A SUPPORT AND INFORMATION NETWORK
The Diabetics Division of the National Federation of the Blind
Volume 10, No. 3, Summer Edition 1995
FREE! FREE!
Voice of the Diabetic is offered absolutely free to any interested person upon request. Readers may receive the publication in print, on audio cassette for the blind, or in both formats. To begin receiving the Voice, please complete the subscription form (or a facsimile) on page 19 and mail it to the editorial office.
Voice of the Diabetic is a national publication of the Diabetics Division 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, M0 65203
Phone: (573) 875-8911
Fax: (573) 875-8902
Copyright ©1995 The Diabetics Division of the National Federation of the Blind. ISSN 1041-8490
Update: Non-Invasive Glucose Monitors
by J.R. Wu
Finding the Tools He Can Live By
Metformin—Good News For Type II's
by Janet Blodgett, M.D.
Experimental Drug May Prevent Adult Diabetes
Social Security, SSI, and Medicare Facts for
1995
by James Gashel
Dialogs About Diabetic Dynamos: Scholarship
available for IDDM Diabetics
by Debra Frank, M.S., M.S.
Double Transplant: A Two-Year Drama
by Marie R. Verrastro
Ask the Doctor
by Wesley W. Wilson, M.D.
What Insulin Manufacturers Say About Vial Design
Change
by Ed Bryant
To Dog or Not to Dog
by Ed and Toni Eames
What You Always Wanted to Know But Didn't
Know Where to Ask
(Resource List)
by J.R. Wu
No more needles is the motto for approximately 44 companies who are researching better blood glucose monitoring techniques. The new non-invasive technology, some ten years in the making, requires no finger pricks, giving diabetics an easy, painless way to check and control their blood-sugar levels more frequently, thus avoiding or minimizing long-term organ damage.
The monitors under development use a beam of light shined through the skin to measure blood glucose levels. Near infrared spectroscopy (NIR), dubbed the "Dream Beam" by Futrex Inc., one company researching this technology, can determine the chemical makeup of an object by analyzing the signal changes in the wavelengths of light after it has passed through the object. By measuring the glucose-emitted signals, the concentration of sugar levels can be determined. However, glucose accounts for only 1/1000 of the mass of blood, making it hard to measure the wavelengths absorbed by glucose which are also absorbed by othermore sizable bodily components such as water and fat. The trick then is to focus on those specific wavelengths that, although weakly absorbed by glucose, are even less captured by surrounding tissue.
When non-invasive monitors hit the market, they will cost several thousand dollars. For diabetics who test glucose three times a day, the yearly cost for equipment, such as a glucometer and accessories, is estimated at $1,050.
In the forefront of the monitor race is Biocontrol Technology, Inc., based in Indiana, PA. They were the first company to submit an application to the Food and Drug Administration for approval. The glucometer, called Diasensor 1000, uses NIR technology to measure glucose levels. If approved, the meter will be marketed to individuals due to its strict calibration requirements. It cannot be used in a clinic or hospital setting and will need to be recalibrated periodically at a Biocontrol office. Diasensor 1000 is an 11" x 18.5" x 11" machine that is not as portable as current smaller meters and will be priced near $8,000.
Another non-invasive technology being developed by the University of California, San Francisco and Cygnus Therapeutic Corporation in Redwood City, CA, has nothing to do with light. Rather, they measure sugar levels transdermally with a GlucoWatch. The process, called reverse iontophoresis, uses a steady electrical current to extract glucose molecules out of the body. Originally, this electrotransport was used to deliver drugs transdermally by enlarging the pores to allow large drug molecules to enter the skin. This non-invasive monitor would include a GlucoPad that adheres to the skin. It is placed on the back of the GlucoWatch that can measure and read sugar levels. Cygnus envisions that the pad would be replaced daily while the watch would allow for continuous monitoring of glucose levels. The transdermal concept has been considered by pharmaceutical giants like Eli Lilly, Becton Dickinson and the Alza Corporation.
Non-invasive monitoring techniques are not limited just to the skin. Other methods measure the concentration of light shined through the eyeball or emanating from glucose. The enthusiasm for this new technology is witnessed in the number of companies involved in the research and the varied methods they come up with. Yet, companies also withdraw because of failed attempts to perfect a machine. Consequently, non-invasive glucometers may not be marketable for several more years. No one knows. The Centers for Disease Control estimates each year 15,000 to 39,000 people become blind from diabetes. When a monitor is approved by the FDA, company representatives say that voice synthesizers may become an accessory.
Until then, accuracy, accessibility, and affordability are important details that still need to be worked out. Reliability and accuracy in the no-prick meter will be vital to prevent any complications and calibration techniques for use in a general setting still have to be refined. The glucose monitoring marketis worth approximately 1.5 billion dollars and demand for the new meters will be high. Companies involved in the research are aware of the immense financial profit to be gained if they are the first to come out with a non-invasive monitor. However, if affordability can't be guaranteed, the monitors won't benefit anyone—consumers or manufacturers. Listed below are some of the companies engaged in the non-invasive blood glucose monitor research:
Americare Transtech, Inc., Miami, FL Bayer Corporation, Diagnostics Division, Tarrytown, NY Biotronics Technology, Inc., Waukesha, WI Biocontrol Technology, Inc., Indiana, PA affiliate - Diasense, Inc., Pittsburgh, PA Boston Advanced Technology, Boston, MA Cedars Sinai Medical Center, Los Angeles, CA Cygnus Therapeutic Systems, Redwood City, CA Futrex, Inc., Gaithersburg, MD LifeScan, Inc., Milpitas, CA Medisense, Inc., Waltham, MA Sandia National Laboratories, Albuquerque, NM University of Iowa, Iowa City, IA Worchester Polytechnical Institute, Worchester, MA.
From the Editor: This story by Alana Hanson was adapted from the Mesabi Daily News, December 11, 1994. Ken Carstens has served in a leadership position for the Diabetics Division of the National Federation of the Blind. He and his wife Linda always lend helping hands to anyone in need.
Ken and Linda Carstens of Virginia, Minnesota have filled their home with furniture and wood decorator items which they made by hand. Items include: book shelves, deacon's benches, domed trunks, doll furniture, toy boxes, and decorative tables. Having operated their in-home wood shop for the past 15 years, they enjoy spending most of their days in the basement workroom. Both Ken and Linda are skilled in using power tools to craft handmade items of wood.
Thirty years ago, Ken began losing eyesight due to complications of diabetes. He had to stop farming and find another occupation. For several years Ken and Linda helped operate a coffee shop at their local county courthouse. Eventually, the Carstens left the shop after deciding to try other kinds of work. However, they remained in the area because they liked northern Minnesota and the Mesabi Range.
"Ken has always liked working with wood," said Linda Carstens. They had a few tools and when a friend brought a toy box over for them to repair, they fixed it and thought they'd like to try to make one. It sold right away and they made another, and anotheruntil they were in business for themselves.
"Now, we make all sorts of chests," commented Ken. To enable them to do different kinds of work, they expanded their tool and equipment collection. The Carstens use a lot of patterns, or jigs to make the more popular items.
Blindness is not Ken's only complication of diabetes. With a kidney donated by his sister, Ruby Thielke, Ken has undergone transplant surgery. (Editor's note: Ken has had a kidney transplant for more than 19 years!) Having had both legs amputated at the knee, Ken sits in a modified wheel chair which he cut down for ease of movement.
Keeping his tools arranged on a shelf at hand level under the table, Ken is able to find needed items quickly. His ruler is notched at appropriate places at the inch and its subdivisions. Each mark is a different length so he can determine which is which. To cut a board to the right length, Carstens fits the ruler slot at the length where he wants to make a cut. After making sure the safety shield is on, he starts the machine and saws the wood by pushing it toward the blade.
Commenting that her husband has learned to adapt his skills, "It's worked out," Linda said, "he's pruned his fingers once or twice," but he has never had anything worse happen.
Ken said that his wife has come a long way using the machinery, particularly since she was unfamiliar with the various pieces of equipment before they began the business. "Now, she's as good as anyone," he said.
"I've had a lot of people ask me to train low-vision people on power tools," said Ken. "But anyone who has any sight at all would try to use it, of course. I just go by touch, sound, and smell."
The Carstens do most of the work as a team. While one is occupied using a machine, the other operates another piece of equipment, or sands wood. After the wood is cut and sanded one member of the team holds while the other fastens the item with screws. Linda said that it is easier to put in screws than nails. "Phillips screws are especially easy to put in with an electric drill."
At various times during the year, the Carstens show their unique, handmade decorator items and pieces of furniture at craft shows and fairs. People who buy items crafted by the Carstens not only gain a quality piece of furniture or a unique decorator item, but also learn that blindness is not synonymous with inability.
by Janet Blodgett, M.D.
Dr. Janet Blodgett is an Assistant Professor of Medicine in the Division of Diabetes at the University of Texas Health Science Center at San Antonio.
If you were diagnosed as having type II diabetes, you have probably been exercising regularly and watching what you eat. To help further control your diabetes, your doctor may have prescribed pills that seem to do the trick, but oral diabetes medicine has some unpleasant side effects and may not work forever. Your only other choice, injecting insulin, is something you would like to avoid for as long as possible. Don't you wish there was another option? Well, now there is.
A drug called metformin, which received Food and Drug Administration approval late December of 1994, is expected to have a major impact on the treatment of type II (non-insulin-dependent) diabetes. Metformin effectively controls blood glucose levels without the side effects of the diabetic drugs that are available now. So if you are currently treating your diabetes with pills or with diet and exercise alone, this new medication may work well for you.
What Is Metformin?
Metformin has actually been around for about 30 years in Europe and 20 years in Canada. It belongs to a class of antidiabetic drugs called biguanides. These agents were developed in the 1920s and were originally available in the United States. However, complications resulting primarily from phenformin, a related, but less effective drug, tarnished the reputation of all the biguanides and the class of drugs was pulled from the market in 1977. Now, after three decades of safe and effective use, the Food and Drug Administration retested metformin and approved it for use alone and in combination with sulfonylureas, the traditional oral diabetes medicine in use long before the approval of metformin. Metformin is manufactured and distributed by Bristol-Myers Squibb under the brand name Glucophage.
Normally, insulin works like a key to unlock a passage into the cells so that glucose can enter and be used for fuel. But with type II diabetes, your cells are resistant to insulin, so they cannot effectively process your blood glucose. Rather than flooding your bloodstream with extra insulin to overwhelm the less-than-hospitable receptors on your body's cells, metformin works by sensitizing your cells to insulin's effects. Thus, the receptors work more efficiently so you can process glucose using the insulin that your body already makes. As a result, you can lower both your blood glucose levels and circulating insulin levels, which protects the blood vessels throughout your body.
In addition, metformin has a number of secondary benefits over currently available pharmacologic treatments. Metformin lowers the levels of triglycerides and other fatty blood components, and, in many people, works as an appetite suppressant. These traits further reduce insulin resistance and improve triglycerideand cholesterol levels, thus keeping blood glucose levels in check while reducing the risk of heart disease and other complications. This aspect of metformin makes it a welcome addition to the repertoire of diabetes treatments.
The Old Order
Right now there are several ways to improve your insulin sensitivity. Sometimes, losing weight and changing your diet and exercise habits will help. However, most people with type II diabetes need to take oral medicine and eventually insulin injections to maintain normal blood glucose levels.
Although highly effective in improving blood glucose and triglyceride levels, a regimen of increased exercise, improved diet, and weight loss alone is rarely successful in treating diabetes over the long term. Indeed, few people achieve their ideal body weight through diet and exercise and those who do lose weight often gain it right back.
So people with type II diabetes often need to use some sort of pharmacological therapy to manage their diabetes. Currently, there are two types of drug therapies available: oral agents called sulfonylureas and insulin injections.
Sulfonylureas work primarily by stimulating the pancreas to produce more insulin so that cells will be more likely to process the glucose coursing through the bloodstream. This therapy also increases the number of insulin receptors on the cell surface. Both of these effects result in lower glucose levels. Currently, if you cannot take oral agents, or if they stop working, the next step is to take insulin, either alone or in combination with the oral agents.
Unfortunately, both sulfonylureas and injected insulin have several counterproductive side effects. Oral agents generally become less effective over time because the overworked pancreas eventually becomes exhausted and burns out. When this happens, people must begin taking insulin injections.
Furthermore, both therapies promote weigh gain because they allow you to absorb calories from blood glucose that would otherwise spill out in your urine. This weight gain can worsen insulin resistance and increase the risk of heart disease.
In addition, it is not healthy to have too much insulin flowing through your system. High levels of insulin, or hyperinsulinemia, is known to contribute to the development of atherosclerosis, or hardening of the arteries. Severe vascular disease, particularly coronary artery disease, is the most common cause of hospitalization and death for people with type II diabetes. So, it's a good idea to try to avoid any therapies that worsen this condition. Insulin and oral agents can also promote hypoglycemia, so you always have to be on the alert for such reactions.
Why Use Metformin?
The introduction of metformin is an exciting prospect since it addresses many of the limitations of the other therapies.
Most important, metformin sensitizes the tissues in your body to the effects of the insulin your body makes without stimulating your pancreas to make more insulin. Because metformin does not affect the action of your pancreas, taking the drug does not cause pancreatic exhaustion, which is the reason that sulfonylureas eventually stop working. Furthermore, you won't have super-high levels of insulin in your bloodstream, as people with type II diabetes tend to have when they use just sulfonylureas or insulin.
In addition, metformin can lower levels of triglycerides and other fatty blood components. Since heart disease is a problem for many people who have type II diabetes, this is a welcome bonus.
