VOICE OF THE DIABETIC
The Diabetes Action Network of the National Federation of the Blind
A Support and Information Network
Volume 14, Number 2, Spring Edition 1999
VOICE OF THE DIABETIC, published quarterly, is the national magazine of the Diabetes Action Network of the National Federation of the Blind. It is read by those interested in all aspects of blindness and diabetes. We show diabetics that they have options regardless of the ramifications they may have had. We have a positive philosophy and know that positive attitudes are contagious.
News items, change of address notices, and other magazine correspondence should be sent to: Ed Bryant, Editor, Voice of the Diabetic, 811 Cherry Street, Suite 309, Columbia, Missouri 65201-4892; Phone: (573) 875-8911; Fax: (573) 875-8902.
Find us on the World Wide Web at: http://www.nfb.org and follow the links for "diabetes."
Copyright 1999 Diabetes Action Network,
National Federation of the Blind. ISSN 1041-8490
Note: The information and advice contained in VOICE OF THE DIABETIC are for educational purposes, and are not intended to take the place of personal instruction provided by your physician, or by your health care team. Discuss any changes in your treatment with the appropriate health professionals.
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INSIDE THIS ISSUE
AMYLIN ANALOG (PRAMLINTIDE) STUDIES REVEAL BETTER GLYCEMIC CONTROL
by Ed Bryant
THE VOICE OF EXPERIENCE
ASK THE DOCTOR
by Wesley W. Wilson, MD
PREVENTING KIDNEY FAILURE
by Shannon Glowacki, MD
CHECK YOUR HEMOGLOBIN A1c I.Q.
ESPECIALLY FOR BLACK PEOPLE
by Enid B. Jones
NEW WORLD-CLASS DIABETES RESEARCH CENTER
DIALYSIS AT NATIONAL CONVENTION
SOCIAL SECURITY, SSI, AND MEDICARE FACTS FOR 1999
by James Gashel
WHY BE IDENTIFIED?
by Karen Mayry
1999 NATIONAL CONVENTION
ORAL DIABETES MEDICATIONS UPDATE
by Peter J. Nebergall, PhD
THE PUMP GIRLS
TALKING BLOOD GLUCOSE MONITORING SYSTEMS
by Ed Bryant
DIABETES AND THE EYE
by David Harper, MD
NEW NOVO NORDISK INSULIN ALMOST HERE
BOOK REVIEWS
by Marilyn Helton
RECIPE CORNER
COOKING WITH SUZI
by Suzi Castle
LETTERS TO THE EDITOR
WORD SEARCH PUZZLE
by Denise R. Depillars
WHAT YOU ALWAYS WANTED TO KNOW BUT DIDN'T KNOW WHERE TO ASK
(Resource Column)
FOOD FOR THOUGHT
AMYLIN ANALOG (PRAMLINTIDE) STUDIES
REVEAL BETTER GLYCEMIC CONTROL
by Ed Bryant
Photo: portrait. Caption: Ed Bryant
For decades, diabetes researchers thought the achievement of euglycemia, normal, stable blood sugars, was a balancing act between two hormones, pancreatic insulin and glucagon. All diabetes medications either stimulated, replaced, or augmented the action of one of these two. Such medications work, but people who use insulin know good control can be difficult, no matter how diligently the diabetic works at it. The blood sugars always seem to fluctuate, and the tightest control is never quite as good as that achieved by a healthy pancreas. There has always seemed to be a third element, another part of the puzzle, one we weren't getting.
We may now have the missing piece. Amylin Pharmaceuticals, Inc., a San Diego, California, company, has been researching the human hormone Amylin, and their findings, while interim and incomplete, are fascinating.
About 100 years ago, researchers discovered white clumps of a substance in the pancreas, while performing autopsies. They called it "amyloid," and no extensive research was done at that time. In 1987, Garth Cooper, PhD, a New Zealand researcher working in the U.K., and his co-workers, published a paper describing the peptide he had sequenced from "amyloid." This peptide was subsequently named "Amylin."
The hormone Amylin, like insulin, is produced in the beta cells of the pancreas. The two are consecrated. A type 1 diabetic, deficient in insulin, is equally deficient in Amylin. A type 2 diabetic may exhibit a lesser Amylin deficit. The question: What is the role of Amylin in blood glucose management?
Amylin Pharmaceuticals has completed 37 clinical trials, and is currently conducting phase 3 studies of its synthetic Amylin analog, Pramlintide, in the United States. Some studies were short, and involved only a few people. Others lasted several years, and hundreds took part. Here's some of what they've found:
* Amylin appears to have a moderating effect on glucose absorption, from the gut into the blood. It acts as a set of brakes, slowing and managing meal-derived glucose inflow, controlling pancreatic glucagon secretion, which in turn regulates hepatic (liver) glucose production. (It is believed that a deficiency of Amylin contributes to excessive post-meal glucose elevation.) It also suppresses after-meal release of glucose from the liver. Both of these activities serve to "smooth the peaks and valleys" of blood sugar fluctuation, and improve overall glycemic control.
* In studies where Hemoglobin A1c test results were compared between those who used both insulin and pramlintide and those who used insulin, the A1c results of those who used the injectable Amylin analog were significantly lower than those who did not. NOTE: Major studies, such as the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study, have established the relationship between lower A1c results (for all diabetics) and a reduced risk of diabetes complications: Kidney disease, blindness, neuropathy, and coronary artery disease. Although the "ideal" HbA1c reading is 7.0% or less, any reduction in Hemoglobin A1c helps reduce the risk of complications.
* The clinical trials showed that many overweight diabetics who received pramlintide lost weight, while most lean diabetics, given the same medications, did not lose weight. Although the mechanism at work here is not yet clear, I find it is exciting, as achieving and maintaining ideal weight contributes to good health, a sense of well-being, and for some, a reduction in the amount of insulin needed to maintain good control.
* Many diabetics have episodes of severe hypoglycemia, dangerously low blood sugar. If the diabetes is being kept under "tight control" (as defined by the CDC, multiple tests and multiple insulin injections, to keep the blood glucose test numbers down in the non-diabetic "normal" or "euglycemic" range), the individual is more likely to experience hypoglycemia. Weight gain can follow as well. Studies in animals have shown that pramlintide, which normally retards release of the liver's glucose stores, suspends its action in the presence of hypoglycemia. What this suggests is that pramlintide helps lower the blood glucose without increasing the risk of hypoglycemia. Some test data appear to show a reduction in hypoglycemic episodes for the duration of Amylin therapy.
* Although there is insufficient data to allow conclusions, test results from several phase 2 and phase 3 studies suggested that pramlintide use could lead to improvement in a diabetic's LDL/HDL cholesterol ratios. The company has stated that their test methodology was not clear enough to allow specific conclusions to be drawn, so this needs more investigation; but if borne out by further tests, it could suggest pramlintide might reduce the coronary artery disease that so often follows diabetes.
* Davida Kruger, MSN, RN, CS, CDE, a diabetes researcher, delivered a paper titled "Amylin: The Clinical Impact of Restoring Both Beta Cell Hormones Insulin and Amylin" at the 25th annual convention of the American Association of Diabetes Educators, held August 19-23, 1998, in Minneapolis, Minnesota. In her presentation she stated: "Amylin controls the rate of glucose inflow into the bloodstream by restraining the rate of gastric emptying and suppressing glucagon secretion, which in turn suppresses post prandial glucose production." Simply, pramlintide appears to slow gastric emptying, which would more closely mimic the way our system is supposed to work, certainly helping to stabilize glycemic control. (Note: Some diabetics have gastroparesis, delayed gastric emptying.) Although the effect of pramlintide in the presence of this complication has not been yet studied, the company plans to do so before the drug is marketed.
Because natural Amylin is too viscous (thick) to inject, Amylin Pharmaceuticals developed its synthetic analog, pramlintide. Pramlintide is injected subcutaneously, with an insulin syringe. Although the use of an insulin/Amylin mix was not tested in this round of clinicals, and test participants were specifically instructed NOT to mix their insulin with their pramlintide, the company did carry out a safety check, and it found no acute (or "short-term") hazard would be created if such mixing did occur (both Humulin and Novolin insulins were tested, though quick-acting Humalog insulin was excluded from study at that time). Still, the company has no plans at this time to offer a mixed insulin/Amylin product when they first market pramlintide.
Interestingly, test volunteers, unable to mix their pramlintide with their insulin, were faced with the need for many more injections. Almost none of them dropped out of the study—and consensus was they perceived the benefits to outweigh the irritation of the extra injections.
A few study participants were insulin pump users. Use of pramlintide in conjunction with the insulin pump may become possible.
Amylin Pharmaceuticals has been testing their product for years, and is currently engaged in phase 3 clinicals in several locations. As of March, 1999, over 1700 people have received the drug. Both type 1 and insulin-using type 2 diabetics received pramlintide in different concentrations and frequencies. Only among type 1 diabetics receiving the highest dosage were there any noticeable side effects—in this case nausea and an increase in hypoglycemic events. All other dosage and frequency levels featured no increase in side effects (except transient nausea) over that seen with the placebo, and in most cases there were significant reductions in hemoglobin A1c numbers—the kind of result known to cut risk of complications.
"Research shows that aggressive treatment...will prevent or delay much of the illness and death," says Dr. Phillip Gorden, Director of the NIH's National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in a June 23, 1998 news release. "Scientific studies provide compelling evidence that maintaining blood sugar levels at less than 7%, as measured by the HbA1c blood test, may reduce risk of complications by 50%-80%," says Dr. Frank Vinicor, director of the CDC's Division of Diabetes Translation, quoted in the same document.
The process of winning approval for a new medication, permission to market it to consumers, from the Food and Drug Administration (FDA), is long, expensive, and complex. To pass, to win approval, a company must prove not only that its product works, and doesn't imperil the safety of its users, but that its results are regular, consistent, and predictable. Unexpected results, surprise findings, or blind alleys can delay or prevent FDA approval. Before permission to market is granted, all such questions must be answered.
Amylin Pharmaceuticals has reported some unexpected results. Two six-month European/Canadian studies yielded, for the highest dosages, less than the hypothesized drug effect, in effect "failing the exam." (Other dosages showed positive effects.) The company must now reexamine its testing strategy in light of the new findings. As a recent news release stated: "The company plans to reassess its regulatory time lines for pramlintide..." It is hoped FDA filing requirements will be completed by the middle of year 2000.
Much work is still underway to determine Amylin's exact role in helping to treat diabetes. If pramlintide can be successfully retested, if the company can answer the questions its high-dosage results exposed, if they can locate sufficient funding to weather the storm, we may see approval by the FDA. If not, it will go into the books as one more idea that didn't quite make it. For the sake of all diabetics, I hope we see this one happen.
For further information, visit Amylin Pharmaceuticals' website: http://www.amylin.com
Resources:
See American Association of Diabetes Educators conference tapes for 1998 (AADE "25th annual meeting and educational program") Numbers #S23, "Amylin, the Other Beta Cell Hormone," by Davida Kruger, MSN, RN, CS, CDE, and Patricia Gatcomb, BSN, RN, CDE, and #T15, "Amylin, the Clinical Impact of Restoring Both Beta Cell Hormones, Insulin and Amylin" #T15, by Davida Kruger, MSN, RN, CS, CDE. Get these tapes and others from the 1998 AADE meeting by calling Landes Slezak Group at 1-800-776-5454. Tapes cost $11 each.
* * * * * SIDEBAR * * * * *
The December 1997 issue of "Practical Diabetology" carried an article titled "A New Look at Glucose Control: The Case for Therapy with Insulin and an Amylin Analog," by Steven V. Edelman, MD, and Davida F. Kruger, MSN, RN, CS, CDE. The text contained a very useful definition of type 1 and type 2 diabetes:
Although type 1 and type 2 diabetes have strikingly different pathophysiologies, the final manifestations of the disease are similar: insulin secretory defects and hyperglycemia. In type 1 diabetes, autoimmune destruction of the pancreatic beta cells virtually eliminates insulin production. In contrast, people with type 2 diabetes develop beta-cell exhaustion due to chronic overstimulation of insulin production by the pancreas in response to increasing insulin resistance. The final result of both pathophysiologic processes is that the plasma glucose profiles of these two forms of diabetes are similar, typified by elevated fasting and excessive postprandial glucose concentrations.
THE VOICE OF EXPERIENCE
Photo: portrait. Caption: Richard Donnell
Doctors of the 1920s and 1930s didn't know very much about diabetes. Insulin had only been discovered in 1921, and there was only one type: animal-source regular. There were all kinds of ideas about how best to treat it: How much insulin, how many injections, what to eat, how much exercise...and how long a diabetic might expect to live. Were those the "bad old days?"
Richard Donnell has had diabetes 64 years, since 1935. And it sounds like his doctors have been doing the right thing! In his own words:
"I was nine years old. I had to go to the john all the time, and I had stomach cramps. I had a sister who was in nurse training, and she said, 'You should go to the doctor!' So my folks took me to the doctor..."
"When I was 12 years old, my folks took me to a doctor, J. H. Worvel, MD, who was THE diabetic specialist in Indianapolis. He told me I had to weigh my food, count out diets, and so forth. It was very difficult to calculate a diet while going into a reaction. But anyway, I got along pretty well, except I had a lot of orange urine sugars and so forth. He sat me down and shook his finger at me; he was pretty stern: 'You have to take care of yourself!' He convinced me to watch my diet, and not to have Cokes and ice cream and things like that."
"When I was in high school, they started me on three shots a day. I had to take insulin for every meal, so I took my lunch to school and had to take my insulin. The library windows were in the back of the senior class room, and there wasn't any glass in the top of them. I had my syringe, and I had to sterilize it with alcohol. Afterwards, I would squirt the alcohol through the open windows onto the students studying in the library... That was over 50 years ago, and I am still taking three shots a day."
"High school was the most difficult time, I think. When you go to the 'sweet shop,' or something like that, what do you have? I finally learned that I could have coffee, just like the grownups did. So my buddies, when we went, would order sodas, and I would order coffee... There was no such thing as a 'diet soda,' so I just had coffee, black, like the big kids did. It was a pretty good deal, and I didn't suffer too much."
And how did Richard keep track of his sugars, in those days long before the home blood glucose monitor? When asked if he used urinalysis, the little tablet and little tube, where it changed colors, he said he used that setup in later years, but:
"Before that you put a copper sulfate tablet in, I forget how much it was. Twenty drops of water, ten drops of urine, then you put a copper sulfate tablet in. Then there was another tablet you burned, to get the blood sugar. There was also a saline solution before that, which you boiled over a test tube with so many drops of urine. It all told you the same thing."
How did it go?
"I am still here. I've got all my fingers and my toes. I need glasses, but otherwise my eyesight is good. Age? I prefer to call it maturity."
"I was an engineer. I went to Purdue, got a degree in engineering, worked for GE, worked for a private company for a while, then worked for Cummings Diesel Engine Company for 28 years, here in Columbus, Indiana. As an electrical engineer, I did a lot with diesel-powered standby generators for hospitals..."
"My wife was a nurse. I met her at the hospital, when I was going to college. I ate my meals at the hospital, and we got acquainted. It worked out pretty well. The idea was I would make the living and she would make the living worthwhile. We've been to Hawaii six or seven times, and around the world in 1989... we enjoyed it tremendously."
"Once, my wife called the police to come get me, because I was in a reaction, and she couldn't get me to eat. She was going to give me a shot of glucagon, and I thought she was going to give me a shot of insulin. I didn't need insulin! She had two policemen hold me down, and she gave me the glucagon shot. It worked..."
Asked what advice he might care to offer VOICE readers, about blood sugar, eating, exercise, and such things, he responded:
"Watching my diet and watching my blood sugars has worked pretty well for me for 64 years. It won't work for everybody, I guess. I am doing fine. I have a dog, and she takes me for a walk, about a mile and 3/10, every night. The dog is a pretty good incentive to go for a walk. And I am still here..."
