VOICE OF THE DIABETIC
The Diabetes Action Network of the National Federation of the Blind
Diabetes Support and Information
Volume 20, Number 1, Winter Edition 2005
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VOICE OF THE DIABETIC, published quarterly, is the national magazine of the Diabetes Action Network of the National Federation of the Blind. It is read by those interested in all aspects of blindness and diabetes. We show diabetics that they have options regardless of the ramifications they may have had. We have a positive philosophy and know that positive attitudes are contagious!
News items, change of address notices, and other magazine correspondence should be sent to: Ed Bryant, Editor, VOICE OF THE DIABETIC, 1412 I-70 Drive SW, Suite C, Columbia, Missouri 65203; Phone: (573) 875-8911; Fax: (573) 875-8902.
Find us on the World Wide Web at: (www.nfb.org) Our direct Web address is: (www.NFB.org/voice.htm)
Copyright (c) 2005 Diabetes Action Network, National Federation of the Blind. ISSN 1041-8490
Note: The information and advice contained in VOICE OF THE DIABETIC are for educational purposes, and are not intended to take the place of personal instruction provided by your physician, or by your health care team. Discuss any changes in your treatment with the appropriate health professionals.
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Please Note: We have a special bulk-mailing permit that we use to ship the VOICE to you at low cost - it does not allow for free re-mailing. The Post Office requires you place first class postage on any VOICE you mail to others.
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Here's the new front cover page for the VOICE.
Includes photo of Vanesa Sutherland with following overprinted on the photo: Vanesa Sutherland says, "We Have a Future."
WHAT CAN YOU DO?
Jean King Writes about Self-empowerment
BEGINNING CARB COUNTING: TEN COST-CUTTING TIPS
Linda Ruholl, RN, PhD, Shows Us How
NEW DIABETIC NEUROPATHY MEDICATION
Cymbalta Receives first FDA Approval for This Use
INSULIN-FREE!
Transplant Surgeon, Dave Sutherland, Discusses Pancreas and Islet Transplantation
DIABETES, HEART ATTACKS, AND STROKE
Ann Williams, RN, MSN, CDE, Discusses the Cardiac Complications
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INSIDE THIS ISSUE
WE HAVE A FUTURE
by Vanesa Sutherland...
SO WHAT CAN YOU DO?
by Jean king...
NEW DIABETIC NEUROPATHY MEDICATION...
READ THE LABEL CAREFULLY...
INSULIN-FREE: PANCREAS AND ISLET TRANSPLANTATION TO TREAT TYPE 1 DIABETES
by David Sutherland, MD, PhD...
AN ASPIRIN A DAY...
BEGINNING CARB COUNTING: TEN COST-CUTTING TIPS
by Linda Ruholl, RN, PhD...
REFLECTING ON OBESITY
by Peter J. Nebergall, PhD...
OPENING BLIND EYES TO SCIENCE...
KIDNEY DISEASE: WHAT CAN YOU DO?
by Ed Bryant...
MEDICARE THERAPEUTIC SHOE PROGRAM...
ANONDYNE THERAPY AND DIABETIC PERIPHERAL NEUROPATHY
by Angie Bowman, PT; Kim Hamel, OT; and Linda Hicks, BSN,
MS, CDE...
DIABETES, HEART ATTACKS, AND STROKES
by Ann Williams, MSN, RN, CDE...
DIABETES: FIRST IMPRESSIONS
by Fred MacDonald...
A WORTHWHILE BOOK
by Peter J. Nebergall, PhD...
DEALING WITH DIABETES DAY-TO-DAY
by Emily Gaines Buchler...
ASK THE DOCTOR
by Wesley W. Wilson, MD...
NEW TREATMENT FOR DIABETIC FOOT ULCERS
by Stephen A. Brigido, DPM...
LIVING WITH DIABETES 50 YEARS
by Pat oswald...
AMPUTATION DUE TO DIABETES CAN BE PREVENTED...
HEALTHY HOME COOKING
by JoAnna Lund...
RECIPE CORNER...
BOOK REVIEWS
by Marilyn Helton
DIABETES: WHERE WE ARE TODAY, WHERE WE WILL BE TOMORROW
by Frank Vinicor, MD, MPH and Jinan Saadine, MD...
RESOURCE ROUNDUP...
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WE HAVE A FUTURE
By Vanesa Sutherland
From the Editor: When I interviewed Vanesa Sutherland, I found her to be extremely knowlegable about pancreas and kidney transplant. Mrs. Sutherland has experienced some of the complications of diabetes, and will explain her organ transplant. Here's what she says:
Every time I consider my experience with diabetes, I see two open ends of my life, and a perpetual question. Neither the beginning (the diagnosis), or the end (the pancreas transplant) are closed points. As time goes by, and medicine finds more answers and explanation for both diabetes and transplantation, I am able to look in a different way at the same facts. As for the perpetual question, "Did you really take care properly of your diabetes/transplant?" -- I think I did, many times; it did escape from my hands at other times, but I always tried.
We were living in Mexico City at the time I was diagnosed. It did not come as a total surprise; a year before, when we were in Colorado, my blood sugar test came back abnormally low. Now, it was ostensibly high -- but as I still had positive c-peptide levels, the physician put me on oral hypoglycemic medication. A year after that, at age five, I was in a pediatric hospital in Mexico, dehydrated, and in a typical diabetic coma. That year, 1969, I started insulin. With no known family history of diabetes type 1, and no understanding of autoimmunity or the possible triggers of autoimmunity, my parents and younger brother and sister became a "diabetic family."
It was not easy growing up with diabetes. I wanted to be like my peers; but many of my teachers were aware of the diabetes and kept a good eye on me, to the point that in elementary school, my physical education teacher kept me from doing sports, to avoid hypoglycemia. Understandably, I was not very thrilled to share that I was diabetic, for fear I'd be treated differently, or prevented from the activities everybody else had access to. So diabetes became something I tried to keep to myself. But it was impossible; everybody around me knew. I am so happy things are more open now, and people in general have a better understanding.
We moved to Puerto Rico, and adolescence came, with its pulsating hormones making diabetes harder to control. Lows and highs were common, and the frustration of trying to stay in the normal glucose range I tried to offset with excelling as a student and a friend, seeking the company of people with whom I did not need to preamble as a diabetic. So that was my perception.
Back in Mexico, I went to college, did my graduate degree and work, with more ups than downs with respect to diabetes. I followed the changes in dietary and insulin treatment proposed by many endocrinologists, from the typical diabetic diet to eating normally, to adjusting my insulin, to treating complex carbohydrates as a "privileged" food; from urine sugar tests to several blood tests, to just two blood tests; from one daily insulin injection to one of NPH adjusted by R insulin, or just R with meals.
For several years, every time I injected myself, part of the insulin (who knows how much?) went out of my skin. Later on I was told that I had developed antibodies to the beef and pork from which those insulins derived.
I have in the back of my mind a faint impression of preparing for a test, and hearing in the news about pancreas transplantation -- while the University of Minnesota's aerial profile showed up on the TV, and a reporter emphasized the shortcomings of such a big surgery and a life on immunosuppression. I recalled thinking: "I am not there yet, and they are not yet there, either." Little I knew that some years after, I would need the University Hospital, need the publicized procedure, and I would call Minnesota home.
Less than nine years later, I found myself flying to New York, to meet my mother, and to have a bilateral vitrectomy. Things did not go as expected; I lost depth perception and a great deal of visual acuity. With time and eye exercises, I have gained some back, but some is lost.
At age 27 I was back with my very supportive parents in Puerto Rico, after quitting a wonderful, fulfilling job, my apartment, my friends and the boyfriend I thought I would marry someday. I spent long hours trying to see better, trying to read, making a word of fragmented letters. My parents and family helped me, and my ability to read was regained. I lost some vision but I still work on my standard computer and enjoy reading and traveling .
Five years after my vision problems, my kidneys failed. I found myself on dialysis, desperately trying to control my blood sugar. Useless were the several graphs and tables depicting food consumed, insulin taken and blood sugars; the endocrinologist just shook her head and told me again, "I do not know what to do with you." Not that I had not heard that before, but now I was on dialysis and my idea of having some worthwhile future was vanishing despite my best efforts, despite my best will. Not knowing that in spite of timely strict control some people are more susceptible than others to develop diabetic complications, I felt guilty and ashamed, not comprehending how other diabetics, who behave less carefully, walk through life practically unscathed.
Then a transplant surgeon who had trained at the University of Minnesota told me I should think about having a pancreas and kidney transplant. He gave me about 15 or 20 names of transplant centers throughout the nation. I wrote to every one of them, read all the information received and decided Minnesota was the best option.
In May 1995, my parents and I came to the University of Minnesota to see (at that time) Dr. David Sutherland (today I lovingly call him Dave; he will not like it another way, but that is now). On August first, the same year, my mother and I were in the preparation room just about to have surgery. She, lovely and beautiful as she is, offered to me not just one of her kidneys, but also half a pancreas. In that moment I reiterate how much she loves all of us, and that she has been my closest partner in diabetes, and in all the complications I had. Today, she is in perfect health, and strong and beautiful as ever.
All the organs worked right away, but I got a disease of the kidney induced by one of the drugs, and my stay in the hospital was protracted. I think Dr. Sutherland got tired of having the same feature in the ward, and asked me to write a computer program for internal organ allocation. After that, which I finished out of the hospital, several other projects followed, for the Diabetes Institute for Immunology and Transplantation, which he directs at the University of Minnesota. Among those projects, and many other ones we have today, we got married (to each other).
Finally that kidney failed, due to the harshness of the drug-induced disease and other factors. I spent some time on dialysis, as because of my high percentage of antibodies (due to a failed transplant and transfusions) I could not get a kidney from the National Waiting List.
Then my aunt (my mother's sister), with her endless generosity and care for her family, gave me one of her kidneys. During the ordeal the half-pancreas my mother donated to me has survived and kept me off insulin.
As you can see by now, I have a lot of people to thank; some I have mentioned, others still remain in my pen (read keyboard) and heart, nevertheless, the idea that we people need to support and get support from each other has been a determinant one in my life. Things have changed in the Fairview-University Transplant Center; they are getting better, the people are very knowledgeable but overall just good people.
