VOICE OF THE DIABETIC

 

The Diabetes Action Network of the

National Federation of the Blind

 

A Support and Information Network

 

Volume 15, Number 3, Summer Edition 2000

 

 

VOICE OF THE DIABETIC, published quarterly, is the national news magazine of the Diabetes Action Network of the National Federation of the Blind.  It is read by those interested in all aspects of blindness and diabetes.  We show diabetics that they have options regardless of the ramifications they may have had.  We have a positive philosophy and know that positive attitudes are contagious.

 

News items, change of address notices, and other magazine correspondence should be sent to:  Ed Bryant, Editor, Voice of the Diabetic, 811 Cherry Street, Suite 309, Columbia, Missouri 65201-4892; Phone:  (573) 875-8911; Fax:  (573) 875-8902.

 

Find us on the World Wide Web at:  http://www.nfb.org and follow the links for "diabetes."

 

Copyright 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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or find us on the Web at:

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For SUBSCRIPTION information, see the end of this document.

 

 

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Please Note:  We have a special bulk-mailing permit that we use to ship the VOICE to you at low cost--it does not allow for free re-mailing.  The Post Office requires you place first class postage on any VOICE you mail to others.  

 

 

INSIDE THIS ISSUE

 

THE EVOLUTION OF INSULIN PUMPS

by Donna Blake

 

ASK THE DOCTOR

by Paul K. Overland, MD

 

REZULIN WITHDRAWN FROM THE MARKET

 

NEW TALKING MEDICINE IDENTIFIER

by Ed Bryant

 

NEW INSULIN RECEIVES FDA APPROVAL

 

I'VE GOTTEN ATTACHED TO MY INSULIN PUMP

by Veronica Elsea

 

DEPRESSION AND DIABETES

by Peter J. Nebergall, PhD

 

NEW HOPE FOR GASTROPARESIS

 

SOCIAL SECURITY, SSI, AND MEDICARE FACTS FOR 2000

by James Gashel

 

NEW ARTIFICIAL EYES

 

MEDICARE WILL PAY FOR INSULIN PUMPS

 

LETTERS TO THE EDITOR

 

ORAL DIABETES MEDICATIONS UPDATE

by Peter J. Nebergall, PhD

 

COOKING WITH SUZI

by Suzi Castle

 

RECIPE CORNER

 

BOOK REVIEWS

by Marilyn Helton

 

TALKING BLOOD GLUCOSE MONITORING SYSTEMS

by Ed Bryant

 

LANTUS INSULIN:  CAUTIONS

 

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

(Resource Column)

 

FOOD FOR THOUGHT

 

 

THE EVOLUTION OF INSULIN PUMPS

by Donna Blake

 

Photo:  portrait.  Caption:  Donna Blake

 

Believe it or not, insulin pumps have been in existence for over 20 years.  In the seventies, the first insulin pump was approximately the size of a microwave oven.  That first pump performed exactly the same functions that the beta cells did in a non-diabetic pancreas.  The Biostater measured blood glucose levels and dispensed insulin into the blood stream every five minutes.  Because of it’s size it was used to treat diabetic ketoacidosis (DKA), and in diabetes related research studies.  As the concept of daily blood glucose monitoring developed and came into being, researchers at Yale University had an idea:  why not allow a person with diabetes to monitor their blood glucose levels and regulate the pump based on their own judgement.  Thus, the concept of a portable insulin pump began.

 

The first portable insulin pump was in fact a chemotherapy pump, and the idea taken from the way cancer patients were given their medicines.  Patients undergoing treatment for cancer wore small portable pumps on their belts, which either delivered their chemotherapy medicines or morphine to help control the pain.  The first pump weighed over a pound (not by much) and used a large syringe placed on the outside of the pump.

 

The early pump was about the size of an aerosol can, only a bit wider and rectangular.  Besides the dials being located on the outside (two round half-inch projections) there were also blinking red LED lights.  The pump delivered diluted regular insulin at a constant rate and the user pumped in extra insulin based upon meal times and blood glucose levels. 

 

In order to become a pump user, people were required to undergo psychological testing, and required at least a one-week stay in a hospital.  Dedication to blood glucose monitoring was an essential condition to using an insulin pump.

 

The first "real" insulin pumps were also fashioned by the manufacturers of the chemotherapy pumps.  The pumps were somewhat smaller and lighter than the chemotherapy pumps, with the syringe mechanisms hidden in a covered compartment.  These pumps were much thinner and sturdier, which gave them distinct advantages over the converted chemotherapy pumps.  First, the pump was more cosmetic for the user.  Second, it allowed for the user to be more active, with a bit less caution, to avoid damaging the pump during activities.

 

However, the pump had a major design flaw.  The pump user still had to dilute U-100 insulin into concentrations like U-18 or U-36 with saline (sterile salty water) and eventually the same fluid that insulin is dissolved in.  The reason why this had to be done was the fact that the pump design was based upon how chemotherapy drugs were delivered and not how hormones such as insulin were produced and used in the body.  The pumps were designed to deliver a specific amount of fluid at specific intervals, with no variations.  These manufacturers did not consider that insulin must be delivered at different rates throughout the day.  Insulin doses had to be calculated out to achieve the proper amount for each patient.

 

In the early days, insulin pumps had only one rate of flow over a 24-hour period and this was called the basal rate.  The basal rate is similar to a long acting insulin in that it is the amount of insulin delivered to keep the blood glucose normal if there are no changes in diet or activity.  Boluses (the doses given at meal times and if the blood glucose was elevated) could be any amount the user needed to manually tell the pump to put in.

 

The popularity of insulin pumps increased based on several “advantages.”  The first advantage of pump use was tighter blood glucose control, one of the most important reasons.  Another advantage of pump use was being able to sleep in the morning and not having to follow such a rigid schedule based upon the peaks of insulin taken with daily injections.  A third popular reason for using a pump was the ability to not be caught without your insulin and the ability to vary the insulin dose based upon activity, meals and other factors.  For most pump users, the stigma of wearing a pump was not a concern, since the main goal of pump therapy was tighter diabetic control.  Activities were not a problem with the pump and in fact, the pump led to a decrease in insulin reactions since the pump could be removed for activities.  The hour by hour changes that could be made with an insulin pump were actually beneficial for active pump wearers--the only exception being that an extended disconnection from the pump was not always beneficial.  Current pumps are worn with all activities including swimming, and it was the early models that led to this advance.

 

As the population of pump users increased, so did the number of pump manufacturers.  Along with the increase of manufacturers, a variety of insulin pumps appeared, with different features.  Lily (CPI) was one of the first manufacturers to make an advanced pump; this was an insulin pump that used U-100 insulin and had four programmable basal rates.  In addition, its size was substantially smaller than the first generation of insulin pumps (half  of the size of a 6" x 4 ½" x 1 ½" cassette shipping container from National Library Service), and it had a numeric touch  keyboard exactly like a microwave oven.  This was considered to be the Cadillac of pumps.  Soon the market was flooded with insulin pumps of all types, some good and others, well, not so good.

 

With the increase in insulin pumps and increase in users, it became apparent there were drawbacks as well as benefits to pump use.  Most pumps required battery charging and changing every few days.  Some pumps used very specialized insulin reservoirs, which were costly.  There were even pumps that used specialized internal pumping mechanisms, which affected the stability of the insulin.  In addition, all pumps delivered insulin under the skin, just like a regular insulin injection--and needed to keep a needle in the site at all times.  Their insertion sites were prone to infection, and frequently were quite sore (especially if the pump user was thin).  The needle had to be changed every three days to prevent irritation and infection; this is still the practice with today’s newer and more comfortable “needles.”

 

In addition to these inconveniences, it quickly became apparent that insulin pump users were more prone to DKA.  Pump users were more susceptible to this condition because at any given moment there were only minutes of insulin within the body, and when this insulin delivery was interrupted, a rapid rise in blood glucose would occur.  A significant drawback for many pump users was the 15 to 20 pound weight gain generally associated with tight diabetes control.

 

After approximately five years of popularity, the use of the insulin pump began to decline.  This was for a variety of reasons, but mainly because the pump did not provide better control than multiple daily injections (at least three or more).  Another noteworthy reason for discontinuing pump use was that the pumps were expensive, and prone to damage and breakdown.  Finally, many of the younger pump wearers didn’t want the stigma of wearing a pump and thus making themselves “different” from their friends whom did not have diabetes.