Metformin can also act as an appetite suppressant, thus promoting weight loss and improving insulin sensitivity and cardiovascular health.
Another side effect connected with insulin and sulfonylurea therapies is hypoglycemia. Metformin alone does not cause hypoglycemia because it does not raise your circulating insulin level the way other medications do. Of course, if you take metformin in combination with sulfonylureas, you will still need to watch out for hypoglycemia.
Is Metformin For You?
Metformin is an exciting alternative for many people with type II diabetes. It may be a good choice for you if you are currently controlling your diabetes with diet and exercise alone or if you are now taking a sulfonylurea.
Taken alone, metformin will allow your body to make better use of your own insulin. If you take metformin in combination with a sulfonylurea, you can achieve a collaborative effect. The sulfonylurea makes your pancreas produce more insulin while the metformin makes your tissues use that insulin better. These methods are in many ways superior to existing treatments.
If you are already taking insulin, chances are that metformin will not be a good choice for you, since you probably don't produce enough insulin naturally or with the help of sulfonylureas. Metformin has not been approved for use with insulin. It is also important to note that people with kidney disease cannot use metformin since they may experience more serious side effects than other users.
Of course, like all drugs, metformin does have some side effects, most notably gastrointestinal discomfort. About 10% to 30% of users experience loss of appetite, nausea, stomach discomfort, and diarrhea. However, these symptoms are temporary and disappear over time. Also, they can be lessened or alleviated by loweringthe dose.
A rare, but serious side effect is a toxic condition called lactic acidosis. It occurs when your tissues are not getting enough oxygen to survive. Although the risk of developing lactic acidosis from metformin is much lower than from the other biguanides, people with kidney disease are at the greatest risk of experiencing this side effect. Thus, physicians in the United States will be given specific guidelines for selecting patients who can safely use the drug.
The Next Step
Metformin is not just another oral agent. Rather, it is an exciting drug that should have a major impact on the treatment of type II diabetes. Whether you use it alone or with sulfonylureas, it can keep your blood glucose levels steady while lowering your levels of circulating insulin and triglycerides, thereby reducing your risks of heart disease. And it does all this with fewer side effects than other available treatments. So see your doctor to find out if metformin is the right treatment for you.
(Note: This article appeared in Diabetes Self-Management, March/ April 1995. Reprinted with permission.)
An experimental drug may help ward off adult diabetes, which afflicts about five percent of all Americans, a study suggests.
The medicine, troglitazone, is being developed as a treatment for people who already have diabetes, but the new study raises the possibility it might also be useful for those who are at high risk of the disease.
Currently, the only known way to prevent adult diabetes is by losing weight and exercising more.
The drug helps the body use insulin more efficiently. As a result, levels of insulin and sugar in the blood go down. However, the study is preliminary and does not prove that lowering blood sugar levels with the drug prevents diabetes.
Doctors from the University of California at San Diego tested the drug on overweight people who had high blood sugar levels but were not considered diabetic. Such people are at high risk of adult, or type II, diabetes which is more common than the variety that strikes during childhood.
In an editorial published with the study, Dr. Harry Keen of Guy's Hospital in London said the potential for a drug treatment is too great to be ignored.
But he added, "Medical moralists will despair that pharmacologicinventiveness may now allow people to become even fatter and lazier without having to face their metabolic nemesis."
The research, conducted by Dr. John Nolan and others, was published in the New England Journal of Medicine.
Doctors experimented on 18 people. Half got troglitazone, while the rest got dummy pills, for 12 weeks.
A condition called insulin resistance is an important underlying factor in adult diabetes. They body needs insulin to absorb sugar. Some people make even more insulin than normal, but their bodies do not use it properly, so sugar levels in their bloodstreams rise too high.
All the study participants had insulin resistance. After taking troglitazone, their insulin levels fell 41 percent and their sugar levels also declined significantly.
(NOTE: This article appeared in the News-Press, North Ft. Meyers, FL.)
by James Gashel
This article appeared in the Braille Monitor January 1995, published by the National Federation of the Blind.
From the Monitor Editor: James Gashel is the National Federation of the Blind's Director of Governmental Affairs.
The beginning of each year brings with it annual adjustments in Social Security programs. The changes include new tax rates, higher exempt earnings amounts, Social Security and SSI cost-of-living increases, and changes in deductible and co-insurance requirements under Medicare. Here are the new facts for 1995:
FICA and Self-Employment Tax Rates: The FICA tax rate for employees and their employers remains at 7.65%. This rate includes payments to the Old Age, Survivors, and Disability Insurance (OASDI) Trust Fund of 6.2% and an additional 1.45% payment to the Hospital Insurance (HI) Trust Fund, from which payments under Medicare are made. Self-employed persons continue to pay a Social Security tax of 15.3%. This includes 12.4% which is paid to the OASDI trust fund and 2.9% which is paid to the HI trust fund.
Ceiling on Earnings Subject to Tax: During 1994 the ceiling on taxable earnings for contributions to the OASDI trust fund was$60,600. The taxable income ceiling for contributions to the OASDI trust fund during 1995 is $61,200. As was true in 1994, there is no ceiling on earnings that are subject to the HI trust fund tax contribution of 1.45% for employees or 2.9% for self-employed persons.
Quarters of Coverage: Eligibility for retirement, survivors, and disability insurance benefits is based in large part on the number of quarters of coverage earned by any individual during periods of work. Anyone may earn up to four quarters of coverage during a single year. During 1994 a Social Security quarter of coverage was credited for earnings of $620 in any calendar quarter. Anyone who earned $2,480 for the year (regardless of when the earnings occurred during the year) was given four quarters of coverage. In 1995 a Social Security quarter of coverage will be credited for earnings of $630 during a calendar quarter. Four quarters can be earned with annual earnings of $2,520.
Exempt Earnings: The earnings exemption for blind people receiving Social Security Disability Insurance (SSDI) benefits is the same as the exempt amount for individuals age sixty-five through sixty-nine who receive Social Security retirement benefits. The monthly exempt amount in 1994 was $930 of gross earned income. During 1995 the exempt amount will be $940. Technically, this exemption is referred to as an amount of monthly gross earnings which does not show "substantial gainful activity." Earnings of $940 or more per month before taxes for a blind SSDI beneficiary in 1995 will show substantial gainful activity after subtracting any unearned (or subsidy) income and applying any deductions for impairment-related work expenses.
Social Security Benefit Amounts for 1995: All Social Security benefits (including retirement, survivors', disability, and dependents' benefits) are increased by 2.8% beginning with the checks received in January, 1995. The exact dollar increase for any individual will depend upon the amount being paid.
Standard SSI Benefit Increase: Beginning January, 1995, the federal payment amounts for SSI individuals and couples are as follows: individuals, $458 per month; couples, $687 per month. These amounts are increased from individuals, $446 per month; couples, $669 per month.
Medicare Deductibles and Co-insurance: Medicare Part A coverage provides hospital insurance to most Social Security beneficiaries. The co-insurance payment is the charge that the hospital makes to a Medicare beneficiary for any hospital stay. Medicare then pays the hospital charges above the beneficiary's co-insurance amount.
The Part A co-insurance amount charged for hospital services within a benefit period of not longer than sixty days was $696 during 1994 and is increased to $716 during 1995. Beginning with the sixty-first day through the ninetieth day, there is a daily co-insurance amount of $179 per day, up from $174 in 1994. Each Medicare beneficiary has sixty "reserve days" for hospital services provided within a benefit period longer than ninety days. The co-insurance amount to be paid during each reserve day is $358, up from $348 in 1994.
Part A of Medicare pays all covered charges for services in a skilled nursing facility for the first twenty days within a benefit period. Beginning with the twenty-first day through the one hundredth day within a benefit period, the Part A co-insurance amount for services received in a skilled nursing facility is $89.50 per day.
For most beneficiaries there is no monthly premium charge for Medicare Part A coverage. Persons who become ineligible for Social Security Disability Insurance cash benefits can continue to receive Medicare Part A coverage premium-free for thirty-nine months following the end of a trial work period. After that time the individual may purchase Part A coverage. The premium rate for this coverage during 1995 is $261 per month. During 1995 this premium rate is reduced by 30% for individuals who have earned at least thirty quarters of coverage under Social Security covered employment. For such individuals the monthly premium rate for purchasing Medicare Part A coverage during 1995 will be $183.
The Medicare Part B (medical insurance) deductible remains at $100 in 1995. This is an annual deductible amount. The Medicare Part B basic monthly premium rate will increase from $41.10 charged to each beneficiary and withheld from Social Security checks during 1994 to $46.10 per month during 1995. Medicare Part B coverage may be continued for persons who complete a trial work period and become ineligible to receive Social Security Disability Insurance cash benefits. This monthly premium rate is $46.10, the same amount paid by Social Security beneficiaries through withholding from their monthly Social Security checks.
Programs Which Help with Medicare Deductibles and Premiums: Low-income Medicare beneficiaries may qualify for help with payments. Assistance is available through two programs - QMB (Qualified Medicare Beneficiary program) and SLMB (Specified Low-income Medicare Beneficiary program).
Under the QMB program states are required to pay the Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) premiums, deductibles, and coinsurance expenses for Medicare beneficiaries who meet the program's income and resource requirements. Under the SLMB program states pay only the full Medicare Part B monthly premium ($46.10 in 1995). Eligibility for the SLMB program may be retroactive for up to three calendar months.
Both programs are administered by the Health Care Financing Administration (HCFA) in conjunction with the states. The rules vary from state to state; but, in general:
An individual may qualify for the QMB program if his or her income is near the national poverty level, approximately $7,596 annually for an individual (about $633 per month) and $10,080 annually for a family of two (or $840 per month). These amounts apply for residents of forty-eight of the fifty states and the District of Columbia. In Alaska the income threshold used to define poverty is approximately $9,444 annually for an individual ($787 per month) and $12,540 annually for a family of two ($1,045 per month). In Hawaii the income threshold used to define poverty is approximately $8,712 annually ($726 per month) for an individual and $11,556 annually ($963 per month) for a family of two. For the SLMB program annual income must be 110 percent or less of the national poverty levels. Under both programs $20 in monthly income is not counted toward the limit. Resources - such as bank accounts or stocks - may not exceed $4,000 for one person or $6,000 for a family of two. (Resources generally are things you own. However, not everything is counted: the house you live in, for example, doesn't count, and, in some circumstances, your car may not count either.)
Here's an idea of what the QMB program provides in 1995. Under Part A the hospital insurance deductibles are $716 for the first sixty days of a hospital stay and $179 per day for days sixty-one through ninety in the hospital. However, to qualify for help under the QMB program, you must file an application. If you think you qualify but you have not filed for Medicare Part A, contact Social Security to find out if you need to file an application. Further information about filing for Medicare is available from your local Social Security office or Social Security's toll-free number, (800) 772-1213.
Remember, only your state can decide if you're eligible for help from the QMB or SLMB program. So, if you're elderly or disabled, have low income and very limited assets, and are a Medicare beneficiary, contact your state or local welfare or social service agency to apply. For more information about either program, call HCFA's toll-free telephone number, (800) 638-6833.
by Debra Frank, M.S., M.S.
Debra Frank holds Masters of Science degrees in Recreation Therapy and Exercise Physiology. She is a member of the American Association of Diabetes Educators (AADE), the International Diabetic Athlete Association (IDAA) and is on the medical advisory board of the Juvenile Diabetes Foundation International (JDFI) Nassau/Suffolk, New York Chapter. As an active athlete with IDDM she shares both her personal and professional experiences with Voice of the Diabetic. She hopes to motivate andeducate others to live rather than merely exist.
Summer, Sun, Sweat and Sport
It's summer time and the living should be easy. Having IDDM in hot and humid climates can make an individual tired and lethargic. Many of us choose to be less active during this season to avoid sudden insulin reactions caused by heat and quick changes in body temperature. There is good reason to be cautious exercising during extreme heat conditions. But there is no reason not to exercise if you're properly prepared. Others choose activities such as swimming, bicycling, tennis, softball, race-walking, or golf rather than remaining indoors taking a fitness class or sitting on a stationary bicycle. Most of these activities involve groups of people and have no set time schedule. Therefore, to prevent unnecessary reactions or complications, carry a portable cooler with plenty of water, insulin and syringes, a blood sugar monitoring kit and strips, juice or your favorite emergency glucose source, and healthy snacks. Additionally, protect your head and eyes. The sun plays tricks on the eyes and diabetics should be cautious when outside. Anyone who is on anti-rejection drugs, antibiotics or any prescription medication should be extra careful. The exaggerated sensitivity and photosynthetic reaction of sun can be extremely dangerous to the dermatome (skin) because of these drugs. Wear light-colored, cotton clothing and bring sun block. Also, remember to wear comfortable shoes, or sneakers, and cotton socks when possible. Carrying baby powder to avoid chafing and irritation during hot weather is also a smart idea. Now you're probably more prepared than anyone else for that daily walk in the park or summer company picnic and softball game.
The Angelo Centano Golf Scholarship
Join in the 'Spirit of Sport' and win a $500 scholarship. Write a 300 to 600 word essay telling us why you feel you should earn the 1995 Angelo Centano Golf Scholarship. Since Angelo's untimely death in 1992, his friends at the Elmont Knights of Columbus, his family, and the Nassau/Suffolk Juvenile Diabetes Foundation have been hosting a golf fundraiser in Angelo's memory. This year's Angelo Centano Golf Tournament is scheduled for early September 1995. One of the event committee members suggested that some of the money be awarded as a scholarship to a person who has IDDM. What good is raising millions in search of a cure(s) when many of us have already fallen victim to the reality of diabetes and its complications? We are already living lives against the odds while awaiting miracle cures.
