VOICE OF THE DIABETIC
The Diabetes Action Network of the National Federation of the Blind
Diabetes Support and Information
Volume 20, Number 1, Winter Edition 2005
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VOICE OF THE DIABETIC, published quarterly, is the national magazine of the Diabetes Action Network of the National Federation of the Blind. It is read by those interested in all aspects of blindness and diabetes. We show diabetics that they have options regardless of the ramifications they may have had. We have a positive philosophy and know that positive attitudes are contagious!
News items, change of address notices, and other magazine correspondence should be sent to: Ed Bryant, Editor, VOICE OF THE DIABETIC, 1412 I-70 Drive SW, Suite C, Columbia, Missouri 65203; Phone: (573) 875-8911; Fax: (573) 875-8902.
Find us on the World Wide Web at: (www.nfb.org) Our direct Web address is: (www.NFB.org/voice.htm)
Copyright (c) 2005 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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Here's the new front cover page for the VOICE.
Includes photo of Vanesa Sutherland with following overprinted on the photo: Vanesa Sutherland says, "We Have a Future."
WHAT CAN YOU DO?
Jean King Writes about Self-empowerment
BEGINNING CARB COUNTING: TEN COST-CUTTING TIPS
Linda Ruholl, RN, PhD, Shows Us How
NEW DIABETIC NEUROPATHY MEDICATION
Cymbalta Receives first FDA Approval for This Use
INSULIN-FREE!
Transplant Surgeon, Dave Sutherland, Discusses Pancreas and Islet Transplantation
DIABETES, HEART ATTACKS, AND STROKE
Ann Williams, RN, MSN, CDE, Discusses the Cardiac Complications
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ADVERTISERS
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For SUBSCRIPTION information, see the end of this document.
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INSIDE THIS ISSUE
WE HAVE A FUTURE
by Vanesa Sutherland...
SO WHAT CAN YOU DO?
by Jean king...
NEW DIABETIC NEUROPATHY MEDICATION...
READ THE LABEL CAREFULLY...
INSULIN-FREE: PANCREAS AND ISLET TRANSPLANTATION TO TREAT TYPE 1 DIABETES
by David Sutherland, MD, PhD...
AN ASPIRIN A DAY...
BEGINNING CARB COUNTING: TEN COST-CUTTING TIPS
by Linda Ruholl, RN, PhD...
REFLECTING ON OBESITY
by Peter J. Nebergall, PhD...
OPENING BLIND EYES TO SCIENCE...
KIDNEY DISEASE: WHAT CAN YOU DO?
by Ed Bryant...
MEDICARE THERAPEUTIC SHOE PROGRAM...
ANONDYNE THERAPY AND DIABETIC PERIPHERAL NEUROPATHY
by Angie Bowman, PT; Kim Hamel, OT; and Linda Hicks, BSN,
MS, CDE...
DIABETES, HEART ATTACKS, AND STROKES
by Ann Williams, MSN, RN, CDE...
DIABETES: FIRST IMPRESSIONS
by Fred MacDonald...
A WORTHWHILE BOOK
by Peter J. Nebergall, PhD...
DEALING WITH DIABETES DAY-TO-DAY
by Emily Gaines Buchler...
ASK THE DOCTOR
by Wesley W. Wilson, MD...
NEW TREATMENT FOR DIABETIC FOOT ULCERS
by Stephen A. Brigido, DPM...
LIVING WITH DIABETES 50 YEARS
by Pat oswald...
AMPUTATION DUE TO DIABETES CAN BE PREVENTED...
HEALTHY HOME COOKING
by JoAnna Lund...
RECIPE CORNER...
BOOK REVIEWS
by Marilyn Helton
DIABETES: WHERE WE ARE TODAY, WHERE WE WILL BE TOMORROW
by Frank Vinicor, MD, MPH and Jinan Saadine, MD...
RESOURCE ROUNDUP...
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WE HAVE A FUTURE
By Vanesa Sutherland
From the Editor: When I interviewed Vanesa Sutherland, I found her to be extremely knowlegable about pancreas and kidney transplant. Mrs. Sutherland has experienced some of the complications of diabetes, and will explain her organ transplant. Here's what she says:
Every time I consider my experience with diabetes, I see two open ends of my life, and a perpetual question. Neither the beginning (the diagnosis), or the end (the pancreas transplant) are closed points. As time goes by, and medicine finds more answers and explanation for both diabetes and transplantation, I am able to look in a different way at the same facts. As for the perpetual question, "Did you really take care properly of your diabetes/transplant?" -- I think I did, many times; it did escape from my hands at other times, but I always tried.
We were living in Mexico City at the time I was diagnosed. It did not come as a total surprise; a year before, when we were in Colorado, my blood sugar test came back abnormally low. Now, it was ostensibly high -- but as I still had positive c-peptide levels, the physician put me on oral hypoglycemic medication. A year after that, at age five, I was in a pediatric hospital in Mexico, dehydrated, and in a typical diabetic coma. That year, 1969, I started insulin. With no known family history of diabetes type 1, and no understanding of autoimmunity or the possible triggers of autoimmunity, my parents and younger brother and sister became a "diabetic family."
It was not easy growing up with diabetes. I wanted to be like my peers; but many of my teachers were aware of the diabetes and kept a good eye on me, to the point that in elementary school, my physical education teacher kept me from doing sports, to avoid hypoglycemia. Understandably, I was not very thrilled to share that I was diabetic, for fear I'd be treated differently, or prevented from the activities everybody else had access to. So diabetes became something I tried to keep to myself. But it was impossible; everybody around me knew. I am so happy things are more open now, and people in general have a better understanding.
We moved to Puerto Rico, and adolescence came, with its pulsating hormones making diabetes harder to control. Lows and highs were common, and the frustration of trying to stay in the normal glucose range I tried to offset with excelling as a student and a friend, seeking the company of people with whom I did not need to preamble as a diabetic. So that was my perception.
Back in Mexico, I went to college, did my graduate degree and work, with more ups than downs with respect to diabetes. I followed the changes in dietary and insulin treatment proposed by many endocrinologists, from the typical diabetic diet to eating normally, to adjusting my insulin, to treating complex carbohydrates as a "privileged" food; from urine sugar tests to several blood tests, to just two blood tests; from one daily insulin injection to one of NPH adjusted by R insulin, or just R with meals.
For several years, every time I injected myself, part of the insulin (who knows how much?) went out of my skin. Later on I was told that I had developed antibodies to the beef and pork from which those insulins derived.
I have in the back of my mind a faint impression of preparing for a test, and hearing in the news about pancreas transplantation -- while the University of Minnesota's aerial profile showed up on the TV, and a reporter emphasized the shortcomings of such a big surgery and a life on immunosuppression. I recalled thinking: "I am not there yet, and they are not yet there, either." Little I knew that some years after, I would need the University Hospital, need the publicized procedure, and I would call Minnesota home.
Less than nine years later, I found myself flying to New York, to meet my mother, and to have a bilateral vitrectomy. Things did not go as expected; I lost depth perception and a great deal of visual acuity. With time and eye exercises, I have gained some back, but some is lost.
At age 27 I was back with my very supportive parents in Puerto Rico, after quitting a wonderful, fulfilling job, my apartment, my friends and the boyfriend I thought I would marry someday. I spent long hours trying to see better, trying to read, making a word of fragmented letters. My parents and family helped me, and my ability to read was regained. I lost some vision but I still work on my standard computer and enjoy reading and traveling .
Five years after my vision problems, my kidneys failed. I found myself on dialysis, desperately trying to control my blood sugar. Useless were the several graphs and tables depicting food consumed, insulin taken and blood sugars; the endocrinologist just shook her head and told me again, "I do not know what to do with you." Not that I had not heard that before, but now I was on dialysis and my idea of having some worthwhile future was vanishing despite my best efforts, despite my best will. Not knowing that in spite of timely strict control some people are more susceptible than others to develop diabetic complications, I felt guilty and ashamed, not comprehending how other diabetics, who behave less carefully, walk through life practically unscathed.
Then a transplant surgeon who had trained at the University of Minnesota told me I should think about having a pancreas and kidney transplant. He gave me about 15 or 20 names of transplant centers throughout the nation. I wrote to every one of them, read all the information received and decided Minnesota was the best option.
In May 1995, my parents and I came to the University of Minnesota to see (at that time) Dr. David Sutherland (today I lovingly call him Dave; he will not like it another way, but that is now). On August first, the same year, my mother and I were in the preparation room just about to have surgery. She, lovely and beautiful as she is, offered to me not just one of her kidneys, but also half a pancreas. In that moment I reiterate how much she loves all of us, and that she has been my closest partner in diabetes, and in all the complications I had. Today, she is in perfect health, and strong and beautiful as ever.
All the organs worked right away, but I got a disease of the kidney induced by one of the drugs, and my stay in the hospital was protracted. I think Dr. Sutherland got tired of having the same feature in the ward, and asked me to write a computer program for internal organ allocation. After that, which I finished out of the hospital, several other projects followed, for the Diabetes Institute for Immunology and Transplantation, which he directs at the University of Minnesota. Among those projects, and many other ones we have today, we got married (to each other).
Finally that kidney failed, due to the harshness of the drug-induced disease and other factors. I spent some time on dialysis, as because of my high percentage of antibodies (due to a failed transplant and transfusions) I could not get a kidney from the National Waiting List.
Then my aunt (my mother's sister), with her endless generosity and care for her family, gave me one of her kidneys. During the ordeal the half-pancreas my mother donated to me has survived and kept me off insulin.
As you can see by now, I have a lot of people to thank; some I have mentioned, others still remain in my pen (read keyboard) and heart, nevertheless, the idea that we people need to support and get support from each other has been a determinant one in my life. Things have changed in the Fairview-University Transplant Center; they are getting better, the people are very knowledgeable but overall just good people.
Sometimes when peoples' health has deteriorated, for whatever reason, they get sad and depressed, because they feel they cannot get out of the quagmire. They feel like they're in a labyrinth. I have learned there is always a way to get out of that feeling. The participatory part, by the patient, is really important, to look for other options and ask yourself if a particular step is for you.
There is a lot of information available, to help you. We, who suffer such a complex condition, should try to obtain it. Just going to one doctor, or one center, is not enough. Get second opinions. Use the Internet. We need to educate ourselves. By the way, our transplant center has a website for those interested in pancreas or islet transplantation: (www.diabetesinstitute.org). It is an extremely good website, very valuable.
I have a pancreas transplant, actually half a pancreas, from a living donor. Not many people have half. The pancreas actually has two functions. One is to help the intestine with digestion; the other function is insulin production. The beta cells, in the islets of Langerhans scattered throughout the pancreas, are the ones responsible for insulin production. The islets, interspersed in the pancreas, accounts for 2% of its total weight.
In the 1960s and '70s, surgeons worked on transplanting just the islets, but also realized, at the time, that a complete pancreas transplant presented less obstacles, and they focused on making it work. Islet transplantation was a less invasive procedure for the patient; but a lot of problems in separating the islets from the rest of the pancreas needed to be solved. In addition, the immunosuppression regime, the series of drugs available to keep the body from rejecting the transplant, were too harsh for the survival of the new islets by themselves; in fact, they were, and some (still used today), are diabetogenic.
Nevertheless people kept working with the islets. A few, like Dr. David Sutherland, worked on both pancreas and islet transplantation. In the early '90s, the islet transplant outcomes at Minnesota were quite successful in some cases, but some of the promising immunosuppressive drugs used were later withdrawn from the market or, like dioxyspergualin, licensed by the FDA.
From the mid-90s to now, Dr. David Sutherland and Dr. Bernard Hering, at the University of Minnesota, worked on the clinical side of islet transplantation. Which drugs should be used? In what amounts? Is it possible to attain tolerance, so drugs are not needed? They studied ways to inject islets into the portal vein or other sites. They have tried to use pork islets (xenotransplantation) to make up for the shortage of human islet cells. Successful use of animal islet cells could open transplantation as an option to almost every individual afflicted who wants to trade in diabetes for immunosuppression.
As of right now, there are de facto restrictions on islet cell transplantation. One is insurance coverage; another is that the FDA is very cautious, especially with biological products. However, for diabetics whose kidneys have failed, Medicare is preparing to pay for an islet as it now does for a pancreas transplant. Some insurances cover pancreas transplant alone in diabetics whose kidneys are functioning. I have no doubt that very soon after clinical trials show islet transplants to be efficacious and safe, the insurance situation will change. We have a present. We really do have a future.
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SO WHAT CAN YOU DO?
by Jean King
I recently called the talking book library and requested an inspirational book that would help me with the task of being legally blind. I received a book the next day. The writer, an elderly, retired columnist of some sort, recounted for me the problems he faced, and documented all the things his wife did FOR him.
At first, I had wished for such complete custodial care.
I had already known those things this man spoke of, but I dutifully finished the book, boxed it up, and promptly sent it back. Then I wheeled myself out onto our beautiful deck and had a good cry.
I could have generated these emotions on my own. I had not needed the book I had spent my day reading. Then, I felt anger at the time and energy wasted in this effort to be "fixed." While I was atoning for my anger, it occurred to me: Since I hadn't found inspiration, I wondered if, perhaps, I might have it to GIVE.
Up to now, I have not shared my experience. I have guarded my feelings just in case they might not be "legitimate." But now I will share them.
Twenty-some years ago, when I was in my forties, my feet began to give me trouble. I did not have diabetes, but I had all the symptoms of peripheral neuropathy. My first task, it soon was apparent, was to convince the medical establishment, and their psychological cohorts, that my pain was not "all in my head."
That done, I traipsed to the major medical clinics, confirmed my own diagnosis, and discovered there was little else to do. I finally accepted reality and went about experiencing the painful loss of real sensation in my feet and legs. (It has since moved on to my hands, face, and gut, but is, somehow, not very relevant to the real living of my life anymore.) It just is part of my reality.
The nerve loss in my feet was taking away the long hikes in the Colorado mountain foothills and impeding my ability to drive, even with the hand controls I used at that time.
Reading was becoming increasingly difficult. I had read constantly since before I started school, so I thought perhaps I should cut back on what could be "over-use of my eyes." It did not help.
My ophthalmologist recognized the problem. Over the years, we had not much discussed my macular degeneration, but in 1992, she sent me off to another specialist, her friend, who specialized in low-vision problems, and she broke the news that I was now "legally blind."
There were not many choices left to make. I had already given up my driver's license. I was NOT ready to give up being a public school teacher.
Registration with the state department of vocational rehabilitation was a given. The staff valiantly attempted to find a means for me to continue teaching. My husband cooperated in every way. Nothing worked. I said goodbye to my last
student. I went home to accept my new situation and to mourn.
My husband returned to work. At home, I huddled under an afghan that my mother had crocheted for me long ago. I could not cry. I huddled. My dog, Daisy,a Cairn terrier, cocked her head and watched my behavior in dismay. She chased her tail in a futile attempt to get me to go for a walk. Then,when I laid down completely, she leaped up and settled herself ON TOP OF ME to wait. She sighed ... and waited. She waited for months. I dwelt on all the things that I could NOT do. Still, she waited.
Finally, my sluggish mind wandered. It wondered: what CAN I do?
If I could find my shoes, I COULD venture outside for Daisy. She was at the door, watching, waiting for me.
While I waited for her, I could see a tall weed in my Columbine garden. I COULD sit on the ground and pull it. I COULD.
I COULD scoot over a bit and reach another. I COULD. They needed water. I COULD.
That night, I met my husband at the door with a grin that he had almost forgotten. I COULD. Daisy smiled with my husband.
Each day, Daisy helped me find things that I COULD do. She smiled again as she got her first good hair brushing in a year. I could smile, too. I COULD.
My emotional and physical pain is not what I need to share with you. We are the experts of what is our own. What I want to give you are the things I learned while dwelling on the things I had lost. You will not have time to do that job yourself once you realize that you, too, CAN do.
In your own life, as you know, you will suffer losses, through aging, perhaps diabetes, peripheral neuropathy, macular degeneration, or some of the other ills of mankind. Whatever those losses are, I ask you to face them. Look at whatever it is in the light of reality. Look it over good. Get to know exactly what you have lost. ACCEPT IT. Mourn it thoroughly, but don't take too long. Life is short.
Then, ask yourself a question: What CAN I do about this condition, now that I have just accepted it? The keyword here is CAN. Don't waste your time on the reverse. Find one thing that you CAN do -- and act on it. Another "I can" WILL follow. If it is slow to appear, do the first "can" again while you wait. Celebrate it.
There might be something else you can do. Think about it; be creative. Hand controls on my car allowed me to keep driving, for a time, in spite of neuropathy and numbness in my feet. Another example: I now read books on tape. I didn't quit reading -- I switched. And, I recorded my own favorite recipes on tapes, while I still could read print. Then we found new measuring cups made for folks with limited vision, at a discount store. We marked the temperature settings better on my oven control -- and I was a cook again!
DO EVERYTHING YOU CAN THINK OF TO HELP YOURSELF. THEN, DROP IT. If there becomes more you can do, you will think of it. DO IT and move on.
Mantra for dealing with loss: FACE THE LOSS. MOURN THE LOSS. DO EVERYTHING YOU CAN DO TO MITIGATE THAT LOSS. LOCATE THE HELP YOU NEED AND ASK FOR IT. ACCEPT THE HELP, GRACIOUSLY. MOVE ON.
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NEW DIABETIC NEUROPATHY MEDICATION
One of the most common complications of diabetes is diabetic neuropathy, diabetes-induced damage to the nerves that run throughout the body, connecting the spinal cord to muscles, skin, blood vessels, and other organs. Diabetic neuropathy can be painful and disabling. Fortunately, the severest forms of neuropathy do not occur often.
Some symptoms of peripheral neuropathy (so named because it occurs outside the brain and spinal cord) occur when the nerve conduction is lost, such as muscular weakness, loss of feeling, even loss of functions not normally under conscious control, like digestion. These neuropathy symptoms include prickling, tingling, burning, aching, or sharp jabs of needle-like pain. This pain can be severe and incapacitating. Or, there can be complete numbness. Different types of neuropathy symptoms can occur together. It is common to have pain even though many fibers have been lost.
What Causes Neuropathy?
Researchers do not yet know what specifically causes diabetic neuropathy. Glucose control seems to play a prominent role -- as neuropathy is more likely to affect people who have had diabetes for a long time or whose glucose control is poor.
Neuropathy can be prevented, slowed, or diminished, in some cases. The Diabetes Control and Complications Trial studied complications in people on tight glucose control and those using regular diabetes treatment. Only one-third as many people in the tight-control group got neuropathy as in the standard-treatment group. In addition, avoiding alcohol and cigarettes will probably help protect your nerves from damage and prevent against neuropathy.
Treatment for Neuropathy
Researchers are still looking for a way to heal nerves damaged by neuropathy (see Anodyne Therapy article in this issue). Right now, most treatment aims to relieve the painful symptoms of neuropathy.