 

Soon many pump users found their pump company had decided to discontinue the pumps, and in some instances, it became difficult to obtain supplies.  By the late eighties, there were only a few pump companies in existence and few advances were being made.  An implantable pump was created, but that generated difficulties.  The implantable pump was placed just under the skin and was visible to others as a projection from the surgery site.  (It looked like a hockey puck under someone’s skin.)  The two areas the pump could be implanted were in the abdomen (just below the ribs), or located on the wearer’s chest where the hand is placed over the heart in “I Pledge Allegiance to The Flag”.  This pump needed to be refilled with a large-gauge needle, and the wearer was required to carry around a programming unit.  The programming unit was about the size of the current Accu-Chek Voice-Mate talking glucose monitor (3" x 2 ½" x 6 ½"), and in order to deliver insulin boluses the wearer had to hold the programming unit over the pump to convey to the pump its instructions.  High magnetic or electric fields could disrupt the programming of the pump.  Though it was rare, the pump could break down, requiring surgery to replace it.  Every five years, the battery of this implantable pump needed to be changed.

 

Despite these drawbacks, two pump companies have continued to create innovations in pump therapy.  These two companies are MiniMed of California and Disetronic Medical Systems of Switzerland, with a United States office in Minnesota.  Today’s pump is much different than its predecessors.  The new-generation pumps are still controlled by the wearer (called an "open loop system") but they offer a much wider variety of features, and a decrease in size.  Often today’s pumps are mistaken for beepers, since they are only slightly larger, and come in a variety of designer colors.  A distinct advantage of today's pumps is they are more durable than their ancestors, and often go unnoticed on the belts (and in other places) of their owners.

 

Modern pumps use a special small syringe, which resides in the pump and is connected to the wearer via a small cannula (like an IV needle/catheter).  Battery changes are every few months and available right off the shelf in just about any store; one pump uses a four-year lithium battery, so no battery changing is needed.  Although not yet self-adjusting, modern pumps are the closest thing to a healthy pancreas we can get.  Just about any type of insulin delivery can be programmed into them, to fit a variety of lifestyles and requirements.  The newer pumps contain a variety of alarms, which warn the user of clogged tubing and low power supplies.

 

The newer pumps also have features which make it easier to track trends in lifestyle.  They store huge quantities of data such as when and how much insulin the user has taken or when alarms have gone off and for what reason.  New pumps also use lighted screens (for sighted users in dark locations) or audio cues for those users who have a visual impairment.

 

The mindset of today’s pump user is also somewhat different.  People who use pumps today really want the pump for its flexibility and tight control, and usually test their blood glucose four to ten times per day.

 

There are no restrictions on the activities of pump users today.  Watertight cases are available to allow for swimming.  People on pumps have done everything from running or biking across America to hiking up Mt. McKinley.  In addition, many professionals, such as 1999’s Miss America, use pumps without anyone ever knowing.  People using a pump today perform all types of jobs and participate in any activity they desire--the pump never holds the user back!  At night, most people just place the pump on the waistband of the garment they are wearing, or in a pocket.  Other pump wearers place the pump next to them when they sleep, since the tubing on the catheter can range from 24 inches to 42 inches.  Wherever the pump is placed for activities or sleeping, it usually does not get in the way.

 

Where are pumps heading in the future?  Pumps are heading toward self-adjustment, toward being a closed-loop system.  Such a pump would test the wearer’s blood glucose and deliver an insulin dose accordingly.

 

Currently, there is a blood glucose sensor, worn at the belt like a pump, which measures the blood sugar at specific short-time intervals, through a catheter, like the pump,  It gives an averaged readout every few minutes.  Eventually, I am sure, this sensor will be incorporated into a pump, making it self-adjusting.  Designs are in the works at this very moment, and the technology is here.  Within a few years such a device should be available to all those who want to become pump users.

 

 

CORRECTION

 

In the last issue of the VOICE, Volume 15, No. 2, April 2000, there was an error in our “Ask the Doctor” column.  There, the Diabetes Control and Complications Trial (DCCT) a major diabetes investigation, was said to have taken 16 ½ years to complete.  In fact, the study was completed in 9 ½ years, running 1983 to 1993.  For more information on the DCCT, see the National Institutes of Health website: http://www.niddk.nih.gov/diabetes/diabetes.htm

 

 

ASK THE DOCTOR

by Paul K. Overland, MD

 

Artwork:  Medical caduceus

 

NOTE:  If you have any questions for “Ask the Doctor,” please send them to the VOICE editorial office.

 

            This issue, our column is by Paul K. Overland, MD, an ophthalmologist working at the Rocky Mountain Eye Center, in Missoula, Montana.

 

Q:  After becoming diabetic, I was afflicted with diabetic retinopathy.  This reduced my vision to 60% of normal in one eye and 10% of normal in the other eye.  Laser surgery has been recommended.  What I want to know is:  How successful is laser surgery?  What are the chances it will, instead, make things worse?  Is this a risk I should take?

 

A:  My first answer to your question is really a statement of the seriousness of diabetic retinopathy, which is the leading cause of new cases of legal blindness among working-age Americans.  One of our great problems is that type 2 diabetes emerges in adulthood, is frequently undiagnosed for many years, and high blood sugars during this time can cause irreversible damage to the retinal circulation.  Once diabetes has been diagnosed, it is essential to tightly control blood sugars, to prevent continuing damage to the blood vessels throughout the body.

 

Your question does not state your age or the duration of your diabetes, nor the type of diabetic retinopathy you have.  In general there are two types of diabetic retinopathy, and both can damage or destroy your vision.

 

The most common form is non-proliferative (“background”) retinopathy in which the tiny blood vessels in the eye develop leaks.  Once the leaking begins, blood and fluid seep into the retina, causing swelling, and fatty material can accumulate within the retina.  Sometimes the fluid accumulates in the retina’s center, called the macula, and the resulting edema causes profound loss of reading vision.  Another cause of permanent loss of clear vision is capillary (small blood vessel) closure, in which blood supply to retinal tissue is stopped and retinal tissue dies.

 

A more serious type of diabetic retinopathy is called proliferative, and in this case retinal blood vessels become obstructed.  Large areas of the retina lose their source of nutrition and oxygen.  When this happens, the retina tries to build new blood vessels to replace the old damaged ones.  However, the new blood vessels are abnormal.  They do not grow within the retina but rather “proliferate” on the surface of the retina.  This can lead to severe bleeding into the vitreous cavity, followed by scarring and ultimately, retinal detachment.  If this proliferative diabetic retinopathy is not treated promptly, it can cause severe loss of vision and blindness.

 

Laser surgery can be successful in preventing severe vision loss in proliferative diabetic retinopathy, and this has been proven scientifically over the past 30 years, in many controlled studies. 

 

Additionally, laser is very useful in preventing visual deterioration in background diabetic retinopathy, where it is used to seal up leaking blood vessels which can cause bleeding and swelling within the retina.

 

Laser surgery does not ordinarily make the vision worse, but there can be some temporary swelling in the retina following laser treatment.  This ordinarily clears within six weeks’ time.  In general, all of our controlled studies on diabetic retinopathy tell us that laser surgery is much safer than and preferable to letting diabetic retinopathy take its natural course, which ordinarily leads to blindness.

 

You should consult an ophthalmologist, eye MD, who is experienced in retinal laser treatment and diabetic retinopathy.

 

Your question underscores the need for everyone to have routine eye examinations every two to three years in adulthood to screen for disorders including cataract, glaucoma and diabetic retinopathy.  Individuals diagnosed with diabetes should have such exams once a year.  Eye MD’s (ophthalmologists) are most qualified to diagnose and treat your eye conditions.

 

 

REZULIN WITHDRAWN FROM MARKET

 

On March 21, 2000, the Food and Drug Administration asked Parke-Davis, the manufacturer of Rezulin (troglitazone) to remove the drug from market.  The manufacturer agreed.

 

FDA took this action after its review of safety data in Rezulin and two similar drugs, rosiglitazone (Avandia) and pioglitazone (Actos) showed that Rezulin is more toxic to the liver than the other two drugs.  Data to date show that Avandia and Actos, both approved last year, offer the same benefits as Rezulin, without the same risk.