If you feel you want to buy a tandem bicycle so you and a friend or family member can enjoy riding together, or you want to go to the next IDAA meeting, or you want to hire a coach to train you for the swimming events at the 1996 Para Olympics in Atlanta, or you have any other special desire which you feel winning this scholarship will help you achieve, pick up your pen, sit down atyour computer or send in a cassette. GO FOR IT! You just might win!
From the Editor: Debra Frank encourages blind diabetics to submit essays. Entries should reflect any activity good for physical health and positive living. Incidentally, a typed, double-spaced submission would be approx. 11/2 to three pages long.
All essays should be labeled "Golf Scholarship Essay 1995"
and sent directly to the Voice of the Diabetic. Please have your submissions
in by October 31, 1995. The winner will be chosen by a committee and announced
in the Voice, Spring 1996 issue. We look forward to reading and hearing from
you in the near future. Remember our IDAA motto, "I Run On Insulin!"
For more information on the scholarship contact: Ed Bryant, editor, Voice
of the Diabetic, 1412 I-70 Drive SW, Suite C,
Columbia, M0 65203, Phone: (573) 875-8911, Fax: (573) 875-8902.
by Marie R. Verrastro
I was sitting on an emergency room cot when a young intern hurried past. "How are you feeling?" he asked, then added, "I guess you wouldn't be here if you felt very good."
"Actually," I replied, "I'm probably the only one here who feels this great. I just got a call. I'm here for a double transplant!"
So began the most exciting, frightening ride of my 27-year-old life. The story began several months earlier, in January 1993, when my kidney was failing and my nephrologist informed me that I would be an excellent candidate for a kidney transplant. He also brought up the possibility of doing a two for one deal: receiving a pancreas as well as a kidney.
Once the plan was formulated, I launched headlong into a flurry of medical activity between January and May. This entailed taking just about every medical test known to mankind in order to ensure my only medical problems were diabetes and kidney failure. The long list of tests included a gynecological exam, an upper and lower GI series, a stress test for my heart, a hepatitis vaccination and many blood tests to check everything from AIDS to exact blood type.
The tests were not painful, but I waited on pins and needles for each result. Before a transplant can be performed, all current health problems must be "fixed" so the transplant will have a healthy environment in which to survive. Each positive result brought me one step closer to my hopeful goal.
After all the results of my tests were in, I was ready for the final phase of this drama. The scene was University Hospital inCincinnati, Ohio. There wasn't a cast of thousands, but it felt like it. Present for the big interview were: Dr. R. Munda, Professor of Surgery, Dr. R. First, Professor of Medicine, Dr. H. Hariharan, Assistant Professor of Medicine, Ann Demmy, RN, Pancreas Transplant Coordinator, Linda Page, MSW, LISW, Renal Social Worker, Kay Bonnar, Administrative Assistant, my husband Richard and myself. We discussed financial matters and the support network I would have from friends and family, but the bottom line was plain and simple: Was I strong and healthy enough to successfully endure the rigors of adding two new organs to my body?
The doctors reviewed my case while Richard and I tried not to bite our nails with anxiety. No one wanted to discourage us, but everyone in the room wanted to present the most realistic picture of the operation. We were educated in the operational procedure itself, the medicines I would need to take and their various side effects. When all participants were satisfied with our answers, the big decision was made. I received a clean bill of health and completed the paperwork to be listed as an organ donor recipient.
I was given a beeper, that electrical lifeline to the doctor's office, in August, about the same time I started hemodialysis. Richard and I knew we might have to wait a year or longer for the right match, so we settled in for the interim.
Much to our surprise, we received the expectant phone call just two months later on a cool October midnight. Anne phoned to let me know they had a donor. "Come to the emergency room as soon as you can," she said. I did two things. I phoned my parents in New York and I showered and washed my hair. Who knew when I would be doing this by myself again? Richard had to laugh. "At least you have your priorities straight during this critical time," he said.
So, this is how I came to be sitting in the emergency room at 2 AM in such good spirits. Anxiously, Richard kissed me good-bye and took up his position in the waiting room, as I was wheeled into the operating room. The last thing I remember thinking was, "This is what I've been waiting for, but what, oh, what have I taken on?"
Updating Richard periodically, the doctors emerged after six hours with the news. Everything went well and the transplant was successful. My creatinan, one measure of kidney function, was .9 and my blood sugar was less than 100, both well within normal range. I was taken to the intensive care unit with my three kidneys and two pancreases. It was an odd arrangement: I had a kidney in my abdomen and a pancreas hooked up to my bladder. Who can believe the surprises of modern medicine?
I thought the actual operation was going to be the hard part, but boy, was I wrong. The transplant story had just begun.
I stayed in ICU for two days, most of which I don't remember. My parents kept vigil and were in charge of alerting the rest of the family and friends of my status. Richard was there also, though he was not as comfortable with the medical environment as my mom, who was a nurse. I had tubes, catheters and lines going everywhere and I'm sure I made a pretty gruesome picture.
When I was moved to 6 West, the transplant wing of the hospital, things became different. Each day the transplant team made rounds and evaluated my case. I was now taking the three medicines I would take for the rest of my life: cyclosporine, prednisone and imuran. These would suppress my immune system and prevent my body from rejecting the new organs. The next ten days brought changes and challenges. My medicine doses were fine tuned each day and I slowly began to recover. I was determined to get strong and was encouraged to take walks in the hall. Because of the placement of the pancreas and also the need for a moist environment for the new organs, dehydration was a constant worry. I started eating solid foods and, believe it or not, I started a daily ritual of trying to drink between four to five liters of fluid a day. It became a game because Richard would count the number of empty fruit punch quarts on the window sill when he visited.
All was going well and the team thought I'd be ready to go home soon. But, like 95 percent of double transplant patients, I suffered my first rejection. The doctors performed a biopsy on my kidney and started a fantastic new anti-rejection medicine called OKT3. Fantastic because it turned the rejection around. Not so fantastic were its side effects: nausea, vomiting, headaches and flu-like symptoms. But, it did its job and after a three-week stay, I was now on my own.
Well, not exactly on my own. In the following weeks I went to the clinic every Monday, Wednesday and Friday. With my immune system compromised I was a target for every germ in the air. The next six months were critical. During each visit, I was weighed, gave a urine specimen and took a blood test. The the same doctors who had been involved in the original operation evaluated my numbers and made adjustments to my daily routine. Since being at the clinic three times a week for several hours, I began to make friends. We commiserated when the numbers were bad and cheered each other on when the numbers were positive.
How can I describe the next three months? It was like the Matterhorn at Disneyland. Thank goodness I had the transplant team, my friends, family and Richard on the ride with me. As determined as I was to get well, I still had a rocky road to travel. I suffered two more rejections severe enough to put me back in the hospital for several weeks throughout December and January. Also, I was still very weak and spent most of my time sleeping and reading.
However, March was the turning point. Finally, after the coldest, snowiest Cincinnati winter in recent history, spring was around the corner. I had not been in the hospital for over a month and had begun to ride my exercise bike to get some strength back. My clinic visits were now spaced to once every two weeks and I wanted to get out and see the world.
A big help was the return of my dog Shelby, who had been staying in Morristown, New Jersey throughout this time. Once back, we started taking long walks several times a day. The sun felt good and it was terrific to get out and exercise.
Things were really looking up. I reached my six-month anniversary in April, and Richard and I felt we could breathe a little easier. Richard began to feel more comfortable leaving me to my own pursuits.
I had a slight set-back in May, though more emotional than physical. I was hospitalized for a minor stomach virus, but some of the side effects of the prednisone when I was on high doses were horrible. I gained ten pounds, had a horrible case of acne and was growing hair everywhere. One day Richard teasingly said he was going to braid my back hair and I burst into tears. The doctors took care of the stomach problem and I found a counselor who helped me cope with my new life.
I made it to my one-year anniversary in October. The team celebrated in their usual style with a few more medical tests that monitored whether the pancreas transplant would stave off some of the diabetic complications.
Now, it is January, two years later. What a difference. I've lost ten pounds, my skin is clear and I'm beardless. I've adjusted to a life without insulin and blood sugar swings. Visiting the clinic about every six weeks, I have more energy and strength than I can remember in a long time. I get out and walk about an hour a day. I've also begun to do some public speaking and am taking an interest in the production department at a local radio station. Though I'm free from insulin and food-related time schedules, I still rely on my good habits picked up from being a diabetic for 17 years. I'm hoping that my diet and exercise routines will help my transplant last a good long time.
by Wesley W. Wilson, M.D.
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 Wilson, M.D. is an Internal Medicine practitioner at the Western Montana Clinic in Missoula, Montana. Dr. Wilson was diagnosed with type I diabetes in 1956, during his second year of medical school.
Q: For five years I've worked hard to control my diabetes, but unexpected high and low blood sugars are frustrating, particularly when I have insulin reactions for no reason that I can understand. I've heard of insulin pumps and I wonder if pump therapy could improve my diabetic control. What is your opinion?
A: I'm guilty of usually answering questions such as yours with a strong maybe and that is my answer again. I will try to provide an answer based on my own investigation and personal experience with pump therapy. I have used insulin for about 40 years and pump therapy for the last year and a half. Pump therapy provides both benefits and problems. I should emphasize that this reply deals only with type I diabetes.
First, a brief discussion of insulin therapy. Both multiple injection therapy (of intermediate duration and rapid acting insulin) and pump therapy are designed to provide a low rate of insulin that should keep the blood sugar level relatively constant. Then extra doses of insulin are timed and taken to prevent high blood sugars after meals. The base rate or basal rate and bolus doses (extra insulin taken to cover meals) are terminology of pump therapy.
Multiple injection insulin therapy usually uses a combination of several doses of rapid acting insulin, Regular, and longer acting insulin, NPH or Lente. Both are taken before breakfast and dinner, with the longer acting insulin taken in smaller doses before dinner and then again at bedtime to prevent a rise in blood sugar during the early morning hours. This mixture provides some degree of a basal insulin plus a bump in insulin activity during meal times. This type of therapy is widely used and usually gives reasonably good blood sugar control.
It seems to me, however, that there are two major problems with it. All insulins, especially the longer-acting ones, seem to be irregularly absorbed. Research has shown that up to 40% more or less rapid absorption of insulin from shot to shot can occur. It is my opinion that the more slowly absorbed insulins, such as Lente or NPH, tend to show a greater degree of variation in rate of absorption than does the more rapidly absorbed Regular type insulin. This variability in insulin absorption and action is a major factor in the unexpected, but frequently seen, wide swings in blood sugar levels. One day there is good control of blood sugar, but another day with seemingly identical factors the blood sugar may be unexpectedly high or low, or both at different times during the day. This fluctuation in insulin action causes a great deal of unpredictability in blood sugar levels.
Another problem with multiple dose insulin therapy is its dependency upon slowly absorbed insulin. Unfortunately, blood sugar levels change with different types of physical activity. Anyone who depends upon insulin injections is well aware that increases in insulin absorption often seem to occur with increased physical activity and muscle use. As they increase physical activity, individuals without diabetes rapidly drop their insulin levels, and with maximum exertion very little insulin can be detected in the blood. Insulin absorbs more quickly during physical activity, while at the same time the body needs less insulin. For diabetics, this fact poses a double risk for hypoglycemia.
A third problem with multiple dose insulin injection therapy is related to the duration of insulin action. All the current insulins require 20 to 30 minutes to become available for absorption and action. Even the rapid-acting insulins must be given 20 or 30 minutes prior to a meal. The main problem is related to intermediate-acting insulin. When a mixture of intermediate-acting and Regular insulin is given before breakfast, it often peaks in one to two hours followed by another peak four to six hours after the injection, requiring the person taking the insulin to eat promptly at noon. Many persons who are taking an intermediate duration insulin in the morning feel as though they are being held hostage by their morning dose of insulin.
Now that we have looked at problems with the most usual form of insulin therapy—multiple dose injection - the question is can pump therapy avoid some of the problems and improve life?
Insulin pump therapy uses only Regular insulin. For most individuals, only the abdominal wall is used as an injection site. This single location and type of insulin minimize, but do not entirely avoid, the variability of insulin absorption and activity. Also, since no slowly absorbed insulin, such as NPH or Lente, is used with pump therapy, the need to eat at a specific time is much less a factor.
Furthermore, if an unusually large or small amount of exertion is encountered or can be expected, with pump therapy the basal rate can be adjusted prior to meals, even if the meal is at an unusual time. Remember that the insulin already injected will continue to act for some hours, so an adjustment of dosage does not cause an immediate change in insulin action. Again, you must predict in advance when a meal is to be expected so the bolus may be taken 20 or 30 minutes prior to the meal. If marked exertion is to be undertaken, the basal rate can readily be reduced an hour or two before the change in physical activity and then adjusted back up afterwards to hopefully keep the blood sugar on a reasonably stable level.
After this complex discussion, it seems worthwhile to point out that the main advantage of pump therapy for myself and for many of my patients is reasonable control of blood sugar with much greater flexibility of lifestyle. Please notice I did not say pump therapy can provide better control than standard insulin programs. Current pumps only do what the wearer tells them to do. A pump which adjusts insulin dose according to blood sugar level or meal size is not yet available. However, a great deal of research is being done to find an implantable glucose sensor capable of measuring blood sugar levels. When that device is available, an automated, artificial, pancreas-type insulin pumpwill be available and should simplify diabetic management.