The U.S. Food and Drug Administration (FDA) recently approved the first treatment specifically for pain associated with diabetic neuropathy. This chemical, Eli Lilly's Cymbalta (duloxetine hydrochloride) is already in world-wide use as a treatment for depression. It targets two chemical messengers in the body, serotonin and norepinephrine, believed to play a role in pain perception. Other antidepressants, not approved by the FDA for this use, are also employed, "off label," to relieve nerve pain -- but Cymbalta is the first to be fully tested by the FDA for this use and found effective. For more information about Cymbalta (which is available now) talk to your doctor, telephone the Lilly Answers Center: 1-800-545-5979, or visit (www.lilly.com), or (www.cymbaltanews.com)
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READ THE LABEL CAREFULLY
From the Editor: The following medication errors took place in a professional setting. Doctors, pharmacists, and medical staff made them. But, just as when we make errors ourselves, it is the patient who winds up with the wrong medication. This time, no one got hurt, but we can't depend on luck. You need to know what you're taking, how much you're taking, and what each pill is supposed to do. And, you have both the right and the obligation to question your doctor, nurse, and pharmacist when something you take gets changed. Ask! You'll be safer.
The following is reprinted from ISMP MEDICATION SAFETY ALERT!, Vol. 9, Number 20, October 7, 2004, published by the Institute for Safe Medication Practices. Used with permission.
A family practice physician in a community health center prescribed metformin 500 mg bid to a newly diagnosed diabetic man from India, who did not speak English. When the patient returned to his office a few months later, he brought his medications with him, as requested. His physician quickly noticed that metformin was missing. Instead, the patient had a prescription bottle labeled as metronidazole with directions to take 500 mg twice a day. The prescription had been refilled several times. Luckily, the patient's diabetes remained stable, and he seemed to suffer no adverse effects from two months of unnecessary antimicrobial therapy.
The physician notified the pharmacy of the error and asked the pharmacist to check the original prescription, which had been written clearly and correctly for metformin. Upon further investigation, the pharmacist found the computer entry screen for selecting these medications included METF (for metformin) and METR (for metronidazole).
Apparently, one of the pharmacy staff members had entered MET and selected the wrong medication that appeared on the screen.
In another community pharmacy, the same mix-up happened twice, one day apart. In one case, metformin was initially dispensed correctly, even though the prescription had been entered incorrectly as metronidazole again, when the wrong mnemonic was chosen. The pharmacist who filled the prescription clearly understood that the physician had prescribed metformin, so he filled the prescription accordingly. However, he failed to notice the order entry error, as he did not compare the prescription vial label to the drug container label.
Unfortunately, the initial order entry error led to subsequent erroneous refills of metronidazole, as stated on the label. In the other case, bulk containers of the medication were available from the same manufacturer, both with similar highly stylized labels. Thus, confirmation bias contributed to staff's selection of the wrong drug. After reading, the staff member believed he had the correct drug.
In a hospital pharmacy, metronidazole 500 mg and metformin 500 mg were accidentally mixed together in the metronidazole storage bin. This resulted in dispensing metformin instead of metronidazole. Fortunately, a nurse recognized the error before giving the patient the wrong medication. Both were generic products, although the brands FLAGYL (metronidazole) and GLUCOPHAGE (metformin) are also available. Unit-dose packages of these drugs contain bar codes, and the printed information is very small, which adds to their similar appearance.
Safe Practice Recommendation:
Metronidazole-metformin mix-ups could be serious, considering the different indications and the potential for drug interactions. To avoid selecting the wrong drug from the screen, consider programming the computer to display the specific brand names along with the generic names whenever the MET stem is used as a mnemonic. To reduce similarity of the containers, purchase these medications from different manufacturers. Another option in hospital settings is to stock only the 250 mg tablets of metronidazole, since metformin is not available in that strength. This option allows a small risk for nurses who may administer just 250 mg when 500 mg is prescribed, but the potential for harm from giving the wrong drug is greater. It's also a good idea to separate the storage of these products.
During the dispensing process, drug names listed on written prescriptions and hospital orders should be matched to computer labels and manufacturers' products. Since metformin is used to treat a chronic condition, and metronidazole is more likely to be used for an acute condition, outpatient refills for metronidazole are less common and, therefore, bear a second look.
Asking physicians to include the drug's indication on the prescription can also help prevent errors. We'll ask FDA to add these drugs to the list of non-proprietary names that would benefit from using tall man letters. Meanwhile, underline or highlight the unique letter characters in these drug names to make their differences stand out.
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INSULIN-FREE: PANCREAS AND ISLET TRANSPLANTATION TO TREAT TYPE 1 DIABETES
by David Sutherland, MD, PhD
An estimated 1 million people in the United States have been diagnosed with Type 1 diabetes. Approximately 30 percent to 50 percent of them will experience secondary complications of the disease, such as heart disease, high blood pressure, stroke, diabetic retinopathy, blindness, kidney disease, nervous system disease, and amputation. A patient's risk of experiencing these complications increases as his or her total lifetime exposure to elevated blood glucose levels increases.
The Diabetes Control and Complications Trial, a clinical study conducted from 1983 to 1993 by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), illustrated that if a patient has a qualified diabetes care team and intensive insulin treatment, the patient's blood glucose levels could be normalized for several years. However, this intensive treatment may be difficult to achieve and sustain because it would increase the patient's burden of diabetes management, require increased medical services and patient monitoring, and be accompanied by more frequent episodes of severe hypoglycemia.
Currently, the only way to restore normal blood glucose levels without the risk of hypoglycemia is to replace the patient's islets, either by transplantation of a whole pancreas or by infusion of isolated pancreatic islets. Beta-cell replacement therapy (pancreas and islet transplantation) should be considered as an option for patients with type 1 diabetes and renal insufficiency who are or will be obligated to immunosuppression for a kidney transplant, or for non-uremic patients who experience hypoglycemia-associated autonomic failure or progressive microvascular complications.
Pancreas transplantation
The first pancreas transplant was performed in 1966, simultaneous with kidney transplant, at the University of Minnesota. To date, more than 20,000 patients worldwide have received pancreas transplants. Nearly 2,000 of these have been performed at the University of Minnesota.
Three types of patients that are candidates for a pancreas transplant:
* Diabetic patients with uremia: they would receive a simultaneous pancreas and kidney (SPK) transplant;
* Nephropathic patients who have already had renal insufficiency corrected, usually by a living donor kidney transplant: they would receive a pancreas transplant after they have had their kidney transplant (PAK); and
* Diabetic patients who are nonuremic: they would receive a pancreas transplant alone (PTA).
SPK transplants represent the majority of pancreas transplants, but there is a trend toward performing more PAK transplants as more living-donor kidney transplants are performed to preempt the need for dialysis in diabetics with nephropathy. In addition, more PTA transplants are being performed for patients with diabetes who do not have advanced nephropathy but who have such difficulty managing their diabetes that immunosuppression is justified.
In addition to insulin independence, pancreas transplant patients have experienced prevention and reversal of secondary complications, improved quality of life, lengthened life span, and reduction of health care costs per quality-adjusted life year. A pancreas transplant can save the life of patients with labile diabetes or hypoglycemia unawareness.
The United Network for Organ Sharing (UNOS) captures data on transplants performed throughout the U.S. From January 1999 to May 2003, more than 5,700 patients received cadaver-donor pancreas transplants for the first time. Outcomes measures reported during this period are shown in Table 1.
Islet transplantation
The first islet transplant was performed in 1974, when the islets from a cadaver-donor pancreas were infused into a diabetic patient who had previously had a kidney transplant. Since then, more than 700 islet allotransplants have been performed. Islet transplant is far less invasive than a pancreas transplant; it requires only a local anesthetic and takes about 60 minutes. The islets are injected into the liver, where they secrete insulin directly into the circulatory system to control blood sugars.
Between 1974 and the early 1990s, insulin-independence was difficult to achieve in patients who had type 1 diabetes. Since that time, islet transplants have become markedly more successful by increasing the number of islets transplanted into the patient and by reducing the diabetogenic side effects of immunosuppression. New generations of immunosuppressive medications have eliminated the use of prednisone in most recipients and have allowed calcineurin inhibitors to be used in low, nondiabetogenic doses.
Recent islet transplant trials have achieved improved results, including the Universities of Alberta, Miami and Minnesota. Most patients at the first two centers required islets isolated from two or more donor pancreases to achieve insulin independence, but at the University of Minnesota we have been able to do so with a single donor by careful selection of large donors for low insulin-requiring recipients and by an isolation process that preserves islet viability to the utmost.
Two islet transplant trials were recently performed at the University of Minnesota, with patients who had type 1 diabetes and who experienced hypoglycemia unawareness. Twelve of 14 patients achieved insulin independence after receiving islets from one cadaver donor pancreas each. After transplant, patients had excellent glycemia control, as shown by elimination of severe hypoglycemia post transplant, normal HbA1c levels, and normal oral glucose-tolerance test results.
The University of Minnesota's high success rate using a single donor pancreas is due to a number of factors. First, by using the two-layer pancreas preservation method, we were able to increase the number of islets isolated from the pancreas and preserve the ability of these islets to reverse diabetes. The two-layer pancreas preservation method involves sandwiching the pancreas between a top layer (which contains a cold preservation solution) and a bottom layer (which contains fluorocarbons that have been saturated with oxygen). This method delivers more nourishing oxygen to the pancreas than the cold preservation layer alone can. Second, during the peritransplant period, we targeted autoreactive T cells with anti-CD3 antibodies or polyclonal T-cell antibodies, which inhibit activated autoreactive T cells. Last, we cultured the islets pretransplant so that T-cell-directed immunosuppression was achieved in the patient well before islet infusion. This step is critical because it likely reduces islet-directed immune responses mediated by autoreactive, primed T cells to which the intravascularly transplanted islets are immediately exposed. Pretransplant culture allows for quality control studies to be performed before infusion and improves the metabolic efficacy of cultured islets. Delaying transplantation until two days after the patient starts therapy with T-cell-depleting antibodies prevents the transplanted islets from being exposed to the cytokine release associated with the first two antibody infusions.
By revising islet transplant protocols to include these advances, we have been able to achieve outcomes in islet transplant patients that are consistent with the outcomes experienced by pancreas transplant patients. Additional improvements in islet transplant outcomes are expected, as unique glucocorticoid- and calcineurin inhibitor-free, nondiabetogenic immunosuppressive regimens have proved safe and effective in relevant preclinical models.
We can expect to see licensure of isolated human islets as biologic products in the foreseeable future as human islet processing techniques are demonstrated to be controlled and consistent, as islet product potency assays illustrate the predictability of post-transplant islet function, and as substantial evidence is provided of the clinical safety and efficacy of islet transplantation. This licensure will help secure third-party reimbursement, which will provide strong incentive to maximize donor pancreas use. In addition, islet transplants will become more available as pancreas preservation techniques are further improved; as regional islet processing centers are created; and as donor pancreas allocation methods, logistics, and technical impediments are overcome.
Treatment considerations
Currently, patients who have either a pancreas transplant or an islet transplant must take immunosuppressive drugs to prevent rejection. Protocols designed to induce immunologic tolerance specific to the donor are underway with islet transplant patients. In the future, immunotherapy will be tailored to the specific needs of the individual transplant patient.
Although a transition from pancreas to islet transplantation may occur over the next few years, pancreas transplantation will always be the better option for certain types of patients. For example, patients with high insulin requirements before transplant would be best served by a pancreas transplant. Diabetic patients with exocrine deficiency would continue to benefit most from an enteric drainage pancreas transplant. And patients who are insulin resistant (type 2 diabetics) or who have very high insulin requirements may need a pancreas transplant in order to obtain enough islets to restore insulin independence from a single donor.
Beta-cell replacement therapy will have a great impact on tissue availability. Of the 6,000 cadaver donors available each year, only half have pancreases suitable for transplantation. Assuming each cadaver pancreas could be split for use in two recipients and that living donors would be used for segmental pancreas transplantation to the extent they have been used for kidney transplants, up to 12,000 pancreas transplants could be performed annually in the U.S. The potential exists to transplant at a rate approaching half the annual incidence of new-onset cases of Type 1 diabetes (30,000 a year) in the U.S.
Although the procedural and immunosuppressive risks now associated with islet transplants will continue to diminish and the efficacy of islet transplant protocols will continue to improve, islet transplants will not be the ultimate approach to diabetes care. However, islet transplants will create and build momentum for the development of xenogeneic and stem/precursor cell-derived islet Beta-cell therapy, which will make cell replacement therapy routine in diabetes care.
Every transplant center should perform pancreas transplantation, and eventually islet transplantation, for treating patients who have diabetes. Every endocrinologist should consider Beta-cell replacement in treating patients with type 1 diabetes who have hypoglycemia-associated autonomic failure or progressive microvascular complications.
Continued clinical research on pancreas and islet transplants is needed to identify the most appropriate patients for transplant, the best time to perform a transplant, and the most suitable donor tissue and transplant protocol for a given patient. Health care providers and third-party payers will support Beta-cell replacement therapy more enthusiastically as prospective, adequately powered clinical trials comparing intensive insulin therapy and Beta-cell transplants earlier in the course of diabetes document superior outcomes in cost-adjusted quality of life. The results of these clinical trials could provide a strong rationale for evidence-based stratification to islet-cell replacement in at-risk patients with incapacitating hypoglycemia or incipient secondary complications.
David Sutherland, MD, PhD, is head of the Transplant Division, director of the Diabetes Institute for Immunology and Transplantation and a professor of surgery at the University of Minnesota.
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AN ASPIRIN A DAY ...
This article originally appeared in the "News You Can Use" section of CONTROL SOLUTIONS, Summer 2004 edition, published by Integrated Diabetes Services
Men and women with diabetes (type 1 or type 2) are at greatly increased risk of developing cardiovascular disease. One of the primary reasons is increased production of thromboxane, which causes blood vessels to constrict and platelets within the bloodstream to become extra "sticky." Because it blocks the production of thromboxane, low-dose aspirin therapy has been shown to be an effective method for preventing heart disease and stroke. The American Diabetes Association recommends daily low-dose aspirin (75-162mg) for the following people:
Aspirin therapy is not recommended for those under age 21,
or anyone who suffers from bleeding problems. For more information, consult your physician.
CONTROL SOLUTIONS is a free newsletter published by Integrated Diabetes Solutions. For a free subscription, you can call Integrated Diabetes Solutions at (610)642-6055, or you can
e-mail them at ([email protected]).
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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 Diabetics Action Network of the National Federation of the Blind, 1800 Johnson Street, Baltimore, Maryland 21230, a District of Columbia nonprofit corporation, the sum of $_______________" (or "_______________ percent of my net estate" or "the following stocks and bonds:____________________") to be used for its worthy purposes on behalf of blind persons."
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BEGINNING CARB COUNTING: TEN COST-CUTTING TIPS
by Linda Ruholl, RN, PhD
(Includes photo of Linda Ruholl)
The newly diagnosed type 2 diabetic must make many life changes in a short period of time. According to the American Diabetes Association, dietary control is essential to all diabetics. It can put off the advent of insulin therapy for years, or perhaps indefinitely. Patients who take no oral medications need to tightly control carbohydrate intake, but carb counting can be confusing and expensive. Basic education from a dietitian or certified diabetic educator (CDE) is essential. These ten simple strategies help cut expenses.
1. Be cautious about purchasing special "diet" or "low carb" foods.
Many "diet" items are quite expensive when you take into consideration other alternatives. Try the smallest size first. Look for coupons and use them at a market that doubles the face value of the coupon. Read the label to find out the manufacturer's definition of a "serving." It probably won't be a "bowlful." Some manufacturers of so-called "low carb" foods keep the carb numbers down by shrinking the serving size.
2. Be equally careful about buying special cookbooks.
It's all too easy to spend $15 or $20 for a cookbook, only to discover the 250-page book has exactly three recipes you and your family would even consider eating. Go the library instead. If you have a card, you can take a cookbook home to spend more time examining it. If you are not a regular patron, study the cookbooks at the library and copy likely recipes onto 3x5 inch index cards. Your local library may also have back issues of DIABETES FORECAST or similar diabetic-focused magazines you can examine or check out.
3. Make your own "healthy" sweets.
Fresh fruits have natural sugars, and you can easily enhance these flavors. Thicken water with a little cornstarch, pour it over the fruit and cook gently until the fruit is soft, but not mushy. Add Equal or Splenda to taste. After one or two tries, you will know how much is enough. Sample the generic sweeteners; they are considerably less expensive than the brand name stuff, and many people can't tell the difference in a blind taste test.
4. Overhaul your favorite recipes.
Many recipes in traditional cookbooks are high in sugar, especially white sugar. Convert them to a lower carb version by substituting an artificial sweetener. Our family's experience is that aspartame and sucralose taste satisfyingly sweet, but other sweeteners leave a bitter aftertaste. Bulk packages of these products include conversion charts that list exactly how much to substitute for a given amount of sugar.
5. Invest in a couple of compact and inexpensive reference books.
Total calorie intake and carbohydrate counts are both important. The Doctor's Pocket Calorie, Fat and Carbohydrate Counter, by Allan Borushek, will give you plenty of information about foods you prepare yourself. Other sections give data about restaurant and international foods, as well as counts for many US fast-food chains. Borushek's book measures only 4.5 by 6 inches, and is about a half-inch thick, making it small enough to fit into a coat pocket, purse or glove compartment. At $6.99, it is a good buy.
A second inexpensive guidebook is The New Glucose Revolution Complete Guide to Glycemic Index Values. The book has two sets of tables: an A to Z listing of foods with their respective GI and carb count, and a listing of foods ranked from low to high GI. This lets you compare foods within a category and make some predictions about how quickly a given food will raise your blood sugar. For example, a quick check of the dry ready-to-eat cereal section shows you that All-Bran has a GI of 38, but Kellogg Corn Flakes rates a 92. This guide is also a bargain at $6.95.
6. Look at directions for food preparation with an open mind.
Packaged foods will often stretch to make more servings. For example, our favorite vanilla diet pudding mix calls for two cups of skim milk and makes four servings. Try adding three cups of milk next time. The mixture sets up just the same, and you get six cups of pudding instead of four. I add a half-teaspoon of vanilla and a little extra sweetener before mixing.
7. Plan fast food and family restaurant trips carefully.
If you are planning to take the kids or grandkids to McDonald's, don't despair. You can eat there, too. McDonald's publishes A Full Serving of Nutrition Facts, which gives the full gamut of nutritional information about all their menu choices. Many of the sandwiches are very high in carbs, but there are a number of options that contain less than 30 grams of carbohydrates, such as Chicken McNuggets and the salads with grilled chicken.
Tuck some of the nutrition sheets from other restaurants into a folder and slip them under your passenger seat. When you travel, you will be able to find something suitable. One useful website contains information about ten different fast food restaurants, including Arby's, Burger King, Hardee's, Taco Bell, Subway, and Wendy's. Go to www.fatcalories.com, and you can search each restaurant's offerings by carb count or by total calorie count. The data base ranks the choices from highest to lowest number of carbs.
8. Pay for food and not for packaging.
Many nutritious foods are inexpensive. A good example is cereal. You can eat it for breakfast, a quick lunch or for a snack. Cereal by the bag is cheaper than boxed cereal. A generic plastic bag of raisin bran cereal sells for 10.8 cents per ounce in the Midwest, while boxed raisin bran cereal costs 16.6 cents per ounce. You would pay 10.5 cents per ounce for toasted oats in the bag, but 16.9 cents per ounce in the box. Over a year's time, the difference adds up.