 

“When considered as a whole, the pre-marketing clinical data and post-marketing safety data from Rezulin as compared to similar alternative diabetes drugs indicate that continued use of Rezulin now poses an unacceptable risk to patients,” said Dr. Janet Woodcock, Director of the FDA’s Center for Drug Evaluation and Research.  “We are now confident that patients have safer alternatives in this important class of Diabetes Drugs,” she said.

 

 Severe liver toxicity has been known to occur with Rezulin since 1997.  After consultation with the FDA, Parke-Davis strengthened warnings on the label several times, and recommended close monitoring of patients’ liver function.  In March 1999, the FDA reviewed the status of Rezulin, and at that time recommended its use be limited to those patients not well-controlled on other medications.

 

After up to nine months of marketing experience with Actos and Avandia, it has become clear those two have less risk of severe liver toxicity than did Rezulin.  The U.S. Department of Health and Human Services says: “Patients using Rezulin are urged to contact their physicians for information about alternative treatments.  Patients should not discontinue taking Rezulin or any other treatment for diabetes without discussing alternative therapies with their physicians.”

 

 

 

NEW TALKING MEDICINE IDENTIFIER

by Ed Bryant

 

Photo #1:  portrait.  Caption:  Ed Bryant

 

Photo #2:  equipment.  Caption:  The ALOUD Model 100 Audio Labeling System

 

Last September, Dr. Marc Maurer, president of the National Federation of the Blind, asked me to attend a meeting at the National Center for the Blind, in Baltimore, Maryland.  Representatives from the ASKO Corporation there discussed and demonstrated a prototype of a device called the ALOUD® Model 100 Audio Labeling System. 

 

We all have to take medications sometimes; many of us, especially diabetics, take them on a regular basis.  Blind individuals, or those with severe visual impairment, can have difficulty independently measuring medication, because there are no tactile marks on the prescription container.  The problem is greatly compounded if the consumer is a blind diabetic who uses insulin.  All insulins are packaged in identically-shaped, cylindrical vials.  If the incorrect insulin is injected, the results can be serious. 

 

But we have been left to our own ingenuity, for the most part, creating our own “recognition systems” by attaching home-made Braille labels, rubber bands, tape, storing medications in specific locations, putting medications in different shaped containers, etc.  The effectiveness and reliability of these home-made solutions can be limited.   

 

Imagine being able to reliably identify each one of your medications, and also being able to remember the directions for use of each medication--anytime and anywhere, without having to ask for help.  A dream?  No longer. 

 

A new product, the ALOUD® Audio Labeling System, from ASKO, can best be described as a “talking prescription container.”  This is how it works:

 

When a pharmacist dispenses your medication, an audio version of the printed prescription label (called an “Audio Label”) is also produced and attached to the medication container.  When the Audio Label is placed into an ALOUD® Replay unit, the Audio Label information recorded by your pharmacist is replayed.

 

Each of your medications has its own Audio Label, and you can play the message over and over, as many times as you like.  It cannot be accidentally erased or altered.  The only person who can change the message is your pharmacist, who has a special recorder in the pharmacy.  The Audio Label is reusable, so when you need to have your prescription refilled or changed, the message can be changed also and attached to your new prescription.

 

The replay unit is portable.  It is only 4" high, about 2" in diameter, and weighs less than 8 ounces.  It has a rechargeable battery, so you can use it anywhere.  The audio fidelity is very good, and you can also use a small earphone for private listening.  The construction is extremely durable, the product is manufactured in the USA, there is absolutely no maintenance required and the product comes with a one-year warranty.

 

The ALOUD® system is scheduled to be available later this year, but those of us attending the NFB national conference in Atlanta had the opportunity of a preview as ASKO presented the product at our Diabetes Action Network seminar, and at General Sessions, where more than 3000 delegates attended.

 

I am extremely impressed with the ALOUD system, which I know will be beneficial for blind people.  Although I have not heard a price, indications are it will be reasonable and affordable.  As soon as the product becomes available, and a selling price is established, VOICE OF THE DIABETIC readers will be apprized.

 

Further information about the ALOUD® system can be obtained from:  ASKO Corporation, 2 South Street, Stamford, NY 12167; telephone, toll-free:  1-877-732-9227; website:  http://www.askocorp.com

 

 

 

NEW INSULIN RECEIVES FDA APPROVAL

 

LANTUS (Insulin Glargine rDNA), from Aventis Pharmaceuticals, has received FDA approval.  Thus Aventis (successor to Hoechst) joins Novo Nordisk Pharmaceuticals Inc., and Eli Lilly and Company, as a U.S.-approved insulin manufacturer.

 

How is this insulin different?  LANTUS is a very slow insulin, somewhat similar in response to Ultralente, although quicker in time-of-onset.  The company describes it as a “long-acting basal insulin...providing a relatively constant profile with no pronounced peak, and a glucose-lowering effect for over 24 hours.”  Company literature states this insulin is for once-a-day administration, at bedtime, to treat adult patients with type 2 or type 1 diabetes, who require basal insulin.

 

LANTUS is a recombinant DNA insulin analog specifically formulated to provide a long, flat response.  Because of its special formulation, LANTUS cannot be mixed in a syringe with any other insulin, so if you wished to take it with Regular or Humalog, you’d have to take two injections. 

 

LANTUS insulin should be available shortly.  Have your physician contact:  Aventis Pharmaceuticals, in Parsippany, NJ, telephone:  1-800-552-3656; website: http://www.aventis.com

 

 

I'VE GOTTEN ATTACHED TO MY INSULIN PUMP

by Veronica Elsea

 

Photo:  portrait.  Caption:  Veronica Elsea

 

FROM THE EDITOR:  Veronica Elsea is a professional musician with her own studio, and a member of the Diabetes Action Network of the National Federation of the Blind.  Here she provides, based on her own experience, a detailed explanation of how blind diabetics can independently use insulin pumps.

 

With the recent awareness of the benefits of tight glycemic control, many of you may be considering the use of an insulin pump.  Yet along with the curiosity, excitement, and optimism come some challenges for blind persons.  We must often start by convincing our health care professionals that yes, we can make use of this new technology; a tricky proposition if we've never actually seen or used the device ourselves!  I hope that by describing how I manage my pump, this challenge will be more quickly and easily met.

 

I am totally blind, a type 1 diabetic, and I have been using the Disetronic (H-Tron V) insulin pump since September of 1991.  The learning process was quick.  I had the entire kit:  pump, supplies and manuals, sent to me ahead of time.  I did not then own an optical scanner, so my husband read the manual to me, and I had the time to privately explore the pump.  This process took one evening, and I found it very helpful.

 

The pump is small, about the same size and shape as a little travel pack of facial tissues.  It has only three buttons, two on top and one on the front.  There are no complex menus or screens to learn.  In fact, for a totally blind person, the training is usually very quick, as most "training time" is spent learning the print symbols for cartridge, battery, etc.

 

Everything you do is confirmed by beeps.  Press once on either top button, and three short beeps tell you your pump is running; one long beep will tell you your pump is stopped.  (When in stop mode, the pump also beeps every minute to remind you of this.  So if I'm removing my pump and don't wish to wake my husband while I shower, I temporarily turn off the beeps.)

 

Batteries:

 

The pump uses two batteries, which are very easy to install and remove.  There is a low battery alarm which I'll cover later.

 

 

Filling the Cartridge:

 

The pump uses a glass cartridge, holding 315 units of regular insulin.  Filling it is a very blind‑friendly process.  I simply place the cartridge in its holder, attach a needle to one end, and its plunger to the other.  After removing the cap from the needle, I insert the needle into an insulin vial, upright on my table.  I then turn the whole works upside down, and grasp the holder in my left hand.  I can then push the plunger all the way up, and begin pulling it out, slowly and steadily, filling the cartridge with insulin.  The holder prevents the plunger from being pulled out too far.

 

The question most sighted people ask is about preventing air bubbles.  I find it's easy to get air bubbles because it's hard to pull the plunger out evenly.  So, after I fill the cartridge, I slowly push the plunger back in again, and surprise; the air bubbles are very audible!  I usually do this a few times, pushing and withdrawing the plunger, sometimes tapping randomly on the holder.  When I push in and hear nothing, I stop, pull it back out, and that's it!  I then pull the insulin vial off, cap the needle, unscrew the plunger and the needle, put a little cap on the cartridge, and lift it out of the holder.  Sometimes just to be safe, I fill the cartridge in the evening, and let it stand overnight, before placing it in my pump the next morning.  This allows the air bubbles to dissipate. Disetronic is now recommending this procedure for sighted pumpers as well.

