ask to receive diabetes education equivalent to what is given to non-disabled people, the more diabetes educators will learn how to provide reasonable accommodations. Already, I have seen many more continuing education offerings for diabetes educators that include information about diabetes self-management for people with disabilities. I certainly hope the time will come when diabetes self-management education is fully accessible to ALL people who need it, including people who have disabilities.

From the Editor: The National Federation of the Blind, with over 50,000 members, is the largest organization of blind people in existence. The Federation's collective expertise, not just in diabetes and blindness, but in all manner of conditions that can cause blindness or occur alongside it, is available to blind people, health professionals (including diabetes educators), family members, prospective employers, and anyone else who wants to know. Much of the NFB's literature (available in many formats) is about coping, about not allowing blindness or any other disability to interfere with each of us living a full, independent and productive life. Any diabetes educator wishing advice about training a blind person to manage diabetes should contact the Federation; telephone: (410) 659-9314; Web site: www.nfb.org.

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TALKING MEDICINE IDENTIFIERS

Blind people, and those losing vision, have always had difficulty identifying their medications and telling them apart. Serious consequences can follow, when prescriptions, oral or injectable, are mistaken, and the wrong dose given. Very serious consequences can follow the misidentification and misdosage of insulin.

As a long-term solution, insulin manufacturers need to make insulin vials distinguishable from each other by type/duration, without sight. The drug companies have not been particularly interested in doing this. We have been left with our homemade Braille labels, rubber bands, tape, and other temporary "recognition systems."

A very partial solution has been the Roche VoiceMate blood glucose monitor, with its "talking insulin identifier" feature. This monitor reads the bar-codes on Lilly insulins -- but not on any others, and, while quite functional, is very expensive. A more general solution is needed.

In September of 1999, Dr. Marc Maurer, president of the National Federation of the Blind, hosted a meeting at the National Center for the Blind, in Baltimore, Maryland. Representatives from the ASKO Corporation discussed and demonstrated a prototype of their ALOUD #100 Audio Labeling System.

First of a new class of "talking prescription containers," the ALOUD consisted of three components: The recording unit (in the possession of your pharmacist, to whom ASKO will provide it without charge), and the playback unit (kit cost: $78.75 for #100 player, charger, and several reusable "audio labels," each of which contains a memory chip.)

When your pharmacist prepares your medication, and creates a written label, an "audio label" is created also. With the ASKO recording unit, the pharmacist reads pertinent dosage information onto the Audio Label, as if into a tape recorder. Like recorded tape, the Audio Label is reusable -- when your prescriptions change, the pharmacist can replace old information with new. And note, there is no language barrier -- whatever language your pharmacist speaks can be easily recorded. Standard reusable "audio labels" cost $10.00 each, and the smaller labels (for insulin vials) will cost $5.00 each.

The original ALOUD, (the "Model #100") was very functional, but a bit large, all right for oral medications, but not particularly convenient for use with an insulin vial. As those of us who most need a "talking label" on our insulin are likely users of an adaptive insulin drawing device such as MediCool's Count-A-Dose, any "talking label" needs to not interfere with insulin drawing. The original ALOUD made using the Count-A-Dose inconvenient.

ASKO then shrank the Audio Label, to make it more convenient for blind diabetics. The new model, the Aloud #200, also does away with the separate recorder; each "playback unit" can now record new messages. The electronics are similar to those of the #100 (which is still available) but memory has been expanded -- each audio label now holds 60 seconds of information. The ASKO #200 kit costs $88.50, including recorder-player, microphone, charger, 3 audio labels, adhesive pads to attach the labels, earbuds and instruction sheet). More #200 audio labels are available for $11.95 each.

A completely different approach to the same problem, far more high-tech, has been taken by En-Vision America, with its ScripTalk system. Like the Aloud System, the ScripTalk consists of recorder, playback unit, and labels; but where the Aloud stores and plays back the pharmacist's voice, the ScripTalk utilizes Radio Frequency Identification (RFID) technology, and encodes a microchip on the medication's label with the same information typed onto the label. When the patient scans the medication container, this computer-loaded information is detected by the user's scanner and played back through a voice synthesizer. As with the Aloud #100, the pharmacist determines the label content; the consumer can only play back the information.

The ScripTalk's "printer" (the "label-maker," which the pharmacist uses to encode the information) is expensive. A pharmacist will pay $4,000.00 to $5,000.00 for the system and training, and each label printed costs $1.75 each. The "Reader," sold to customers, is priced at $325.00. This is a voice synthesizer, not a voice recorder, and is available in English or Spanish at this time.

Because the ScripTalk's special microchip is in the label, no great bulk is added to the label or container, and an insulin vial with label attached should easily fit into adaptive measuring devices like the Count-a-Dose. They offer two label sizes (same chip) with the smaller label 1/2" x 3/4" specifically for small vials like insulin.

En-Vision's system, while far more expensive than its competitors, has two virtues: The specialized labels it requires are the least obtrusive of any system so far, and, their favorite selling point, the system "places the liability for providing correct information where it belongs, on the pharmacist."

A simpler, more limited approach is offered by Millennium Compliance Corp., maker of the Talking RX audio label. Although the Talking RX looks much like the Aloud, and stores spoken information on a digital chip, there is no separate "recorder" -- each unit has the capacity to record. Where the Aloud requires a different "audio label" on each prescription, but only one playback unit, each Talking RX unit is self-contained, recorder and playback, and no separate "audio label" is required. You attach pillbox or insulin vial to the unit, and leave it there until you've finished that course of medication. They're inexpensive ($19.95 each, suggested retail); but if you take a lot of meds, you may need to buy a lot of Talking RX devices, a different Talking RX for each of your medications.

A modification of this device is sold separately as the E-Pill "Beep'N Tell." To the Talking RX, E-Pill has added an alarm clock, which sits on the pillbox's lid (so of course this system is not for insulin vials!).

The MedivoxRX "Rex" system shares features with the ScripTalk and the TalkingRX. "Recording Station" and playback unit are separate, and the playback unit is the special pill bottle itself. The bottles don't need to be put into a separate playback unit (each is its own player). The system records the speech of whoever is using it (so any language can be recorded). However, unlike the other voice-driven units, the "Rex's" battery is not rechargeable, and MedivoxRX calls the playback units "disposable talking bottles." The company claims each unit's battery should last about six months, or about 300 playbacks. The "Starter Kit" (Recording Station and three disposable talking bottles) costs $54.95 plus shipping, and more disposable talking bottles are available for $24.95 per set of three. MedivoxRX was founded by a blind man, and has taken positive steps, such as an accessible Web site (www.rxtalks.com) and cassette instructions for the "Rex." This is commendable.

All the systems have their pluses, and their problems. Although both the Aloud and the Talking RX are "lifetime" products, endlessly reprogrammable, and both are simple and relatively inexpensive, neither is particularly convenient for use with an insulin vial. The MedivoxRX has similar problems, plus the playback units are not rechargeable, and it is somewhat fragile in construction. All three of these are really too big to work well with adaptive measuring equipment, unlike the ScripTalk.

An alternative approach to medicine identification is demonstrated by the Israeli-made ASSISTec Voila and the American En-Vision ID-Mate. These machines scan bar codes and read out contents from stored memory. The VoiLa (for "Voice Label") comes with a set of tactile, raised barcodes you apply to medicines needing tactile ID, and then the needed information must be read into the unit for each (and of course the system could work on many other containers, such as food, paint or other liquids, or even music CDs. It holds approximately 13 minutes of memory, which the user may subdivide as needed. The VoiLa (U.S. release date May 2003), is priced at $190.00, available in the US from Adaptive Technologies; telephone: 978-462-3817; Web site: www.adaptivetech.net.