Richard Donnell is indeed "still here." He is living proof that with the exercise of reasonable diabetes care, the complications, the tragedies, and the foreshortened life are not "inevitable." His is the voice of experience.
ASK THE DOCTOR
by Wesley W. Wilson, MD
Artwork: Medical caduceus
NOTE: If you have any questions for "Ask the Doctor," please send them to the VOICE editorial office. The only questions Dr. Wilson will be able to answer are the ones used in this column.
Wesley W. Wilson, MD has retired as an Internal Medicine practitioner at the Western Montana Clinic in Missoula, Montana. Dr. Wilson was diagnosed with type 1 diabetes in 1956, during his second year of medical school. He remains interested and involved in diabetes education for patients and professionals.
Q: What is brittle diabetes, and what makes someone "brittle?" If you are brittle, can you become not brittle?
A: Brittle diabetes is hard to define. Often physicians label a person as a "brittle diabetic" when attempts to achieve control of the blood sugar result in wildly fluctuating blood sugar levels. Persons who have such unstable blood sugar levels almost always have type 1 diabetes, are often slender (and very likely to have variable activity), and of course, are more likely to have a variable diet—items that certainly lead to fluctuations in blood sugar levels.
Some authorities state that if everyone with diabetes practiced good, tight control, no one would be "brittle," and they are partly right; many people's symptoms would be improved by tighter control. Sometimes, despite our best efforts, we are unable to reduce the blood sugar variations—some folks do everything right and still experience wild, out-of proportion swoops and rises in their blood sugars—and these are the truly "brittle." Luckily there are not many.
I wish I could tell you how to be less brittle. Often the usual methods of diabetes management can improve blood sugar control and even out the blood sugar fluctuations. Frequent tests and careful attention to diet and meticulous efforts to keep exercise the same from day to day act to stabilize blood sugar levels. Oftentimes, if a person is very slender, an effort to gain a modest amount of weight does help smooth out blood sugar levels. Most persons with the symptoms of brittle diabetes show a significant improvement when they work with a nurse educator, dietician, and physician in a team effort to smooth out blood sugar control.
Q: My Hemoglobin A1c has almost always run between 11 and 13.5, and I need to get them down to single digits. How do I do this, and what is a good range for hemoglobin A1c?
A: The Hemoglobin A1c test is used to estimate what your blood sugar has been during the 6-8 weeks prior to the blood sample drawn for the test. Perhaps the best way to demonstrate the importance of knowing your Hemoglobin A1c is to inspect the results of the Diabetes Control and Complications Trial (DCCT). In that study, the conventionally treated (one or two tests a day, one or two insulin injections a day) group's Hemoglobin A1c averaged a little over 9%, and that of the intensively treated group averaged slightly over 7%. The importance, of course, is that the intensively treated group developed far fewer complications than the conventionally treated group after six and a half years. After nine years, the differences between the two groups were even more pronounced.
The rest of your question is harder to answer, namely, how should you attempt to reduce the Hemoglobin A1c level? It is the same answer as usual in diabetes: frequent blood sugar tests, careful attention to diet and exercise, and careful teamwork with your care giver, nurse educator, and dietician are all important in order to achieve careful control of your blood sugar. The tighter the control, the lower the A1c.
Your next question, what should the A1c be ideally? Clearly, a normal, non-diabetic Hemoglobin A1c of 3.5 to 6.5 would be best. The problem with THAT target is the risk of hypoglycemia, particularly in insulin-treated persons. Most diabetics opt for a slightly higher A1c target, about 7, to give them a margin of safety. The target range of A1c must be decided by the person with the diabetes, and the health-care team, since the dangers of severely low blood sugar levels are very real. Severe hypoglycemia was three times greater in the intensively-treated group in the DCCT. Very tight blood sugar control with fasting sugars 120 or less and post-prandial (after meal) sugars 180 or less requires hard work by the person with diabetes, and by the treating team. This offers the best chance to minimize micro vascular diabetes complications (kidney, eye, and nerve diseases).
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
1999 NFB CONVENTION AGENDA
Wednesday, June 30 -- Seminars
Thursday, July 1 -- Convention Registration
Friday, July 2 -- National Board Meeting (open to all)
Saturday, July 3 -- General Sessions
Sunday, July 4 -- Tour Day
Monday, July 5 -- Banquet
Tuesday, July 6 -- General Sessions, Adjournment
PREVENTING KIDNEY FAILURE
by Shannon Glowacki, MD
Dr. Glowacki delivered the following as the keynote address at the Diabetes Action Network's July 6 seminar, held as part of the 1998 annual convention of the National Federation of the Blind, in Dallas, Texas.
First of all, thank you very much for inviting me. It's an honor to be here. Somebody said to me, "Remember in any talk give three points." Today, my points are EDUCATION, SCREENING and EARLY INTERVENTION.
I am going to start by telling you a story, one that I hear too often. About every third or fourth patient who comes to our nephrology office has it. Typically, she is a 55-year-old female, most often, in my practice, African-American and obese. She will come to me and say, "Gee, my doctor sent me saying that there is something wrong with my kidneys." She may have had diabetes for 20 years, and hypertension for ten years, coronary artery disease (maybe not a myocardial infarction), but she does have angina. Our typical patient has no significant diabetic ulcers or amputations, but she will have had an ulcer. She'll have early diabetic retinopathy. She'll have seen an ophthalmologist and they'll have done laser intervention.
These patients come with information, sent by the reference physician; a blood test, maybe more... I can tell that they have approximately 25-30% kidney function. I make sure it is in fact diabetic nephropathy (99% of the time it is), as just because you are diabetic doesn't mean you can't have another kidney disease.
On the next visit or two we talk about the fact that I cannot fix their kidney. All we can do, right now, is try to prevent the disease from progressing too quickly. Most often, these people are on dialysis in the next two to three years despite all of our efforts.
When we talk about education, we don't just mean you, the patient, but also the referring physicians and just about everybody else in the population. A lot of what I am going to say actually I never get a chance to implement—but if we are going to make a difference in this disease, the intervention has to be early on, before you ever get to me. Hopefully, you won't have to see me.
First of all, diabetic nephropathy we need to take seriously—not just you, not just me, but our neighbors out there. It is one the most expensive diseases out there, as I am sure you are aware. We are looking at 30-50% suffering from diabetes and not in combination with other diseases. Dialysis and transplantation cost $3 billion in 1994, and a large part was due to diabetes.
In the type 1 diabetic population, approximately 40% will develop a renal insufficiency or disease. However, 60% of the diabetics on dialysis are type 2. It is a huge problem, and we need to go back and look at intervening early, before you even need to see me.
Let's go back into the type 1 information of what we know about nephropathy. "How can I predict if I am going to be one of the 40% who develops kidney disease?" There is no absolute answer to that question, but there are lots of markers, there's a lot of indicators, there's a lot of what we call "risk factors." There is no absolute way that we can predict 100%, but let's talk about some of the interventions.
Genetics certainly are a factor. If you have siblings, if you have family history, if you have a genetic susceptibility, if you have hypertension, then you are at more risk.
Glucose. Glycemic control early on is crucial. By the time you see me, it is likely not going to be a huge factor in the rate of progression of deterioration. Early on it is certainly a factor, as you know with all our other organs.
One other issue is race. There is no question that African-Americans, Mexican-Americans, and Native Americans have increased risk at incidence and prevalence of kidney problems compared to Caucasian diabetics. There is still a genetic susceptibility that we haven't put our finger on.
Let's come back to the kidney. The kidney is a sensor; it filters poisons and it filters fluids. Those are its two main jobs. It is also involved in blood pressure, and it responds to anemia by sending a messenger to the bone marrow to make red blood cells, etc. But the two big things are getting rid of fluids and poisons, the biggest one being poisons. You cannot live without this kidney function.
Dialysis is not a cure; it is only a replacement therapy, replacement for the function of the kidney. Usually we talk about dialysis when kidney function, for whatever reason, gets down to 10%.
The kidney is a filter, it is a big filter. We each have a million little filters called glomeruli in each kidney. In the normal kidney with no disease, by the time you are 80 years old, all those filters are not working 100%. If you look at an old person's kidney under microscope half the filters are scarred up. That is just age, the kidney ages.
Let's go back to the diabetic kidney. Early on, almost all diabetic kidneys are working overtime. Why? I will be honest with you, we don't know why. It is not just insulin, it is not just the glucose, the glucagon, or the hormones. A kidney working overtime is not a good thing because it is going to burn out faster.
Everybody with diabetes has functional changes in the kidney. Every kidney with diabetes undergoes minor changes; that still is not a bad thing. It is when you move on and progress to more serious lesions and scarring in the kidney that things may change. You have a kidney that is working overtime and even if you have great glycemic control and great blood pressure control, and the diet is perfect and we are doing everything we can, every diabetic kidney is going to be working a little bit overtime because there is no such thing as perfect glycemic control.
One of the markers now that we do know, we've known quite a few years, is microalbuminuria. It identifies that we are moving into the target zone. During that microalbuminuria time everything else is looking good, the kidney is still filtering at a 100% and the urine is still a 100 or better. We are starting to see a problem, this is the marker.
I will be honest with you; I have never measured for microalbuminuria. I am a nephrologist and have never measured for microalbuminuria! Why? Because by the time they get to me, patients are past that stage. This is a stage that needs to be done in the family doctor's office; a screening test, identifying the problem. Hopefully this is the time when we need to make that intervention, to make the difference so that it doesn't worsen.
Worsen how? By developing a slow progression of deterioration in the kidney function. You want to prevent that—we've got to stop it—before it gets to that point.
What can we do to make a difference? Best would be preventing diabetes in the first place, but changing the environment of what diabetes is, early on, is number one. Number two is blood pressure. This is a message, diabetic or not, that everyone needs to hear. Hypertension is one of the worst things you can do to your body, diabetic or not. If affects your brain, it affects your heart, and it affects your kidneys. No matter what disease you have, when you come to see me, I rely on that kidney.
High blood pressure is one of the most significant causes for progression of deterioration of renal function. It is usually a very straight line, not the same line in everybody, but usually a very predictable and slow course. Obviously we wanted to find things that would change that slope of that line, flatten it out a bit, make it slower, make it stable. The first thing, still to this day, that can change that line is blood pressure control, just garden variety blood pressure control. What blood pressure control are we aiming for? If you have hypertension, we would be aiming for 140/90, a general recommendation. When too low we are talking 100/60. In the diabetic population, clearly that goal has been readjusted by the hypertensive society and I believe the diabetic society. The hypertensive recommendation is 130/80. I still think that we all, both patients and physicians, fail miserably at reaching that goal, maintaining that goal, and monitoring that goal.
We all need to know our blood pressure. The most important thing is blood pressure control, blood pressure control, blood pressure control. Those studies that show the straightening of the line weren't done with any of that fancy stuff you've all heard about, they were done with very early and simple hypertensive medication.
What about the fancy blood pressure medication? What about the ace-inhibitors? Hopefully anybody with any microalbuminuria should be on an ace-inhibitor. Obviously if you have hypertension and early signs of kidney disease, that ace-inhibitor is the first line drug of choice. Generally speaking, the ace-inhibitor should be the drug of choice.
It also helps to decrease pressure within the kidney. Remember that filter with blood going in and blood going out? Well, guess what happens. There is pressure across there, as with any artery changing into a vein. Any increase in pressure there, a kidney working overtime, or a little filter working overtime, only serves to hasten scarring and deterioration. Lessening the pressure, not only in the blood vessels all over your body, but also specifically in the glomeruli, as the ace-inhibitor does, helps to decrease that protein, and hopefully does decrease the scarring and disease progression.
Lets talk about people who have microalbuminuria. If they have normal blood pressure, should they be on an ace-inhibitor? The answer to that is yes, a careful low dose. If you have normal pressure and are taking an ace-inhibitor, it should not drop your blood pressure significantly. There are some people who have a blood pressure of about 110/60, and who have a little bit of kidney disease, but cannot tolerate a low dose ace-inhibitor, because they seriously do feel light headed and dizzy. But everyone should be tried on it, as generally speaking it is very well tolerated.
To summarize: Ace-inhibitors should be used as a first line in hypertension and diabetes, they should be tried in a low dose in a normal tension person with microalbuminuria, and they should definitely be used in a person with identified renal problems and hypertension, as the first line of therapy.
Next, what about the next group of medications, the calcium channel blockers? Calcium channel blockers work obviously by blocking calcium channels in cells and blood vessels, to help with hypertension. Very effective group of drugs. It's very effective hypertension control—I like that group.
Let's go back a minute. We talked about glycemic control, blood pressure control in general, then the choice of blood pressure control, ace-inhibitors, and calcium channel blockers. As we may or may not know, some of the side effects of those blood pressure medications have to be considered. One of those side effects concerns lipids.
Let's go to lipids. Lipids are hard on the kidney, diabetes or not, but it has been shown in diabetes that lipids are especially dangerous. High cholesterol, bad for your heart and brain, is also bad for your kidneys, too. It makes the scarring, the thickening, and the loss of efficiency happen faster. There is no question that you need to be attentive to your cholesterol and to the medication that are required to take care of your cholesterol and triglycerides. Not only for your diabetes, but for your heart, brain and your kidneys.
The other thing is diet. Is there a perfect diet in this world? NO! I think that we should all live on fresh fruit and vegetables, and fish and chicken. Wouldn't that be fun?! There is no such thing as a perfect diet for anybody, I think. Added to the mix of everything else you have to deal with is protein. How many people here have a protein restricted diet?! That must be hard balancing all the carbohydrates and everything else.
Let's go over the protein studies for just a minute. Protein is a tough one. Those initial studies on protein restriction, from Italy, were not just done on diabetics; diabetics were in the mix, but so were chronically ill from all other issues. There were people with established, not just early, kidney disease, and researchers found out that by restricting the protein you can make a difference in the pressure of renal disease. We know now that the pressure on the filters, produced by higher protein diet can be decreased by a low protein diet. Just by some decrease in protein consumption, you decrease the work of that filter, and you are protecting your kidneys.
We know the other side pushing that restriction is malnourishment. Protein restriction can help decrease those poisons your kidneys filled up, but if you go into needing dialysis, one thing we discovered is not to go in malnourished. There are a lot of controversies about protein restriction, but common sense is not to protein overload on a regular basis.
We've already had a disease that is affecting the process, and we are trying to make broad flashes at intervention of that process. There are studies coming more specifically at the diabetic intervention with glucose and metabolism, and their results hopefully will make some big differences down the road. I think they are getting closer with those interventions, but they are going to be more specific to diabetes. The good news is that there is no question these interventions can make a difference.
That story I told you at the beginning should not be happening—not without a long fight. What I find so interesting is the people who come to me know nothing about it, have no sense of where they are. There is no question that we need early intervention and teaching, this goes back to the patient being informed, the internists being informed, and certainly the endocrinologist. I think we all really need to be on board, you need to know your screening, you need to know what you are looking for.
CHECK YOUR HEMOGLOBIN A1c I.Q.
The following is courtesy of the National Institute of Diabetes and Digestive and Kidney Diseases, a division of the U.S. National Institutes of Health.
Find out how much you know about the Hemoglobin A1c test (also called HbA1c). Mark each statement true (T) or false (F). Then see how you did by checking the correct answers and explanations, found below.