 

Priming the Pump:

 

Near the battery compartment there is a hole into which the cartridge fits.  I insert what's called the "piston rod" into the cartridge, where the plunger had been.  This piston rod is what moves, forcing the insulin out of the cartridge. Once the cartridge is in the pump, I pull off its cap and put on what's called the "gray adapter."  It forms an airtight seal and has an opening in the top where the tubing is attached.

 

By pushing a few buttons, I tell the pump it has a new cartridge, and it sets its display accordingly.  The pump beeps when the process is complete.

 

Getting Insulin Where It's Needed:

 

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.

 

Tubing: 

 

The cannula is connected to the pump through special tubing.  One end of the tubing is pushed into the end of the cannula, and the other screws into the gray adapter, as mentioned above. Before I connect the tubing, it must be primed (filled with insulin).  This is very simple:  Press all three buttons at once.  When priming, I hold the end of the tubing in my left hand, and extend one finger until it rests directly under the spot where the insulin will come out.  When that finger is damp, I know my tubing is completely primed.  I stop the insulin flow by pushing one button with my right hand.  I then attach the tubing to the cannula.  Priming is treated as a separate function because the pump keeps track of your daily insulin usage, so the amount of insulin used in this process is not added on to your total.

 

Insulin Delivery:

 

With a pump, you receive insulin in two different ways, the basal and the bolus.  When your pump is running, you will automatically receive insulin every few minutes.  You program (set) an hourly rate.  For instance, my basal rate for this current hour is .4 units.  The pump then portions that amount over the hour.  I can set a different rate for each hour, or make many of them the same, depending on my needs.  (I keep a list of my rates in a file in my Braille Lite.)

 

The process of setting basal rates is one of counting beeps.  With the pump stopped, I push one button to move from one hour to the next.  The remaining two buttons allow me to go either up or down, .1 unit at a time.  There are special shortcuts (button combinations) for some tasks, such as setting all rates alike, or repeating the same setting for the next hour, etc.  And yes, if you really get lost, you can just go back to "0" and start over.

 

When you eat, or if you need to take extra insulin because you're high (elevated sugars), you give yourself a "bolus."  When the pump is running, a press of either button on top will deliver .5 units of insulin.  So if you wanted three units, you'd press the button six times.  The pump will beep as you press the button, and then will repeat the beeps back to you, before actually delivering the insulin.  By the way, these buttons are designed to be felt through clothing, so you need not stop and fish out the pump.  I have often given myself a bolus while standing in the buffet line, making my food selection.  In the same manner, you can temporarily reduce your basal rate in cases such as extra exercise.

 

Carbohydrate Counting:

 

This is a skill you will learn as part of your pump training.  In my case, I take one unit of insulin for every 12 grams of carbohydrates, except in the morning, when one unit covers 10 grams.  I worked with a dietitian to learn portion sizes, and read food packages.  There are many print books which list the carbohydrates and calories for various foods, and I'm hoping we'll shortly find this information on line.

 

Alarms: 

 

The pump has alarms for low batteries, occlusion, electronic problem, "out of insulin" and end of use of your pump.  Although the same beep sounds, the different alarms behave differently.  Disetronic has expressed willingness to make these alarms easier to understand by having the beep match the "error number."  For instance, error 3 means a low motor battery.  In the future, the alarm for this might be a repeating pattern of 3 beeps (it doesn't yet).  But for now, we just have to learn what the beeps mean.  An alarm will beep constantly until you silence it.  If you do nothing else, you'll get beeped at again in one hour.  This process can go on for as long as 12 hours.

 

I have learned that I usually get about two months' use on one battery set.  So if I'm planning a trip, I usually just change them when I think it's about time, not waiting for the alarm.  Incidentally, the pump does not forget your basal settings when you change batteries.  The occlusion alarm, on the other hand, will emit the same constant beep until you silence it.  But you'll hear it again every time the pump tries to deliver insulin, every few minutes.  It also puts the pump in stop mode.

 

The pump lets you know as you're approaching the end of your cartridge.  You hear one beep when you have 20 units of insulin left, (I often miss this one), two for 15, three for 10, four when you have 5 units left, and an alarm when you run out.  This alarm acts like the occlusion alarm, but it has of course been preceded by all those warnings!

 

 

The Display:

 

I have not found any way to successfully read the display; it's too small to read with my Optacon.  This display shows the amount left in the cartridge, the total amount of insulin used since midnight, the amount and time of the last bolus, and the current basal rate.  It also shows symbols or numbers as you prime, install a cartridge, set the clock, and set basal rates.  At first, I used a calculator to keep track of my insulin usage, but now I know that under normal conditions, a cartridge lasts me about eight days.  Once in a great while, I just ask my husband to check a number, or to double check my readjustment of my basal rates.  I rarely miss this display.

 

The clock is also set by counting beeps.  It can get a bit tedious though, as you can only go forward; just be patient when changing back to standard time!

 

Wearing the Pump:

 

It only weighs a few ounces, has very rounded edges, and is very rugged.  Many people place the pump in a pants pocket or on a belt loop.  I prefer wearing mine tucked in my bra or in a shirt pocket.  If I'm wearing a very nice dress, I often put it around my waist (You can buy all sorts of pouches for holding the pump).  It doesn't hurt to roll over on it, bump it or anything.  I find that I only occasionally startle someone who gives me a big hug and wonders what that "thing" is!  I've gone swimming with mine, hiking, shopping, dining and more.

 

Until the arrival of the "Tenders," I carried the pump into the shower every day.  I would put it in a bag that I could hang on the faucet, or clip to a shower curtain, and yes, the tubing is long enough to allow plenty of room for moving around.  You can buy tubing in different lengths, although I prefer the shortest, 31 inches long.

 

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.

 

 

Questions or Problems:

 

I have found the people at Disetronic to be very helpful when I had a problem.  They've done very well at giving blind-friendly descriptions of things over the phone, listening to my suggestions, and sending me things for trial purposes.

 

 

Advantages:

 

I really notice a difference in my control.  I use less insulin, have fewer highs and lows, and just plain feel better.  I also love the flexibility; I decide when it's mealtime, and can easily make adjustments if I am surprised by things like a sauce they didn't mention, or a walk that was longer because some street didn't go through!  I love the convenience of not having to carry around all those little bits and pieces.  Here's one example:  I regularly attend breakfast meetings.  I test my blood before I leave home.  Since I never know when breakfast will actually arrive, I wait until the meeting has started, then just reach up and push the button.  People don't even notice that I'm doing it; their pagers and mobile phones are much louder.

 

I feel very efficient and inconspicuous, just the way I like it.  If I'm out and unable to test, or don't get a valid test, I find the pump very helpful.  I take the amount of insulin which will match the upcoming carbohydrates or familiar diet pattern, and know that it's easily straightened out later, just by pushing a button.  I'm also not so worried about going out and getting in trouble from low blood sugars, since there's no long acting insulin.  If I'm low, once I eat something, I know I'll be okay.

 

I sincerely hope that relating my experiences with the pump will help you have a constructive discussion with your health care team about whether or not the pump is right for you, based on your diabetes, not your blindness.

 

Note:

 

Disetronic Medical Systems (H-Tron V Insulin Pump): 5201 River Road, Suite 312, Minneapolis, MN 55421-1014; telephone:  1-800-688-4578.  Control buttons are raised, and easy to distinguish by touch.  The device has clear audio cues.

 

Minimed Technologies (Minimed 506 Insulin Pump):  12744 San Fernando Road, Sylmar, CA 91342; telephone:  1-800-933-3322.  Control buttons require modification for non-sighted use.  The device is not as accessible as the Disetronic, though some blind diabetics use it quite successfully.

 

++++++++++++++++++++++++++++++++++++++++++++++++++++++

 

DEPRESSION AND DIABETES

by Peter J. Nebergall, PhD

 

There is a growing body of evidence linking episodes of emotional depression with long-term diabetes.  The relationship is complex, and needs to be carefully explored.

 

First, there are several kinds of depression.  An emotional low that stems from a depressing situation, "circumstances got you down," is said to be "situational depression."  Depression that stems from hormonal imbalance, brain injury or chemical instability is said to be "organic depression." 

 

Now we all know that diabetes is depressing.  There is a lot about it that can "get you down," and little to lift you up again.  If that were all, it would be pretty simple.  But it's not all.