The ID-Mate 2 (scheduled availability: June 2003) is designed to work with the UPC ("Universal Price Code") barcodes already on most items. No special attachment or label is necessary. The system holds up to a huge 2.5 hours of digital voice memory, so there is room for lots of complex instructions. Also available is an "encrypted food database" that can provide, spoken, full nutritional breakdowns on any food package, when loaded into the machine. The ID-Mate 2 should cost $1,599.00, available from En-Vision America (address below).

Between these two systems, the VoiLa is perhaps best seen, like the insulin identifier in the AccuChek VoiceMate, as a label-reader, a "medicine identifier," while the vastly more complex ID-Mate 2 provides room for instructions, cautions, and in-depth information. As a consumer, you must determine your own need.

To conclude, our main interest has always been the ability to distinguish one insulin vial from another. Systems designed for pill bottles, such as the Aloud and Talking RX systems, are only partial answers for insulin identification. Most of the systems reviewed here require sighted intervention or "programming" -- and until there is some way a blind person can reliably and independently tell insulins apart, without such aid, the job is not completed. Discuss your needs for such a device with your health care team, and stay tuned for further improvement!

ASSISTec Ltd.
12 Lochamei Hagetaot, Suite 27
Naharia, Israel 22102
Telephone: 972-4-900-0656
e-mail: [email protected]
www.assis-tec.com

ASKO Corporation
2 South St.
Stamford, NY 12167
1-877-732-9227
www.askocorp.com

En-Vision America
1013 Porter Lane
Normal, IL 61761
1-800-890-1180
www.envisionamerica.com

E-Pill, LLC
70 Walnut Street
Wellesley, MA 02481
1-800-549-0095
www.epill.com

MedivoxRX Technologies, Inc.
28 Saxony Road
Pittsford, NY 14534
1-866-798-2557
www.rxtalks.com

Millennium Compliance Corp.
PO Box 649
Southington, CT 06489
860-681-9277
www.talkingrx.com

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QUESTIONS AND ANSWERS

Q. I have had two episodes of hypoglycemia during which I lost consciousness, but eventually regained it with no intervention from anyone else. How is this possible? Can the body raise its blood glucose level on its own?

A. The body does have a mechanism for raising its blood glucose level, but it cannot be relied on to reverse all cases of hypoglycemia. For that reason, people who use insulin or blood-glucose-lowering pills that can cause hypoglycemia should know how to prevent, detect, and treat hypoglycemia. Those who have lost the ability to sense the early signs of hypoglycemia should talk to their doctors about ways to reverse such hypoglycemia unawareness.

Normally, the body maintains its blood glucose level in a relatively constant range through the actions of insulin (which lowers blood glucose level) and its counter-regulatory hormones (which raise it). When a person's blood glucose level increases, say after eating a meal, the body releases insulin, which causes fat cells and muscle cells to absorb glucose from the blood. When the blood glucose level drops, counter-regulatory hormones such as glucagon and epinephrine cause the liver to release glucose to the blood. However, the pancreatic alpha cells, which produce most of the body's glucagon, are often damaged or deficient in people with type 1 diabetes. People with type 1 diabetes are also prone to losing their epinephrine response to low blood glucose.

Hypoglycemia occurs when there is a relative excess of insulin circulating in the bloodstream. Skipping meals or exercising more than usual can lead to hypoglycemia if corresponding adjustments in diabetes medicines or snacks are not made. In addition, people who take pre-meal short-acting insulin should learn to adjust the insulin dose according to the amount of carbohydrate they're planning to eat to avoid injecting too much and ending up with hypoglycemia.

Symptoms of hypoglycemia vary according to the individual and the size and rate of fall of the blood glucose level. Glucose is the main fuel the brain uses for energy, so low blood sugar levels can lead to irritability, confusion, seizures, and eventually to unconsciousness or coma.

The recommended treatment for hypoglycemia is to eat something containing 15 grams of carbohydrate. People who take insulin or sulfonylureas such as Glucotrol, Amaryl, and DiaBeta should always carry a source of glucose with them. Many people use glucose tablets for this purpose. If hypoglycemic symptoms make a person unable to swallow, glucose gel can be applied to the gums. A person with type 1 diabetes and their family members should also have an emergency glucagon injection kit.

Because the body can release hormones that stimulate the liver to release glucose, it is possible your blood sugar may rise enough to help you recover from hypoglycemia even if food is not eaten. However, because of the progressive unreliability of the body's innate response to low blood glucose in people with diabetes, a person who experiences frequent episodes of hypoglycemia, especially those severe enough to require the assistance of others, should speak with his diabetes team about making changes in his treatment regimen.

By Robin Goland, MD, Co-director, Naomi Berrie Diabetes Center, Columbia Presbyterian Medical Center, and Irving Associate Professor of Medicine, Columbia University College of Physicians & Surgeons, New York, New York.

Reprinted with permission from Diabetes Self-Management. Copyright � 2003 R.A. Rapaport Publishing, Inc. For subscription information, call (800) 234-0923.

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NEW NEUROPATHY TREATMENT

One of the most common complications of diabetes is peripheral neuropathy, nerve damage. Most often first appearing in the feet and hands, neuropathy can cause unexplained pain, numbness, hypersensitivity, burning sensations, or other discomfort. As no two cases of peripheral neuropathy are the same, there is considerable variation in treatment. People use medication, massage, yoga, electronic stimulation ... whatever works - and one size does NOT "fit all."

Now there is another treatment option. Anodyne Therapy LLC, from Tampa, Florida, offers "anodyne neuropathy care." Their device (which they describe as "FDA approved,") utilizes infrared light emitted directly into the affected area. The company claims that not only does its treatment relieve neuropathy pain, but that it also restores lost sensation (as measured by monofilament test).

Neuropathy is mysterious. It appears to have more than one causational mechanism - which is why as yet there is no "cure," and why symptom-relief treatments that work for some do not for others. Anodyne postulates its product stimulates release of endogenous Nitric Oxide, thus accounting for the observed reversal of loss of sensitivity - but company documents state: "The debate and research goes on, and hopefully, one day we will have the answer."

Anodyne therapy is available at a number of clinics across the country. To find the nearest, telephone them at: 1-800-521-6664, or visit their Web site: www.anodynetherapy.com.

Anodyne markets their apparatus, both to health professionals and to consumers. Their "professional" system is priced at $4,895.00, and their "consumer" system retails for $2,495.00. For more details, contact: Anodyne Therapy LLC, 13570 Wright Circle, Tampa, FL 33626; telephone: 1-800-521-6664; Web site: www.anodynetherapy.com.

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BOOK REVIEWS

by Marilyn Helton

Focus On The Future

This column is dedicated to a heightened awareness of diabetes in our nation's children. Type 1 (formerly known as juvenile-onset diabetes), used to be the kind of diabetes associated with childhood. Today, however, the Centers for Disease Control and Prevention (CDC) reports type 2 diabetes is rapidly increasing among children and adolescents. In fact, type 2 diabetes, which used to be called adult-onset diabetes, is so prevalent among youngsters that it is no longer referred to as adult-onset diabetes.

The incidence of type 2 diabetes in children has risen significantly in recent years, along with a high prevalence of obesity. According to researchers at the recent meeting of the Pediatric Academic Societies in Seattle, Washington, abnormally high insulin levels are showing up in children as young as four years old. In addition, 13 percent of 147 children tested had abnormal liver-function tests, according to reports.

Parenting or caring for a child with diabetes is not easy. The good news is that there are numerous health care professionals, authors, and organizations reaching out to communities and families with practical advice and tips on healthy eating and physical activities for children and teens with diabetes. Better educated is better informed, and there is a wealth of good information available for surviving the devastating statistics of juvenile diabetes.