1. A Hemoglobin A1c test measures the average amount of sugar in your blood over the last three months.
[ ]T [ ]F
2. It's important to know your Hemoglobin A1c number.
[ ]T [ ]F
3. All people with diabetes need to have a Hemoglobin A1c test.
[ ]T [ ]F
4. The Hemoglobin A1c goal for people with diabetes is less than 7 percent.
[ ]T [ ]F
5. Most people can tell what their blood sugar levels are simply by how they feel.
[ ]T [ ]F
6. You can have a "touch of sugar" but don't have to do anything about it.
[ ]T [ ]F
7. You can do something about high blood sugar.
[ ]T [ ]F
8. A Hemoglobin A1c number over 8 percent is a sign that one or more parts of your treatment plan needs to be changed.
[ ]T [ ]F
9. A Hemoglobin A1c test should be done about once a year.
[ ]T [ ]F
10. There's no proof that lowering your Hemoglobin A1c number can reduce your chances of getting serious eye, kidney, and nerve disease.
[ ]T [ ]F
Answers to the HEMOGLOBIN A1c I.Q. QUIZ:
1. TRUE: The Hemoglobin A1c test shows the average amount of sugar in your blood over the last three months. It is a simple lab test done by your health care provider. The Hemoglobin A1c is the best test to find out if your blood sugar is under control.
2. TRUE: If you know your Hemoglobin A1c number, you will know if your blood sugar is under control. A high number is a sign that you should work with your health care provider to change your treatment plan. A good test result is a sign that your treatment plan is working and your blood sugar is under control.
3. TRUE: All people with diabetes should have a Hemoglobin A1c test at least twice a year. Regular Hemoglobin A1c testing can help you track your blood sugar levels over time to see if they stay close to normal or go up and down. If your blood sugar levels are too high or too low, work with your health care provider to change your treatment plan and reach your target level of control.
4. TRUE: The Hemoglobin A1c goal for people with diabetes is less than 7 percent. The findings of a major diabetes study, the Diabetes Control and Complications Trial (DCCT), showed that people with diabetes who keep their Hemoglobin A1c levels close to 7 percent have a much better chance of delaying or preventing diabetes problems that affect the eyes, kidneys, and nerves than people with Hemoglobin A1c levels 8 percent or higher. A change in treatment is almost always needed if your Hemoglobin A1c is over 8 percent. But, if you can lower your Hemoglobin A1c number by any amount, you will improve your chances of staying healthy.
5. FALSE: Research shows that few people can tell their blood sugar levels simply by how they feel. Testing your blood sugar is the only way to know for sure whether you are reaching your blood sugar goals.
6. FALSE: If you have "sugar" you have diabetes. Diabetes is a serious disease that causes the sugar in your blood to build up in your body. This buildup of sugar can cause you to go blind, suffer a heart attack, lose your feet or legs to amputations, stop your kidneys from working, and even kill you. There is no cure for diabetes, but there is a lot you can do to control it. For example, you can see your health care provider more often. You can change some of the foods you eat. You can stay at a weight that is right for you. And you can get regular physical activity.
7. TRUE: You can do a lot to bring down high blood sugar and get it under control. Start by asking your health care provider for a Hemoglobin A1c test. If your Hemoglobin A1c test result is too high, talk to your health care provider about how to lower it. To get your blood sugar under control, follow the meal plan recommended by your health care provider, stick to a physical activity program, take prescribed diabetes medicines, and consult your health care provider often.
8. TRUE: A change in treatment is almost always needed if your Hemoglobin A1c is over 8 percent. Common causes of high blood sugar include eating too much food or eating the wrong foods, lack of physical activity, stress, a need to change medicines, and infection or illness. If your Hemoglobin A1c number is too high, work with your health care provider to change your treatment plan and reach the goal of less than 7 percent.
9. FALSE: You should get a Hemoglobin A1c test at least two times a year if your blood sugar is in the target range and stable. If your treatment changes or if your blood sugar stays too high, you should get a Hemoglobin A1c test at least every 3 months until your blood sugar level improves.
10. FALSE: The DCCT showed that the lower the Hemoglobin A1c number, the greater the chances that people with diabetes will slow or prevent the development of serious eye, kidney, and nerve disease. The study also showed that if you can lower your Hemoglobin A1c number by any amount, you will improve your chances of staying healthy.
ESPECIALLY FOR BLACK PEOPLE
by Enid B. Jones
Photo: portrait. Caption: Enid Jones
Five years ago I was diagnosed as diabetic (type 2) by my gynecologist—a strange way to learn this fact. Fifteen years ago I was told I had gestational diabetes, and then that I was a "borderline diabetic." I developed arrhythmia (irregular heartbeat), recurring yeast infections, irritable bowel syndrome, dizziness, recurring lesions under my toes, bouts of severe thirst, etc...
Now that I have read all that I can about diabetes I realize that I have been diabetic for a long time. I should also point out that I was very active in that I played tennis and was always enrolled in exercise classes of one type or another until my son entered high school and I had to sublimate my activities to support his. At that time I developed a fairly sedentary life style, sitting through basketball games, track meets, and after-school events.
The issue is why was my diabetes was not detected earlier? Several blood tests were done, but the results of these tests showed "close to normal" blood sugar levels and so I did not receive treatment—not until I went through the pre-op screening for elective surgery and was told that my sugar level was too high for surgery to be done at that time. So finally, I began to receive treatment for my type 2 diabetes.
Why did I title this article "Especially For Black People"? For three and a half years I was treated as a borderline type 2 diabetic, though my daily blood glucose tests ran from 165 to 185mg/dL, and my quarterly A1c test readings averaged 7.0. I was doing the things I was supposed to do, and taking my medications on time, but my diet control/exercise plan did not alleviate my problems, and my daily doses of glucotrol were not bringing my numbers down. I was experiencing problems common to a person with far higher sugar levels. Why?
Then I moved to another state, and had to change doctors, twice in fact. The second doctor, who tested my blood with the three-month gHb test instead of HbA1c, asked me: "Did you know you have the gene for sickle cell?"
I responded: " Yes! I've known for a long time that I have sickle cell trait. It is not a problem, is it?"
Doctor: "Yes, in a way, because you need and should have had a hemoglobin-S test; your sugar level is masked otherwise (with the A1c)."
My reading under the new test (new to me) was a few decimals below nine. I was not close to "normal" at all! My doctor changed my treatment to reflect this—and my daily readings dropped to within the normal range, while the quarterly tests are down to eight. I now take glucophage, which is helping tremendously. I have no more trouble with my feet and only occasional discomfort in my stomach.
Since sickle cell is found predominantly in black people, and presence of the sickle trait can make the A1c test read falsely low, the blood glucose gHb test should be recommended for standard screening of black people, or anyone who knows they are carrying the trait for sickle cell.
NEW WORLD-CLASS DIABETES RESEARCH CENTER
Britain's Oxford University will be home for a new diabetes research center. Employing approximately 150 clinicians and researchers, the Oxford Centre for Diabetes, Endocrinology, and Metabolism will integrate, under one roof, basic and clinical research, clinical care, and scientific and patient education in hormone-related and metabolic diseases. This "Care to Cure" approach, as it is termed, should benefit patients by giving them faster access to new discoveries, and it should benefit the research process as well, by encouraging the different specialists to communicate about their work in process. Great things are expected.
Many of the researchers are veterans in the field: Professor Robert Turner recently completed the United Kingdom Prospective Diabetes Study(UKPDS); Dr. Keith Frayn is researching the causes of obesity; and Professor John Wass leads the endocrine team. Oxford University Vice Chancellor Dr. Colin Lucas says: "We have some of the most innovative medical researchers in the world, who are able to translate scientific discoveries into real clinical benefit for the patient."
But new research centers do not spring forth unbidden. There are a lot of costs associated with the establishment and maintenance of such a new institution. Some funding will come from the British government, through its National Health Service, but a large part has been donated by founding partner Novo Nordisk A/S, an international pharmaceutical company with headquarters in Denmark. Novo Nordisk A/S is the parent of U.S. based Novo Nordisk Pharmaceuticals Inc., maker of the familiar "Novolin" insulins, insulin pens, and many other products.
In the U.S., in the U.K., and world-wide, Novo Nordisk is committed to initiating and supporting pharmaceutical innovation, strategic partnerships, and multi-disciplinary research toward both improving the lives of diabetics and finding a cure for the disease. In many parts of the world, Novo Nordisk is funding physicians' meetings and conferences, training seminars, and clinical courses for diabetes specialists. The company also sponsors a number of research fellowships and awards. They deserve a big "thank you" for this effort.
DIALYSIS AT NATIONAL CONVENTION
During this year's annual convention of the National Federation of the Blind in Atlanta, Georgia (Wednesday, June 30, through Tuesday, July 6), dialysis will be available. Individuals requiring dialysis must have a transient patient packet and physician's statement filled out prior to treatment. Conventioneers must have their unit contact the desired location in the Atlanta area for instructions, well in advance. NOTE: The convention will take place at the Atlanta Marriott Marquis, 265 Peachtree Center, in downtown Atlanta.
Individuals will be responsible for, and must pay out of pocket, prior to each treatment, the approximately $30 not covered by Medicare, plus any additional physician's fees, and any charges for other medications.
DIALYSIS CENTERS SHOULD SET UP TRANSIENT DIALYSIS LOCATIONS AT LEAST THREE MONTHS IN ADVANCE. THIS HELPS ASSURE A LOCATION FOR ANYONE WANTING TO DIALYZE. There are many centers in the Atlanta area, but that area is quite large, so early reservation is strongly recommended, if you would avoid long taxi rides!
Here are some dialysis locations:
* Dialysis Clinic Inc.—Piedmont, 120 Piedmont Ave. NE, Atlanta, GA 30303; telephone: (404) 888-4510.
* Dialysis Clinic Inc.—West Peachtree, 820 West Peachtree Street NW, Atlanta, GA 30308; telephone: (404) 888-4520.
* Gambro Healthcare (on Ralph McGill), 448 Ralph McGill Blvd., Atlanta, GA 30312; telephone: (404) 872-7211.
* Gambro Healthcare Atlanta, 400 Decatur Street, Atlanta, GA 30312 telephone: (404) 577-9097.
* Gambro Healthcare Peachtree, 524 W. Peachtree Street, Atlanta, GA 30308; telephone: (404) 249-1563.
PLEASE REMEMBER TO SCHEDULE DIALYSIS TREATMENTS EARLY, TO ENSURE SPACE. If scheduling assistance is needed, have your dialysis unit's social worker contact: Diabetes Action Network President Ed Bryant at (573) 875-8911. See you in Atlanta!
SOCIAL SECURITY, SSI, AND MEDICARE FACTS FOR 1999
by James Gashel
Photo: portrait. Caption: James Gashel
Artwork: walking blind man with cane and briefcase
FROM THE EDITOR: This article appeared in the December 1998 issue of the BRAILLE MONITOR, published by the National Federation of the Blind (NFB). Mr. Gashel is Director of Governmental Affairs for the NFB, and is one of the world's leading experts in this field.
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 1999:
FICA AND SELF-EMPLOYMENT TAX RATES: The FICA tax rate for employees and their employers remains at 7.65 percent. This rate includes payments to the Old Age, Survivors, and Disability Insurance (OASDI) Trust Fund of 6.2 percent and an additional 1.45 percent 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 percent, which includes 12.4 percent paid to the OASDI trust fund and 2.9 percent paid to the HI trust fund.
CEILING ON EARNINGS SUBJECT TO TAX: During 1998, the ceiling on taxable earnings for contributions to the OASDI trust fund was $68,400. This ceiling is raised to $72,600 for 1999. All earnings are taxed for the HI trust fund.
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 1998 a Social Security quarter of coverage was credited for earnings of $700 in any calendar quarter. Anyone who earned $2,800 for the year (regardless of when the earnings occurred during the year) was given four quarters of coverage. In 1999 a Social Security quarter of coverage will be credited for earnings of $740 during a calendar quarter. Four quarters can be earned with annual earnings of $2,960.
EXEMPT EARNINGS: The monthly earnings exemption for blind people who receive disability insurance benefits was $1,050 of gross earned income during 1998. In 1999 earnings of $1,110 or more per month before taxes for a blind SSDI beneficiary 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 1999: All Social Security benefits are increased by 1.3 percent beginning with the checks received in January, 1999. The exact dollar increase for any individual will depend upon the amount being paid.
STANDARD SSI BENEFIT INCREASE: Beginning January, 1999, the federal payment amounts for SSI individuals and couples are as follows: individuals, $500 per month; couples, $751 per month. These amounts are increased from individuals, $494 per month; couples, $741 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 60 days was $764 during 1998 and is increased to $768 during 1999. Beginning with the sixty-first day through the ninetieth day there is a daily co-insurance amount of $192 per day, up from $191 in 1998. Each Medicare beneficiary has 60 "reserve days" for hospital services provided within a benefit period longer than 90 days. The co-insurance amount to be paid during each reserve day is $384, up from $382 in 1998.
Part A of Medicare pays all covered charges for services in a skilled nursing facility for the first 20 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 $96 per day, up from $95.50 per day in 1998.
For most beneficiaries there is no monthly premium charge for Medicare Part A coverage. Those who become ineligible for SSDI cash benefits can continue to receive Medicare Part A coverage premium-free for 39 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 1999 is $309 per month. This is reduced to $170 for individuals who have earned at least 30 quarters of coverage under Social Security-covered employment.
The Medicare Part B (medical insurance) deductible remains at $100 in 1999. This is an annual deductible amount. The Medicare Part B basic monthly premium rate will increase from $43.80 charged to each beneficiary in 1998 to $45.50 for 1999. This premium payment is deducted from Social Security benefits checks. Individuals who remain eligible for Medicare but are not receiving Social Security benefits because of working pay this premium directly.
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 ($45.50 in 1999). 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. In order to qualify, the income of an individual or couple must be less than the poverty guidelines currently in effect. The guidelines are revised annually and were last announced in the spring of 1998. New guidelines will be issued in the spring of 1999. The rules vary from state to state, but in general:
A person may qualify for the QMB program if his or her income is approximately $691 per month for an individual and $925 per month for a couple. These amounts apply for residents of 48 of the 50 states and the District of Columbia. In Alaska the income threshold used to define poverty is approximately $860 per month for an individual and $1,151 per month for couples. In Hawaii income must be less than approximately $792 per month for an individual and $1,060 per month for couples.
For the SLMB program the income of an individual cannot exceed $825 per month or $1,105 for a couple in 48 of the 50 states and the District of Columbia. In Alaska the income amount is $1,027 for an individual and $1,377 for couples. An individual in Hawaii can qualify if his or her income is approximately $946 per month; for couples the amount is $1,268.
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.)
If you qualify for assistance under the QMB program, you will not have to pay:
* Medicare's hospital co-insurance amount, which is $768 per benefit period in 1999;
* The daily co-insurance charges for extended hospital and skilled nursing facility stays;
* The Medicare Medical Insurance (Part B) premium, which is $45.50 per month in 1999;
* The $100 annual Part B deductible;
* The 20% co-insurance for services covered by Medicare Part B, depending on which doctor you go to.
If you qualify for assistance under the SLMB program, you will not have to pay the $45.50 monthly Part B premium.
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.
WHY BE IDENTIFIED?
by Karen Mayry
Photo: portrait. Caption: Karen Mayry
FROM THE EDITOR: Karen Mayry is the energetic President of the National Federation of the Blind of South Dakota. She was the first president of our Diabetes Action Network, when it formed in 1985.
Are you one of those diabetics who wishes not to have others know about it? Many of us have gone through that phase. Some of us change; we realize it is not fair to those around us to not know what might be happening, as we slip into an insulin reaction (low blood sugar) or head toward a coma. However, others—and certainly not just diabetics—carry no identification to alert those around us as to the nature of our difficulty. Of course, we want to be treated in proper manner if we are not able to communicate to others as to our needs. We need to get the message out, especially when we are in trouble.