Sometimes when peoples' health has deteriorated, for whatever reason, they get sad and depressed, because they feel they cannot get out of the quagmire. They feel like they're in a labyrinth. I have learned there is always a way to get out of that feeling. The participatory part, by the patient, is really important, to look for other options and ask yourself if a particular step is for you.
There is a lot of information available, to help you. We, who suffer such a complex condition, should try to obtain it. Just going to one doctor, or one center, is not enough. Get second opinions. Use the Internet. We need to educate ourselves. By the way, our transplant center has a website for those interested in pancreas or islet transplantation: (www.diabetesinstitute.org). It is an extremely good website, very valuable.
I have a pancreas transplant, actually half a pancreas, from a living donor. Not many people have half. The pancreas actually has two functions. One is to help the intestine with digestion; the other function is insulin production. The beta cells, in the islets of Langerhans scattered throughout the pancreas, are the ones responsible for insulin production. The islets, interspersed in the pancreas, accounts for 2% of its total weight.
In the 1960s and '70s, surgeons worked on transplanting just the islets, but also realized, at the time, that a complete pancreas transplant presented less obstacles, and they focused on making it work. Islet transplantation was a less invasive procedure for the patient; but a lot of problems in separating the islets from the rest of the pancreas needed to be solved. In addition, the immunosuppression regime, the series of drugs available to keep the body from rejecting the transplant, were too harsh for the survival of the new islets by themselves; in fact, they were, and some (still used today), are diabetogenic.
Nevertheless people kept working with the islets. A few, like Dr. David Sutherland, worked on both pancreas and islet transplantation. In the early '90s, the islet transplant outcomes at Minnesota were quite successful in some cases, but some of the promising immunosuppressive drugs used were later withdrawn from the market or, like dioxyspergualin, licensed by the FDA.
From the mid-90s to now, Dr. David Sutherland and Dr. Bernard Hering, at the University of Minnesota, worked on the clinical side of islet transplantation. Which drugs should be used? In what amounts? Is it possible to attain tolerance, so drugs are not needed? They studied ways to inject islets into the portal vein or other sites. They have tried to use pork islets (xenotransplantation) to make up for the shortage of human islet cells. Successful use of animal islet cells could open transplantation as an option to almost every individual afflicted who wants to trade in diabetes for immunosuppression.
As of right now, there are de facto restrictions on islet cell transplantation. One is insurance coverage; another is that the FDA is very cautious, especially with biological products. However, for diabetics whose kidneys have failed, Medicare is preparing to pay for an islet as it now does for a pancreas transplant. Some insurances cover pancreas transplant alone in diabetics whose kidneys are functioning. I have no doubt that very soon after clinical trials show islet transplants to be efficacious and safe, the insurance situation will change. We have a present. We really do have a future.
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SO WHAT CAN YOU DO?
by Jean King
I recently called the talking book library and requested an inspirational book that would help me with the task of being legally blind. I received a book the next day. The writer, an elderly, retired columnist of some sort, recounted for me the problems he faced, and documented all the things his wife did FOR him.
At first, I had wished for such complete custodial care.
I had already known those things this man spoke of, but I dutifully finished the book, boxed it up, and promptly sent it back. Then I wheeled myself out onto our beautiful deck and had a good cry.
I could have generated these emotions on my own. I had not needed the book I had spent my day reading. Then, I felt anger at the time and energy wasted in this effort to be "fixed." While I was atoning for my anger, it occurred to me: Since I hadn't found inspiration, I wondered if, perhaps, I might have it to GIVE.
Up to now, I have not shared my experience. I have guarded my feelings just in case they might not be "legitimate." But now I will share them.
Twenty-some years ago, when I was in my forties, my feet began to give me trouble. I did not have diabetes, but I had all the symptoms of peripheral neuropathy. My first task, it soon was apparent, was to convince the medical establishment, and their psychological cohorts, that my pain was not "all in my head."
That done, I traipsed to the major medical clinics, confirmed my own diagnosis, and discovered there was little else to do. I finally accepted reality and went about experiencing the painful loss of real sensation in my feet and legs. (It has since moved on to my hands, face, and gut, but is, somehow, not very relevant to the real living of my life anymore.) It just is part of my reality.
The nerve loss in my feet was taking away the long hikes in the Colorado mountain foothills and impeding my ability to drive, even with the hand controls I used at that time.
Reading was becoming increasingly difficult. I had read constantly since before I started school, so I thought perhaps I should cut back on what could be "over-use of my eyes." It did not help.
My ophthalmologist recognized the problem. Over the years, we had not much discussed my macular degeneration, but in 1992, she sent me off to another specialist, her friend, who specialized in low-vision problems, and she broke the news that I was now "legally blind."
There were not many choices left to make. I had already given up my driver's license. I was NOT ready to give up being a public school teacher.
Registration with the state department of vocational rehabilitation was a given. The staff valiantly attempted to find a means for me to continue teaching. My husband cooperated in every way. Nothing worked. I said goodbye to my last
student. I went home to accept my new situation and to mourn.
My husband returned to work. At home, I huddled under an afghan that my mother had crocheted for me long ago. I could not cry. I huddled. My dog, Daisy,a Cairn terrier, cocked her head and watched my behavior in dismay. She chased her tail in a futile attempt to get me to go for a walk. Then,when I laid down completely, she leaped up and settled herself ON TOP OF ME to wait. She sighed ... and waited. She waited for months. I dwelt on all the things that I could NOT do. Still, she waited.
Finally, my sluggish mind wandered. It wondered: what CAN I do?
If I could find my shoes, I COULD venture outside for Daisy. She was at the door, watching, waiting for me.
While I waited for her, I could see a tall weed in my Columbine garden. I COULD sit on the ground and pull it. I COULD.
I COULD scoot over a bit and reach another. I COULD. They needed water. I COULD.
That night, I met my husband at the door with a grin that he had almost forgotten. I COULD. Daisy smiled with my husband.
Each day, Daisy helped me find things that I COULD do. She smiled again as she got her first good hair brushing in a year. I could smile, too. I COULD.
My emotional and physical pain is not what I need to share with you. We are the experts of what is our own. What I want to give you are the things I learned while dwelling on the things I had lost. You will not have time to do that job yourself once you realize that you, too, CAN do.
In your own life, as you know, you will suffer losses, through aging, perhaps diabetes, peripheral neuropathy, macular degeneration, or some of the other ills of mankind. Whatever those losses are, I ask you to face them. Look at whatever it is in the light of reality. Look it over good. Get to know exactly what you have lost. ACCEPT IT. Mourn it thoroughly, but don't take too long. Life is short.
Then, ask yourself a question: What CAN I do about this condition, now that I have just accepted it? The keyword here is CAN. Don't waste your time on the reverse. Find one thing that you CAN do -- and act on it. Another "I can" WILL follow. If it is slow to appear, do the first "can" again while you wait. Celebrate it.
There might be something else you can do. Think about it; be creative. Hand controls on my car allowed me to keep driving, for a time, in spite of neuropathy and numbness in my feet. Another example: I now read books on tape. I didn't quit reading -- I switched. And, I recorded my own favorite recipes on tapes, while I still could read print. Then we found new measuring cups made for folks with limited vision, at a discount store. We marked the temperature settings better on my oven control -- and I was a cook again!
DO EVERYTHING YOU CAN THINK OF TO HELP YOURSELF. THEN, DROP IT. If there becomes more you can do, you will think of it. DO IT and move on.
Mantra for dealing with loss: FACE THE LOSS. MOURN THE LOSS. DO EVERYTHING YOU CAN DO TO MITIGATE THAT LOSS. LOCATE THE HELP YOU NEED AND ASK FOR IT. ACCEPT THE HELP, GRACIOUSLY. MOVE ON.
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NEW DIABETIC NEUROPATHY MEDICATION
One of the most common complications of diabetes is diabetic neuropathy, diabetes-induced damage to the nerves that run throughout the body, connecting the spinal cord to muscles, skin, blood vessels, and other organs. Diabetic neuropathy can be painful and disabling. Fortunately, the severest forms of neuropathy do not occur often.
Some symptoms of peripheral neuropathy (so named because it occurs outside the brain and spinal cord) occur when the nerve conduction is lost, such as muscular weakness, loss of feeling, even loss of functions not normally under conscious control, like digestion. These neuropathy symptoms include prickling, tingling, burning, aching, or sharp jabs of needle-like pain. This pain can be severe and incapacitating. Or, there can be complete numbness. Different types of neuropathy symptoms can occur together. It is common to have pain even though many fibers have been lost.
What Causes Neuropathy?
Researchers do not yet know what specifically causes diabetic neuropathy. Glucose control seems to play a prominent role -- as neuropathy is more likely to affect people who have had diabetes for a long time or whose glucose control is poor.
Neuropathy can be prevented, slowed, or diminished, in some cases. The Diabetes Control and Complications Trial studied complications in people on tight glucose control and those using regular diabetes treatment. Only one-third as many people in the tight-control group got neuropathy as in the standard-treatment group. In addition, avoiding alcohol and cigarettes will probably help protect your nerves from damage and prevent against neuropathy.
Treatment for Neuropathy
Researchers are still looking for a way to heal nerves damaged by neuropathy (see Anodyne Therapy article in this issue). Right now, most treatment aims to relieve the painful symptoms of neuropathy.
The U.S. Food and Drug Administration (FDA) recently approved the first treatment specifically for pain associated with diabetic neuropathy. This chemical, Eli Lilly's Cymbalta (duloxetine hydrochloride) is already in world-wide use as a treatment for depression. It targets two chemical messengers in the body, serotonin and norepinephrine, believed to play a role in pain perception. Other antidepressants, not approved by the FDA for this use, are also employed, "off label," to relieve nerve pain -- but Cymbalta is the first to be fully tested by the FDA for this use and found effective. For more information about Cymbalta (which is available now) talk to your doctor, telephone the Lilly Answers Center: 1-800-545-5979, or visit (www.lilly.com), or (www.cymbaltanews.com)
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READ THE LABEL CAREFULLY
From the Editor: The following medication errors took place in a professional setting. Doctors, pharmacists, and medical staff made them. But, just as when we make errors ourselves, it is the patient who winds up with the wrong medication. This time, no one got hurt, but we can't depend on luck. You need to know what you're taking, how much you're taking, and what each pill is supposed to do. And, you have both the right and the obligation to question your doctor, nurse, and pharmacist when something you take gets changed. Ask! You'll be safer.