* * * * * * * *

THE TEN KEYS TO HELPING YOUR CHILD GROW UP WITH DIABETES is a good starting point. According to author Tim Wysocki, Ph.D., parents and caregivers need to understand the psychological impact of diabetes in order to learn the practical coping skills needed to overcome common hurdles children and their families encounter.

In pyramid format, Wysocki identifies ten fundamental tasks or "keys" needed

to make a healthy adjustment to managing childhood diabetes. Beginning with a broad base of Diabetes Knowledge, the steps up the pyramid are followed by Emotional Coping, Family Communication, Family Sharing of Diabetes Responsibilities, Managing Stress, Treatment Adherence, Diabetes Problem Solving, Social Skills, School Adjustment, up to the tip of the pyramid, which he identifies as Relating to Health Professionals.

The "Resources" chapter at the end of the book neatly ties each identified task

with additional reading for those interested in more detailed discussions of the issues raised in each chapter. TEN KEYS TO HELPING YOUR CHILD GROW UP WITH DIABETES, (c)1997 by the American Diabetes Association, Inc., is a practical and very helpful guide for parents and caregivers of children with diabetes.

* * * * * * * *

Are you wrestling with how to balance diabetes control and good nutrition with family peace? If you are, SWEET KIDS (Second Edition) may have the answers you're seeking. Each chapter begins with a story of a child with diabetes, to help introduce you the book's topics. Balancing food, exercise, and insulin can be the most demanding issue for parents in the life of a child with diabetes. From what to fix for a toddler's breakfast to preparing a teenager to care for his diabetes wisely away from home, this book helps parents and caregivers make informed decisions for management of the diabetic child.

In practical language, SWEET KIDS is an easy-to-understand book that gives the reader more information about:

Healthy eating and feeding for your family

Nutrition and meal planning in diabetes

Food, diabetes, and proper development

Techniques for caregivers of diabetic children

SWEET KIDS is co-authored by Betty Page Brackenridge, MS, RD, C.D.E., and Richard R. Rubin, Ph.D., C.D.E, (c) 2002 by the American Diabetes Association, Inc.

* * * * * * * *

TYPE 2 DIABETES IN TEENS, a great new publication by Jean Betschart-Roemer, M.S.N., CPNP, C.D.E., will help your teen get a handle on diabetes to get on with life!

More and more teens are being diagnosed with type 2 diabetes, and this book is written to let your teenagers know they're not alone. It's a given that teens diagnosed with Type 2 diabetes struggle not only with their diagnosis, but with their diabetes treatment as well. TYPE 2 DIABETES IN TEENS was written to help teens and parents better understand and cope with the challenges of this chronic disease.

Accenting the importance of good self-care, and following the treatment plan, the book gives good information on living well, including such topics as:

How to keep blood sugar in control

What to do when you get cravings

How to manage your diabetes in school

What to say to your friends and your dates

How to balance exercise and food when you take insulin

Where to find help when you need it

Ways to eat healthier

How to be patient with yourself and enjoy life

There's also a special section of tips and suggestions for parents, designed to help families support their teens in the management of their diabetes and show them how to have a positive outlook on life.

TYPE 2 DIABETES IN TEENS is a 2002 publication by John Wiley & Sons, Inc.

* * * * * * * *

A GUIDE TO RAISING A CHILD WITH DIABETES, Second Edition, by Linda M. Siminerio, R.N., Ph.D., C.D.E., and Jean Betschart MN, M.S.N., CPNP, C.D.E., will help you learn how to help your child cope with diabetes. Focusing on the latest advances in diabetes care, including plenty of problem-solving examples and easy-to-read tables throughout, you'll learn how to help your child:

Adjust insulin to allow for foods kids like to eat

Have a busy schedule and still feel healthy and strong

Negotiate the twists and turns of being "different"

Accept the physical and emotional challenges life has to offer

Filled with the most up-to-date information, this second edition also features updated management sections, including expanded information on nutrition and insulin; coverage of Lispro, a newer type of insulin recommended for children who won't always eat what's put before them; treatment for children with type 2 diabetes; and a cartoon section to help you talk with your child.

In her own words, author Siminerio states the most important thing we need to know about diabetes is, "Diabetes is a very difficult everyday lifestyle disease, so you can never forget it. That's a huge barrier for patients. It's not like a disease where you can take a pill and then forget about it for the rest of the day. With diabetes, it affects every moment of every day of your life."

Dr. Siminerio continues that knowledge alone is not enough, "...we learned through trial and error, that teaching patients means more than that. We need to assess how they live. We need to be flexible. We used to have these rigid plans. Ten years ago, before the DCCT [study was published] we used to tell our pediatric patients, 'Well, you just can't have candy.' Guess what? They were eating candy. And they were hiding it, and we called them [on it] - that they cheated - and it was terrible. And now we know we need to learn what patients with diabetes like, how they live, and then work these into their lifestyle. We can't abolish all of these things from their life, but we need to learn how to individualize a plan."

On the very insightful words of Dr. Simenerio, I rest my case for surviving the statistics of diabetes.

Until we meet again in October, may you each be able to live each day in your most positive attitude, one day at a time, in harmony with your diagnosis of diabetes!

Marilyn Helton, diabetic since 1993, is the publisher of CINNAMON HEARTS: THE ART OF LIVING A WINNING DIABETIC LIFESTYLE, a positive-power E-zine for diabetics and their families. Visit the CINNAMON HEARTS Web site: www.cinnamonhearts.com.

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THE SALAD DAYS OF SUMMER

by Robyn Webb, MS, LN

There is nothing more pleasurable on a hot, sticky day than to bite into a crisp, cold, fresh garden salad! We all know the benefits of eating more vegetables, but all too often our salads become an afterthought in food preparation. And a wedge of iceberg lettuce sprinkled with a few slices of cucumber, well that just doesn't cut it!

With so much interest in fresh foods, more and more home gardeners are planting all kinds of delicious lettuces, going beyond the usual comfort zone of planting just iceberg and romaine. When preparing salads at home, broaden your range. You'll not only eat more interesting salads, but chances are the nutritional profile of your salads will increase. Even in you do not grow lettuces yourself, today's supermarkets offer a wide range of crunchy leaves just waiting for you!

Building Your Salads:

Try a few of these greens to build the base of your salad:

Belgian endive is slightly bitter, with white crunchy leaves. It is used in many French salads and goes well with asparagus and fruits like oranges and strawberries. It can also be used as a scoop for ratatouille or salsa.

Bibb lettuce has a small head with pale, tender leaves. It is a very mild tasting lettuce.

Bok choy is not often thought of as a salad green, but give it a try, it can really perk a salad up. Bok choy has slightly bitter leaves attached to a white base. It's best to slice about 3- to 4-inches off the bottom, then slice all the way to the top.

Boston lettuce has a buttery taste and soft leaves.

Escarole is used primarily in Italian cooking and has green curly leaves. It takes a little getting used to in salads, but it's great mixed with spinach.

Frisee is often included in the popular field green mix. It has white curly leaves with a slightly bitter flavor.

Green cabbage is traditionally used in coleslaw, but try shredding some to add with other lettuces. The beauty is that it stores well; it can be kept for up to two weeks.

Kale has a dark green leaf and tastes great in salads, or cook until slightly wilted and serve as a warm salad.

Napa cabbage is often referred to as Chinese cabbage. It has very little green, curly leaves attached to a white base and has a more delicate flavor than bok choy.

Radicchio has bright purple leaves. It has a slightly bitter, peppery flavor and is used to make salads more colorful.

Red cabbage is also used to add color to salads. Use it in combination or instead of green cabbage.

Spinach is best when used fresh. Buy loose spinach, for best flavor.

Watercress has tiny round, green, leaves with a spicy, peppery flavor. Use in salads instead of just as a garnish.