The disadvantages of pump therapy are many and for that reason anyone who considers a change to pump therapy must choose carefully. Pump therapy is expensive. Even if insurance covers most of that expense, many diabetes management experts are cautious about recommending pump therapy.
Pump therapy brings increased risk of infection at the needle site. The needle remains in place for two or three days and infections, sometimes severe, certainly may occur. Meticulous care seems the best way to minimize these problems.
Some people dislike the concept of being attached to a small box by a length of plastic tubing all the time and for them it does represent a significant problem in lifestyle.
In addition, some aggravations of pump therapy include: blocked tubing, injury to the pump, wearing out of batteries, the need to carry extra sets of tubing, injection sets, and always needing to have a backup unit containing standard insulin. I realize many readers of Voice of the Diabetic have visual impairment, which also represents a significant problem for pump therapy. (Editor's Note: The Disetronic H-TRON V100 insulin pump incorporates both audio and tactile cues, and is used successfully by blind diabetics. For further information, contact Disetronic Medical Systems at 1-800-688-4578.)
In conclusion, I feel that pump therapy is worth serious consideration if flexibility in meal times and activity levels with continued careful control of blood sugar seems worth the trade off of expense, inconvenience, and risk of infection. The insulin pump requires a lot of work by both patient and physician. Remember, the pump does nothing by itself, only what the wearer tells it to do. So it requires a great deal of attention to detail on the part of the person with diabetes attempting pump therapy.
I would be very interested to hear comments from other insulin pump users, particularly anyone with impaired vision.
by Ed Bryant
Our Diabetics Division has lobbied more than three years for modifications in insulin vial design. Currently, all insulins are packaged in identical cylindrical vials, a practice which makes non-visual identification of containers impossible.
In a meeting with the Food and Drug Administration (FDA), the two insulin manufacturers, Eli Lilly and Company and Novo Nordisk Pharmaceuticals Inc., agreed to color code vial labels. Color coding is of course not adequate for thousands of blind diabetics and most individuals with diminished visual acuity. Additionally, there are diabetics who experience fluctuating vision or who are color blind.
It is logical that insulin containers have sufficient tactile coding for identification by the blind and those losing vision. If vials were differentiated by shape and labels had distinguishable tactile cues, blind diabetics could independently handle their insulin needs. These men and women would have the basic human dignity of being able to self-manage their diabetes. Knowing they could handle their own health requirements, they would be more likely to seek employment. They would not be limited to job opportunities near home. Some would no longer need the services of visiting nurses just to draw insulin, and could save approximately $150 per month. Often these services are paid for by Medicare and/or Medicaid.
Good metabolic control matters. For many this means increased insulin injection frequency. Tight control is good but it places diabetics at more risk for hypoglycemia. Low blood sugar reactions can mean injury, hospitalization, and even death. Individuals should not draw insulin when disoriented, whether due to low blood glucose or other distraction, but unfortunately some do. If vials were differentiated by shape, errors would be minimized.
During previous meetings between the FDA and insulin industry, the blind were excluded from the planning process. The insupportable, antiquated myth about the blind needing to have everything done for them still exists. It is well documented that blind individuals can self-manage their diabetes by using adaptive equipment to independently draw insulin(s), test blood sugars, etc. THEY CANNOT SAFELY DISPENSE INSULIN, A CRITICAL STEP, IF ALL CONTAINERS ARE THE SAME.
Years ago, the FDA made insulin manufacturers change vial shapes. Before this ruling, some insulins had been packaged in containers having either a rounded top cross-section, a square cross-section or a hexagonal cross-section. The agency was concerned that there were too many vial shapes on the market. This mandate was probably well-intentioned on the government's part, but unfortunately enough research wasn't done. Simply put, the federal agency DID NOT check with blind consumers!
We need this regulation changed! To expedite such changes in federal law, formal application to alter the regulations must come from the insulin manufacturers, who will have to agree on standardized vial marking(s). Once a specific amendment is requested (to the relevant section in the code of federal regulations) from the FDA, Health and Human Services and the Office of Management and Budget will commence regulatory review. I find it interesting that the insulin industry and/or the FDA may not really be interested in modifying vial configuration for consumer safety. In the past when one consumer wrote to Novo Nordisk (not Eli Lilly) about this matter, the company's response was that the FDA should be contacted for help in the tactile marking of insulin vials. The same person also received correspondence from an FDA consumer safety officer who wrote, "We can only suggest that your group and possibly others contact the insulin manufacturers to urge them to alter their packaging." Not to mention the apparent buck passing on both sides, I wonder why the FDA, which is mandated to be vigilant with drugs and their containers for consumer safety, would advise people making obviously good suggestions to seek help from the insulin industry? The FDA knows full well the dangers if the wrong type or amount of insulin is administered. I FIND IT ASTONISHING THAT THIS FEDERAL AGENCY HAS NOT INTERVENED TO HELP ENSURE THE SAFETY OF THOUSANDS OF DIABETICS.
In a letter dated July 11, 1994, Dr. Solomon Sobel, M.D., FDA Director, Division of Metabolism and Endocrine Drug Studies, said the National Federation of the Blind would be invited to a meeting of organizations, associations, and the insulin manufacturers. Months later I received a copy of correspondence Dr. Sobel had sent to a consumer regarding insulin vial shapes. The letter stated that following a meeting with associations there would be another meeting with Eli Lilly and Novo Nordisk to determine what changes would be feasible. My written response on April 7, 1995, to Dr. Sobel said in part: "Why would the FDA not want consumers, organizations, and the insulin industry to discuss possible modifications together? Why wouldn't the FDA moderate the meeting? If the goal is to move toward solution of this problem, more would be accomplished if all groups are represented. Does the FDA and/or the insulin manufacturers not want all aggregations to meet together? It seems judicious and in fact logical that ALL concerned meet to discuss the issue." AS OF PRESS TIME JUNE 16, NO RESPONSE HAD BEEN RECEIVED FROM DR. SOLOMON SOBEL OF THE FDA.
CONSENSUS IS UNANIMOUS-INSULIN SHOULD BE PACKAGED IN DIFFERENTLY SHAPED CONTAINERS. The cost of changing vial design would not be prohibitively high. Mr. William Gierke, Manager of Pharmaceutical Package Engineering, Eli Lilly and Company, said on May 6, 1992, "As much insulin as we make, cost of the molding would perhaps be up front quite a bit. But per product it would probably round off. I don't think the extra cost would really be a factor."
Eli Lilly and Novo Nordisk always seem enthusiastic about helping insulin-dependent diabetics in any way possible. They are always willing to work with diabetes educators to improve services to insulin users. Nevertheless, readers should also be cognizant that the industry has a huge vested interest in insulin. Profits each year are in the multi-million dollar range.
Movement toward solution sometimes comes slowly, but action should be expected. Instead of remaining noncommittal and duckingresponsibility, the FDA and the insulin industry should resolve this consumer hazard. If the insulin industry proposes vial shape changes to the FDA, the agency is required to respond. I decided to write to both insulin manufacturers, hoping to bring the insulin vial issue to fruition. Are the companies really willing to initiate vial shape change? Incidentally, the insulin industry is fully aware that container design change would benefit the sighted as well as the blind.
Lilly Responds to Letter
In December 1994, I met with Lilly representatives, who brought prototype designs for my review and input. It was obvious they were working toward a method of identifying insulins by touch.
When Eli Lilly received my May 9 letter regarding vial design change, they responded promptly via telephone and letter (letter appended below). Their reply was positive and they are working toward a solution. Mr. Timothy Button, Marketing Associate with Lilly, phoned June 1 regarding my letter. He said that to learn more about the needs of blind diabetics, he would attend the National Federation of the Blind Annual Convention in Chicago. There Mr. Button will host a meeting with consumers to discuss insulin vial change.
He said Lilly has something very promising on the drawing board, but because it involves patents, he could not divulge what it is. He said that in 1996, Lilly will have a product available to help diabetics distinguish different types of insulins.
Until then, Mr. Button said, Lilly is looking for a temporary solution and will probably make a test run of 2000 to 3000 sets of devices that could be attached to the bottom of vials, to aid tactile identification. This would be a temporary solution, he said, until they can get their permanent design onto their manufacturing lines.
Cost effectiveness is important for any marketing plan, especially if it crosses international borders. Mr. Button said his company has a global perspective because Lilly has 17 world-wide sites where insulin is produced or has a contract relationship with an insulin producer. As stated above, a Lilly engineer said the cost of changing insulin vial shapes should not substantially alter the cost of production. Besides, there is more involved than how cheaply insulin can be produced. Vial shape change would substantially improve the safety factor, a major concern for blind as well as sighted diabetics.
Lilly is exploring the possibilities of vial shape change. However, the FDA requires "stability testing" on anything the manufacturers do that affects the primary containers holding insulin. The industry must prove to the FDA that the insulin will not be affected in any way by container shape changes. The entire process could perhaps take two to five years.
Mr. Button said Lilly was willing to work with Novo Nordisk inchanging vial designs. It is absolutely clear that Eli Lilly and Company is striving to help customers. They know diabetic retinopathy and neuropathy can affect all diabetics at some point in their lives. Lilly is to be commended for realizing this and working toward a solution.
Novo Nordisk Finally Responds In January 1995, I met with Novo Nordisk representatives and discussed the need for change in insulin vial design. They had not yet developed any prototypes or solutions. Mr. Jim Smart, Senior Vice President of Marketing, said in an April 26th letter to me that Novo Nordisk is "continuing to explore possibilities at their Denmark headquarters."
On June 7, Mr. Alan W. Scobie, Novo Nordisk's Director of Medical Marketing, responded to my May 9 letter (both are reprinted below). His letter was distant, guarded, and noncommittal. I have been in contact with both insulin manufacturers for several years now, and while Lilly is an active participant in the search for a solution, Novo Nordisk is still on the sidelines. As such, they are in danger of being left behind.
Novo Nordisk is a huge international organization with many layers of management. My "contact person" within the company has changed many times, and things always seem to be "just getting underway." Perhaps they will note Lilly's offer "to work with Novo Nordisk in changing insulin vial designs" (as stated by Mr. Timothy Button, above) and finally join the process.
The following letter was sent to both insulin manufacturers on May 9. (The letter to Lilly made reference to prototypes presented at their December meeting -- otherwise the letters are identical.)
May 9, 1995
Jim Smart
Senior Vice President, Marketing
Novo Nordisk Pharmaceuticals Inc.
Princeton, NJ
Dear Mr. Smart: What is the status of Novo Nordisk's work toward finding a solution so insulin vials can be identified tactually by blind or visually impaired diabetics? Discussing possibilities for container and/or label design change on January 10, 1995, I appreciated you and Mr. Cugini meeting with me. You had no prototypes of tactile markings, so I assumed work toward a solution had not yet begun. Your April 25 letter said in part that you are continuing to explore possibilities with your product development team in Denmark. It has been four months since we met, and I cannot help but wonder if this issue has been given any priority?
I have been contacted by MANY health professionals and consumers wanting to know what insulin manufacturers are doing to make the containers tactually identifiable. Episodes of hypoglycemia, hospitalization, and even death will be minimized if vials can be identified by touch. Years ago, insulin containers were of different designs, so why not join forces with Eli Lilly and work toward getting vials of different shapes re-established in the Code of Federal Regulations? It would help so many!
Dr. Solomon Sobel, FDA, Director, Division of Metabolism and Endocrine Drug Studies, wrote July 11, 1994 that the National Federation of the Blind, other organizations, and insulin manufacturers would meet and discuss ways to accommodate blind diabetics. In a February 27, 1995 letter to a consumer, Dr. Sobel stated that associations would meet to discuss possible modifications blind persons would find useful, and in a separate meeting, the FDA would present ideas to the insulin manufacturers. More would be accomplished if ALL interested parties met together for discussion. It is logical and judicious to have an open meeting. QUESTION: DO YOU KNOW WHY THE FDA IS PLANNING SEPARATE MEETINGS WHICH WOULD PREVENT DIRECT QUESTIONS AND SUGGESTIONS TO THE INSULIN INDUSTRY?
WILL NOVO NORDISK PHARMACEUTICALS INC. PRIORITIZE GETTING INSULIN PACKAGED IN DIFFERENTLY SHAPED CONTAINERS? AS YOU KNOW, THE FDA WILL CONSIDER ANY DESIGNS INSULIN MANUFACTURERS SUBMIT. ARE YOU WILLING TO DO THIS SO THIS ISSUE REACHES FRUITION?
While my primary interest is insulin users in the United States, you obviously view insulin from a global marketing perspective. By producing vials in different shapes, humans worldwide would benefit.
Voice of the Diabetic readers and many others want to know what the insulin industry is doing to correct this vexing problem. I AWAIT YOUR RESPONSE TO THE ABOVE.
Yours truly,
Ed Bryant
President
Diabetics Division
National Federation of the Blind
The following was Novo Nordisk's response:
June 7, 1995
Mr. Ed Bryant, President Diabetics Division National Federation of the Blind
Dear Mr. Bryant, We acknowledge receipt of your letter of 9 May 95. Several meetings have been held to discuss the issue of tactile coding of our vials as an aid to blind or visually impaired persons with diabetes. Numerous options have been identified that will require extensive investigation to ensure that they will not only be feasible from a production and safety standpoint but also will meet the needs of the greatest number of affected individuals.
You mentioned in your letter that the FDA was undertaking an initiative to explore this issue and that they would be contacting manufacturers. We are contacting the FDA to determine their intentions in this regard and to ensure that we participate in the discussions.