The following is reprinted from ISMP MEDICATION SAFETY ALERT!, Vol. 9, Number 20, October 7, 2004, published by the Institute for Safe Medication Practices. Used with permission.
A family practice physician in a community health center prescribed metformin 500 mg bid to a newly diagnosed diabetic man from India, who did not speak English. When the patient returned to his office a few months later, he brought his medications with him, as requested. His physician quickly noticed that metformin was missing. Instead, the patient had a prescription bottle labeled as metronidazole with directions to take 500 mg twice a day. The prescription had been refilled several times. Luckily, the patient's diabetes remained stable, and he seemed to suffer no adverse effects from two months of unnecessary antimicrobial therapy.
The physician notified the pharmacy of the error and asked the pharmacist to check the original prescription, which had been written clearly and correctly for metformin. Upon further investigation, the pharmacist found the computer entry screen for selecting these medications included METF (for metformin) and METR (for metronidazole).
Apparently, one of the pharmacy staff members had entered MET and selected the wrong medication that appeared on the screen.
In another community pharmacy, the same mix-up happened twice, one day apart. In one case, metformin was initially dispensed correctly, even though the prescription had been entered incorrectly as metronidazole again, when the wrong mnemonic was chosen. The pharmacist who filled the prescription clearly understood that the physician had prescribed metformin, so he filled the prescription accordingly. However, he failed to notice the order entry error, as he did not compare the prescription vial label to the drug container label.
Unfortunately, the initial order entry error led to subsequent erroneous refills of metronidazole, as stated on the label. In the other case, bulk containers of the medication were available from the same manufacturer, both with similar highly stylized labels. Thus, confirmation bias contributed to staff's selection of the wrong drug. After reading, the staff member believed he had the correct drug.
In a hospital pharmacy, metronidazole 500 mg and metformin 500 mg were accidentally mixed together in the metronidazole storage bin. This resulted in dispensing metformin instead of metronidazole. Fortunately, a nurse recognized the error before giving the patient the wrong medication. Both were generic products, although the brands FLAGYL (metronidazole) and GLUCOPHAGE (metformin) are also available. Unit-dose packages of these drugs contain bar codes, and the printed information is very small, which adds to their similar appearance.
Safe Practice Recommendation:
Metronidazole-metformin mix-ups could be serious, considering the different indications and the potential for drug interactions. To avoid selecting the wrong drug from the screen, consider programming the computer to display the specific brand names along with the generic names whenever the MET stem is used as a mnemonic. To reduce similarity of the containers, purchase these medications from different manufacturers. Another option in hospital settings is to stock only the 250 mg tablets of metronidazole, since metformin is not available in that strength. This option allows a small risk for nurses who may administer just 250 mg when 500 mg is prescribed, but the potential for harm from giving the wrong drug is greater. It's also a good idea to separate the storage of these products.
During the dispensing process, drug names listed on written prescriptions and hospital orders should be matched to computer labels and manufacturers' products. Since metformin is used to treat a chronic condition, and metronidazole is more likely to be used for an acute condition, outpatient refills for metronidazole are less common and, therefore, bear a second look.
Asking physicians to include the drug's indication on the prescription can also help prevent errors. We'll ask FDA to add these drugs to the list of non-proprietary names that would benefit from using tall man letters. Meanwhile, underline or highlight the unique letter characters in these drug names to make their differences stand out.
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INSULIN-FREE: PANCREAS AND ISLET TRANSPLANTATION TO TREAT TYPE 1 DIABETES
by David Sutherland, MD, PhD
An estimated 1 million people in the United States have been diagnosed with Type 1 diabetes. Approximately 30 percent to 50 percent of them will experience secondary complications of the disease, such as heart disease, high blood pressure, stroke, diabetic retinopathy, blindness, kidney disease, nervous system disease, and amputation. A patient's risk of experiencing these complications increases as his or her total lifetime exposure to elevated blood glucose levels increases.
The Diabetes Control and Complications Trial, a clinical study conducted from 1983 to 1993 by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), illustrated that if a patient has a qualified diabetes care team and intensive insulin treatment, the patient's blood glucose levels could be normalized for several years. However, this intensive treatment may be difficult to achieve and sustain because it would increase the patient's burden of diabetes management, require increased medical services and patient monitoring, and be accompanied by more frequent episodes of severe hypoglycemia.
Currently, the only way to restore normal blood glucose levels without the risk of hypoglycemia is to replace the patient's islets, either by transplantation of a whole pancreas or by infusion of isolated pancreatic islets. Beta-cell replacement therapy (pancreas and islet transplantation) should be considered as an option for patients with type 1 diabetes and renal insufficiency who are or will be obligated to immunosuppression for a kidney transplant, or for non-uremic patients who experience hypoglycemia-associated autonomic failure or progressive microvascular complications.
Pancreas transplantation
The first pancreas transplant was performed in 1966, simultaneous with kidney transplant, at the University of Minnesota. To date, more than 20,000 patients worldwide have received pancreas transplants. Nearly 2,000 of these have been performed at the University of Minnesota.
Three types of patients that are candidates for a pancreas transplant:
* Diabetic patients with uremia: they would receive a simultaneous pancreas and kidney (SPK) transplant;
* Nephropathic patients who have already had renal insufficiency corrected, usually by a living donor kidney transplant: they would receive a pancreas transplant after they have had their kidney transplant (PAK); and
* Diabetic patients who are nonuremic: they would receive a pancreas transplant alone (PTA).
SPK transplants represent the majority of pancreas transplants, but there is a trend toward performing more PAK transplants as more living-donor kidney transplants are performed to preempt the need for dialysis in diabetics with nephropathy. In addition, more PTA transplants are being performed for patients with diabetes who do not have advanced nephropathy but who have such difficulty managing their diabetes that immunosuppression is justified.
In addition to insulin independence, pancreas transplant patients have experienced prevention and reversal of secondary complications, improved quality of life, lengthened life span, and reduction of health care costs per quality-adjusted life year. A pancreas transplant can save the life of patients with labile diabetes or hypoglycemia unawareness.
The United Network for Organ Sharing (UNOS) captures data on transplants performed throughout the U.S. From January 1999 to May 2003, more than 5,700 patients received cadaver-donor pancreas transplants for the first time. Outcomes measures reported during this period are shown in Table 1.
Islet transplantation
The first islet transplant was performed in 1974, when the islets from a cadaver-donor pancreas were infused into a diabetic patient who had previously had a kidney transplant. Since then, more than 700 islet allotransplants have been performed. Islet transplant is far less invasive than a pancreas transplant; it requires only a local anesthetic and takes about 60 minutes. The islets are injected into the liver, where they secrete insulin directly into the circulatory system to control blood sugars.
Between 1974 and the early 1990s, insulin-independence was difficult to achieve in patients who had type 1 diabetes. Since that time, islet transplants have become markedly more successful by increasing the number of islets transplanted into the patient and by reducing the diabetogenic side effects of immunosuppression. New generations of immunosuppressive medications have eliminated the use of prednisone in most recipients and have allowed calcineurin inhibitors to be used in low, nondiabetogenic doses.
Recent islet transplant trials have achieved improved results, including the Universities of Alberta, Miami and Minnesota. Most patients at the first two centers required islets isolated from two or more donor pancreases to achieve insulin independence, but at the University of Minnesota we have been able to do so with a single donor by careful selection of large donors for low insulin-requiring recipients and by an isolation process that preserves islet viability to the utmost.
Two islet transplant trials were recently performed at the University of Minnesota, with patients who had type 1 diabetes and who experienced hypoglycemia unawareness. Twelve of 14 patients achieved insulin independence after receiving islets from one cadaver donor pancreas each. After transplant, patients had excellent glycemia control, as shown by elimination of severe hypoglycemia post transplant, normal HbA1c levels, and normal oral glucose-tolerance test results.
The University of Minnesota's high success rate using a single donor pancreas is due to a number of factors. First, by using the two-layer pancreas preservation method, we were able to increase the number of islets isolated from the pancreas and preserve the ability of these islets to reverse diabetes. The two-layer pancreas preservation method involves sandwiching the pancreas between a top layer (which contains a cold preservation solution) and a bottom layer (which contains fluorocarbons that have been saturated with oxygen). This method delivers more nourishing oxygen to the pancreas than the cold preservation layer alone can. Second, during the peritransplant period, we targeted autoreactive T cells with anti-CD3 antibodies or polyclonal T-cell antibodies, which inhibit activated autoreactive T cells. Last, we cultured the islets pretransplant so that T-cell-directed immunosuppression was achieved in the patient well before islet infusion. This step is critical because it likely reduces islet-directed immune responses mediated by autoreactive, primed T cells to which the intravascularly transplanted islets are immediately exposed. Pretransplant culture allows for quality control studies to be performed before infusion and improves the metabolic efficacy of cultured islets. Delaying transplantation until two days after the patient starts therapy with T-cell-depleting antibodies prevents the transplanted islets from being exposed to the cytokine release associated with the first two antibody infusions.
By revising islet transplant protocols to include these advances, we have been able to achieve outcomes in islet transplant patients that are consistent with the outcomes experienced by pancreas transplant patients. Additional improvements in islet transplant outcomes are expected, as unique glucocorticoid- and calcineurin inhibitor-free, nondiabetogenic immunosuppressive regimens have proved safe and effective in relevant preclinical models.
We can expect to see licensure of isolated human islets as biologic products in the foreseeable future as human islet processing techniques are demonstrated to be controlled and consistent, as islet product potency assays illustrate the predictability of post-transplant islet function, and as substantial evidence is provided of the clinical safety and efficacy of islet transplantation. This licensure will help secure third-party reimbursement, which will provide strong incentive to maximize donor pancreas use. In addition, islet transplants will become more available as pancreas preservation techniques are further improved; as regional islet processing centers are created; and as donor pancreas allocation methods, logistics, and technical impediments are overcome.
