VOICE OF THE DIABETIC

The Diabetes Action Network of the

National Federation of the Blind

A Support and Information Network

Volume 15, Number 2, Spring Edition 2000

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: http://www.nfb.org

and follow the links for "diabetes."

Copyright 2000 Diabetes Action Network, National

Federation of the Blind. ISSN 1041-8490

Note: The information and advice contained in VOICE OF

THE DIABETIC are for educational purposes, and are not

intended to take the place of personal instruction provided

by your physician, or by your health care team. Discuss any

changes in your treatment with the appropriate health

professionals.

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INSIDE THIS ISSUE

69 YEARS WITH DIABETES: HAROLD FELENDER

MANY BLIND DIABETICS SUCCESSFULLY USE INSULIN PUMPS

by Ed Bryant

TEN YEARS WITH MY INSULIN PUMP

by Joanna Stottler

AN OPEN LETTER TO READERS

by Marc Maurer

DIABETES: WHERE WE ARE TODAY, WHERE WE'LL BE TOMORROW

by Frank Vinicor, MD, MPH

BENEFITS OF THE INSULIN PUMP

TYPE 1 DIABETES PREVENTION TRIAL NEEDS VOLUNTEERS

TYPE 2 AND HEALTHY LIFESTYLE

by Peter J. Nebergall, PhD

TAKE TIME TO SMELL THE ROSES: MARIA JOHNSON

TYPE 1 VACCINE?

BOOK REVIEWS

by Marilyn Helton

RECIPE CORNER

ASK THE DOCTOR

by Wesley W. Wilson, MD

DIALYSIS AT NATIONAL CONVENTION

by Ed Bryant

2000 NATIONAL CONVENTION

COOKING WITH SUZI

by Suzi Castle

FOOD FOR THOUGHT

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

(Resource Column)

69 YEARS WITH DIABETES: HAROLD FELENDER

Photo: portrait. Caption: Harold Felender

"I was born October 19, 1918. I can't remember

exactly when I was diagnosed with diabetes--I believe I was

12 or 13 years old. I was very young, and I'm 81 now. I

went into the hospital at Christmastime, but I don't

remember which year. I've had diabetes at least 69 years...

It could be even more.

A little incident in that hospital sounds funny now.

First I went to the clinic, and from there they sent me to

the hospital. It was Christmastime, then. My diet was so

restricted... They served me a tray with a little ornament-

-a gumdrop and one of those candy bubble ornaments. I ate

the whole thing! I was so hungry I ate anything that was

around. It was kind of cute. You weren't supposed to eat

that kind of thing--I found that out later.

I wasn't in a coma, yet. I urinated a lot, all the

normal symptoms of new diabetes. Fortunately, they got me

OK before I passed out or anything.

I was taught, there in the hospital, how to give myself

shots. My mother had tuberculosis, so she was not at home,

and my grandmother was there but she didn't know too much

about those things, so I had to do everything myself. The

hospital staff taught me... I think they used an orange or

a grapefruit for me to put the needle into, just to get the

feel of it.

I ate a lot of oranges in the evenings, back when I was

young. That was my bad time--lots of hypos--and we would

buy dozens of oranges and I would eat them quite a bit.

Oranges used to be a pretty standard thing to get you back

up. I couldn't use any sugar back then. But I used to slip

a bit into my coffee to give it a little flavor, you know.

I started out with three shots a day (there was only

Regular insulin, those days). I was going to school, so

they took that into consideration, and shifted me to two

shots, morning and night. Now I'm on a sliding scale

besides two shots a day. Now I use the Ultralente for

morning and night and in between, on a sliding scale, I use

Humalog.

You know, I was a Boy Scout. I made Senior Patrol

Leader, and even went on an overnight, sleeping in a pup

tent, with my insulin.

My sugars fluctuate too much, now. They call it

"brittle diabetes." My numbers can go from 350 down to 80

or 70, and I won't feel any different. I don't really know

why all this happens. Sometimes, you do a lot of exercise

or something and you know that will help bring it down. But

I found out later that when the sugar was high to start

with, exercising could make it even higher. (Editor's Note:

Doctors advise caution starting physical exercise with a

blood sugar reading of 250mg/dL or higher. Diabetics should

consult with their health care team before beginning an

exercise program.)

I was strict on my diet. I didn't eat sugar. That was

the main thing. As far as everything else, I would eat most

any food that didn't have added sugar. I ate within reason,

I didn't measure anything. The hospital put me on an 1800-

calorie diet and that seemed to be plenty for me. They

increased it to 2000, I think, when I got married.

Of course when they released saccharin for diabetics

that was really great. I've used that for over 30 years. I

still use it as a sweetener.

My wife, Beatrice, and I had three children. Those

were the days when they thought it wasn't too wise for a

diabetic to have children. But we went ahead and we have

three lovely children. My wife passed away two years ago.

She had cancer.

My oldest is Donna. My son, Duane, was next. And the

baby is Elizabeth. They are all married and have their own

children. The first was born in '41. One about four years

later and the last one was four or five years after that.

My oldest, Donna, is the one who takes care of me all the

time. The youngest daughter is in South Carolina so she's

out of the picture. My son is in Simi Valley, California,

but he has to work all the time, so he comes in the evenings

and during the weekend sometimes, and we go to dinner. But

my daughter is here every week and calls me every day.

From the Editor: Daughter Donna describes her father

as "amazing... strong in mind and body, someone who figures

things out. Diabetes never seemed to interfere with any

part of his life," she says. "I have diabetes as well, and

he has been a role model--I look at him, and know I'll be

all right."

To keep track of my diabetes, in those early days

(Harold continues), I regularly tested my urine. I didn't

have to use the test you boiled over a Bunsen burner. I had

strips you dip into the urine, then look at the color.

That's what I used for a long time.

When I was young, my diabetes seemed to be under

control. Once we first got married, my wife, Beatrice, took

over my diabetes management. She was really excellent. She

watched everything. I didn't have to do a thing. I

depended on her, and that's what made it so difficult when

she passed away. I didn't know anything. I had to learn

everything again.

I started out as a sheet-metal worker, making aircraft.

That was another thing. Jobs were scarce at the time and

just before I got married I went to North American Aviation

two times. And they didn't hire me. But then I went to an

air conditioning school, that agreed to find me a job. When

I finished the school, they sent me back to North American,

and I got the job. I had diabetes, but in those days you

didn't advertise it too much. So that's one reason I guess,

they did take me on.

In 1970, when only our youngest daughter, Elizabeth,

was still living at home, she decided she wanted to attend

college in Israel. Not taking it seriously, I told her we

could not afford to send her, but that if she could find me

a job there, we would all move to Israel, so she could

attend the college. I thought that a fair offer, as I was

working for Rockwell Rocketdyne, and had 33 years of

seniority at the time.

A few months later, I received a formal questionnaire

from Israel. I completed and returned it, and shortly

received a 3-year contract from Israel Aircraft Industries,

which would also pay our moving and transportation both

there and back to the U.S.A. This would be a great

adventure.

Once we arrived in Israel, our first emergency was

finding out that the only insulin Israel produced was U-40,

far less concentrated than my U-100. Plus, the insulin

types I was using were unavailable. We immediately had my

company wire New York, and had some insulin flown in. This

was expensive.

The next thing we found was that their syringes had a

needle about 1/16 inch diameter--big! The people using them

had a scab each time, but didn't know any different. We had

my daughter Donna, in the U.S.A., send us the needles I

needed, and later we found drugstores that imported the

insulin I needed. All this went on while I was working with

the Westwind business jet.

As I was working all day, my wife Beatrice had to do

all the running around, on the bus (we didn't get a car

until later). Finding different drugstores, in a strange

town and different language, she earned more than her pay

then.

I joined Lodge #51 of the Free and Accepted Masons,

there in Israel, and stayed involved with them. When we

returned to the U.S.A. in 1980, we transferred to a Masonic

Lodge near where we lived, in Canoga Park, California. When

I moved to Coldwater North Co-Op, North Hollywood, I

transferred to Beverly Hills Lodge #528, and went through

the stations, becoming Master of the Lodge in 1991.

Now, it's much easier for a diabetic to get jobs. Some

companies are still restrictive, but generally it's easier

all around. Of course, I'm Jewish, and I had more trouble

getting a job being Jewish when I first started than having

the diabetes! But, that's another story. I ended up

professionally as a quality assurance engineer. I was a job

shopper the last five years I worked. It's higher than an

inspector. It was for metal work, but I worked in

electronics, too. Some people say I had too much experience

for the years that I worked.

I have a lot of friends and family, not close, but

distant, who have diabetes, and who thought it was a joke.

They would take some beer sometime or would eat chocolate

bars sometime, and they paid the price--the side effects of

diabetes. In the end, it killed some of them--the side

effects. I would say definitely to watch the diet. That's

the important thing. The exercise? I never believed in

tying myself down to a routine of exercise which I knew

every day I wouldn't be doing. But some exercise is

definitely good. And they say walking is the easiest thing,

which I used to do. I used to walk three miles in about 45

minutes which is about three miles an hour, not fast.

I am having some problems now. I haven't had any

amputations or anything like that. I'm passing out from the

low blood sugar reactions. I don't have any warning, I

don't feel anything's coming, but out I go. Like Saturday

night here. We went out for lunch and finished about 3:00.

And about 7:00, I came in to take a test at home and my

meter said "error." So I tried it again and it said "error"

again. The third time I really watched everything I was

doing to be sure I wasn't doing anything wrong and it said

"error" for the third time. I went to get my manual, and I

passed out.

I test six to eight times a day. I have to now. It

fluctuates so much and I pass out so easy that I have to be

more careful. (Editor's Note: The "hypoglycemia

unawareness" Mr. Felender describes is not uncommon, and the

actions he takes in response, to test more often and be more

careful, are the correct ones.)

The people who have diabetes, they don't have to worry

about being so exact and everything, you know. It isn't

torture to have it. It's just if they stay away from foods

with sugars. Now that everything is marked, it's much

easier. If something has more than 2 grams of sugar, I

don't use it except for special purposes. I control it that

way. I try to use zero sugars in all the foods I eat.

From the Editor: Although the concept of "diabetic

diet" has moved on from "no sugar" to meal planning that

controls the entire food intake, allowing sugar in

moderation while limiting fat intake, Mr. Felender is right,

it is important to stick to your diet, and to test blood

glucose regularly. He is to be congratulated for his

diligence, and for doing so well.

MANY BLIND DIABETICS SUCCESSFULLY USE INSULIN PUMPS

by Ed Bryant

Photos (5 total, in order): portraits. Captions (in

order): Tom Ley, Donna Blake, Sally York, Anne Whittington,

Veronica Elsea.

Insulin pumps, which deliver a continuous dose of

insulin, are being used by more and more diabetics, blind

and sighted, to achieve better diabetes control.

Unfortunately, there are health professionals who assume it

isn't possible for a blind patient, or one with severe

vision loss, to operate an insulin pump. Too many health

professionals, and some blind people, have the misconception

that blindness is synonymous with inability.

This article is intended to educate both the health

care community and blind diabetics, to show them that most

people with type 1 diabetes can successfully use an insulin

pump if they desire.

Today's pump is about the size of a deck of cards, and

is computerized. Insulin runs from the pump, through a tube

(catheter or cannula) which is usually attached to the

abdomen or thigh. Insulin is delivered under the skin,

through the tiny, flexible tube. The user programs the pump

for basal (continuous) delivery, small amounts of short-

acting insulin 24 hours a day. He/she also programs the

insulin pump for bolus insulin delivery, to receive extra

insulin just before eating. Insulin pumps have several

different controls and alarms, and your doctor may want you

to spend a few days in the hospital for training.

Insulin pump users need to check their blood glucose at

least four times a day. Since only short-acting insulin is

used, it is important the user check blood sugars regularly

to avoid really high or low blood glucose. Warning: If the

needle, or catheter, comes out from under the skin, there is

no warning alarm to alert the user; and ketone can start

building up in about one hour. With little or no insulin in

the body, ketoacidosis can develop in just a few hours.

Note: Pump users say the needle or cannula rarely, if ever,

comes out; and if it does, they can feel what happened.

Additionally, if the needle has detached from the skin, then

insulin will flow onto the clothing which will after a while

become wet. Most users should also be cognizant of leaking

insulin, as it smells very bad. To reiterate, it is

important that you closely monitor your blood sugars.

An insulin pump might be what you need if you are

having major problems controlling your blood glucose with

insulin shots. You might consider a pump if insulin

injections do not keep your blood glucose near a normal

level, or if you have big glucose swings. Nighttime can be

difficult for some, because they have episodes of

hypoglycemia, or get up in the morning with high blood

sugars before breakfast. The pump can be programmed, so it

can deliver less insulin at night and more insulin before

dawn, minimizing nighttime lows and before breakfast glucose

highs. We should all be monitoring our blood glucose,

working toward tight control. We should all be working with

our health care team to reach euglycemia, normal blood

glucose.

You may be able to wear your insulin pump while bathing

or swimming. Some pumps are waterproof and some come with a

water protective case.

Insurance

Some insurance companies will help with the cost of

pumps and supplies. They realize better diabetes control

means less diabetes complications, less time in the

hospital, and a bottom line of less expense for the

insurance provider. Your doctor should be able to help show

insurance companies the value of covering the cost of pumps

and supplies.

As of April 1, 2000, Medicare began helping type 1

diabetics with the cost of pumps and related supplies. For

information, telephone: 1-800-633-4227, and ask for

"Durable Medical Equipment."

Pump Manufacturers and Costs

Disetronic Medical Systems, Inc.

5151 Program Avenue

St. Paul, MN 55112

telephone: 1-800-280-7801

website: http://www.disetronic-usa.com

They offer the H-tron Plus which costs $4,995, and

comes with a second, backup pump (after 30 months, you send

the first pump back for servicing, and use the backup).

Their much smaller pump, the Dahedi, about 2/3 the size and

weight, should cost about $5,000, and has simple, two-button

programming (but no backup pump). Disetronic says this pump

will be available in May. Their newest insulin pump, the D-

Tron, scheduled for later this year, will offer computer

interfacing, increased programmability, vibration and audio

alarms, plus compatibility with insulin pen cartridges (no

price data yet). Supplies for any current pump, including

test strips, cost about $300 per month. Disetronic does not

currently provide adaptive instructions on audiocassette--

and when I asked them, they said they were afraid of

"litigation."

MiniMed Technologies

12744 San Fernando Road

Sylmar, CA 91342

telephone: 1-800-933-3322

website: http://www.minimed.com

They offer the MiniMed 508. It costs $5,495. Again,

supplies, including test strips, should cost about $300 per

month. This pump allows remote control setting with a key-

ring sized "control unit," and a "vibrating" mode can be

chosen, instead of the beep, for both settings and alarms.

Minimed is currently working with our Diabetes Action

Network to produce an audiocassette of instructions for

blind pumpers.

The insulin pump is an amazing device. If you have

type 1 diabetes, and need to use insulin, the pump best

approximates the function of a healthy, non-diabetic

pancreas. Can a blind diabetic use it, fill it, program it,

attach it, independently, without sighted aid? Absolutely.

As I said, there are still people who believe

otherwise, and some who just don't know. Who are the

"experts" in this case? The blind pumpers who are doing it

for themselves. Here's what they had to say about their

pumps:

Why should a blind diabetic consider the insulin pump?

Susan Stewart, a blind pump user from Medina, Ohio,

says: "I've always wanted to be on the pump; it was a

convenience thing. The pump gives me more flexibility. If

you're considering an insulin pump, definitely really look

into it, because it has given me independence and

freedom..."

Tammy Rupp, a blind pumper from Carrolton, Georgia,

says: "The good thing about the pump is that you can be

real flexible. You don't have to be on a schedule. You can

be, but you don't have to be."

Sally York, a blind pumper from Castro Valley,

California, and Board Member of our National Federation of

the Blind Diabetes Action Network, says: "My MiniMed

insulin pump has given me back my independence. I can't

imagine going back to life on multiple injections. I can

honestly declare my pump has given my life a positive

boost."

What specialized techniques do you use to manipulate

the pump without sight?

"With respect to filling the syringe," says Tom Tobin,

a blind pumper from Cleveland, Ohio, "I have developed a

system that works well without any sighted assistance.

First, when filling the syringe, I pull down on the plunger

until the bottom of the syringe barrel and the plunger are

about the distance from the tip of my index finger to my

first knuckle; so as a measuring device, you always have

your knuckle.

"Then, as with a regular syringe, I tap the sides of

the syringe barrel and then push the insulin back into the

vial. I repeat this step until I cannot hear any "bubbles"

escaping when pushing the insulin back into the vial; there

should be a "smooth" sound.

"Next, since air may trap at the top of the syringe

itself, I pull a little air into the syringe and push up on

the plunger ever so slightly until insulin comes out the tip

of the needle; just a little push. That completes filling

the syringe.