 

Statistical studies show solid "association" between significant diabetic complications and serious depression.  Does this prove that "depression causes diabetes?"  No.  Does it prove that "diabetes is depressing?"  No.  It is an association, which means only that far more of the factors were found together than could be explained by random happenstance.  It doesn't mean you're nuts.

 

Why does this matter?  We already know that diabetes is serious--that its rules must be followed, and its complications taken seriously, if health is to be preserved.  We know almost as much about depression.

 

Major depression, regardless of cause, can lead to eating disorders, physical inactivity, abandonment of consistent routine, and other behavioral changes that can harm your diabetes control.  The feelings of hopelessness and worthlessness that are a common symptom of depression can lead one to "noncompliance," to abandonment of necessary self-care, or worse.

 

Successful treatment for depression, whether with counseling, medication, or both, improves one's capacity to independently carry out the necessary tasks of diabetes self-management.  The person who becomes less depressed is able to do a better job with his/her diabetes.  But there's more. 

 

Certain medications used to treat depression have also proven effective against diabetic complications.  Tricyclic antidepressants appear effective against certain forms of diabetic neuropathy.  Other medications may be effective as well, although such medications may impact one's blood sugar control.

 

To Review:  It is a real spiderweb of interlocking causes.  We see a lot of folks who have both long-term diabetes and serious depression--and depression appears up to five times more likely among diabetics than among the rest of the population.  But depression doesn't cause diabetes, and diabetes doesn't "cause" depression, either.  The nature of the link is still unclear.  What is clear is that significant improvement to either condition can improve the other.  We may not know the exact nature of the linkage we are observing, not yet, but we know the old word "holistic," all parts considered together, is the right word to use here.

 

 

NEW HOPE FOR GASTROPARESIS

 

One of the complications of diabetes is autonomic neuropathy, damage to the central nervous system.  The body's autonomic nerves control basic functions, like heart rate and digestion.  When autonomic neuropathy affects digestion, the condition is called gastroparesis.

 

Symptoms of gastroparesis may range from early fullness and lack of appetite to nausea, vomiting and stomach pain.  Peristalsis, the churning movement of the stomach, is intermittent, or ceases outright, so sufferers may vomit up food eaten days before--and find it almost undigested.  In such circumstances diabetes control, not to mention quality of life, can become very difficult.

 

In April, 2000, the Food and Drug Administration approved MedTronic Corp.'s Enterra implant, to control gastroparesis.  The Enterra is a small electronic "neurostimulator," much like a heart pacemaker, with electrodes implanted into the stomach muscle.  The theory is that the small shocks (one every six seconds) delivered onto the stomach, stimulate nerves lining the stomach that control digestion.

 

Both the researchers and the FDA state the theory is not proved, and the completed clinicals have been small--33 people--but the device seems to work, so the FDA offered a special "Humane Treatment" review, and accepted the device.

 

Most diabetic gastroparesis is not severe enough to warrant such a device.  The researchers estimate up to 100,000 people may suffer measurable gastroparesis, but in most cases it is controllable by better diabetes control, special diet, and medications.  The FDA estimates that perhaps 400 people per year do not respond to medications, and might benefit from the Enterra.

 

For more information, have your physician contact:  MedTronic Corp., 7000 Central Ave. NE, Minneapolis, MN 55432; telephone:  1-800-664-5111, extension 3000; website: http://www.medtronic.com

 

 

Graphic:  Blind Man walking with cane and briefcase

 

 

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."

 

 

SOCIAL SECURITY, SSI, AND MEDICARE FACTS FOR 2000

by James Gashel

 

Photo:  portrait.  Caption:  James Gashel

 

FROM THE EDITOR:  This article appeared in the December 1999 issue of the BRAILLE MONITOR, published by the National Federation of the Blind (NFB).  Mr. Gashel is Director of Governmental Affairs for the NFB, and is one of the world’s leading experts in this field.

 

The beginning of each year brings with it annual adjustments in Social Security programs.  The changes include new tax rates, higher exempt earnings amounts, Social Security and SSI cost-of-living increases, and changes in deductible and coinsurance requirements under Medicare.  Here are the new facts for 2000:

 

FICA and Self-Employment Tax Rates:   The FICA tax rate for employees and their employers remains at 7.65 percent. This rate includes payments to the Old Age, Survivors, and Disability Insurance (OASDI) Trust Fund of 6.2 percent and an additional 1.45 percent payment to the Hospital Insurance (HI) Trust Fund from which payments under Medicare are made. Self-employed persons continue to pay a Social Security tax of 15.3 percent, which includes 12.4 percent paid to the OASDI trust fund and 2.9 percent paid to the HI trust fund.

 

Ceiling on Earnings Subject to Tax:  During 1999 the ceiling on taxable earnings for contributions to the OASDI trust fund was $72,600.  This ceiling is raised to $76,200 for 2000.  All earnings are taxed for the HI trust fund.

 

Quarters of Coverage:  Eligibility for retirement, survivors, and disability insurance benefits is based in large part on the number of quarters of coverage earned by any individual during periods of work.  Anyone may earn up to four quarters of coverage during a single year.  During 1999 a Social Security quarter of coverage was credited for earnings of $740 in any calendar quarter.  Anyone who earned $2,960 for the year (regardless of when the earnings occurred during the year) was given four quarters of coverage.  In 2000 a Social Security quarter of coverage will be credited for earnings of $780 during a calendar quarter.  Four quarters can be earned with annual earnings of $3,120.

 

Exempt Earnings:  The monthly earnings exemption for blind people who receive disability insurance benefits was $1,110 of gross earned income during 1999.  In 2000 earnings of $1,170 or more per month before taxes for a blind SSDI beneficiary will show substantial gainful activity after subtracting any unearned (or subsidy) income and applying any deductions for impairment-related work expenses.

 

Social Security Benefit Amounts for 2000:  All Social Security benefits are increased by 2.4 percent beginning with the checks received in January, 2000.  The exact dollar increase for any individual will depend upon the amount being paid.

 

Standard SSI Benefit Increase:  Beginning January, 2000, the federal payment amounts for SSI individuals and couples are as follows:  individuals, $512 per month; couples, $769 per month.  These amounts are increased from individuals, $500 per month, and couples, $751 per month.

 

Medicare Deductibles and Coinsurance:  Medicare Part A coverage provides hospital insurance to most Social Security beneficiaries.  The co-insurance payment is the charge that the hospital makes to a Medicare beneficiary for any hospital stay.  Medicare then pays the hospital charges above the beneficiary's co-insurance amount.  The Part A co-insurance amount charged for hospital services within a benefit period of not longer than 60 days was $768 during 1999 and is increased to $776 during 2000.  From the sixty-first day through the ninetieth day there is a daily co-insurance amount of $194 per day, up from $192 in 1999.  Each Medicare beneficiary has 60 "reserve days" for hospital services provided within a benefit period longer than 90 days.  The co-insurance amount to be paid during each reserve day is $388, up from $384 in 1999.

 

Part A of Medicare pays all covered charges for services in a skilled nursing facility for the first 20 days within a benefit period.  From the twenty-first day through the one-hundredth day within a benefit period, the Part A co-insurance amount for services received in a skilled nursing facility is $97 per day, up from $96 per day in 1999.

 

For most beneficiaries there is no monthly premium charge for Medicare Part A coverage.  Those who become ineligible for Social Security Disability Insurance cash benefits can continue to receive Medicare Part A coverage, premium-free for 39 months following the end of a trial work period.  After that time the individual may purchase Part A coverage.  The premium rate for this coverage during 2000 is $301 per month.  This is reduced to $166 for individuals who have earned at least 30 quarters of coverage under Social Security-covered employment.  The Medicare Part B (medical insurance) deductible remains at $100 in 2000.  This is an annual deductible amount.  The Medicare Part B basic monthly premium rate charged to each beneficiary for the year 2000 is $45.50.  (The 1999 premium rate was also $45.50.)  This premium payment is deducted from Social Security benefits checks.  Individuals who remain eligible for Medicare, but are not receiving Social Security benefits because of working, pay this premium directly.