Treatment considerations
Currently, patients who have either a pancreas transplant or an islet transplant must take immunosuppressive drugs to prevent rejection. Protocols designed to induce immunologic tolerance specific to the donor are underway with islet transplant patients. In the future, immunotherapy will be tailored to the specific needs of the individual transplant patient.
Although a transition from pancreas to islet transplantation may occur over the next few years, pancreas transplantation will always be the better option for certain types of patients. For example, patients with high insulin requirements before transplant would be best served by a pancreas transplant. Diabetic patients with exocrine deficiency would continue to benefit most from an enteric drainage pancreas transplant. And patients who are insulin resistant (type 2 diabetics) or who have very high insulin requirements may need a pancreas transplant in order to obtain enough islets to restore insulin independence from a single donor.
Beta-cell replacement therapy will have a great impact on tissue availability. Of the 6,000 cadaver donors available each year, only half have pancreases suitable for transplantation. Assuming each cadaver pancreas could be split for use in two recipients and that living donors would be used for segmental pancreas transplantation to the extent they have been used for kidney transplants, up to 12,000 pancreas transplants could be performed annually in the U.S. The potential exists to transplant at a rate approaching half the annual incidence of new-onset cases of Type 1 diabetes (30,000 a year) in the U.S.
Although the procedural and immunosuppressive risks now associated with islet transplants will continue to diminish and the efficacy of islet transplant protocols will continue to improve, islet transplants will not be the ultimate approach to diabetes care. However, islet transplants will create and build momentum for the development of xenogeneic and stem/precursor cell-derived islet Beta-cell therapy, which will make cell replacement therapy routine in diabetes care.
Every transplant center should perform pancreas transplantation, and eventually islet transplantation, for treating patients who have diabetes. Every endocrinologist should consider Beta-cell replacement in treating patients with type 1 diabetes who have hypoglycemia-associated autonomic failure or progressive microvascular complications.
Continued clinical research on pancreas and islet transplants is needed to identify the most appropriate patients for transplant, the best time to perform a transplant, and the most suitable donor tissue and transplant protocol for a given patient. Health care providers and third-party payers will support Beta-cell replacement therapy more enthusiastically as prospective, adequately powered clinical trials comparing intensive insulin therapy and Beta-cell transplants earlier in the course of diabetes document superior outcomes in cost-adjusted quality of life. The results of these clinical trials could provide a strong rationale for evidence-based stratification to islet-cell replacement in at-risk patients with incapacitating hypoglycemia or incipient secondary complications.
David Sutherland, MD, PhD, is head of the Transplant Division, director of the Diabetes Institute for Immunology and Transplantation and a professor of surgery at the University of Minnesota.
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AN ASPIRIN A DAY ...
This article originally appeared in the "News You Can Use" section of CONTROL SOLUTIONS, Summer 2004 edition, published by Integrated Diabetes Services
Men and women with diabetes (type 1 or type 2) are at greatly increased risk of developing cardiovascular disease. One of the primary reasons is increased production of thromboxane, which causes blood vessels to constrict and platelets within the bloodstream to become extra "sticky." Because it blocks the production of thromboxane, low-dose aspirin therapy has been shown to be an effective method for preventing heart disease and stroke. The American Diabetes Association recommends daily low-dose aspirin (75-162mg) for the following people:
Aspirin therapy is not recommended for those under age 21,
or anyone who suffers from bleeding problems. For more information, consult your physician.
CONTROL SOLUTIONS is a free newsletter published by Integrated Diabetes Solutions. For a free subscription, you can call Integrated Diabetes Solutions at (610)642-6055, or you can
e-mail them at (garyscheiner@prodigy.net).
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If you or a friend would like to remember the Diabetes Action Network of the National Federation of the Blind in your will, you can do so by employing the following language:
"I give, devise, and bequeath unto the Diabetics Action Network of the National Federation of the Blind, 1800 Johnson Street, Baltimore, Maryland 21230, a District of Columbia nonprofit corporation, the sum of $_______________" (or "_______________ percent of my net estate" or "the following stocks and bonds:____________________") to be used for its worthy purposes on behalf of blind persons."
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BEGINNING CARB COUNTING: TEN COST-CUTTING TIPS
by Linda Ruholl, RN, PhD
(Includes photo of Linda Ruholl)
The newly diagnosed type 2 diabetic must make many life changes in a short period of time. According to the American Diabetes Association, dietary control is essential to all diabetics. It can put off the advent of insulin therapy for years, or perhaps indefinitely. Patients who take no oral medications need to tightly control carbohydrate intake, but carb counting can be confusing and expensive. Basic education from a dietitian or certified diabetic educator (CDE) is essential. These ten simple strategies help cut expenses.
1. Be cautious about purchasing special "diet" or "low carb" foods.
Many "diet" items are quite expensive when you take into consideration other alternatives. Try the smallest size first. Look for coupons and use them at a market that doubles the face value of the coupon. Read the label to find out the manufacturer's definition of a "serving." It probably won't be a "bowlful." Some manufacturers of so-called "low carb" foods keep the carb numbers down by shrinking the serving size.
2. Be equally careful about buying special cookbooks.
It's all too easy to spend $15 or $20 for a cookbook, only to discover the 250-page book has exactly three recipes you and your family would even consider eating. Go the library instead. If you have a card, you can take a cookbook home to spend more time examining it. If you are not a regular patron, study the cookbooks at the library and copy likely recipes onto 3x5 inch index cards. Your local library may also have back issues of DIABETES FORECAST or similar diabetic-focused magazines you can examine or check out.
3. Make your own "healthy" sweets.
Fresh fruits have natural sugars, and you can easily enhance these flavors. Thicken water with a little cornstarch, pour it over the fruit and cook gently until the fruit is soft, but not mushy. Add Equal or Splenda to taste. After one or two tries, you will know how much is enough. Sample the generic sweeteners; they are considerably less expensive than the brand name stuff, and many people can't tell the difference in a blind taste test.
4. Overhaul your favorite recipes.
Many recipes in traditional cookbooks are high in sugar, especially white sugar. Convert them to a lower carb version by substituting an artificial sweetener. Our family's experience is that aspartame and sucralose taste satisfyingly sweet, but other sweeteners leave a bitter aftertaste. Bulk packages of these products include conversion charts that list exactly how much to substitute for a given amount of sugar.
5. Invest in a couple of compact and inexpensive reference books.
Total calorie intake and carbohydrate counts are both important. The Doctor's Pocket Calorie, Fat and Carbohydrate Counter, by Allan Borushek, will give you plenty of information about foods you prepare yourself. Other sections give data about restaurant and international foods, as well as counts for many US fast-food chains. Borushek's book measures only 4.5 by 6 inches, and is about a half-inch thick, making it small enough to fit into a coat pocket, purse or glove compartment. At $6.99, it is a good buy.
A second inexpensive guidebook is The New Glucose Revolution Complete Guide to Glycemic Index Values. The book has two sets of tables: an A to Z listing of foods with their respective GI and carb count, and a listing of foods ranked from low to high GI. This lets you compare foods within a category and make some predictions about how quickly a given food will raise your blood sugar. For example, a quick check of the dry ready-to-eat cereal section shows you that All-Bran has a GI of 38, but Kellogg Corn Flakes rates a 92. This guide is also a bargain at $6.95.
6. Look at directions for food preparation with an open mind.
Packaged foods will often stretch to make more servings. For example, our favorite vanilla diet pudding mix calls for two cups of skim milk and makes four servings. Try adding three cups of milk next time. The mixture sets up just the same, and you get six cups of pudding instead of four. I add a half-teaspoon of vanilla and a little extra sweetener before mixing.
7. Plan fast food and family restaurant trips carefully.
If you are planning to take the kids or grandkids to McDonald's, don't despair. You can eat there, too. McDonald's publishes A Full Serving of Nutrition Facts, which gives the full gamut of nutritional information about all their menu choices. Many of the sandwiches are very high in carbs, but there are a number of options that contain less than 30 grams of carbohydrates, such as Chicken McNuggets and the salads with grilled chicken.
Tuck some of the nutrition sheets from other restaurants into a folder and slip them under your passenger seat. When you travel, you will be able to find something suitable. One useful website contains information about ten different fast food restaurants, including Arby's, Burger King, Hardee's, Taco Bell, Subway, and Wendy's. Go to www.fatcalories.com, and you can search each restaurant's offerings by carb count or by total calorie count. The data base ranks the choices from highest to lowest number of carbs.
8. Pay for food and not for packaging.
Many nutritious foods are inexpensive. A good example is cereal. You can eat it for breakfast, a quick lunch or for a snack. Cereal by the bag is cheaper than boxed cereal. A generic plastic bag of raisin bran cereal sells for 10.8 cents per ounce in the Midwest, while boxed raisin bran cereal costs 16.6 cents per ounce. You would pay 10.5 cents per ounce for toasted oats in the bag, but 16.9 cents per ounce in the box. Over a year's time, the difference adds up.
9. Use the internet to learn about your condition.
Both commercial and public service sites have good information The American Diabetes Association (ADA) site is the mother lode of current and accurate information. There is a special section of this site for the newly diagnosed diabetic. It will help clear up confusion about carbohydrate counting and other issues. Check out the ADA at (www.diabetes.org).
DIABETES DIGEST offers a one-page glycemic index list of the 300 most common foods. You can access it at (www.diabetesdigest.com). This same site has a useful one-page sheet of hints, Ten Tips for Taming Your Cravings.
10. Keep track of your daily blood sugars, and glycosated hemoglobin levels, as well as your blood lipid levels.
Health providers find it easier to interact with an informed and motivated patient. Your doctor or nurse practitioner will be impressed with your organizational skills, and will work harder with you to manage your diabetes cost-effectively. The newer oral medications for diabetes are quite expensive. Why enrich the pharmaceutical industry if you can avoid it?
Go to (www.equal.com) to download your own copy of EASY EVERYDAY LOGBOOK. This booklet has a section where you can track your lipid and HbA1c levels, as well as day-by-day sheets for carbohydrate counting and blood glucose tracking. This same site offers a two-page educational offering titled: Ready, Set and Start Counting: How to Use Carbohydrate Counting to Keep Your Blood Glucose Healthy. Use this information to supplement and review the information you received from your dietitian or certified diabetic educator.