The Next Step:

Use any of these greens to form the base of your salad. Try two or three them together for more nutrition. Next, add any variety of vegetables. I really like very lightly steamed broccoli and cauliflower, tomatoes, peppers, carrots and sprouts. Other interesting items to add include canned-in-water artichoke hearts, roasted red pepper strips, and capers. And if you want to make a main dish or salad consider adding cooked shellfish or fish, chicken, turkey, pork, veal or lean beef.

For the very best salads, remember these important tips:

* Wash the greens in a salad spinner directly after bringing them home from the store. Pat dry and wrap the leaves in damp paper towels, then place the leaves in a vegetable bag with tiny breather holes.

* Lettuces lose their freshness quickly, so plan on shopping for them twice a week.

* Always tear your greens when preparing a salad. Never cut greens with a knife or their edges will turn brown.

* Thoroughly tear greens prior to adding other ingredients and salad dressing. Otherwise you'll end up with a diluted flavor and small puddles of water in your salad!

* Rub a wooden salad bowl with fresh-cut garlic prior to adding your ingredients to the bowl. The garlic adds a really robust flavor.

* The salad should not be drowned with dressing. Just mist your salads with dressing, the lighter the better. For thin dressings, pour the dressing into a plant sprayer and mist your salads.

* Use herbs like greens, including whole leaves of basil, mint, oregano and chervil.

Preparing Salads With Ease:

The salad bar is a great way to get salad fast, but "buyer beware." First, always go to a salad bar you know has a high turnover. Then stick with the lower-fat, lower-calorie items and skip the mixed salads like potato and coleslaw, and avoid the croutons, peanuts, and cheeses.

The pre-bagged salads have become very popular in the supermarket. While certainly easy, try to buy lettuces whole and cut them yourself. The moment a green is cut open the vitamins and minerals start to diminish.

Here is a really tasty salad sure to liven up any summer:

California Walnut and Turkey Salad

3 cups cooked brown rice

2 cups diced, cooked white-meat turkey

1/2 cup diagonally sliced celery

1/4 cup pineapple chunks, drained

1/4 cup mandarin oranges, drained

1/4 cup water chestnuts, drained and thinly sliced

1/4 cup thinly sliced scallions

1/4 cup toasted walnuts

6 cups mixed lettuce leaves

Dressing:

1/2 cup low-fat lemon yogurt

1/2 cup low-fat mayonnaise

1 tsp. grated lemon rind

1/2 tsp. curry powder

Instructions:

Combine all ingredients for the salad except the salad greens in a large bowl. Whisk together the dressing ingredients. Add the dressing to the salad mixture, cover and place in the refrigerator. To serve, place one cup of greens on a plate, top with some of the salad. Repeat with remaining plates.

Makes six one cup servings. 262 calories, 6gm fat, 34mg cholesterol, 205mg sodium, 33gm carbohydrates, 4gm dietary fiber, 6g sugars, 20gm protein. Exchanges: 2 starch, 2 lean meat.

Note: Reprinted with the permission of Diabetes Research and Wellness Foundation, (c) June 2001.

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RECIPE CORNER

This issue, all our recipes are "Good Hearted Cuisine," published on the World Wide Web by Wellaware, Boone Hospital Center, Columbia, Missouri; Web site: www.boone.org.

Autumn Wheat Berry Soup

Ingredients:

1 cup great northern beans

1 cup wheat berries

4 cloves garlic, minced

1/2 small head cabbage, chopped

1 Tbsp. olive oil

1 tsp. sage

1 onion, chopped

1 tsp. rosemary

1/2 cup fresh parsley

One 14-oz, can diced tomatoes

2 carrots, peeled and cut into cubes

3 cups reduced-sodium chicken broth

1/2 cup cut green beans

4 cups water

1/2 cup grated Parmesan cheese (optional)

Instructions:

Put wheat berries in a bowl and cover with water; soak for at least eight hours or overnight. Drain wheat berries and set aside. In a large pot, heat oil over medium heat. Add onion, and cook, stirring, until soft, four to five minutes. Add garlic, sage, and rosemary. Cook, stirring, for about one minute. Add reserved wheat berries, tomatoes, broth and water; bring to a simmer. Cover and adjust heat to maintain a gentle simmer.

Cook wheat berries until al dente, about 1 to 1.5 hours. Add cabbage, carrots, green beans, cauliflower and beans. Bring to a simmer, cover until vegetables are tender, 25 to 30 minutes. Stir in parsley and season with pepper. Optional: Garnish with Parmesan cheese. Makes about 16 one-cup servings.

Exchanges: 2 Carbohydrate.

Calories per serving: 170; fat: 3 gm; sat. fat: 0.4 gm; sodium: 210 gm; protein: 8 gm; Fiber; 6 gm.

Stuffed Pork Loin

Ingredients:

2 cups frozen spinach, thawed

1 cup onions, chopped

1 tsp. olive oil

3/4 tsp. garlic, minced

1/2 tsp. pepper

1/4 cup honey

1/3 cup Parmesan cheese

1/2 tsp. garlic powder

1/4 cup reduced-sodium soy sauce

2 lbs. pork tenderloin, split and pounded flat

Instructions:

Saute onions and garlic in olive oil; add pepper. Let cool. Mix onions and garlic with thawed spinach and Parmesan cheese. Spread mixture 1/4-inch deep on flattened pork loin. Roll tightly and place in 2-inch deep pan. Sprinkle with garlic powder. Mix soy sauce and honey together; ladle over top of pork. Bake at 325 degrees for 40 minutes or to internal temperature of 165 degrees. Slice into medallions. Serves 8.

Exchanges: 3 Lean Meats + one Starch.

Calories: 220; Fat: 5.5 gm. carbohydrate: 15 gm; sat. fat: 2.3 gm; sodium: 485 mg; protein 26 gm.

Creamy Swirled Brownie

Ingredients:

1 pkg. (8 oz.) fat-free cream cheese

1 pkg. (21 oz.) low-fat brownie mix

2 egg whites (1/4 cup)

2 tsp. vanilla extract

1 Tbsp. sugar

Instructions:

Preheat oven to 350 degrees. Coat a 9-inch square baking pan with non-stick baking spray. In a medium bowl, with an electric mixer on medium speed, beat cream cheese, egg whites, sugar, and vanilla until fluffy. Prepare the brownie mix according to directions on the package.

Spread half the brownie batter into the baking pan. Spoon the cream cheese mixture over the batter, then spread the remaining half of the brownie batter on top. With a table knife, swirl through batter to create a marbled effect. Bake for 35 to 40 minutes, or until a wooden toothpick inserted into the center comes out clean. Allow to cool, then cut into squares and serve, or cover and refrigerate until ready to serve.

Note: Garnish with fat free whipped topping, sprinkles, or a maraschino cherry, if desired (topping not included in the nutritional analysis).

Exchanges: 1.5 Carbohydrate.

Calories per serving: 109; carbohydrate 20 gm; fat: 2 gm; sodium: 140 mg; protein: 3 gm; fiber: 1gm.

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CHANGING MY DIET

Question: I need help! I have been on insulin for 51 years and have always tried to have lots of fiber in my diet. Now I have been diagnosed with severe gastroparesis and have been told by my certified diabetes educator to try to limit fiber in my diet to 10 to 15 grams per day. I now feel guilty every time I eat a tossed salad, a banana, some strawberries, or a piece of whole-grain bread. I have also been told not to drink orange juice with "lots of pulp." I am dismayed because it seems all the things I have loved and felt right about eating are now off my list.

I take one teaspoon of Reglan before every meal and at bedtime. My blood sugars are in a lower range now that I have been on this program for two months. I have been on the pump for almost three years, which has also helped. My A1Cs are in the 6 percent range.

I would like some help on how to change my diet, what to avoid, and how much I can eat of these now-forbidden foods.