"Next, while holding the syringe in my left hand, I

take the infusion tubing and remove the cover at the end of

the tubing that goes over the neck of the syringe, where the

needle once was. Make sure that there is a snug fit as you

tighten down the collar of the infusion set over the neck of

the syringe. (I sometimes use my teeth to make sure it is

really tight.) Then I put the plunger of the syringe on a

flat surface, usually a table top, and begin pushing down on

the barrel of the syringe, thus filling the infusion set. I

want to stress, that this should be done very, very slowly

to avoid any pocketing of air in the tubing. If it is done

right, there should be no air bubbles at all in the tubing.

Letting a drop fall on the back of your hand is fine,

although I put the needle guard at the other end of the

infusion set between my teeth, and use my tongue to feel

when the drop falls. Whatever works for you."

Tom Ley, from Baltimore, Maryland, a blind pumper and

former president of our NFB Diabetes Action Network, says:

"The process of filling the Mini Med 507 C pump with a fresh

supply of insulin can be performed successfully by a person

using non-visual techniques. I will cover the subject of

inserting the cannula into the skin and securing the cannula

with tape. Let me say, at the beginning, that not once in

my two years of experience has the cannula ever crimped or

otherwise unsuccessfully seated itself under the skin when

being implanted. I also find this aspect of the process

very easy non-visually.

"It is much like giving a shot in many ways. Once the

needle is inserted into the skin, a piece of special tape is

used to hold the cannula in place. The tape is designed in

such a way that is extremely easy to position correctly

without yet exposing the sticky side of the tape. Once the

tape is in place, three pieces of paper that cover the

sticky part of the tape must be removed. The pieces of

paper are pre- folded and shaped by the factory to make

locating and removing extremely easy.

"Then, the final step is to remove the needle from the

Teflon cannula. One simply must locate the large plastic

end of the needle protruding from the skin through a hole in

the tape, twist it a quarter of a turn, and pull out to

remove. It is possible that the cannula might crimp as it

is being inserted. However, it is standard operating

procedure to check your blood sugar an hour after changing

the pump set. If the sugar is abnormally high, then a set

of procedures should be followed to remedy the situation.

This is no different than what a pump user does any time

blood sugars seem unusually high. As said earlier, in two

years, I have not yet experienced any problems of this

nature when changing my pump set."

"One of the first things I learned was to line up my

insulin bottle with the needle and syringe that holds the

insulin in the pump," says blind pumper Donna Blake, from

Waterbury, Connecticut. "This may have not seemed like much

but at that time, I had never seen a Count-A-Dose (tactile

insulin measuring device that enables blind people to

accurately measure insulin without sight), nor had I heard

about any alternative techniques for taking care of insulin

and blood sugar needs.

"After I got the syringe filled, I devised a simple way

to connect the syringe to the tubing aseptically (in a

sterile manner). I placed my thumbs together guiding the

hub of the syringe into the Leur lock of the tubing. I drew

the syringe back two fingers' width and this gave me the

correct amount of insulin for three days. Next, I realized

that I had bubbles that I did not know about, so back I went

to step one. I found by pushing the insulin in and out of

the bottle several times (gently), I could eliminate almost

all of the bubbles--most of the time, all of the tiny

bubbles.

"In order to ensure that all of the air was out of the

syringe, I would lightly tap the syringe on the side of a

table to bring the bubbles to the top. Then I took the

syringe, pulled a bit of air into it, reinserted the needle

into the bottle of insulin and shot out the air. I then

tapped the needle on the side of the table and pushed the

plunger until a few drops of insulin came out (you can

really smell the insulin). I connected the tubing and the

syringe. I held the syringe and the first few inches of

tubing upright and slowly depressed the plunger so the

insulin filled the initial portion of the tubing without

bubbles. I continued pushing insulin through the tubing

until I felt a drop fall out and hit the back of my hand.

"I was almost ready to insert the needle/catheter. I

began this stage of the procedure after a shower where I

scrubbed the site, where the catheter was placed, thoroughly

with soap. I dried this area off with a clean towel,

separate from my other towels. Next I prepared the site

with a liquid spray called "Sween Prep," a protective skin

coating that keeps me from having an allergic reaction to

the adhesive placed over the catheter site. While this

stuff dried, I placed the syringe in the pump and primed two

units of insulin through. This step ensured that the

syringe inserted snugly within the pump and I did not miss

any dose of insulin.

"When my site was ready to receive the catheter, I

inserted the needle just like anyone else with diabetes does

giving an injection. After I inserted the catheter, I

pulled out the small (25-gauge) needle and placed a

protective tape over the catheter and now I could go for

about three to four days."

What adaptive features are there to help you?

"It has a tone-activate button," says Tammy Rupp. "You

press it, and it has a tone, and you count the tones for

each unit you need, to get your insulin bolus. Mine goes in

whole units; it can go in half-units, too. And it will

automatically count it back to you so you can check it.

"There's also a select button that you use with the

activate button, to clear the pump's alarm, if it goes off.

There's an alarm for "low battery," for if something's wrong

with the infusion set, or if the pump is out of insulin. It

beeps six times when you're out of insulin.

Visually-impaired pumper Anne Whittington, MBA, MSN,

RN, CDE, from Augusta, Georgia, says: "Initially I was on

the MiniMed 504. I found the buttons cumbersome (with my

rheumatoid arthritis) and the contrast poor on the screen.

In 1993, I switched to the Disetronic pump. The audible

alarms and crisp contrast met my needs well."

Susan Stewart says: "My insulin pump has a screen,

which I cannot read, that shows date and time, and when the

alarm goes off, it tells what the alarm is for. It has four

buttons, and one of them is the "select" button, with which

you select whatever screen you want. I use it by counting.

Once I hit the activate button, it beeps. And it has the up

and down arrows. When I do a bolus before I eat, I push the

button. Say I want ten units; I'll push the button up;

it'll be 20 beeps. Then I push the activate button again,

and it will replay the number of beeps, each 1/2 unit of

insulin, that I selected. Another push on the activate

button, and it will start giving me the insulin."

What about the cannula? Does it bother you? Is it safe?

Veronica Elsea, a blind pumper from Sylmar, California,

says: "The insulin is delivered through a needle or

cannula, which is placed anywhere you'd give an injection

with a syringe. I only use my abdomen; I find it easier and

more reliable. I use a Teflon cannula called "Tenders,"

made by Disetronic. I find them easy to insert and very

forgiving. In fact, if you have any neuropathy in your

hands, you may actually find these cannulas and cartridges

quite a blessing, as they're fatter and larger than regular

syringes. The "Tenders" are inserted at an angle, anything

up to 45 degrees or so. I just hold it at a slant, push it

in and don't worry about it! As you might expect, once you

insert the cannula and remove its insertion needle, it is

held in place with tape. With the new "Tenders," the tape

is part of the cannula, so I no longer find myself holding

something in place while searching for a piece of tape

somewhere on a table! It's designed for one-handed

operation by a sighted person, which means we can do it

easily and comfortably with two.

"Only once, during an exuberant "good morning," did my

guide dog reach up and catch her paw in the tubing. It's a

weird feeling when you catch the tubing on something, but it

takes real effort to knock out the cannula."

"I'm not afraid that the catheter would fall out," says

Susan Stewart. "I use three pieces of medical tape holding

it in, and never in the months I've been using it has it

come out, unless I mean to, when I'm taking it off. You

have to really tug on it sometimes to get it off--the tape

is very sticky. Although there's no alarm that would sound

if it fell out, you would definitely know--you would notice.

For one, my shirt would be soaked with the insulin!

"Once you get used to wearing the cannula, and to the

need to rotate it, you can tell if something's wrong. I can

tell if the tape's loose. Usually on the third day, the

tape gets a little looser than the first or second days,

since you've taken three showers since you attached it.

"I can honestly say I feel practically no discomfort at

all from the cannula that delivers my insulin," says Tom

Ley. "I find its presence far more comfortable than taking

four insulin injections per day."

Do you have any advice for blind diabetics who are

considering

the insulin pump?

"A lot of people say to me, 'Oh, I want the pump and I

don't want to get injections anymore," says blind pumper

Tricia Kline, from Doylestown, Ohio. They think the pump is

the easy way out. And I would say, unless you have the

commitment to continue, if you think all you have to do is

get a pump and you can eat anything you want to, that you

don't have to do this and that, and you don't have to do

blood sugar testing, unless you are committed to do that and

really work at it, you won't succeed with the pump. It's

not less work. Sure, some people think you throw out your

injecting needles and that, but it's still a big commitment.

And unless you're willing to do that, and willing to, and

have the confidence to do, your own adjustments, you won't

succeed with the pump. You have to develop, with your

doctor, a sliding scale; like if my blood sugar is this

much, then I take this much insulin, or if it's low I take

this much less. You get to know your body. But unless

you're willing to gain this much confidence in yourself to

be able to make these changes on your own, you will drive

your doctor crazy."

Anne Whittington says: "Before selecting the company

with the best pump for you, consult your diabetes management

team members. These team members go beyond your doctor, and

include your nurse dietitian, blind rehabilitation

specialist, and whoever else may be assisting you in

learning about the pump and its day-to-day operation. Also,

please speak with customer service representatives from the

major companies before you select a pump. Explain to them

your needs as a blind person. Both Disetronic and MiniMed

have very helpful service personnel."

"With the MiniMed 507 pump at my side," says Tom Ley,

"I'm eagerly beginning a new phase of my life with diabetes.

After 25 years, I welcome days free from insulin injections.

I'm excited about the prospect of fewer high and low blood

sugar incidents, and I will enjoy my new mealtime

flexibility immensely. I'm comfortable, confident, and

content."

TEN YEARS WITH MY INSULIN PUMP

by Joanna Stottler

Photo: portrait showing pump. Caption: Joanna Stottler

Retired nurse Joanna Stottler has had type 1, insulin

dependent diabetes for 52 years. A veteran of both sides of

diabetes care, she has also, for the last 10 years, been

using an insulin pump, instead of a syringe, to supply the

insulin she must have. Here she shares with us some

observations on the insulin pump.

"My doctor suggested I try the pump (he tried for eight

years!), but at first I didn't like the idea of its

catheter--I didn't want to be connected up to a machine!

Also, I didn't know any other diabetics. But I finally came

around to his point of view. So what did it?

I was a nurse in a hospital diabetic unit then, and a

person came in from MiniMed (an insulin pump manufacturer)

to talk to us nurses about the pump. And at that time I

thought, well, gee, this sounds like a pretty good thing.

But, like I say, it took me eight years to decide that was

what I wanted to do. My doctor was the one who put the idea

into my head, but I really didn't connect with it until I

met the MiniMed representative through my work.

When I made the decision to try the pump, 10 years ago,

I was taking approximately three to four shots a day, and my

blood sugars were not doing well. Every time I went to the

doctor, he would change my sliding scale. I tried-- but it

just seemed like I couldn't figure out how to get my blood

sugars even. It was just up and down all the time, with

A1c's of 8 or 9. And I was still feeling ok, but I just

couldn't get the tight control that would be good for a

diabetic. That has changed now.

Back when I started, I felt like the pump was some kind

of secret thing. I tried to find diabetics who were using a

pump, and I couldn't find them. When I did find some, these

individuals weren't that interested in discussing it with

me, for some reason. Now, there are a lot of new users, so

it is far easier to find someone to talk to; but I truly

believe that people who use the pump should share their

knowledge, help spread the word.

The pump is a very simple device. It holds a reservoir

of insulin, and a pump that dispenses a tiny amount of

insulin, every few minutes, according to how you set it. It

dispenses two ways: the basal rate and the bolus. The

basal rate is the basic 24 hours a day "floor;" but it

doesn't have to be the same rate each hour of the day. You

can change it for different hours of the 24-hour period, at

certain times of the day when you need more or less insulin.

The basal rate means if you don't eat anything at all for 24

hours, with this insulin pump your basal rate will still

give you normal blood sugars. Now that is the ideal. And

that will occur. If I don't eat anything for 24 hours, but

my basal rates are set correctly, I will not run into

trouble. I can have normal blood sugars for that period. A

person on multiple injections cannot do this, but a pump

user can.

I use quick-acting Humalog in my pump. And, like I

say, there's no back-up insulin to take over if something

happens with the pump. (NOTE: Wise pump users keep an

insulin vial and syringe available, in case the pump

malfunctions.) But if my pump is working correctly, as it

does for most of the time, and if I don't eat for 24 hours,

my blood sugar will stay normal at my basal rate. And I

also have multiple basal rates to choose from (my basal rate

doesn't stay the same all the time), as it depends on my

blood sugars and on the Dawn Phenomenon (the early morning

blood sugar rise).

The other insulin dose a pump dispenses is called the

bolus, and it is the specific dose of insulin you give

yourself to cover a specific meal. Depending on how many

grams of carbohydrates you eat at each meal, you set your

pump to give yourself a specific bolus of insulin. My bolus

is 1 unit per 15 carbs. And then I also include my protein

in that, along with my carbohydrates. So the number of

carbohydrates I have in the protein, and the number of

carbohydrates I have in the meal, I will count up, and then

give myself a bolus equal to 1/15 the number of

carbohydrate grams consumed, for breakfast and lunch. And

then for dinner it's 20 carbs for 1 unit. It doesn't depend

on the number of calories. It depends on the number of

carbohydrates.

There are a few things on the pump that are really

great. My pump has a light on it, so if you're in a movie

or something and you want to see what you're bolusing you

can do that. And there is a feature called a "Square Wave

Bolus," which is what you can bolus in over a period of

time. If you eat a meal heavy in fats, it takes you longer

to digest, so you use a square wave bolus over a longer

period of time. You can have the bolus go in over two hours

rather than all at once. And there is also a temporary

basal rate, which means if you're exercising, or if your

blood sugars are too high, or if you're sick, you can put in

a temporary basal rate, and increase your basal rate over a

certain period of time, too, for certain hours. That's only

temporary, and then you can bring it back to what your

normal rates are.

I test my blood sugars a minimum of six times a day.

You want to do it a lot, because you need to set your basals

and your boluses right. I can get by with four, but I

prefer doing it six because it helps me know what I'm doing.

And it helps me be able to regulate my pump correctly. You

have to do that.

Remember, the pump is just a mechanical device, and you

are still the one in control behind the pump. It's not

automatic, controlling the settings. If you're not going to

do the finger sticks, I would say a minimum of four times a

day, it's real hard to do the pump. And another thing, you

know I've been sticking my fingers for a long time, and it

doesn't bother me anymore. I know a lot of people who it

really bothers. But it's just a part of me, like my diet is

part of me.

I get discouraged at times, like every diabetic, and

it's not easy. The pump takes a while to learn in the first

place. But you have to realize that it's more like a normal

pancreas than shots are. The pump works like a normal

pancreas, more or less. Now if they could get the blood

sugars somehow connected to the pump, that would be a big

plus. Someday!

If people think about the pump, and wonder if it might

be right for them, and they really don't know anything

about it, I think that they need to call the manufacturer

(MiniMed or Disetronic) and get some information. The best

thing is to meet somebody who uses it, and at least look at

it. Remember, I never saw it in the eight years I wanted

to be on it.

I wear my pump on my waist. I just clip it on. And

there are different things you can attach it to, but most of

the time nobody can really see it. It stays on 24 hours a

day and I change it about every two to three days. I use

the Sof-Set, a small Teflon catheter. It's not a needle.

They have different ones. It goes into the skin at an

angle. The needle goes in, and you pull the needle out and

the Teflon catheter stays in your skin. And then you just

tape it down then and you're set. You don't even feel it

when it's in there.

The pump costs a lot, but I think a lot of times that

insurance will cover it. But if they don't, sometimes

different companies will support you. I did read someplace

that the companies are getting more involved in having

payments being made. The company will pay for it up-front

and the patient can pay them back or something like that.

I'm not exactly sure what it is. I know there are a lot of

people who can't afford the pump.

The pump is not just for type 1 diabetics. There are

a lot of Type 2's who take a pill every day, and think their

diabetes is under control. They take one blood sugar test a

day and think that this is fine. It's terrible, it's just

awful. I see this, because I belong to a pump support

group. And that's real important, too, for people to belong

to a pump group.

I've been very happy with the pump. Can't imagine

going back to shots again. Intensive insulin therapy is

probably what the next best thing would be.

You still have to be in very good contact with your

doctor and your educator. This is really important--to get

those basals right, because the basal is like the foundation

of the house. If your basals aren't right, you don't have

good control.

For more information, contact the insulin pump

manufacturers:

Disetronic Medical Systems, Inc: 5151 Program Avenue,

St. Paul, MN 55112; telephone: 1-800-280-7801; fax: (612)

671-6061; website: http://www.disetronic-usa.com

Minimed Technologies, Inc.: 12744 San Fernando Road,

Sylmar, CA 91342; telephone: 1-800-933-3322; website:

http://www.minimed.com

AN OPEN LETTER TO READERS

by Marc Maurer, President, National Federation of the Blind

Photo: portrait. Caption: Marc Maurer

From the VOICE Editor: This article first appeared in

the Braille Monitor, Volume 43, No. 2, February 2000,

published by the National Federation of the Blind (NFB).