Please be assured that we at Novo Nordisk Pharmaceuticals Inc. are putting substantial energy into this issue and that we are desirous of reaching a solution that addresses the needs of all parties involved.
Thank you for your letter. I will contact you again when I have further information.
Sincerely,
Alan W. Scobie
Director, Medical Marketing
Novo Nordisk
Pharmaceuticals Inc.
Princeton, NJ
The following was Lilly's response to my letter. Mr. Button also phoned me, on June 1 and June 9, to further clarify details.
May 31, 1995
Mr. Ed Bryant, President Diabetics Division National Federation of the Blind
Dear Mr. Bryant: Thank you for your letter dated May 9, I apologize for tardiness in responding. Since we met last December in Columbia, Missouri along with Dr. Jerry Buhler and Robert Porter of Lilly, we have been aggressively exploring options that might meet the challenge of providing blind and visually impaired people with diabetes with the ability to independently identify insulin vials.
Please be assured that meeting the needs of our customers is a priority for Lilly and the need for vial identification for the blind and visually impaired is currently an unmet need for those people with diabetes. We are working on this challenge and have some promising options in development. Lilly plans to test these concepts with a diverse group of blind and visually impaired people with diabetes to determine their utility, appropriateness and acceptability. We hope that you will assist us in theseefforts.
In the upcoming months, Lilly is making plans to attend key meetings to share information and gather more customer input. As part of this commitment, I will be attending the annual convention for the National Federation of the Blind in Chicago to learn more about how people who are blind or visually impaired independently manage diabetes.
Thank you for your continued interest and efforts, and please do not hesitate to call me at anytime to talk about our progress to date.
Sincerely,
Timothy H. Button
Marketing Associate,
Global Diabetes Care
Eli Lilly and Company
Indianapolis, IN
The following are samples of letters to: Dr. David A. Kessler, Commissioner, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857. These Voice readers made their thoughts known!
March 20,1995
Dear Dr. Kessler: By now, I am sure that you have received much correspondence in support of the National Federation of the Blind proposal to require tactile marking on insulin vials indicating the various types of insulin. You can add this letter to that body of correspondence.
I have been a diabetic for 43 years. That makes me old enough to have experienced the days of U40 and U80 strength insulins. Those insulins were packaged in varied vials indicating the type of insulin contained in the vial. Regular insulin was packaged in a round vial. NPH insulin was in a rectangular vial. The three types of Lente insulin were all packaged in the same round vial with octagonal vial shoulders. As a sighted diabetic, I found this packaging helpful, but when I became blind, those packaging differences became crucial. I was most alarmed when the advent of U100 insulin brought with it the elimination of the different vial shapes in favor of a round vial for all types of insulin.
As a blind diabetic, I learned to adapt by producing my own homemade labels and placing the two different types of insulin I was using in different parts of my refrigerator and I was consistently good at using these alternative techniques. However, I had no control over the information provided by the pharmacy where I bought my insulin. They once told me that my Regular insulin was Lente. The next injection resulted in a nearly fatal episode of hypoglycemia. Since then, I have often wondered howmany times this was happening to other diabetics.
A return to varied vial shapes is absolutely essential. It is the only way by which blind diabetics can be assured of getting and using the products they intend to use. I shudder to think of the consequences of failing to recognize this problem and acting to correct it. Please do so as quickly as possible.
Sincerely,
Donovan Cooper
Burbank, CA
May 5, 1995
Dear Dr. Kessler: I work with a large population of elderly diabetic patients, many with poor visual acuity, as an RN and Certified Diabetes Educator for a Home Health Care Service. I recently became aware of the amazingly simple idea of changing the shape of insulin vials to provide tactile cues to the patient of which type of insulin they are drawing up. I strongly support this idea.
Thank you,
Lois Hollingsworth, RN, CDE
Nurse's House Call
Hooper Holmes, Inc.
Akron, OH
May 7, 1995
Dear Dr. Kessler: I am writing to express my personal support for needed changes in insulin packaging. I wholeheartedly embrace the National Federation of the Blind's campaign to incorporate tactile cues in insulin vial packaging. As an insulin treated diabetic with sight, I know only too well the importance of proper insulin administration and the possibly fatal effects of improper administration. I urge you to take action on the recommendations given you by the above association.
I have also written to Eli Lilly and Company, as well as Norvo Nordisk Pharmaceuticals.
Sincerely, Kathleen Kimberling, RN, BA Member of American Association of Diabetes Educators Moorpark, CA
* * * * * *
May 8, 1995
Dear Dr. Kessler: I am an allied health professional who manages a hospital-based diabetes management center. Over 1,000 inpatients and outpatients with diabetes utilize our services annually. Many of these 1,000 individuals with diabetes suffer from impaired vision.
I am extremely concerned that the FDA still has not intervened in the dangerous practice of insulin manufacturers supplying all U-100 insulins (R, N, & L) in identical vials.
Please consider the fact that diabetes is the leading cause of blindness in people ages 25-74. It makes no sense to me that the FDA has not mandated tactile packaging of insulin.
Dr. Kessler, there are simply too many blind or visually impaired diabetics drawing their own insulin - several times daily - for this potentially fatal discriminatory situation to go unrectified. I implore you to lead the FDA to mandate that insulin manufacturers package their products for tactile recognition.
I look forward to a response from you in this regard.
Sincerely,
Nancy White, RN
Program Director
Coliseum Diabetes Management Center
Macon, GA
May 9, 1995
Dear Dr. Kessler: I am writing in support of the Diabetics Division of the National Federation of the Blind's request for the insulin package change. I believe that the incorporation of standardized, nonvisual cues into insulin vial packaging is important and essential for the protection of many diabetics.
As an educator, I am aware of many diabetics who have taken the wrong insulin because of a mix up with the vials. The majority of these patients were not blind.
Once again I wish to encourage the package/vial change for insulin.
Sincerely,
Stacia R. Pickard, RD, LD, CDE
Diabetes Support Center
Jacksonville, FL
May 9, 1995
Dr. Kessler: I am a pharmacist with specialized training in the care and management of patients with diabetes mellitus. I would like to express my concern regarding the packaging of insulin. Presently, all insulin products (within a manufacturer's product line) are packaged in identical vials. This makes the identification of the different types of insulin extremely difficult for patients with visual impairments. As you are aware, patients with diabetes are frequently blind or visually impaired.
I hope the FDA will consider a policy whereby insulins (e.g., Regular, NPH, Lente) are packaged in different shaped vials, have colored coded labels, and use permanent tactile cues that enable visually impaired persons to correctly identify the type of insulin. I fully support the efforts of the National Federation of the Blind in this endeavor.
Sincerely,
Stuart T. Haines, Pharm.D., CDE
Assistant Professor University of Maryland
Baltimore, MD
May 12, 1995
RE: Packaging of insulin needs to include permanent tactile cues
I agree with those who are promoting the packaging of insulin in containers that contain permanent tactile cues. This is important not just for blind individuals with diabetes, but for all individuals who are handling insulin containers. We who are sighted also may make mistakes, and differently shaped containers will help everyone.
Sincerely,
Judith Tomer, RD, CDE
University of Michigan Medical Center
Ann Arbor, MI
If you or a friend would like to remember the Diabetics Division 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 Division 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."
by Ed and Toni Eames
From the Editor: Ed and Toni Eames are active members of the National Federation of the Blind (NFB). Toni is president and Ed is treasurer of the NFB of California, Fresno Chapter.
Ed Eames says:
Unlike my wife Toni who became acquainted with guide dogs while in her twenties, my adventure with guide dogs began much later in life. In fact, my relationship with Toni was based upon my romance with guide dogs.
When I was diagnosed at age 42 with retinitis pigmentosa in 1972, I was informed that I would need a white cane or a guide dog in the not too distant future. This stunning prediction caught me totally off-guard because I was on my way to participate in my weekly poker game at the Temple University Faculty Club. Unable to comprehend the news, I played poker and had the biggest winning night ever!
The ophthalmologist advised me not to change jobs because it would be easier getting around in a familiar environment while my sight deteriorated. However, his recommendation was a little late. I had previously decided to leave my position on the faculty at Temple University in Philadelphia and had already accepted a position as professor of anthropology at Baruch College in New York City. I continued residing in Philadelphia even though my travels between these two cities involved a complicated commute. Still trying to use my limited residual vision, twice I experienced terror and trauma when I fell off the subway platform onto the tracks. Looking back, surviving those two accidents seems miraculous.
As the ophthalmologist had predicted, my sight deteriorated and I learned to use a white cane. In the 1980-1981 academic year I took a sabbatical, got a research grant and went to India to do anthropological field work. Sidewalks in India's cities are rare and pedestrians share the roadway with bicycles, bicycle-driven rickshaws, bullock carts, cows, cars and buses. Under these conditions, my white cane lost much of its effectiveness as a mobility aid. I felt compelled to rely on sighted guides as my safest and most effective mobility tools.
I had never owned a pet and did not consider myself a dog lover. However, in the course of rehabilitation I had met several guide dog users and was impressed with their confidence and ability to get around. When I returned home from India, the first thing I did was apply for a guide dog. Although my ex-wife was even less enthusiastic than I about dogs, at least, she recognized my need for a safer and more effective mobility aid.
I spent the month of August 1981 at the Seeing Eye in Morristown, New Jersey, training with my black Labrador, Perrier. Thinking only about having a more effective mobility aid, I had no inkling the impact the dog would have on my life.
Three days after completing the training, Perrier and I began our commute from Philadelphia to New York. Following the same route I had used for years, I was amazed at the ease with which Perrier guided me on and off trains, subways and buses. He handled the streets of New York as if born to the task. My colleagues at Baruch welcomed Perrier, and students seemed more relaxed about my blindness with a dog in the classroom. I'm not sure how much anthropology Perrier learned by attending my classes because he slept noisily through most of them. For that matter, I wonder the same thing about most of my students but, at least, they had the good manners not to snore!
My increased feelings of independence and self-reliance became a sore point with my ex-wife. Although she did not mind my need to care for Perrier -- feeding, providing water, daily outings for relief and occasional visits to the vet, she did resent the attention he drew when he accompanied us to restaurants, theaters, religious services and the homes of friends. She saw no need for Perrier's presence when she could assume the guiding role. In contrast, my children and grandchildren readily incorporated him as a member of the family.
Professors are always seeking new areas of interest for research and publication and I was no different. As my relationship with Perrier blossomed, I became intrigued with the guide dog/blind person partnership. Questions began churning in my mind. Why do some people opt for partnership with guide dogs? On what basis do people select particular training programs? Does having a guide dog help or hinder employment prospects? How do training programs select canine and student applicants? What are the advantages and disadvantages of working with guide dogs? Obviously, these burning issues required immediate research and could only be adequately addressed in a book. My research brought me face-to-face with a variety of blindness-related issues which pushed me toward the assumption of an advocacy role. I discovered the National Federation of the Blind and became an activist. My ex-wife, a very private person, became increasingly uncomfortable with my outspoken advocacy role. For many of us who go blind in middle age, life may seem to be a never-ending tragedy. However, most of us get past that stage and, with proper training in the techniques of blindness, resume active and productive lives. For me, becoming blind was a turning point. It led to getting Perrier, researching my book on guide dogs and, ultimately, to meeting Toni. Initially, she was a consultant on the book, then co-author, and eventually became my wife. At our wedding in June 1987, Perrier was ring bearer and Toni's guide, Ivy, was maid of honor.
It was fun living and traveling with two dogs. Although I had never considered myself an animal person, I had no difficulty becoming part of a family consisting of dogs and cats. After Toni and I married, I took early retirement and we moved to Fresno, California. Over the next few years we became itinerant educators and writers.
Unfortunately, Perrier had to be euthanized two years after our move to California. My feeling that Perrier was magic and irreplaceable is shared by many of those who have lost their first partners in independence. The transition to a successor dog is usually emotionally wrenching. When I began working with Kirby at Guide Dogs of the Desert in Palm Springs, California, I compared him unfavorably with Perrier. Perrier's guiding style was confident, but Kirby's was cautious. However, Kirby was far more outgoing and his exuberance and joy of life soon endeared this lovable Golden Retriever to me and all who met him.
Although Kirby's short working life was spent in Fresno, a small and laid back city located in the agricultural belt of California, he was equally at ease in our travels to New York, San Francisco, Philadelphia and Boston. Like Ivy, he earned an AKC Companion Dog Excellent title. However, his major claim to fame occurred after the amputation of his left front leg as a result of bone cancer. His rehabilitation and resumption of work as my guide was an historic event. Everyone who saw his un-Golden-like tail continuously waving over his back realized this enthusiastic dog took pride in his work. His heroism and devotion to duty was recognized by the California Veterinary Medical Association. In September 1994, he was posthumously inaugurated into the CVMA Animal Hall of Fame.
My grief at the loss of Kirby exceeded the feelings I had when Perrier was euthanized. At least Perrier had a full working life of eight years, but Kirby was euthanized after only four-and-a-half years of our partnership. At the end of July 1994 I went to Rochester, Michigan, to train with Jake, a 21-month-old Golden Retriever. At the time of this writing, we've been home a few months and I still call him Kirby about half the time. Jake, trained at Leader Dogs for the Blind, is a sensitive and bright dog. In contrast to Kirby's exuberance, Jake is quiet and mellow. Although I still miss Kirby, Jake is nudging his way into my heart and will become a beloved companion as well as a partner in independence.