Beverly L. Bennett
Bradenton, Fla.

Kathleen E. Stanley, C.D.E., RD, responds: Fiber content in a diabetes meal plan has been an area of continuous debate for years. Overall, for good nutrition, 20 to 35 grams of fiber each day is recommended.

There are two main classes of fiber: soluble and insoluble. Soluble fiber from plants like oat bran, rice bran, dried beans, and other legumes (peas, corn, all dried beans, lentils) absorbs water and slows down the passage of foods in the digestive tract and has been shown to help lower blood cholesterol. Insoluble fiber from whole-grain products, wheat bran, brown rice, seeds, fresh fruit, and vegetables contains indigestible plant components, which aid digestion by speeding up the passage of food in the digestive tract. This helps prevent constipation.

Gastroparesis is a condition in which the stomach has abnormal emptying, causing the passage of foods to be delayed. Large amounts of processed food may pass into the lower intestines at abnormal rates, which causes bloating and cramping. High-fiber foods may make this condition worse.

Reglan helps you to properly empty your stomach. Your symptoms (such as stomach fullness, vomiting, heartburn, cramping, diarrhea, or constipation) will often be the best indicator of how much fiber your can tolerate. Overall, people with gastroparesis have fewer symptoms with a low-fiber diet.

When you're grocery shopping, read the nutrition labels so you can identify foods low in fiber. Your best bets include plain processed cereals without nuts, seeds or whole grain products; canned fruits and vegetables; white bread, crackers, and white flour products; jellies rather than jams; and clear juices without pulp. Also, pay attention to symptoms that may result from eating salads (start with small portions); this may help guide your portion sizes and tolerance limits.

Fruits and vegetables are not necessarily prohibited. If peeled, cored, and de-seeded, some fresh vegetables and fruits could still be worked into your meal plan. Cooking peeled vegetables until they're soft creates an opportunity to be creative with seasoning. Try a bit of lemon juice (no pulp!), onion powder, or other refined spice blends. Stewing fruit softens the fiber and makes delicious side dishes or desserts.

When you change your diet to include more fiber, you should do so gradually. That's because sudden changes may aggravate your symptoms, or cause constipation. Review your favorite foods with your certified diabetes educator or registered dietitian and talk about your options.

Lastly, your pump is an advantage, as you can adjust your bolus delivery times to account for the extra time it takes for you to empty your stomach. In time, you will be able to master your meal plan and perhaps discover new favorite foods to add to your list.

Copyright (c) 2003 American Diabetes Association, From DIABETES FORECAST, February 2003, Reprinted with permission from The American Diabetes Association.

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TOWARD CURING BLINDNESS

BBC Online, the Internet wing of the British Broadcasting Corporation, recently reported on two different studies of procedures aimed at restoring sight. Both are in early stages, but both show some promise.

In the first study, researchers at the Doheny Eye Institute, in Los Angeles, California, transplanted 2mm squares of retinal tissue into the eyes of patients suffering from retinitis pigmentosa. One patient, "who could see virtually nothing before the operation," reported after that she could see the "eyes, noses, and mouths of people sitting across from her."

Researchers caution that the observed improvements might be short term, and plan to carefully observe these retinal-transplant patients. If the results prove durable, the team wants to use the procedure to help people with less-advanced RP.

The second study involves an electronic device. Professor Mark Humayun, of the Keck School of Medicine at University of Southern California-Los Angeles, and his team, implanted 4x5mm electrodes into the retinas of individuals who had gone blind from retinitis pigmentosa or macular degeneration. The electrodes "plug into" the normal retinal circuitry, replacing the dead light-sensing cells.

The device is simple, and resolution is limited, but users have been able to recognize simple shapes, such as a cup or plate. At this time, the images are not captured by the eye, but by a small video camera.

Improvement is expected; research continues.

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TALKING BLOOD GLUCOSE MONITORING SYSTEMS

by Ed Bryant

Includes photo of Ed Bryant.

As editor of Voice of the Diabetic, I am often asked about the relative strengths and weaknesses of the various voice-enunciation equipped home blood glucose monitors available today. As regular blood-glucose metering is tremendously important, and as new developments regularly occur, I periodically update and reprint this article.

There is no "best" talking glucose meter; no one monitoring system is ideal for everyone. Features, prices, convenience, and clarity of instructions vary. Although many companies make blood glucose monitors, and some of these display their results in large print, only four currently available meters allow voice enunciation, in which the device's voice synthesizer "speaks" the meter's instructions and test results.

I advise all new blood glucose monitor users, blind or sighted, and all those uncertain of their meter's operation, to obtain further instruction from their health care team, and I advise them to self-test in the presence of their doctor or diabetes educator.

MEDICARE PROVIDES COVERAGE FOR THESE MONITORS, AND FOR ADD-ON VOICE SYNTHESIZERS FOR THESE BLOOD GLUCOSE METERS. THEY ARE CLASSED AS "DURABLE MEDICAL EQUIPMENT," AND COVERED UNDER MEDICARE PART B. BE SURE YOU AND YOUR SUPPLIER FOLLOW ALL GUIDELINES FOR REIMBURSEMENT. THERE ARE TWO "SPECIFICATIONS" TO NOTE: EO607, FOR "NON-ADAPTIVE" METERS, AND (this is new) E2100, FOR METERS AND/OR ADD-ON VOICE SYNTHESIZERS, AVAILABLE FOR DIABETICS AT LEAST LEGALLY BLIND. For Medicare information (in English or Spanish), telephone: 1-800-633-4227, and ask for "Durable Medical Equipment."

Highlights

My personal favorite is the Accu-Chek VoiceMate. This talking meter, which incorporates the proven Accu-Chek Advantage into a system designed and built by Roche Diagnostics, is the most advanced on the market today, and the easiest for a blind person to use. Its Comfort Curve test strip allows quick and reliable nonsighted placement of the blood sample. No more hanging drop of blood -- just smear or dab it on; the strip sticks well out of the meter, and you just find the tactile cutout on the side. Even if you have fairly severe neuropathy in your hands, this feature should make it easy to find the blood placement spot. And blood never drips onto the meter--so there is far less need to clean it. Its voice is clear and understandable. The VoiceMate includes two unique features: A "code key" system for calibrating the meter to a new set of strips (no more numbers to punch in!), making this the only talking meter a blind person can calibrate without any sighted aid at all; and a talking insulin vial identifier. If you use Eli Lilly insulins, you can insert them into the special opening, follow the spoken directions, and the machine will tell you what type of Humulin insulin you have there. (If your insulins are not from Eli Lilly, the VoiceMate's other features will still be completely operational.)

The VoiceMate can be ordered through any pharmacist. Have your pharmacist contact Roche Diagnostics; telephone: 1-800-428-5076, and ask for catalog #2030802.

NOTE: For customer service department and meter user advice, in English or Spanish, you should call: 1-800-858-8072.

The LifeScan One Touch meters: The Profile, and the now-discontinued One Touch II, are often adapted to voice synthesis. Recently, the LifeScan Basic and SureStep meters became speech-capable as well. The three One Touch meters: Basic, II, and Profile use the same procedures, the same test strips, and feature the same detachable test strip holder. All require a "hanging drop of blood." All are accurate, but their operating drill may make them difficult for blind users. All three accept "talk boxes," but voice synthesizers designed for the One Touch II will not operate with the Profile or Basic, and vice versa. Note: The LifeScan SureStep, a very different type of meter, features a "touchable" test strip, and does not require a hanging drop of blood.

The "voice boxes," speech synthesizer modules that plug into the meter's data port and provide its voice, are not made by LifeScan, but by several competing firms, described below. These manufacturers have been producing voice units for the old One Touch II, and updated versions for use with the Profile, and now for the SureStep. If you already have a LifeScan One Touch II, Profile, Basic, or SureStep, no modifications are needed to allow use of the appropriate speech synthesizer. If you do not yet own a LifeScan monitor, shop around, as some pharmacies and major discount stores sell these glucose monitors substantially below list price.