9. Use the internet to learn about your condition.
Both commercial and public service sites have good information The American Diabetes Association (ADA) site is the mother lode of current and accurate information. There is a special section of this site for the newly diagnosed diabetic. It will help clear up confusion about carbohydrate counting and other issues. Check out the ADA at (www.diabetes.org).
DIABETES DIGEST offers a one-page glycemic index list of the 300 most common foods. You can access it at (www.diabetesdigest.com). This same site has a useful one-page sheet of hints, Ten Tips for Taming Your Cravings.
10. Keep track of your daily blood sugars, and glycosated hemoglobin levels, as well as your blood lipid levels.
Health providers find it easier to interact with an informed and motivated patient. Your doctor or nurse practitioner will be impressed with your organizational skills, and will work harder with you to manage your diabetes cost-effectively. The newer oral medications for diabetes are quite expensive. Why enrich the pharmaceutical industry if you can avoid it?
Go to (www.equal.com) to download your own copy of EASY EVERYDAY LOGBOOK. This booklet has a section where you can track your lipid and HbA1c levels, as well as day-by-day sheets for carbohydrate counting and blood glucose tracking. This same site offers a two-page educational offering titled: Ready, Set and Start Counting: How to Use Carbohydrate Counting to Keep Your Blood Glucose Healthy. Use this information to supplement and review the information you received from your dietitian or certified diabetic educator.
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REFLECTING ON OBESITY
by Peter J. Nebergall, PhD
(includes photo of Peter J. Nebergall, with cat)
I've been reading a lot of different articles about childhood obesity and its impact on long term health. The phrase: "experts say..." must surely be the most abused in the language. What experts? And where are they looking?
I've heard "suburban sprawl" blamed for overweight kids. That's silly. Go to the inner cities, and look at the children. If increasing "suburban sprawl" was the significant agent of obesity, these ghetto kids (whose environment is just as it was for their parents and grandparents) wouldn't be so quickly getting heavier, faster than the suburbanites. Hypothesis disproved.
Moviemaker/prankster Morgan Spurlock recently produced a shockumentary film called "Supersize Me," in which he ate only fast food for a month, a LOT of fast food, and did not exercise. He gained a lot of weight, and his cholesterol shot up. Spurlock would have us blame the fast food industry (and it is easy to eat a lot of calories at a fast food restaurant) but he knowingly set out to consume three times the "maintenance amount" (1800 calories) a sedentary adult needs to maintain weight -- and one could just as easily do this at the local barbecue, all-you-can-eat catfish restaurant, or kitchen table, with biscuits and gravy for breakfast. Bad food choices.
Spurlock has a point, however. Fast food is so easy to overeat. Ralph Nader called the double cheeseburger "a weapon of mass destruction." We are subjected to an incredible cacophony of adverts urging us to have more, that "bigger is better," whether it be soap powders, washing machines, SUVs, or "$6 burgers for 3.95." The fast food marketing industry is certainly part of this problem -- but so are we, the consumers -- and all this "Madison Avenue" only works if WE fall for it. We don't have to.
Another study found that, if offered more food, at the same price, people take it. "We're getting something free! Yippie!"
Right. Isn't that why "all you can eat" buffets are so popular? Go watch, and, if you can, take a foreigner with you, someone from a country that doesn't have such places (most don't.) They'll be shocked at the overeating -- and you should be too.
We, and our children, ARE gaining weight. There are several causes, and overuse of "junk food" outlets is one of them. But, if we don't cook healthy food, and don't provide our children an alternative, what else can we expect?
Lack of exercise is an issue. A BIG issue. Our explosive expansion in waist sizes perfectly maps on the cutback or cancellation of serious school physical education classes ("for budgetary reasons") and on the arrival of "virtual reality" computer games. When you want an adventure, do you rent one, or do you go have one? If you move less, its just the same as if you eat more. You gain. What else can we expect?
I've written about the "trick food" diets that would have us "eat all you want" -- if you buy it from THEM." When they work, is it not because their stuff is so expensive its high price limits consumption? They are neither an economical nor a healthy answer to obesity -- just another product to sell.
Obesity is a problem for all of us. If you have diabetes, or if you have the genetic background for type 2, it can make it worse. Excess weight can bring on the symptoms, and what was once "adult onset" diabetes is now arriving in pre-teen years. More years with diabetes means more time for serious complications -- so we need to act, now, before more damage is done.
What can WE do? A bunch. We can stop "supersizing it," and remember Gluttony was one of the "Seven Deadly Sins" -- for good reason. We can count our calories, and stop when we've had enough. We can commence an exercise program. We can stop pretending it isn't better to be fit. It is.
Obesity is a solvable problem. We can all help; by action, and by good example. Let's roll.
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OPENING BLIND EYES TO SCIENCE
(the following article is courtesy NASA and the National Federation of the Blind)
A 14-year-old blind boy named Steven is digging in a container of soil at the Maryland Science Center. Steven and Amelia are blind, yet both were able to read the temperature with a thermometer and measure precipitation with a rain gauge at a science camp this past summer.
Their secret?
Steven and Amelia, along with 10 other blind students ages 11-14, were using a talking thermometer, a Braille-marked rain gauge and other tools identified by NASA for use by the visually impaired.
The tools got their first major test in July at the end of the week-long "Circle of Life" camp put on by the National Federation of the Blind and sponsored by NASA. On the camp's final day, students visited the pond and forest area of NASA's Goddard Space Flight Center in Greenbelt, Md., where they made observations of the soil, vegetation, weather and birds.
For many of the kids it was the first time they had used observation instruments specifically geared toward the senses of sound and touch, rather than sight.
"I didn't know they existed," said Steven, now a ninth-grader at a science-oriented high school in New York. "It was amazing to see the technology."
Goddard soil scientist Elissa Levine has been leading NASA's effort to introduce various blind-friendly gadgets to the visually impaired community. Her work is aimed at making activities such as GLOBE -- a NASA-sponsored science education program in which K-12 students around the world take measurements of soil, land cover, air, water and living things -- more accessible to the blind.
"I have been working with the GLOBE program for many years and am aware of how effective it is as a learning experience, which made me interested in seeing if it would be as effective for blind students as well," Levine said.
The new instruments include two kinds of talking thermometers -- one for the air and a "meat thermometer" that can be inserted into the soil. There's also a talking compass, and a talking sensor that analyzes soil color. A graduated cylinder with a floating Styrofoam plug serves as a rain gauge. The plug moves up or down depending on the volume of water and is attached to a plastic measuring scale marked with Braille.
Unlike other sciences that are sometimes more abstract, Earth science provides plenty of convenient opportunities for interactive, nonvisual activities, such as listening to birds or rubbing soil between one's fingers.
"The best thing about Earth science is that there is a natural laboratory right outside the classroom door," Levine said.
Promoting interest in science -- Earth or otherwise -- among the more than 93,000 estimated blind school-age children in the United States is as much about educating teachers as it is kids, according to the camp's lead instructor, Robin House, who says teachers often underestimate the potential of blind students.
"Many times blind students are left out of sciences and math because some educators think, 'Oh, this is too difficult, they couldn't possibly grasp these concepts,'" said House, who herself is blind. "The idea of this particular camp was a little bit of exposure in all the areas of science to get kids going, 'I can do science, I can do it. I can become a scientist if I want to.'"
In the days preceding their visit to Goddard, the campers dissected a dogfish shark and dug for dinosaur fossils at the Maryland Science Center, explored seashells with blind shell expert Geerat Vermeij, took a boat ride on the Chesapeake Bay, and listened to sounds from space with blind physicist Kent Cullers.
The camp was the first step in the National Federation of the Blind's initiative to create a National Center for Blind Youth in Science. A second camp held in August -- "Rocket On!" -- challenged blind high school students to develop, build and launch a 12-foot rocket from NASA's Wallops Flight Facility on Virginia's Eastern Shore.
For 12-year-old Amelia, the "Circle of Life" camp was a rare chance to experience science up close and personal. "We don't usually get to have so much hands-on activities when we're with a classroom. We have to touch stuff to be able to know what they really are like," Amelia said. "There are a lot of tools out there that blind people can use to investigate science. Blind people can pretty much do anything, but they just do it differently."
In addition to having the right kinds of tools, House says it is critical to the success of blind students that educators help dispel misconceptions among sighted students as to what blind people are capable of.
"Sometimes it might take a little bit longer, maybe there's a different way that the blind student has to go about doing something," House said. "But that's what science is really about anyway -- trial and error, trying things, taking risks."
Steven has a simple, straightforward message for both students and teachers: "Blindness doesn't have to be a barrier. Being blind doesn't stop you from having a brain and doing science."
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KIDNEY DISEASE: WHAT CAN YOU DO?
by Ed Bryant
(includes photo of Ed Bryant)
I am a long-term diabetic who experienced renal failure. On August 9, 1983, I had a kidney transplant. To date, 21 years later, I feel great, and the new organ is functioning perfectly.
Knowing that nephropathy, kidney failure, is a frequent complication of diabetes, what can YOU do to prevent, minimize, or slow it? There is a tight statistical link between quality of diabetes control - and ramifications such as heart and blood vessel disease, diabetic eye disease, and diabetogenic kidney failure. We know the tighter your control, the less chance you will experience these complications. Good self-management is the BEST way to cut the risk.
There are things you can do. First, don't smoke. Nicotine, the narcotic active ingredient in tobacco, is a vasoconstrictor, raising blood pressure, stiffening capillaries, and making it harder for the kidneys to filter wastes.
Urinary tract infections need prompt treatment, to limit the damage they can do to already strained kidneys. Tell your doctor promptly if you think you have such an infection.
Excessive obesity raises blood pressure and increases insulin resistance. Keeping your weight down helps in general, and the resultant blood pressure drop is good for your kidneys.
You need to control your cholesterol, as too much of this fatty substance in your blood overworks your kidneys. Proper diet, exercise, and appropriate medications can lower your cholesterol levels. Consult a Registered Dietitian (RD) for advice; kidney failure imposes unique constraints.
High levels of stress can be damaging. It drives up blood pressure, can harm the kidneys by raising fluid pressure, further straining already weakened filter networks. Stress reduction is part of a healthy lifestyle. Ask your health care team for advice here.
Other than "keep your diabetes under the best possible control, and live a healthy lifestyle," I can offer little advice about prevention.
Once kidney disease is diagnosed, however, a great deal can be done to retard its progression. Current statistics suggest perhaps four out of every ten diabetics may experience measurable kidney disease, though many of these individuals should be able to avoid progressing to outright kidney failure, End Stage Renal Disease (ESRD).
Testing Your Kidney
How is the severity of kidney disease measured? Several tests measure creatinine, a waste product from muscle mass. Although everyone's body produces creatinine, people whose kidneys are failing cannot properly excrete it. One test measures the amount of creatinine in the blood, and the other is "creatinine clearance," a 24-hour urine test. Normal "blood creatinine," for someone with healthy kidneys, is about 0.7 to 1.3. Government guidelines (April 1995) recommend dialysis when the blood creatinine rises to 6 or above (the number rises as you get worse). However, some diabetics will experience kidney failure before that point. There is much variation between individuals who have ESRD, and the actual range for "kidney failure" runs from 3 through 8--but at or above 6, Medicare will pay for dialysis.
"Creatinine clearance" is considered a more reliable test. In this 24-hour urine test, the numbers produced approximately indicate the percent of normal kidney function remaining to the individual (the number goes own as you get worse). The 1995 government guidelines (which relate to Medicare part B eligibility) state they will fund dialysis when this test produces a reading of 15 or less.
Two other tests measure protein spillage into the urine. These are the microalbumin test and the test for proteinurea. The protein albumin is not normally excreted into the urine, and its presence in the urine, in small amounts (microalbuminuria) or larger concentrations (proteinurea) can indicate kidney disease. While not considered absolute diagnostic evidence, a positive finding in either should be immediately followed by further testing, as these tests are very sensitive, and the microalbumin test can detect kidney disease long before the other tests--allowing earlier medical intervention.
Options
Individuals experiencing impaired kidney function, but whose test results indicate they do not yet need dialysis or transplantation, might benefit from regular use of ACE (Angiotensin Converting Enzyme) Inhibitors, commonly used to control hypertension, high blood pressure. Now widely accepted, these ACE Inhibitors have been shown to significantly reduce further kidney degeneration. Note: A diabetic experiencing kidney failure, but whose blood pressure is not elevated, can still use ACE Inhibitors for keeping fluid pressure down in the kidneys. This therapy has been shown to significantly reduce strain on eyes and cardiovascular system, as well. Talk to your nephrologist (kidney specialist) about the ACE Inhibitors.
End Stage Renal Disease
The damaged kidney may worsen to the point where it can no longer carry out its blood-purifying function. Then dialysis or transplantation are necessary in order to preserve life. This is ESRD, end stage renal disease. What are your options then?
There are three: In hemodialysis, the patient's circulatory system is temporarily linked with a machine that performs the blood-cleansing functions of the human kidney. In peritoneal dialysis (CAPD or CCPD) a tube is inserted into the patient's peritoneal cavity, allowing urine and unneeded fluids to periodically drain from the body. The third option is kidney transplantation, in which a donated kidney is surgically implanted into the patient's body.
National Institutes of Health statistics show that 42.9 percent of all individuals facing dialysis are there because of diabetes, and about 40 percent of those commencing dialysis or seeking a transplant at this time are diabetic. Some remain on dialysis long-term; others make use of the process while awaiting a kidney transplant.
Dialysis
Dialysis is not an "artificial kidney." A person undergoing hemodialysis must be hooked up to a machine three times a week, three to four hours per session.
Like the kidney, a hemodialysis machine is a filter. Where it uses tubes and chemicals, the kidney uses millions of microscopic blood vessels, fine enough to pass urine while retaining suspended proteins. Long-term high blood glucose can significantly damage the kidney's filters, leading to scarring, blockage, and diminished renal function. Diabetes is the leading cause of kidney disease (the second is hypertension). Long-term diabetics often have cardiovascular and blood pressure problems as well, and the added strain of hemodialysis, with its rise in blood pressure straining eyes and heart function, can be too much for some. The diabetic dialysis patient spends, on the average, 33 percent more time in the hospital than does the non-diabetic dialysis patient, according to 1999 USRDS figures.
Some patients choose CAPD (continuous ambulatory peritoneal dialysis) or its variant, CCPD (continuous cycling peritoneal dialysis), both of which can be carried out at home, without an assistant. Though the risk of infections is heightened (as it is with any permanent catheterization), these two processes have their advantages.
Transplantation
Kidney transplantation is a logical alternative for many. A transplant frees the patient from the many hours spent on hemodialysis procedures each week, or from the periodic "exchanges" and open catheter of CAPD, allowing a nearly normal lifestyle. It can bring real improvement in quality of life and overall longevity.
An article, published November 1999 in the New England Journal of Medicine, shows the longevity gains have been major. The average graft survival (how long the kidney remained functional, not the patient) was, from a living donor, 17 years, in 1988. Per 1996 statistics, it is now 36 years. The typical cadaver kidney transplanted in 1988 lasted 11 years, but in 1996, the life expectancy of the organ was nearly 19 years. The study, led by Dr. Sundaram Hariharan, at the Medical College of Wisconsin, funded by the National Institutes of Health, concludes the improvement is largely due to the development of better anti-rejection medications.
"Fifty percent of all kidney transplantations taking place today are into diabetics," states Giacomo Basadonna, MD, PhD, a transplant surgeon at Yale University School of Medicine, in New Haven, Connecticut. He reports that success rates are identical with kidney transplants performed on non-diabetic ESRD patients. "Today," he advises, "average kidney survival, from a living donor, is greater than 15 years."
"Will you survive longer once you get a transplant?" asks Marianna Markel, MD, Director of Transplant Nephrology at SUNY Health Science Center, in Brooklyn, New York. "If you're a diabetic, it looks like the answer may be yes, perhaps because certain substances which build up in the blood of diabetics (advanced glycosylation end-products) are not removed well by dialysis, and may contribute to a shortened lifespan for diabetic patients on dialysis."
I and others knowledgeable in kidney transplantation advise you to pick the best transplant center possible. Once you have read their statistics, ask your prospective center plenty of questions. If they don't answer to your satisfaction, you should consider going to another center.
Facts and Statistics
What is the success rate for kidney-transplant surgery? According to the "United States Renal Data System 1999 Annual Data Report," published by the National Institutes of Health, about 75 percent for a cadaver-donated kidney, better than 90 percent with a kidney donated by a living relative, with an overall success rate of better than 85 percent, better than 90 percent in some centers. UNOS data indicate the averages (based on graft survival, healthy kidney, five years after transplant) are improving. The National Institutes of Health reports that current "graft survival" (donated kidneys successfully functioning in the transplant recipient) rates are approximately the same now, whether the recipient has diabetes or not.
What percentage of type 1 diabetics will face ESRD? Current statistics suggest between 20 and 25 percent, with many factors (genetic, ethnic, lifestyle) taken into account.
Must the ESRD patient be on dialysis before being considered eligible for a transplant? NO! Although some behind-the-times nephrologists still believe so, Fairview-University Medical Center's Transplant Center, which pioneered diabetic kidney and pancreas transplantation, recommends once your physician has determined kidney failure is on the way, further delay could be harmful. The more time spent subjecting your body to the toxic excesses of kidney failure and the strains of dialysis, the greater the risk of serious complications like retinopathy and cardiovascular (heart) degeneration.
Your nephrologist should be able to tell you more about your options. For information about kidney transplantation, contact a reputable kidney transplant center (there are approximately 250 in the U.S. today), or the United Network for Organ Sharing, 1100 Boulders Park, Suite 500, Richmond, VA 23225; telephone: 1-800-243-6667; website: (www.unos.org). All UNOS information is available on the World Wide Web, but they will also send you pertinent information, by mail, about transplant centers in your area or nationwide. Contact them at the above address, and ask them for the "kidney transplant package." They also offer the brochure "What Every Patient Needs to Know," and an organ-donor card for you to carry.
For information or assistance with interpreting transplant center data, contact: Health Resources and Services Administration, Bureau of Health Resources Development, Division of Transplantation, OSP, Park Lawn Bldg., 5600 Fishers Lane, Room 7C-22, Rockville, MD 20857; telephone: (301) 443-7577; website: (www.hrsa.gov/osp/dot). This agency also maintains the website: www,organdonor.gov, which offers many useful links and much pertinent information.
Renal failure is not a kiss of death. There are options, and at least one of them will be right for you. Keep your diabetes under good control, and your blood pressure down, to cut the risks--but if it happens (like it did to me), remember that with proper care you stand every chance of living just as long as you would have with healthy kidneys.
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TRANSPLANT PATIENTS SPEAK:
The following individuals are the real experts. Collectively, they have more than 168 years experience living with a transplant! All of them would choose transplantation again. Although kidney and pancreas transplantation are not for everyone, and sometimes they don't work, they should be given strong consideration.