 

Programs Which Help with Medicare Deductibles and Premiums:  Low-income Medicare beneficiaries may qualify for help with payments.  Assistance is available through two programs--QMB (Qualified Medicare Beneficiary program) and SLMB (Specified Low-Income Medicare Beneficiary program).  Under the QMB program, states are required to pay the Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) premiums, deductibles, and co-insurance expenses for Medicare beneficiaries who meet the program's income and resource requirements.  Under the SLMB  program, states pay only the full Medicare Part B monthly premium ($45.50 in 2000).  Eligibility for the SLMB program, also dependent on income and resource requirements, may be retroactive for up to three calendar months.  Both programs are administered by the Health Care Financing Administration (HCFA) in conjunction with the states.  In order to qualify, the income of an individual or couple must be less than the poverty guidelines currently in effect.  The guidelines are revised annually, and were last announced in the spring of 1999.  New guidelines will be issued in the spring of 2000. The rules vary from state to state, but in general:

 

*          A person may qualify for the QMB program if his or her income is approximately $707 per month or an individual and $942 per month for a couple.  These amounts apply for residents of 48 of the 50 states and the District of Columbia.  In Alaska, the income threshold used to define poverty is approximately $880 per month for an individual and $1,174 per month for couples.  In Hawaii, income must be less than approximately $811 per month for an individual and $1,081 per month for couples.

 

            For the SLMB program the income of an individual cannot exceed $844 per month or $1,126 for a couple in 48 of the 50 states and the District of Columbia.  In Alaska, the income amount is $1,052 for an individual and $1,404 for couples.  An individual in Hawaii can qualify if his or her income is approximately $969 per month; for couples the amount is $1,293.

 

*          Resources--such as bank accounts or stocks--may not exceed $4,000 for one person or $6,000 for a family of two.  (Resources generally are things you own.  However, not everything is counted.  The house you live in, for example, doesn't count, and in some circumstances your car may not count either.)

 

 

            If you qualify for assistance under the QMB program, you will not have to pay:

 

*          Medicare's hospital co-insurance amount, which is $776 per benefit period in 2000;

 

*          The daily co-insurance charges for extended hospital and skilled nursing facility stays;

 

*          The Medicare Medical Insurance (Part B) premium, which is $45.50 per month in 2000;

 

*          The $100 annual Part B deductible;

 

*          The 20 percent co-insurance for services covered by Medicare Part B, depending on which doctor you go to.

 

            If you qualify for assistance under the SLMB program, you will not have to pay the $45.50 monthly Part B premium.

 

            If you think you qualify but you have not filed for Medicare Part A, contact Social Security to find out if you need to file an application.  Further information about filing for Medicare is available from your local Social Security office or Social Security's toll-free number:  1-800-772-1213.  Remember, only your state can decide if you're eligible for help from the QMB or SLMB program.  So, if you're elderly or disabled, have low income and very limited assets, and are a Medicare beneficiary, contact your state or local welfare or social service agency to apply. For more information about either program, call HCFA's toll-free telephone number:  1-800-638-6833.

 

 

Graphic:  National Federation of the Blind logo.

 

 

NEW ARTIFICIAL EYES

 

 

Artwork:  Graphic describing Dobelle’s Artificial Eye

 

 

            "New eyes for the blind."  Who has not dreamed of the day when lost vision could be restored by a piece of technology?  A lot of old dreams are well on the way to being new realities. 

 

            The Dobelle Institute, of Zurich, Switzerland, and New York City, has developed devices it calls "neurostimulators."  One of these is an artificial eye.  Regulatory approval, to implant this system in the United States, is pending.

 

            This device has three components, as shown in the accompanying drawing.  First is a small black-and-white television camera, worn on a pair of spectacles.  Second is a small, portable computer, currently weighing about ten pounds (and it will get smaller).  The third component is a set of electrodes implanted in the visual cortex of the user's brain.

 

            The idea is to replace the vanished electrical stimulation produced by the retina and the optic nerve with similar electrical stimulation produced by camera and computer, delivered to the same area of the brain by the electrodes.  Only the electrodes themselves are implanted; all other components are external, for easy repair and upgrading.

 

            A special interface in the system's computer allows the user to plug directly into television or the internet.  The system designers feel this feature will increase employability of the blind, even more than the system's camera, originally conceived as an orientation and mobility aid.

 

            How much can you "see" with this system?  William H. Dobelle, PhD, designer of the system, describes it as:  "A visual prosthesis...produces black and white display... analogous to images projected on the light bulb display at stadium scoreboards.  The  system was primarily designed to promote independent mobility, not reading."

 

            The theory of electrical neurostimulation is not new; it was first spelled out in the 1960's, when the necessary computer weighed about 700 pounds.  TV cameras and computers are microminiaturizing at great rate, and the package will only get smaller. 

 

            Pricing is not finalized, and "will depend on the number of units sold," says the Dobelle Institute, but they expect the price to drop to around $50,000 per unit (including installation surgery).

 

            For more information about the artificial vision device, contact:  The Dobelle Institute, Inc., at the Columbia-Presbyterian Medical Center, 3960 Broadway, New York, NY 10032-1543; telephone:  (212) 927-4000; fax:  (212) 927-6300; website:  http://www.artificialvision.com

 

 

 

MEDICARE WILL PAY FOR INSULIN PUMPS

 

 

            As of April 1, 2000, Medicare recipients who have type 1 diabetes can receive coverage for purchase of insulin pumps.  The Health Care Financing Administration (HCFA) now classes insulin pumps as Durable Medical Equipment, and will cover them as “medically necessary” where the patient meets the following criteria (A or B):

 

 

A.        The patient has completed a comprehensive diabetes education program, and has been on a program of multiple daily injections of insulin (i.e. at least 3 injections per day) with frequent self-adjustments of insulin dose for at least 6 months prior to initiation of the insulin pump, and has documented frequency of glucose self-testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin pump, and meets one or more of the following criteria while on the multiple daily injection regimen:

 

            1.         Glycosylated hemoglobin level (HbA1c) greater than 7.0%

 

            2.         History of recurring hypoglycemia

 

            3.         Wide fluctuations in blood glucose before mealtime

 

            4.         Dawn phenomenon with fasting blood sugars frequently exceeding 200mg/dL

 

            5.         History of severe glycemic excursions

 

 

B.         The patient with type 1 diabetes has been on a pump prior to enrollment in Medicare, and has documented frequency of glucose self-testing an average of at least 4 times per day during the month prior to Medicare enrollment.

 

 

Other Requirements:

 

            Type 1 diabetes needs to be documented by a C-peptide level less than 0.5.

 

            The pump must be ordered by, and follow-up care of the patient must be managed by a physician who manages multiple patients with CSII (pump therapy), who works closely with a team including nurses, diabetes educators, and dietitians who are knowledgeable in the use of CSII.

 

            Coverage for subcutaneous insulin infusion pumps will continued to be denied (as “not medically necessary”) for all type 2 diabetics.

 

            For more information, call the Medicare “Durable Medical Equipment” telephone line:  1-800-633-4227.

 

            Source:  “HCFA Coverage Issues Manual,” 60-14.

 

 

 

LETTERS TO THE EDITOR

 

 

Artwork:  Quill writing pen in an ink well

 

 

January 5, 2000

 

            I feel the newsletter/paper VOICE OF THE DIABETIC is very informative.  I like having it available in my waiting room for my patients.

 

            Please accept my donation of $50 to help with its continuance.

 

Sincerely,

 

Libby K. Kristal, MD

Peru, IL

 

 

January 12, 2000

 

            Thank you so much for sending copies of your newspaper, VOICE OF THE DIABETIC.  It is not only informative, but also inspirational to your readers who are sight-impaired or may, someday, have to face blindness.

 

            We appreciate your efforts to get this sort of information out to the public.  It is a great help to those of us who provide one-on-one counseling.

 

Sincerely,

 

Sue Edwards, RN, CDE

Abilene, TX

 

 

January 24, 2000

 

            Thank you so much for providing our group with your newspaper.  They are distributed to each of the members who attend our monthly meetings.  Monthly attendance is from 50 to 80 and up to 100 in the winter months.

 

            Sometimes I do have some left over, and these are distributed to the Hope Eye Clinic and the various other ophthalmologist and optometrists and the local county library by myself. 

 

            Thank you again for providing a very informative and educational newspaper to our group.

 

Sincerely,

 

Margaret Katz

Sun Lakes, AZ

 

 

February 14, 2000

 

            I receive your publication and find it very informative.  I am president of the Wayne County Chapter of the American Diabetes Association.  We are located  in Goldsboro, North Carolina.  Our chapter has monthly meetings and I would be glad to distribute your publication to our members.