What about medical ID? I feel that the use of a Medic-Alert necklace/bracelet is necessary to our well being. It is a natural symbol notifying others that we have special needs regarding our health. The Medic-Alert organization keeps an individual's personal medical history on file with a toll-free number to call engraved into the necklace or bracelet. Emergency room doctors, who may have never seen you before you arrive, unconscious, can call this number and access this information. It can help save your life.
I have several items listed on my necklace. They are: blind, diabetic, kidney transplant, taking steroids, my file number and Medic-Alert's phone number (1-800-344-3226; their address is: Medic-Alert, 2323 Colorado Avenue, Turlock, CA 95382). I feel it is vital to have this type of information in one's wallet or purse if not on one's person. If we attend a meeting where others are unaware of our condition, we are not only being unfair to ourselves, but to those around us who wish to help. They will be unable to obtain the best treatment for us, quickly, should we need it. Precious time will be wasted figuring out what happened. Let's help them by making a conscious effort to have with us at all times proper medical information.
ELECTRONIC AIDS
Sometimes there is no one nearby. What can you do if you head into a "low" and nobody is there to intervene? What if you need emergency aid, and you can't get to a phone? What if you don't want to have someone there to "keep an eye on you?" New technology allows you to wear a device, smaller than a pager, and push one button to summon aid if needed, 24 hours a day. Magnavox makes one, the "Personal Emergency Response System," marketed by American Secure Care, of Knoxville, Tennessee; telephone: 1-800-584-4176; website: http://www.magnavox-security.com (NOTE: American Secure Care has an affiliation with Medic-Alert, allowing emergency responders to access vital information even before the ambulance arrives!) Diabetics, seniors, people in wheelchairs, or with special health needs, might find this an option.
1999 National Convention
It will soon be time for the 1999 convention of the National Federation of the Blind, to be held, for the first time, at the Atlanta Marriott Marquis, 265 Peachtree Center Avenue, Atlanta, Georgia 30303. The Marquis is a beautiful hotel, in a convenient, central location.
Although Marriott has a national reservation number: 1-800-228-9290, do not use it. To receive our special rates, all hotel reservations must be made with the Marriott Marquis directly. Please telephone them at: (404) 521-0000, or write them at the address above. Be sure you tell them you will be attending the annual convention of the National Federation of the Blind. REMEMBER: No reservation will be valid unless it has been made directly with the Marriott Marquis Hotel in Atlanta. To confirm a telephone reservation, you will need a credit card number, and the reservation charge is $60, applied toward your stay.
Here are our hotel rates for 1999: one in a room, $57 per night; two in a room, $59; three in a room, $61; four in a room, $63. Local taxes will apply.
Here are the convention dates and schedule. Notice that we are slightly off from our usual schedule:
Wednesday, June 30 -- Seminars
Thursday, July 1 -- Convention registration
Friday, July 2 -- National Board Meeting (open to all)
Saturday, July 3 -- General Sessions
Sunday, July 4 -- Tour Day
Monday, July 5 -- Banquet
Tuesday, July 6 -- General Sessions, adjournment.
Our Diabetes Action Network Seminar
Our Diabetes Action Network will have its annual seminar and business meeting, on Friday, July 2, from 1:30pm to 4:30pm. For the keynote speaker, we are working on getting a podiatrist, to cover diabetic foot care. An open panel discussion will follow this presentation, covering all aspects of diabetes (including talking glucose monitors). Once again, we will have our "Make the President Pay" diabetes quiz game—and President Bryant says he will give a nice donation to the Division for each right answer! Our seminar is free and open to the public. Its location will be posted in the agenda (provided when you register).
The displays of new technology; the meetings of special interest groups, committees, and divisions; exciting tours; hospitality and renewed friendships; the solid program items; and the exhilaration of being where the action is and where the decisions are being made—all of these join together to call the blind of the nation to the Atlanta Marriott Marquis Hotel in July of 1999. Come and help make it happen!
ORAL DIABETES MEDICATIONS UPDATE
by Peter J. Nebergall, PhD
Photo: portrait, holding cat. Caption: Peter J. Nebergall
Currently there are an estimated 16 million diabetics in the United States. Perhaps 5 to 10 percent are insulin-dependent; the rest are type 2 diabetics, controlling their condition with diet, exercise, insulin, and oral diabetes medications.
"Oral diabetes medications" are not insulin pills; rather five classes of drugs designed to improve the body's utilization of what insulin is still present. These are: The sulfonylureas, repaglinide, metformin, troglitazone, and acarbose.
Most of today's "diabetes pills" are sulfonylureas, a class of chemicals that stimulate the pancreas to produce more insulin, effectively lowering blood glucose levels. Type 2 diabetics, those who need better management than diet and exercise can provide alone, often turn to these medications: tolbutamide, chlorpropamide, tolazamide, glyburide, glipizide, and new glimepiride, for effective self-management. The sulfonylureas are effective, but only so long as the pancreas maintains some of its insulin-making capacity.
But the sulfonylureas grow ever less effective with the passage of time. They drive the failing pancreas to greater effort, but the patient may well require ever-increasing doses. At some point, no further increase in medication will be effective; the pancreas isn't doing its job, and the patient needs to start injecting insulin. When the islet cells of the pancreas cease producing sufficient insulin, insulin must be injected.
Repaglinide (trade name Prandin), the second medication on our list, is a completely new chemical formulation. Prandin resembles the sulfonylureas in its mechanism of action, in that it stimulates the release of pancreatic insulin, improving blood sugar control (and is of no use in type 1 diabetes). But it differs from the sulfonylureas in several ways:
* Prandin is short-acting, with quick onset and fast excretion; allowing more freedom in the timing of meals (dosages can be taken 0 to 30 minutes before mealtime).
* Unlike the sulfonylureas, Prandin is excreted via the liver. Individuals with renal insufficiency (kidney disease) should use caution ("dosage for each patient should be individualized, to achieve optimal clinical response" says the manufacturer), but even ESRD, end stage renal disease, is not a contraindication for Prandin.
* Individuals with hepatic (liver) impairment should proceed with caution, and with longer intervals between dosages, as the drug will take longer to clear the body.
Metformin (trade name Glucophage), the third oral diabetes medication on our list, works to raise the body's sensitivity to its own insulin. Used for decades in Europe, it can be prescribed alone or with the sulfonylureas. Metformin helps the type 2 diabetic make better use of the insulin he or she has left. Like the sulfonylureas, it becomes useless when the pancreas ceases producing insulin.
Troglitazone (trade name Rezulin, from Parke-Davis) is the fourth oral medication. Rezulin directly attacks the problem of insulin resistance, the increasing inability to process insulin, that is the chief component of type 2 diabetes. In tests, Rezulin enabled many diabetics to reduce volume and frequency of insulin injections. A few were able to discontinue insulin injections entirely.
Initially, Rezulin was tested and approved for use with insulin-using type 2 diabetics. As tests continued, it became clear that it was also an effective blood glucose reducer, either alone (in combination with diet and exercise), or in combination with a sulfonylurea, for type 2 diabetics who did not need insulin (although not a replacement for the sulfonylureas). On August 4, 1997, the Food and Drug Administration approved Rezulin for these new uses. Other applications may well follow.
As with other oral diabetes medications, Rezulin's effectiveness depends on the presence of insulin. If sufficient insulin is not present, it must be injected, and Rezulin therapy will not change that fact. Where insulin supply rather than insulin resistance is the issue (as in type 1 diabetes), Rezulin therapy as yet offers nothing. Investigations continue. "Because of its mechanism of action," states Parke-Davis, "Rezulin is active only in the presence of insulin. Therefore, Rezulin should not be used in type 1 diabetes or for the treatment of diabetic ketoacidosis."
Published data state that although degree of renal insufficiency has no effect on Rezulin dosage, persons with hepatic (liver) disease should exercise caution, as there have been reports of individuals sustaining liver damage from this medication. Although statistical incidence is small, the potential is there—talk to your doctor. Parke-Davis (the manufacturer) now recommends regular testing of liver function, and cessation of Rezulin use if hepatic impairment is discovered.
Other data warn that in premenopausal anovulatory women, Rezulin therapy may result in resumption of ovulation, and risk of pregnancy. There is further recommendation to proceed with caution if the individual is taking antirejection drugs such as cyclosporine or tacrolimus.
Acarbose (trade name Precose, from Bayer), the fifth of the "oral meds" on our list, is completely different. A carbohydrase inhibitor, it temporarily suppresses the digestive enzymes which turn carbohydrates into glucose, slowing digestion and glucose absorption, keeping glucose levels more even. More a management tool than an antidote to insulin shortage, Acarbose helps some diabetics keep a more constant blood glucose level. A "temperamental" medication, it has many side effects, and is less than universal in its utility. New Glyset, from Pharmacia-UpJohn, appears to work in the same manner.
Problems
Unfortunately, oral medications are often eventually insufficient. Many type 2 diabetics, diagnosed as young adults, at first successfully control their condition with diet and exercise, but find they need the pills as they grow older. A number of years (and dosage increases) later, these diabetics have reached the limit of what oral medications can do for them; they are "maxed out," and really need to start injecting insulin. (Note: Regular, frequent blood glucose monitoring and HbA1c testing will show if you have reached the point where you should begin insulin therapy.)
Here we encounter what the drug companies call "psychological insulin resistance." Some of this is plain old fear of sticking yourself with needles—nurtured by memories from our childhood in the bad old days of dull-as-nails reusable syringes! Many men would rather face a bayonet. But some doctors contribute to the problem when they don't make it clear to the patient what the high glucose levels (consequent to remaining on now-useless oral medications) will bring in their wake, or worse, when they assume their patient would resist regular insulin injections—so they don't even suggest it. Yes, insulin is a powerful medication, with risks if used incorrectly—but what in this world DOESN'T have risks if used incorrectly? The risks of remaining on oral diabetes medications once pancreatic insulin has diminished or ceased entirely are far greater than the risks of taking insulin.
Oral Insulin?
Recent reports have mentioned insulin administration by mouth. The nature of insulin, and of human digestion, make oral administration of insulin ineffective for blood glucose management—the insulin is digested before it can reach the bloodstream. The oral insulin administration here noted is taking place as part of several diabetes prevention trials. In one example, individuals considered at high risk for developing diabetes (but not yet "diabetic") are given oral insulin in an effort to misdirect their body's autoimmune attack on the Beta cells of the pancreas. Oral insulin, very "investigational" at this time, is not currently an option for blood glucose management.
The Future
Researchers at Johns Hopkins are testing aminoguanidine, a new medication that may prevent or reduce some of the ramifications of diabetes. Amylin Pharmaceuticals (whose investigational injectable, pramlintide, may help type 2 diabetics), is testing Extendin-4, an insulin stimulant for type 2 diabetics (like the sulfonylureas), but one that appears to shut off its action during periods of hypoglycemia. Clinical tests are just beginning.
Swedish and American researchers are testing still another, APO A1 MILANO, that may help reduce diabetic heart disease. Inhaled insulin (for nasal administration) is being tested in the U.S. and U.K., and may someday supplant injection. Vitrase, from Advanced Corneal Systems, a drug that may help clear vitreous hemorrhage, is currently in FDA clinicals. Trental (pentoxifyline, from Hoechst Marion Roussel) is now available to treat "intermittent claudication," a painful circulatory ailment and frequent companion of diabetic peripheral neuropathy. Some doctors are prescribing the antidepressant Paxil or the antiseizure medication Neurontin to treat neuropathy symptoms. Avandia (rosiglitazone), new from Smith Kline Beecham, now in the final stages of FDA approval, is similar to Rezulin. ACE inhibitors, a class of blood pressure medications like Capoten (Captopril), have been proven to deter and retard diabetic kidney complications. Other oral medications are constantly being evaluated for possible diabetic applications, and some will make it to the pharmacy shelf. Change is coming quickly.
THE PUMP GIRLS
Photo #1: The four Pump Girls in cheerleading outfits; insulin pumps are visible on all four. Caption: The Pump Girls show their pumps.
Photo #2: The four Pump Girls in casual clothes at the beach, smiling. Caption: The Pump Girls.
FROM THE EDITOR: The Pump Girls are a southern California singing/dancing group on the Spice Girls Model. Their clean, catchy teen-beat party tunes deal with life, fun, boys, and living with diabetes. This makes them just a little bit different.
The four Pump Girls, Sara Cronstedt, Colleen Elizabeth Cottrell, Brittany Rausch, and Janelle Munion, do not look like crusaders. Ranging in age from 12 to 15, they look like what they are, California teenagers with common interests.
One of those interests is diabetes. The Pump Girls (who all have type 1) met at a diabetes camp sponsored by the diabetes support group PADRE (Pediatric Adolescent Diabetes Research and Education Foundation). They started singing together, and found they were good at it. Jackie Teichmann, executive director at PADRE, thought so too, and took the girls to a record producer, and the rest is history.
But that's not all of it! There are a lot of singers in southern California, but how many of them volunteer to donate a share of their record sales to charity? The Pump Girls (who take their name from the insulin pumps they wear to help manage their diabetes) are giving part of their profits to their own "Pump for a Better Life" fund, dedicated to assisting children around the world who are in need of insulin pump therapy, and whose parents can't afford the pump.
The Pump Girls are helping to spread the word. There have been insulin pumps for a number of years. Even the current Miss America, Nicole Johnson, is a diabetic and pump user. But a lot of people remember the complexity of early pumps, and there is a lot of reluctance to use this therapy with a child, or with an active teenager. The Pump Girls know from very personal experience what good control the insulin pump can bring—and, as Sara (age 14) says: "We're all about spreading diabetes awareness to other kids, other adults even, about insulin pumps, what they do for you, and how they make a big difference in your life."
Brittany, at age 12 the youngest Pump Girl, states: "There are a lot of kids who have really bad problems with diabetes, and we're trying to help them."
There is no better way to teach than by example. Janelle, at 15 the oldest Pump Girl, says: "I hope with the Pump Girls we can get out there and show how good we're doing, to show other teens, children, and even adults, as Sara was saying, how easy the pump is for better control and just better lifestyle." Quality of life.
How do the Pump Girls know what they're talking about? Experience. Janelle, the oldest, was diagnosed at age eight months. Brittany, the youngest, was diagnosed at the age of two. Sara was six; Colleen was seven. That makes 38 years of diabetes experience. And major studies in the U.S. and Europe have proved that good tight diabetes control, keeping your blood glucose as close to non-diabetic "normal" levels as possible, is the best way to deter diabetes complications, like kidney disease, nerve disease, and eye disease. Tight control takes frequent insulin administration, and the insulin pump can be the most convenient way to do just that. Pump Girl Colleen (age 13) says of her pump: "It keeps you on a regular lifestyle as opposed to the lot of shots you'd have to take..." Pumps work.
So do the Pump Girls. Since they started singing together (in February of 1998) there have been practice sessions, performances in Orange County (their home) and shows for diabetic groups. They recorded their first CD (more hard work with producers, engineers, and session musicians), and on March 9, they launched their "Whirl" tour (media stops, performances, and special events at children's hospitals and schools), kicking off with an event at Tower Records on Hollywood's Sunset Boulevard. As of press time, they are scheduled to appear in New York and Chicago, too.
We are expecting great things from the Pump Girls, and from the message they carry. If you want to hear their music, their CD (and cassette), titled "The Pump Girls," should be at major record outlets. For more information, see the Pump Girls website: http://www.members.home.net/ cottrell.11/pumpgirls/default3.htm
TALKING BLOOD GLUCOSE MONITORING SYSTEMS
by Ed Bryant
Artwork: NFB logo, in middle of article
Photo #1: meters. Caption: (L to R): Sure Drop (on Profile meter), Waco-U-Finger Guide, Smart Dot (on One Touch II meter).
Photo #2: finger guides. Caption: Modified LifeScan test strip guides.