Karen Mayry, from South Dakota, received her kidney transplant at Fairview-University Medical Center, in Minneapolis, Minnesota, on January 12, 1977. She declares, "I feel great!"
Betty Walker, from Missouri, received her kidney on July 13, 1978, at Yale-New Haven Hospital in Connecticut. In her words: "I was just existing on dialysis; and my transplant gave life back to me."
Lenny Ruygt, from California, received her kidney transplant at Pacific Medical Center, in San Francisco, on St. Patrick's Day, March 17, 1980. She says: "On dialysis, I had no energy at all--I would sleep all but two hours of a day. After my transplant, I felt energized!"
Linda Bingham, from Ohio, who received her kidney transplant at University Hospital in Cincinnati, Ohio, on December 10, 1981, says, "I feel great. I have been given a whole new life."
Ed Bryant, from Missouri, received his kidney on August 9, 1983, at Fairview-University Medical Center, in Minneapolis, Minnesota. He says: "There is no comparison between life on dialysis, and how I've felt since my transplant."
Faith Tootel, from California, received her new kidney on September 24, 1984, and her new pancreas on September 29, 2000, from Fairview-University Medical center, in Minneapolis, Minnesota. She says: "My quality if life is tremendously improved now, since I received my transplants."
Tim Cox, from South Carolina, received his combined kidney-pancreas transplant, also from Fairview-University Medical Center, in Minneapolis, on Christmas Eve, 1988. He says: "I'm not handicapped; I'm handicappable."
Lindy Guidry, From Louisiana, received her combined kidney and pancreas transplant, on August 8, 1993, at the University Hospital of New Orleans, and she says: "I want to make the most of my second opportunity."
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MEDICARE THERAPEUTIC SHOE PROGRAM
In an effort to prevent foot ulcers in people with diabetes who are at risk, Medicare will help pay for therapeutic shoes. For those who qualify, Medicare will pay 80 percent of the allowed amount for one pair of shoes and up to three pairs of molded innersoles per year. (The allowed amount varies, depending on the kind of footwear you need.) Most secondary insurers will help pay the other 20 percent.
Who Qualifies?
Not everyone with diabetes needs special shoes. To qualify, you must be under a comprehensive diabetes treatment plan and have one or more of the following:
Who Does NOT Qualify?
People with diabetes who do not have one of the above conditions. It is not enough to just have diabetes.
What Paperwork is Required?
The physician treating you for your diabetes must certify that you have diabetes, that you have one or more foot problems just mentioned, that you are under a comprehensive diabetes treatment plan, and that you need special shoes. Medicare has a form for this certification. You will also need a prescription for the shoes.
Who Prescribes the Shoes?
A prescription is required from a podiatrist or physician who knows how to fit shoes and inserts for people with diabetes. The prescription should indicate a particular type of footwear, such as shoes, inserts, or modifications.
Who Supplies the Shoes?
The footwear must be fitted and furnished by a podiatrist or other qualified individual, such as a pedorthist, orthotist, or prosthetist. The certifying physician may not furnish the footwear unless he or she practices in a defined rural area or area where there is a shortage of heath professionals. The prescribing podiatrist may be the supplier.
What Do You Get?
Coverage is limited to one of the following per calendar year:
I Have Diabetes and Need Special Shoes. Why Shouldn't I Get Them Free From Medicare?
Remember, there is no such thing as a free lunch -- and there is no such thing as a free pair of shoes. There are over 16 million people with diabetes in the United States. Many of them are of Medicare age. If every Medicare beneficiary with diabetes gets special shoes, there will be no money left for other important aspects of the Medicare program. If we abuse the shoe benefit, Medicare suffers -- and everyone who depends on Medicare will suffer as well.
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This patient Information Guide first appeared in PRACTICAL DIABETOLOGY, September 2004, copyright (c) 2004 R.A. Rapaport Publishing, Inc., New York, NY. Reprinted with permission.
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ANODYNE THERAPY AND DIABETIC PERIPHERAL NEUROPATHY
by Angie Bowman, PT; Kim Hamel, OT; and Linda Hicks, BSN, MS, CDE
"When I met a patient who had stepped on a nail and didn't even know it until he couldn't remove his shoe that night, I knew how important our work is here at our Anodyne Neuropathy Care Center at LifeCare Center of Charleston," said Angie Bowman, PT. "We have treated over 400 patients with the Anodyne Therapy System and all but a handful have shown improvement in their symptoms including significantly reduced pain, improved sensation and improved balance. We have also used it on chronic diabetic ulcers with good success. It has been rewarding to see these patients improve and get their lives back to normal."
If you have peripheral neuropathy, you are not alone. An estimated more than 20 million people suffer from its complications, which can include pain, numbness, balance problems and slow-healing foot wounds and amputations.
What Causes Peripheral Neuropathy (PN)?
PN is one of the most common complications of diabetes, but may also be caused by circulatory problems, certain drugs, chemotherapy, alcohol abuse, anemia, AIDS, back problems, surgery, and by unknown causes (referred to as idiopathic neuropathy).
Research now shows one cause of Diabetic Peripheral Neuropathy (DPN) is poor microcirculation to the nerves in the feet, legs and hands. In addition, recent studies have suggested an important molecule called nitric oxide (NO) may be in short supply in the blood vessels of people with diabetes. This molecule is critical for opening the blood vessels with each beat of your heart. Combine high blood pressure, high cholesterol or plaque build-up in your blood vessels with low amounts of NO (all common in diabetes), and the result is significantly reduced blood flow to the areas furthest from your heart. The nerves and tissues in those areas are not getting the oxygen and nutrients they need to stay healthy. The result can be pain, numbness, slow healing, and skin breakdown.
What is the standard of care for treatment of DPN?
Good glucose control is most important to prevent the progression of neuropathy. If that doesn't reduce your symptoms, then your doctor may prescribe drugs such as anti-depressants, anti-seizure medications or topical ointments like capsaicin cream. These drugs have been effective in relieving some painful symptoms of neuropathy. In addition, studies have shown that certain supplements like B12, folic acid and alpha lipoic acid may also help reduce neuropathic symptoms.
Along with medical interventions, special shoes, custom orthotics, and regular foot exams can protect feet from injuries or relieve pressure points. Despite these treatments, the majority of people suffering from PN continue to experience worsening pain, skin breakdown and a decline in quality of life. However, a new option has offered thousands relief from the symptoms of PN.
Monochromatic infrared energy (MIRE) may help!
MIRE is a photo-energy or light therapy used by doctors, physical and occupational therapists, and wound care specialists to increase circulation and reduce pain. The most promising device, called Anodyne Therapy, is already cleared by the FDA and holds a patent for the treatment of peripheral neuropathy. Nine studies published or currently in press show its effectiveness. Six of the studies were conducted on over 1100 neuropathy patients.
Why does MIRE work on neuropathy and pain?
It is believed this infrared wavelength of photo energy increases the availability of nitric oxide by breaking it free from the red blood cells. Once NO is free, it increases blood flow to the area by up to 3200% in just 30 minutes. Over time, NO will facilitate the growth of tiny new blood vessels (capillaries) in the area, improving circulation with each treatment. If the nerve pain is due to lack of circulation, then getting better blood flow to them can have immediate results. The release of NO also has a direct effect on pain itself. Several studies published in the 1990s showed that NO was directly responsible for the pain-relieving effect of morphine and similar drugs.
Is MIRE 100% effective? No, nothing in medical science is 100 percent. But clinical studies show a majority have positive results. In fact, this technology is used by our U.S. military on all types of injuries because they have found it gets soldiers back to duty faster than any other therapy.
As a result of this clinical success, there are now over 2000 Anodyne Neuropathy Care Centers using MIRE nationwide. These centers are located in hospitals, universities, rehabilitation clinics, nursing homes, home health agencies, pain clinics, wound care centers and doctors' offices.
How do I get MIRE treatments?
The best way to start is with a trained therapist or doctor who has experience using MIRE. They will begin with an individual assessment of the difficulties you are experiencing due to your neuropathy. They will ask you questions about your goals for improvement and design a specialized therapy program to help you reach those goals.
How long do the treatments take and what should I expect?
A comprehensive program usually involves 10 to 24 therapy sessions with 30-45 minutes of Anodyne Therapy and may include any or all of the following treatments depending on your particular needs:
* MIRE to reduce pain and increase circulation to tissues and nerves
* Stretching and strengthening exercises
* Dynamic and static balance exercises
* Massage and the use of other therapeutic modalities for pain
* Sensory integrative techniques to put it all together
Is this therapy for everyone?
MIRE has been safely used for over 10 years on thousands of patients. No significant side effects or drug interactions have been reported as long as MIRE is properly used and monitored. If you have diabetes, check your blood sugars often during any therapy or activity. If you are pregnant or have an active cancer, there are special cautions when using this therapy. Always follow the directions of your doctor or therapist when using MIRE.
Is this therapy reimbursed?
Medicare and most private insurance carriers will reimburse for this therapy when you are being treated by a physical or occupational therapist. In some cases, doctors can also be reimbursed for treatments, however, that varies state by state. You will need a prescription from your doctor for this therapy.
Will I need ongoing treatment?
Unfortunately, diabetes and most other causes of neuropathy are chronic conditions. Your therapist or doctor will recommend home exercises to improve your balance and ability to walk. They may also suggest continued use of MIRE therapy at home for ongoing pain relief and to help you maintain your peripheral circulation. Medicare or your private insurance may cover a MIRE home treatment system with your doctor's prescription if you have shown improvement during your clinical treatment program.
You do not have to suffer with neuropathy. By controlling your blood sugar, blood pressure and cholesterol, as well as exercising and adding this promising photo-energy therapy to increase circulation, you can make a difference in your life.
For information and a listing of Anodyne Neuropathy Care Centers, call 800-521-6664 or visit www.anodynetherapy.com
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DIABETES, HEART ATTACKS, AND STROKE
By Ann S. Williams, MSN RN CDE
This column focuses on providing information to help people
make their diabetes care fit their needs and their lives.
This month's column will be shorter than usual. I need to make an emergency trip out of town to see a relative who has just had a stroke. He, like myself, and like many other members of my family, has type 2 diabetes. So I want to take this opportunity to write about the link between diabetes and cardiovascular disease -- in other words, heart attacks and stroke.
Many people do not realize there is a very strong link between diabetes and cardiovascular disease. If you have diabetes, you have two to four times the risk of having a heart attack or stroke than you would if you did not have diabetes. You have two to four times the risk of having a heart attack or stroke than you would if you did not have diabetes. You are much more likely to die of heart attack or stroke than of diabetes itself.
In fact, your risk of heart attack or stroke is as high as someone who has already had a heart attack or stroke. However, there is a lot you can do to reduce your risk and protect your health.
What can you do to avoid heart attack and stroke?
You need to reduce all the risks you can control. These include:
1. Keep your blood sugar as close to normal as you can without having too much hypoglycemia. It's good to aim for:
a. A1C: below 6.5.
b. Blood glucose readings before meals: under 110.
c. Blood glucose readings two hours after meals: under 140.
But if you get too much hypoglycemia at these levels, aim for as close as you can reasonably get.
2. Do not smoke. If you do, quit.
3. Keep your blood pressure normal.
a. Blood pressure: under 130/80.
The goals for people with diabetes are lower than the goals for everyone else, because of the increased risk. If your blood pressure regularly runs higher than this, ask your diabetes educator or doctor to help you learn how to control your blood pressure through lifestyle changes or through a prescription medication.
4. Keep your cholesterol and triglycerides (blood fats) normal.
This is a complicated subject, which I will not discuss in detail here. The goals are:
a. LDL cholesterol: less than 100.
b. HDL cholesterol: greater than 40 for men, and greater than 50 for women.
c. Triglycerides: under 150
If your cholesterol or triglycerides regularly run higher than this, ask your diabetes educator or doctor to help you learn how to control your cholesterol or triglycerides through lifestyle changes or through a prescription medication.
5. Take a baby aspirin every day, unless you are allergic to it or have had other bad effects from aspirin.
6. Move around! Be as active as you can. Make physical activity an everyday part of your life.
7. Eat less fat in general, and especially less saturated fat (fat that is hard at room temperature).
8. Eat more vegetables, especially low-calorie vegetables, and fruit. The vegetables and fruits that are deeply colored are especially good for you. For example, dark green, leafy vegetables, deep orange winter squash, blueberries, raspberries, and strawberries, and red watermelon all contain many vitamins and minerals and other substances that help to protect against heart attack and stroke.
9. Strive to reach and maintain a healthy weight.
I hope you all take the risk of heart attack and stroke very seriously. As I think of my own aunts and uncles who had diabetes (there were seven of them), I remember which ones worked at controlling their heart risk factors, and which ones didn't. I also remember which of them died when they were in their 40s and 50s, compared to the ones who lived well into their 80s. Now, as I face another stroke in my family, thinking about my aunts and uncles with diabetes who lived long and healthy lives provides me with the motivation I need to keep up my efforts to control my risk factors.
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DIABETES, FIRST IMPRESSIONS
by Fred MacDonald
I first learned I had type 2 diabetes on the night of October 9, 2003. I was resting in the local hospital with a severe infection in my left big toe (the "greater toe," on my medical chart). Neuropathy had deadened the feeling in my feet to such an extent I wasn't aware I'd developed an infection in a small cut -- and that had led to gangrene. I was a very sick person.
Now I learned the surprising news that I was diabetic. I had never shown any classic signs of the disease: excess thirst, frequent urination, I was never overly tired, and my weight, 150 pounds, was not that heavy either. I knew of no history of diabetes in my family, so I was stumped on how I had developed this condition (a more detailed check of the family history revealed one family member did develop diabetes, but only near the end of his life, so this information was ignored).
With the word "diabetes" ringing in my ears, I realized everything in my life was changed. I had always considered myself fairly healthy, and now I was facing a disease that would always be with me. As expected, my first reactions to the news were equal bouts of anger and denial, but as I was currently suffering from a serious side effect of the disease, it was hard to remain in the state of denial for very long.
The anger took longer to channel out of my system. My fiancee, and to a lesser extent my parents, had to deal with a person who wanted to lash out at the world. The hospital staff were doing a good job of treating the problems of my diabetes and gangrene, but I wasn't a 'willing' patient yet. I did what the doctors and nurses wanted, but nothing more. I was simply in a passive mode.
Julia, my fiancee, has dealt with low blood sugar for nearly 20 years, so she had some information about my new diagnosis. She gave my mother a number of books and magazines, so she could learn about my condition. Then, on one of her visits to the hospital, she brought two books for me to look over. I'm afraid her suggestion that I read them didn't go down well at first (let's just say that this was one of Julia's shorter visits).
As the days went by, my boredom started to take over, and finally I decided to look at one of the books. The introduction caught my attention -- this writer had the same problems I had.
I started to read like a person possessed. The information was clear; there was humor in it as well. Side stories and case notes made the work very easy to understand; but the best thing was the tone of the book. Anger over the disease, denial, doubts, and fears of the unknown, everything I'd been feeling was there, yet the volume also spoke of hope.
As I read more, my mood quickly changed. Yes, I had diabetes; but it wasn't going to rule my life. I was going to be its MASTER.
I spent time learning about my condition. My focus changed; I now worked with the staff to get well as soon as possible. I was determined to have a normal life again.
There were still serious problems. Since I had always been healthy, I had very limited experience with the general health care system. I learned I had to switch doctors, due to my insurance coverage (before this event I had always paid out of my own pocket for whatever care I needed). I was going to be out of work for quite a while, so I had to set up the paper work for short-term disability, but I was lucky, my insurance company had always given very good coverage, and was willing to do almost anything to help me get better, fast.
My employer's attitude was even better. Because I work for a human service organization dealing with people with various disabilities, they have a rather open attitude in dealing with matters such as this. I was told to take care of myself. My job would be waiting for me on my return.
My friends and family made certain I was visited regularly at the hospital. Get-well cards and gifts arrived, to keep my spirits up, but there were long periods of loneliness. Time seemed to stand still, every once in a while, and I kept hoping this would be the day I would finally get out of the hospital.
There was good reason for the delay. The infection in my foot was lessening, but was still powerful enough to pose a risk to my general health. Finally, one of the staff members made the decision to bring in a foot surgeon. After a careful review of the case notes and a glance at my foot itself, the specialist stated removal of the toe was my best option.
I told him I wanted the surgery done as soon as possible, so one day after being discharged from the hospital, I was back in, getting my left toe removed.
The infection was so strong that, besides having the toe removed, the doctor had to cut off two additional inches, to scrape the infection out of the good bone. After an extra day of bed rest, came the long road of home health care.
While it was good to be out of the hospital room, I still had to deal with many doctor appointments, paperwork for the insurance company, moving around on crutches, and keeping my injured foot up as much as possible. I discovered I was considered a "fast healer," for a diabetic, yet it seemed to me things were moving at a snail's pace. Finally, in early November, I was allowed out of the house to go to a local science fiction convention. I still had trouble moving around, but being around my friends and talking about something other than my diabetes did wonders for my spirits. Life was slowly returning to a more normal existence.
The holiday season was a bit strained, due to my limited ability to get around; but on the plus side, my oral medications were doing a good job of controlling my sugar levels. I could eat almost everything I wanted, as long as the quantities were limited. Yes, there were some things I had to give up; but if I needed a reminder about what could happen, all I had to do was look down at my left foot.
At the start of the new year, I went to another surgeon, to see what could be done with the large open wound on my foot. A surface skin graft was discussed; but the wound had to close up some more before the attempt could be made, thus more waiting. During this time, I often met with a diabetes educator to learn more about my new lifestyle, and with a dietitian, to deal with my food concerns.
Upon being discharged from the hospital, I had been placed on a 2000-calorie meal plan, but this had left me underweight. I was currently 137 pounds, and most of my regular clothes were too loose on me. I couldn't increase my carbs that much or my sugar levels would spike. Even by eating a lot of extra meat my weight wasn't going up. Finally, the sugar-free energy shakes were approved for my use. There are two types -- one to lose weight, and one to gain. Needless to say, I was given the latter. These shakes, taken twice a day, with some extra food, finally brought my weight to a more normal level. I'm still roughly five to eight pounds under my old weight of 150 pounds, but at least I look okay in my clothes now.
By mid-January my wound had healed enough to try the skin graft. The procedure was a limited success. For the first week it appeared the skin graft was going to take with no problem, but during the second week it started to fail. By the end of week three, most of the skin graft was dead, but as it died, it acted like a bandage, allowing the tissue underneath it to knit together faster. I still had a decent size wound, but its depth had decreased. This was a setback, but by now I was getting used to them.
Near the end of January, I was permitted to return to work. It had been almost four months, and I wondered if I would be able to do all my duties. I quickly discovered that it wasn't a big problem. Walking around the various work sites on crutches was difficult, but I could do it. My strength wasn't back up to full potential yet, but I had enough to get by. I was also very lucky there was very little snow or ice in my state that year.
After a few more weeks another great day came -- I was told I could put my crutches away and use a cane. My sense of freedom grew. Now I could carry something in my free hand.