At Leader, I joined 24 other students who were in training. Of these 24 individuals, seven were diabetics. Four of the seven were training with a guide dog for the first time and the other three were retrainees. Special dietary provisions were made for the seven diabetic students. They had an additional snack at night, were given special meals and received snacks to take with them during the morning and afternoon training sessions. At least two trainers were in residence at all times. They were familiar with first aid techniques and were sensitive to the needs of people with diabetes. During my third night in the dorm, a student went into diabetic shock. Unable to administer to this student's needs, the trainers on duty called 911 and an emergency crew arrived within a short time. She was taken to the hospital where she regained control of her blood sugar. The next morning she returned to school. Like the other six diabetic members of the class, she completed the course and is now home working with her canine partner.
In the last few years, Leader Dogs has developed a cooperative relationship with a nearby kidney dialysis unit. Several students on dialysis have completed the Leader program. Community volunteers or trainers transport the students to and from the unit. The time needed for treatment is worked into the training schedule. Brad Scott, Director of Training, has observed that only two or three students a year fall into this category. As long as accommodations can be made for individuals on dialysis, Leader will work with them.
Toni Eames says:
Regardless of my mother's admonition to be cautious, I was the kind of kid who had to pet every animal I could get my hands on. With limited vision, my infatuation with furry things led to some embarrassing moments. On several occasions, I reached out to cuddle what I perceived to be an animal, only to discover a fur collar on a coat or the head of a crawling child.
My love affair with dogs began at age five when my family acquired Ginger, our pet dog. He remained part of our family until his death during my freshman year in college. Two years later, during my senior year, I moved from the college dorm into my own apartment. Before obtaining furniture, I rushed to the nearest humane society and found a new canine companion. Loki, a Shepherd-Terrier cross, was a spoiled brat until Charm, my first guide dog, entered the family. Being teamed with a guide dog stimulated my interest in becoming an outstanding dog handler. With my newly-acquired skills, I transformed Loki into a well-mannered pet.
Even though I'd been a dog devotee for years, I waited until I had graduated from college before seeking partnership with a guide dog because I had picked up many negative attitudes toward canine partners which permeated the blindness system. When I was a youngster participating in recreational activities at the New York Lighthouse, I encountered guide dog users, but none took the time to discuss the benefits of working with dogs. I was horrified when one of those adults told me that guide dogs could never be petted or played with, not even by their blind partners. This and other myths were never dispelled by teachers, camp and rehab counselors, and others including my mobility instructor. Like most blind kids growing up in the '50s, my training with a white cane did not begin until I was 16. Although theprofessionals said I was a competent cane user, I never felt comfortable with it. I felt insecure, vulnerable and very much alone. Perpetuating the myths, my mobility instructor failed to discuss the reality of working with a guide dog. As an undergraduate college freshman in 1961, I discovered that school policy prohibited guide dogs from living with blind students in the dormitory. As I look back, I cannot believe how unsophisticated I was about guide dogs.
When I was in my early twenties, I met a woman my age who was playing with her dog in the basement of the Lighthouse. Then, I realized that guide dogs could be both friends and pets. She and I began spending time together and became good friends. Through her, I met several other guide dog users. I was continuously amazed by the working abilities of their dogs. They stopped at curbs, located subway stairs, avoided obstacles, negotiated crowds, guided their partners to empty tables inside busy, popular restaurants.
One day, another friend and I arranged to meet at the Port Authority bus terminal, one of the busiest, noisiest, and most complicated transportation hubs in the city. I was astonished by his dog's skill in locating the ticket booth, the stairs to the upper level and the bus departure gate. He explained these abilities weren't feats of a miracle dog, but responses of a well-trained guide dog who had mastered a familiar route. After that trip, I was ready to trade my cane for a furry mobility device.
In March 1967 I spent a month at Guiding Eyes for the Blind in Yorktown Heights, New York, training with a Golden Retriever named Charm. Developing my partnership with this Golden girl was one of the most significant turning points in my life. That September I began graduate school at Hunter College in the heart of New York City. I could not believe how tension-free traveling had become. With Charm as my guide, we used subways and buses, walked along unfamiliar streets, negotiated crowded thoroughfares and found our way to lecture halls, classrooms and the library. I was thrilled when Charm and I breezed through the Port Authority bus terminal with the same ease and proficiency demonstrated several months earlier by my friend and his dog.
When I received my Master's degree, Charm was an integral partner in my search for a job. Like many blind people, I ran into employment discrimination. With my furry friend as emotional support, job interviews were less scary. On my way home from these ordeals, I discussed my impressions with Charm before phoning my human friend to talk about my latest interview.
Charm shared the joy of my first job as rehabilitation counselor at a state psychiatric hospital. In fact, she was one of the reasons I was offered the job. My supervisor recognized the therapeutic impact of a dog on the lives of mentally ill patients long before there was documented evidence of this fact.
Charm's impact on my life was revolutionary. B.C. (Before Charm), I lacked confidence and had difficulty advocating on my own behalf. A.D. (After Dog), I became self-assured and spoke out for my rights. Charm became my alter ego. I took inordinate joy in her accomplishments and was acutely embarrassed by her mistakes. I had no intention of allowing school authorities, restaurant owners, theater managers and taxi drivers to deny access to my well-behaved, well-trained canine companion. Instead of reducing me to tears, phrases such as "Get that dog out of here" and "No dogs allowed" made me angry enough to fight such rampant discrimination. Backed by state white cane/guide dog laws and the federal Americans with Disabilities Act, my guides and I have been able to go to nearly all places open to the public.
Charm's death in 1977 left my life in turmoil. I had never experienced such a devastating loss. Charm's successor, a Golden Retriever named Flicka, was so different in temperament that it took months to learn to love her. Charm was calm and gentle, but Flicka was rough and energetic. They both had the impeccable manners of a professional guide in harness, but when not on duty, Flicka was a dynamo. For the seven years of our working partnership, Flicka and I lived and worked in New York.
In contrast to my first two guides, Ivy, my third Golden, split her working career between New York and California. I met Ed and after we were married, we decided to move. Just before her fifth birthday, Ivy gave up the hectic life of a New York City commuter for the routine suburban life in a small California city. Memories of subway travel, incessantly honking car horns and congested sidewalks are revived when we visit New York. Our relatively sedentary daily routines have been punctuated by exciting and busy trips to Israel, Bermuda, Canada, Mexico and more than 20 states.
All three of my Golden girls have successfully competed in American Kennel Club obedience trials. In fact, Ivy became the first guide dog to obtain the intermediate level title of "Companion Dog Excellent." They have all been good will ambassadors for the guide dog movement with their impeccable public behavior and outstanding performance as guides. People are attracted to dogs and feel more comfortable speaking with those of us partnered with guide dogs. I enjoy these unsolicited contacts and have met and have become friends with many interesting people through the canine connection.
Ivy has earned her place in California history by helping to change the law. Now, privately trained guide dogs have the same access rights as those trained at guide dog schools. Ivy received her greatest award in 1993 when she was bestowed with the coveted title of the "Delta Society Guide Dog of the Year." Along with Ed and Kirby, his guide dog, she and I were flown to New York where we appeared on local and national news shows.
Having passed her twelfth birthday, Ivy's step is slower and more labored; she is on medication to alleviate the pain of arthritis.She has lost sight in her right eye and is not a good candidate for cataract surgery. Our time together as working partners is limited. She will soon be retired and will spend her days lounging at home while her successor steps proudly into her paw prints.
Ed and Toni Eames reflect:
We are committed to using guide dogs as our preferred mobility aid. Our dogs are such vital elements in our lives that the mere thought of being without them is distressing. Regardless of the cause of blindness, we believe guide dogs would be of great benefit to many of our blind peers.
Because diabetes is the single, most reported cause of blindness in the United States, all guide dog schools welcome applications from diabetics. Dietary and other accommodations facilitate the completion of training courses by diabetics.
Currently, 14 programs in the United States train guide dogs and their blind or visually impaired partners. All receive financial support from the public through donations, grants and estate bequests. The dogs, equipment and training are furnished free, or at minimal cost, to applicants selected for training.
Full details about the programs and the the impact of guide dogs on the lives of their partners are contained in the revision of our book, A Guide to Guide Dog Schools. The book is available in standard print or computer disk at a cost of $10 including handling and shipping. Make check(s) payable to Disabled on the Go (DOG) and send the order to Ed Eames, 3376 North Wishon, Fresno, CA 93704-4832. If ordering a computer disk, please specify size. The cassette and Braille versions are currently in production by the National Library Service and will be available in the near future through your local NLS branch. To contact us, write to Toni and Ed Eames, 3376 North Wishon, Fresno, CA 93704-4832, or call (209) 224-0544.
Figure: food pyramid from top to bottom: Fats, Oils & Sweets (use sparingly) on top; Milk, Yogurt, & Cheese Group (2-3 servings); Meat, Poultry, Fish, Dry Beans, Eggs & Nuts Group (2-3 servings); Fruit Group (2-4 servings); Vegetable Group (3-5 servings); and Bread, Cereal, Rice & Pasta Group (6-11 servings).
Eating a balanced and nutritious diet can seem impossible at times. And while many people have become more conscious of the amount of fat they eat in their diet, they sometimes forget that low-fat doesn't necessarily mean low-calorie. "These people have fallen in that fat trap," says Tina Watson, a registered dietitian at University Hospital and Clinics. "The secret is to eat a balanced diet using the food pyramid as your guide." Watson offers these simple tips to limit total fat, saturated fat and cholesterol in your diet while increasing complex carbohydrates and fibers.
The Food Guide Pyramid
Cereals, grains, fruits and vegetables should be the focal point of your meals and snacks. Here are some ways to add them to your diet and create healthy eating habits.
1. Put fruit that doesn't need refrigeration where you can see it. Make a habit of grabbing a few pieces on your way out the door.
2. Keep carrots or other raw vegetables in your briefcase.
3. Keep dried fruits in your desk for snacks.
4. Give a healthy gift for the holidays and other special occasions by filling a bright basket with fruits and/or vegetables. Welcome spring with a basket of strawberries, papaya, pineapple, green peas and asparagus and accent with daffodils, bows and limes or lemons.
5. Nibble on spears of fruit such as strawberries, grapes and pineapple chunks on small skewers or cocktail sticks. Serve with low-fat or nonfat vanilla or lemon yogurt.
6. Top melon wedges with a small scoop of fruit sorbet or sherbet.
7. Microwave small winter squash halves stuffed with apples, raisins and spices. Serve with fish or poultry.
8. Serve lots of shredded carrots, cabbage, lettuce and peppers with traditional Mexican tacos, burritos and enchiladas. Have plenty of fresh salsa on hand and serve with low-fat tortilla chips.
9. Drink fruit or vegetable juice instead of grabbing a can of soda. Try individual servings of 100 percent juice such as V-8, tomato, orange, pineapple and grapefruit juice.
10. Try adding thin slices of banana to pancake batter. Top with fresh or frozen strawberries that have been microwaved until hot. Garnish with light whipped topping.
11. Spread reduced-fat or nonfat cream cheese on reduced-fat or nonfat crackers. Garnish with sun-dried tomatoes, cucumber slices and pimento or smoked salmon and dill.
12. Bake apple, pear and banana pieces along with raisins, dried apricots and powdered cinnamon for a wonderful fruit dish.
13. Marinate red and yellow pepper pieces, onion slices, baby carrots and whole mushrooms in reduced-sodium soy sauce, ginger and one to two teaspoons of olive oil. Gently cook and serve over brown rice.
14. Saute onions, mushrooms and red pepper in a small amount of diet margarine. Add this mixture to prepared wild rice, barley or couscous.
Recipe Makeovers
Baking cakes, pies, cookies and muffins for both special occasions and everyday eating can weaken the strongest resolve to eat healthfully. But you can bake your cake and eat it, too, by following some of these suggestions.
15. Replace oil, butter or margarine with an equal amount of applesauce. This works well with box cake mixes, cakes made from scratch, brownies and zucchini bread. For each half-cup of oil replaced with applesauce, 907 fat calories are saved.
16. Replace oil with half applesauce and half milk (nonfat or skim milk is best). This alternative is useful if the oil in your recipe is the only liquid.
17. Replace regular margarine, shortening or butter with diet margarine. This will reduce fat calories by half, a savings of 400 calories per half-cup.
18. Replace shortening, butter or margarine with liquid oil. Although this will not reduce calories, it will reduce cholesterol-raising saturated fat.
19. Replace regular cheese with low-fat cheese. To qualify as low in fat, cheese should have fewer than five grams of fat per ounce.
20. Replace heavy cream with evaporated skim milk.
21. Replace sour cream with plain yogurt or fat-free sour cream.
22. Replace a traditional pie crust with a graham cracker crust.
23. Reduce sugar by 25 percent. For example, instead of one cup of sugar, use three-quarters of a cup. This change does not significantly alter the taste of most recipes, especially if you increase the amount of sweet spices such as cinnamon, nutmeg and vanilla.
24. Reduce nuts by half.
25. Reduce chocolate chips by 25 to 50 percent. Chocolate chips should be called chocolate fat bits: a cup of semisweet chocolate chips has about 912 calories, and 49 percent of those calories are from fat.
26. Use two egg whites in place of one whole egg.
27. Replace at least half of the white flour with whole-wheat flour. This will increase the amount of fiber and nutrients.
Healthy Snacking
Eating between meals is a way of life these days as people rush from activity to activity. The challenge is to find healthful snacks that fit into a busy lifestyle. Try these tips.
28. Prepare a pot of soup or meatless chili and invite everyone to help themselves.
29. Place covered bowls of low-fat snacks such as dried fruits or pretzels around eating areas for easy access.
30. Bake a batch of moist, low-fat muffins to be enjoyed throughout the day. When you use whole grains and fruits in the recipe, you pack in needed vitamins and minerals as well.