As editor of VOICE OF THE DIABETIC, I am often asked about the relative strengths and weaknesses of the various voice-enunciation equipped home blood glucose monitors available today. Although individuals have their preferences, there is no "best" talking glucose meter; no one monitoring system is ideal for everyone. Features, prices, convenience, and clarity of instructions vary, and new equipment periodically appears.
Although many companies make blood glucose monitors, and some of these display their results in large print, only four currently available meters allow voice enunciation, in which the device's voice synthesizer "speaks" the meter's instructions and test results.
Highlights
My personal favorite is the Accu-Chek Voicemate. This talking meter, which incorporates the proven Accu-Chek Advantage into a system designed and built by Roche Diagnostics, is the most advanced on the market today, and the easiest for a blind person to use. Its new Comfort Curve test strip allows quick and reliable nonsighted placement of the blood sample. No more hanging drop of blood—just smear or dab it on; the strip sticks well out of the meter, and you just find the tactile cutout on the side. Even if you have fairly severe neuropathy in your hands, this feature should make it easy to find the blood placement spot. And blood never drips onto the meter—so there is far less need to clean it. Its voice is clear and understandable. The Voicemate includes two completely new features: A "code key" system for calibrating the meter to a new set of strips (no more numbers to punch in!), making this the only talking meter a blind person can calibrate without any sighted aid at all; and an insulin vial identifier. If you use Eli Lilly insulins, and they are new enough to be barcoded (1/2001 expiration date or later), insert them into the special opening, follow the spoken directions, and the machine will tell you what type of Humulin insulin you have there. (If your insulins are not barcoded, or not from Eli Lilly, the Voicemate's other features will still be completely operational.)
Past Boehringer-Mannheim meters (Roche has purchased B-M) were only available through company representatives. The new Voicemate can be ordered through any pharmacist. Have your pharmacist contact Roche Diagnostics; telephone: 1-800-428-5076, and ask for catalog #2030802.
The LifeScan One Touch meters: the Profile, and the now-discontinued One Touch II are often adapted to voice synsthesis. These two meters use the same procedures, the same test strips, and feature the same detachable test strip holder. Both require a "hanging drop of blood." Both meters are accurate, but their operating drill makes them difficult for some users. Both accept "talk boxes," but voice synthesizers designed for the One Touch II will NOT operate with the Profile and vice versa.
The "voice boxes," speech synthesizer modules that plug into the meter's data port and provide its voice, are NOT made by LifeScan, but by several competing firms, described below. These manufacturers have been producing voice units for the old One Touch II, and updated versions for use with the Profile. If you already have a LifeScan One Touch II or Profile, no modifications are needed to allow use of one of the speech synthesizers. If you do not yet own a LifeScan monitor, shop around, as some pharmacies and major discount stores sell glucose monitors substantially below list price.
Talking Glucose Monitors and Voice Boxes:
1.) The Accu-Chek Voicemate talking glucose monitor:
Roche Diagnostics Corporation, 9115 Hague Road, Indianapolis, IN 46250-0100; telephone: 1-800-428-5076.
The Accu-Chek Voicemate, developed in cooperation with Eli Lilly and Company, incorporates the Accu-Chek Advantage glucose monitor. The Voicemate is small, portable, and weighs only 12.5 ounces. It contains a "bar code reader" to describe insulin type (Lilly insulins only). First offered for sale in 1998, the Voicemate is supplied with a new test strip, the Comfort Curve, which vastly simplifies the problem of blood sample placement. Very good audiocassette and large-print instructions are supplied (in English). Suggested retail $495-$525, available through your pharmacist. Spanish-language customer service is available. Purchase price includes a carrying bag with adjustable strap.
2.) The Voice-Touch speech synthesizers, for the LifeScan One Touch II or LifeScan Profile:
Myna Corporation, 239 Western Avenue, Essex, MA 01929; telephone: (978) 768-9000.
Myna makes a pair of light, compact, convenient, and reliable glucose meter speech modules. The two models are not interchangeable. The Voice-Touch modules attach firmly to the meter, adding little bulk, and forming a single reliable unit. There are no separate switches to remember; the modules operate off the controls of the LifeScan monitor. The user may choose male or female voice enunciation. A Spanish-speaking Voice-Touch is now available.
The Myna Corporation offers the Voice-Touch speech synthesizers for $225 for One Touch II or Profile, the LifeScan meters alone for $135 (One Touch II) or $109 (Profile). An optional AC adapter is offered, as is a carrying case, $15 each. Myna's instructional cassettes and large-print instructions clearly explain the speech modules, but do not describe operation of the LifeScan glucose monitors.
The LifeScan One Touch meters and Voice-Touch speech synthesizers are also offered by the National Federation of the Blind (NFB), Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314. NOTE: The Materials Center is open 12:30pm to 5:00pm, weekdays, Eastern Time. The NFB offers the combination (One Touch II meter plus voice module) for $309 (the lowest price for a talking glucose monitor in the U.S.), the voice module alone for $189 (specify whether for One Touch II or Profile), or the glucose meter alone for $120 (one Touch II) or $135 (Profile). An optional AC adapter costs $12.
3.) The Digi-Voice modules:
Science Products, Box 888, Southeastern, PA 19399; telephone: 1-800-888-7400.
Science Products makes several versions of their robust and reliable Digi-Voice speech module: The Digi-Voice Deluxe, and the smaller Mini Digi-Voice. Voice boxes designed for the One Touch II will NOT operate with the Profile, and vice versa! The Digi-Voice modules connect to the meter by a 22-inch patch cord, providing audio output for its readings. Controls are simple; on the Deluxe a volume control knob and a toggle switch run the voice synthesizer, separate from the monitor's controls. The Mini's single button both turns on the voice box and adjusts the volume control, again, separate from the meter's controls. Readings are announced in a clear, somewhat military, male voice. Thorough cassette instructions explain the voice box and briefly cover the Profile meter (Science Products' instructional cassettes do not cover operation of the One Touch II glucose monitor). No large-print instructions are supplied. Science Products sells the Digi-Voice Deluxe module alone for $275, and the Mini Digi-Voice modules alone for $199 (9-volt battery) or $219 (with AC adapter). They offer the LifeScan Profile glucose monitor for $120. The One Touch II meter is no longer available.
4.) The LHS7 Module, a voice box for the LifeScan Profile:
LS&S Group, P.O. Box 673, Northbrook, IL 60065; telephone: 1-800-468-4789.
The small and light LHS7 attaches to the bottom of the Profile glucose meter by means of a Velcro patch, and operates through the meter's controls. Two-position volume control (loud and soft); AC adapter included in purchase price. English-language voice only; no audiocassette or large-print instructions are provided. Cost $199, or $313 with a new Profile meter.
5.) Connecting Cables for Adaptive Computers:
Blazie Engineering, 105 E. Jarretsville Road, Forest Hill, MD 21050; telephone: (410) 893-9333.
Users of Blazie's adaptive computers can connect these machines to the LifeScan One Touch II or Profile, by plugging into the meter's data port with the appropriate adaptive cable (such as the Blazie BNS-6). With the appropriate software (available free from Blazie; One Touch II users need no software) their computer will speak the LifeScan meter's commands and results.
6.) The Diascan Partner talking glucose monitor:
Home Diagnostics, Inc., 2400 NW 55th Court, Ft. Lauderdale, FL 33309; telephone: 1-800-342-7226.
The Diascan Partner is unique in that its voice synthesizer is internal, part of the meter itself. There is no separate speech module to attach or cords to plug in. This slim, "user friendly" unit allows somewhat more leeway in application of blood to test strip—with care, blood may be "painted" onto the strip; many other speech assisted units require a hanging drop of blood. Powered by two AA batteries, weight is approximately eight ounces, English or Spanish-language voice.
Some individuals with limited dexterity may find the Partner difficult to operate, as its test strips are designed to receive the blood outside the machine, on a flat surface like a table, so there is no strip guide to aid correct finger placement. Others may appreciate this feature, as it allows movement of strip to sample site, where others require movement of sample site to meter.
An over-the-shoulder tote bag with adjustable strap is included. Large-print and easy-to-understand audiocassette instructions (Note: No Spanish-language instructions; call Home Diagnostics for assistance) are also supplied. Suggested retail price is $399.
Medicare
Medicare recognizes home blood glucose monitors as "Durable Medical Equipment," and coverage is provided for diabetics, under Medicare Part B. Glucose meters without audio output have one specification on the "Fee Schedule" (EO607), and glucose meters with voice synthesis, or add-on voice boxes for home blood glucose monitors, have another (EO609) available to diabetics who are at least legally blind. Be sure to follow all guidelines for reimbursement.
An Invitation to Manufacturers
Currently available "talk boxes" (speech synthesizers) make use of the same "data port" installed in the meter to allow interfacing with and downloading to a computer. For many monitors, the hardware is already in place, and adding speech compatibility should be a simple process. The National Federation of the Blind urges manufacturers to go the rest of the distance, and make talking versions of their monitors available to those diabetics who need and want them. NFB Resolution 97-12 (adopted at the 1997 annual convention in New Orleans, Louisiana) calls on monitor manufacturers to make their meters speech-compatible.
Hints and Tips
If an insufficient amount of blood is placed on the test strip, most meters will indicate "not enough blood." You may even have to prick your finger again! There are several possible explanations for this frustrating occurrence:
A. The initial drop of blood was too small: Some folks don't bleed enough. They can get more blood by holding hands below waist level for about 15 seconds, shaking them, and/or washing/soaking hands in warm water for a few minutes before the test. Warm water stimulates the flow of blood to the fingers. A slightly longer lancet, with deeper penetration, may help some. "Milking the finger" (squeezing it gently) can also help, as can wrapping a doubled rubber band between the first and second joint of the finger to be lanced. This will help cause the finger to become engorged with blood. Hold the rubber band down with the thumb while lancing. REMOVE THE BAND AS SOON AS YOU LANCE.
Doctors and diabetes educators who treat heart patients have noted that "prophylactic aspirin therapy," an enteric-coated aspirin a day to thin the blood and reduce risk of a heart attack, makes it easier for their diabetic patients to obtain a blood sample. If you are a "difficult bleeder," the same therapy with enteric-coated aspirin might help you too. Be sure to talk to your primary-care doctor about aspirin, and to your eye doctor as well, because blood thinners like enteric aspirin can increase the risk of retinopathy.
B. There may have been enough blood, but it was placed onto the wrong part of the test strip: Some folks bleed fast, and may lose the blood off the finger before they're ready. By the time they get the finger to the test strip, the blood has fallen in the wrong place. A fast bleeder needs to work closer to the test strip, and perhaps to employ one of the blood placement aids discussed in this article. Users of the Diascan Partner should try bending up the tail of the test strip as an aid to location and placement. If you are new to your meter, I suggest you test in front of your diabetes educator, or someone familiar with your meter—perhaps there is some part of the drill you could do better.
C. Some enthusiastic people, placing the blood on the strip, press down too hard and push the blood out of its correct position, squishing it onto the wrong part of the strip: If you use the LifeScan One Touch II or Profile, it is best to very gently deposit a hanging drop of blood onto the test strip. Marla Bernbaum, MD, writing in "The ADEVIP Monitor," offered the following suggestion, pertinent to diabetics with severe neuropathy (who wouldn't feel the otherwise painful fingertip "stick" she discusses here):
I have discovered another way to apply blood to the LifeScan test strip, which has been useful for several of our patients. This method allows them to stick the tip rather than the side of the finger. We use the same platform modification [described below], with a dot of Hi-Marks or T-shirt paint on each side of the strip guide near the depression where the blood is to be applied. For this approach the meter should be turned sideways. The patient can then place the pad of the finger on the raised dot perpendicular to the length of the strip and rock the finger forward so that the tip of the finger lines up with the depression on the strip and deposits the blood droplet in the appropriate place. This method increases the portion of the fingertip that can be used, and is preferable for some patients, particularly for those who bleed slowly and therefore must place the blood drop in precisely the right location.
LifeScan Modifications
If you use any of the LifeScan "One Touch" series glucose meters, some blood placement problems can be solved by modification of the Test Strip Holder (LifeScan Part #043-123, and note this same part fits all LifeScan "One Touch" meters). The idea is simply to provide tactile locating aids for finger location and placement of the blood sample on the test strip. A raised dot on either side of the test strip will work for some, but diabetics with limited sensation in the fingertips may find a U-shaped guide more useful. Most diabetics puncture the side of a fingertip, but those with severe neuropathy, who can't feel the lancet, and who prick the center of the fingertip, may be helped by the U-shaped guide. With practice, and the use of such tactile cues, blind diabetics can correctly place blood samples on the test strip. (Editor's Note: Thanks to Ann S. Williams, RN, MSN, CDE, for providing the modified LifeScan Test Strip Holders shown here.)
The Test Strip Holder is detachable, and modifications as described will in no way interfere with the operation, accuracy, or cleaning of the LifeScan meter. LifeScan's Technical Services Department (phone: 1-800-227-8862) will provide a spare Test Strip Holder upon request, without charge. It is recommended that the modifications be to this spare.
The dots and U-shaped ridge were created with T-shirt paint, of the type that stands up sharply from a fabric surface. Upon application, the paint spreads a little, so apply sparingly. Best results come from "tack-painting," applying a small amount, then letting it dry (minimum 12 hours), with subsequent applications to build up the height. Practice first on some other material (posterboard or paper plate), as the paint can come out quickly. Be sure to have the Test Strip Holder OFF THE METER when applying the T-shirt paint. For best results, insert a test strip in the holder as an aid to placement of the dots or U-shaped ridge. T-shirt paint is inexpensive and is available at most craft and fabric stores. Although a full spectrum of colors is available, bright, contrasty colors like orange may aid in low vision situations. Brands and types vary; find one that gives you a nice hard tactile ridge. Some paints feel too rubbery. "Puffy paint" flakes off too easily. You may have to experiment.
Several vendors offer commercial alternatives to modifying the test strip holder. One slips over the LifeScan meter, and the other attaches directly to the test strip holder. Both devices aid in proper finger placement, and serve to guide the drop of blood more surely to the test strip. Science Products (address above, telephone: 1-800-888-7400), makes the Sure Drop, which slips over the body of the meter. The special Teflon-like coating on the surface of the device helps direct the blood, but can be damaged by bleach or a hard brushing—clean with mild soap and warm water. A Sure Drop made for the One Touch II will not fit the Profile, and vice versa. The unit for the Profile appears well-made and easy to use. Both units are priced at $24.95 each.
Smart Dot, 2655 West Central Avenue, Toledo, OH 43606; telephone: 1-800-984-1137. The Smart Dot clips directly to the test strip holder of the LifeScan One Touch II meter. This plastic platform is easy to clean and convenient to use, but there have been cases of it detaching from the meter in mid-test. Cost: $19.45.
Don Kramolis and Gary Allman, Blind Rehab Specialists (Manual Skills), at Waco VA Medical Center, Blind Rehab Clinic, Bldg. 7, BRU, 4800 Memorial Drive, Waco, TX 76711; telephone: (817) 752-6581 ext. 7489, have developed the Waco-U-Finger Guide, which, like the Smart Dot, fits any LifeScan Meter. Much like the T-shirt paint described above, the Waco Guide helps finger orientation. The guide's other features help tactile strip insertion. Its designers do not sell finished guides, but offer plans and advice to interested individuals.
I have discussed the strengths and weaknesses of the blood glucose monitoring systems with voice enunciation currently manufactured. This evaluation should help blind diabetics and those losing vision, who are just as capable as the sighted of independently testing their blood sugar levels, and performing all the other tasks of daily diabetes self-management. Both blind and sighted diabetics are encouraged to consult with their health care team, and with individuals experienced in use of glucose monitoring equipment.
Choosing the most appropriate home blood glucose monitor is an important step in diabetes self-management. As blind diabetics increase their participation in the mainstream, efficient glycemic control is needed to maintain good quality of life. The Diabetes Action Network of the National Federation of the Blind, a support and information network, welcomes your input on blood glucose testing.