The wound kept healing, at a fairly stable rate, but I was getting a bit frustrated. I was still wearing winter ski boots because of the dressing on my left foot. However, warmer weather was now in the area and my feet started to get very warm. At one point, I tried a pair of my dad's extra wide sneakers instead, but after two days I noticed some breakdown in the surrounding tissue, so I put the boots back on.
Currently I'm at a point where my injury is almost completely healed. I have been allowed to switch into any type of shoe, as long as it doesn't put any strain on the healing tissue. My sugar levels are under control, and there are not other signs of the dangerous side effects of diabetes. I have even regained a good sense of feeling in both feet. I was lucky my body has been able to repair itself. Even though I lost my big toe, my balance is still good, so I don't believe I will need special shoes. I also have friends, family, and co-workers ready to help me at a moment's notice.
Yes, I would prefer not to have diabetes; but I have learned some important guidelines about living with this condition. First is to seek out any information relating to the problems you have. With the data, you can make a better decision on the various problems diabetes throws at you. Second, remember diabetes is something you can LIVE WITH. There will be days the world seems against you, and you may want to give up dealing with your diabetes. DON'T GIVE INTO THOSE FEELINGS. Talk to a doctor, a family member, a friend, a co-worker, anyone who can give you a different viewpoint. It's true you have diabetes, but you don't have to deal with it just by yourself. Other people can help.
As one person told me: "With diabetes you have two kinds of people. The ones who work with their doctors, and the ones who don't. Doctors are more willing to work with people who take an active interest in the treatment of the disease, than to deal with the ones who just half-follow their advice."
This seem a pretty good standard for the care of diabetes. Be willing to work on the problem and you'll feel better, and most likely have a longer and better life. Do little or nothing and you start on the slow side to an early death. The final choice is your own.
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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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A WORTHWHILE BOOK
by Peter J. Nebergall, PhD
DIABETIC EYE DISEASE: Lessons From A Diabetic Eye Doctor, by A. Paul Chous, MA, OD. Fairwood Press, 2003. Price: $15.99 plus shipping, available from Fairwood Press (www.fairwoodpress.com) or from Dr. Chous at: (www.diabeticeyes.com); or at telephone: (425) 432-5929.
There is usually a yawning (pun intended) gap between "professional" medical literature and the "dumbed-down" texts doctors put out for the consumer. The motivated consumer, who really wants to know, but lacks medical training, often has to choose between incomprehension and disappointment. Not here. Not this time. Dr. Chous comes to his material from both sides. He is a trained medical professional, ready to help you save your eyes; but he also is a diabetic, with personal experience.
His book covers basic definitions of diabetes and eye disease, the forms of damage diabetes can take, and what to do about preventing or minimizing eye damage. He shows how diabetes does what it does to the eyes - and what you ought to do about it. He details what you should expect from your eye doctor, and from your examination.
Spread throughout the book are his uniquely useful observations, like the fact that changes in blood sugar control can alter eye-test results, causing rapid apparent changes in "prescription." He discusses LASIK corrective eye surgery, and the fact it may not be a really good idea for diabetics. He feels the same about contact lenses - that they present additional problems when diabetes is present. And there is much more.
If you are truly motivated to manage your diabetes, if you are one of those people who practices "tight control," uses a sliding scale to get the best possible control, this book is for you. There's a lot of material in here, but none of it "out of reach" - so take the time, go through it, and put his suggestions into practice. This book has my highest recommendation.
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DEALING WITH DIABETES DAY-TO-DAY
by Emily Gaines Buchler
(includes photo of Emily Gaines Buchler)
In 1912, my grandmother's aunt, Grace Goforth, died on a small farm in the foothills of North Carolina. What did this have to do with me? Diabetes.
Grace had grown up like any other kid on a farm. She rose early to milk cows and cultivate seeds, delivered bread four miles on foot to the nearest neighbor, and played rounds of Kick the Can and Ante Over for fun. At age 18, she fell in love with George, a young man who traveled to town by horse and buggy to sell the tobacco, milk, chicken, and eggs produced by the Goforth farm and other establishments in the area.
Soon after, Grace started accompanying George from the country to town, and it was during this 30-mile stretch she first felt the pangs of diabetes. She complained of thirst, stopped frequently to urinate, and slept the whole trip back, despite bumps and holes in the winding dirt road. Within one year, Grace dropped from a robust 130 pounds to just below 100, and when she finally saw a doctor, on the eve of her twentieth birthday, her condition was grave. On May 16, 1912, Grace slipped into a coma and died.
My grandmother first mentioned Grace a few years after my own diagnosis of type 1 diabetes in 1983. She started her story by stressing my luck in developing diabetes in the late twentieth century and not earlier. "My aunt Grace," my grandmother would say, "lived before insulin was even available. Can you imagine your own life without insulin?"
As a nine-year-old, happy-go-lucky kid who loved to showcase her ability to inject insulin without crying, thoughts of dying from diabetes never crossed my mind. I viewed Grace as a mystery and wondered if she really had diabetes, or if some sort of cancer or heart failure had in fact claimed her life.
Reaching the 20-year milestone of my life with diabetes, I realize the deadly consequences of the disease. At the same time, I feel fortunate to live in the era of insulin and blood glucose monitoring systems. Had Grace held out for another ten years, she might have lengthened her life with injections of insulin, the wonder drug invented in 1921 by Banting and Best and mass-produced the next year by Eli Lilly and Company.
The invention of insulin transformed diabetes from a deadly disease to a chronic illness. Prior to 1922, a diagnosis of diabetes meant death. Pre-insulin era patients were put on "starvation diets" of lettuce, cabbage, broccoli, cucumbers, and other low-carbohydrate foods. Subsisting on less than 900 calories a day, most of these patients wasted away within a year from starvation and acidosis.
By the 1940s, the average life-span approached the non-diabetic "normal," due to the development of longer-acting and purer forms of insulin. Yet diabetes treatment was not as we know it today. There was no home blood glucose monitoring equipment, and assessing the level of sugar in the body could only be done through urine tests, or through a (very slow) hospital pathology lab.
By the time sugar showed up in the urine, it had long since entered the bloodstream, making the result far less "immediate" than those results read by meters today. Nevertheless, as the only means of regularly assessing sugar, home urine tests were administered every morning, afternoon, evening, and night.
Obtaining the result required more than peeing on a strip and watching it turn color. It required a rigmarole of steps that took close to ten minutes. The most widely used urine test was the Benedict test, which included a test tube, dropper, and a bottle of Benedict solution.
After collecting a urine sample, patients used the dropper to transfer eight to ten drops of urine to a test tube containing a teaspoon of the Benedict solution. The mixture was then heated to a boil for three minutes, after which it cooled and turned color. Blue indicated no sugar, while green indicated a trace, and orange and red revealed an excess.
Phil Johnson, a native of Charlotte, North Carolina, diagnosed with diabetes 50 years ago, remembers a variation of the Benedict test: "All the mixing of solutions and dropping of urine from one test tube to another really took a lot of time. But the worst part of the whole experience was waiting for that dreaded orange color. If the color turned out blue, I rewarded myself and felt proud, but if the color turned out orange or red, I felt like I'd been bad."
Along with the lengthy urine testing, preparing syringes for injecting took much longer back then, too. Phil recalls getting up early before school to boil a pot of water to sterilize the glass barrel and steel piston of the syringe, along with the steel needle. "The old steel needles weren't like the sharp little needles we have today," Phil says. "The old needles were thick, and they felt like ice picks!"
After injecting the insulin, Phil remembers rinsing the needle and syringe in cold water, while a burning sensation lingered for several minutes beneath the surface of his skin.
A cartoon produced in the late 1920s by Guy Rainsford, a traveling salesman from Maine, and patient of the renowned diabetes doctor, Elliott Joslin, depicts this kind of early diabetes treatment. Test tubes, droppers, and bottles of Benedict solution line the table, transforming an ordinary home into a scientific laboratory. A larger-than-life syringe and needle pierce the top of Rainsford's knee, while a caption reads: "Here goes, folks."
Despite the hassle of preparing the treatment and the painful poke of the needle, the patient maintains a hearty sense of humor. In the lower center of the page, he informs his audience that his slippers came from Japan, and cost only 19 cents, and he bids onlookers a friendly "cheerio."
Sharper needles, disposable syringes, and home glucose monitoring systems are not the only major changes in treatment over the years. The emergence of diabetes specialists represents another major advancement. As Phil Johnson recalls: "When I was little, there was no such thing as a diabetes educator, and there were certainly no diabetes camps or support groups. I saw a family doctor, and he just didn't have the kind of handle on diabetes that many specialists have today. I'll never forget that first week in the hospital when he told me I'd never eat a candy bar or piece of birthday cake again. As a kid, that really killed me, and it and made me that much more tempted to sneak."
My own week in the hospital, during my initial diagnosis of diabetes, left me envisioning, like Phil, a life without sweets. "I can't eat sugar," I told my best friend, Barry. "I can eat sugar-free cake and ice cream, and my mom makes sugar-free pudding, but I can't have any other sweets." In the 20-plus years since my diagnosis, faster-acting insulin and carbohydrate counting have given diabetics more opportunity to incorporate desserts into their diet.
Aaron Corns, a recently diagnosed 14-year-old from Tomah, Wisconsin, confessed to worrying more about not eating sugar than the box of 100 syringes placed on his bedside table the first week of treatment. "My grandmother has type 2 diabetes, and I always associated the disease with not eating sugar. I was pleasantly surprised when my doctor finally told me that diabetes doesn't mean I can't have sugar. It just means I can't have it all the time."
Given the recent rise in popularity among the Atkins diet and other low-carbohydrate plans, a wide range of low sugar-desserts now line most grocery store shelves, making it that much easier to satisfy cravings without taking in an excess of carbs. Growing up in the seventies and eighties, my dessert options included Jell-O pudding, Sweet'n Low ice cream, and a few Estee brand products -- all of which contained large doses of sickeningly sweet saccharin.
The "diabetic food exchange" adorned the side labels of these products. Eating a piece of sugar-free cake meant giving up a piece of bread for dinner, while indulging in chocolate pudding meant going without a helping of potatoes.
In this pre-carbohydrate counting era, diabetics exercised much less control over what, and when, they ate. Their medication determined both schedule and amount. As a child and teenager, I ate when my Regular and NPH insulin peaked: breakfast at seven, a mid-morning snack, lunch at noon, a mid-afternoon snack, dinner at six-thirty, and a bedtime snack around nine. My daytime snacks consisted of apples and crackers with cheese, while my bedtime snacks included a cup of sugar-free hot chocolate and ginger snaps with peanut butter. I ate this same series of snacks for ten years, with little-to-no variation.
Although today's doctors advise people with diabetes to follow regular eating routines, the development of Humalog insulin made mealtime planning a lot more flexible. Approved by the FDA in 1996, Humalog takes an average of 15 minutes to take effect, compared to the 45-minute lag with Regular insulin.
Mandy Hunter, a part-time pharmaceutical consultant and mother of a six-month-old daughter, designated Humalog the greatest advancement in diabetes treatment since her diagnosis in the mid 1980s: "My body never responded well to Regular insulin, which peaked three hours after my meals," Mandy recalls. "As a kid, I remember going low almost every day, on my way to the school cafeteria for lunch. Taking Humalog really changed that. It lets me eat when I'm hungry, instead of when my insulin peaks."
Warren Prickett, a 29-year-old type 1 diabetic diagnosed in 1991, sees little room for improvement in daily diabetes management. " We're almost at a peak," Warren says. "Daily management is almost maxed-out. Needles are as small and sharp as they can get, the pump delivers doses in one-tenth of a unit, and glucose monitors give results in five seconds. The way I see it, there's just one way to go, and that's for people with diabetes not to have diabetes."
Although Warren anticipates a cure, he also welcomes the development of a way to gauge blood sugar without stopping to draw blood. "Knowing my blood sugar level at all times would make a huge difference in my treatment," Warren says. "If I was sitting in a business meeting and noticed my blood sugar climbing, I could give a little dose of insulin before it climbed too high. I could prevent highs and lows, and maintain readings in the normal range, like people without diabetes."
Frequent or continuous glucose monitoring, multiple injections throughout the day, and the widespread use of insulin pumps characterize the new wave of diabetes treatment. Tighter control is now possible, improving the quality of life and preventing complications.
Although tighter control leads to a longer, healthier life, it does require work; but when I weigh the alternatives, diabetes management is worth every ounce of hard work. As the renowned diabetes doctor, Elliott Joslin, wrote in his DIABETIC MANUAL of 1959, "Work shortens the day, but lengthens the life." In an era of constant monitoring and tight control, his words ring true in many ways.
Dealing with diabetes is not a walk in the park, and it's easy to get discouraged from the day-to-day roller-coaster of the disease. As we continue to hope for a cure, either through islet transplant or some other means, we should feel fortunate to live with the many advancements in diabetes management that have occurred over the years. We do not boil water to sterilize syringes in the morning; we do not sharpen needles on a whetstone; and we do not rely on urine tests to determine our insulin and dietary needs. Grace Goforth, along with the many other people diagnosed with diabetes in the pre-insulin era, literally wasted away from the disease. Thanks to medical science, grassroots efforts, and other invaluable measures, we continue to go forth in our quest for better control and healthier lives.
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ASK THE DOCTOR
by Wesley W. Wilson, MD
(includes art: Medical caduceus symbol)
NOTE: If you have any questions for "Ask the Doctor," please send them to the VOICE editorial office. The only questions Dr. Wilson will be able to answer are the ones used in this column.
Wesley W. Wilson, MD, has retired as an Internal Medicine practitioner at the Western Montana Clinic in Missoula, Montana. Dr. Wilson was diagnosed with type 1 diabetes in 1956, during his second year of medical school. He remains interested and involved in diabetes education for patients and professionals.
Q: I have type 2 diabetes. Most of my life I've been a real type "A" person, full of conflicts and stresses. Well, I've been seriously reducing the stresses in my life, and now my foot problems are a lot less, and my blood sugars are better. Is this valid? What is the link between being a high-stress type person and good blood sugar management? What happens when I achieve a lower stress lifestyle?
A. Congratulations on being able to achieve a lower stress lifestyle. Now tell us how you did it! Changing a life-long behavior pattern is very difficult. Many people wish they could somehow control the stresses and problems in their lives but can't find the way to change their responses to the troubles and concerns we all must deal with. This is particularly true since individuals vary so much in their response to problems or stresses.
Hormonal changes do occur with a "high-stress" state. Increases in epinephrine, cortisone and growth hormone may be seen with stress and anxiety. But even more important, I"d feel, is the effect anxiety can have on your attention to the routines required to maintain your diabetic control. Careful attention to diet, exercise, and blood sugar testing is much harder during periods of stress than it is when things are on a fairly even, smooth routine.
Certainly you are the one to answer the validity question. Perhaps the most convenient way to determine the degree of improved control is to compare a hemoglobin A1c taken after several months on your lower stress period with a previous HbA1c taken during a higher stress time. You can get some idea of control by looking back on your blood sugar diary; but the HbA1c gives a more accurate look at your degree of control over a several-month time period. That's why physicians use the HbA1c to check on diabetic control.
It's generally agreed that some high-stress situations lead to higher blood sugar levels. Surgery, a heart attack, or an acute illness do lead to higher blood sugars, and these often require greater efforts to control blood sugar. Emotional turmoil has a similar effect on blood sugar.
So, to answer your question, lowering your stress level is good for you, good for your heart, and good for your diabetes control.
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NEW TREATMENT FOR DIABETIC FOOT ULCERS
by Stephen A. Brigido, DPM.
What are diabetic foot ulcers?
Diabetic foot ulcers are slow-to-heal sores, appearing on the foot or ankle, as a result of a combination of loss of nervous sensation and poor circulation. This serious side-effect of diabetes afflicts 15 percent of the diabetic population, and is the primary cause of hospital admissions for all diabetics. Over 80,000 lower-limb amputations occur each year in the diabetic population, 85 percent of which are preceded by foot ulcers that are not treated sufficiently. The good news is that new treatment options now exist to heal diabetic foot ulcers before they become infected and necessitate amputation.
How do you treat diabetic foot ulcers?
Conventional treatment for diabetic foot ulcers includes removal and cleansing of the affected tissue, dressing the wound and off-loading the treated foot in a special cast or off-loading boot until the wound heals sufficiently. In patients where these treatments fail to close the wound, the chance of infection and amputation are increased, and patients are forced to make additional trips to their physicians' offices, burdening their schedules and pocketbooks. For these reasons, more aggressive treatment options have been developed. One of the more aggressive treatments on the market is an ulcer repair matrix called GRAFTJACKET, which has been shown to heal foot ulcers after just one application of the graft.
What is GRAFTJACKET?
The GRAFTJACKET family of products is composed of human dermal tissue components, and is readily accepted by the body. It serves as a repair matrix that is rapidly converted to the patient's own tissue by quickly renewing blood, cellular and nutrient activity throughout the matrix. Over time, the tissue graft aids in the repair of the wound and is replaced by tissue like the patient's own.
What benefits does GRAFTJACKET offer to patients and physicians?
GRAFTJACKET can require only one application to repair a diabetic foot ulcer -- reducing the time and cost of recovery. Additionally, GRAFTJACKET Ulcer Repair Matrix is a strong tissue graft, which results in improved suture retention and higher likelihood of a successful repair.
To learn more about treating diabetic foot ulcers, or about GRAFTJACKET®, contact Stephen A. Brigido, DPM, at 570-420-8080, or visit (www.wmt.com/graftjacket/).
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LIVING WITH DIABETES 50 YEARS
by Pat Oswald
I, Pat Oswald, of Marysville, Kansas, recently received two medals for having lived with type 1 diabetes for five decades (50 years). I received recognition both from the maker of my insulin, the Eli Lilly Company, of Indianapolis, Indiana (who awarded me the "Lilly for Life 50 Year Insulin Award"), and also from the Joslin Diabetes Center in Boston, Massachusetts, that awarded me the "Joslin 50-Year Medal and Certificate of Achievement."
Fifty years of dealing with diabetes has not been an easy task; but I have done pretty much everything in life non-diabetics could do: job, family, children. Sometimes it has meant more finger sticks and a snack, here and there. You do what you need to do.
Exactly 50 years ago, in November 1953, I was having all the symptoms of diabetes -- frequent urination, hunger, fatigue, loss of weight, thirst, and I was irritable. My parents took me to the doctor, a small-town physician, who treated me for a few weeks for a supposed kidney infection. Since I continued to get worse, he then did a urinalysis, which showed a lot of sugar. I was diagnosed with diabetes.
At the time I was diagnosed, I was the only child in the area with diabetes. I was a child of 12 years, growing up in the rural area near Winside and Carroll, Nebraska, a place of small farmers, near Norfolk, Nebraska.
In 1955, my parents, Forrest and Bessie Nettleton, took me to Dr. William J. Lear's office in Norfolk, Nebraska. He was just out of medical college, freshly trained. Dr. Lear turned out to be one of the many "great doctors" in my life. He taught me so much, and contributed to my complication-free 50 years with diabetes. Of all the complications, my biggest fear has been that of losing my eyesight. So far, I have very good eyes and health, thanks, I am sure, to the good advice of my doctors.