Talking Glucose Monitors and Voice Boxes

1.) The Accu-Chek VoiceMate talking glucose monitor:

Roche Diagnostics Corporation, 9115 Hague Road, Indianapolis, IN 46250-0100; telephone: 1-800-858-8072.

The Accu-Chek VoiceMate, developed in cooperation with Eli Lilly and Company, incorporates the Accu-Chek Advantage glucose monitor. The VoiceMate is small, portable, and weighs only 12.5 ounces. It contains a "bar code reader" to describe insulin type (Lilly insulins only). First offered for sale in 1998, the VoiceMate is supplied with a new type test strip, the Comfort Curve, which vastly simplifies the problem of blood sample placement. Very good audiocassette and large-print instructions are supplied (in English). Suggested retail $495.00 to $525.00, available through your pharmacist. Spanish-language customer service is available. Purchase price includes a carrying bag with adjustable strap. The VoiceMate is also offered by the National Federation of the Blind (NFB), Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314.

Note: The Materials Center is open 8:00 am to 5:00 pm, EST, weekdays. The NFB offers this meter for $475.00.

The only weakness I have detected in this otherwise excellent meter concerns the lack of a "Not Enough Blood" warning. The VoiceMate cannot distinguish between not enough blood on the strip and a low blood glucose reading. This occurrence seems to be uncommon, and Roche advises "double-dosing" the test strip (applying a second drop of blood to the same strip within 15 seconds of the first) in such cases. You might find it beneficial to test in front of your doctor or diabetes educator, who can advise you if you are not getting adequate blood onto the strip. I advised Roche of this problem, some time ago, but they have not yet rectified it.

2.) The Digi-Voice modules, for the LifeScan Basic, Profile, and SureStep:

Science Products, Box 888, Southeastern, PA 19399; telephone: 1-800-888-7400.

Science Products makes several versions of their robust and reliable Digi-Voice speech module: The big Digi-Voice Deluxe, and the smaller Mini Digi-Voice. Old voice boxes designed for the One Touch II will not operate with the Basic or Profile, and vice versa -- and the SureStep requires its own! The Basic uses the same talk-box as the Profile. Be SURE to tell them WHICH meter you have--they will supply the correct synthesizer for it! The Digi-Voice modules connect to the meter by a 22-inch patch cord, providing audio output for its readings. Controls are simple; on the Deluxe a volume control knob and a toggle switch run the voice synthesizer, separate from the monitor's controls. The Mini's single button both turns on the voice box and adjusts the volume control, again, separate from the meter's controls. Readings are announced in a clear, somewhat military, male voice. Thorough cassette instructions explain the voice box and briefly cover the Profile meter, no large-print instructions are supplied. Science Products sells the Digi-Voice Deluxe module alone for $275.00, and the Mini Digi-Voice modules alone for $199.00 (9-volt battery) or $219.00 (with AC adapter). Remember to specify which meter you own. They offer the LifeScan Profile glucose monitor for $120.00.

3.) The LHS7 Module, a voice box for the LifeScan Profile: LS&S Group, P.O. Box 673, Northbrook, IL 60065; telephone: 1-800-468-4789.

The small and light LHS7 attaches to the bottom of the Profile glucose meter by means of a Velcro patch, and operates through the meter's controls. Two-position volume control (loud and soft); AC adapter included in purchase price. English-language voice only; no audiocassette or large-print instructions are provided. Cost: $185.95, or $299.95 with a new Profile meter.

Medicare

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

An Invitation to Manufacturers

Currently available "talk boxes" (speech synthesizers) make use of the same "data port" installed in the meter to allow interfacing with and downloading to a computer. For many monitors, the hardware is already in place, and adding speech compatibility should be a simple process. The National Federation of the Blind urges manufacturers to go the rest of the distance, and make talking versions of their monitors available to those diabetics who need and want them. NFB Resolution 97-12 (adopted at the 1997 annual convention in New Orleans, Louisiana) calls on monitor manufacturers to make their meters speech-compatible.

Hints and Tips

If an insufficient amount of blood is placed on the test strip, the test will not take place, or the results will be inaccurate. Most meters will indicate "not enough blood." You may even have to prick your finger again! There are several possible explanations for this frustrating occurrence:

A. The initial drop of blood was too small: Some folks don't bleed enough.

They can get more blood by holding hands below waist level for about 15 seconds, shaking them, and/or washing/soaking hands in warm water for a few minutes before the test. Warm water stimulates the flow of blood to the fingers. A slightly longer lancet, with deeper penetration, may help some. (Are you using the shortest lancet? It may not be appropriate for you.) "Milking the finger" (squeezing it gently) can also help, as can wrapping a doubled rubber band between the first and second joint of the finger to be lanced. This will help cause the finger to become engorged with blood. Hold the rubber band down with the thumb while lancing. Remove the band as soon as you lance.

Doctors and diabetes educators who treat heart patients have noted that "prophylactic aspirin therapy," an enteric-coated aspirin a day to thin the blood and reduce risk of a heart attack, may make it easier for their diabetic patients to obtain a blood sample. If you are a "difficult bleeder," the same therapy with enteric-coated aspirin might help you, too. Be sure to talk to your primary-care doctor about aspirin, and to your eye doctor as well, because blood thinners like enteric aspirin can increase the risk of retinopathy.

B. There may have been enough blood, but it was placed onto the wrong part of the test strip (i.e."You Missed"): Some folks bleed fast, and may lose the blood off the finger before they're ready. By the time they get the finger to the test strip, the blood has fallen in the wrong place. A fast bleeder needs to work closer to the test strip, and perhaps to employ one of the blood placement aids discussed in this article. Users of the LifeScan SureStep should try bending up the tail of the test strip as an aid to location and placement. If you are new to your meter, I suggest you test in front of your diabetes educator, or someone familiar with your meter--perhaps there is some part of the drill you could do better.

C. Some enthusiastic people, placing the blood on the strip, press down too hard and push the blood out of its correct position, squishing it onto the wrong part of the strip: If you use the LifeScan One Touch meters, II, Basic, or Profile, it is best to very gently deposit a hanging drop of blood onto the test strip. Marla Bernbaum, MD, writing in The ADEVIP Monitor, offered the following suggestion, pertinent to diabetics with severe neuropathy (who wouldn't feel the otherwise painful fingertip "stick" she discusses here):

I have discovered another way to apply blood to the LifeScan test strip, which has been useful for several of our patients. This method allows them to stick the tip rather than the side of the finger. We use the same platform modification [described below], with a dot of Hi-Marks or T-shirt paint on each side of the strip guide near the depression where the blood is to be applied. For this approach the meter should be turned sideways. The patient can then place the pad of the finger on the raised dot perpendicular to the length of the strip and rock the finger forward so that the tip of the finger lines up with the depression on the strip and deposits the blood droplet in the appropriate place. This method increases the portion of the fingertip that can be used, and is preferable for some patients, particularly for those who bleed slowly and therefore must place the blood drop in precisely the right location.

LifeScan Modifications

If you use any of the LifeScan "One Touch" series glucose meters, some blood placement problems can be solved by modification of the Test Strip Holder (LifeScan Part #043-123, and note this same part fits all LifeScan "One Touch" meters). The idea is simply to provide tactile locating aids for finger location and placement of the blood sample on the test strip. A raised dot on either side of the test strip will work for some, but diabetics with limited sensation in the fingertips may find a U-shaped guide more useful. Most diabetics puncture the side of a fingertip, but those with severe neuropathy, who can't feel the lancet, and who prick the center of the fingertip, may be helped by the U-shaped guide. With practice, and the use of such tactile cues, blind diabetics can correctly place blood samples on the test strip. (Note: Thanks to Ann S. Williams, R.N., M.S.N., C.D.E., for providing the modified LifeScan Test Strip Holders mentioned here.)