 

Sincerely,

 

Peggy Edwards

LaGrange, NC

 

 

February 19, 2000

 

            Thanks for your winter issue.  I found much of interest, especially since I have kidney disease.  I’d like to contribute occasionally.  You help so many of us.

 

Sincerely,

 

Helen Oswalt

San Diego, CA

 

 

 

ORAL DIABETES MEDICATIONS UPDATE

 

by Peter J. Nebergall, PhD

 

 

Photo:  Peter and cat.  Caption:  Peter J. Nebergall, PhD

 

 

            Currently there are an estimated 16 million diabetics in the United States.  Perhaps 5 to 10 percent are insulin-dependent; the rest are type 2 diabetics, controlling their condition with diet, exercise, insulin, and oral diabetes medications.

 

            "Oral diabetes medications" are not insulin pills; rather five classes of drugs designed to improve the body's utilization of what insulin is still present.  These are:  The sulfonylureas, repaglinide, metformin, the “glitazones”, and acarbose.

 

            Most of today's "diabetes pills" are sulfonylureas, a class of chemicals that stimulate the pancreas to produce more insulin, effectively lowering blood glucose levels.  Type 2 diabetics, those who need better management than diet and exercise can provide alone, often turn to these medications:  tolbutamide, chlorpropamide, tolazamide, glyburide, glipizide, and glimepiride, for effective self-management.  The sulfonylureas are effective “insulin secretagogues,” but only for as long as the impaired pancreas maintains some part of its insulin-making capacity.

 

            But the sulfonylureas grow ever less effective with the passage of time.  They drive the failing pancreas to greater effort, but the patient may well require ever-increasing doses to maintain good diabetes control.  All this time, the pancreas is continuing to fail, and at some point, no further increase in medication will be effective; the pancreas isn't doing its job.  This patient needs to start injecting insulin.  When the islet cells of the pancreas cease producing sufficient insulin, insulin must be injected.

 

            Repaglinide (trade name Prandin), the second medication on our list, is a completely new chemical formulation.  Prandin resembles the sulfonylureas in its mechanism of action, in that it stimulates the release of pancreatic insulin, improving blood sugar control (and is of no use in type 1 diabetes, where pancreatic insulin is not present).  But it differs from the sulfonylureas in several ways:

 

*          Prandin is short-acting, with quick onset and fast excretion, allowing more freedom in the timing of meals (dosages can be taken 0 to 30 minutes before mealtime).

 

*          Unlike the sulfonylureas, Prandin is excreted via the liver.  Individuals with renal insufficiency (kidney disease) should use caution ("dosage for each patient should be individualized, to achieve optimal clinical response" says the manufacturer), but even ESRD–end stage renal disease--is not a contraindication for Prandin.

 

*          Individuals with hepatic (liver) impairment should proceed with caution, and with longer intervals between dosages, as the drug will take longer to clear the body.

 

            Metformin (trade name Glucophage), the third oral diabetes medication on our list, works to raise the body's sensitivity to its own insulin.  Used for decades in Europe, it can be prescribed alone or with the sulfonylureas.  Metformin helps the type 2 diabetic make better use of the insulin he or she has left.  Like the sulfonylureas, it becomes useless when the pancreas ceases producing insulin.

 

            The “glitazones” (medically the thiazolidinediones):  Actos, from Takeda Pharmaceuticals; Avandia, from Smith-Kline Beecham; and now-banned Rezulin, from Parke-Davis, are the fourth class of oral medication.  These medications directly attack the problem of insulin resistance, the increasing inability to process insulin, that is the chief component of type 2 diabetes.  In tests, they have enabled many diabetics to reduce volume and frequency of insulin injections.  A few were able to discontinue insulin injections entirely.

 

            Initially, the glitazones were tested and approved for use with insulin-using type 2 diabetics.  As tests continued, it became clear they were also effective blood glucose reducers, either alone (in combination with diet and exercise), or in combination with a sulfonylurea, for type 2 diabetics who did not need insulin (although not a replacement for the sulfonylureas).  Other applications and combinations may well follow.

 

            Rezulin was the first of the class to be approved, and was very widely prescribed.  It did its job very well, but collected a history of hepatic (liver) side effects.  Doctors were asked to closely monitor their Rezulin-using patients.  Much of the liver damage proved temporary, with normal function restored upon cessation of Rezulin therapy, but there were cases of serious permanent damage, and more than 60 deaths.  Early this year, the Food and Drug Administration asked Parke-Davis to remove Rezulin from the market.

 

            At this time, there is no evidence that Actos (pioglitazone hydrochloride) or Avandia (rosiglitazone maleate) cause the same permanent liver damage damage, but doctors have been advised to follow the same liver-monitoring routines as for Rezulin, in case a similar pattern of damage appears.

 

            Acarbose (trade name Precose, from Bayer), the fifth of the "oral meds" on our list, is completely different.  A carbohydrase inhibitor, it temporarily suppresses the digestive enzymes which turn carbohydrates into glucose, slowing digestion and glucose absorption, keeping glucose levels more even.  More a management tool than an antidote to insulin shortage, Acarbose helps some diabetics keep a more constant blood glucose level.  A "temperamental" medication, it has many side effects, and is less than universal in its utility.  New Glyset, from Pharmacia-UpJohn, appears to work in the same manner.

 

 

Problems

 

            Unfortunately, oral medications are often eventually insufficient.  Many type 2 diabetics, diagnosed as young adults, at first successfully control their condition with diet and exercise, but find they need the pills as they grow older.  A number of years (and dosage increases) later, these diabetics have reached the limit of what oral medications can do for them; they are "maxed out," and really need to start injecting insulin, to keep their blood glucose at a safe level.  (Note:  Regular, frequent blood glucose monitoring and HbA1c testing will show if you have reached the point where you should begin insulin therapy.)

 

            Here we encounter what the drug companies call "psychological insulin resistance."  Some of this is plain old fear of sticking yourself with needles-nurtured by memories from our childhood in the bad old days of dull-as-nails reusable syringes!  Many men would rather face a bayonet.  But some doctors contribute to the problem when they don't make it clear to the patient what the high glucose levels (consequent to remaining on now-useless oral medications) will bring in their wake, or worse, when they assume their patient would resist commencing regular insulin injections-so they don't even suggest it.  Yes, insulin is a powerful medication, with risks if used incorrectly-but what in this world DOESN'T have risks if used incorrectly?  The risks of remaining on oral diabetes medications once pancreatic insulin has diminished or ceased entirely are far greater than the risks of taking insulin.

 

 

Oral Insulin?

 

            Recent reports have mentioned insulin administration by mouth.  The nature of insulin, and of human digestion, make oral administration of insulin ineffective for blood glucose management--the insulin is digested before it can reach the bloodstream.  The oral insulin administration here noted is taking place as part of several diabetes prevention trials.  In one example, individuals considered at high risk for developing diabetes (but not yet "diabetic") are given oral insulin in an effort to misdirect their body's autoimmune attack on the Beta cells of the pancreas.  Oral insulin, very "investigational" at this time, is not currently an option for blood glucose management.

 

 

The Future

 

            Amylin Pharmaceuticals, Inc., has continued work on their Extendin-4 (AC2993), an analog of the hormone GLP-1, glucagon-like-peptide.  This investigational diabetes drug has shown a number of potentially therapeutic effects.  Extendin-4 appears to stimulate insulin secretion, except during periods of hypoglycemia (dangerously low blood sugars).  It appears to modulate gastric emptying, slowing the entry of ingested nutrients into the blood.  It appears it may lessen food consumption in obese animals, leading to reduction of body weight.  Most important, it has resulted in "near normalization of glucose control in animal models of type 2 diabetes."

 

            Researchers at Johns Hopkins are testing aminoguanidine, a new medication that may prevent or reduce some of the ramifications of diabetes.  Swedish and American researchers are testing still another, APO A1 MILANO, that may help reduce diabetic heart disease.  Inhaled insulin (for nasal administration) is being tested in the U.S. and U.K., and may someday supplant injection.  Vitrase, from Advanced Corneal Systems, a drug that may help clear vitreous hemorrhage, is currently in FDA clinicals.  Trental (pentoxifyline, from Hoechst Marion Roussel) is now available to treat "intermittent claudication," a painful circulatory ailment and frequent companion of diabetic peripheral neuropathy.  Some doctors are prescribing the antidepressant Paxil or the antiseizure medication Neurontin to treat neuropathy symptoms.  ACE inhibitors, a class of blood pressure medications like Capoten (Captopril), have been proven to deter and retard diabetic kidney complications.  Other oral medications are constantly being evaluated for possible diabetic applications, and some will make it to the pharmacy shelf.