Because diabetes is the biggest producer of new blindness in

the United States, the NFB is the principal funding source

for VOICE OF THE DIABETIC. The following message is well

worth your consideration.

As many of you know, during the final months of his

life Dr. Jernigan devoted much of his creative energy and

imagination to planning an exciting new facility to be built

on our property at 1800 Johnson Street, which he named the

National Research and Training Institute for the Blind. A

little more than 20 years ago, when we first began

renovating the turn-of-the-century factory building that we

intended to transform into the National Center for the Blind

and the headquarters of the National Federation of the

Blind, many of us found it hard to imagine that we could

ever use all the space available in the block-long building.

We told each other that rent income from the unused areas

would help us meet day-to-day operating expenses.

Through these past two decades our dreams have expanded

to keep pace with our growing strength and experience as an

organization. The Materials Center and all the publications,

literature, and equipment it stores and ships; the

International Braille and Technology Center; NEWSLINE for

the Blind; bedrooms for visiting groups; and the expanding

staff to meet the demands of a growing organization: all

these have been added and require significant space to

operate.

Now the unimaginable has come to pass. We have just

about run out of space for the programs we are already

conducting. More to the point, our dreams of finding ways

to use our experience and expertise to improve programs and

increase opportunity for all blind people demand expanded

space if we are to carry out the training and research that

must be done.

Dr. Jernigan saw all this coming; that is why he

conceived the plan to erect a new building. We have

dedicated ourselves to bringing his dream and our own to

fruition. We have embarked on an ambitious capital campaign

to raise 18 million dollars during the next two years.

Never before have we taken on a program as demanding as this

one, but we have now begun discussing our plans and hopes

with foundations, corporations, and wealthy individuals as

we make contacts with organizations and people who might be

interested in helping us make our dreams reality.

Federationists have never been content to ask others to

do all the work for us. We may not have millions ourselves,

but we have always taken pride in doing whatever we can to

bring our dreams to fruition. The entire Board of Directors

have now made five-year personal pledges toward our campaign

goal, and many other Federation leaders and rank-and-file

members have begun planning their gifts.

The time has come for all Federation members and

friends to learn more about our plans in order to determine

what they can do to help. Perhaps you have friends or

family members who would be interested in making a gift.

Perhaps you have contacts that we should know about. I hope

that each of you will plan to make a significant gift, and I

know many of you will. What is significant? That depends

on your personal resources and responsibilities. The

Research and Training Institute will allow us to affect the

lives of blind people in ways we have never before dared to

attempt. A gift, no matter what its size, generous enough

to cause strain on your personal budget, will honor both Dr.

Jernigan's memory and you.

I ask each of you to take some time to reflect on who

you know and what you might do to assist in this ambitious

campaign. You can contact Vince Connelly, who is working on

this project, if you have ideas or information. Call (410)

659-9314 and ask for Mr. Connelly. I hope you will use the

pledge form printed at the end of the article to make your

personal gift and send it to NRTI Project, 1800 Johnson

Street, Baltimore, Maryland 21230.

So that you have a complete picture of opportunities,

here is a brief description of gift possibilities:

Contributors may choose to have their gifts recognized

through dedication to one of the Institute's Initiatives or

through naming opportunities associated with specific

floors, wings, rooms, facilities, equipment, or furnishings

of the National Research and Training Institute. Please

contact the NFB Capital Campaign Office for more information

on specific naming opportunities.

The Wall of Honor:

A permanent wall display listing individual donors

above the $5,000 level will further recognize contributors.

All contributors, including those below $5,000, will be

listed in the appropriate gift level on the Campaign Honor

Roll to be announced and published during the campaign

victory celebrations.

Gift Amount Title

$1,000,000+ Jernigan Circle, Master Builder

$ 500,000+ President's Circle, Program Builder

$ 250,000+ Director's Circle, Opportunity Builder

$ 100,000+ Leader's Circle, Independence Builder

$ 50,000+ Patrons

$ 25,000+ Partners

$ 10,000+ Benefactors

$ 5,000+ Fellows

$ < 4,999 Friends

What follows is the text of a document that briefly

describes the initiatives and programs we expect to

undertake as the result of this capital campaign. I hope

that the plans will kindle your imagination and fuel your

dreams. Join us in making the future our own.

The Campaign to Change What It Means to Be Blind

Vision for the Future

The spirit and passionate dedication of the over 50,000

members of the NFB are directed toward building a future for

the blind in this country that includes opportunity for

education, employment, and full participation in our

society. Our message is one of hope and personal

responsibility. We are determined to demonstrate that blind

people can achieve and prosper, if trained using a

philosophy of blindness that emphasizes capacity and mutual

support. We envision a new approach to helping blind

people--an approach which transcends ancient images of

darkness, ignorance, and isolation. We foresee a revolution

in services for the blind which views blindness as a

characteristic to be dealt with through the acquisition of

pragmatic skills and self- acceptance. We are a people with

abilities and dreams, a people of hope and tenacity, too

long held down by our own and others' misconceptions and

fears. We are working toward a time when all of us can

achieve to our capacity and contribute fully to our society.

The next chapter of blind people's struggle for full

integration into all aspects of our society will include the

nation's first research and training institute inspired and

operated by the organized blind. We have long known who we

are; now it is time to demonstrate and implement model

programs and services that will forever change what it means

to be blind.

The National Research and Training Institute for the Blind

A new five-story, 170,000-square-foot building will be

attached to the present national headquarters of the NFB,

located in Baltimore, Maryland. The new facility will

include a research library, technology training labs,

classrooms, a distance learning center, an adaptive

technology development center, and office and flexible

meeting space. We have begun an 18-million-dollar capital

campaign. Funds are being solicited from members and

individual supporters of the NFB, corporations, foundations,

and governmental sources. The goal is to raise the needed

funds by summer 2001 and to complete the project in the

summer of 2003.

At least 50 percent of this country's 1.1 million blind

citizens will be directly affected by the programs,

research, and technology developed during the first ten

years of the Institute's operation:

* Through the use of newly developed distance learning

technologies and training methods, we will work toward

providing an opportunity for all of the 57,000 blind

children in this country to learn Braille and other

needed skills.

* The 788,000 blind seniors today, and the projected 1.6

million by 2015 and 2.4 million by 2030, will have

access to improved services and resources stimulated by

the senior initiatives of the Institute.

* Partnerships between private-sector employers and the

NFB will result in lowering the 74 percent unemployment

rate among working-age blind people in this country.

* Non-visual speech and Braille technology will be

developed, making it possible for the blind to access

an ever-increasing number of services and resources

delivered by computer technology.

Major Initiatives

The following initiatives will provide the structure

for the programs, projects, and services of the National

Research and Training Institute for the Blind.

Technology Access and Training Initiative

Technology is a critical element in both education and

employment opportunities today and will be even more so in

the future, for the blind just as for the general public.

Advances in speech, Braille, and large-print access

technology lead some to assume that the blind now have or

soon will have access to nearly all of what technology has

to offer.

Unfortunately, due to the widespread obsession with

visual design in technology, the shortage of good technology

training, the cost of equipment, and the rapid advancements

of technology applications, blind people now face the

dismaying prospect of being left out if non-visual access is

not continually updated and improved. This means that

advances in software and hardware must include design that

allows non-visual access.

The Institute will be the center of technological

advancement for the blind. Along with development and

promotion of adaptive technology, training will be provided

to ensure that the blind move smoothly with their sighted

peers into the emerging technological age and do not become

casualties of what Bill Gates has called the digital divide.

Blind Children's Initiative

The 57,000 legally blind children in this country face

unique educational and daily-living challenges. Today the

majority of blind children have other disabilities, are

educated in public schools rather than residential schools

for the blind, and have other individualized needs.

Blind children are often discouraged from using

alternative reading and travel methods because uninformed

parents and teachers believe that as far as possible their

children should avoid being labeled as blind. For too long

these useful tools of independence have been associated with

the negative stereotype of the hopeless, isolated blind.

Unfortunately this has resulted in less than 10 percent of

blind children being able to read Braille and many not being

able to travel independently.

Because the NFB knows that alternative skills are basic

to self-esteem among the blind and to successful employment

(today 85 percent of blind people who use Braille are

employed), we have already directed significant resources

toward changing this alarming trend. By establishing a

national Braille literacy campaign, promoting early mobility

training for young blind children, and contributing to

development of adaptive technology, the NFB has led the way

in innovation and change. However, because many school

districts are hiring only general special education teachers

rather than specially trained teachers of the blind,

families face a growing shortage of qualified educators and

services for their blind children.

Braille Literacy Initiative

In 1968, 40 percent of blind children in this country

read Braille, 45 percent read large print, and only 9

percent read neither. However, today less than 10 percent

of legally blind children read Braille, and more than 40

percent read neither Braille nor large print. This problem

reflects a dangerous trend: the functional illiteracy of

tens of thousands of blind children.

In the 1970's, blind children began to be mainstreamed

into regular classrooms. Most school systems did not know

how to teach children Braille, so they tried to teach the

children using any method available. For blind children

this meant listening and memorizing; they never learned to

read and write. For those with some sight, it meant the use

of magnifiers. Imagine trying to learn how to read when you

can see only one letter at a time. The result has been

predictable: many blind children have fallen behind in

school and as adults are now significantly limited.

For too long Braille has been associated with total

blindness and many of the misconceptions associated with

this disability. Parents of blind children are easily

convinced that, if their child has some residual vision

(even if that vision is minimal, unstable, or likely to

deteriorate), reading print will somehow mean their child is

not really blind. It takes people who are positive about

Braille and familiar with the real benefits of this

alternative technique to convince reluctant parents. Also

much work is necessary to upgrade the Braille skills of

teachers of the blind and to improve Braille-production and

Braille-teaching technology.

The National Research and Training Institute will be

the center of a growing Braille Literacy Initiative that

will ensure that the progress led by the NFB continues and

that Braille is recognized to be a communications tool as

essential to the blind as American Sign Language is to the

deaf.

Research Initiative

Despite the tremendous outlay of public and private

funds throughout most of the decades of this century, the

objective situation of the blind as a group remains

intractably bleak: 74 percent unemployment, functional

illiteracy for tens of thousands of blind children, and

exclusion from the mainstream of society. These facts make

it starkly clear that the techniques and systems used to

serve the blind in the United States are in dire need of

overhaul.

The unsolved problems demand innovative solutions.

Effective training programs that will teach the professors

who will teach the teachers and other professionals who will

teach the blind must be developed so that the age-old cycle

of dependency and despair can be broken. The Research

Initiative of the National Research and Training Institute

will focus on identifying and solving the root causes of

these endemic problems.

Blind Seniors Initiative

Less money is spent and fewer services are available to

those over 55 losing vision than to younger blind people.

Yet far more people lose vision after retirement age than

before. New approaches must be developed and taught to

state and local staff members in rehabilitation, older

blind, and older Americans programs and in centers for

independent living. The National Research and Training

Institute will bring together knowledgeable professionals

who will design materials and develop training programs to

assist state and local agencies in helping blind and

visually impaired seniors remain independent and continue to

participate in the activities they hope for in their

retirement years. Blindness can happen to anyone. Without

training and opportunity it can be devastating. In short,

seniors have huge needs. The Blind Seniors Initiative of

the National Research and Training Institute will focus on

finding ways to meet them.

Employment Initiative

Work is one of the fundamental ways in which

individuals express their talents, make a contribution, and

take responsibility for themselves. For too long many blind

people have been told by their families, teachers, and even

rehabilitation counselors that the world of competitive

employment is most likely out of reach for them.

Since its founding in 1940, the NFB has been committed

to the principle that otherwise-able blind people should be

expected to work and should be given every opportunity to

achieve. This means that the blind must believe in

themselves and employers must learn that qualified blind

people make productive, loyal employees.

With an unemployment rate of 74 percent, many working-

age blind people are not enjoying the challenges and

responsibilities of competitive employment. Although

hundreds of millions of dollars have been invested in job-

preparation programs around the country, this staggering

number has not changed in recent years. The employment

initiative of the National Research and Training Institute

will provide focus, resources, and direction for a

comprehensive evaluation of contemporary methods for helping

the blind. From such an evaluation will come the necessary

knowledge to develop, demonstrate, and replicate innovative

training programs to replace existing efforts which have

failed to bring the blind into the workforce.

The new National Research and Training Institute will

be the center of research, demonstrations, and job-

development partnerships with private industry. These

partnerships in combination with successful employment

preparation programs will create national momentum toward

the full employment of the blind.

The Campaign To Change What It Means To Be Blind

Capital Campaign Pledge Intention

Name:______________________________________________________

Home Address:______________________________________________

Address:___________________________________________________

City, State, and Zip:______________________________________

Home Phone:_________________ Work Phone:_________________

E-mail Address:____________________________________________

Employer:__________________________________________________

Work Address:______________________________________________

City, State, Zip:__________________________________________

To support the priorities of the Campaign, I (we) pledge the

sum of $________________.

My (our) pledge will be payable in installments of $

__________ over the next _______ years (we encourage pledges

paid over 5 years), beginning ____________________, on the

following schedule (check one):

___ annually ___ semi-annually ___ quarterly __ monthly

I (we) have enclosed a down payment of $ ________________

____ Gift of stock: ________ shares of ____________________

____ My employer will match my gift.

Please list (my) our names in all Campaign Reports and on

the Campaign Wall of Honor in the appropriate Giving Circle

as follows:

___________________________________________________________

___ I (We) wish to remain anonymous.

Signed: _____________________________ Date: ___________

DIABETES: WHERE WE ARE TODAY, WHERE WE WILL BE TOMORROW

by Frank Vinicor, MD, MPH

Dr. Vinicor, director of the Division of Diabetes

Translation at the U.S. Centers for Disease Control, in

Atlanta, Georgia, gave the following as the keynote address

at the 1999 annual conference of the Diabetes Action Network

of the National Federation of the Blind. The conference

took place on July 2, 1999, at the annual convention of the

National Federation of the Blind, in Atlanta, Georgia.

I have been here at Centers for Disease Control for

about ten years. Prior to that time I was at Indiana

University School of Medicine. I'm a card-carrying

endocrinologist and diabetologist. I did clinical work and

clinical studies, and then went to the University of North

Carolina, to the School of Public Health and received a

masters in public health, and then I came to the CDC. I

think many people are wondering why diabetes is studied at

the CDC. It is because we do not just study the outbreak of

infectious diseases, like hanta virus or influenza, but

there's also a lot of activity at the CDC now in chronic

diseases.

In the United States, probably 70% of health problems

and their costs are related to chronic illnesses like heart

disease and diabetes and the like and so there's a big

program, the Division of Diabetes Translation, to get all

those research findings out into regular practice. It's no

longer good enough for people to do research and publish it

in the professional journals, and just wait for it to affect

medical practice. Research that isn't applied in daily

practice is research that's wasted. And so, our primary

responsibilities are to actively translate research into

practice--to take all those articles that appear, all the

funding research that NIH does, and at the CDC, translate

them into practice. The public health part of what we do

falls into three main responsibilities:

First is to know something; such as how many people

have diabetes, how much it costs, what kind of health

problems people have. We try to figure out the size of the

problem of diabetes. Another thing we do at CDC is try to

know why things are the way they are. For example, why

diabetes is much more common in Hispanic communities or

African American communities. We know that African

Americans, for example, once they have diabetes, have more

problems with kidney failure. We now need to know why that

is. That makes us very different from NIH--because CDC has

a congressional mandate to do something. It isn't just

enough to do the research, but once you have the answers,

there is a responsibility to develop programs that make a

difference.

We produce documents. One that's very popular is

called Take Charge of Your Diabetes. It's a very practical,

patient-oriented book, also available, from the National

Library Service for the Blind and Physically Handicapped, in

Braille and on audiocassette. That's one example of what we

do. There's a heck of a lot more that we can and should be

doing.

What I thought I'd do is initially cover four areas:

one is give you a sense of the size of the problem of

diabetes in the world, including the United States. Then

talk in general terms about where we can make a difference.

What are our choices about where we can make a difference to

stop some of these problems of diabetes? Then I'll talk

about some of the research directions that perhaps aren't

right there today, but soon will be. Then I'll just pose

some challenges that I think exist for all of us in taking

on this thing called diabetes.

In terms of the problems of diabetes in the United

States, how many people have it? How many people are going

to develop it? What kind of problems they have? How many

times do they go see those doctors? What does it cost?

Whatever criteria you want to use, to decide if a problem is

a big problem, diabetes fits the bill. If you want to think

about how common it is, diabetes, sixteen million people

have the condition. About five million or so have it, and

don't know it. Those are accurate figures, but, to me, that

number, "sixteen million," doesn't grab me in the gut. It's

too big a number. Another way to think about it is, between

when you woke up this morning and when you wake up tomorrow

morning, there will be slightly over 2000 Americans

diagnosed with diabetes, every day. And that's going to

happen every day of the week. It's going to happen on the

fourth of July, and it's going to happen on the weekends.

Every day there are going to be about 2000 more people

diagnosed with diabetes. That's giving you some sense of

how common this is.