DIABETES AND THE EYE
by David Harper, MD
As a diabetic, you will be aware of the changes that occur in the body of a person who has diabetes, as well as the specific tasks you must perform to properly control this disease. Even though we know the importance of these activities, we often take for granted the importance of sight.
A sight-threatening condition known as diabetic retinopathy affects a high percentage of diabetics annually. It is a disease that, if detected early enough, can be treated, and blindness may be prevented.
The Normal Eye
Our eye works very much the same way as a camera. When you take a picture, the lens of the camera focuses light through the front of the camera onto the film that is loaded along the back wall of the camera. Once the light hits the film, a picture is taken.
With regards to the human eye, light passes through the cornea, the clear outer layer of the eye. This light is focused by the cornea and the lens onto a thin layer of tissue located in the back of the eye called the retina. Once the light hits the retina, a picture is taken. This picture is transmitted to the brain through the optic nerve and transformed into what we see.
Diabetic Retinopathy
Diabetic retinopathy can be simply defined as changes in the blood vessels of the eye resulting from diabetes. The retina is filled with a series of tiny blood vessels that supply the oxygen necessary to maintain a healthy retina. Diabetes causes blood chemistry changes, such as high blood glucose levels that can damage these tiny blood vessels, reducing the supply of oxygen to the retina.
There are two stages of diabetic retinopathy; Non-proliferative Diabetic Retinopathy (NPDR, often called background retinopathy), and Proliferative Diabetic Retinopathy (PDR).
NPDR is the early stage of diabetic retinopathy. In this stage, the original blood vessels, once damaged, begin to leak fluid or blood into the retina. This small amount of blood or fluid may not affect your vision immediately—however, if left untreated, it could cause vision problems.
PDR is a more severe form of diabetic retinopathy. To compensate for the reduction in oxygen supply resulting from the damaged vessels, the retina may begin to grow new blood vessels. This process is known as neovascularization. These new blood vessels are weak and may eventually break, leaking a significant amount of blood into the vitreous, the clear gel that fills the back portion of the eye between the lens and the retina. This leakage of blood into the vitreous is commonly referred to as a "vitreous hemorrhage," and it typically compromises a person's vision.
Treatment of Diabetic Retinopathy
Research has shown that you can reduce the risk of developing diabetic retinopathy by controlling your blood sugar level. For those who have developed diabetic retinopathy, early treatment is very important. Diabetic retinopathy can be treated by laser surgery that uses a tiny laser beam to close off areas of the damaged retina, in order to stop the bleeding or development of abnormal blood vessels. This is performed in your ophthalmologist's office on an outpatient basis.
If significant bleeding has occurred and a vitreous hemorrhage exists, your doctor may not be able to view the retina, thereby restricting his/her ability to treat it with a laser. At the same time, your vision would be obstructed. Two options are available to you when this happens. You can wait for a period of time to see if the hemorrhage clears on its own (commonly called "watchful waiting"), or you can undergo a surgical procedure called a vitrectomy where the blood clouded vitreous is removed from the eye. Once this vitreous is removed, and replaced with a clear substance, the retina can be treated with a laser as described above.
Future Treatment Options on the Horizon
Many treatment options are currently being explored for the prevention and treatment of diabetic retinopathy and of conditions caused by diabetic retinopathy. Advanced Corneal Systems, Inc., of Irvine, California, is currently evaluating the use of an investigational drug, Vitrase™ (hyaluronidase) for ophthalmic intravitreal injection. A Phase III clinical investigational trial is currently underway in the U.S., to determine its safety and effectiveness in the clearance of vitreous hemorrhage. This investigational drug could potentially decrease the time that diabetics would have to wait for a hemorrhage to clear, and/or decrease the need for a vitrectomy procedure. Early studies have shown the drug to be well tolerated by most patients.
While this investigational drug looks promising, the best treatment is always prevention. People with diabetes should work with their health care provider to achieve good blood glucose and blood pressure control and have regular eye examinations in order to detect diabetic retinopathy at an early stage and initiate early treatment.
NEW NOVO NORDISK INSULIN ALMOST HERE
Novo Nordisk, a world leader in insulin and diabetes care, has been developing a new quick-acting insulin, to be known as Insulin Aspart in the U.S., and as NovoRapid elsewhere. Last August, NovoRapid was submitted to the European Medicines Evaluation Agency for review, and on September 16, 1998, Novo Nordisk submitted a New Drug Application to the U.S. Food and Drug Agency for Insulin Aspart.
Novo Nordisk describes Insulin Aspart as: "A rapid-acting insulin product that is intended for injection immediately before meals. As with any insulin, the dose and timing of doses depend on blood sugar level and known individual response to a given type of insulin. The rapid action of Insulin Aspart leads to significantly reduced variability in blood sugars compared to regular human insulin in the period immediately following a meal."
Specific details of this insulin's action, and how it differs from its competitors, will emerge once the FDA approval process is completed. Company documents state Novo Nordisk is developing "a series of insulin analogue products." Insulin Aspart is the first to appear.
BOOK REVIEWS
by Marilyn Helton
"Anna was striking. At 72, she was radiant and beautiful despite the wrinkles, the dependency on a wheelchair for mobility, and even the recent loss of a grandchild. Her tenderness and comfort with herself radiated to others beyond the cloak of an aging body. She did not dwell on the fact that she was unable to keep up with the rest of the group nor that she needed help with some of her diabetes self-care tasks. Her focus was on living the moment, enjoying the view, and experiencing a new adventure. Her acceptance of herself enabled her to go beyond any external limitations and events imposed on her."
Thus begins the first chapter of "Women & Diabetes," written by Laurinda M. Poirier, RN, MPH, CDE, and Katharine M. Coburn, MPH.
This beautifully painted illustration of health, wholeness and fulfillment reminds us that it is possible to live a rewarding life as a woman with diabetes. The predominant message throughout this encouraging book is that our state of wellness is determined by much more than the absence of illness.
"Women & Diabetes" speaks to women with any chronic disease, and especially to those of us who face the special problems of women with diabetes. Specifically, how diabetes (and the emotions that attend it) can complicate a woman's other natural concerns, like PMS, lactation, pregnancy, child raising, sex, and menopause. I especially liked the section on "Diabetes and Your Body, Mind & Spirit," which exemplifies how to listen to your body, as the tool you use to relate to the world; how your mind works in harmony with your body and spirit to make sense of it all; and how the spirit in which we feed our souls determines what frame of reference we give to our chronic condition. Poirier and Coburn show us in detail how it's possible to become whole, spiritually, emotionally, physically and socially, just by having to live with the daily challenges of diabetes.
"Women & Diabetes" acquaints us, in every chapter with REAL WOMEN who have REAL PROBLEMS. We all find bits and pieces of ourselves in the stories of Anna, Sara, Lucy, Brenda, Dorothy, Loretta, Hannah, and more. We are all different, yet we are all the same by virtue of our condition. By learning to listen to our bodies, feed our souls, deal with fear, create joy and affirm what we believe in, each reader, with or without diabetes, comes away with a special gift for herself. Highly recommended.
"Women & Diabetes," by Laurinda M. Poirier and Katharine M. Coburn, published by the American Diabetes Association, 1997, $14.95 ($13.95 ADA members). Call 1-800-232-6733 and ask for Item #4907-01.
"Caring for the Diabetic Soul: Restoring Emotional Balance For Yourself and Your Family," published by the American Diabetes Association, 1997. So many good books on diabetes from an emotional perspective: the thoughts, feelings and fears that must be faced every day by every diabetic, are finally beginning to surface in our bookstores and libraries. "Caring for the Diabetic Soul" is one of them.
Having diabetes presents more challenges than successfully managing your food intake. Stress, depression, parenting, self-blame, self-esteem, anger and just plain coping with an unpredictable, yet permanent condition, makes up the heart of "Caring for the Diabetic Soul." A quick read with many helpful ideas for coping with the psychological challenges of the disease, it includes a significant chapter on "Testing your Attitude" (Who is responsible for your diabetes? Your attitude can make all the difference). Solutions and simple exercises for relaxation are included, as well as what to expect from a diabetic support group, and how to start one of your own.
Each chapter of "Caring for the Diabetic Soul" was written by professionals whose lives have been touched in some way by diabetes—nurses, counselors, professors, doctors, and parents. Their personal experiences will touch you, too. Recommended reading.
"Caring for the Diabetic Soul," American Diabetes Association, 1997, $9.95 ($8.95 ADA members). Call 1-800-232-6733 and ask for Item #4815-01.
"The Diabetes Snack, Munch, Nibble and Nosh Book," by Ruth Glick, published by the American Diabetes Association, 1998. This reviewer is already familiar with other cookbooks Ms. Glick has authored or coauthored, including "100 Percent Pleasure" written with Nancy Baggett (Rodale 1994), and "Skinny Italian Cooking" (Surrey 1996). Not only were the foods delicious, the recipes were healthy! ("100 Percent Pleasure" was also named one of the 12 best cookbooks of 1994 by "USA Today".)
"Snack, Munch, Nibble and Nosh" features a large chapter filled with flavorful salads, ready to grab when you need an afternoon pick-me-up. You can prepare them ahead and keep them for several days in the refrigerator. Glick set a goal to expand consumption of vegetables and fruits (to five a day) by including them in a wide array of recipes throughout the book, and she has obviously succeeded!
Judicious amounts of reduced-fat and fat-free dairy products, such as Neuchatel (light) cream cheese, fat-free sour cream, and reduced-fat mayonnaise are recommended in many recipes, and her recipes, using tub-style margarine (defined as having no more than 4.5 grams of fat per tablespoon) are delectable. The author does include recipes using sugar, honey or molasses for sweeteners, since diabetes researchers have taken a closer look at sugars and concluded that, when counted as part of a regular meal plan and consumed with other foods, a moderate amount of sugar does not harm blood glucose control in people with either type 1 or type 2 diabetes.
Other special features of the book include recipes for one or two, as well as parties and crowds; snack ideas for hard-to-please kids (this is a very imaginative chapter); nutrient analysis, preparation times and exchanges with every recipe.
"The Diabetes Snack, Munch, Nibble and Nosh Book," by Ruth Glick, published by the American Diabetes Association, 1998, $14.95. Call 1-800-232-6733 and ask for Item #4622-01.
If you or a friend would like to remember the Diabetes Action Network of the National Federation of the Blind in your will, you can do so by employing the following language:
"I give, devise, and bequeath unto the Diabetics Action Network of the National Federation of the Blind, 1800 Johnson Street, Baltimore, Maryland 21230, a District of Columbia nonprofit corporation, the sum of $___________________" (or "___________ percent of my net estate" or "the following stocks and bonds:___________") to be used for its worthy purposes on behalf of blind persons."
RECIPE CORNER
Artwork: Fruits and vegetables
Send your great food ideas to the editor. Your recipes will be evaluated by dietitians, and if necessary, adjusted to make them more diabetically appropriate. Then he gets to taste them...
This issue, all of our recipes were provided by Marilyn Helton, editor of "Cinnamon Hearts," an upbeat magazine dedicated, among other things, to bringing joy to the diabetic diet. Contact: "Cinnamon Hearts DLE," PO Box 578340, Modesto, CA 95357-8340.
Parmesan Triangles
Try these crispy Parmesan snacks the next time your friends drop in.
Ingredients:
1 tbsp. olive oil
1 tbsp. water
1 garlic clove, minced
1 tsp. Italian seasoning
25 wonton wrappers, cut in half to form triangles
2 tbsp. grated Parmesan cheese
Instructions:
Preheat the oven to 400F degrees. Spray a large baking sheet with nonstick spray coating. Set aside. In a small bowl, stir together the oil, water, garlic, and Italian seasoning. Set the wonton wrappers on the baking sheet in a single layer. With your finger, spread the oil mixture over the wonton triangles. (If the mixture begins to separate, stir again). Sprinkle with the cheese.
Bake for 3 to 4 minutes until the triangles have crisped. Cool in pan on a wire rack, or serve warm. Triangles will keep for up to a week in an airtight container.
Yield: 10 Servings, 5 pieces each. Per Serving: 61 calories; 2g total fat; 9g carbohydrates; 4mg cholesterol; 111mg sodium; 2g protein; 1g dietary fiber. Exchanges: � Starch/Bread, � Fat.
Just Peachy Oat Bran Muffins
From the "Cinnamon Hearts" kitchen. Betcha can't eat just one!
Ingredients:
1 cup all-purpose flour
� cup whole wheat flour
� cup oat bran
2 tsp. baking powder
� cup brown sugar, firmly packed
1 tsp. ground cinnamon
1-1/2 cups dehydrated peaches, chopped & packed
1 large egg white (approx. 2 tablespoons)
1-1/4 cups lowfat (2%) milk
2 tbsp. vegetable (canola) oil
Instructions:
Preheat oven to 350F degrees. Spray a 12-cup muffin tin with vegetable spray, or line with 2-1/2-inch muffin cups.
In a large bowl, stir together flours, oat bran, baking powder, sugar and cinnamon. Add chopped peaches and stir until evenly distributed. In a medium-sized bowl, beat egg white, milk and oil until smoothly blended. Add milk mixture to flour mixture and stir just until dry ingredients are evenly moistened. Do not over-stir! Bake in preheated oven until muffins are well-browned, about 30 minutes. Serve warm or cool.
Yield: 12 Muffins. Per Serving (1 muffin): 176 calories; 3g fat; 4g protein; 33g carbohydrates; 1mg cholesterol; 105mg sodium. Exchanges: 1 � bread, � fruit, � fat.
Lamb & Green Bean "Stew"
This meal-in-a-dish is more the consistency of a soup rather than a stew. Delicately perfumed with cinnamon and a hint of allspice, its Mediterranean flavor has been a Helton family favorite for years. Serve over steamed rice, and complete the meal with a full-bodied bread or rolls.
Ingredients:
1 � pounds boneless lamb stew meat, cut in 1-inch cubes
2 tbsp. butter or margarine
2 medium-large onions, cut into thin wedges
1 � tsp. seasoned salt, such as Morton "Nature's Seasoning"
� to 1 tsp. cinnamon
� tsp. allspice
1 � pounds fresh whole green beans, ends snapped and broken into 1 inch pieces
2 cups water (a little more if needed)
Instructions:
String and break green beans into 1-inch pieces; wash, drain, and set aside. In a 4-quart Dutch oven or soup pot, brown cubed lamb in butter or margarine; add onion wedges and saute until yellow and soft. Add seasonings.
Combine beans with meat and onion mixture and stir well. Cover, reduce heat and simmer for 15 minutes. Add water and cook over low heat approximately one hour, or until meat is tender. Turn into a large vegetable dish or casserole and serve over rice.
Yield: 6 Servings. Per Serving (without rice): 199 calories; 5g total fat; 27g carbohydrates; 12g protein; 27mg cholesterol; 426mg sodium. Exchanges: � starch/bread, 1 meat, 3 � vegetables, � fat.
Deep Dish Pizza
From "Cooking Healthy & Fast," by Rachel Rudel, RD, 1994. (Rachel Rudel is a frequent contributor to "Cinnamon Hearts.") To order her cookbook, call 800-428-8309 during business hours, Monday-Friday.
Ingredients:
1 pound loaf frozen white or wheat bread dough 1 tbsp. vegetable oil (canola or olive oil)
8 ounces part-skim mozzarella cheese, shredded
8 ounces lean ground pork, browned
� cup chopped onion
� cup chopped green pepper
1 (8 ounce) can sodium-reduced tomato sauce
� tsp. garlic powder
� tsp. fennel seed
� tsp. pepper
1 tsp. basil
1 tsp. oregano
� tsp. sugar
Instructions:
Thaw frozen dough the day before in the refrigerator, or oven-thaw. To oven-thaw, preheat the oven to 200F degrees. Turn oven off. Place oiled bread dough in oiled 15x8-inch or 12-inch round pan. Cover with a towel and leave for 45 minutes in the preheated oven. Work thawed dough to the edges of the pan and part way up the sides. Sprinkle first with cheese, then browned pork, onions and peppers.