31. Keep on hand quick pizza fixings such as English muffins, tomato sauce and skim-milk cheese.
32. When traveling, take along mini-bagels spread with low-sugar fruit spread or peanut butter and jelly sandwich halves. You also can bring along frozen turkey or lean roast beef sandwiches and eat them en route after they defrost.
(NOTE: Reprinted from Caring magazine, a University of Missouri-Columbia Hospital and Clinics publication.)
Fruit-Milk Dessert (a pudding and pie filling)
from Sandra Nebergall of Chattanooga, TN
Sandra and her husband Peter, enjoy this tasty sweet often.
1 package sugar-free Jell-O
1-8 oz. fortifier yogurt
1-16 oz. tin unsweetened fruit or fruit cocktail (optional)
Follow first stage of directions for Jell-O preparation (mix package contents with one cup boiling water), then refrigerate until cool ("preset stage"; approx. 30 minutes). Next, place yogurt in deep mixing bowl, blend Jell-O with yogurt, mixing thoroughly. If you will be adding fruit, do it now. Allow mixture to set, in refrigerator (approx. 1.5 hours).
If you will be using tinned fruit, first drain off and discard the juices. Many fresh fruits would work as well, but DO NOT use fresh pineapple - it will cause the Jell-O to not set. Tinned pineapple is OK. Choose compatible fruit flavors, i.e., raspberry Jell-O with raspberry yogurt, orange Jell-O with lemon yogurt, cherry Jell-O with vanilla yogurt.
Yield: 4 servings; Calories: 80; Protein: 2g; Fat: 0g; Carbohydrates: 18g; Sodium: 40mg; Diabetic Exchanges: 1 starch.
Spicy Shrimp
NOTE: To receive one free set of "Around the World With Butter Buds" recipe cards, please contact: Butter Buds, P.O. Box 140, Dept. ATW, Great Neck, NY 11021; telephone: 1-800-231-1123.
1 packet Butter Buds Mix, liquefied
2 tablespoons minced fresh parsley
1 1/2 teaspoons cajun seasoning
1 tablespoon olive oil
1 large garlic clove, minced
1 pound jumbo shrimp, peeled and deveined (about 24 shrimp)
Preheat oven to 400 F. In a medium bowl, combine all ingredients except shrimp. Add shrimp and toss to coat. Cover and refrigerate one hour. Transfer shrimp and the marinade to a baking dish large enough to hold the shrimp in a single layer. Bake 10 minutes, or until cooked through. Do not overcook. Serve hot or at room temperature with toothpicks.
Yield: 12 servings; Per serving (2 shrimp): 45 calories, 7g protein, 1g carbohydrate, 1g fat, 1g saturated fat, 65 mg cholesterol, 185 mg sodium; Diabetic exchanges: 1 lean meat.
Variation: Shrimp-Vegetable Medley
To serve as a main dish, after refrigeration stir four cups assorted raw vegetables (such as small whole mushrooms, bell peppers and zucchinni chunks) into shrimp. Bake as directed.
Yield: 6 servings; Per serving (4 shrimp with vegetables): 170 calories, 20g protein, 11g carbohydrate, 5g fat, 1g saturated fat, 195mg cholesterol, 553mg sodium; Diabetic exchanges: 2 vegetable, 2 lean meat.
Thanks to the Cosmopolitan International Diabetes Center, Columbia, MO, for the following recipes.
Zero Salad Dressing
8 ounce can tomato sauce
2 tbsp. vinegar
1 tbsp. Worcestershire sauce
1 tsp. sugar (or 1/2 packet sugar substitute)
1 tsp. dried onion
1 tsp. horseradish
1/2 tsp. salt (optional)
2 drops Tabasco sauce
Combine all ingredients and mix well.
Yield: 20 (1 tbsp.) servings; Calories: 5; Diabetic Exchanges: free.
L.E.A.N. for Life Soup
3 10-ounce cans beef bouillon
3 10-ounce cans water 2 cups tomato or V-8 juice
1/4 cup chopped onion
1 cup green beans, canned
1 cup shredded cabbage (optional)
1/2 cup sliced canned mushrooms, drained
1/2 cup green pepper, chopped
2 tbsp. lemon juice
1 cup chopped celery
Pepper to taste
Combine all ingredients above. Simmer until vegetables and soup is of desired consistency. If desired, add more water.
Yield: 12 servings; Per 1 cup serving: Calories 20, Fat 0mg, Sodium 520mg, Cholesterol 0mg; Diabetic Exchanges: free.
Tip: for a heartier soup, add one can kidney beans and a package of frozen mixed vegetables. This would provide: 75 calories, 703mg sodium, 0g fat, 0mg cholesterol and 1 starch/bread exchange.
Inclusion of materials in this publication is for information only and does not imply endorsement by the Diabetics Division of the NFB.
Diabetes Education Video
The Best of Living with Diabetes Television Video Series is a new video explaining the basics about diabetes. Produced by CNBC andLifetime television medical correspondent Pat Gallagher, this 73-minute video is a compilation of 100 episodes of the newsmagazine television show, "Living With Diabetes."
This video explains type I and type II diabetes, weight loss, exercise, cholesterol, high blood pressure, neuropathy, foot care, eye disease, kidney disease, and proper disposal of syringes. It can be ordered by calling 1-800-433-2469 for Visa, MasterCard, Discover orders or send a check made payable to "Medicool" for $12.95 plus $3 shipping and handling to: Medicool, Inc., 23762 Madison Street, Torrance, CA 90505.
Rover Seeing Aid
The Rover Seeing Aid is a new device that may be helpful to the blind. This lightweight sensor mounts on a person's wrist and, with a few waves of the hand, the brain can assemble a complete picture of its surroundings through tactile feedback.
The Rover Seeing Aid, released by the Possibilities Company in Columbia, Missouri, is priced under $100. It comes with a no-risk, 30-day home trial, and a one-year warranty. A 20% discount will be given if ordered before Sept. 30, 1995. For more information call: 1-800-566-3333.
Finger Skin Cream
Diabetics who suffer from sore, cracked or calloused fingers because of frequent use of blood lancets for glucose monitoring may find new relief.
Formulated For Fingers, a new skin cream by Can-Am Care Corporation, features the Australian Tea Tree Oil as a moisturizing and soothing ingredient.
This cream, packaged in four-ounce squeezable bottles, is priced at $9.99. For more information contact: Can-Am Corporation, Cimetra Industrial Park, Box 98, Chazy, NY 12921-0098; telephone: 1-800-461-7448.
The Insulcap
Draw insulin safely and with less waste using the Insulcap. It fits on any insulin bottle and allows the syringe to be inserted until it stops automatically in the right position. Users would need some sight to correctly insert the needle in the device slot. You don't have to hold the bottle in place or fear the needle bending. The caps are color coded in orange or blue to distinguish different types of insulin. The orange caps also have guides on them as tactile cues. Not only is recovering hard to reach insulin easier, but Insulcaps are also reusable. Contact your pharmacist or medical supplier to obtain Insulcaps or for more information write or call: Diabetic Insulcap, Inc., P.O. Box 34347, Las Vegas, NV 89133-4347; telephone: (702) 363-0426; fax: (702) 363-0427.
Book for Diabetics Now on Cassette
Living With Diabetic Complications: A Survival Guide for Patients by a Patient by Judy Curtis is now available on audiocassette through the National Library Service for the Blind and Physically Handicapped.
The print version of the 294-page book was reviewed in the Voice (Vol. 8, No. 2) by Ed Bryant, editor, who had this to say about it: "This informative publication ... lets diabetics know they are not alone ... It not only explains what can happen and why, but also provides treatment options and other important resources. It further elaborates on the emotional and social aspects of living with complications ... It is loaded with information pertinent for all type I and type II diabetics, as well as anyone interested in diabetes."
Ask for it by catalog number RC36956 when ordering an audiocassette. For further information, contact the National Library Service for the Blind and Physically Handicapped at telephone: 1-800-424-8567. To order it in print, send $15.95 (check or money order) to: Outreach Enterprises, 2309 SW 1st Ave., Suite 1842, Portland, OR 97201.
Foot Cleanser and Conditioner
Clean and condition your feet without the use of water. That is what the new product Apply & Dry Foot Cleanser and Conditioner by IGI, Inc. is offering. Ingredients in the liquid gel are activated when massaged into the skin. The resulting foam will trap the dirt and lift it away from the skin, allowing it to be toweled off, leaving the skin clean without drying it out. Apply & Dry is available in 12-oz. bottles or single-use packets. It is only available through drug stores. For further information contact Jack Sullivan, director of sales and marketing at 1-800-531-9092.
Diabetic Meal Planning Made Easy!
Thirty different breakfasts, lunches and dinners all for diabetic needs - and it's not a cookbook.
Diabetic Meal Planning Made Easy! is a complete 30-day meal plan based on the American Diabetes Association's food exchange system. It offers a variety of food and snack ideas.
Author Marilyn White developed the meal-planning guide to help diabetics realize that they can eat well on their prescribed diets and avoid serious reaction problems.
Diabetic Meal Planning Made Easy! is available from L & M Enterprises, Box 4352 D, Shreveport, LA 71134 for $9.95 postage paid.
Diabetes Literature
The following came from the Spring/Summer 1995 catalog called the Diabetic Reader. To order the tapes and/or books contact: Prana Publications, 5623 Matilija Ave., Van Nuys, CA 91401; telephone: 1-800-735-7726; fax: (818) 786-7359. Checks, money orders or MasterCard, Visa or Discover cards accepted. A $19 minimum with credit card orders.
1. New Nutritional Guidelines for a New Day in Diabetes Care: Most Commonly Asked Diet Questions (#A12) by Betty Brackenridge, MS, RD, CDE, is a 60-minute audiocassette.
Confused by the big changes in diet for diabetics announced in the 1994 ADA Nutritional Guidelines? (Who isn't?!) Betty Brackenridge, former president of The American Association of Diabetes Educators answers such questions as: "What do you mean there's no more 'diabetic diet?'" "What do you mean I can eat sugar?" "What do you mean I don't need to be my 'ideal' weight?'" And she continues with a segment on other most commonly asked diet questions. The book costs $11.95 plus $3.25 handling.
2. The Diabetic's Book: All Your Questions Answered (#B08) by June Biermann and Barbara Toohey is a 233-page paperback book that gives information to people who are diagnosed with diabetes. The book also has a supplement on weight loss. It costs $12.95 plus handling.
3. Convenience Food Facts (#B52) by Arlene Monk, RD, is a 456-page paperback reference book on over 1,500 popular brand name products plus diabetically oriented ones. The book also gives facts about calories, carbohydrates, fat, cholesterol and exchanges. It costs $10.95 plus handling.
Diabetes Curriculum Book
The American Association of Diabetes Educators is offering a reference text on state-of-the-art diabetes education. A Core Curriculum for Diabetes Education, Second Edition, written by experts in the field, provides comprehensive knowledge about diabetes care. It can be an important source of information for rehabilitation teachers who do not have easy access to diabetes educators in their areas or who work with many diabetics, or for anyone who is preparing for the Certified Diabetes Educator examination. Cost for members is $60 and for nonmembers is $85. To order contact: AADE, 444 North Michigan Ave., Suite 1240,Chicago, IL 60611-3901; telephone: (312) 644-2233.
We invite blurbs and tidbit articles for inclusion in this column. Materials received may be edited and used as space permits. Products and services included in this column are for information only and do not imply endorsement by the Diabetics Division of the NFB.
Drug Slows Kidney Damage
For many type I insulin-dependent diabetics, good control of glucose levels and blood pressure can help to keep kidneys healthy, though it cannot prevent kidney damage. No drug can prevent this from occurring. However, in a study published by the New England Journal of Medicine, a prescription drug named Capoten (captotril) has been proven to slow the progression of diabetic nephropathy.
A group of people with type I insulin-dependent diabetes and signs of kidney disease such as high levels of protein in their urine and damage to the small blood vessels in their eyes, were given the drug for an average of three years. Results showed that kidney damage progressed more slowly for some patients who received Capoten.
Only a doctor can prescribe the drug because it has side effects such as swelling of the face, rash, cough and stomach upset. Also, it should not be taken by pregnant women. For more information on Capoten, contact your doctor, pharmacist or diabetes educator or call: 1-800-993-8993.
Windows From the Keyboard
We have been asked to announce: Windows from the Keyboard is a Braille guide to show how to use your keyboard instead of a mouse. The book includes Quick-Reference Keystroke Command Charts for Windows 3.1 and Word For Windows, Ami Pro for Windows, WordPerfect for Windows, Quartro Pro for Windows, Excel for Windows, and Lotus 1-2-3 for Windows.
Four volumes in Braille cost $16.95. Order from National Braille Press, 88 St. Stephen Street, Boston, MA 02115; telephone: (617) 266-6160.
Screen Magnification Software
We have been asked to announce: The computer company Ai Squared has announced the release of the new ZoomText 5.0 product line. The new product includes ZoomText for Windows 5.0, ZoomText for DOS 4.5, and ZoomText Plus 5.0 (for Windows and DOS). Designed specifically for the visually impaired, ZoomText magnifies the display of all software, including word processors, spreadsheets, databases, and online services.
Using ZoomText 5.0, the screen can be magnified in power ranging from 2x to 16x. The display can be moved in and moved out at the touch of a button. ZoomText for Windows and ZoomText for DOS retail for $395. ZoomText Plus retails for $595. For information contact: Ai Squared, P.O. Box 669, Manchester Center, VT 05255-0669; telephone: (802) 362-3612; fax: (802) 362-1670.