The complications of diabetes are also big, and

obviously you have been dealing and wrestling with the

visual problems. Blindness, kidney failure, and amputations

are three of the big problems, as is heart disease. Again,

let me give you a flavor of how common these problems are.

I know this sounds discouraging, but I think we have to get

a sense of where we are and where we're going, to appreciate

the importance of good research and good translation. In

terms of kidney failure, again, between when you woke up

this morning and when you wake up next morning, about 70

people will experience kidney failure and will have entered

kidney failure programs, either going on dialysis, or

getting a kidney transplant. In terms of amputations,

diabetes will cause, every day, between this morning and

tomorrow morning, 150 amputations, again, every day. And

finally, in terms of legal blindness, about 75 people in

this country will go blind, every day, from diabetes.

That's a lot. That gives you a flavor.

Every morning you wake up, it will have happened. So

we're not dealing, obviously, with a rare, uncommon, or

benign disease. And we're not dealing with a cheap disease.

Diabetes costs the country about a hundred billion dollars a

year. What that means for the individual is, whatever the

average person, who doesn't have diabetes, pays for

healthcare, people with diabetes will pay three times that

much. So, on average again (there are exceptions where

people are paying more or less), people with diabetes are

going to be paying roughly $10,000 a year for their care, or

somebody's going to pay for that. Diabetes is incredibly

expensive.

Now I realize that all of that is discouraging, but

I've got to stick with this, because I want to say that it's

not only discouraging in the United States, but it's

becoming very discouraging throughout the world. In a study

that we did at the CDC with the World Health Organization,

we know that right now there are approximately 125 million

people with diabetes in the world. By the year 2025, only

25 years from now, there will be 300 million people with

diabetes. Most, almost all, of those people will be type 2.

The reasons why this explosion in the number of people with

diabetes are several.

Lifestyle is certainly one of them. All of us are less

active and getting heavier. In the United States, obesity,

improper nutrition, and increased television watching are

all epidemic. So, one of them is our behaviors. The second

one has to do with what are called demographics; changes in

the population. Generally, people, even in developing

countries, are not dying of childhood diseases as much as

they used to. And that's a wonderful accomplishment.

They're not dying of diarrhea, or dehydration, or measles,

or the like. And so, on average, countries' populations are

getting older, so more people are reaching an age where

diabetes is more common. Another factor is that in the

United States there are populations who are particularly

prone to get diabetes; we're talking about African

Americans, American Indians, Hispanics, Alaskan natives and

Pacific Islanders. Those populations are growing at a rate

considerably higher than the white population, such that by

approximately 2050 AD, the minority populations would be, in

the aggregate (all of them together), about the same

percentage as the white population. So another reason why

diabetes is growing, in terms of prevalence, how many people

have it now, is because those populations that really face a

greater challenge from diabetes are increasing at greater

number. So we've got all our behaviors, and we've got these

demographic changes.

Also there's another major factor which accounts for

why we know that diabetes is going to be a bigger problem.

And it has to do with the word ascertainment, which means

accurately obtaining data. Diabetes has always been a big

problem, but the systems that collect information on various

diseases haven't been collecting information on diabetes

very well. For example, if you take 100 people who have

diabetes, and they know they have diabetes, and they're in

the health care system, the system knows they have diabetes,

and they die, only 40 of them will have diabetes listed

anywhere on their death certificate. In terms of looking at

mortality, death, as an indicator of how bad a condition is,

we have been underestimating the contribution of diabetes to

that indicator of health. Likewise, if you look at people

who have diabetes, they know they have diabetes, they're in

the hospital, and you look at the discharge summary, 40% of

those people will not have diabetes listed on the hospital

discharge summary--there'll be no record of the role their

diabetes played in putting them there.

That's all changing now. Our systems of collecting

information are getting a lot better, and we're not missing

the problems of diabetes. So when we put all those things

together, our general view about diabetes is that things are

going to get worse before they get better--in terms of the

number of people and the kind of problems. Now, that's the

first part, and I know that's discouraging, but I wanted to

get it out of the way. Because if you ask yourself: Are we

locked into this scenario? Is there nothing we can do today

about diabetes? Is it inevitable that things are going to

get bad and it's going to happen like clockwork and there's

nothing we can do? The answer is no, no, no, no and again,

no. We are not "stuck." There are things we can do today

for diabetes.

Let me just mention three general areas of what we can

do for diabetes today. Let's talk about what we now call

type 2 diabetes. We used to use the term "adult onset",

then we started using the term "non-insulin-dependent

diabetes" and now we use the term "type 2". And what we're

talking about typically is the situation in which the

individual is "over, under, over". Over forty, underactive,

overweight.

Type 2 probably accounts, in the United States, for

about 90% of diabetes. We now know that for type 2 diabetes

that there may be an approximately ten-year time period, on

average, between when somebody develops type 2 diabetes and

when it is diagnosed clinically. In other words, people

with type 2 diabetes will typically go, on average, one

decade with the condition, with the high blood sugar, and

the bad things that can happen with the high blood sugar, so

at time of the diagnosis of type 2, about a third of these

"new" diabetics will already have preventable complications

of diabetes.

One thing we can do to stop this from happening, is to

try to identify people earlier, before we clinically make

the diagnosis. When the condition is present, but maybe

there aren't symptoms, or the symptoms don't suggest

diabetes, we need to have a good look. For example, VOICE

editor Ed Bryant mentioned that he's 54. I'm four years

older than he is, I'm 58. If I woke up in the middle of the

night a couple of times and had excessive urination, I

probably wouldn't think first about diabetes. I'd wonder

about my prostate gland. Or, if for my age, I started

having some visual blurring, I probably wouldn't think about

diabetes, necessarily. I might think about cataracts or

something like that, 'cause I'm getting up there in age.

So, even for people who have these symptoms of diabetes,

they don't necessarily know they ought to be tested for it.

So, one of the things that we're doing in the United States,

is trying to develop a reasonable early screening program.

One requires a simple blood test. It's not expensive. It's

not particularly painful. Particularly, if you have

diabetes in your family, if you're overweight, if you're

from minority groups. Trying to find diabetes earlier and

start treatment earlier to prevent the complications is one

thing that we all can do together.

The second thing that we can do together is to ensure

access. I think it's an embarrassment in this country, that

when diabetes is discovered, many people still don't have

access to quality care. And particularly at a time when

this country economically is doing very well, particularly

at a time when the unemployment rate is down to 3 1/2 to 4%,

particularly at a time when certain people are bringing in

huge amounts of money, the fact that the number of people

who are uninsured, who don't have financial coverage for

health care, is going up. I just find that unacceptable. I

personally think that's ethically unacceptable, from a

social justice standpoint. So, I believe we need to ensure

that when people have their diabetes discovered, they in

fact get access to good care. That's the second thing we

can do.

The third thing we can do is insure, once diabetes is

discovered, that you get care of appropriate quality. Now

let me explain what I mean by that. We now know, and have

good, excellent studies, solid scientific and economic

studies that show that if you control your blood sugar

pretty well, if you control your blood pressure pretty well,

and if you control your blood lipids, your blood fats,

pretty well, you do not have to go blind, develop kidney

failure, or develop heart disease. We also know now that if

you have diabetes, and you find retinopathy, eye changes,

early, or if you find early kidney changes, such as a little

protein in the urine, or for example you use the little

monofilament to test your feet, this little plastic

monofilament that is very, very inexpensive, costs about 10

cents, and can be used repeatedly, that tells you if you

have what's called an insensate foot, a foot that's lost its

sensation; if you find that out, and you wear protective

shoeing, we now have studies that show you don't have to

have a foot ulcer or an amputation.

We don't need to "prove it." We have the proof. And

so what I'm saying is that quality of care is our most

potent weapon today to prevent those very things from

occurring. I believe strongly that with good care we don't

need to see 75 people go blind every day, 70 people enter

kidney failure programs or 150 amputations a day.

The real challenge is to ensure that people get access

to quality care. That's not an easy challenge, but with the

private sector and the public sector empowering people with

diabetes, all of that is coming together to make a

difference. So even though I do believe that things are

going to get worse, I think we all contain the power to make

that period of getting worse short.

With the knowledge we have today, we can move forward,

and make a difference. But let me go on, and talk a little

bit about research. I love reading the VOICE. I'm glad Ed

keeps sending me a copy of it. You all have your own

contacts, you all obviously are very energetic about your

interest in diabetes. I've heard already here about your

awareness about the pumps and the non-invasive monitors.

You're currently on the cutting edge of this. But let me

share my sense of the research area.

Now, if I see somebody, an individual with diabetes,

and I really want to do something to help that person, I've

only got three choices. I could prevent diabetes. That's

one choice. The second choice is that once they have it I

could cure it. And the third choice I have is to do the

best job that I can, to care for them. So let me share with

you a little bit about what's going on in the research

field, in each of those categories. What are we doing, what

do we know, where are we, in terms of trying to prevent

diabetes. Where are we and what do we know and what do we

not know about trying to cure it, and then where are we in

trying to do a better job in caring for it.

So let's first talk about preventing diabetes.

Wouldn't it be great if we didn't have to worry about

diabetic retinopathy and blindness because we didn't develop

diabetes in the first place? It'd be wonderful. What do we

know about preventing type 1 diabetes? We know a lot. And

there are studies going on now to try to prevent type 1

diabetes. I don't know about you, but when I was a young

man, which seems like years ago, in medical school, I was

always taught that the person with type 1 diabetes was

healthy on Tuesday, and on Wednesday was sick as could be.

That type 1 diabetes was a sudden-onset condition, that

would develop in 24 hours, and could be lethal unless you

got treatment for your acidosis.

We don't think that anymore. We now hold a completely

different view of type 1 diabetes. We know that as many as

10 to 15 years before the clinical onset of type 1, for

whatever reason, the body starts to see its own insulin-

producing cells as foreign, "not mine," and starts setting

up an immune destructive response, one that goes on and on

and on and destroys the insulin-producing beta cells.

Eventually it kills off enough of the one million beta cells

we have in our body that you develop type 1 diabetes. That

process can take 10 years. Furthermore, we know that by

doing certain genetic studies, you can identify people who

are at risk for this condition, and further, if you do

measurements of proteins in the body that are directed

against the insulin producing cells, you can actually

predict very accurately who, within a year or two, will

develop type 1 diabetes, unless something is done. That's

all new information in the last five to 10 years.

There are now three major studies identifying people

who have this genetic marker; people who have these

antibodies present, directed against their own insulin

producing cells. Now they don't have diabetes, their blood

sugars are normal--but these three major studies are trying

to stop the immune destruction, to try to stop that sort of

self-destructive process in the person's own body that is

the onset of type 1 diabetes. One of the studies is called

"The Diabetes Prevention Trial Type 1." It's going on in

the United States. The second study is called E.N.D.I.T.,

the "European Nicotinamide Diabetes Intervention Trial." In

this, researchers are giving this compound nicotinamide to

people at risk for developing type 1 diabetes, to try to

stop the destructive super-oxygenation that goes on when the

Beta cells are attacked. And the third study, just coming

out of Scandinavia, is called the TRIGGER Study. The

important point is that these big multi-center studies will

probably come up with some answers, by 2002 or 2003, as to

whether or not we can prevent type 1 diabetes.

What about type 2 diabetes? All of us know that type 2

diabetes occurs in people who are "over, under, over." What

happens if we can find people who are at risk for type 2

diabetes? What we look for is people who have what we call

impaired glucose tolerance. If you test their blood sugars,

their values aren't yet in the diabetes range, but they're

above normal. Can we stop those people from getting more

"over, under, over?" We can't do much about their age, but

the underactive or overweight? What if we can do something

about those two? Right now there are two or three studies,

the biggest one, being the Diabetes Prevention Program Type

2, in which about 6000 people identified with impaired

glucose tolerance are being randomly assigned to either

continue very mild activity or behavioral interventions or

also to receive the oral medication Metformin. Now these

folks don't have diabetes, but the idea is to see whether

development of diabetes can be stopped, to prevent type 2

diabetes. That study is going on at many locations. Its a

25-center study, and those results will also be out in

about the year 2002.

So current research has gone beyond basic

understanding, test tube research, etc., to intervention

trials. It may mean that by the time you meet three years

from now there'll be exciting news about whether type 1 or

type 2 diabetes can be prevented.

There are now increasing amounts of type 2 diabetes in

children. Most of us have been trained to think about type

2 diabetes as "over, under, over", over 40, underactive,

overweight. And if I told you I had someone who was 14

years old and had diabetes, you might automatically think

that person had type 1 diabetes. Particularly in minority

communities, there are now a number of case series in which

youngsters most often in their 15, 16, 17 year age range

have full-blown classical type 2 diabetes. Particularly

American Indians, African-Americans and Hispanics, but cases

are now also being reported in white communities. Almost

always this condition is associated with being overweight

and underactive... Interestingly enough, there is often a

very unusual skin condition, called Acathosis nigricans,

associated with it. "Acathosis" means a thickened, velvety

skin on the back of the neck and "nigricans" means dark. So

it's a darkened, thickened, velvety skin on the back of the

neck, in the armpits, etc., associated with this juvenile

type 2 upsurge. For all the world, it is type 2 diabetes,

as best we can tell--and it is occurring at age 15 years.

What does that mean? Well, it's really scary, because what

it means is that normally we think of type 2 diabetes on

average occurring at age 50, and we are wrestling with what

it means to have type 2 diabetes for 30 years. Well, are we

gonna have to start asking the question: "What does it mean

to have type 2 diabetes for 60 years?"

Right now there are several projects addressing type 2

diabetes in youth. One is through the CDC, to document the

existence of this on a population basis. Another on July 20

and 21, a conference at NIH, will look at some of the basic

biomedical and biological reasons why this might be

happening. The ADA has just issued a position paper.

Everybody is aware of, interested in, and frightened by this

phenomenon.

Now let's go on to the next area. Where do we stand

with cures? The whole understanding of curing diabetes has

changed in my lifetime. If the problem of type 1 diabetes

is just losing your insulin-producing cells, why can't we

just replace those? There are four different types of

studies going on for "curing" type 1 diabetes. Number one

is transplanting the pancreas. The pancreas is a strange

organ. Most of the pancreas is there not to prevent

diabetes, but to help us digest food. All the enzymes in

your stomach and your intestines come out of the pancreas,

and in fact the insulin producing cells represent about .01%

of the pancreas, a very small percentage. But, if we can

transplant hearts and kidneys, why can't we transplant a

pancreas? It's tricky, because it's located way in the back

of the abdominal cavity, in front of your spine.

They do now transplant pancreases--not the whole thing

but what's called the Segment Transplant where if someone,

for example, has died in an auto or motorcycle accident,

they can remove the pancreas, a part of it, and transplant

that. There have been about, throughout the world, maybe

10,000 or 12,000, pancreas transplants. Again, it's not

your pancreas so you're gonna have to take some drugs to

prevent rejection. But some people have had a remarkably

successful experience.

Doctors have actually been doing the whole pancreas

transplants in some centers, like University of Minnesota,

for 10-15 years. A number of people have lived that long.

A larger number of people have been transplanted in the last

three to five years, and generally it's been quite

successful, both certainly in terms of people surviving, and

also in terms of the pancreas transplant functioning well.

What's the success ratio? This we define in two ways. The

most basic is, did the individual live? And the second one

is, did the transplanted pancreas live? And for the

individual, you go out three, four, five years, probably 95%

of the people are still alive. So the success of the

pancreas transplant depends on how you define the word. If

you define that as going completely off insulin, that's a

pretty rigorous definition. Generally speaking, the

pancreases seem to work three to five years out, in the

range of 70-80%. It's a pretty high success rate as things

go.

Who is eligible for a pancreas transplant? In general,

the criteria are that if you need a kidney transplant, and

you're going to be exposed to immunosuppressive medications,

lets go ahead and try to do a pancreas transplant at the

same time. There's a little bit of "opening up" now; some

people now are just having a pancreas transplant. If you

have a kidney and a pancreas transplant, Medicare has just

decided they would pay for that.

The likelihood of rejection, that the body will reject

the new foreign organ, is about the same for a pancreas as

it is for a kidney. There are a lot of new, less toxic,

medications coming out to prevent rejection, and that's

encouraging.

A person with a kidney transplant, already taking

immunosuppressants, might well be eligible. It depends on

individual circumstances.

There was a question about diabetic coma and its effect

on transplants. There are three types of diabetic coma.

One is when you have what's called acidosis which for type 1

is where the pH number, the measure of acid in your body,

gets so low that you can go into coma. There's another kind

of coma, where the blood sugar gets so high, that in the

absence of acidosis you can go into coma. And then there is

the low blood sugar coma. Those don't really affect the

success of transplantation, in and of themselves.

Let me go on and tell you about three other choices

that we might have in the near future. I spoke about

transplanting a chunk of the pancreas, like half of it.