I never feared insulin injections, and I still have my very first insulin kit-the glass syringe and needles I used back then. We had to boil the syringe and needles in soft water before each use. My family did not have soft water, so I would walk 3/4 of a mile to a neighbor's farm, with a gallon jar in hand to get my supply of soft water from their soft water cistern. The walk was good exercise, and was part of my treatment.
My parents never gave me an insulin injection. I have done it myself from day one, except when hospitalized.
At the time I was diagnosed, there were no home glucose monitors. Sugars were checked with a urinalysis test using five drops of urine, 10 drops of water, and a pill purchased at the pharmacy. If it boiled to blue, you were negative. Green meant a trace of sugar and bright orange meant a lot of sugar. Urine tests measured spillover of sugar from the blood excreted by the kidneys. Home glucose meters and small finger sticks are much better -- they tell you the amount of sugar in your blood at that moment. I'd never want to go back to urine tests, even though blood glucose test are more expensive.
So much has changed since the early days: meal plans, treatments, and technology, as well as the price we pay for medications and supplies. Diabetes is an individual disease, and must be treated as such.
Over the 50 years I've had diabetes, what has remained constant is the need for daily exercise, which I do by walking my treadmill, taking a pleasant walk, or riding the exercise cycle. My job at the local motel helps as well, since I do much walking there, and climb steps each day.
My advice to others is to follow your treatment plan, be open with your physician, ask questions, and be honest with your diabetes care team. Be sure to get an answer you understand to all your questions.
I have only been hospitalized a couple of times for my diabetes. They were when I was running a lot of very low blood sugars. My doctor could not get me regulated, so I was sent to a diabetes treatment center in Wichita, Kansas. There I was re-evaluated, and steered back into good control. Such problems can occur in life's changes.
Diabetes has made me a stronger person. It has been a daily challenge, and has helped me learn how to cope with living. Diabetes is much easier to control now than it was 50 years ago. There were no sugar-free foods then, nor sugar substitutes for sweetener, except saccharin, which tasted awful. Much more is known now, about diet, exercise, and diabetes control, than was known in my rural area in 1953.
Family support has been a big plus all my life. We have always eaten foods that fit into my meal plan and ate on time.
You could say diabetes is "popular" in my family. My great-grandmother, on my dad's side of the family, had diabetes. Five of his sisters had it. One had type 1, and the others had type 2. My husband, Ed, has type 2. Douglas, the elder of our two sons, has had type 1 since age 14 (almost 29 years). Daniel, our younger, doesn't have it.
We also have a pet cat living with diabetes. I give him two insulin injections per day, and monitor his food intake.
There is so much to be thankful for. Most of it is what people take for granted, but I've learned to appreciate. And I keep busy. I work five to six days a week for 7-1/2 to 8 hours a day, plus home upkeep -- canning, mowing, etc.
Over the years, I served as Marshall County Diabetes Chapter American Diabetes President. I set up monthly meetings, an annual fund-raising bike ride and walk, and annual seminars with diabetes specialists presenting the day's program. I was president for about 15 years (The chapter is no longer going).
I do have much to be thankful for. And I'm far from finished with the list.
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AMPUTATIONS DUE TO DIABETES CAN BE PREVENTED
(This story courtesy of the ACFAS NEWS, published by the American College of Foot and Ankle Surgeons.)
For National Diabetes month, the American College of Foot and Ankle Surgeons urges diabetic patients to take simple precautions to help save their feet. Taking a minute or two every day to inspect your feet and observing a few simple rules can make the difference in sparing diabetes patients from a preventable outcome of the disease -- a foot amputation.
Of all diabetes-related complications, a serious foot ulcer and subsequent amputation might be the most preventable with proper care and vigilance in checking the feet at least once a day for small cuts and other abrasions, said Troy J. Boffeli, DPM, FACFAS, a Minneapolis-based foot and ankle surgeon speaking for the American College of Foot and Ankle Surgeons. Even those with good control of their blood sugar can experience foot ulcers, especially if neuropathy, a frequent diabetes complication, has caused decreased feeling on the bottom of their feet.
Loss of sensation inhibits the body's normal pain response. As a result, walking can apply repetitive, unfelt pressure to a wound, making it larger and deeper. Left untreated, diabetic ulcers lead to serious infections, which may result in amputation.
Boffeli said foot and ankle surgeons use a variety of surgical and non-surgical methods to heal diabetic ulcers, but stressed early intervention yields the most favorable outcomes. "Daily self-exams are the best protection. Too often, patients fail to check their feet for small cuts or punctures that, over time, will ulcerate and become infected," said Boffeli. "If you have diabetes and see anything suspicious on your feet, consult a foot and ankle surgeon for diagnosis and treatment. Even a few days can make a difference in preventing serious foot problems from developing."
An estimated 7 in 10 diabetic patients have nerve damage that impairs feeling in their feet. Fifteen percent of diabetic patients eventually will develop a foot ulcer. Among those with ulcers, one in four will lose a foot. Each year more than 86,000 amputations are performed as a direct result of diabetes; and studies show half of those who have a foot or a leg amputated will lose the other within five years. Proper diabetic foot care, says Boffeli, prevents foot loss.
In some cases, amputations might be the preferred option. If vascular and podiatric surgeries can't improve blood circulation, resolve infection or restore foot function, amputations may be the only solution that enables the patient to heal. Today, advances in prosthetics make it possible for patients to return to an active lifestyle, a necessity for keeping diabetes under control.
Foot problems are not an inevitable consequence of diabetes. The risk can be lessened significantly by following a few simple precautions:
* Keep your blood sugar under control to help minimize cardiovascular and blood circulation problems.
* Lose weight, don't smoke, and adhere to prescribed dietary, medication and exercise regimens.
* At least once a day, examine your feet for cuts and other small wounds you may not feel.
* Never walk barefoot, outdoors or indoors.
* Cut nails carefully -- straight across and not too short; never trim corns and calluses yourself.
* Wash your feet every day in lukewarm water; dry carefully.
* Choose comfortable shoes with adequate room for the toes.
* Wear clean, dry, non-bulky socks; change daily.
* Shake pebbles or bits of gravel out of your shoes before wearing.
* Seek treatment from a foot and ankle surgeon if minor cuts and sore spots don't seem to be healing.
For further information about diabetic foot conditions, and to locate a foot and ankle surgeon in your area, visit www.footphysicians.com or www.acfas.org
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HEALTHY HOME COOKING
by JoAnna M. Lund
(includes photo, portrait of JoAnna Lund)
Welcome back into my kitchen, where the cooking is easy and the food is both healthy and tasty! I have more cooking tips to share with you, and a few recipe makeovers I've gladly recreated for others in the Healthy Exchanges way. I hope you enjoy, and maybe, just maybe, some of my tips will help make the winter seem shorter!
Somehow a soothing cup of hot chocolate seems to chase the cold winter winds away. I have a quick and easy way to spruce up that dull mug of fat- and sugar-free hot chocolate mix. After combining the dry chocolate mix and the hot water, stir in a 1/2 teaspoon of vanilla extract, and give it a light sprinkle of ground cinnamon. If you really want to "live decadent," top it all off with one tablespoon of cool Whip Lite. Sit back in your favorite comfortable chair and savor every sip. It truly is nectar for the spirit!
For the most heavenly-tasting fruit topping in the world, try stirring 1/2-cup of any flavor of spreadable fruit into a small bowl (remember to look for it in the jelly section of the grocery), and then stir in one cup of Cool Whip Lite. If you really want to impress others, then add one teaspoon of coconut or almond extract. Refrigerate until you are ready to serve, then spoon a couple of tablespoons on top of a slice of angel food cake, and garnish with either 1/2-teaspoon of flaked coconut or slivered almonds. Everyone will think you slaved for hours in the kitchen for this sensational treat. Only you will know differently -- unless you share our secret with them.
Did you know that if you lightly spray the inside of paper baking cups with butter-flavored cooking spray before spooning muffin batter into them, you won't end up with clinging paper on your freshly baked muffins? If you like muffins as much as I do, but hate washing muffin tins like I do, you probably will think this idea is worth its weight in muffin batter!
To help keep fresh fruits and veggies fresh, just give them a quick "shower" with lemon juice. The easiest way to do this is to pour purchased lemon juice into a kitchen spray bottle and store in the refrigerator. Then, anytime you use fresh fruits or vegetables for salad or dessert, simply give them a quick spray with your "Lemon Spritzer." You just might be amazed by how this little trick keeps your produce from turning brown so fast.
Did you know you can make purchased fat-free salad dressings taste more like "the real thing" by adding a small amount of fat-free mayonnaise and a pinch of sugar substitute to the diet dressing? If you want exact portions, I'd start with two tablespoons fat-free salad dressing (any flavor and any brand) and add one teaspoon fat-free mayonnaise and sugar substitute to equal 1/2-teaspoon sugar. Mix well and spoon over your salad. Unless you remind yourself that you're eating "diet" dressing, you just may fool yourself into thinking you reached for the high-fat counterpart by mistake!
I thought I should share an ultra easy tip I just take for granted, but that amazed some folks in the audience recently when I was doing a cooking demo. Whenever you are preparing a pie with the purchased pie crusts, simply tear out the paper label on the plastic cover (check it out for a coupon for savings on a future purchase) and turn the cover upside down over the prepared pie. You now have a cover that protects the beautifully garnished pie from having anything fall on top of it. It also makes the pie very portable when taking to a get-together when it's your turn to bring dessert.
Now for our Recipe Makeovers
CM, of TN, wanted me to revise a traditional meatball recipe so that not only was it healthier -- it was also easier! She wanted to have them already cooked and frozen, so she could get supper on the table fast after a hard day at work. I think you'll agree these meatballs hit the spot not only for spaghetti, but for meatball sandwiches as well!
Ultra Quick Meatballs
16 ounces extra-lean ground sirloin or turkey breast
1 cup + 2 tablespoons dried fine bread crumbs
1/2-cup fat-free milk
1 teaspoon dried parsley flakes
1 teaspoon Worcestershire sauce
In a large bowl, combine meat, bread crumbs, milk, parsley flakes, and Worcestershire sauce. Mix well to combine. Form into 36 (1-inch) meatballs. Place meatballs in a large skillet sprayed with butter-flavored cooking spray. Brown meatballs on all sides. Lower heat and simmer for 6 to 8 minutes, turning occasionally. Freezes well.
Serves 6 (6 each). Each serving equals:
181 Calories, 5gm Fat, 18gm Protein, 16gm Carbo., 246mg Sodium, 0gm Fiber; Diabetic Exchanges: 2 Meat, 1 Starch
MG, of MO, sent me a banana fudge cake recipe to play with. If you like banana cake and if you like chocolate cake, then I think you will this cake!
Banana Fudge Cake
1-1/3 cups Carnation Nonfat Dry Milk Powder
1-1/2 cups water
1 teaspoon white distilled vinegar
1-1/2 cups all purpose flour
1/4 cup unsweetened cocoa powder
1/2 cup Splenda Granular
1 teaspoon baking soda
1/4 cup chopped pecans
2/3 cup (2 medium) mashed ripe banana
1 teaspoon vanilla extract
3/4 cup Kraft fat-free mayonnaise
1 (4-serving) package JELL-O sugar-free instant banana pudding mix
1/2 cup Cool Whip Lite
Preheat oven to 350 degrees. Spray a 9-by-9-inch cake pan with butter-flavored cooking spray. In a small bowl, combine 2/3-cup dry milk powder, 1/2-cup water, and vinegar. Set aside. In a large bowl, combine flour, cocoa, Splenda, baking soda, and 2 tablespoons chopped pecans. In a medium bowl, combine mashed bananas, vanilla extract, and mayonnaise. Stir in milk mixture.
Add banana mixture to flour mixture. Mix well to combine. Spread batter into prepared cake pan. Bake for 18 to 22 minutes or until a toothpick inserted near center comes out clean. Place cake pan on a wire rack and allow to cool completely. In a medium bowl, combine dry pudding mix, remaining 2/3-cup dry milk powder, and remaining 1-cup water. Mix well using a wire whisk. Blend in Cool Whip Light. Spread mixture evenly over cooled cake. Sprinkle remaining 2 tablespoons pecans over top. Cut into 12 servings. Refrigerate leftovers; freezes well.
Serves 12. Each serving equals:
138 Calories, 2gm Fat, 5gm Protein, 25gm Carbo., 382mg Sodium, 2gm Fiber; Diabetic Exchanges: 1-1/2 Starch/Carb.
I hope you enjoyed our time together in the kitchen. Remember, if you'd like me to revise one of your family favorites so it's healthier, send your request to: JoAnna Lund, Healthy Exchanges, PO Box 80, DeWitt, IA 52742. Also, be sure to visit my website at (www.healthyexchanges.com) for more "common folks" healthy recipes to try. Until next time ...
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RECIPE CORNER
This issue's simple recipes come to you from the DIABETIC FOUR-INGREDIENT COOKBOOK, by Linda Coffee and Emily Cale, published by Coffee and Cale, available by telephone: 1-800-757-0838, or at their website: (www.fouringredientcookbook.com). Used with permission.
Green Bean Salad
Ingredients:
1 can (16 oz.) French style green beans (drained)
8 cherry tomatoes (halved)
four fresh green onions (sliced)
1/2-cup fat-free French dressing
Instructions:
Combine ingredients. Chill at least one hour before serving. Serve on a crisp bed of lettuce. Makes four 1/2-cup servings.
Per serving: 77 calories, 2gm protein, 0gm fat, 16gm carb, 0gm cholesterol, 531mg sodium, 2gm fiber.
Exchanges: 1-1/2 vegetable, 1/2 bread.
French Onion Rice
Ingredients:
1 cup long-grain white rice
1/4 cup fat-free margarine
one can onion soup (plus one can water)
1 can (4 oz.) chopped mushrooms
Instructions:
Lightly brown rice in margarine. Add soup, water, and mushrooms. Cover and simmer about 25 minutes or until liquid is gone. Fluff and serve. For less sodium, use fresh mushrooms instead of canned. Makes six 1/2-cup servings.
Per serving: 133 calories, 3gm protein, 1gm fat, 0gm saturated fat, 28gm carbohydrate, 0mg cholesterol, 365mg sodium, 1gm fiber.
Exchanges: 2 starch.
Savory Sunday Roast
Ingredients:
2 pounds lean chuck roast
1/2 package onion soup mix
1 cup carrots (peeled)
2 cups potatoes (peeled and quartered)
Instructions:
Place chuck roast in roasting pan with lid. sprinkle onion soup mix on top of roast. Place carrots and potatoes around meat. Put 1/4-cup water into pan. Bake at 250 degrees for about four hours. Makes six servings (4 ounces of meat each).
Per serving: 284 calories, 33gm protein, 9gm fat, 3gm saturated fat, 17gm carbohydrate, 80mg cholesterol, 163mg sodium, 2gm fiber.
Exchanges: 4 ounces lean meat, 1 starch, 1 vegetable.
Pineapple Orange Fluff
Ingredients:
1 package (3 oz.) sugar-free orange Jello
1 can (15 oz.) water-packed crushed pineapple juice (undrained)
2 cups buttermilk
1 container (8 oz.) Cool Whip Lite
Instructions:
Heat crushed pineapple and add orange Jello. Stir until Jello is dissolved. Cool for about 15 minutes. Add buttermilk and Cool Whip. Stir until blended, then refrigerate until firm. Makes ten 1/2-cup servings.
Per serving: 86 calories, 2gm protein, 4gm fat, 11gm carbohydrate, 2mg cholesterol, 87mg sodium, 0gm fiber.
Exchanges: 1/2 fruit, 1 fat.
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BOOK REVIEWS
by Marilyn Helton
Greetings and welcome to 2005! As we start our journey through another year, I can't help but wonder how many of you are newly diagnosed with diabetes and have postponed any lifestyle changes you need until "after the holidays." It's a perfectly normal reaction, so don't feel too guilty about it. My job is to help you find the resources to better cope with the many changes you'll be experiencing in finding a new and healthier lifestyle.
A commitment to change begins with a dedicated, positive mindset, so the first book on my January list of recommendations is 365 DAILY MEDITATIONS FOR PEOPLE WITH DIABETES, by Catherine Feste, published by the American Diabetes Association. Catherine speaks from her own experience of over 30 years as a health educator, who has also lived with diabetes for 47 years. Author of THE PHYSICIAN WITHIN and a co-author of 101 COPING TIPS FOR PEOPLE WITH DIABETES, Catherine Feste is one of my favorite inspirational authors.
Special features of 365 DAILY MEDITATIONS include:
* One meditation for every day of the year, to help you to reflect on what really matters in your life.
* Inspirational quotes from famous people, as well as quotes from the Bible, the Koran, Buddha and Rumi to help you find understanding, inner strength and spiritual peace with your life in order to better cope with your illness.
* Practical diabetes tips, and healthy ways of coping with stress and strong emotions.
* A guide to your inner resources and strengths, i.e., being able to see yourself as a hero, not as a victim
This is a book you can use as a practical guide to help you move beyond day to day obstacles, and gain a deeper understanding of your life and the challenges living with diabetes presents. I've long believed that the mind and body are inseparable in coping with a chronic disease.
The introduction to 365 DAILY MEDITATIONS is written by Rachel Naomi Remen, MD (another favorite author on my bookshelf), bestselling author of KITCHEN TABLE WISDOM and MY GRANDFATHER'S BLESSINGS. Dr. Remen succinctly sums up the whole of this book in stating, "Through illness, people may come to know themselves for the first time, to recognize not only who they really are, but what really matters. Illness shuffles the hierarchy of our values like a deck of cards. Often a value that has been on the bottom of the deck for years turns out to be the top card. In illness, people abandon values they have never questioned before, and uncover ways of living far more genuine and unique. Often these ways are also more soul-infused." Dr. Remen further states, "In all the years I have listened to people with cancer, no one has ever said to me that if they died, they would miss their Mercedes, even though such a car and all that it represents has been the focus of their lives for many years. This shift may represent a kind of healing."
365 DAILY MEDITATIONS, by Catherine Feste, is a wonderful book which will help you find your way whether you are newly diagnosed or have many years of experience with diabetes. I highly recommended this book as a must-have for anyone searching for inner strength to cope with a chronic disease.
An estimated 17 million Americans already have type 2 diabetes and another estimated 16 million Americans have what is now called "prediabetes." In THE COMPLETE DIABETES PREVENTION PLAN, A Guide to Understanding the Emerging Epidemic of Prediabetes and Halting Its Progression to Diabetes (Avery/Penguin Group USA), two of the country's leading authorities on nutrition and diabetes -- Sandra Woodruff, MS, RD, author of several books on healthy cooking (all of which are already on my personal bookshelf), and Christopher Saudek, MD, director of the Johns Hopkins Diabetes Center and former president of the American Diabetes Association -- have combined their expertise to present a total life plan addressing the emerging epidemic of prediabetes.
Full of information on preventing or even reversing the development of diabetes by a total nutrition, exercise, and lifestyle program, THE COMPLETE DIABETES PREVENTION PLAN contains a checklist of diabetes risk factors, thoughts on drugs versus diet and lifestyle changes, strategies for weight-loss success, foods that help fight diabetes (and belong in your pantry), eating out, and the power of physical activity (the big-E word). Completing the package, THE COMPLETE DIABETES PREVENTION PLAN features 150 easy and appealing recipes that emphasize good carbs, healthful fats, and controlled calories -- all crucial elements in a diabetes-fighting meal plan.