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REFLECTING ON OBESITY
by Peter J. Nebergall, PhD
(includes photo of Peter J. Nebergall, with cat)
I've been reading a lot of different articles about childhood obesity and its impact on long term health. The phrase: "experts say..." must surely be the most abused in the language. What experts? And where are they looking?
I've heard "suburban sprawl" blamed for overweight kids. That's silly. Go to the inner cities, and look at the children. If increasing "suburban sprawl" was the significant agent of obesity, these ghetto kids (whose environment is just as it was for their parents and grandparents) wouldn't be so quickly getting heavier, faster than the suburbanites. Hypothesis disproved.
Moviemaker/prankster Morgan Spurlock recently produced a shockumentary film called "Supersize Me," in which he ate only fast food for a month, a LOT of fast food, and did not exercise. He gained a lot of weight, and his cholesterol shot up. Spurlock would have us blame the fast food industry (and it is easy to eat a lot of calories at a fast food restaurant) but he knowingly set out to consume three times the "maintenance amount" (1800 calories) a sedentary adult needs to maintain weight -- and one could just as easily do this at the local barbecue, all-you-can-eat catfish restaurant, or kitchen table, with biscuits and gravy for breakfast. Bad food choices.
Spurlock has a point, however. Fast food is so easy to overeat. Ralph Nader called the double cheeseburger "a weapon of mass destruction." We are subjected to an incredible cacophony of adverts urging us to have more, that "bigger is better," whether it be soap powders, washing machines, SUVs, or "$6 burgers for 3.95." The fast food marketing industry is certainly part of this problem -- but so are we, the consumers -- and all this "Madison Avenue" only works if WE fall for it. We don't have to.
Another study found that, if offered more food, at the same price, people take it. "We're getting something free! Yippie!"
Right. Isn't that why "all you can eat" buffets are so popular? Go watch, and, if you can, take a foreigner with you, someone from a country that doesn't have such places (most don't.) They'll be shocked at the overeating -- and you should be too.
We, and our children, ARE gaining weight. There are several causes, and overuse of "junk food" outlets is one of them. But, if we don't cook healthy food, and don't provide our children an alternative, what else can we expect?
Lack of exercise is an issue. A BIG issue. Our explosive expansion in waist sizes perfectly maps on the cutback or cancellation of serious school physical education classes ("for budgetary reasons") and on the arrival of "virtual reality" computer games. When you want an adventure, do you rent one, or do you go have one? If you move less, its just the same as if you eat more. You gain. What else can we expect?
I've written about the "trick food" diets that would have us "eat all you want" -- if you buy it from THEM." When they work, is it not because their stuff is so expensive its high price limits consumption? They are neither an economical nor a healthy answer to obesity -- just another product to sell.
Obesity is a problem for all of us. If you have diabetes, or if you have the genetic background for type 2, it can make it worse. Excess weight can bring on the symptoms, and what was once "adult onset" diabetes is now arriving in pre-teen years. More years with diabetes means more time for serious complications -- so we need to act, now, before more damage is done.
What can WE do? A bunch. We can stop "supersizing it," and remember Gluttony was one of the "Seven Deadly Sins" -- for good reason. We can count our calories, and stop when we've had enough. We can commence an exercise program. We can stop pretending it isn't better to be fit. It is.
Obesity is a solvable problem. We can all help; by action, and by good example. Let's roll.
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OPENING BLIND EYES TO SCIENCE
(the following article is courtesy NASA and the National Federation of the Blind)
A 14-year-old blind boy named Steven is digging in a container of soil at the Maryland Science Center. Steven and Amelia are blind, yet both were able to read the temperature with a thermometer and measure precipitation with a rain gauge at a science camp this past summer.
Their secret?
Steven and Amelia, along with 10 other blind students ages 11-14, were using a talking thermometer, a Braille-marked rain gauge and other tools identified by NASA for use by the visually impaired.
The tools got their first major test in July at the end of the week-long "Circle of Life" camp put on by the National Federation of the Blind and sponsored by NASA. On the camp's final day, students visited the pond and forest area of NASA's Goddard Space Flight Center in Greenbelt, Md., where they made observations of the soil, vegetation, weather and birds.
For many of the kids it was the first time they had used observation instruments specifically geared toward the senses of sound and touch, rather than sight.
"I didn't know they existed," said Steven, now a ninth-grader at a science-oriented high school in New York. "It was amazing to see the technology."
Goddard soil scientist Elissa Levine has been leading NASA's effort to introduce various blind-friendly gadgets to the visually impaired community. Her work is aimed at making activities such as GLOBE -- a NASA-sponsored science education program in which K-12 students around the world take measurements of soil, land cover, air, water and living things -- more accessible to the blind.
"I have been working with the GLOBE program for many years and am aware of how effective it is as a learning experience, which made me interested in seeing if it would be as effective for blind students as well," Levine said.
The new instruments include two kinds of talking thermometers -- one for the air and a "meat thermometer" that can be inserted into the soil. There's also a talking compass, and a talking sensor that analyzes soil color. A graduated cylinder with a floating Styrofoam plug serves as a rain gauge. The plug moves up or down depending on the volume of water and is attached to a plastic measuring scale marked with Braille.
Unlike other sciences that are sometimes more abstract, Earth science provides plenty of convenient opportunities for interactive, nonvisual activities, such as listening to birds or rubbing soil between one's fingers.
"The best thing about Earth science is that there is a natural laboratory right outside the classroom door," Levine said.
Promoting interest in science -- Earth or otherwise -- among the more than 93,000 estimated blind school-age children in the United States is as much about educating teachers as it is kids, according to the camp's lead instructor, Robin House, who says teachers often underestimate the potential of blind students.
"Many times blind students are left out of sciences and math because some educators think, 'Oh, this is too difficult, they couldn't possibly grasp these concepts,'" said House, who herself is blind. "The idea of this particular camp was a little bit of exposure in all the areas of science to get kids going, 'I can do science, I can do it. I can become a scientist if I want to.'"
In the days preceding their visit to Goddard, the campers dissected a dogfish shark and dug for dinosaur fossils at the Maryland Science Center, explored seashells with blind shell expert Geerat Vermeij, took a boat ride on the Chesapeake Bay, and listened to sounds from space with blind physicist Kent Cullers.
The camp was the first step in the National Federation of the Blind's initiative to create a National Center for Blind Youth in Science. A second camp held in August -- "Rocket On!" -- challenged blind high school students to develop, build and launch a 12-foot rocket from NASA's Wallops Flight Facility on Virginia's Eastern Shore.
For 12-year-old Amelia, the "Circle of Life" camp was a rare chance to experience science up close and personal. "We don't usually get to have so much hands-on activities when we're with a classroom. We have to touch stuff to be able to know what they really are like," Amelia said. "There are a lot of tools out there that blind people can use to investigate science. Blind people can pretty much do anything, but they just do it differently."
In addition to having the right kinds of tools, House says it is critical to the success of blind students that educators help dispel misconceptions among sighted students as to what blind people are capable of.
"Sometimes it might take a little bit longer, maybe there's a different way that the blind student has to go about doing something," House said. "But that's what science is really about anyway -- trial and error, trying things, taking risks."
Steven has a simple, straightforward message for both students and teachers: "Blindness doesn't have to be a barrier. Being blind doesn't stop you from having a brain and doing science."
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KIDNEY DISEASE: WHAT CAN YOU DO?
by Ed Bryant
(includes photo of Ed Bryant)
I am a long-term diabetic who experienced renal failure. On August 9, 1983, I had a kidney transplant. To date, 21 years later, I feel great, and the new organ is functioning perfectly.
Knowing that nephropathy, kidney failure, is a frequent complication of diabetes, what can YOU do to prevent, minimize, or slow it? There is a tight statistical link between quality of diabetes control - and ramifications such as heart and blood vessel disease, diabetic eye disease, and diabetogenic kidney failure. We know the tighter your control, the less chance you will experience these complications. Good self-management is the BEST way to cut the risk.
There are things you can do. First, don't smoke. Nicotine, the narcotic active ingredient in tobacco, is a vasoconstrictor, raising blood pressure, stiffening capillaries, and making it harder for the kidneys to filter wastes.
Urinary tract infections need prompt treatment, to limit the damage they can do to already strained kidneys. Tell your doctor promptly if you think you have such an infection.
Excessive obesity raises blood pressure and increases insulin resistance. Keeping your weight down helps in general, and the resultant blood pressure drop is good for your kidneys.
You need to control your cholesterol, as too much of this fatty substance in your blood overworks your kidneys. Proper diet, exercise, and appropriate medications can lower your cholesterol levels. Consult a Registered Dietitian (RD) for advice; kidney failure imposes unique constraints.
High levels of stress can be damaging. It drives up blood pressure, can harm the kidneys by raising fluid pressure, further straining already weakened filter networks. Stress reduction is part of a healthy lifestyle. Ask your health care team for advice here.
Other than "keep your diabetes under the best possible control, and live a healthy lifestyle," I can offer little advice about prevention.
Once kidney disease is diagnosed, however, a great deal can be done to retard its progression. Current statistics suggest perhaps four out of every ten diabetics may experience measurable kidney disease, though many of these individuals should be able to avoid progressing to outright kidney failure, End Stage Renal Disease (ESRD).
Testing Your Kidney
How is the severity of kidney disease measured? Several tests measure creatinine, a waste product from muscle mass. Although everyone's body produces creatinine, people whose kidneys are failing cannot properly excrete it. One test measures the amount of creatinine in the blood, and the other is "creatinine clearance," a 24-hour urine test. Normal "blood creatinine," for someone with healthy kidneys, is about 0.7 to 1.3. Government guidelines (April 1995) recommend dialysis when the blood creatinine rises to 6 or above (the number rises as you get worse). However, some diabetics will experience kidney failure before that point. There is much variation between individuals who have ESRD, and the actual range for "kidney failure" runs from 3 through 8--but at or above 6, Medicare will pay for dialysis.
"Creatinine clearance" is considered a more reliable test. In this 24-hour urine test, the numbers produced approximately indicate the percent of normal kidney function remaining to the individual (the number goes own as you get worse). The 1995 government guidelines (which relate to Medicare part B eligibility) state they will fund dialysis when this test produces a reading of 15 or less.