Another choice we have, since I said the insulin-producing

cells make up such a small amount of the pancreas, like

.01%, is to get just the insulin producing cells. What

we're talking about is Islet Cell Transplantation. It is

possible now to collect those, such that you can sort of

slice up the donated pancreas, and quickly and pretty easily

collect those. It turns out that you don't need a million

insulin producing cells--to not get diabetes, you need a lot

less. Somebody was smart, and put in some reserve, I guess.

You probably need 100,000, maybe 200,000 at most, to get

away from diabetes and you can get those cells. A number of

centers are doing studies, not transplanting the whole

pancreas, but the islets, the insulin-producing cells

themselves.

The new islets are injected into a vein, with a regular

syringe. Most often they go into the liver and set up

housekeeping there. It's technically not a big deal, but

the body is just so darn smart, so much smarter than we are.

It even knows about these little cells, and the body's smart

enough to say, "they ain't mine." The body again will try

to reject these.

There are a couple of ways people are trying to stop

this rejection. One of them is to again give various

immunosuppressant drugs, just like you do for kidney

transplant or whatever. Again, the drugs are getting

better; they're getting less toxic, more effective. Another

tack they're trying is to use engineering techniques. They

put these little insulin producing cells inside something

like a straw, a small straw, with small holes, big enough to

let sugar come in and insulin come out. But the holes are

too small to let the destructive proteins, or the white

blood cells, get in at them. Just two or three weeks ago,

the National Institutes of Health made a decision to devote

$125 million to a project to do clinical trials on islet

cell transplantation. That means moving along, outside of

the laboratories.

Because of the location of the pancreas, and because

you only have one, at this point in time new islet cells

must come from cadavers only. Now there are studies going

that are looking at fetal islet cells, but that raises a lot

of ethical questions, about abortion and studying fetuses.

But fetal islets are viewed as less formed; some people are

doing studies on transplanting pig islets, because pig

insulin is only different from human insulin by one little

amino acid. So what works right now is cadaver transplants-

-but this second way of just transplanting the islets is now

going to be big time with this $125 million.

The clinical trial just started; they just made the

decision last week. There'll be advertisements coming out

about 800 numbers to call. A lot of information will be

published shortly.

I mentioned about the whole pancreas. I talked about

the islets. We're pretty smart. I mean we can send people

to the moon and all that kind of stuff... Why can't we make

an artificial pancreas? In fact, we can make two out of the

three parts really well, and we've been able to do that for

ten years. We know how to make a little reservoir to store

insulin right below the skin. That's a piece of cake. We

know how to make pumps to squirt out insulin. A lot of

people have been doing that for years. The third necessary

part, which we are really struggling with, is that

interactive sugar sensor. To get a glucose sensor, a sugar

sensor, that will last more than a few days, and will give

us accurate readings, there is much effort in the private

sector. Pump manufacturer MiniMed just got FDA approval to

do some work with their sensor. All of that is so exciting

in terms of completing the third of the three parts.

Right now, if you wanted an artificial pancreas, some

exist in experimental units. They probably weigh about 200

pounds. You could carry that on your back, you know, like a

backpack and walk around. But the first two parts, the

insulin reservoir and the pump, they've been miniaturized,

they're failsafe. No big deal. But until we can get that

glucose sensor thing worked out (and they've made a lot of

strides), we're not going to be able to do that. I predict

that within two years there will be a reliable group of

sensors that will last for a long time. And then we'll have

this artificial pancreas that may be the size of a cassette

player or something. It'll probably be ultimately internal,

"internal" being right below the skin.

Why do we have to depend on islet cells? I mentioned

that they're hard to get. The pancreas is way in the back

of the belly. It is a pain to get at it. But we do genetic

research today. Most of the insulin that you're using (if

you inject) isn't produced by a human. We've tricked some

bacteria into making human insulin. Why can't we trick fat

cells, for example, or muscle cells, to make human insulin.

Why can't we take the human insulin gene and insert it into

a human cell, and have it produce human insulin? This

fourth source of insulin replacement would be to take non-

insulin-producing cells, insert the insulin gene, have it

produce insulin, and then inject those cells into the body.

You could take somebody's own fat cells and do that, and re-

inject it, and not have to worry so much about rejection,

itself, because it's their own fat cells. They can do that

now; they have the techniques to do that. The challenge is

to be sure those fat cells, or muscle cells that have been

tricked into producing insulin, turn off the insulin release

when it should be off and turn it on when it should go on.

We don't want those cells suddenly putting out a whole bunch

of insulin, when in fact, my blood sugar is 40. And we do

want it to produce insulin if our blood sugar is starting to

sneak up. And that's the part that still hasn't been worked

out yet. We can make those cells produce insulin, but, are

they sensitive, like our Beta cells? That's the next

challenge. But within three to four years we're going to

have more choices on curing type 1 diabetes. Pancreas

transplant, islet cell transplant, artificial pancreas, and

"tricked fat cells."

Some of you have questions about non-invasive blood

glucose monitoring, and about the Glucowatch monitoring

system. There are five or ten different approaches people

are exploring, to measure sugar without having to prick the

finger, or do a blood test. One of them is on the skin,

where the idea is that, in essence, the skin juices, like

sweat, will change as your blood glucose changes, and that

would give you some indication of the sugar. Another

technique actually uses a Laser beam that literally, blows a

small hole in your skin. And there are other techniques.

What about the new developments with inhaled insulin?

We know that we have to take injections. The needles and

syringes have gotten smaller, better, sharper. We've got

the pen. We've got pumps. There have been a number of

studies done to look at how insulin could be administered,

other than by subcutaneous injection. One was through the

nose, a nasal spray. Another was through a rectal

suppository, but I don't see a lot of enthusiasm for that,

even though it worked. And recently, there have been two or

three studies about inhaled insulin. In other words,

insulin is aerosolized, and it gets down into the lungs; way

down deep into the lungs. The initial studies with both

type 1 and type 2 diabetes have been very, very positive, in

terms of the body's ability to absorb insulin; very, very

positive in terms of the ability to control blood sugar, but

the concentration that you need to have there is quite a bit

higher than U100. U100 means 100 units per CC; the

concentration is quite a bit higher than that. But the

studies have been so exciting and so positive that all of

the major insulin producing companies, Lilly, Hoechst,

European companies, etc, have an active program on

developing inhaled insulin. They are now going into other

studies, what are called Phase II and Phase III trials,

where the number of people involved is greater, where

they're looking to see what's the effect if I have a cold or

bronchitis, does that change the absorption of insulin, for

example.

The initial results are very encouraging. The study

subjects love it. I suspect within a year or two, you'll

see major studies, and probably within three years or so

you'll begin to see some availability. I don't suspect it

will be available to everybody, as there are very practical

issues to work out, like if the absorption doubles when you

go to a humid zone, you probably need to know that, so you

don't have a hypo... But, the initial experiments are very

positive.

Let's go on and talk a little bit about caring. I

mentioned preventing and curing Let's talk about caring.

Where are we now with "caring?" Well, we've come a long

way. I've been in diabetes now for about 30 years, in terms

of my professional life. I don't have diabetes myself. And

I think as bad as it is to get diabetes today, July 2, 1999,

it is so much better than it was to get diabetes ten years

ago, let alone 20 or 30 years ago. We have better, purer,

more varied forms of insulin. We now have four, and soon

we'll have six or seven types of oral tablets to take. We

now have better meters, they're smaller and cheaper and more

accurate; strips still cost way too much.

But we've got better meters. We now have a way to

ensure that you're not fibbing me when you come in to see

me. Everybody who comes in to see me in my office when I

do a blood sugar test when they're there to see me, it's

beautiful. And, right before, they stop eating the cake and

they start to exercise...

We now have this test that has dramatically changed our

understanding of long term control of diabetes, the A1c or

glycosylated hemoglobin test. That's a major improvement in

our ability to care. The A1c does not show peaks and

valleys, but averages. The A1c will give you your overall

average blood glucose to help you and your doctor or your

nurse to see how you've been doing.

We now have better ways, for example, to detect kidney

disease. We now know that well before kidney tests indicate

kidney diseases, for both type 1 and type 2, if we look at

the urine and detect small amounts of protein in the urine,

micro-albumin, we now know that's a sign of very, very early

kidney problems. And we further know that if we use certain

medicines to lower the blood pressure, or to treat that

protein, the ACE Inhibitors, we know we can substantially

prevent the development of kidney failure, regardless of

what the blood sugar is. And if you put those two things

together, you control the blood sugar, the blood pressure,

and take this medicine to stop the protein, you really can

prevent kidney failure.

What about the side effects of the ACE Inhibitors?

With any medicines there are certain side effects. Some of

them are mild and some of them are severe, but most of them

are infrequent. For example, with any blood pressure

medicine you can have what's called postural (or

orthostatic) hypotension. That is, when you first stand up

or sit up, you're getting out of bed or you stand from a

chair, your blood pressure can fall because your blood

vessels aren't contracting. That could be one side effect.

Another side effect, you can have problems with potency.

Almost all blood pressure medicine can interfere with sexual

function. One of the special problems with ACE Inhibitors,

very uncommon, is a cough. People can have this cough, that

can't seem to come under control. It's very rare, but when

it happens, it can be a problem. Fortunately, there are

other medicines to take. So those are some of the general

thoughts about the ACE Inhibitors. In general, they are

considered to be pretty darn good and pretty effective

medicine, especially for people who have diabetes with a

little bit of protein in the urine.

There are three or four ways to measure the protein

spillage, microalbumin, that is characteristic of kidney

disease. One is a 24-hour urine. Another test you can do

is called the spot test, where you get a urine sample and

you look at the amount of protein compared to the amount of

another substance called creatinine. And then there are a

couple of what's called dipstick tests. We can put a strip

into the urine and see if albumin is present. We can do

that now, so we can know if your kidneys are failing early.

For the eyes, we now know what to look for. In this

day and age, only about 40%, 50% of people are having their

eyes examined well, and at regular frequencies. We knew

twenty years ago that if you looked in the eyes and you

found changes and you got laser treatment, that could help

reduce the likelihood of going blind. We knew that 20 years

ago, but we're still having trouble getting that done

regularly.

I wanted to cover neuropathy, the nerve damage produced

by diabetes, the damage done by high blood sugar on the

nerves, especially in the legs and feet, sometimes in the

hands. There are different kinds of neuropathy. But

peripheral neuropathy tends to have different kinds of signs

and symptoms. It can manifest itself by having slightly

cold, numb feet. On the other hand, it can be painful, if

different size nerves are affected. Or it can make your

feet so incredibly sensitive that you don't even want the

bed sheet to touch you. It can be all those things or just

some of them. The problem with neuropathy is not

necessarily the problems of having it, but also that it

causes your foot to change shape, to be exposed to bruises

and bumps that it normally wouldn't be. You can step on a

nail, or a stone, or have your sole of your shoe double up,

and you don't know it. Pain can be a wonderful thing, in

that it tells you there's something wrong with your foot.

If you've lost the nerve function, you don't know it. All

of us in the office have had experiences where people come

in, we say, "How're things going?" "Great, Any problems

with this that and the other thing?", "No." You take off

their socks, look at their socks, there is some pus and

blood, and there's a big hole on the bottom of the foot.

The people haven't even sensed it and so then the ulcer is

associated with amputation.

Again, we know that the neuropathy can very much be

prevented with good sugar control and that there are

medicines now being studied, such as the Aldose Reductase

inhibitors, that tend to stop the conversion of high sugars

into a compound called Sorbitol. And the scientific

rationale behind why this particular medicine is available?

Neuropathy is very common. It's probably the most common

difficulty with diabetes. The major cause of amputation is

peripheral neuropathy. Highly preventable, highly

treatable.

My own sense is that there are going to be more people

with diabetes. We don't yet know enough how to stop that,

although I think we'll know enough within three to four

years. But once someone gets diabetes, we know how to stop

them from having problems.

We don't need a lot more science to tell us how to do

it. What we need are to find ways to get it done. And

that's not an easy thing, because it involves making sure

doctors know and nurses know, and making sure that people

with diabetes feel they have the right, opportunity, and

responsibility to demand these things, and those aren't easy

things to deal with. But I think, today, we can do a lot.

I think tomorrow we're going to know a lot more; and I would

see, at the end of that rainbow, for people with diabetes,

not a pot of baked beans, but a pot of gold. Thanks.

BENEFITS OF THE INSULIN PUMP

Insulin pump therapy, what the doctors call continuous

subcutaneous infusion, offers a number of advantages over

traditional (hypodermic injection) insulin therapy.

Although the insulin pump is complex and expensive, it does

a better job than the needle, and if you use insulin, it may

do a better job for you.

Where needle-injecting insulin users generally mix

different insulin types to achieve optimal "coverage," pump

users use only short-acting insulin, adjusting the machine

rather than their insulin mix. This produces results more

resembling those of a healthy (non-diabetic) pancreas.

Once the new steps necessary to using the pump have

been mastered, insulin pumpers report greater ease in

diabetes self-management, less anxiety and depression, and

significantly fewer problems with hypoglycemic events,

compared with those on multiple insulin injection therapy.

One place where the pump offers marked improvement is

in meal planning. The diabetic who injects insulin several

times a day must schedule meals to match his or her

insulin's response curve. You thus must eat when the

medication you injected says so. With the pump, that

constraint is minimized. The pumper merely adjusts the

dosage for the desired amount of food, and goes about it.

Remembering that exercise burns blood glucose, a

diabetic using multiple injection therapy cannot engage in

nonscheduled exercise (or miss scheduled exercise), without

diet adjustment. Everything must be scheduled around those

injections. With the pump, however, you can immediately

take action to adjust the dose, and go have that off-

schedule meal or exercise. The pump user has far more

freedom to vary his or her activities than does the syringe

user.

Today's pumps are not perfect robots, however. They do

not autodetect your blood level and respond--so you still

have to test regularly, four to six times a day. You have

to take an active interest in intensive therapy and

controlling your diabetes, and, as the doctors say, be

"self-motivated and willing to learn and accept the

responsibility for insulin pump therapy as well as the

troubleshooting and self-care..."

Although the pump user has to take an active hand, that

hand does not have to be sighted! Just as there are

adaptive blood glucose monitors and insulin-drawing tools,

modern pumps contain audio cues that enable many blind

individuals to use them successfully.

If you are diabetic, interested in pursuing insulin-

pump therapy, meet with a diabetes educator who is

knowledgeable with the pump, and with a physician who is

enthusiastic and knowledgeable with this form of treatment.

These health professionals will discuss with you the

advantages, disadvantages, realistic goals, and expectations

regarding insulin pump therapy.

Talk to your health care team--and happy pumping!

TYPE 1 DIABETES PREVENTION TRIAL NEEDS VOLUNTEERS

Can type 1, insulin-dependent diabetes be prevented?

If blood tests suggest you are at high risk of developing

the condition, can anything be done to stop the process?

Type 1 diabetes, with its absolute insulin deficiency

and the resulting need for daily insulin injections, occurs

when the body's own immune system mistakes the insulin-

producing Beta cells of the pancreas for "invaders," as if

they were germs, and attacks them. Researchers, who already

know how the body's immune system picks its targets and

destroys them, wondered if the "ICA" (islet cell antibody)

attack on the Beta cells could be deterred or short-

circuited, preventing or delaying the onset of diabetes.

The National Institutes of Health has launched a

research study to answer that question. Researchers want to

know:

A. Whether daily insulin injections, given to persons

judged at high risk of developing type 1 diabetes (but

not yet "diabetic"), might slow or prevent the disease.

B. Whether oral insulin, insulin pills, might "teach" the

immune system and its ICAs to "accept" the Beta cells,

halting the destructive process that causes type 1

diabetes. This "oral tolerization" has already worked

in animal trials.

Major tests of this type cannot be done in some

laboratory. They cannot be done quickly. They cannot be

simply modeled on a computer. "The Diabetes Prevention

Trial--Type 1" needs volunteers, people at high risk of

developing diabetes, to participate, to prove whether either

of these approaches has merit. If either technique results

in a significant reduction or delay in full-blown diabetes

(as compared to similar folks not receiving the insulin), we

will have a potent new tool for diabetes prevention.

Researchers are still looking for close relatives of

persons with type 1 diabetes, to participate in the study.

Eligible participants must: Be between the ages of three

and 45 years, be willing to accept either "injecting,"

"oral," or "control group" assignment, have blood test

results that show the person is at high risk of developing

type 1 diabetes, and must have a close relative with type 1

diabetes. The researchers have very specific questions to

answer, and need to interview thousands of people to get the

right test subjects. If you fit the criteria, and a free

preliminary test finds you have the ICAs, the islet cell

antibodies, in your blood, you might be one of them.

Nine different diabetes centers, located in California,

Colorado, Minnesota, Washington state, Florida, and

Massachusetts, will gather data. More than 350 "screening

sites" across the country will help researchers find the

right test subjects. Participants living in other areas can

have tests forwarded by their family physician. For

information and a list of screening sites, call the Diabetes

Prevention Trial--Type 1 (DPT-1) National Coordinating

Center, located in Miami, Florida; telephone:

1-800-425-8361.