Combine tomato sauce with seasonings and pour over all. Bake at 450F degrees for 40 minutes, or until edges are browned and the middle has risen. Remove from oven and allow to stand for 10 minutes. Cut and serve. Freeze or refrigerate leftovers (if there are any!)
Yield: 12 (1 slice) Servings. Per Slice: 229 calories; 10g fat; 22mg cholesterol; 293mg sodium. Dietary Exchanges: 1 � bread/starch, 2 lean meat, 1 fat.
Grand Marnier Morning Pie
Another sweet success from the Cinnamon Hearts kitchen. Consider it as a side dish for your Easter brunch menu. What better way to get your protein?
Ingredients:
2 cups low fat cottage cheese
1 tbsp. orange juice
3 eggs, OR � cup liquid egg substitute
2/3 cup granulated sugar
2 tbsp. all-purpose flour
1 tbsp. fresh orange peel, grated (1 tsp. dry)
1 tbsp. Grand Marnier liqueur, OR 1 tsp. Grand Marnier flavoring, OR � tsp. orange extract
� cup low fat or all-fruit orange marmalade for topping
Instructions:
In blender container, beat cottage cheese on high speed for one minute. Add eggs, sugar, flour, orange juice and Grand Marnier liqueur or flavoring. Blend well. Gently fold in the grated orange peel.
Pour mixture into a 9-inch, deep dish pie plate which has been sprayed with vegetable coating. Bake for 50 minutes, or until a knife inserted near the center comes out clean. Cool and refrigerate overnight. Serve chilled the next morning. Garnish with a twist of orange peel or all fruit orange marmalade.
Yield: 8 Servings. Per Serving: 167 calories; 2g fat; 9g protein; 28g carbohydrates; 50mg cholesterol (much lower if you use egg whites); 245mg sodium. Exchanges: 1 � lean meat, 1 � starch/bread.
COOKING WITH SUZI
by Suzi Castle
Artwork: paper sack, overflowing with groceries, at the end of a rainbow
Salads make great warm-weather meals. But watch out for high-fat salad dressings and ingredients. They can turn a healthy dish into a fat- and cholesterol-laden, high-calorie disaster. Instead, choose low-fat and fat-free ingredients such as fat-free cheeses, cooked chicken and turkey breast and lean ham. Your local deli can supply many of the ingredients, a great time-saver for the cook. Some supermarkets even have the ready-made fruit, gourmet lettuce, and vegetable salad mixtures. Add your own low-fat or fat-free dressing! For a quick, delicious low-fat warm-weather meal, try this:
Spa Pasta Salad
Ingredients:
� cup reduced-fat mayonnaise
� cup fat-free Italian salad dressing
1-1/2 teaspoons Original Blend Mrs. Dash seasoning mix
10 ounces dry tricolored rotelle pasta, cooked according to package direction
8 ounces cooked chicken or turkey breast, cut into � inch cubes
1 medium carrot, peeled and thinly sliced
� cup each: chopped celery and sliced green onion
1 cup sliced fresh mushrooms
1 cup broccoli florets or fresh Chinese pea pods (or use � cup of each)
Cherry tomatoes and lettuce leaves
Instructions:
Mix mayonnaise with salad dressing and Mrs. Dash. Mix gently with cooked pasta, chicken, carrot, celery, green onion, mushrooms, broccoli and/or pea pods. Serve on lettuce leaves and garnish with cherry tomatoes cut in half.
Yield: 6 servings. Per serving: 289 calories (15% from fat); 13.4g protein; 4.8g fat (0.77g saturated fat); 44g carbohydrates; 421mg sodium; 25mg cholesterol; 3.54g fiber. Exchanges: 1 lean meat, 3 bread.
Suzi Castle's "Deliciously Healthy Favorite Foods Cookbook" is available now in (or can be ordered at) most bookstores or by calling 1-800-444-2524. For an autographed copy, please send a check or money order to Health Cookbooks, RR 4 Box 208, Porterville, CA 93257 ($14.95 + $3.95 S&H).
LETTERS TO THE EDITOR
Artwork: Quill writing pen in an ink well
January 11, 1999
Thank you so much for your VOICE OF THE DIABETIC newspaper. I am a nurse doing education for patients with a diagnosis of diabetes. Your paper helps me and them very much. We also distribute it in our Diabetes Support group. We all enjoy the inspirational stories. It helps to know we are not alone!
Thank you,
Marion Dawe, RN CETN
Georgetown Memorial Hospital
Georgetown, SC
* * * * * * * *
January 15, 1999
The VOICE OF THE DIABETIC is an excellent newsletter. I have learned lots from your articles and letters. My patients enjoy the copies that I can provide, through you, in our waiting area.
Thanks again,
Denise K. Costa
Major, Army Nurse Corps
Adult Nurse Practitioner
Enterprise, AL
* * * * * * * *
January 29, 1999
I would like to help in the distribution of the magazine VOICE OF THE DIABETIC. I myself do not have diabetes, but have a lot of it in my family. I have learned a lot from reading the magazine and hopefully will help myself and others from getting diabetes. It's a great magazine full of information, and I like the recipes and the humor! I have worked in the home health field for the last 20 years and know many people who would benefit from this magazine. I would like to put this magazine in all of our doctors' and dentists' offices, libraries, hospitals, and any place that provides reading material to people.
Please send me 100 copies to start and I will let you know if I need more or less. Thanks again for a great magazine.
Gail Carriere
Massena, NY
* * * * * * * *
February 16, 1999
I picked up my first VOICE from my eye doctor's office—it was fantastic! It answered a lot of questions and addressed many of my concerns about diabetic retinopathy. Keep up the good work! And, thank you!
Sharon Kapsa
Shelby Township, MI
We welcome your comments and suggestions to create a better VOICE. Address all correspondence to Editor: VOICE OF THE DIABETIC, 811 Cherry Street, Suite 309, Columbia, MO 65201-4892.
WORD SEARCH PUZZLE
by Denise R. Depillars
EDITOR'S NOTE: Denise R. Depillars is a Continuous Ambulatory Peritoneal Dialysis (CAPD) patient. She shares her puzzle with VOICE readers.
Consult the "Word List" below. To solve the puzzle, search in all directions (forward, backward, and diagonal). Some letters will be used in more than one word. Once you locate a word on the puzzle, circle each one of its individual letters (not the word). Once you have found all the words, the left-over letters will reveal the hidden message.
KIDNEY CONCERNS
N E P H R O L O G I S T U B E
B A C C E S S A R E S R U N N
L M R A N D B C A P D A V I I
O I T P A B U N V E I N S A H
O F A I L U R E I L N S A R C
D A P L L D I E T D S P A D A
P T E K I D N E Y E E L A E M
R I A L F E E L D E R A H S Y
E G N A H C X E S N T N U H S
S U D N W E I G H T H T A E D
S E O E S N I M A T I V O L T
U B C M T L A S L L I P O L E
R O T I S I I S E S A E S I D
E X O A E E R A C H T L A E H
P E R I T O N E A L F L U S H
WORD LIST:
access, air, anemia, arm, bag, blood pressure, box, BUN, CAP, CAPD, death, diet, disease, doctor, drain, exchange, failure, fatigue, feel, fill, flair, flush, gravity, health care, insert, IV, kidney, machine, meal, needle, nephrologist, nurse, pad, peritoneal, pills, pole, renal, salt, shared, shunt, tape, test, transplant, tube, veins, vitamins, volt, weight
Hidden Message: DIALYSIS
(NOTE: This puzzle appeared in "Common Concerns," Vol. 6, No. 1. Reprinted courtesy of the author.)
WHAT YOU ALWAYS WANTED TO KNOW BUT DIDN'T KNOW WHERE TO ASK
(Resource Column)
Artwork: Hand pulling a book from a shelf of books.
Inclusion of materials in this publication is for information only and does not imply endorsement by the Diabetes Action Network of the NFB.
NUTRITION SUPPLEMENT
Your insulin or oral diabetes medications are only part of your diabetes self-management. Although food supplements do not replace your medications, and the U.S. Food and Drug Administration has not evaluated their efficacy to prevent or treat any disease, a healthy diet is important, and research is continuing on the role specific supplements may play in controlling diabetes. AlphaBetic Multi-Vitamin Supplement is a food supplement formulated for the special needs of diabetics. A blend of vitamins, antioxidants, and minerals, it is available in sugar-free caplets. Contact: Abkit, Inc.; telephone: 1-800-226-6227; website: http://www.alphabetic.com
TALKING COMPUTERS
Henter-Joyce, Inc., maker of the "JAWS" series of computer screen readers, offers screen-to-speech software such as JAWS For WINDOWS (JFW), the new MAGic 6.1 screen magnifier, and tutorials on cassette for programs like Internet Explorer and Microsoft Word 8. Find out more at their website: http://www.hj.com, or contact them for information: Henter-Joyce, Inc., 11800 31st Court North, St. Petersburg, FL 33716; telephone: 1-800-336-5658; fax: (813) 803-8001; e-mail: [email protected]
DIABETES SUPPLIES
Can-Am Corporation carries a full line of discount-priced diabetes supplies, including: Dex-4 glucose tablets, skin cream, and the Monoject line of insulin syringes and lancets. Many Can-Am products are also sold as "house brand" at major pharmacy chains. Their low price in no way compromises their high quality.
For information, contact: Can-Am Care Corporation, Cimetra Industrial Park, Box 98, Chazy, NY 12921-0098; telephone: 1-800-461-7448.
DIABETES SUPPLIES
American Diabetic Supply, Inc., will ship your diabetes supplies to your door. They handle all insurance claims and provide free delivery. Folks with Medicare and/or private insurance (no HMOs) may receive supplies with no further cost. For information, contact: American Diabetic Supply, Inc., 400 S. Atlantic Ave., Suite 108, Ormond Beach, FL 32176; telephone: 1-800-453-9033.
NEW TALKING BLOOD GLUCOSE MONITOR
Roche Diagnostics has developed a new talking blood glucose monitor. Based on the proven Accu-Chek Advantage meter, the new Accu-Chek Voicemate provides the following: Clear, high-quality speech synthesis, talking the user through preparations, test procedures, and results, without the need for sighted assistance; an "insulin vial identifier" which reads Eli Lilly insulin vials and speaks their type, as a safety aid in tactile insulin mixing; a new, improved, "touchable" test strip—the Accu-Chek Comfort Curve (no more "hanging drop of blood!); no meter cleaning required; and a new "code-key" system for programming test strip codes. The Voicemate is the most "blind-friendly" talking glucose monitor available today, and the only one whose regular operations require no sighted assistance at all.
The Voicemate comes with an adjustable over-the-shoulder carrying case, with meter, voice box, battery, adapter cord, 10 Comfort Curve strips, earphone, insulin check-vial, manual and quick-reference guide (in print), and instructions on audiocassette. Also included is the Accu-Chek Softclix lancing device, and a packet of 10 lancets. The new meter (catalog # 2030802) can now be ordered through any pharmacy (suggested retail price $495-525). Have your pharmacist contact Roche Diagnostics, 9115 Hague Road, Indianapolis, IN 46250; telephone: 1-800-428-5074.
WINDOWS SCREEN READER
GW Micro now offers WINDOW-EYES for WINDOWS 98, a screen reader program that also supports Microsoft WINDOWS 3.1 and WINDOWS 95. Once equipped with a voice synthesizer such as the Dectalk (your standard soundcard won't do), any computer that can run WINDOWS can run WINDOW-EYES. A free demo disk is available, or you may download the demo program from the Internet. The WINDOW-EYES program is available from: GW Micro, 310 Racquet Street, Fort Wayne, IN 46825; telephone: (219) 489-3671; fax: (219) 489-2608, e-mail: [email protected]; website: http://www.gwmicro.com
OWEN MUMFORD PRODUCTS
Owen Mumford, Inc. is the American arm of British medical supplies manufacturer Owen Mumford Ltd. Along with its eye-care aids (the Autodrop and AutoSQUEEZE), to make administering eyedrops easier and more consistent, the firm makes insulin pens (the Autopen), lancing devices (the Autolet), automatic injection devices (the Autoject) and more! To find out more, contact: Owen Mumford, Inc., 849 Pickens Industrial Drive, Suite 14, Marietta, GA 30062; telephone: 1-800-421-6936.
DIABETES SUPPLIES
Diabetic Supply Distributors, Inc., helps you save four ways with your diabetes supplies:
1. Insurance billing. They file the claim, and they pay for delivery. No advance payment needed—and THEY do the paperwork.
2. Medicare billing. Medicare pays for approved diabetes supplies, (and, since last July that list has covered type 2 diabetics!). Diabetic Supply will handle the details.
3. Free, fast home delivery. Your order comes quickly to your door.
4. Friendly personal service. You're not talking to a computer.
Contact: Diabetic Supply Distributors Inc., PO Box 1820, Laurel Springs, NJ 08021; telephone: 1-800-962-8098.
COMFORTABLE SOX
If you have diabetes, you are at risk for foot complications. Thick, comfortable socks can help protect your feet against injury, and can cushion injured feet against aggravation.
We have been asked to announce: TheraSocks, from TheraFoot Technologies, offer comfortable fit and friction reduction, along with the latest fibers to keep your feet dry and bacteria-free. They are available in several styles; prices start at $11.95 a pair. For information, contact: TheraFoot Technologies, Inc., 200 West 18th Street, Newton, NC 28658; telephone: 1-888-466-0001.
ELECTRONIC EMERGENCY WARNING DEVICE
Today, many people with diabetes, or with other conditions that might require emergency response, live alone. If they require aid, but are unable to get to a telephone to summon it, they might wait hours to be found. They could wait too long.
For a long time, people in such a situation didn't have many alternatives. They could continue to gamble that there would be no emergencies, or they could move, to live with family members, or in a nursing home facility.
Now there is another choice. The Magnavox SecureWatch is smaller than a pager, designed to be worn like a pendant. Pushing one button triggers an alarm, which alerts monitoring specialists (on call 24 hours a day) who will immediately summon the emergency responders.
American SecureCare (who administers this device) is now affiliated with MedicAlert, so now your emergency medical information can be in the doctor's hands—even before you are. For more information, call: 1-800-518-9422.
DIABETES SUPPLIES
Preferred RX offers three ways to help you save on diabetes supplies and prescription drugs:
1. Insurance billing. They file the claim, handle the paperwork, and pay for delivery. No advance payment needed.
2. Medicare billing. Medicare pays for approved diabetic supplies (and starting July 1 that list will cover type 2 diabetics!). Preferred RX will handle the details, and pay for delivery.
3. Discount Prescription Club. No insurance? No prescription drug coverage? Preferred RX offers discounts at over 36,000 pharmacies nationwide. Contact: Preferred RX, 34208 Aurora Road, Suite 132, Solon, OH 44139; telephone: 1-800-843-7038; website: http://www.preferredrx.com
FREE DIABETES LITERATURE
The National Federation of the Blind maintains an extensive literature collection, with free materials on many subjects available in a variety of formats. The articles listed below make up one part of the collection, the "diabetes" category:
"Insulin Measurement Devices," "Diabetic Peripheral Neuropathy," "Diabetics, Don't Give Up on Braille," "How I Went Blind...And Then What," "Review of Oral Diabetes Medications," "Preventing, Minimizing, or Delaying Kidney Failure," "Impotence, and How to Prevail," "Can I Eat Sugar?," "Cardiovascular Health: Bypass May Be Better for Diabetics," "Arthritis and Diabetes: A Common Association," "Blind Diabetics Can Draw Insulin Without Difficulty," "New Dietary Guidelines for Diabetes Management," "Keeping Your Feet," "What Is Diabetes Mellitus?" "Talking Blood Glucose Monitoring Systems," "Diabetic Eye Disease," and "Kidney Failure, Dialysis, and Transplantation."