Two other tests measure protein spillage into the urine. These are the microalbumin test and the test for proteinurea. The protein albumin is not normally excreted into the urine, and its presence in the urine, in small amounts (microalbuminuria) or larger concentrations (proteinurea) can indicate kidney disease. While not considered absolute diagnostic evidence, a positive finding in either should be immediately followed by further testing, as these tests are very sensitive, and the microalbumin test can detect kidney disease long before the other tests--allowing earlier medical intervention.
Options
Individuals experiencing impaired kidney function, but whose test results indicate they do not yet need dialysis or transplantation, might benefit from regular use of ACE (Angiotensin Converting Enzyme) Inhibitors, commonly used to control hypertension, high blood pressure. Now widely accepted, these ACE Inhibitors have been shown to significantly reduce further kidney degeneration. Note: A diabetic experiencing kidney failure, but whose blood pressure is not elevated, can still use ACE Inhibitors for keeping fluid pressure down in the kidneys. This therapy has been shown to significantly reduce strain on eyes and cardiovascular system, as well. Talk to your nephrologist (kidney specialist) about the ACE Inhibitors.
End Stage Renal Disease
The damaged kidney may worsen to the point where it can no longer carry out its blood-purifying function. Then dialysis or transplantation are necessary in order to preserve life. This is ESRD, end stage renal disease. What are your options then?
There are three: In hemodialysis, the patient's circulatory system is temporarily linked with a machine that performs the blood-cleansing functions of the human kidney. In peritoneal dialysis (CAPD or CCPD) a tube is inserted into the patient's peritoneal cavity, allowing urine and unneeded fluids to periodically drain from the body. The third option is kidney transplantation, in which a donated kidney is surgically implanted into the patient's body.
National Institutes of Health statistics show that 42.9 percent of all individuals facing dialysis are there because of diabetes, and about 40 percent of those commencing dialysis or seeking a transplant at this time are diabetic. Some remain on dialysis long-term; others make use of the process while awaiting a kidney transplant.
Dialysis
Dialysis is not an "artificial kidney." A person undergoing hemodialysis must be hooked up to a machine three times a week, three to four hours per session.
Like the kidney, a hemodialysis machine is a filter. Where it uses tubes and chemicals, the kidney uses millions of microscopic blood vessels, fine enough to pass urine while retaining suspended proteins. Long-term high blood glucose can significantly damage the kidney's filters, leading to scarring, blockage, and diminished renal function. Diabetes is the leading cause of kidney disease (the second is hypertension). Long-term diabetics often have cardiovascular and blood pressure problems as well, and the added strain of hemodialysis, with its rise in blood pressure straining eyes and heart function, can be too much for some. The diabetic dialysis patient spends, on the average, 33 percent more time in the hospital than does the non-diabetic dialysis patient, according to 1999 USRDS figures.
Some patients choose CAPD (continuous ambulatory peritoneal dialysis) or its variant, CCPD (continuous cycling peritoneal dialysis), both of which can be carried out at home, without an assistant. Though the risk of infections is heightened (as it is with any permanent catheterization), these two processes have their advantages.
Transplantation
Kidney transplantation is a logical alternative for many. A transplant frees the patient from the many hours spent on hemodialysis procedures each week, or from the periodic "exchanges" and open catheter of CAPD, allowing a nearly normal lifestyle. It can bring real improvement in quality of life and overall longevity.
An article, published November 1999 in the New England Journal of Medicine, shows the longevity gains have been major. The average graft survival (how long the kidney remained functional, not the patient) was, from a living donor, 17 years, in 1988. Per 1996 statistics, it is now 36 years. The typical cadaver kidney transplanted in 1988 lasted 11 years, but in 1996, the life expectancy of the organ was nearly 19 years. The study, led by Dr. Sundaram Hariharan, at the Medical College of Wisconsin, funded by the National Institutes of Health, concludes the improvement is largely due to the development of better anti-rejection medications.
"Fifty percent of all kidney transplantations taking place today are into diabetics," states Giacomo Basadonna, MD, PhD, a transplant surgeon at Yale University School of Medicine, in New Haven, Connecticut. He reports that success rates are identical with kidney transplants performed on non-diabetic ESRD patients. "Today," he advises, "average kidney survival, from a living donor, is greater than 15 years."
"Will you survive longer once you get a transplant?" asks Marianna Markel, MD, Director of Transplant Nephrology at SUNY Health Science Center, in Brooklyn, New York. "If you're a diabetic, it looks like the answer may be yes, perhaps because certain substances which build up in the blood of diabetics (advanced glycosylation end-products) are not removed well by dialysis, and may contribute to a shortened lifespan for diabetic patients on dialysis."
I and others knowledgeable in kidney transplantation advise you to pick the best transplant center possible. Once you have read their statistics, ask your prospective center plenty of questions. If they don't answer to your satisfaction, you should consider going to another center.
Facts and Statistics
What is the success rate for kidney-transplant surgery? According to the "United States Renal Data System 1999 Annual Data Report," published by the National Institutes of Health, about 75 percent for a cadaver-donated kidney, better than 90 percent with a kidney donated by a living relative, with an overall success rate of better than 85 percent, better than 90 percent in some centers. UNOS data indicate the averages (based on graft survival, healthy kidney, five years after transplant) are improving. The National Institutes of Health reports that current "graft survival" (donated kidneys successfully functioning in the transplant recipient) rates are approximately the same now, whether the recipient has diabetes or not.
What percentage of type 1 diabetics will face ESRD? Current statistics suggest between 20 and 25 percent, with many factors (genetic, ethnic, lifestyle) taken into account.
Must the ESRD patient be on dialysis before being considered eligible for a transplant? NO! Although some behind-the-times nephrologists still believe so, Fairview-University Medical Center's Transplant Center, which pioneered diabetic kidney and pancreas transplantation, recommends once your physician has determined kidney failure is on the way, further delay could be harmful. The more time spent subjecting your body to the toxic excesses of kidney failure and the strains of dialysis, the greater the risk of serious complications like retinopathy and cardiovascular (heart) degeneration.
Your nephrologist should be able to tell you more about your options. For information about kidney transplantation, contact a reputable kidney transplant center (there are approximately 250 in the U.S. today), or the United Network for Organ Sharing, 1100 Boulders Park, Suite 500, Richmond, VA 23225; telephone: 1-800-243-6667; website: (www.unos.org). All UNOS information is available on the World Wide Web, but they will also send you pertinent information, by mail, about transplant centers in your area or nationwide. Contact them at the above address, and ask them for the "kidney transplant package." They also offer the brochure "What Every Patient Needs to Know," and an organ-donor card for you to carry.
For information or assistance with interpreting transplant center data, contact: Health Resources and Services Administration, Bureau of Health Resources Development, Division of Transplantation, OSP, Park Lawn Bldg., 5600 Fishers Lane, Room 7C-22, Rockville, MD 20857; telephone: (301) 443-7577; website: (www.hrsa.gov/osp/dot). This agency also maintains the website: www,organdonor.gov, which offers many useful links and much pertinent information.
Renal failure is not a kiss of death. There are options, and at least one of them will be right for you. Keep your diabetes under good control, and your blood pressure down, to cut the risks--but if it happens (like it did to me), remember that with proper care you stand every chance of living just as long as you would have with healthy kidneys.
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TRANSPLANT PATIENTS SPEAK:
The following individuals are the real experts. Collectively, they have more than 168 years experience living with a transplant! All of them would choose transplantation again. Although kidney and pancreas transplantation are not for everyone, and sometimes they don't work, they should be given strong consideration.
Karen Mayry, from South Dakota, received her kidney transplant at Fairview-University Medical Center, in Minneapolis, Minnesota, on January 12, 1977. She declares, "I feel great!"
Betty Walker, from Missouri, received her kidney on July 13, 1978, at Yale-New Haven Hospital in Connecticut. In her words: "I was just existing on dialysis; and my transplant gave life back to me."
Lenny Ruygt, from California, received her kidney transplant at Pacific Medical Center, in San Francisco, on St. Patrick's Day, March 17, 1980. She says: "On dialysis, I had no energy at all--I would sleep all but two hours of a day. After my transplant, I felt energized!"
Linda Bingham, from Ohio, who received her kidney transplant at University Hospital in Cincinnati, Ohio, on December 10, 1981, says, "I feel great. I have been given a whole new life."
Ed Bryant, from Missouri, received his kidney on August 9, 1983, at Fairview-University Medical Center, in Minneapolis, Minnesota. He says: "There is no comparison between life on dialysis, and how I've felt since my transplant."
Faith Tootel, from California, received her new kidney on September 24, 1984, and her new pancreas on September 29, 2000, from Fairview-University Medical center, in Minneapolis, Minnesota. She says: "My quality if life is tremendously improved now, since I received my transplants."
Tim Cox, from South Carolina, received his combined kidney-pancreas transplant, also from Fairview-University Medical Center, in Minneapolis, on Christmas Eve, 1988. He says: "I'm not handicapped; I'm handicappable."
Lindy Guidry, From Louisiana, received her combined kidney and pancreas transplant, on August 8, 1993, at the University Hospital of New Orleans, and she says: "I want to make the most of my second opportunity."
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MEDICARE THERAPEUTIC SHOE PROGRAM
In an effort to prevent foot ulcers in people with diabetes who are at risk, Medicare will help pay for therapeutic shoes. For those who qualify, Medicare will pay 80 percent of the allowed amount for one pair of shoes and up to three pairs of molded innersoles per year. (The allowed amount varies, depending on the kind of footwear you need.) Most secondary insurers will help pay the other 20 percent.
Who Qualifies?
Not everyone with diabetes needs special shoes. To qualify, you must be under a comprehensive diabetes treatment plan and have one or more of the following:
Who Does NOT Qualify?
People with diabetes who do not have one of the above conditions. It is not enough to just have diabetes.
What Paperwork is Required?
The physician treating you for your diabetes must certify that you have diabetes, that you have one or more foot problems just mentioned, that you are under a comprehensive diabetes treatment plan, and that you need special shoes. Medicare has a form for this certification. You will also need a prescription for the shoes.