TYPE 2 AND HEALTHY LIFESTYLE

by Peter J. Nebergall, PhD

Strictly speaking, we don't know what causes diabetes.

We know about 10% will have type 1, with its sudden,

unambiguous symptoms and immediate need for injected

insulin; but about 90% of all diabetics have type 2, with

its slow, creeping onset, and increasing need for first oral

medications, then insulin. How'd they get it? Where did

they get it from?

We know genetics plays a role in type 2, as it clearly

runs in families. We know lifestyle plays a role, and we

know there's something about weight. Let's see how they fit

together. Keep in mind that although we can see the genetic

link, no researcher has yet isolated which gene is

responsible for type 2 diabetes.

Now things get a bit complex. Geneticists know there

is a difference between carrying a trait (like having the

gene for type 2 diabetes) and expressing that trait (having

overt type 2 diabetes). In so many words, having the gene

is not the same thing as having the disease. People can

have the trait, and not show the overt symptoms of diabetes.

How?

Type 2 is also known as adult-onset diabetes. In past

centuries, a good many people didn't live long enough for

the diabetes they were doubtless carrying to express, to

give them the diagnosable symptoms of type 2 diabetes. They

died of childhood diseases, accidents, plague, war, or

filth-borne killers like typhus and cholera instead. Now we

live longer, and type 2 appears.

In the past, most peoples jobs involved hard physical

labor. There was no shortage of exercise, and few but kings

had the opportunity to get fat and be sedentary. Now, far

too many of us sit down to work, and eat junk food. Diet

and exercise? Type 2 appears.

Here's how it all fits together. In the past, if

someone lived long enough for type 2 to appear, his/her diet

(most people couldn't afford to overeat) and hard-labor

lifestyle kept the symptoms at bay, either long enough to

die of something else, or for the eventual fatality to be

put down to "old age." When I was a child, the official

life expectancy of an American male was 67 years. Medicine

has improved, we live longer, and more cases of type 2

appear.

We have far better tests now. We can detect the

symptoms of type 2 years before we would have, and

intervene. A person with insulin resistance, judged "at

risk" of developing diabetes, can turn to diet and exercise,

the "healthy lifestyle" espoused thousands of years ago by

Greek physician Hippocrates of Kos. It won't eliminate the

trait (the genetic predisposition toward type 2), but it

will retard its expression (full-blown diabetes), and (a

free gift from Hippocrates to us), it can partially, or even

completely, reverse the symptoms of type 2.

No two cases of diabetes are alike. We don't know all

the factors involved, so prediction cannot be precise. But

we do know that a person with the gene for type 2 diabetes,

who lives a healthy lifestyle, will probably express

(develop diagnosable) diabetes later, with less severity, or

not at all. We know that someone who has already been

diagnosed with overt type 2 diabetes, who adopts a healthy

lifestyle, will slow, maybe even stop, the disease process.

That should be reason enough.

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

TAKE TIME TO SMELL THE ROSES: MARIA JOHNSON

Photo: portrait. Caption: Maria Johnson

You never know your own strength, until you are tested.

You may think you have a "breaking point," a level of

difficulties you can't handle, a morass from which you can't

escape. You're probably wrong.

Maria Johnson has diabetes. She believes it started at

around the age of 12, but she was 15 years old when a nurse

at a birth-control clinic first told her she had high

sugars. "I couldn't tell my mother I'd been there," she

says.

"I was pregnant with my first son, at the age of 17,

and was diagnosed at that time with insulin-dependent

diabetes," she says. "My sugars were 550-600 mg/dL. I was

overwhelmed with medications, diet, and exercise...

"Many people in my family have diabetes," she reports.

"I have a very large family. My grandmother, father, uncles

and aunts from both sides of the family have diabetes; most

take shots, but some also take pills. But," she adds, "from

my generation, out of cousins ranging from age 15 to 29, I

am the only one who has it. They do not know how hard it is

to live with this disease, nor do they ask."

Maria has had a lot of recurring problems. Some stem

from her diabetes, some don't, but all have to be dealt

with, at the same time. She has dealt with neuropathy in

the feet and lower legs, retinopathy ("floaters" in both

eyes, and a vitrectomy in February of 1999), frequent yeast

infections (not uncommon for diabetic women), gum disease

(again, not an uncommon complication of diabetes), postural

hypotension, unexplained pain in various parts of her body,

weight gain, hair loss, and nuisance infections. Add to

these difficulties with her upbringing (her family emigrated

from the Philippines when she was one year old). But Maria

is not a "quitter."

Maria and husband Terence have two children: Tyler, age

nine, and Tyson, age one (neither of whom have diabetes) .

And she is getting control, going about with her life.

"My health care team now consists of a family

practitioner, an endocrinologist, an ophthalmologist, a

neurologist, a podiatrist, a dentist, and a dermatologist.

I have seen many doctors. I have changed doctors, when one

did not meet my needs. I believe that you and your doctor

should have a good relationship, because this is your health

and your life.

"My life has always been hard," she says. "It still

is. I try my best to stay positive, but at times I just

can't. I am writing a book, about my diabetes, about the

stresses of my upbringing. Some people will never

understand what I've been through, because they've never

walked two miles in my shoes. When I tell my stories, it

helps me heal."

Maria is determined to carry on with her life: "I take

care of myself, at least I try. I take 4 shots a day, and

check my blood sugar five to six times a day. I've ordered

a MiniMed 508 insulin pump. I use large-print settings on

my computer screen, I still model, part-time, and I work for

ABC TV as a receptionist/operator."

Maria believes that when you were born, you were

crying, and everyone around you was smiling--so live your

life so that when you die, you're the one who is smiling and

everyone else around you is crying. Her words of wisdom:

"I almost fell into a coma, exactly one year ago. My doctor

said I almost died. Now I take time to smell the roses, and

I try not to sweat the small stuff in my life. Thank you,

and stay healthy."

TYPE 1 VACCINE?

Swedish pharmaceutical company Diamyd Medical AB

announced in January that its experimental type 1 diabetes

vaccine, Diamyd, has successfully completed a Phase-I

clinical study, in human subjects. The company plans to

seek permission to conduct a Phase II clinical study in

about three months.

The Phase I trial, designed solely to address the

clinical safety of the product, was started in February

1999. Twenty-four healthy male Caucasian volunteers were

selected for inclusion in this double-blind study, which

involved sub-cutaneous injection of one of four ascending

dose levels up to a maximum of 0.5mg/person. There were no

adverse clinical effects, and all dose levels, including the

maximum, 0.5mg/person, were well tolerated.

Diamyd(TM) is the proprietary name for recombinant

human GAD65 (glutamic acid decarboxylase). As previously

reported in the scientific literature, several studies with

GAD65 using diabetic mice have shown that administration of

GAD to diabetes prone animals can prevent type 1 diabetes.

Based on the animal studies, and the successfully completed

Phase 1 clinical, Diamyd Medical is currently developing

GAD65 as a biopharmaceutical for treatment and/or prevention

of type 1 diabetes.

In April 2000 Diamyd Medical plans to apply for

regulatory approval to conduct a multi-center Phase II study

in LADA (Latent Autoimmune Diabetes in the Adult) patients

in Europe. The Phase II study is intended to enable

selection of doses and surrogate tolerance assays for

further clinical development.

The company hopes, if all regulatory hurdles are

successfully passed, to place their vaccine on the market by

the end of year 2004.

BOOK REVIEWS

by Marilyn Helton

Spring Brings New Beginnings

By the time you read this we will have celebrated Mardi

Gras, St. Patrick's Day, Passover and Easter; probably

weeded, raked and prepared for the summer vegetable garden;

and set our clocks forward and generally plunged full

throttle into Spring!

It had to happen soon or later, and I just wish I had

thought of doing it! "The Diabetic Four Ingredient

Cookbook," by Linda Coffee and Emily Cale, has made its

debut. If you're interested in quick and inexpensive

recipes, this book is your answer. I haven't tried any of

the recipes yet, but they look good. (After you've read as

many cookbooks as I have, you can just about "eye-ball" a

recipe and almost be able to taste it!) Each recipe has a

complete nutritional analysis with dietary exchanges.

If you're looking for simple recipes requiring less

time, less ingredients and less hassle, and will still meet

your diabetic menu guidelines, give this book a try. Over

200 delicious dishes requiring four ingredients or less.

Published by Coffee and Cale, 1999, ISBN 0-9628550-4-9,

$9.95. You can order by calling their toll-free number:

1-800-757-0838. Visa and Mastercard are accepted.

"The All New Diabetic Cookbook," by Kitty Maynard, RN,

Lucian Maynard, RN, and Theodore Duncan, MD, offers

traditional recipes from appetizers to desserts, and new

vegetarian recipes using a variety of rices, grains and

vegetables. If you associate the Maynard names with

non-diabetic cookbook titles, you're absolutely correct.

They have authored "The American Country Inn Cookbook" and

"The Bed & Breakfast Cookbook," both of which I have in my

library. It was a pleasant surprise to learn that they are

both RNs with extensive experience in the care and knowledge

of all diabetic conditions.

With bed and breakfast and country inn cookbook

expertise infused into "The All New Diabetic Cookbook," one

can't go wrong. It caters to anyone who loves to cook,

loves the kitchen and wishes to be aware of the nutritional

value of the foods they prepare. More than 400 deliciously

tempting recipes are included and, while the recipes are

designed to meet the needs of diabetics, they will satisfy

everyone. I usually read a new cookbook from desserts back

to appetizers (you can tell what I like to eat!) and this

book certainly has a wealth of great food ideas. There is a

special recipe section for children called "Kids' Meals," an

area frequently overlooked in general diabetic cookbooks.

Recipes for healthy pizzas, burgers and fries, tacos, and

desserts will tempt adult appetites, as well.

Information on how diet affects diabetes, designing an

individualized meal plan, how to count carbohydrates, types

of sugars, and practical tips for living with diabetes are

presented by the third author, Theodore Duncan, MD. Dr.

Duncan is president of the Diabetes Education and Research

Center, assistant professor of Clinical Medicine at the

University of Pennsylvania School of Medicine, and former

chief, Department of Diabetes Mellitus and Metabolism at

Pennsylvania Hospital in Philadelphia. You can access the

Diabetes Education and Research Center website at

www.libertynet.org/~diabetes

"The All New Diabetic Cookbook" is published by

Rutledge Hill Press, 1999, $19.95, ISBN 1-55853-675-2

(paperback). I like this cookbook and I think you will,

too!

Speaking of desserts, one of my favorite low-fat

cookbook authors, Sue Spitler, has teamed up with Linda R.

Yoakam, RD, MS, to publish "1,001 Low-Fat Desserts." I am a

great fan of Sue Spitler's books and have several of her

other titles, including "1,001 Low-Fat Recipes, Skinny

Pastas, Skinny Cookies, Cakes & Sweets," and her recent

"Skinny Comfort Foods."

With over a thousand dessert recipes in "1,001 Low-Fat

Desserts," you can satisfy your sweet tooth without

sabotaging your waistline. Deep-dish pies, tangy tarts,

cookies by the dozen, sugary cobblers, crunchy crisps,

fluffy cheesecakes, custards, souffles, fruit and frozen

desserts, cream puffs, pastries and dessert sauces are

layered between 650 pages of palate-pleasing bliss. There's

even a chapter of quick-and-easy desserts made with

artificial sweeteners instead of sugar.

Complete nutritional information and diabetic exchanges

are included for each recipe. For a dessert lover like me,

I figure the cost of this dream book amounts to about two

cents per recipe--a terrific bargain! Published by Surrey

Books, Inc., 1999, $19.95, ISBN 1-57284-028-5 (paperback).

If you're looking for home cooking just like Mom's,

you'll find more than 250 fast, low-fat recipes with

old-fashioned good taste in "The Complete Quick & Hearty

Diabetic Cookbook." From breakfast to dinner, appetizers to

desserts, it's all here. Uncomplicated recipes with

easy-to-find ingredients are accompanied by titillating

culinary comment. Some recipes also have "serve-with"

suggestions. I like the fact that the serving size is also

included. Each recipe has dietary exchanges as well as

nutritional analysis. Dietary fiber and sugar content are

also included. Published by the American Diabetes

Association, 1998, 272 pages (soft cover), $12.95 (ADA

member price $10.95. You can order toll-free,

1-800-232-6733; ask for #4624-01).

If you'd like to read more reviews, visit the Cinnamon

Hearts website at http://www.cinnamonhearts.com and click on

"Cook's Library." Until we meet again this summer, stay

healthy and positive!

NOTE: Marilyn Helton is the editor of "Cinnamon

Hearts~The Art of Living A Winning Diabetic Lifestyle," a

positive-power newsletter for diabetics and their families.

Subscriptions to "Cinnamon Hearts" newsletter are available

for $19.80/year (USA); $20 (Canada); from Cinnamon Hearts

DLE, PO Box 578340, Modesto, CA 95357-8340.

RECIPE CORNER

Artwork: Fruits and vegetables

Send your great food ideas to the editor. Your recipes

will be evaluated by dietitians, and if necessary, adjusted

to make them more diabetically appropriate. Then he gets to

taste them...

This issue, all recipes were provided by the California

Avocado Commission (website: http://www.avocado.org), and

all feature the avocado, a healthful fruit that is very low

in things like fat and cholesterol. Give them a try!

California Avocado and Wheatberry Salad

by Marilou Cerny, MS, RD

Wheat berries are the whole, unrefined grain of wheat.

They retain all their original goodness, including B

vitamins, antioxidants, and fiber. Total calories are a

bargain for the healthy advantages this versatile dish

provides.

Ingredients:

2 cups wheat berries

4 cups water

1 teaspoon dried thyme

1 teaspoon dried basil

1 teaspoon salt

2 sun-dried tomatoes

1 avocado, peeled and pit removed, diced

juice of 1 lemon

1 small red pepper, finely diced

1/2 cup red onion, finely chopped

1 basket (1 pint) cherry tomatoes, quartered

Up to 1/4 cup fresh chopped herbs: parsley, basil, chives

1 tablespoon extra virgin olive oil

1 teaspoon balsamic vinegar

1 teaspoon salt

Instructions:

Wash the dried wheat berries and soak them overnight in

the water. When ready to cook, add the dried herbs, 1

teaspoon salt, and the sun-dried tomatoes. Water should

cover the grains with about 1/2" on top. Bring to the boil,

then reduce heat to very low and simmer, covered, 45 minutes

or until tender. Set aside to cool.

Drain off any extra liquid (save to use in soup stock).

Put cooked wheat berries in a bowl. Chop the sun-dried

tomato finely and add back to the wheat berries. Add the

olive oil, vinegar, crushed garlic, and salt. Mix

thoroughly. (Up to this point, the salad can be prepared

ahead and held in the refrigerator for 1-2 days). Add the

red pepper, onion, and tomato. Toss and add the fresh

herbs.

Toss the avocado dice in the lemon juice. Add to the salad

and mix in gently.

Makes 8 servings. Per serving: 200 calories; 7g

protein; 40g carbohydrate; 2.5g fat (0.5g saturated fat,

1.5g mono-unsaturated fat, 0.5 polyunsaturated fat); 0mg

cholesterol; 7g fiber; 590mg sodium.

California Guacamole--Diabetic Diet

by the California Avocado Commission

Ingredients:

2 medium California avocados

3 tbsp. fresh lemon juice

1/2 cup onion, diced

3 tbsp tomato, chopped

1/2 tsp. salt

2 tbsp. cilantro, minced

Instructions:

Cut the avocados in half and remove the seeds. Scoop

out the pulp and place in a bowl. Drizzle the pulp with

lemon juice and mash. Combine with the remaining

ingredients, mix well and serve.

Serve with 1 cup raw vegetables for 1 vegetable

exchange. Use to prepare California Tuna Sandwich. Use as

a spread on bread or rolls in place of margarine or

mayonnaise.

Makes 12 servings: Per serving: 55 calories, 5g fat,

0.8g saturated fat, 0.6g polyunsaturated fat, 3.2g mono-

unsaturated fat, 0mg cholesterol, 93mg sodium, 3g total

carbohydrate, 1g dietary fiber, 1g sugars, 1g protein.

Exchanges: 1 fat.

California Tuna Sandwiches--Diabetic Diet

by the California Avocado Commission

Ingredients:

3/4 cup California Guacamole

1 can (6 oz.) water-packed tuna, drained

1 1/2 cup celery, diced

1 1/2 cup onion, diced

6 pitas pita pocket bread

6 leaves Romaine lettuce

1/4 radishes, sliced

Instructions:

Prepare California Guacamole according to recipe. In a

bowl, combine Guacamole, tuna, celery, and onion and mix

well. Lightly toast pita pockets and cut in half. Fill

each half with the tuna mixture and 1/2 lettuce leaf.

Garnish with radish slices.

This makes a good lunch meal with a piece of fresh

fruit and a glass of low-fat or non-fat milk. To increase

the protein, add another can of tuna to the recipe for an

additional lean meat exchange (55 calories) per serving.