The Test Strip Holder is detachable, and modifications as described will in no way interfere with the operation, accuracy, or cleaning of the LifeScan meter. LifeScan's Technical Services Department (phone: 1-800-227-8862) will provide a spare Test Strip Holder upon request, without charge. It is recommended that the modifications be to this spare.

The dots and U-shaped ridge were created with T-shirt paint, of the type that stands up sharply from a fabric surface. Upon application, the paint spreads a little, so apply sparingly. Best results come from "tack-painting," applying a small amount, then letting it dry (minimum 12 hours), with subsequent applications to build up the height. Practice first on some other material (posterboard or paper plate), as the paint can come out quickly. Be sure to have the Test Strip Holder OFF THE METER when applying the T-shirt paint. For best results, insert a test strip in the holder as an aid to placement of the dots or U-shaped ridge. T-shirt paint is inexpensive and is available at most craft and fabric stores. Although a full spectrum of colors is available, bright, contrasty colors like orange may aid in low vision situations. Brands and types vary; find one that gives you a nice hard tactile ridge. Some paints feel too rubbery. "Puffy paint" flakes off too easily. You may have to experiment.

Several vendors offer commercial alternatives to modifying the test strip holder. One slips over the LifeScan meter. This device aids in proper finger placement, and serves to guide the drop of blood more surely to the test strip. Science Products (address above, telephone: 1-800-888-7400), makes the Sure Drop, which slips over the body of the meter. The special Teflon-like coating on the surface of the device helps direct the blood, but can be damaged by bleach or a hard brushing--clean with mild soap and warm water. The unit appears well-made and easy to use. Price: $24.95.

I have discussed the strengths and weaknesses of the blood glucose monitoring systems with voice enunciation currently manufactured. This evaluation should help blind diabetics and those losing vision, who are just as capable as the sighted of independently testing their blood sugar levels, and performing all the other tasks of daily diabetes self-management. Both blind and sighted diabetics are encouraged to consult with their health care team, and with individuals experienced in use of glucose monitoring equipment.

Choosing the most appropriate home blood glucose monitor is an important step in diabetes self-management. As blind diabetics increase their participation in the mainstream, efficient glycemic control is needed to maintain good quality of life. As new companies and inventors grapple with the problem of talking blood glucose monitoring systems, we should see steady improvement in this equipment. The Diabetes Action Network of the National Federation of the Blind, a support and information network, welcomes your input on blood glucose testing.

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Voice DISTRIBUTORS NEEDED

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

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

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MEDICARE REFERENCE CODE CHANGE

Medicare has very specific "code specifications" for the various medical devices it will fund. For proper reimbursement, you need to use the correct number. There have always been two such "reference codes" for glucose monitors: EO607 for conventional glucose monitors, and EO609 for talking glucose meters, or talk boxes for existing meters. This second number has been changed. For purchase of a talking glucose monitor, or voice synthesizer for a glucose monitor, the correct specification is now E2100. Don't use EO609 anymore.

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WHAT YOU ALWAYS WANTED TO KNOW BUT DIDN'T KNOW WHERE TO ASK

(Resource Column)

Includes Art: Hand removing book from shelf.

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

Free Diabetes Literature

The National Federation of the Blind maintains an extensive literature collection, with free materials on many subjects available in a variety of formats. Twenty-three articles on aspects of diabetes, all previously published in the Voice, have been assembled into a single volume, available in large print and four-track audiocassette, titled: "Diabetes Action Network Articles." Both formats are free of charge. To order, or to request a complete NFB literature catalog, contact: NFB Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314. You may also order by e-mail: [email protected] The Materials Center is open 8:30 pm to 5 pm, EST, weekdays.

Relief

Many diabetics suffer from dry feet. It "goes with the territory." They hurt, they itch, they dry out and crack, and you need to do something about it. Sometimes neuropathy, nerve inflammation, in your feet can really drive you 'round the bend. But Steuart Laboratories offers help. Steuart's Foot Cream, with Melalenca Oil, is excellent for dry diabetic feet. Steuart's CNS Liposomes offers relief from neuropathy; also good for back, muscle, and joint pain. Prices (2-oz. jar): $9.25 plus shipping for the Foot Cream; $19.80 for the CNS Liposomes. Contact: Steuart Laboratories, PO Box 535, Mabel, MN 55954; telephone: 1-800-210-9665; Web site: www.steuartlabs.com.

Diabetic Supplies Online

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

Easy Diabetic Cookbook

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

News From Bayer

Ascensia Care, the diabetes subsidiary of Bayer, announces two new glucose monitors. First, they have replaced their "Dex" with the new "Dex 2," which is electronically the same, but incorporates mechanical upgrades in the name of increased reliability. The second new meter, the "Breeze," available August 1, is based on the Dex, and uses the same 10-test "autodisc," but is larger and simpler, designed for beginners.

There was an opportunity to make this new meter speech-compatible -- but, sadly, "the marketing department did not see sufficient demand." One hopes they will shortly correct this error.

Full Service Diabetes Supplier

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

New Web site for the Blind

www.eyes2eyes.com is a Web site for people who are blind or visually impaired. The site offers information about medical, safety, employment, vision and personal issues. Visitors can submit articles, tips, comments, and post messages. The webmaster, Julia Johnson, is visually impaired, and has a Master's degree in Counseling. Check it out: www.eyes2eyes.com.

New Treatment for Erectile Dysfunction

Erectile dysfunction (male impotence) is a frequent complication of diabetes, affecting perhaps 33 percent of diabetic men--and, by extension, their partners. Consequences can be devastating, and many different treatments have been tried.

The reliable, successful, FDA-approved treatments have been surgery, penile injections, Viagra (with limited success where diabetic circulatory damage is present), and vacuum therapy.

Pos-T-Vac Medical, from Dodge City, Kansas, has been manufacturing FDA-approved vacuum therapy systems for impotence treatment for many years. Company literature states their products enjoy a 98 percent success rate, without drugs, surgery, or medical intervention. And, because vacuum therapy devices are reusable, they constitute the least expensive approved treatment for the condition.

Pos-T-Vac's newest vacuum system is the BOSS-2000, a system consisting of cylinder, battery-operated pump, rubber ring, and safety valve. The system is certified safe, and can be used as often as desired. It comes with a 30-day, money-back guarantee and a two-year warranty. Price is $149.99, and the BOSS-2000 is available now. Contact: Pos-T-Vac, telephone (toll-free): 1-866-513-7328; Web sites: www.postvac.com or www.bosselite.com.

Diabetes Supplies

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

Did You Use Rezulin?

Some diabetics who used the now-banned medication Rezulin experienced complications from the drug. If you used this medication, were a caregiver for someone who did, or used Baycol or Vioxx, you might want to find out more about your legal options. Contact: Dean Spurlock, Attorney, 5601 Bridge Street, Fort Worth, TX 76112; telephone: 1-800-700-1075.

Full Service Diabetes Supplier

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

Learn Window Eyes

GW Micro, maker of the adaptive computer program Window Eyes, regularly offers training workshops in different parts of the country. Window Eyes users can receive tutoring in a number of "basic" and "intermediate" computer skills. On September 11 and 12, the National Center for the Blind will host one of these workshops. Tuition is $250.00 per day per person, if you bring a computer, or $350.00 per day if GW Micro provides. For information, contact: GW Micro, 725 Airport North Office Park, Fort Wayne, IN 46825; telephone: (260) 489-3671; fax: (260) 489-2608; Web site: www.gwmicro.com.