Who Prescribes the Shoes?
A prescription is required from a podiatrist or physician who knows how to fit shoes and inserts for people with diabetes. The prescription should indicate a particular type of footwear, such as shoes, inserts, or modifications.
Who Supplies the Shoes?
The footwear must be fitted and furnished by a podiatrist or other qualified individual, such as a pedorthist, orthotist, or prosthetist. The certifying physician may not furnish the footwear unless he or she practices in a defined rural area or area where there is a shortage of heath professionals. The prescribing podiatrist may be the supplier.
What Do You Get?
Coverage is limited to one of the following per calendar year:
I Have Diabetes and Need Special Shoes. Why Shouldn't I Get Them Free From Medicare?
Remember, there is no such thing as a free lunch -- and there is no such thing as a free pair of shoes. There are over 16 million people with diabetes in the United States. Many of them are of Medicare age. If every Medicare beneficiary with diabetes gets special shoes, there will be no money left for other important aspects of the Medicare program. If we abuse the shoe benefit, Medicare suffers -- and everyone who depends on Medicare will suffer as well.
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This patient Information Guide first appeared in PRACTICAL DIABETOLOGY, September 2004, copyright (c) 2004 R.A. Rapaport Publishing, Inc., New York, NY. Reprinted with permission.
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ANODYNE THERAPY AND DIABETIC PERIPHERAL NEUROPATHY
by Angie Bowman, PT; Kim Hamel, OT; and Linda Hicks, BSN, MS, CDE
"When I met a patient who had stepped on a nail and didn't even know it until he couldn't remove his shoe that night, I knew how important our work is here at our Anodyne Neuropathy Care Center at LifeCare Center of Charleston," said Angie Bowman, PT. "We have treated over 400 patients with the Anodyne Therapy System and all but a handful have shown improvement in their symptoms including significantly reduced pain, improved sensation and improved balance. We have also used it on chronic diabetic ulcers with good success. It has been rewarding to see these patients improve and get their lives back to normal."
If you have peripheral neuropathy, you are not alone. An estimated more than 20 million people suffer from its complications, which can include pain, numbness, balance problems and slow-healing foot wounds and amputations.
What Causes Peripheral Neuropathy (PN)?
PN is one of the most common complications of diabetes, but may also be caused by circulatory problems, certain drugs, chemotherapy, alcohol abuse, anemia, AIDS, back problems, surgery, and by unknown causes (referred to as idiopathic neuropathy).
Research now shows one cause of Diabetic Peripheral Neuropathy (DPN) is poor microcirculation to the nerves in the feet, legs and hands. In addition, recent studies have suggested an important molecule called nitric oxide (NO) may be in short supply in the blood vessels of people with diabetes. This molecule is critical for opening the blood vessels with each beat of your heart. Combine high blood pressure, high cholesterol or plaque build-up in your blood vessels with low amounts of NO (all common in diabetes), and the result is significantly reduced blood flow to the areas furthest from your heart. The nerves and tissues in those areas are not getting the oxygen and nutrients they need to stay healthy. The result can be pain, numbness, slow healing, and skin breakdown.
What is the standard of care for treatment of DPN?
Good glucose control is most important to prevent the progression of neuropathy. If that doesn't reduce your symptoms, then your doctor may prescribe drugs such as anti-depressants, anti-seizure medications or topical ointments like capsaicin cream. These drugs have been effective in relieving some painful symptoms of neuropathy. In addition, studies have shown that certain supplements like B12, folic acid and alpha lipoic acid may also help reduce neuropathic symptoms.
Along with medical interventions, special shoes, custom orthotics, and regular foot exams can protect feet from injuries or relieve pressure points. Despite these treatments, the majority of people suffering from PN continue to experience worsening pain, skin breakdown and a decline in quality of life. However, a new option has offered thousands relief from the symptoms of PN.
Monochromatic infrared energy (MIRE) may help!
MIRE is a photo-energy or light therapy used by doctors, physical and occupational therapists, and wound care specialists to increase circulation and reduce pain. The most promising device, called Anodyne Therapy, is already cleared by the FDA and holds a patent for the treatment of peripheral neuropathy. Nine studies published or currently in press show its effectiveness. Six of the studies were conducted on over 1100 neuropathy patients.
Why does MIRE work on neuropathy and pain?
It is believed this infrared wavelength of photo energy increases the availability of nitric oxide by breaking it free from the red blood cells. Once NO is free, it increases blood flow to the area by up to 3200% in just 30 minutes. Over time, NO will facilitate the growth of tiny new blood vessels (capillaries) in the area, improving circulation with each treatment. If the nerve pain is due to lack of circulation, then getting better blood flow to them can have immediate results. The release of NO also has a direct effect on pain itself. Several studies published in the 1990s showed that NO was directly responsible for the pain-relieving effect of morphine and similar drugs.
Is MIRE 100% effective? No, nothing in medical science is 100 percent. But clinical studies show a majority have positive results. In fact, this technology is used by our U.S. military on all types of injuries because they have found it gets soldiers back to duty faster than any other therapy.
As a result of this clinical success, there are now over 2000 Anodyne Neuropathy Care Centers using MIRE nationwide. These centers are located in hospitals, universities, rehabilitation clinics, nursing homes, home health agencies, pain clinics, wound care centers and doctors' offices.
How do I get MIRE treatments?
The best way to start is with a trained therapist or doctor who has experience using MIRE. They will begin with an individual assessment of the difficulties you are experiencing due to your neuropathy. They will ask you questions about your goals for improvement and design a specialized therapy program to help you reach those goals.
How long do the treatments take and what should I expect?
A comprehensive program usually involves 10 to 24 therapy sessions with 30-45 minutes of Anodyne Therapy and may include any or all of the following treatments depending on your particular needs:
* MIRE to reduce pain and increase circulation to tissues and nerves
* Stretching and strengthening exercises
* Dynamic and static balance exercises
* Massage and the use of other therapeutic modalities for pain
* Sensory integrative techniques to put it all together
Is this therapy for everyone?
MIRE has been safely used for over 10 years on thousands of patients. No significant side effects or drug interactions have been reported as long as MIRE is properly used and monitored. If you have diabetes, check your blood sugars often during any therapy or activity. If you are pregnant or have an active cancer, there are special cautions when using this therapy. Always follow the directions of your doctor or therapist when using MIRE.
Is this therapy reimbursed?
Medicare and most private insurance carriers will reimburse for this therapy when you are being treated by a physical or occupational therapist. In some cases, doctors can also be reimbursed for treatments, however, that varies state by state. You will need a prescription from your doctor for this therapy.
Will I need ongoing treatment?
Unfortunately, diabetes and most other causes of neuropathy are chronic conditions. Your therapist or doctor will recommend home exercises to improve your balance and ability to walk. They may also suggest continued use of MIRE therapy at home for ongoing pain relief and to help you maintain your peripheral circulation. Medicare or your private insurance may cover a MIRE home treatment system with your doctor's prescription if you have shown improvement during your clinical treatment program.
You do not have to suffer with neuropathy. By controlling your blood sugar, blood pressure and cholesterol, as well as exercising and adding this promising photo-energy therapy to increase circulation, you can make a difference in your life.
For information and a listing of Anodyne Neuropathy Care Centers, call 800-521-6664 or visit www.anodynetherapy.com
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DIABETES, HEART ATTACKS, AND STROKE
By Ann S. Williams, MSN RN CDE
This column focuses on providing information to help people
make their diabetes care fit their needs and their lives.
This month's column will be shorter than usual. I need to make an emergency trip out of town to see a relative who has just had a stroke. He, like myself, and like many other members of my family, has type 2 diabetes. So I want to take this opportunity to write about the link between diabetes and cardiovascular disease -- in other words, heart attacks and stroke.
Many people do not realize there is a very strong link between diabetes and cardiovascular disease. If you have diabetes, you have two to four times the risk of having a heart attack or stroke than you would if you did not have diabetes. You have two to four times the risk of having a heart attack or stroke than you would if you did not have diabetes. You are much more likely to die of heart attack or stroke than of diabetes itself.
In fact, your risk of heart attack or stroke is as high as someone who has already had a heart attack or stroke. However, there is a lot you can do to reduce your risk and protect your health.
What can you do to avoid heart attack and stroke?
You need to reduce all the risks you can control. These include:
1. Keep your blood sugar as close to normal as you can without having too much hypoglycemia. It's good to aim for:
a. A1C: below 6.5.
b. Blood glucose readings before meals: under 110.
c. Blood glucose readings two hours after meals: under 140.
But if you get too much hypoglycemia at these levels, aim for as close as you can reasonably get.
2. Do not smoke. If you do, quit.
3. Keep your blood pressure normal.
a. Blood pressure: under 130/80.
The goals for people with diabetes are lower than the goals for everyone else, because of the increased risk. If your blood pressure regularly runs higher than this, ask your diabetes educator or doctor to help you learn how to control your blood pressure through lifestyle changes or through a prescription medication.
4. Keep your cholesterol and triglycerides (blood fats) normal.
This is a complicated subject, which I will not discuss in detail here. The goals are:
a. LDL cholesterol: less than 100.
b. HDL cholesterol: greater than 40 for men, and greater than 50 for women.
c. Triglycerides: under 150
If your cholesterol or triglycerides regularly run higher than this, ask your diabetes educator or doctor to help you learn how to control your cholesterol or triglycerides through lifestyle changes or through a prescription medication.
5. Take a baby aspirin every day, unless you are allergic to it or have had other bad effects from aspirin.
6. Move around! Be as active as you can. Make physical activity an everyday part of your life.
7. Eat less fat in general, and especially less saturated fat (fat that is hard at room temperature).
8. Eat more vegetables, especially low-calorie vegetables, and fruit. The vegetables and fruits that are deeply colored are especially good for you. For example, dark green, leafy vegetables, deep orange winter squash, blueberries, raspberries, and strawberries, and red watermelon all contain many vitamins and minerals and other substances that help to protect against heart attack and stroke.