Makes two servings. Per serving: 257 calories, 4g

fat, 0.7g saturated fat, 0.8g polyunsaturated fat, 2.2 mono-

unsaturated fat, 5mg cholesterol, 424mg sodium, 40g total

carbohydrate, 3g dietary fiber, 4g sugars, 14g protein.

Exchanges: 2 bread, 1 lean meat, 1 vegetable, 1 fat.

California Avocado Veggie Tacos--Diabetic Diet

by the California Avocado Commission

Ingredients:

1 med. California avocado

as needed, non-stick cooking spray

1 1/4 cup onion, julienne strips

1 1/2 cup sweet green pepper, julienne strips

1 1/2 cup sweet red pepper, julienne strips

1 cup cilantro

1 1/2 cup Fresh Tomato Salsa (recipe below)

12 flour tortillas, 8-inch

Instructions:

Prepare Fresh Tomato Salsa in advance (see below).

Spray skillet with non-stick cooking spray. Lightly saute'

the onion and green and red peppers. Mince cilantro and cut

avocado into 12 slices. Warm tortillas in oven and fill

with sauteed peppers and onions, cilantro, avocado slices,

and salsa. Fold tortilla over and serve.

Makes a quick snack for children after school, or easy

lunch. The fresh salsa can be made ahead and keeps for two

days under refrigeration.

Fresh Tomato Salsa:

Ingredients:

1 cup fresh tomatoes, diced

3 cup onions, diced

1/2 clove garlic, minced

1/3 tsp. jalapeno peppers, minced

2 tsp. cilantro, minced

1 pinch cumin

1 1/2 tsp. fresh lime juice

Instructions:

Salsa Preparation: Mix together all ingredients and

refrigerate. Yields: 1 1/2 cups of salsa.

Makes 12 servings. Per serving: 158 calories, 5g fat,

0.8g saturated fat, 1.3g polyunsaturated fat, 2.7g mono-

unsaturated fat, 0mg cholesterol, 175mg sodium, 25g total

carbohydrate, 2g dietary fiber, 3g sugars, 4g protein.

Exchanges per serving: 1 bread, 1 vegetable, 1 fat.

ASK THE DOCTOR

by Wesley W. Wilson, MD

NOTE: If you have any questions for "Ask the Doctor,"

please send them to the VOICE editorial office. The only

questions Dr. Wilson will be able to answer are the ones

used in this column.

Wesley W. Wilson, MD has retired as an Internal

Medicine practitioner at the Western Montana Clinic in

Missoula, Montana. Dr. Wilson was diagnosed with type 1

diabetes in 1956, during his second year of medical school.

He remains interested and involved in diabetes education for

patients and professionals.

Q: My doctor and I are arguing about my A1c numbers.

He says an ideal A1c is below 7, but my sugar fluctuates.

I'm worried about hypos if I fight to keep it that low. If

I keep it CLOSE to 7, and give myself a little safety room

against "lows," isn't that better?

A: I'm pleased you and your doctor are discussing

your hemoglobin A1c values. Medical advice must be a two-

way street, with each willing to listen to the other.

Ideally, the A1c should be in the normal range--below 6.2%,

but in real life, the concerns you mention prevent such

tight control for many individuals.

I find it interesting to review the research studies

that have attempted to demonstrate the benefits of tight

control versus "conventional" control. In all studies,

particularly in the Diabetes Control and Complications Trial

(DCCT), even with very careful supervision of the tight

control group, the average A1c was very close to 7%. The

target was under 6.2% at the start of the study, but the

increased risk of hypoglycemia posed by such low numbers

required a bit less intensive blood sugar control. The

treatment team and the patients decided that the risk of low

blood sugars required a reduction in insulin dose. Similar

results were found in the recently-reported United Kingdom

Prospective Diabetes Study (UKPDS), for persons with type 2

diabetes. The Kumamoto study, in which type 2 persons were

treated with insulin, showed the same result. All studies

were able to achieve a hemoglobin A1c of about 7%. Today,

treatment of diabetes with insulin, or with any of the other

agents used to control blood sugar, is just not precise

enough to allow "perfect" blood sugar control, but we should

attempt to achieve the best possible A1c.

Most individuals in the DCCT could not achieve a

"normal," (non-diabetic) A1c (below 6.2%), but 5% of the

intensively-treated type 1 persons were able to maintain a

normal A1c for the 9 1/2 years of the study. We wish we

could bottle what it was they had to allow such tight

control! Many persons balance high sugars with too low

sugars to achieve their low A1c's, but hypoglycemia is

dangerous and risky. Most diabetes professionals know of

patients who have been involved in auto accidents while

"low."

The current ADA recommendations are a compromise--the

target A1c is described as "7% or lower," and if the test

results are 8% or higher, "a change in treatment is

suggested." It is recognized that each person is different,

and each achievable A1c is different, and there is agreement

that an 8% HbA1c is too high.

Your situation may be unique: Do you have hypoglycemia

unawareness? If you can't "feel" the onset of hypoglycemia,

your first sign of low blood sugar may be passing out or

falling down. Do you always check your sugar before

beginning a hazardous activity (like driving)? It is really

dangerous to drive while low. How careful are you with the

routine things required to maintain ideal blood sugar, such

as counting carbs and giving just the right amount of

insulin with each meal? A visit to your dietitian or nurse

educator may be helpful.

The bottom line is that insulin and some other

lifesaving drugs are very powerful, and therefore very

dangerous. We need better ways of treating diabetes. We

need to support research into better techniques for

treatment of diabetes. We know that the closer to normal

your A1c, the less the risk of microvascular complications

(neuropathy, retinopathy, nephropathy,...) It's hard to be

perfect, but even though we cannot achieve "normal"

hemoglobin A1c values in most persons with diabetes, getting

that value down to 7% clearly reduces the risk of

microvascular disease.

DIALYSIS AT NATIONAL CONVENTION

by Ed Bryant

Photo: portrait. Caption: Ed Bryant

During this year's annual convention of the National

Federation of the Blind in Atlanta, Georgia (Sunday, July 2,

through Saturday, July 8), dialysis will be available.

Individuals requiring dialysis must have a transient patient

packet and physician's statement filled out prior to

treatment. Conventioneers must have their unit contact the

desired location in the Atlanta area for instructions, well

in advance. NOTE: The convention will take place at the

Atlanta Marriott Marquis, 265 Peachtree Center, in downtown

Atlanta.

Individuals will be responsible for, and must pay out

of pocket, prior to each treatment, the approximately $30

not covered by Medicare, plus any additional physician's

fees, and any charges for other medications.

DIALYSIS CENTERS SHOULD SET UP TRANSIENT DIALYSIS

LOCATIONS AT LEAST TWO MONTHS IN ADVANCE. THIS HELPS ASSURE

A LOCATION FOR ANYONE WANTING TO DIALYZE. There are many

centers in the Atlanta area, but that area is quite large,

so early reservation is strongly recommended, to avoid long

taxi rides! Here are some dialysis locations:

* Dialysis Clinic, Inc. -- West Peachtree, 820 West

Peachtree Street NW, Atlanta, GA 30308; telephone:

(404) 888-4520.

* Gambro Healthcare , 699 Ponce De Leon Ave., Suite 19,

Atlanta, GA 30308; telephone: (404) 872-7211.

* Gambro Healthcare Atlanta, 400 Decatur Street,

Atlanta, GA 30312; telephone: (404) 577-9097.

* Gambro Healthcare , 524 West Peachtree Street,

Atlanta, GA 30308; telephone: (404) 249-1563.

PLEASE REMEMBER TO SCHEDULE DIALYSIS TREATMENTS EARLY,

TO ENSURE SPACE. If scheduling assistance is needed, have

your dialysis unit's social worker contact me: Diabetes

Action Network President Ed Bryant; telephone: (573)

875-8911. See you in Atlanta!

2000 NATIONAL CONVENTION

It will soon be time for the 2000 convention of the

National Federation of the Blind, to be held again at the

Atlanta Marriott Marquis, 265 Peachtree Center Avenue,

Atlanta, Georgia 30303. The Marquis is a beautiful hotel,

in a convenient, central location.

Although Marriott has a national reservation number:

1-800-228-9290, do not use it. To receive our special

rates, all hotel reservations must be made with the Marriott

Marquis directly. Please telephone them at: (404) 521-

0000, or write them at the address above. Be sure you tell

them you will be attending the annual convention of the

National Federation of the Blind. REMEMBER: No reservation

will be valid unless it has been made directly with the

Marriott Marquis Hotel in Atlanta. To confirm a telephone

reservation, you will need a credit card number, and the

reservation charge is $60, applied toward your stay.

Here are our hotel rates for 2000: one in a room, $57

per night; two in a room, $59; three in a room, $61; four in

a room, $63. Local taxes (about 14 percent) will apply.

Here are the convention dates and schedule:

Sunday, July 2 -- Seminars

Monday, July 3 -- Convention registration

Tuesday, July 4 -- National Board Meeting (open to all)

Wednesday, July 5 -- General Sessions

Thursday, July 6 -- Tour Day

Friday, July 7 -- Banquet

Saturday, July 8 -- General Sessions, adjournment.

Our Diabetes Action Network Seminar

At the 2000 convention of the National Federation of

the Blind, in Atlanta, Georgia, our Diabetes Action Network

will have its seminar and business meeting, on Monday, July

3, from 6 to 9 pm. There will be a presentation about a new

talking device that will provide information on any

prescription medication (including insulin).

Our keynote speaker will be dietitian and diabetes

educator Brooks Kent, RD, CDE, who will discuss all phases

of the healthy "diabetic diet" (healthy for non-diabetics,

too!). We will also hear from blind diabetic Bernadette

Jacobs, who will share views of life, diabetes, and a

humorous bus ride. There will be an open panel discussion,

on "Diabetics in the Workplace."

Once again, we will have our "Make the President Pay"

diabetes quiz game--and President Ed Bryant says he will

give a nice donation to the Division for each right answer!

Our seminar is free and open to the public. Its location

will be posted in the agenda (provided when you register).

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."

COOKING WITH SUZI

by Suzi Castle

Got a craving? Go ahead! Chocolate can stimulate your

brain's production of serotonin, which soothes an edgy mood.

A craving for chocolate may be our body's way of telling us

that we need more of this mood-enhancing nutrient. The good

news is that experts say you can indulge in your favorite

treats by choosing a small portion of a low-calorie version.

This rich-tasting, yet low-fat, sugar-free chocolate truffle

will satisfy your chocolate cravings without guilt!

Chocolate Truffles

Ingredients:

1 package (2 teaspoons) plain gelatin

1/3 cup water

1 tablespoon vanilla

3 tablespoons cocoa, divided

1/4 cup water

1 cup (2% fat) milk powder (equal to 4 cups low-fat milk)

Sugar substitute equal to 1/3 cup sugar (i.e., 8

packets Equal)

2 tablespoons dried currants

6 tablespoons finely chopped walnuts, divided

Instructions:

Mix gelatin with 1/3 cup water in a heat-proof

measuring cup. Let soften for 2 minutes, then dissolve by

heating in a microwave oven for 20 seconds. In a blender,

mix dissolved gelatin, vanilla, 1 tablespoon cocoa, 1/4 cup

water, milk powder and sugar substitute. Pour into a small

bowl and stir in currants and 1 tablespoon chopped walnuts.

Refrigerate until mixture thickens and is firm enough to

shape. Meanwhile, mix remaining 2 tablespoons cocoa with

remaining 5 tablespoons walnuts. Using two teaspoons, shape

gelatin mixture into 20 small balls. Roll each ball into

the cocoa-walnut mixture. Refrigerate until firm. Makes 20

truffles.

Per truffle: 40 cal. (2% from fat); 2.64gm protein;

1.64gm fat (0.36gm saturated fat); 3.85gm carbohydrates;

31mg sodium; 1.7mg cholesterol.; 0.12gm fiber. Exchanges: 1

nonfat milk.

"Suzi Castle's Deliciously Healthy Favorite Foods

Cookbook" is available now in most bookstores or by sending

$18.90 ($14.95 + $3.95 S&H) to Health Cookbooks Dept. M,

3520 McCourry Street, Bakersfield, CA 93304.

FOOD FOR THOUGHT

Artwork: Dancing fruits and vegetables

We invite blurbs and tidbit articles for inclusion in

this column. Materials received may be edited and used as

space permits. Products and services included in this

column are for information only and do not imply endorsement

by the Diabetes Action Network of the NFB.

BEEF-SOURCE INSULIN

Both U.S. insulin manufacturers, Eli Lilly and Company,

and Novo Nordisk Pharmaceuticals Inc, have ceased production

of beef-source insulins, and are winding down their

production of pork-based insulins as well. To help supply

those diabetics who desire an animal-source insulin, CP

Pharmaceuticals, a British-based drug manufacturer, has

announced it will increase its production of its Hypurin

beef-source insulin.

CP Pharmaceuticals has also announced it is filing for

approval to market its insulin products in the United States

and Canada. Until such regulatory approval is granted,

diabetics in the U.S. who wish to use this product must go

through formal personal import procedures.

CP Pharmaceuticals has established a special toll-free

number for consumers in the U.S. and Canada: 011-800-667-

55555. Write to them: CP Pharmaceuticals Limited, Ash Road

North, Wrexham Industrial Estate, Wrexham, LL13 9UF, United

Kingdom.

BOARD MEMBERS

The Diabetes Action Network of the National Federation of

the Blind.

President: Ed Bryant

Columbia, MO

First Vice President: Eric Woods

Denver, CO

Second Vice President: Sandie Addy

Prescott Valley, AZ

Treasurer: Bruce Peters

Akron, OH

Secretary: Sally York

Castro Valley, CA

Board Member-At-Large: Gisela Distel

Albany, NY

Board Member-At-Large: Paul Price

Valley Center, CA

INSULIN INFORMATION

In Februrary of this year, Novo Nordisk Pharmaceuticals

announced it was discontinuing its complete line of purified

pork insulins. Novo reminds us this process, of switching

from animal-derived to human insulin, has been underway for

some time, and that its last supplies of Lente Purified Pork

insulin expired in February. They state they will maintain

product availability of Regular and NPH Purified Pork

insulins through July 2000--but no further--so they

encourage all doctors to "review your medical records as

soon as possible to identify patients who currently use the

insulin products listed above, and begin appropriate

transfer to an alternate insulin therapy."

If you are using Novo Nordisk animal source insulins,

you need to do just that--talk to your doctor about transfer

to an alternate insulin therapy.

ELECTIONS COMING UP

At this year's national convention in Atlanta, Georgia,

elections will be held to fill our Diabetes Action Network

divisional board positions. These are one-year terms,

running from July 1, 2000 to June 30, 2001. Positions to be

filled are: President, First Vice-President, Second

Vice-President, Secretary, Treasurer, and two Board

Members-at-Large. If you are interested in a board

position, or know someone who you think would do a good job,

then contact our Diabetes Action Network President, Ed

Bryant. Yes, hard work and dedication are prerequisites for

board positions--but one must lead by good example.

EQUAL(r) FOR YOUR DIABETES

As a proud sponsor of the American Diabetes Association

for 16 years, Equal has worked closely with the diabetes

community, sponsoring special programs and events. What's

more, experts agree that aspartame--the sweetening

ingredient in Equal--doesn't affect glucose or insulin

levels. No wonder it's recognized as acceptable as a

diabetes meal plan by the ADA! For further information,

visit the Equal website at http://www.equal.com or call 1-

800-323-5316.

PROTECTIVE SHOES FOR DIABETICS

We have been asked to announce: Medicare Part B will

pay for one pair of protective shoes for diabetics (All

diabetics, one pair per year), along with three pairs of

special shock-absorbing insoles (materials such as

plastizote). Medicare also pays for custom inserts (after

partial amputation) to ensure better shoe fit.

To find out more, contact: CHOICE Healthcare, PO Box

99, Charleston, AR 72933; telephone: 1-888-442-3390.

ABOUT PROPULSID AND AVANDIA

ISMP Medication Safety Alert reports two findings of

interest to diabetics. In the first, Avandia

(rosiglitazone), prescribed for type 2 diabetes, has been

implicated in the same sort of liver damage as its

competitor Rezulin. The paper notes that once the drug was

discontinued, the man's liver returned to health, and the

authors recommend closely monitoring a patient's liver

enzymes, throughout therapy, and discontinuing the drug if

difficulties are noted (these instructions are identical to

those for Rezulin).

In the second note, the newsletter relays a warning

from FDA Medwatch, a "watchdog" agency of the U.S.

Government, about Propulsid (cisapride) a medication often

prescribed for autonomic neuropathy/gastroparesis. The

study warns that Propulsid is contraindicated in patients

with serum electrolyte disorders, so patients treated with

diuretics need to be closely followed.

The Institute for Safe Medication Practices (ISMP);

telephone: 215-947-7797; website: http://www.ismp.org

JEWISH MATERIALS

We have been asked to announce: The Jewish Heritage

for the Blind is pleased to announce the availability of

many sacred texts in large print. For ordering information,

please call, fax, or write to: The Jewish Heritage for the

Blind, Department of Large Print Publications, 1655 East

24th Street, Brooklyn, NY 11229; telephone: (718) 601-9128;

fax: (718) 338-0653.