New Web site

Syringe maker and diabetes supplier BD has a new Web site, with features in both English and Spanish. There they showcase their latest products, but also provide a good bit of useful diabetes information. Some is available for download. Web site: www.bddiabetes.com.

Diabetes Supplies

Do you get tired of having to "shop around" for your various diabetes items? "Go to this place for these; to that place for those ..." Do something about it. Check out www.diabetesstore.com, the leading online source for discount diabetes products. Contact them by telephone: 1-800-891-9399; or Web site: www.diabetesstore.com.

Available from The NFB

At its headquarters in Baltimore, Maryland, The National Federation of the Blind maintains a store, the "Materials Center." A great many items of interest to the blind are offered for sale, on the web (www.nfb.org) or through two free catalogs (in large print, Braille, or audiocassette): "Literature," and "Aids and Appliances." Some of these items would be of interest to blind diabetics and those losing vision.

The NFB Materials Center offers the Accuchek VoiceMate talking glucose monitor, for the lowest price on record, $475.00. The Center also offers the Heartalker Personal Trainer (a talking personal trainer/exercise timer) for $75.00; a talking blood-pressure meter for $169.00 (complete with standard cuff; larger or smaller cuffs available); a digital talking clinical (fever) thermometer, for $15.00; and the "Lo-Dose Count-A-Dose (uses B-D 1/2 cc (50-unit) syringes, clicks for each unit drawn, both audio and tactile cues), cost $40.00. Note: The larger, 1cc, Count-A-Dose is out of production and unavailable.

Check out the NFB Materials Center. There are a lot of things for sale there, from canes and slates to Braille games, talking measuring devices, various recorders and players, literature about all aspects of blindness, and much more. Since the Federation is non-profit, we work to keep our prices as low as possible, for your benefit. Contact: Materials Center, National Federation of the Blind, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314; fax: (410) 685-5653; e-mail: [email protected]; Web site: www.nfb.org.

Portable Magnification System

We have been asked to announce: A new, portable magnification system allows people with macular degeneration or other visual impairments to live more independently is now available from Telesensory. Called the Olympia, this lightweight, handheld device magnifies reading material, food labels, checks, prescriptions and other items, enabling people with low vision to do more for themselves.

The Olympia magnifies reading material, checks, letters, prescriptions, food labels and pictures up to 26 times. The magnification system features a tilted screen for comfortable viewing, glare reduction and adjustable brightness capabilities to meet the needs of specific vision conditions. The system also has a wide-screen viewing option for text.

The Olympia allows users to view information in three modes: full color, negative mode with white letters on black background for high contrast and positive mode with black letters on white background for maximum clarity. The system can connect to a television for people who prefer a larger screen, increasing the magnification range up to 76 times. A folding writing stand provides 4.75 inches of clearance, allowing the user to set the system over the base and then write letters and checks or do other paperwork with ease. The carrying case, battery pack and optional car adapter provide additional portability.

Olympia and other Telesensory products are available through dealers and distributors worldwide. Olympia is priced at $2,495.00. For more information on the products or to find a local distributor, contact Telesensory at [email protected] or 800-804-8004.

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FOOD FOR THOUGHT

Includes picture of 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.

Oral Insulin Update

On June 2, 2003, Generex Biotechnologt Corp. announced it is commencing "Phase 2B" clinical tests of its Oralin oral insulin spray. These large, long-term tests will evaluate the efficacy of Oralin in type 1 and insulin-using type 2 diabetics, at various clinic sites across the United States.

This is a beginning. The Phase 2 clinicals must be successfully completed, and then Phase 3 must do the same, before the Food and Drug Administration will consider approval. It will be a few years; stay tuned.

Diabetes and Heart Attack

It is known that having diabetes increases your risk of cardiac events, like heart attack. Some heart attacks are asymptomatic, they're not painful, and may come as a complete surprise when detected by the doctor. For some time, it has been believed that being diabetic increased one's risk of asymptomatic heart attack.

A recently-completed study suggests that may not be the case. Dr. Patrick McNulty, of the Pennsylvania State College of Medicine, Principal Investigator of this study, said his data showed about 25 percent of heart attacks experienced by both diabetic and non-diabetic individuals were pain-free, even though potentially life-threatening--and that's dangerous, because people don't seek treatment when they don't know anything's happened to them.

Conclusion: Diabetics have many more heart attacks than non-diabetics, but the same percentage of these events will be asymptomatic--only the total number of events will be higher. Talk to your doctor about what you can do for a healthy heart, and get those regular check-ups, whether you "feel something" or not.

Important Notice

Insulin manufacturer Eli Lilly is discontinuing its animal-source Lente insulin, Iletin2-Pork. The company announces the last vials of this formulation will expire in March 2004 -- but "less than 500 users in the U.S. and Canada will be affected." These consumers will need to switch to another insulin formulation, and should first discuss such changes with their doctor.

Lilly states it has "no plans at this time to discontinue its other Iletin2-Pork formulations, of Regular or NPH insulin." For more information, contact Lilly Customer Service: 1-800-545-5979, or the Lilly Diabetes Answer Center: 1-888-885-4559.

Voice Formats

Voice of the Diabetic is offered in two formats: standard print, and 15/16 ips audiocassette, "talking book" speed. Anyone who is currently receiving the Voice in print and having difficulty reading it, may receive it on cassette at no charge. Voice tapes require the special tape player available free to the legally blind from Regional Libraries for the Blind and Physically Handicapped, which can be obtained by telephoning the National Library Service at: 1-800-424-8567. Note: Attempting to play Voice tapes (or any other tapes in NLS format) on a conventional music-speed tape player will yield incomprehensible "chipmunk sounds."

The Voice is also available by e-mail, distributed quarterly. Go to: www.nfbcal.org/listserv-signup.html to sign up.

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

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

The Chi Machine

We have been asked to announce: "Complimentary therapies" are procedures an individual might choose to adopt alongside (not instead of) regular medical treatment. Two, closely related, are massage and exercise. Japanese researchers have developed a machine said to aid both. The Chi Machine, an electric "aerobic exerciser," is said to provide aerobic/exercise benefits equal to those of brisk walking.

The Chi Machine is priced at $480.00. For more information, or a 14-day free trial, contact: Rob Webster; telephone: 1-800-548-2527; e-mail: [email protected].

Simlyn Update

Last issue (Voice Vol. 18, No. 2, April 2003), we reviewed how Simlyn, an analog of the hormone Amylin, might help insulin-dependent diabetics achieve better blood sugar control. The road from "possible breakthrough" to FDA approval is long and arduous--and many "promising" medications fall by the wayside.

On May 27, 2003, Amylin Pharmaceuticals, Inc., from La Jolla, California, announced its recently-completed clinical test showed its diabetes drug Simlyn met federal regulators' expectations for glucose control. Test participants who took both Simlyn and insulin were also able to lose weight - and those using insulin only are far more prone to gain weight.

Amylin says they hope to have Simlyn approved by the end of the year.

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 322,231 Voice readers could benefit from your story.

For information and article submission guidelines, contact: Voice of the Diabetic, 1412 I-70 Drive SW, Suite C, Columbia, MO 65203; telephone: (573) 875-8911.

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SUBSCRIPTION/DONATION FORM

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

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

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

The Voice is free to any interested person upon request. Each subscription costs the Diabetes Action Network approximately $20.00 per year. To help defray publication expenses, members are invited, and nonmembers are encouraged, to cover the subscription cost.

To begin receiving the Voice, please check one:

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

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

Send the Voice in (check one):

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

Optionally check this box:

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

PLEASE PRINT CLEARLY

Name:_____________________________________________________

Address:__________________________________________________

__________________________________________________

City:_______________________ State:______ Zip:__________

Telephone: ( )________________________

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