THE COMPLETE DIABETES PREVENTION PLAN gets two thumbs-up for its simplicity of language, completeness of subject matter, ample recipe and meal-planning sections and easy-to-read format. This book is well worth your investment and highly recommended.
Last November, the American Diabetes Association focused on the link between diabetes and heart disease for American Diabetes Month. People with diabetes are at high risk for heart attack or stroke, and their heart attacks tend to be more serious, and can happen early in life. In fact, two out of three people with diabetes die from heart disease or stroke. Both women and men are at risk.
CHARTING A COURSE TO WELLNESS, by Treena and Graham Kerr (the former "Galloping Gourmet"), have teamed up to share their inspiring journey of partnership in love, food, and life with the story of Treena's stroke, heart attack and diagnosis of type 2 diabetes. With a focus on using food to make you well, the Kerrs have learned it helps tremendously to have a partner for getting well.
From my perspective, one of the best sections of CHARTING A COURSE TO WELLNESS is found in the chapter titled The Nine Stages of Change, which the authors have broken down as follows: Stage One: Aware Yet Disinterested; Stage Two: Relative Impact; Stage Three: Concern Leads to Enquiry; Stage Four: Denial; Stage Five: Acceptance; Stage Six: Possibility of Success; Stage Seven: Engagement; Stage Eight: All Things Can Work Together for Good; and Stage Nine: Taking Action. The Kerrs have devoted over 20 pages in the book to this formula for success.
CHARTING A COURSE TO WELLNESS also provides you with more than 430 ways to learn how to eat right, in recipes for breakfast, brunch, main dishes, side dishes, desserts and sauces. Each recipe is low in fat and carbs, and is accompanied by a complete nutritional analysis, and diabetic exchanges. In addition, the book introduces The Food Preference Sheet, a really innovative food inventory tool you can use to design your food choices according to Tastes, Aromas, Color, Textures and Ambience (in serving style). There are also other food choice considerations, such as Appearance, Preparation, and Cultural Styles of Cooking, i.e., French, Italian, Mexican, North African, Caribbean, Mediterranean, etc. Change isn't so hard when you like the way it tastes, and, in this book, there's a plethora of creative and innovative ways of looking at food preparation, from kitchen to table, to keep your mouth satisfied and your body on track.
In summarizing the content of this book, Graham and Treena Kerr say it best: "Food can make you sick, and food can make you well. Getting well is a challenge, and it helps tremendously to have a partner. We have learned there is no better gift you can give to yourself, to each other, and to your family. With the epidemic of obesity and diseases caused by poor diet in our country, all of us are learning (or re-learning) the value of coming home, cooking dinner, and gathering around the table together."
Reviewer's Footnote: Having reviewed and published many food articles from the American Institute for Cancer Research, I was extremely pleased to see the number of recipes in this book recommending foods healthy in phytochemicals and antioxidants, natural cancer-fighting properties. CHARTING A COURSE TO WELLNESS (published by the American Diabetes Association) is well worth your time and investment, and gets a super-star rating.
That's a wrap for this issue, folks. Stay focused and in the moment because your future is now!
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 website: www.cinnamonhearts.com
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DIABETES:
WHERE WE ARE TODAY, WHERE WE WILL BE TOMORROW
by Frank Vinicor, MD, MPH, and Jinan Saadine, MD
From the Editor: Dr. Frank Vinicor is the director of the Division of Diabetes Translation, part of the U.S. Centers for Disease Control and Prevention. He and his colleague, ophthalmologist Dr. Jinan Saadine, addressed the annual meeting of the Diabetes Action Network, held in Atlanta, Georgia, on July 1, 2004, at the annual convention of the National Federation of the Blind. Then the doctors took questions from the audience. The first part of the presentation appeared last issue, VOICE Volume 19, No. 4, October 2004. Here is the conclusion:
Q: I have been having neuropathy problems in my hands and feet. Is there anything I can do about that? It is irritating and itchy.
A: Neuropathy is a very common problem for people with diabetes. It is generally viewed as the most common complication, and it can be severe. For some people, if the bedsheet touches their feet, it just sends them through the wall. There are a lot of treatments and medicines, which tells you we really don't know what to do about it. If you go in the bookstore, and go to the nutrition/diet section, and you see there are 375 books on nutrition and diet control, that should tell you at least one thing: "we don't know how to do it." If you go up there, and you see maybe one or two, and they all say the same thing, that means we've learned something. It's like that with treatment of neuropathy. There is a list of five, six, maybe seven different medicines available. Its trial and error. Try one; see if it works; if it doesn't, then try another. One of them is an anti-seizure medicine; one is a medicine for anxiety. There are different kinds; try them. Usually you can find one that works, for you. But it is not easy, and it is not quick.
Q: For people who have diabetes complications, what is the outlook for improvement?
A: It depends on the complications, what they are, and how long you've had them. How far advanced are they? If one of the complications, for example, is sudden hypoglycemia, and you are unprepared for it -- people's quality of life is getting better. The stability of their blood sugar is now dramatically better. If you are talking about eye problems, and the problems are already far advanced, they really don't get better. If it's not so far advanced, yes, it can be improved. The same with nerve and kidney problems. Advanced, established "opathies" are unlikely to get better, but they probably won't get worse. That's where we are now, but these are relatively small, and recent, studies, done in the last two or three years. We sure have a lot to learn.
Q: What is brittle diabetes? How is one identified as a "brittle" diabetic?
A: Everyone with diabetes is not brittle. People who, in spite of their best efforts (and those of their doctors), have wide, unanticipated swings and unexplained falls in their blood sugar, such as they would have side effects: seizures or whatever, and you can't figure out why it happens - they are described as "brittle." You try different insulins, different diets, and different activities, and the problem continues. That is generally what is meant by "brittle diabetes." In general, the term is most applied to certain people with longstanding type 1 diabetes.
The Edmonton Protocol has specific inclusion criteria they use, for defining a diabetic as "brittle." You can imagine after this study came out in the NEW ENGLAND JOURNAL OF MEDICINE on seven patients, their phones were ringing off the wall. Everybody with type 1 diabetes understandably wanted to volunteer for islet-transplant studies. They set up a protocol, and they still get literally 20,000-30,000 calls a month. And they have a very well-defined protocol (I don't have the specifics with me) where they review the specific conditions that have to be met before they will enroll people in studies. It still is not available for regular clinical care but just for these expanded islet cell studies.
No congestive heart failure and no coronary artery disease are two of the criteria. Why? A lot of studies look at people with heart problems and diabetes, but when you do studies in general, you want some assurance the people who enroll in the study will be around for a while to see whether the intervention works. Now they are. It use to be if you had diabetes you couldn't get into any studies, heart or otherwise - and you couldn't get a kidney transplant either.
Q: I have an under-active thyroid problem. Is there a relationship between thyroid problems and diabetes?
A: For some kinds of diabetes, the autoimmune attack can do damage to the thyroid and cause it to be under-active. I don't know if that is your case. Hypothyroid treatment is very simple - we used to love to find people who needed it. It's a pill, it works well, and people feel better. In internal medicine, it is rare to find a condition for which you can help people feel better with a single pill. Once your thyroid condition is treated, if you have pre-diabetes (they're separate conditions), as long as your condition stays pre-diabetes, you are not at heightened risk for eye disease or kidney disease.
Q: I am losing my sight from toxoplasmosis. Is there any chance I can volunteer for the CDC retinal cell transplant studies?.
A: At this stage there isn't any retinal cell transplant that is working, but in the future you'll have to wait for that. Your condition is one in a million. At the CDC they look at bigger problems more common in the population. Yours is so rare. They do a lot of studies, in a lot of areas.
Q: Could you explain what is autonomic neuropathy?
A: In general there are two types of nerves in the body. There are the kind of nerves that go to your feet or hands, and make sure you aware if things are too hot or too cold. And there is a set of nerves called the autonomic nerves. For example, we probably aren't thinking about breathing right now, and we're not thinking about my heart beating regularly, and after supper tonight, I'm not thinking about my stomach and intestines digesting food after dinner. All that stuff is controlled by autonomic nerves - automatic. They sort of just carry on and do what they are supposed to do. Sometimes, with longer standing diabetes, it is not only the nerves in the hands and feet, but also the autonomic nerves can also be effected. It can be a real challenge. If those nerves are affected, it can cause dizziness when you stand up, you can't digest your food as well as you would want to, and your stomach can get large ... That is part of what is called autonomic neuropathy. Pathy means "damage." Sometimes people with diabetes get it. It's not as common as peripheral nerve problem. But It can be a real pain if you have it.
Q: I have been told certain vitamins build up the immune system. It this true? Which are the good ones to build up immune system. Are there any?
A: There was a study that finished about one year ago, and it looked at vitamins and antioxidants for macular degeneration. They had a protocol of specific amounts of zinc, antioxidant and vitamins to be in the pill. The study was done with people who already had macular degeneration, the intermediate stage of macular degeneration. And it proved to help in stopping or delaying macular degeneration. The formula that study used is a little bit on the expensive side. You can't just go to the drug store and get it over the counter. There is one combination of these vitamins, and it helps for macular degeneration. It will help slow the progression of the disease.
Q: I heard something about an extract from spinach to help the retina?
A: I don't know anything about this spinach extract ... I think all of us take different things, and that's OK. The most important thing is that you tell your doctor what you're taking. It's better they know. But to date there are no studies, in fact there are some negative studies, where people with diabetes who were right on the cusp of developing heart disease or the like were given combinations of vitamins, but they didn't seem to help prevent heart problems. We still have a ways to go to understand if and what kind of vitamins might be helpful in terms of diabetes.
Q: What can you tell me about insulin resistance and sleep apnea, and would you conclude that in diabetics with sleep apnea this is a neuropathy related to the diabetes?
A: This whole things about diabetes and sleep apnea (apnea means you don't get a good night's sleep). There is a breathing difficulty - you wake up repeatedly, after building up carbon dioxide in your blood, then fall back to sleep. During the day, because you haven't had a good night's sleep, you're tired all the time. That relationship with diabetes has been described now for maybe two or three years. The studies suggest there is a relationship.
Being overweight alone has been related to sleep apnea. Being overweight, having weight difficulties, is also associated with type 2 diabetes. As far as I know, it hasn't been possible to tell whether or not this sleep apnea - diabetes connection is related to just weight, or whether, as you're suggesting, it might be related to autonomic neuropathy of the lungs, which is a possibility. But I don't know which it is; I don't think anyone knows which it is -- and it is being actively studied.
There is a condition called central (as opposed to peripheral) apnea. It is very severe, and can require an individual be placed on a ventilator. It is infrequent, not very common at all, thankfully, and has little association with diabetes. I am not a neurologist, but I believe its causes may be specific, targeted strokes or other brain injury, or perhaps congenital/genetic conditions. It is peripheral apnea that correlates with diabetes, with weight situations, and with the autonomic nerves. The damage is not in the brain stem, but in the nerves after they have left, such as the nerves that enervate the diaphragm - that tell your diaphragm every 20 seconds to contract - to breathe. You don't think about it - it just happens. That is the much more common one and the one that is being related to diabetes. The association has been noted, but the cause of it, I don't know what it is in terms of diabetes.
Q: Are you familiar with the claims of the companies marketing what they call "Glyco-nutrients?" These people also claim milk is the number one cause of diabetes.
A: I don't know about the first part, these "eight essential sugars," I don't know one way or the other. I would ask all to be cautious with these proclamations. All of us are looking for easy answers, and, unfortunately, for diseases like diabetes, I just don't know. I'm not saying it's not good or not true, I just don't know.
Let me talk about the milk issue. For type 1 diabetes, there were some studies which suggested if youngsters were exposed to cow's milk when they were receiving feedings, there was a protein part of the cow's milk that had an identical structure to a particular protein in the insulin-producing cell. And the body, once it saw the cow's milk protein, said "that's not mine" and would produce these white blood cells to destroy this milk protein, then say: "Wait a minute, that protein is in my insulin-producing cells; I'm going to destroy those cells, too." Maybe ten years ago there were these "observational studies" exploring whether early exposure to milk protein could be a factor in setting off type 1 diabetes.
There have been subsequent studies - and these have not shown such an association. Right now, in Finland, there is a study (Finland has the highest incidence of type 1 diabetes) where an entire community is exposed to cows' milk, and another community to mothers milk, and the researchers will look to see whether or not this milk association has a role to play in explaining type 1 diabetes. But, there is no consensus about that, in the more recent studies. They don't show the relationship some earlier studies did.
Q: I've heard that babies who were heavy milk drinkers were more likely to get type 1?
A: You can look at different studies and get different things. Again, in general the initial studies looking at cow's milk suggested an association, but the later studies have not been able to confirm that. So now there is this important study from Finland, which will look at it prospectively, not retrospectively, so we will know. These studies take a while - but we will have an answer.
Q. If you receive a diagnosis of diabetes, but you get your numbers under control, are you still considered to be diabetic?
A: From 1979 to 1997, there was a category of diabetes called "previous diagnosis of diabetes." It got confusing, so in 1997 the American Diabetes Association and the World Health Organization re-did the diagnosis and classification of diabetes, and they removed that category. So, in general, I think all of us now are comfortable saying if you legitimately have the diagnosis of diabetes, it does not go away. If you stay under good control, fantastic, that's great, but you still have the diagnosis of diabetes.
Q: Is there anything specific for eye care people with diabetes can do to prevent vision loss?
A: For diabetics, good control is the most important thing. You have to control your blood sugar. High blood pressure and cholesterol are also risk factors. These can make it worse. There isn't anything like a pill you can take for eye care. Eye complications are part of the diabetes, and the best thing you can do for them is to take care of blood pressure, cholesterol, and blood sugar. Also, it is recommended you see your eye care specialist once a year. If you are not a high risk person, meaning you have no background retinopathy, you can go two to three years, as it takes that long to develop any aneurysm or retinopathy. But it is recommended you go once a year to the ophthalmologist, and not just to look for retinopathy. Look for everything: macular degeneration, cataract, glaucoma, refractive errors, visual acuity, glasses, etc. And get some regular exercise, ideally walking, 30 minutes five days a week. More would be better, this is a minimum.
Q: Once you are diagnosed with diabetic retinopathy, how often should you see your retinal specialist?
A: If you are diagnosed with diabetic retinopathy, you should go every year. If you are diagnosed with advanced diabetic retinopathy, or are at high risk for it to become proliferative, then you might be advised to see your ophthalmologist much more often.
Q: I note every doctor is going to say "early intervention, the sooner the better." If they see symptoms that may become serious, they send the patient on to a specialist. Why is it that when a doctor sees someone who maybe at risk for vision loss or eye problems, they don't refer them to a blindness specialist until all hope is lost, and they've exhausted everything they have? How do we start them to think of early prevention, so we don't get to blindness? I'm talking about the fear some doctors have of telling a patient they might become blind, or that they ought to think about learning alternative (non-sighted) ways of doing things; that they might have to change their lifestyle. Some say they won't talk to you until you are already legally blind.
(Editor's Note: This question, and the next, were answered by Dr. Saadine)
A: That is why I said earlier, really now more work is being done on not just the clinical definition of visual loss - but on the functional. What is 20/200, or 20/40?. It's what is the impact on the quality of life -- not just what is the number of visually impaired? And, as I mentioned earlier, we should have plans for the disease and any loss of vision, and we must refer people to low-vision specialists who can help to make the most of the limited vision
Q: When I started losing my sight, they strung me along, didn't say what might happen, and couldn't tell me where to go or what to do. They sent me to all kinds of specialists for medical things, but made me try to reinvent the wheel, and all they had to say was suggest to me: "Why don't you try and go talk to some blindness people?" It can't hurt to be prepared, to learn Braille even if you never need it. It might save your job, or your future.
A: Too many medical people, the last thing they want to do is use the word "blind," because they feel they've failed. Blindness to an ophthalmologist is what death is to a general practitioner. There is a new attitude in the rehab field, as they have been authorized to look at functional models rather than sickness models of disabilities.
Blindness is not the end of things. There are so many things you can do with people who are blind. But ophthalmologists don't have expectations of a person becoming blind. You're asking for prevention before happening. Like learning Braille before becoming blind. They don't expect blindness unless it is going to happen.
Q: But some people will fall into predictive models where they may be 70 percent likely ...?
A: I think this is a generic problem for a lot of our health care system. Most of us in the past were trained a certain way. The health care system is set up for repair, not for prevention. That is the nature of the health care system. Medicare, for example, will pay the $40,000 to $50,000 to safely and effectively complete an amputation, but won't pay the 15 cents for the little monofilament to tell if a person has an insensitive foot, so they know to get special shoes. That isn't Medicare's fault; they follow what the law said in 1965 and on. There is an absolute disconnect between chronic conditions in which finding it early and preventing its progression is the thrust of chronic diseases -- versus a healthcare system and training that has gone on and is now training, but training that was just saying: repair, repair, repair. Who doesn't want to be repaired? But it takes away from finding things early and doing something about it.
One quick comment: this maybe a shock to you, but doctors aren't uniquely smart (they're not uniquely stupid either); you will find some not so good ones and fantastic ones and most of the ones in the middle. It's coming out of a system that was put in place in the 1940s, for repair, and set up for repair, and reimbursement, and education. And we are dealing with a very different system here, of need.
Q: Last time you spoke to us, you stated many people have diabetes for ten years before being diagnosed. Is that still valid?
The statement in the study suggested that for someone with type 2 diabetes, they probably had it for five to ten years at a low level. Now, depending on how you define type 1, if you define it as having this autoimmune process (normal blood sugar, but autoimmune going on destroying cells), they have had it for ten years or more. That is why we are trying to move to find diabetes early, back to this entity called "pre-diabetes." We now know, with type 1 diabetes, if you have certain genetic structure and have evidence in blood stream the Beta cells are being destroyed, you maybe can stop it there, before blood sugar even starts going up. But as I indicated, the earlier studies didn't show we could do that. They're trying other studies now.
Q: Many of us who have diabetes have put on more weight since we became diabetic. I feel it is because I have to eat more frequently. My doctors and nurses say I have to eat three meals a day, to keep my diabetes under control -- and my body will not digest three meals a day. I didn't used to eat that much.
A: Most people, when first diagnosed, have amazing amounts of calories coming out in their urine. Remember when we used to test urine for sugar? That was calories we couldn't digest. You ate it, couldn't digest it, and peed it out into the toilet. When you first get diagnosed, and treated, and your blood sugar comes down, all that stuff we got rid of, that went down the toilet, now stays in your body, for energy. So almost everybody, when they first get treated, gains weight, over the first three or four days. You retain water, and you drive the sugar you used to pee out into the cells. Then, beyond that, some of the medicines we still use today cause us to gain weight. For example, insulin is a growth-promoting hormone. One of its consequences is your body gets the signal it should eat. There are some tablets people take which also give that same signal to eat. There are other tablets now out that don't give us that signal. I'm not saying one is better or worse; they work in different ways.