These articles are available in large print and four-track 15/16 IPS audiocassette for the blind (all the diabetes articles are on one tape). All are free of charge. To order, or to request a complete NFB literature catalog, contact: NFB Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314. The Materials Center is open 12:30pm to 5:00pm, EST, weekdays.
FOOD FOR THOUGHT
Artwork: Dancing fruits and vegetables
We invite blurbs and tidbit articles for inclusion in this column. Materials received may be edited and used as space permits. Products and services included in this column are for information only and do not imply endorsement by the Diabetes Action Network of the NFB.
NEW VIDEO FOR KIDNEY PATIENTS
"CHOICES: Options for Living With Kidney Failure" is a new patient education video from Baxter Healthcare, aided by the American Association of Kidney Patients. It offers advice from people who have faced renal failure, and who play active roles in their own care, determining what treatment options are most suited to them and to their lifestyle. The video is now available for rent at Blockbuster Video stores nationwide.
HEAR YE, HEAR YE, A RAFFLE
The Diabetes Action Network of the National Federation of the Blind reaches out and provides support and information to thousands of people. Because it costs to operate this valuable network and to produce the VOICE OF THE DIABETIC, we must generate funds to help cover these expenses. Our Diabetes Action Network has elected to hold a raffle, which will be coordinated by our division treasurer, Bruce Peters.
THE GRAND PRIZE WILL BE $500! The winning ticket will be drawn, and the winner's name announced, on July 5, 1999, at the banquet held during the annual convention of the National Federation of the Blind.
Raffle tickets cost $1 each, or a book of six may be purchased for $5. Tickets may be purchased from state representatives of our Diabetes Action Network or by contacting the VOICE Editorial Office, 811 Cherry Street, Suite 309, Columbia, MO 65201; telephone: (573) 875-8911. Anyone interested in selling tickets should also contact the VOICE Editorial Office. Tickets are available now! Names of persons who sell 50 tickets or more will be announced in the VOICE.
Please make checks payable to the National Federation of the Blind. Money and sold raffle ticket stubs must be mailed to the VOICE office no later than June 10, 1999, or they can be personally delivered to Raffle Chairman Bruce Peters, at this year's NFB convention in Atlanta, Georgia. This raffle is open to anyone age 18 or older, and the holder of the lucky raffle ticket need not be present to win. Each ticket sold is a donation, helping keep our Diabetes Action Network moving forward.
NEW DISPOSABLE INSULIN PEN
Eli Lilly and Company announces a new product: the Humulin and Humalog Pens. These are disposable, prefilled syringe devices, each holding 300 units of Humulin 70/30, Humulin N, or quick-acting Humalog insulin. These pens (which require detachable pen needles such as the Becton Dickinson Insulin Pen Needles, sold separately) adjust in single-unit increments, with an audible click for each unit. They also have a clear plastic barrel, and a magnifying dose window to help show the exact dose.
Insulin pens have their strengths and weaknesses. They offer undeniable dosing convenience, but make precise insulin mixing difficult. Talk to your health care team about whether an insulin pen is the best choice for you. For more information about the Humulin and Humalog Pens, contact Eli Lilly; telephone: 1-888-885-4559; website: http://www.humulinpen.com
ON THE LIGHTER SIDE
from Col. David Hackworth, US Army (Ret.)
Try not to dwell upon these too much. You may need an aspirin.
Only in America...does a pizza get to your house faster than an ambulance.
Only in America...are there handicap parking places in front of a skating rink.
Only in America...do people order double cheese burgers, a large fry, and a diet coke.
Only in America...do banks leave both doors open and then chain the pens to the counters.
Only in America...do we leave cars worth thousands of dollars in the driveway and leave useless things and junk in boxes in the garage.
Only in America...do we use answering machines to screen calls and then have call-waiting so we won't miss a call from someone we didn't want to talk to in the first place.
Only in America...do we buy hot dogs in packages of ten and buns in packages of eight.
Only in America...do we use the word "politics" to describe the process so well: "Poli" in Latin meaning "many" and "tics" meaning "blood-sucking creatures."
INDEX OF SUPPORT GROUPS
Have you ever wished to join a support group in your community? There are millions of support groups, covering a tremendous number of topics—but where is the one you need, in your community? The American Self-Help Clearinghouse, a national non-profit organization, offers an index of such groups, indexed by region and by topic. You can access this index by phone: (973) 625-9565; e-mail: [email protected]; on the World Wide Web: http://www.cmhc.com/selfhelp; or by mail (send self-addressed, stamped envelope): American Self-Help Clearinghouse, Northwest Covenant Medical Center, Denville, NJ 07834. The Clearinghouse has also published a book: "The Self-Help Sourcebook: Your Guide to Community and Online Support Groups," priced at $10, available at the above address.
REPORT MEDICARE FRAUD
If you receive Medicare, you need to inspect your receipts, to make sure the bills reflect services you actually received. Sometimes unscrupulous providers try to take advantage, and inflate prices, or bill for services never delivered. If you find such a charge (they DO happen!), and you can't resolve it with your Medicare contractor, report it! Call the Medicare Fraud Hot Line: 1-800-447-8477. Remember, you're part of the team.
IN MEMORIAM
On September 17, 1998, our National Federation of the Blind Diabetes Action Network lost a friend and long-time leader. Cheryl McCaslin Smith died that day, of complications from diabetes mellitus and diabetes insipidus.
Originally from Iowa, she spent most of her working life in Texas, where she was a teacher and librarian. An active member of the National Federation of the Blind for more than 22 years, she was part of our Division since the very beginning, and for many years served as our Resource Librarian.
Our condolences to her husband Lyn. Cheryl will be missed.
WHAT IS DIABETES INSIPIDUS?
As if the types and terms of diabetes mellitus were not enough to remember, there is an unrelated medical condition also called "diabetes." This is diabetes insipidus.
Diabetes insipidus (DI) results from the body's inability to properly retain and concentrate urine, so the kidneys just keep flushing it out. The word "diabetes" in this case refers to the very rapid flow of water through and out of the body. The sufferer's urine is almost colorless and odorless. Unlike the more common diabetes mellitus, this condition does not alter blood glucose levels.
The cause of this incontinence is in the pituitary gland, located in the brain. Normally the pituitary secretes a hormone called vasopressin, which acts on the kidneys to retain water, allowing concentration of urine. If this hormone is absent or in short supply ("central cranial DI"), or if the kidneys fail to respond to its commands ("nephrogenic DI"), large volumes of dilute urine will be passed.
Although the impact of diabetes insipidus is benign (provided one ingests enough fluid to replace urinary losses), such is not always possible. When a person with DI is unable to ingest sufficient fluids, severe dehydration can result.
Central cranial DI can be treated with DDADP (desmopressin acetate antidiuretic replacement therapy), administered by nasal spray.
Diabetes insipidus is fairly rare, and is unrelated to diabetes mellitus, but one can have both conditions. Of course men who have unexplained urinary incontinence should consult their doctor, as prostate difficulties can cause some of the same symptoms.
FREE RESEARCH INFORMATION
Joslin Diabetes Center is one of the most famous names in diabetes research and treatment. This institution has been involved in major research for more than 50 years. Now, Joslin offers a free 20-page report on the latest in diabetes research and its implications, written in plain language, for you to share with your doctor. To obtain this summary of current diabetes research, send your name and mailing address to: Joslin Diabetes Center, One Joslin Place, Boston, MA 02215; Attn: Communications Department; telephone: (617) 732-2415. Or you can e-mail them (with your postal address in the message) at: [email protected]
SEEKING COMMUNICATION
We have been asked to announce: Ria Meade knows all human beings have feelings. She does not believe illnesses or complications should limit one's life. Diabetic 33 years, blind for the last 16, with a kidney transplant in 1985, she lives independently. She'd like to communicate, to start a dialog, with others facing the same issues, of bias, hesitancy, limitation... Contact: Ria Meade, 13 Locust Avenue, Port Washington, NY 11050; telephone: 516) 883-0251.
A NAME EXPLAINED
If you've ever examined any U.S. government documents relating to diabetes, you may have seen that they came from the Centers for Disease Control, Division of Diabetes Translation. The "centers" part is clear, of course, as many different institutes make up this facility, but what about "translation?" The CDC explains that "The `translation' part indicates that the primary focus is the translation of scientific data and information to daily practice."
GLUCOSAMINE CAUTION
It is always important to consider how medications you may be taking might interact with each other. Make sure your doctor knows all the pills you're taking—even those you bought at the Health Food Store. There are many meds you should not mix! For example, glucosamine, an over-the-counter medication sometimes used to reduce arthritis pain, is known to increase insulin resistance. As insulin resistance is the primary symptom/root cause of type 2 diabetes, if you have diabetes, you need to steer clear of glucosamine. Nobody needs to make themselves sicker.
ELECTIONS COMING UP
At this year's national convention in Atlanta, Georgia, elections will be held to fill our Diabetes Action Network divisional board positions. These are one-year terms, running from July 1, 1999 to June 30, 2000. Positions to be filled are: President, First Vice-President, Second Vice-President, Secretary, Treasurer, and two Board Members-at-Large. If you are interested in a board position, or know someone who you think would do a good job, then contact our Diabetes Action Network President, Ed Bryant. Yes, hard work and dedication are prerequisites for board positions—but one must lead by good example.
BOARD MEMBERS
The Diabetes Action Network of the National Federation of the Blind.
President: Ed Bryant—Columbia, MO
First Vice President: Janet Lee—Cedar, MN
Second Vice President: Sandie Addy—Prescott Valley, AZ
Secretary: Sally York—Castro Valley, CA
Treasurer: Bruce Peters—Akron, OH
Board Member-at-Large: Gisela Distel—Albany, NY
Board Member-at-Large: Eric Woods—Denver, CO
PLAN AHEAD AND BE PREPARED
At this year's annual convention of the National Federation of the Blind, there will be many insulin-dependent diabetics in attendance. Each of us should have the foresight to bring extra insulin and syringes so as to avoid needing to search for a pharmacy.
At every convention, a few diabetics undergo avoidable hypoglycemic attacks. Hotels are jammed, and restaurants are packed, with long waits for a table. We diabetics should always be prepared for an insulin reaction. THINK AHEAD! Always carry something sweet, such as candy or glucose tablets, that can be used for reactions. We should be sure to have, in our rooms, snack foods to help control our food needs.
We diabetics can travel anywhere and do almost anything we want, except go without food. Our bloodstreams should have a balance of insulin and glucose. If there is not enough glucose (food), then we have an insulin reaction.
"Plan ahead and be prepared."
THE SPEECH EXPRESSOR
Users of talking-book machines and tape players that have a variable speed control have known for years that they can comprehend audio material (recorded speech) at a faster rate than normal spoken speech. Thus many people speed up their taped books and magazines, to save time. Unfortunately, running an audio recording at faster or slower than normal rate will change its pitch.
Some readers find this pitch change irritating, but up to now, there has been nothing to do about it. That has changed.
The American Printing House for the Blind announces the Speech Expressor, a device that allows you to shift the pitch of a signal such as a taped voice. If you speed up the playback, the pitch will rise, but then you can use the Speech Expressor to drop the pitch again, without slowing the now-faster conversation. Used with any variable-speed speech device (including the National Library Service Talking Book Player), the Speech Expressor turns that fast, squeaky chipmunk-voice into something still fast, but more normal (Note: If you hook it to the radio, you can change the pitch, but it will not alter the speed of speech). For information, or to order (cost is $125), contact: American Printing House for the Blind, 1839 Frankfort Avenue (PO Box 6085), Louisville, KY 40206-0085; telephone: 1-800-223-1839; website: http://www.aph.org
ARTICLES NEEDED
If you have diabetes, are a family member or friend of a diabetic, or a health professional with an interest in diabetes, we invite you to submit an article for publication in the VOICE OF THE DIABETIC.
Our philosophy regarding diabetes is positive. Do you have an inspiring, enlightening story? We, the Diabetes Action Network of the National Federation of the Blind, seek to show people they are not alone, and do have options, regardless of diabetic complications. If you have experienced ramifications, others, who may be facing the same side-effects, could benefit from what you have to say.
Perhaps you have not experienced complications—your unique insight, coping strategies, and lifestyle can still inspire others. Are you a relative, a friend, or a health professional? More than 243,445 VOICE readers could benefit from your story.
For information and article submission guidelines, contact: VOICE OF THE DIABETIC, 811 Cherry Street, Suite 309, Columbia, MO 65201; telephone: (573) 875-8911.
VOICE DISTRIBUTORS NEEDED
Since the VOICE is now offered free, our Diabetes Action Network will provide extra copies to anyone wanting to help spread the word. We will gladly send from five to five hundred-plus copies each quarter to be used as free literature. Medical facilities can order as needed for patients. Individuals can usually place copies of the VOICE in libraries, pharmacies, hospitals, doctors' offices, or other public locations.
Diabetes education is essential. Anyone who distributes the VOICE will be helping people with diabetes, and their families, to learn about the disease and its ramifications; to learn that they have options; and that their world is far greater than whatever "limits" may be imposed by the disease. If you would like to help spread the word by distributing the publication, please contact: VOICE OF THE DIABETIC, 811 Cherry Street, Suite 309, Columbia, MO 65201; telephone: (573) 875-8911, fax: (573) 875-8902. Please provide a phone number so we can reach you.
SUBSCRIPTION/DONATION FORM
The VOICE OF THE DIABETIC is a quarterly magazine published by the Diabetes Action Network of the National Federation of the Blind (NFB) for anyone interested in diabetes, especially diabetics who are blind or are losing vision. An outreach publication, it emphasizes good diabetes control, diet, and independence.
Donations are gladly accepted and appreciated. Contributions are not only tax deductible but are needed to keep the VOICE and the Diabetes Action Network moving forward to help people with all aspects of diabetes.
Members of the NFB Diabetes Action Network enjoy priority services and unique benefits such as a continuous free subscription to the VOICE, automatic access to committees covering all aspects of diabetes, free counseling concerning all facets of blindness and diabetes, as well as access to diabetics who have experienced complications.
The VOICE is free to any interested person upon request. Each subscription costs the Diabetes Action Network approximately $20 per year. To help defray publication expenses, members are invited, and nonmembers are encouraged, to cover the subscription cost.
To begin receiving the VOICE, please check one:
[ ] I would like to become a member of the NFB Diabetes Action Network and receive the VOICE OF THE DIABETIC. (Members are entitled to special benefits.)
[ ] I would like to receive the VOICE OF THE DIABETIC as a nonmember. (Nonmembers are encouraged to pay the institutional rate of $20/one year; $35/two years; $50/three years.)
Send the VOICE in (check one):
[ ] print [ ] cassette tape for the blind [ ] both
and physically handicapped
(recorded at slower-than-
standard speed of 15/16 IPS)
Optionally check this box:
[ ] I would like to make (or add) a tax-deductible
contribution of $__________ to the Diabetes Action
Network of the National Federation of the Blind.
PLEASE PRINT CLEARLY
Name:_____________________________________________________
Address:__________________________________________________
City:_______________________ State:______ Zip:__________
Telephone: ( )________________________
Send this form or a facsimile to:
Voice of the Diabetic
811 Cherry Street, Suite 309
Columbia, MO 65201
Telephone: (573) 875-8911
Fax: (573) 875-8902
Please make all checks payable to:
NATIONAL FEDERATION OF THE BLIND
END of VOICE OF THE DIABETIC, Volume 14, Number 2, Spring Edition 1999