The following is from Kay McCoy, a nurse in Drake, CO.
"The art of medicine consists of amusing the patient while nature cures the disease."
- Voltaire
"The art of nursing consists of caring for and about a person until and after health has been restored or suffering ended."
- Kay McCoy
Diabetic Health Insurance
We have been asked to announce: Lifestyles Marketing Group, Inc. offers a health insurance product that can be purchased by diabetics. Coverage can be adjusted to fit each individual's budget and needs. The policies even include coverage for diabetes after a six-month waiting period. Additionally, Lifestyles offers a Heart Attack and Heart Surgery Indemnity policy which entitles the owner of the policy to collect up to a $50,000 lump sum payment. Diabetics can qualify for this coverage even if they have high blood pressure provided that they have not previously been diagnosed with a heart disease, had a heart attack or heart surgery.
For information about these and other products please call Michael Kronick or Jamie Woolard at 1-800-899-0606.
New Lancet
We have been asked to announce: The Cleanlet 25 is a new lancet designed to minimize discomfort from finger punctures, such as callusing and bruising. It utilizes a small 25 gauge needle, rather than the 21 or 23 gauge sizes most other lancets have. Note, a 21 gauge lancet occupies approximately 21/2 times the volume of a 25 gauge needle. The Cleanlet also has a cap which can be snapped over the needle after use to minimize accidental sticks. Special offer: Consumers may receive 25 free Cleanlet 25 lancets when you call and give the name and order number from the box of lancets you are currently using. Ask for the samples department. For information contact: Gainor Medical, P.O. Box 353, McDonough, GA 30253; telephone: 1-800-825-8282.
Large Print Dictionary Needed
We have been asked to announce: Vincent P. Fisher, who is legally blind, is in need of a large print dictionary to aid him in his reading. He wrote to the Voice asking for help because he is in a corrections unit and without income. To donate a dictionary or make suggestions please contact him at: HSU/#194532, P.O. Box 351 WCI, Waupun, WI 53963.
Herbal Healing With Horse Chestnuts
(To Voice readers: The following tidbit has not been clinically proven to work, but you might find the information interesting.)
Eight years ago, a woman lost her vision because of diabetic retinopathy. She consulted nine specialists and even underwent laser therapy in futile attempts to restore vision. Then, on a trip to Europe with her husband, a specialist suggested that they collect the hulls from the nuts of a horse chestnut tree that had seven fingered leaves. They were to use the hulls to prepare a tea. The specialist said that after about two months of drinking the tea, the blood vessels should quit hemorrhaging and therefore make surgery possible. The advice rang true and the woman's vision was restored in an operation after she began drinking the tea. She was able to read newsprint and drive, if she had wanted to.
Apparently, the tea stopped the bleeding from diabetic retinopathy. A horse chestnut tree is different from a chestnut tree. It has seven leaflets, but sometimes there are only five. The specialist stressed that only the seven fingered leaves are to be used and that the tea must be made with the hulls from the horse chestnut tree. Its scientific name is Aesculus and the species is called Hippocastanum. The tree grows predominantly in the north and northeast, but has been found as far south as mid Arkansas, the Carolinas, Virginia, and even in the mountainous areas of California.
Humor
The following was received from Betty Walker, a federationist from Missouri:
Spongecake: Dessert made from ingredients borrowed from neighbors.
Keep your words soft and sweet, you never know when you'll have to eat them.
Insulin Shot Reminder
We have been asked to announce: If you forget whether or not you have taken your insulin shot, there is a new product called the "Insulin Shot Forget Me Not" system to help you remember. This wallet-shaped, portable system consists of a cloth holder divided into seven sections for each day of the week. There are four pockets for each section. At the beginning of the week, load one to four alcohol swabs in the pockets coinciding with the number of shots taken each day and you're set for the week.
Cloth holder colors are available in teal green, royal blue, plum pink and red orange. The cost of the "Insulin Shot Forget Me Not" is $19 plus $1 shipping. Please allow four to six weeks for delivery. Order from: Olin Fimreite, 1840 Sheila Blvd., Whitehall, WI 54773; telephone: (715) 538-4045.
Large Type Textbooks
We have been asked to announce: The American Printing House for the Blind (APH) is offering over 500 new textbook titles in large type in their Early Start Program. Book subjects include economics, environmental science, health, literature, math, music, psychology and many more. Pricing is 25 cents per page, including binding and all titles are available for purchase with Federal Quota Funds.
APH titles are also in the on-line database CARL ET AL that lists materials accessible to visually-impaired people. Listings include Braille books, large type books, music scores, sound recordings, software programs and tactile graphics from over 200 agencies across North America. CARL ET AL costs $7.50 per month, plus $0.25 per minute after the first hour of connect time. Customers can search for books, communicate with agencies through electronic mail and order from APH on CARL ET AL. To obtain a catalog, subscribe to CARL ET AL, or for more information contact: Resource Services, American Printing House for the Blind, P.O. Box 6085, Louisville, KY 40206-0085; telephone: 1-800-223-1839.
Protein Causes Blindness
An important discovery that may eventually make the difference between sight and blindness for many thousands of people was announced by a research team in Boston.
Based on pioneering experiments in animals, the researchers haveidentified a protein that stimulates the abnormal growth of tiny blood vessels in the eye.
The leakage of blood from the new capillaries gradually destroys the retina, the eye's light-sensing organ, and causes the form of blindness called diabetic retinopathy. Striking 25,000 to 50,000 Americans annually, it is the most common form of blindness in young adults, most of them with insulin-dependent diabetes. Similar abnormal blood vessel growth is also seen in other eye disorders such as age-related macular degeneration and neovascular glaucoma, and the research might eventually apply to them, also.
Now, the new research shows for the first time that the levels of a protein, a hormone-like growth factor called vascular endothelial growth factor, or VEGF, correlate closely with the extent of damage done to the eye in monkeys, suggesting it is responsible for the abnormal growth of new blood vessels.
The team also suspects that such abnormal growth can be blocked, and that the retina might be saved. Drugs that may fill that role are already being studied.
The discovery was reported by ophthalmologists Joan Miller, Anthony Adamis, and 10 co-workers at the Massachusetts Eye and Ear Infirmary, Children's Hospital and Beth Israel Hospital, all in Boston. Their work is based on more than 30 years of research on blood vessel growth conducted by Dr. Judah Folkman, at Children's Hospital.
A full report on the new research is to be published in the American Journal of Pathology. Other reports, highlighting results from human studies that are now underway, will be published soon, Adamis said.
In fact, preliminary results of studies of the amounts of the growth factor in the eyes of diabetics compared with non-diabetics "indicate that VEGF is significantly elevated in patients" with diabetic retinopathy, the team reported. If confirmed, treatments aimed at blocking growth factor production, or its action, in the eye could be useful. "Studies with neutralizing antibodies suggest that such an approach is feasible," they wrote.
According to Dr. Martin Wand, an ophthalmologist in private practice in Hartford, Conn., who has followed the experiments closely, they are "really phenomenal work." If the results hold up, he added, "then for the first time they have something they can block" to prevent eye damage. "You can see the pieces of the puzzle coming together." (Note: This article appeared in the Duluth News-Tribune September 7, 1994, Duluth, MN.)
Helen Keller Speaks Through Miss America
We have been asked to announce: Helen Keller and Miss America have teamed up this year to help deaf-blind youths and adults.
Heather Whitestone, the first woman with a disability to be crowned Miss America 1995, leads the Helen Keller National Center's (HKNC) 1995 Deaf-Blind Awareness Campaign. She wants to inspire deaf-blind people with her message of "face your obstacles, work hard and build a support team."
The Awareness Campaign begins in June, the month of Keller's birthdate, and continues throughout the year. Citizens, agencies and organizations are encouraged to plan state and local activities, especially during the week of June 25 to July 1.
The HKNC is a nonprofit program providing comprehensive rehabilitation and personal adjustment training, job preparation and placement for all Americans who are deaf-blind. For more information contact: Helen Keller National Center, 111 Middle Neck Road, Sands Point, NY 11050; telephone: 1-800-255-0411 ext. 275.
Braille/Print Greeting Cards
We have been asked to announce: Tessa Creations is offering Braille/ print greeting cards for $1.00 per card with envelope. They do custom printing and have a wide variety of topics to select from. For a limited time, the cards are offered on a buy one get one free basis. For more details contact: TESSA Creations, 14139 Western Avenue, Suite 211, Blue Island, IL 60406; telephone: (708) 396-1937.
Push Instead of Pull
Sometimes when a person has dexterity problems, it is difficult to remove the strip holder from the One Touch meter for cleaning. In the Spring 1995 issue of the The Adaptive Monitor, a newsletter published by the Visually Impaired Persons Specialty Practice Group, American Association of Diabetes Educators, Marilyn Teasley, RN, CDE, of Cleveland advises that, instead of pulling, pushing the holder may be more effective. The meter should be turned so the window end is facing the user, with the thumbs placed on the small bumps in the corners of the strip holder. The user can then press and push the strip holder out.
Sense-Sations
This appeared in the New Hampshire Federationist, Spring 1995 issue published by the National Federation of the Blind of New Hampshire. Sense-Sations offers a selection of magnifiers and Braille watches. They also have magazine listings from Recorded Periodicals.
Write to them at: 919 Walnut St., Philadelphia, PA 19107.
Diabetes, Complications, Options
The Diabetics Division of the National Federation of the Blind has a pamphlet titled "Diabetes, Complications, Options," which explains our outreach programs. Full of essential information, it reaches out to anyone concerned with diabetes and its ramifications.
Unlimited free copies are available to all interested parties. The pamphlet is great for libraries, pharmacies, physicians' offices, seminars, hospitals and so on. "Diabetes, Complications, Options" may be ordered from: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314.
Jewish Braille Books
We have been asked to announce: Menachem Shaingarten has produced a collection of Jewish Braille books. They include pamphlets and essays on the Chassidic movement and its interpretation of Biblical verses based on talks of the Lubavitcher Rebbe. Children's books are also available that depict Jewish history, from 10th centruy Constantinople to the German ghetto of the Middle Ages, from life under the Cossacks to the Enlightenment of the 19th century. The books can be borrowed from the Jewish Braille Institute, 110 E. 30th St., New York, NY 10016, or they can be purchased through Rabbi Chitrik, 732 Eastern Parkway, Brooklyn, NY 11213.
Diet May Reduce Dialysis Deaths
We have been asked to announce: Researchers at Johns Hopkins Medical Institutions have found that a very-low-protein diet before kidney dialysis may reduce patient deaths by three-fourths during the first two years of dialysis.
Earlier studies have indicated a very-low-protein diet produces normal, rather than low, levels of bloodstream protein. This diet eliminates a part of the high-protein foods that is difficult for kidney patients to metabolize properly.
However, Josef Coresh, M.D., Ph.D., a Hopkins epidemiologist and author of the study warned, "This is a small study [of 44 patients], so there's a fair amount of imprecision involved."
If similar reduction in deaths occur in a broader, more representative population, the diet may become an important tool for prolonging the lives of dialysis patients.
New Company
We have been asked to announce: IRIS Avenews is a new company with the mission of providing daily living information (such as the ingredients on food and medication packages, ads for store sales, instructions and warranties for products) in various formats, mostly on cassette. They have prepared a survey on tape to find out what information people need and are also running a couple of contests. One is poetry about information and one is writing fiction to add to a story already started. For more information contact: Independent Reading, Information Services, 2255 North Main Street #108-292, Longmont, CO 80501; Internet address: [email protected]
Voice Distributors Needed
Since the Voice is now offered free, our Diabetics Division 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, M0 65203, Phone: (573) 875-8911, Fax: (573) 875-8902.
The Diabetics Division of the National Federation of the Blind
Ed Bryant, President/Editor Columbia, MO
Janet Lee, Vice-President Cedar, MN
Bill Parker, Vice-President Norfolk, VA
John Yark, Treasurer Stamford, CT
Tom Ley, Secretary Baltimore, MD
Advertisers
Effective advertising doesn't scream at its audience. It persuades. It sells. The key to cost-effective advertising is making your voice heard where an audience is already listening. Voice of the Diabetic, circulation 114,000+, offers such an outlet. Make your voice heard. For advertising information contact:
Voice of the Diabetic Ed Bryant, Editor 1412 I-70 Drive SW, Suite C, Columbia, M0 65203, Phone: (573) 875-8911, Fax: (573) 875-8902
The Voice of the Diabetic is a quarterly magazine published by the Diabetics Division of the National Federation of the Blind (NFB) for anyone interested in diabetes, especially diabetics who are blind or losing vision. It is an 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 Diabetics Division moving forward to help people with all aspects of diabetes.
Members of the NFB Diabetics Division 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 Diabetics Division approximately $20 per year. To help defray publication expenses, members are invited, and nonmembers are requested, to cover the subscription cost.
To begin receiving the Voice, please check one:
[ ] I would like to become a member of the NFB Diabetics Division and receive the Voice of the Diabetic. (Members are entitled to special membership 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):
[ ] cassette tape for the blind and physically handicapped
[ ] both (recorded at slower-than-standard speed of 15/16 IPS)
Optionally check this box:
[ ] I would like to make (or add) a tax-deductible contribution of $ ___________ to The Diabetics Division of NFB.
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, M0 65203, Phone: (573) 875-8911, Fax: (573) 875-8902
Please make all checks payable to:
NATIONAL FEDERATION OF THE BLIND