For example, people who take metformin (glucophage) generally don't gain weight. They keep it the same. It may be in part because the medication tends to cause you to be a little bit sick to your stomach. But -- you don't gain weight.
It's a hard balance, but what you're experiencing is in fact, very common. The way it's best approached is not to stop the frequency of eating, but to perhaps decrease the amount you would eat at each meal, and, if possible, increase how much you burn up, by increasing your activity. The old idea, that you would have regular mealtimes, I think that's still good; but the amount you have at each meal, and the amount you could burn up, if you were a little more active, that's the way we deal with the tendency to gain weight. What you're experiencing is not rare at all; it is a common story.
Q: What about the combination of diabetic drugs?
A: Let me tell you in general the way we're going, and for people who don't like to take a lot of pills, boy, the diabetes community is in trouble. It used to be we recommended one injection of insulin a day. Or, we recommended one pill. Nowadays, just for blood sugar alone, it's much more common; most people are recommending combinations. You could take two or three tablets, and each of them work in a different way. You might take insulin, if you're not on the pump, two different types, twice a day. The "combination approach" to controlling blood sugar is now in vogue.
This approach is also now used with blood pressure. Almost all of us [doctors] now assume if you have diabetes, you have high blood pressure. You're going to need at least two blood pressure medicines. We'll tell you to take your aspirin. It's "poly-pharmacy" in 2004 for people with diabetes. The reason is we know from good studies, if we can get the blood pressure, blood sugar, and cholesterol down, you don't have to have the problems. The tradeoff is, taking lots of medicines (and that's a real pain, taking lots of medicines); but the benefit is you keep your feet and your eyes and your kidneys and your heart. It's a real challenge. You're going to see more and more of that, taking a lot of medicine.
I have enjoyed being at your seminar again this year. Thank you again for having us.
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RESOURCE ROUNDUP
(includes art: hand pulling a book off a shelf)
Inclusion of materials in this publication is for information only; it does not imply endorsement of any product by the Diabetes Action Network of the NFB.
SugarTrac Update
The SugarTrac is a new non-invasive glucose monitor. It does not need blood, it is small, small, inexpensive, and equipped for speech. The manufacturer, LifeTrac, from Fort Myers, Florida, is seeking official approval, from the Food and Drug Administration, and expects to receive it by April of 2005.
Richard Peters, inventor of the SugarTrac, is upbeat about his product's prospects. His company is working with Harvard Medical School to complete the administrative requirements.
We need a practical, inexpensive, easy-to-use, talking, non-invasive blood glucose monitor, and the SugarTrac, given any luck at all, should be that meter. I'll be waiting, and as soon as I know something more, I'll let VOICE readers know the specifics. For information, contact LifeTrac, from Fort Myers, Florida; telephone: 1-877-768-6978; website: (www.sugartrac.net)
Newsline for the Blind
The National Federation of the Blind's NEWSLINE is an electronic publication of major daily newspapers, specifically tailored for blind and visually-impaired readers. Newsline electronically "reads" all of each day's edition, which is immediately made available via modem to the local distribution centers. Users listen to the articles they choose, read to them in a synthesized voice. The reader is free to jump between articles, sections, and publications, and to pick the speed of reading to suit their needs. There is no subscription fee, and Newsline is not the Internet, so no computer is necessary to use it, just a touch-tone telephone. Service is available to any person at least legally blind. There is no charge.
For further information, contact Newsline Network, National Federation of the Blind, 1800 Johnson Street, Baltimore, MD 21230; telephone: 1-888-882-1629.
Tax Help
For assistance with completing your year 2004 tax forms, you can telephone the Internal Revenue Service, toll-free: 1-800-829-1040; website: (www.irs.ustreas.gov/prod/forms_pubs)
New Gastroparesis Treatment
Gastroparesis is interuption of parastalsis, the normal travel of food dthrough the digestive system. It is one result of autonomic neuropathy, nerve damage to the functional systems of the body -- and, for diabetics, it can be extremely serious. Interfering with the regularity of digestion, gastroparesis can make blood glucose control next to impossible.
There have been few treatments. DIABETES CARE magazine (27:2341-47, 2004), a leading, peer-reviewed, professional medical journal, reports a new one, from an unlikely source.
Botulism is an often fatal form of food poisoning, but botulism toxin has been used (as Botox) by plastic surgeons, to remove wrinkles. It is a paralyzing agent, and researchers wondered if, injected into the pylorus, the sphincter valve at the base of the stomach (a frequent site of the spasms that can characterize gastroparesis), Botox might offer relief.
Eight patients with type 1 diabetes and gastroparesis volunteered for the study -- and experienced general relief of symptoms.
Researchers immediately called for larger studies of the procedure, to determine its long-term safety and efficacy. NOTE: It will be some time before these studies are completed.
Diabetes Supplies
American Diabetic Supply, Inc., will ship your diabetes supplies to your door. They handle all insurance claims and provide free delivery. Folks with Medicare and/or private insurance (no HMOs) may receive supplies at no further cost. For information, contact: American Diabetic Supply, Inc., 400 S. Atlantic Ave., Suite 108, Ormond Beach, FL 32176; telephone: 1-800-453-9033, ext. 200; website: (www.americandiabeticsupply.com)
Healthy Cookbooks
JoAnna Lund writes healthy cookbooks. They are simple, "common folks" recipes, and all contain both complete nutrient counts and diabetic exchanges. There are three titles: Fast, Cheap, and Easy; Grandma Jo's Soup Kettle; and Fresh From the Hearth. Price is $10 each, or $25 for all three. There is no shipping charge. Contact: Healthy Exchanges, PO Box 80, DeWitt, IA 52742; telephone: 1-800-766-8961; website: (www.healthyexchanges.com)
Small Package
We Have Been Asked To Announce: Exercise is important -- but do you need all those machines at the gym? Maybe not. Fitness expert Phil Black, a former U.S. Navy SEAL, knows a lot about workouts that just take space on your floor -- and he has packaged his manual as a deck of cards. Now the Navy SEALs are the fittest of all, but the FITDECK workout is designed for beginners through advanced, for folks who want to get fit. New FITDECK ULTRA will target the "ironman" types.
FITDECK costs $18.95 ($24.95 with instructional DVD as well), from: FITDECK, 7081 Weller Street, San Diego, CA 92122; telephone: (858) 453-6644; website: (www.fitdeck.com)
Large Print Books
Many people keep up with the latest bestsellers through book clubs. The clubs are bargains. The problem has been all their books came in standard print, and some of us need something bigger. Doubleday, a major book publisher, has come to the rescue. Check out the Doubleday Large Print Book Club. All text is 14 point or larger, and the books are up to 30% cheaper than publisher's list price. Get your bestsellers in a font you can read more easily. Contact: Doubleday Large Print Book Club, PO Box 6338, Camp Hill, PA 17001-9058; website: (www.joinDLP.com)
New E-mail Diabetes List
Our Diabetes Action Network now offers its own 'listserv,' ([email protected]). Although its primary focus is on blindness and diabetes, any and all discussions concerning diabetes are welcome. We welcome topics like: diet, devices, healthcare, diabetes control, and how to improve the VOICE OF THE DIABETIC. Remember, please do not give any direct medical advice, unless you are a medical professional. Membership is free, and open to all.
There are two ways to sign up. You can go to the following website: (www.nfbnet.org/mailman.listinfo/diabetes-talk), or you can sign up by e-mail, by sending a message to: ([email protected]) and putting "subscribe" in the subject line.
Did You Use Vioxx?
Some individuals who used the pain medication Vioxx experienced complications from the drug. If you used this medication, were a caregiver for someone who did, 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.
New Survey
We Have Been Asked To Announce: Volunteers are needed for a survey of blind or visually impaired users of home blood pressure monitors, who have diabetes. The survey covers your experiences using your home blood pressure monitor, and should take approximately 1/2-hour of your time over the telephone. A $15 stipend will be paid to all participants. Contact: Darren Burton or Taine Duncan, American Foundation for the Blind, 949 3rd Avenue, Suite 200, Huntington, WV 25701; telephone: (304) 523-8651; e-mail: ([email protected])
Diabetic Foot Products
The following products were specifically designed by podiatrist Dr. Kenneth B. Rehm, DPM, to help treat diabetic conditions of the human foot.
* DiabetiCream; $30 (plus S&H) for a 4-oz. tube. Apply to clean, dry feet, to help alleviate dryness and cracking. Use with massage will help circulation.
* ToeSoak; $20 each (plus S&H). Foot shampoo.
* ToesEase; (foot and toenail cleaner) $20 (plus S&H) for an 8-oz. supply
All these products are available from: The Diabetic Foot and
Wound Treatment Center, 1529 Grand Avenue, Suite C, San Marcos, CA 92069; telephone: (760) 471-8637; website: (www.thediabeticfoot.com)
Diabetic Supplies On Line
Pharmacist Bryan Luna, Rph, offers diabetes supplies, including glucose monitors, on line at (www.diabeticsupplies.com). This convenient website 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.
Jelly Beans
Everybody likes jelly beans. We avoid them, of course, because they're full of sugar. Isn't it time for some tasty sugar-free ones? Jelly Belly Candy Company, the experts, offer a line of sugar-free jelly beans, gummy bears, and other candies, all 35 percent lower in total calories. Make a child happy -- maybe the one inside? Contact: Jelly Belly Candy Company, One Jelly Belly Lane, Fairfield, CA 94533; telephone: 1-800-522-3267; website: (www.jellybelly.com)
Diabetes Literature from NFB National Center
The National Federation of the Blind maintains an extensive literature collection, with free materials on many subjects, including diabetes, available in a variety of formats. The diabetes articles are available, in large print or on 4-track audiocassette, in a single volume titled: DIABETES ACTION NETWORK ARTICLES, or singly, in large print. These are free of charge.
The Materials Center also has a supply, in Braille and on 4-track audiocassette, of the new ADA EXCHANGE LIST FOR MEAL PLANNING, 2003 Edition. In Braille, price is $10; on tape, $2.
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 8:00 am to 5 pm, EST, weekdays.
New Diabetes Resource List
The Diabetes Action Network of the National Federation of the Blind now offers the 2004-2005 edition of DIABETES RESOURCES: EQUIPMENT, SERVICES AND INFORMATION, our comprehensive list of resources for diabetics. Diabetes Resources is our compilation of companies and individuals offering products and/or information to help diabetics, especially those who are blind or are losing vision, self-manage their diabetes. The list contains many subject categories, including: Insulin Measurement Devices, Insulin Syringe Magnifiers, Insulin Injection Systems, Diabetic Foot Care, Blood Glucose Monitoring Systems, Insulin Pumps, Products for the Blind, Food and Diet, Literature and Information, Distributors of Diabetes Equipment and Supplies, and Medication Assistance.
Blind diabetics can and do accurately draw up insulin, monitor blood glucose, and perform the other tasks of independent self-management. By using alternative techniques and products, they can continue being independent, and control their diabetes as efficiently as do their sighted peers. Limitations are usually self-imposed -- often, all that is needed to overcome negative thinking is simply to know where to go for information.
DIABETES RESOURCES: EQUIPMENT, SERVICES, AND INFORMATION (2004-2005 edition) costs $5 per copy, and is available in Braille, large print, and 4-track audiocassette, or you can access it on the NFB website: (www.nfb.org/diabres)
Please order from: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314. Note: the NFB Materials Center is open weekdays 8 am to 5 pm Eastern time.
Medical Equipment and Supplies
Specialty Shoes and Diabetic Supplies, Inc., from Beaumont, Texas, is a one-stop supplier for your diabetes needs. They stock blood glucose meters, strips, lancets, vacuum erection devices (for diabetic impotence), other diabetes care items, and, of course, specialty pedorthic footwear. They accept Medicare, Medicaid, Blue Cross, Blue Shield, and private insurance. Contact them at: SSDS, 229 Dowlen Road, Suite 15A, Beaumont, TX 77706; telephone: 1-877-817-7737; e-mail: ([email protected])
The 2005 National Federation of the Blind Scholarship Program
This year's scholarship program, for blind students planning higher education, will be the 22nd since the organization determined to expand the number, variety, and value of the scholarships presented at the NFB annual convention every July. The Federation plans to present at least three of the scholarships to students who won scholarship awards in a previous competition. All current students who were scholarship winners in previous years should take particular note of this program and consider applying for the 2005 National Federation of the Blind scholarships.
Full-time employees interested in pursuing post-secondary degrees should take a close look at the scholarship form, because one award may be given to a part-time student holding down a full-time job.
Order scholarship forms from: Materials Center, National Federation of the Blind, 1800 Johnson Street, Baltimore, MD 21230, or from NFB State presidents. The 2005 scholarship application form is now downloadable from the NFB website:
(www.nfb.org)
Diabetes Planner
We Have Been Asked To Announce: Executives, students, teachers, and busy professionals use planners to organize their appointments. What about a planner specifically for your diabetes? Day-Timers, Inc., now offers the Diabetes Management Planner. There are two formats: "pocket" and "desk" size, and the planner is available in English or Spanish. Price is $29.99, available from Day-Timers Website: (www.daytimer.com/diabetes), or by telephone: 1-800-832-6625.
Easy Diabetic Cookbook
If you want to prepare healthy diabetic meals, but find most cookbooks just too complicated, you need Linda Coffee and Emily Cale's new and improved DIABETIC 4 INGREDIENT COOKBOOK. There are almost twice as many recipes as before, 350, in all food categories, with complete nutritional and exchange information, each one using four ingredients. The book costs $19.95 (+$3.50 shipping), from: Coffee and Cale, PO Box 2121, Kerrville, TX 78029; telephone: 1-800-757-0838; (www.fouringredientcookbook.com)
Diabetic Products
Health Care Products makes many over-the-counter medications and supplements for diabetics, including Multi-Betic Vitamins and DiabetiDerm skin cream (with L-Arginine) for the feet. Find these products in the diabetic section of Eckerd, Osco, Sav-on, Target, GNC, and other retailers. For information, contact: Health Care Products, 369 Bayview Avenue, Amityville NY 11701; telephone: 1-866-263-9003; website: (www.diabeticproducts.com)
Adaptive Computing Equipment
Freedom Scientific is a powerhouse adaptive equipment maker for the blind and visually impaired computer user. A union of Arkenstone, Blazie Engineering, and Henter-Joyce, Freedom Scientific offers screen magnifiers (including MAGic 9 software, which both magnifies up to 16x and speaks the words on the screen), talking attachments (voice synthesizers) for your computer, Braille printers and much more. Whether you need adaptive software or hardware, check them out: Freedom Scientific; telephone: 1-800-444-4443; website: (www.freedomscientific.com)
New Hypoglycemia Alarm
Diabetes brings with it the risk of hypoglycemia, low blood sugar. Some of us need some help. What many of us need is an alarm, a device to warn us we're going low, when we cannot tell for ourselves. There is now such a device -- FDA approved.
Diabetes Sentry Products, from Bellingham, Washington, offers the Sleep Sentry, a wrist watch-sized device that sounds an audible warning whenever the wearer's blood sugar drops too low. Not a blood glucose monitor, this noninvasive device meters changes in body temperature and sweat consistent with hypoglycemia, and sounds a warning in time for you to take action. Completely noninvasive and continuous, the Sleep Sentry costs $399, shipping included, and may be ordered from: Diabetes Sentry Products Inc., 1200 Dupont St., Suite #1D, Bellingham, WA 98225; telephone: 1-866-270-5675; website: www.sleepsentry.com
Input Needed
Diabetes Educator Ann Williams, who writes a column for the VOICE each issue, wants to do one on "diabetes definitions," all those $64 words the doctors "use to confuse." Do you have a favorite(!) diabetes term or two you'd like to see defined in plain English? Send it in, to: Ann Williams, c/o VOICE OF THE DIABETIC, 1412 I-70 Drive SW, Suite C, Columbia, MO 65203; or at e-mail: ([email protected])
VOICE Formats
VOICE OF THE DIABETIC is offered in two formats: standard print, and 15/16 ips audiocassette, "talking book" speed. Anyone who is currently receiving the VOICE in print and having difficulty reading it, may receive it on cassette at no charge. Voice tapes REQUIRE the special tape player available free to the legally blind from Regional Libraries for the Blind and Physically Handicapped, which can be obtained by telephoning the National Library Service at: 1-800-424-8567. Note: Attempting to play Voice tapes (or any other tapes recorded for the Blind in NLS format) on a conventional music-speed tape player will fail, yielding only incomprehensible "chipmunk sounds."
The VOICE is also available, free, 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.
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 339,025 VOICE readers could benefit from your story.
For information and article submission guidelines, contact: VOICE OF THE DIABETIC, 1412 I-70 Drive SW, Suite C, Columbia, MO 65203; telephone: (573) 875-8911.
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SUBSCRIPTION/DONATION FORM
The VOICE OF THE DIABETIC is a quarterly magazine published by the Diabetes Action Network of the National Federation of the Blind (NFB) for anyone interested in diabetes, especially diabetics who are blind or are losing vision. It is outreach publication emphasizing good diabetes control, diet, and independence.
Donations are gladly accepted and appreciated. Contributions are not only tax deductible but are needed to keep the VOICE and the Diabetes Action Network moving forward to help people with all aspects of diabetes.
Members of the NFB Diabetes Action Network enjoy priority services and unique benefits such as a continuous free subscription to the VOICE, automatic access to committees covering all aspects of diabetes, free counseling concerning all facets of blindness and diabetes, as well as access to diabetics who have experienced complications.
The VOICE is free to any interested person upon request. Each subscription costs the Diabetes Action Network approximately $20 per year. To help defray publication expenses, members are invited, and nonmembers are encouraged, to cover the subscription cost.
To begin receiving the VOICE, please check one:
[ ] I would like to become a member of the NFB Diabetes Action Network and receive the VOICE OF THE DIABETIC. (Members are entitled to special benefits.)
[ ] I would like to receive the VOICE OF THE DIABETIC as a nonmember. (Nonmembers are encouraged to pay the institutional rate of $20/one year; $35/two years; $50/three years.)
Send the VOICE in (check one):
[ ] print [ ] cassette tape for the blind [ ] both
and physically handicapped
(recorded at slower-than-
standard speed of 15/16 IPS)
To receive VOICE OF THE DIABETIC by e-mail, go to:
(www.nfbcal.org/listserv-signup.html). (NOTE: If you want a print or tape copy as well, send this form to the VOICE office).
Optionally check this box:
[ ] I would like to make (or add) a tax-deductible
contribution of $__________ to the Diabetes Action
Network of the National Federation of the Blind.
PLEASE PRINT CLEARLY
Name:_____________________________________________________
Address:__________________________________________________
__________________________________________________
City:_______________________ State:______ Zip:__________
Telephone:( )________________________
Send this form or a facsimile to:
VOICE OF THE DIABETIC
1412 I-70 Drive SW, Suite C
Columbia, MO 65203
Telephone: (573) 875-8911
Fax: (573) 875-8902
Please make all checks payable to:
NATIONAL FEDERATION OF THE BLIND
(V20#1)
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End Voice of the Diabetic Vol 20#1