ARTICLES NEEDED

If you have diabetes, are a family member or friend of

a diabetic, or a health professional with an interest in

diabetes, we invite you to submit an article for publication

in the VOICE OF THE DIABETIC.

Our philosophy regarding diabetes is positive. Do you

have an inspiring, enlightening story? We, the Diabetes

Action Network of the National Federation of the Blind, seek

to show people they are not alone, and do have options,

regardless of diabetic complications. If you have

experienced ramifications, others, who may be facing the

same side-effects, could benefit from what you have to say.

Perhaps you have not experienced complications--your

unique insight, coping strategies, and lifestyle can still

inspire others. Are you a relative, a friend, or a health

professional? More than 280,382 VOICE readers could benefit

from your story.

For information and article submission guidelines,

contact: VOICE OF THE DIABETIC, 811 Cherry Street, Suite

309, Columbia, MO 65201; telephone: (573) 875-8911.

HEAR YE, HEAR YE, A RAFFLE

The Diabetes Action Network of the National Federation

of the Blind reaches out and provides support and

information to thousands of people. Because it costs to

operate this valuable network and to produce the VOICE OF

THE DIABETIC, we must generate funds to help cover these

expenses. Our Diabetes Action Network has elected to hold a

raffle, which will be coordinated by our division treasurer,

Bruce Peters.

THE GRAND PRIZE WILL BE $500! The winning ticket will

be drawn, and the winner's name announced, on July 7, 2000,

at the banquet held during the annual convention of the

National Federation of the Blind.

Raffle tickets cost $1 each, or a book of six may be

purchased for $5. Tickets may be purchased from state

representatives of our Diabetes Action Network or by

contacting the VOICE Editorial Office, 811 Cherry Street,

Suite 309, Columbia, MO 65201; telephone: (573) 875-8911.

Anyone interested in selling tickets should also contact the

VOICE Editorial Office. Tickets are available now! Names

of persons who sell 50 tickets or more will be announced in

the VOICE.

Please make checks payable to the National Federation

of the Blind. Money and sold raffle ticket stubs must be

received at the VOICE office no later than June 10, 2000, or

they can be personally delivered to Raffle Chairman Bruce

Peters, at this year's NFB convention in Atlanta, Georgia.

This raffle is open to anyone age 18 or older, and the

holder of the lucky raffle ticket need not be present to

win. Each ticket sold is a donation, helping keep our

Diabetes Action Network moving forward.

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

(Resource Column)

Artwork: Hand pulling a book from a shelf of books

Inclusion of materials in this publication is for

information only, and does not imply endorsement by the

Diabetes Action Network of the NFB.

NEW STUDY NEEDS VOLUNTEERS

Diabetic retinopathy is a frequent complication of

diabetes. In some cases, ruptured capillaries leak blood

into the eye, a "vitreous hemorrhage," which can cloud the

eye, obscure vision, and cause blindness.

Diabetes is only one of many reasons vitreous

hemorrhage can occur. Those conditions have each their own

treatment--but the problem they share is getting the opaque

blood out of the eye. Traditionally, you can wait for it to

clear by itself (up to 18 months in some cases!), or you can

undergo a vitrectomy, a surgical procedure where the blood

is removed.

Advanced Corneal Systems (ACS), of Irvine, California,

is engaged in testing a third alternative. ACS has

developed an investigational medication, called Vitrase,

which offers a quick, non-surgical alternative to vitrectomy

surgery. They need volunteers to help them complete their

tests of Vitrase. If you are 18 years or older, and have

experienced retinal bleeding, please contact Clinicor to

discuss participation. Telephone: 1-800-208-7023.

SAVE YOUR SKIN

Lantiseptic is a line of skin care products of interest

to diabetics. The line includes a cream and a skin

protectant, both appropriate for the dry skin diabetics can

face. The cream is especially appropriate for dry feet, and

has been clinically tested as appropriate for diabetic foot

care.

Both products come in tube or jar, and FREE SAMPLES ARE

AVAILABLE. For information, or to obtain a free sample,

contact: Summit Industries, Inc., PO Box 7329, Marietta, GA

30065; telephone: 1-800-241-6996. For a free sample,

telephone: 1-800-347-2456.

DIABETES SUPPLIES

American Diabetic Supply, Inc., will ship your diabetes

supplies to your door. They handle all insurance claims and

provide free delivery. Folks with Medicare and/or private

insurance (no HMOs) may receive supplies at no further cost.

For information, contact: American Diabetic Supply, Inc.,

400 S. Atlantic Ave., Suite 108, Ormond Beach, FL 32176;

telephone: 1-800-453-9033.

READING MACHINE

There are many ways to cope with the problems loss of

vision brings to reading. One is to use an optical reading

machine like the Kurzweil 1000. With such a machine, you

scan a printed page into computer memory, from where it is

then read by a synthesized voice. Large-print text is not

necessary; you can read most any text.

Reading machines vary in accuracy, size of vocabulary,

and quality of synthesized voice. Kurzweil has been a

leading name in sound synthesis for over 20 years, and the

L&H Kurzweil 1000, their newest product, is a superb

instrument. To find out more about this reading machine,

contact: Lernout and Hauspie Speech Products USA, Inc.,

Kurzweil Educational Systems Group, 52 Third Avenue,

Burlington, MA 01803; telephone: 1-800-894-5374; e-mail:

education.sales@lhsl.com; website:

http://www.lhsl.com/kurzweil1000

ADAPTIVE EQUIPMENT CONVENTION

The Assistive Technology Industry Association, an

organization of adaptive equipment manufacturers,

distributors and related service personnel, is having a

conference and exposition, in Orlando, Florida, January 24

through 27, 2001. In their words: "The purpose of this

conference will be to provide a forum for education and

communication to professional practitioners serving those

with disabilities (teachers, occupational therapists,

rehabilitation counselors, physicians, psychologists,

speech-language pathologists, etc.), with the overarching

goal of providing enhanced benefits and opportunities to

people with disabilities."

The organizers expect more than 100 presentations, more

than 100 exhibitors, and many networking opportunities. For

more information, contact: ATIA; telephone: 1-877-687-

2842; e-mail: atia@northshore.net; website:

http\\www.atia.org

Insta-Glucose

If you have type 1 diabetes, you know low blood glucose

can be a sneaky enemy. Diabetes medications are powerful

but imprecise; and, if you misdose, if you miss a meal, if

you are ill, or if you have unexpected, unscheduled

exercise, you can find yourself going down. You need sugar,

fast! You need to be carrying it with you, before trouble

hits.

Many people carry sugar candy, or diabetic glucose

tablets; but one practical alternative is Insta-Glucose, by

ICN Pharmaceuticals. Insta-Glucose is stronger (one tube,

one treatment, equals 24 grams of glucose), and it works

faster than glucose tablets. It is easy to use, and very

easy to carry. Be prepared! It is available at many

pharmacies and discount chains. For information, contact:

ICN Pharmaceuticals, ICN Plaza, 3300 Hyland Ave., Costa

Mesa, CA 92626; telephone: 1-800-711-9486; website:

http://www.instaglucose.com

DIABETES SUPPLIES

When you need it, you need it. When it's time to test,

when it's time for medication, you need it already there.

Diabetic Care Center will ship your diabetes supplies to

your door, and they do the paperwork. No forms, no trips to

the pharmacy. Medicare and most private insurance accepted.

Call the Diabetic Care Center, telephone: 1-800-633-7167;

website: http://www.diabeticare.com

TALKING COMPUTERS

Henter-Joyce, Inc., maker of the "JAWS" series of

computer screen readers, offers screen-to-speech software

such as JAWS For WINDOWS (JFW), the new MAGic 6.1 screen

magnifier, and tutorials on cassette for programs like

Internet Explorer and Microsoft Word 8. They also offer

Windows 95, 98, and NT compatibility, and as of August

31,1999, there have been significant price cuts. Find out

more at their website: http://www.hj.com, or contact them

for information: Henter-Joyce, Inc., 11800 31st Court

North, St. Petersburg, FL 33716; telephone: 1-800-336-5658;

fax: (813) 803-8001; e-mail: info@hj.com

NUTRITION SUPPLEMENT

Your insulin or oral diabetes medications are only part

of your diabetes self-management. Although food supplements

do not replace your medications, and the U.S. Food and Drug

Administration has not evaluated their efficacy to prevent

or treat any disease, a healthy diet is important, and

research is continuing on the role specific supplements may

play in controlling diabetes. AlphaBetic Multi-Vitamin

Supplement is a food supplement formulated for the special

needs of diabetics. A blend of vitamins, antioxidants, and

minerals, is available in sugar-free caplets. Contact:

Abkit, Inc. New York, NY 10128; telephone: 1-800-226-6227;

website: http://www.alphabetic.com

DIABETES SUPPLIES

Can-Am Corporation carries a full line of discount-

priced diabetes supplies, including: test strips, Dex-4

glucose tablets, skin cream, etc. The company also markets

the Monoject line of insulin syringes and lancets. Many

Can-Am products are also sold as "house brand" at major

pharmacy chains. Their low price in no way compromises

their high quality.

For information, contact: Can-Am Care Corporation,

Cimetra Industrial Park, Box 98, Chazy, NY 12921-0098;

telephone: 1-800-461-7448.

NEW TALKING BLOOD GLUCOSE MONITOR

Based on the proven Accu-Chek Advantage meter, the

Roche Diagnostics Accu-Chek Voicemate provides the

following: Clear, high-quality speech synthesis, talking

the user through preparations, test procedures, and results,

without the need for sighted assistance; an "insulin vial

identifier" which reads Eli Lilly insulin vials and speaks

their type, as a safety aid in tactile insulin mixing; a

new, improved, "touchable" test strip--the Accu-Chek Comfort

Curve (no more "hanging drop of blood" needed!); no meter

cleaning required; and a tactile "code-key" system for

programming test strip codes. The Voicemate is the most

"blind-friendly" talking glucose monitor available today,

and the only one whose regular operations require no sighted

assistance at all.

The Voicemate comes with an adjustable over-the-

shoulder carrying case, with meter, voice box, battery,

adapter cord, 10 Comfort Curve strips, earphone, insulin

check-vial, manual and quick-reference guide (in print), and

instructions on audiocassette. The new meter (catalog #

2030802) can now be ordered through any pharmacy (suggested

retail price $495-525). To do so, have your pharmacist

contact Roche Diagnostics, 9115 Hague Road, Indianapolis, IN

46250; telephone: 1-800-428-5074. For direct purchase, and

a price below $500, contact any of the following retailers:

BeyondSight, Inc., Littleton, CO: 303-795-6455 ($498);

Independent Living Aids, Inc., Plainview, NY ($495): 1-800-

537-2118; or the National Federation of the Blind Materials

Center, Baltimore, MD ($475): 410-659-9314.

LIFE INSURANCE FOR DIABETICS

If you have diabetes, you know it can be very difficult

to find life insurance. Empire Financial, based near

Baltimore, Maryland, specializes in insuring people with

"high-risk" conditions, especially diabetes and its

complications. "We are specialists in high risk," says

Gardner Redd, their CEO. "For 18 years we have covered all

ages, 0 to 90, and all impairments, even people who have

transplants."

Contact Empire Financial Insurance, 600 Reierstown

Road, Pikesville, MD 21208; telephone: 1-877-263-8603.

TREAT MALE IMPOTENCE

For men who've had diabetes many years, one possible

ramification is impotence, the inability to sustain an

erection. This can be treated in a number of ways, but the

least invasive is vacuum therapy.

The Vet-Co Vacuum Therapy System for male impotence is

FDA-approved, safe, non-invasive, and easy to use. For

information, call: Coast To Coast Home Medical; telephone:

1-800-330-6316.

WINDOWS SCREEN READER

GW Micro now offers WINDOW-EYES for WINDOWS 98, a

screen reader program that also supports Microsoft WINDOWS

3.1, WINDOWS 95 and WINDOWS 98. Once equipped with a voice

synthesizer such as the Dectalk (your standard soundcard

won't do), any computer that can run WINDOWS can run

WINDOW-EYES. WINDOW-EYES reads the internet, too! A free

demo disk is available, or you may download the demo program

from the internet. The WINDOW-EYES program is available

from: GW Micro, 725 Airport North Office Park, Fort Wayne,

IN 46825; telephone: (219) 489-3671; fax: (219) 489-2608,

e-mail: support@gwmicro.com; website:

http://www.gwmicro.com

DIABETES SUPPLIES

Diabetic Supply Distributors, Inc., helps you save four

ways with your diabetes supplies:

1. Insurance billing. They file the claim, and they

pay for delivery. No advance payment needed--and THEY do

the paperwork.

2. Medicare billing. Medicare pays for approved

diabetes supplies (and, since last July, that list has

covered type 2 diabetics!). Diabetic Supply will handle the

details.

3. Free, fast home delivery. Your order comes quickly

to your door.

4. Friendly personal service. You're not talking to a

computer.

Contact: Diabetic Supply Distributors, Inc., PO Box

1820, Laurel Springs, NJ 08021; telephone: 1-800-962-8098.

DELIVERED TO YOUR DOOR

Homed Pharmacy Services will deliver your diabetic

supplies to your door. If you have Medicare, and/or private

insurance, your supplies may come at no cost to you. Homed

handles all insurance claims, and delivery is free. For

more information, call Homed Pharmacy Services; telephone:

1-800-226-7212; fax: 1-800-381-9929; internet:

http://www.diabetsupply.com

NEEDLE-FREE INSULIN INJECTION

There is a way to inject insulin without a needle! The

Vitajet 3 administers a fine jet of insulin through the skin

without need for a needle. It works, and users report less

discomfort. Try it yourself; 30-day money back guarantee.

Contact: Bioject, Inc., 7620 SW Bridgeport Road, Portland,

OR 97202; telephone: 1-800-848-2538; website:

http://www.vitajet.com

VOICE DISTRIBUTORS NEEDED

Since the VOICE is now offered free, our Diabetes

Action Network will provide extra copies to anyone wanting

to help spread the word. We will gladly send from five to

five hundred-plus copies each quarter to be used as free

literature. Medical facilities can order as needed for

patients. Individuals can usually place copies of the VOICE

in libraries, pharmacies, hospitals, doctors' offices, or

other public locations.

Diabetes education is essential. Anyone who

distributes the VOICE will be helping people with diabetes,

and their families, to learn about the disease and its

ramifications; to learn that they have options; and that

their world is far greater than whatever "limits" may be

imposed by the disease. If you would like to help spread

the word by distributing the publication, please contact:

Voice of the Diabetic, 811 Cherry Street, Suite 309,

Columbia, MO 65201; telephone: (573) 875-8911, fax: (573)

875-8902. NOTE: Please provide a phone number so we can

reach you.

SUBSCRIPTION/DONATION FORM

The VOICE OF THE DIABETIC is a quarterly magazine

published by the Diabetes Action Network of the National

Federation of the Blind (NFB) for anyone interested in

diabetes, especially diabetics who are blind or are losing

vision. An outreach publication, it emphasizes good

diabetes control, diet, and independence.

Donations are gladly accepted and appreciated.

Contributions are not only tax deductible but are needed to

keep the VOICE and the Diabetes Action Network moving

forward to help people with all aspects of diabetes.

Members of the NFB Diabetes Action Network enjoy

priority services and unique benefits such as a continuous

free subscription to the VOICE, automatic access to

committees covering all aspects of diabetes, free counseling

concerning all facets of blindness and diabetes, as well as

access to diabetics who have experienced complications.

The VOICE is free to any interested person upon

request. Each subscription costs the Diabetes Action

Network approximately $20 per year. To help defray

publication expenses, members are invited, and nonmembers

are encouraged, to cover the subscription cost.

To begin receiving the VOICE, please check one:

[ ] I would like to become a member of the NFB Diabetes

Action Network and receive the VOICE OF THE DIABETIC.

(Members are entitled to special benefits.)

[ ] I would like to receive the VOICE OF THE DIABETIC as a

nonmember. (Nonmembers are encouraged to pay the

institutional rate of $20/one year; $35/two years;

$50/three years.)

Send the VOICE in (check one):

[ ] print[ ] cassette tape for the blind [ ] both

and physically handicapped

(recorded at slower-than-

standard speed of 15/16 IPS)

Optionally check this box:

[ ] I would like to make (or add) a tax-deductible

contribution of $__________ to the Diabetes Action

Network of the National Federation of the Blind.

PLEASE PRINT CLEARLY

Name:_____________________________________________________

Address:__________________________________________________

__________________________________________________

City:_______________________ State:______ Zip:__________

Telephone: ()________________________

Send this form or a facsimile to:

Voice of the Diabetic

811 Cherry Street, Suite 309

Columbia, MO 65201

Telephone: (573) 875-8911

Fax: (573) 875-8902

Please make all checks payable to:

NATIONAL FEDERATION OF THE BLIND

END of VOICE OF THE DIABETIC, Volume 15, Number 2, Spring

Edition 2000