9. Strive to reach and maintain a healthy weight.
I hope you all take the risk of heart attack and stroke very seriously. As I think of my own aunts and uncles who had diabetes (there were seven of them), I remember which ones worked at controlling their heart risk factors, and which ones didn't. I also remember which of them died when they were in their 40s and 50s, compared to the ones who lived well into their 80s. Now, as I face another stroke in my family, thinking about my aunts and uncles with diabetes who lived long and healthy lives provides me with the motivation I need to keep up my efforts to control my risk factors.
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DIABETES, FIRST IMPRESSIONS
by Fred MacDonald
I first learned I had type 2 diabetes on the night of October 9, 2003. I was resting in the local hospital with a severe infection in my left big toe (the "greater toe," on my medical chart). Neuropathy had deadened the feeling in my feet to such an extent I wasn't aware I'd developed an infection in a small cut -- and that had led to gangrene. I was a very sick person.
Now I learned the surprising news that I was diabetic. I had never shown any classic signs of the disease: excess thirst, frequent urination, I was never overly tired, and my weight, 150 pounds, was not that heavy either. I knew of no history of diabetes in my family, so I was stumped on how I had developed this condition (a more detailed check of the family history revealed one family member did develop diabetes, but only near the end of his life, so this information was ignored).
With the word "diabetes" ringing in my ears, I realized everything in my life was changed. I had always considered myself fairly healthy, and now I was facing a disease that would always be with me. As expected, my first reactions to the news were equal bouts of anger and denial, but as I was currently suffering from a serious side effect of the disease, it was hard to remain in the state of denial for very long.
The anger took longer to channel out of my system. My fiancee, and to a lesser extent my parents, had to deal with a person who wanted to lash out at the world. The hospital staff were doing a good job of treating the problems of my diabetes and gangrene, but I wasn't a 'willing' patient yet. I did what the doctors and nurses wanted, but nothing more. I was simply in a passive mode.
Julia, my fiancee, has dealt with low blood sugar for nearly 20 years, so she had some information about my new diagnosis. She gave my mother a number of books and magazines, so she could learn about my condition. Then, on one of her visits to the hospital, she brought two books for me to look over. I'm afraid her suggestion that I read them didn't go down well at first (let's just say that this was one of Julia's shorter visits).
As the days went by, my boredom started to take over, and finally I decided to look at one of the books. The introduction caught my attention -- this writer had the same problems I had.
I started to read like a person possessed. The information was clear; there was humor in it as well. Side stories and case notes made the work very easy to understand; but the best thing was the tone of the book. Anger over the disease, denial, doubts, and fears of the unknown, everything I'd been feeling was there, yet the volume also spoke of hope.
As I read more, my mood quickly changed. Yes, I had diabetes; but it wasn't going to rule my life. I was going to be its MASTER.
I spent time learning about my condition. My focus changed; I now worked with the staff to get well as soon as possible. I was determined to have a normal life again.
There were still serious problems. Since I had always been healthy, I had very limited experience with the general health care system. I learned I had to switch doctors, due to my insurance coverage (before this event I had always paid out of my own pocket for whatever care I needed). I was going to be out of work for quite a while, so I had to set up the paper work for short-term disability, but I was lucky, my insurance company had always given very good coverage, and was willing to do almost anything to help me get better, fast.
My employer's attitude was even better. Because I work for a human service organization dealing with people with various disabilities, they have a rather open attitude in dealing with matters such as this. I was told to take care of myself. My job would be waiting for me on my return.
My friends and family made certain I was visited regularly at the hospital. Get-well cards and gifts arrived, to keep my spirits up, but there were long periods of loneliness. Time seemed to stand still, every once in a while, and I kept hoping this would be the day I would finally get out of the hospital.
There was good reason for the delay. The infection in my foot was lessening, but was still powerful enough to pose a risk to my general health. Finally, one of the staff members made the decision to bring in a foot surgeon. After a careful review of the case notes and a glance at my foot itself, the specialist stated removal of the toe was my best option.
I told him I wanted the surgery done as soon as possible, so one day after being discharged from the hospital, I was back in, getting my left toe removed.
The infection was so strong that, besides having the toe removed, the doctor had to cut off two additional inches, to scrape the infection out of the good bone. After an extra day of bed rest, came the long road of home health care.
While it was good to be out of the hospital room, I still had to deal with many doctor appointments, paperwork for the insurance company, moving around on crutches, and keeping my injured foot up as much as possible. I discovered I was considered a "fast healer," for a diabetic, yet it seemed to me things were moving at a snail's pace. Finally, in early November, I was allowed out of the house to go to a local science fiction convention. I still had trouble moving around, but being around my friends and talking about something other than my diabetes did wonders for my spirits. Life was slowly returning to a more normal existence.
The holiday season was a bit strained, due to my limited ability to get around; but on the plus side, my oral medications were doing a good job of controlling my sugar levels. I could eat almost everything I wanted, as long as the quantities were limited. Yes, there were some things I had to give up; but if I needed a reminder about what could happen, all I had to do was look down at my left foot.
At the start of the new year, I went to another surgeon, to see what could be done with the large open wound on my foot. A surface skin graft was discussed; but the wound had to close up some more before the attempt could be made, thus more waiting. During this time, I often met with a diabetes educator to learn more about my new lifestyle, and with a dietitian, to deal with my food concerns.
Upon being discharged from the hospital, I had been placed on a 2000-calorie meal plan, but this had left me underweight. I was currently 137 pounds, and most of my regular clothes were too loose on me. I couldn't increase my carbs that much or my sugar levels would spike. Even by eating a lot of extra meat my weight wasn't going up. Finally, the sugar-free energy shakes were approved for my use. There are two types -- one to lose weight, and one to gain. Needless to say, I was given the latter. These shakes, taken twice a day, with some extra food, finally brought my weight to a more normal level. I'm still roughly five to eight pounds under my old weight of 150 pounds, but at least I look okay in my clothes now.
By mid-January my wound had healed enough to try the skin graft. The procedure was a limited success. For the first week it appeared the skin graft was going to take with no problem, but during the second week it started to fail. By the end of week three, most of the skin graft was dead, but as it died, it acted like a bandage, allowing the tissue underneath it to knit together faster. I still had a decent size wound, but its depth had decreased. This was a setback, but by now I was getting used to them.
Near the end of January, I was permitted to return to work. It had been almost four months, and I wondered if I would be able to do all my duties. I quickly discovered that it wasn't a big problem. Walking around the various work sites on crutches was difficult, but I could do it. My strength wasn't back up to full potential yet, but I had enough to get by. I was also very lucky there was very little snow or ice in my state that year.
After a few more weeks another great day came -- I was told I could put my crutches away and use a cane. My sense of freedom grew. Now I could carry something in my free hand.
The wound kept healing, at a fairly stable rate, but I was getting a bit frustrated. I was still wearing winter ski boots because of the dressing on my left foot. However, warmer weather was now in the area and my feet started to get very warm. At one point, I tried a pair of my dad's extra wide sneakers instead, but after two days I noticed some breakdown in the surrounding tissue, so I put the boots back on.
Currently I'm at a point where my injury is almost completely healed. I have been allowed to switch into any type of shoe, as long as it doesn't put any strain on the healing tissue. My sugar levels are under control, and there are not other signs of the dangerous side effects of diabetes. I have even regained a good sense of feeling in both feet. I was lucky my body has been able to repair itself. Even though I lost my big toe, my balance is still good, so I don't believe I will need special shoes. I also have friends, family, and co-workers ready to help me at a moment's notice.
Yes, I would prefer not to have diabetes; but I have learned some important guidelines about living with this condition. First is to seek out any information relating to the problems you have. With the data, you can make a better decision on the various problems diabetes throws at you. Second, remember diabetes is something you can LIVE WITH. There will be days the world seems against you, and you may want to give up dealing with your diabetes. DON'T GIVE INTO THOSE FEELINGS. Talk to a doctor, a family member, a friend, a co-worker, anyone who can give you a different viewpoint. It's true you have diabetes, but you don't have to deal with it just by yourself. Other people can help.
As one person told me: "With diabetes you have two kinds of people. The ones who work with their doctors, and the ones who don't. Doctors are more willing to work with people who take an active interest in the treatment of the disease, than to deal with the ones who just half-follow their advice."
This seem a pretty good standard for the care of diabetes. Be willing to work on the problem and you'll feel better, and most likely have a longer and better life. Do little or nothing and you start on the slow side to an early death. The final choice is your own.
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VOICE DISTRIBUTORS NEEDED
Since the VOICE is now offered free, our Diabetes Action Network will provide extra copies to anyone wanting to help spread the word. We will gladly send from five to five hundred-plus copies each quarter to be used as free literature. Medical facilities can order as needed for patients. Individuals can usually place copies of the VOICE in libraries, pharmacies, hospitals, doctors' offices, or other public locations.
Diabetes education is essential. Anyone who distributes the VOICE will be helping people with diabetes, and their families, to learn about the disease and its ramifications; to learn that they have options; and that their world is far greater than whatever "limits" may be imposed by the disease. If you would like to help spread the word by distributing the publication, please contact: Voice of the Diabetic, 1412 I-70 Drive SW, Suite C, Columbia, MO 65203; telephone: (573) 875-8911, fax: (573) 875-8902. NOTE: Please provide a phone number so we can reach you.
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A WORTHWHILE BOOK
by Peter J. Nebergall, PhD
DIABETIC EYE DISEASE: Lessons From A Diabetic Eye Doctor, by A. Paul Chous, MA, OD. Fairwood Press, 2003. Price: $15.99 plus shipping, available from Fairwood Press (www.fairwoodpress.com) or from Dr. Chous at: (www.diabeticeyes.com); or at telephone: (425) 432-5929.
There is usually a yawning (pun intended) gap between "professional" medical literature and the "dumbed-down" texts doctors put out for the consumer. The motivated consumer, who really wants to know, but lacks medical training, often has to choose between incomprehension and disappointment. Not here. Not this time. Dr. Chous comes to his material from both sides. He is a trained medical professional, ready to help you save your eyes; but he also is a diabetic, with personal experience.
His book covers basic definitions of diabetes and eye disease, the forms of damage diabetes can take, and what to do about preventing or minimizing eye damage. He shows how diabetes does what it does to the eyes - and what you ought to do about it. He details what you should expect from your eye doctor, and from your examination.