 

            Many of these are new, investigational or just-licensed prescription medications.  Talk to your doctor about them.  I list them here as an example of how unbelievably rapid is the pace of change.  Where will we be two years from now?  We'll be doing even better!

 

 

 

COOKING WITH SUZI

by Suzi Castle

 

 

            We're all concerned with healthful eating, but none of us want to give up occasional treats, food that really tastes good.  We miss those rich-tasting desserts from the days when we weren't counting calories and fat grams.  Eating "healthy" doesn't have to mean depriving yourself of special treats, like the amazingly "lite" Cherry-Topped Cheesecake.  You will find it sinfully rich tasting, yet very low in fat and sugar-free.  It's a quick-to-fix dessert that the whole family will enjoy.

 

 

Cherry-topped Cheesecake

 

Crust:

 

1          cup low-fat graham cracker crumbs

3          tablespoons unsweetened peach or apricot jam

 

 

Cheesecake:

 

3                      envelopes unflavored gelatin

1-1/2    cups water, divided

2                      tablespoons vanilla extract

2                      teaspoons almond extract

                        Sugar substitute equal to 3/4 cup sugar (i.e., 18 packets Equal)

1                      can (20 oz.) "lite" cherry pie filling or water-packed sweet cherries with juice

4                      cups low-fat (2% fat) cottage cheese

 

 

Crust:

 

            In a food processor or blender, combine crumbs and jam. Pour mixture into a 9" springform pan sprayed with nonstick spray.  Using your fingers, press the crumbs into the bottom to form an even bottom layer.  Bake in a preheated 375 oven for ten minutes.  Cool crust.

 

 

Cheesecake:

 

            Mix gelatin with 3/4 cup water in a heat-proof glass measuring cup.  Let soften for two minutes.  Heat in a microwave oven for one minute, or until hot.  Stir to dissolve.  Add  3/4 cup cool water, vanilla, almond extract and sugar substitute.  Mix 1/3 of gelatin mixture with cherries, then chill in refrigerator.  Mix remaining gelatin mixture with cottage cheese in a food processor or blender.  Pour the cheese mixture over the crust and refrigerate.  When the cheese mixture has begun to set up, but before the cherry mixture is firmly set, pour the cherry mixture over the cheese mixture.  Refrigerate for several hours before serving.  Serves 10.

 

            Per serving: 170 cal. (13% from fat); 15.4g protein; 2.43g fat (1.12g sat.); 22g carbohydrate; 425mg sodium; 7.2mg cholesterol; 0.88g fiber. Exchanges:  2 lean meat, 2 bread, 2/3 fruit.

 

            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.

 

 

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 our recipes were supplied by Jennifer Layton, RD, Clinical Nutrition Manager at Capital Region Medical Center, in Jefferson City, Missouri.

 

 

Tortellini & Chicken Soup

 

 

            Here’s a soup with a wide range of ingredients-- chicken, rice, vegetables, even cheese-filled spinach pasta.  Let diners add Parmesan cheese to taste.  If you’re concerned about sodium, consider using reduced-sodium chicken broth.

 

 

Ingredients:

 

3          large cans (about 49-1/2 oz./1.4 kg each) chicken broth; or 4-1/2 quarts (4.3 liters) homemade chicken broth

1          package (about 9 oz./255g) fresh cheese-filled spinach tortellini

1          pound (455g) spinach, stems removed, leaves rinsed and coarsely chopped

1          pound (455 g) skinless, boneless chicken breasts, cut into ½ inch (1cm) chunks

8          ounces (230g) mushroom, sliced

1          medium-size red bell pepper (about 6 oz./170g), seeded and diced

1          cup (130g) cooked rice

2          teaspoons dried tarragon

            Salt and pepper

            Grated Parmesan cheese

 

 

Instructions:

 

            In an 8- to 10-quart (8- to 10-liter) pan, bring broth to a boil over high heat.  Add tortellini; reduce heat and boil gently, uncovered, until just tender to bite (about six minutes).

 

            Add spinach, chicken, mushrooms, bell pepper, rice, and tarragon to broth; return to a boil over high heat.  Then reduce heat, cover, and simmer until chicken is no longer pink in center; cut to test (about two minutes).  Season soup to taste with salt and pepper; serve with cheese to add to taste.

 

            Makes 11 servings.  Per serving:  204 calories; 18g protein; 19g carbohydrate; 6g fat (1g saturated); 39mg cholesterol; 2g fiber; 1,785mg sodium.  Exchanges:  1 starch, 3/4 vegetable, 2 lean meat.

 

 

Winter Flower Bud Rice

 

 

            When fresh cauliflower and broccoli are at their seasonal peak, try this savory, vegetable-studded rice as an accompaniment to your favorite veal and poultry entrees.

 

 

Ingredients:

 

2          cups (200g) cauliflower flowerets

2          cups (145g) broccoli flowerets

1          tablespoon butter or margarine

1          large onion (about 8 oz./230g), finely chopped

2          gloves garlic, minced or pressed

1          cup (200g) short-grain white rice

½         cup (120mL) dry white wine

3-3 1/4 cups (710 to 770 mL) fat-free reduced-sodium chicken broth

2/3       cup (60g) grated Parmesan or Romano cheese

            Pepper

 

 

Instructions:

 

            In a 3- to 4-quart (2.8- to 3.8-liter) pan, bring 2 quarts (1.9 liters) water to a boil.  Add cauliflower and cook for three minutes; add broccoli and continue to cook until both vegetables are barely tender when pierced (about two more minutes).  Drain, immerse in ice water until cool, and drain again.

 

            Melt butter in a wide nonstick frying pan over medium heat.  Add onion and garlic.  Cook, stirring often, until onion begins to brown (about five minutes).  Add rice and cook, stirring often, until rice begins to look opaque (about three minutes).  Stir in wine and 3 cups (710 mL) of the broth; cook, stirring, until mixture comes to a boil.  Reduce heat so mixture boils gently; continue to cook, uncovered, stirring occasionally, for ten more minutes.

 

            Stir cauliflower and broccoli into rice mixture.  Continue to cook until rice is tender to bite and almost all broth has been absorbed (eight to ten minutes).  Add more broth if rice becomes too dry.  Stir in 1/3 cup (30g) of the cheese; season to taste with pepper.

 

            To serve, spoon rice mixture into a warm serving bowl and sprinkle with remaining 1/3 cup (30g) of cheese.

 

            Makes 6 servings.  Per serving:  240 calories; 10g protein; 36g carbohydrate; 6g fat (3g saturated); 12mg cholesterol; 3g fiber; 264mg sodium.  Exchanges:  1-1/2 starch, 1/4 other carbohydrates/sugar, 2 vegetables, ½ high-fat meat/protein, ½ fat.

 

 

Light Chicken Stroganoff

 

 

            To make this tempting dish, we revised a favorite that contained a generous measure of butter and sour cream.  The new version is far lower in fat than the original, but just as rich in flavor.

 

 

Ingredients:

 

½         cup (35g) sun dried tomatoes, not packed in oil

1          pound (455g) skinless, boneless chicken breasts, cut crosswise into ½-inch (1cm) strips

            Ground white pepper

1-1/2-2            tablespoons all-purpose flour

1-1/2    tablespoons (23mL) vegetable oil

1          medium-size onion (about 6 oz./170g) thinly sliced

8          ounces (230g) mushrooms, sliced

½         teaspoon grated fresh ginger

½         teaspoon dried thyme

4          teaspoons cornstarch mixed with 2 tablespoons (30mL) water

½         teaspoon sugar

1          cup (240mL) plain low-fat yogurt

8          ounces (230g) medium-wide eggless noodles

2          cloves garlic, minced or pressed

1/4       cup (60mL) fat-free reduced-sodium chicken broth

3/4       cup (180mL) dry white wine

2          tablespoons (30mL) dry sherry

            Chopped parsley

 

 

Instructions:

 

            In a small bowl, soak tomatoes in hot water to cover until very soft (about one hour).  Drain well, cut into strips, and set aside.

 

            Sprinkle chicken with white pepper; dust with flour and shake off excess.  Heat 1 tablespoon (15mL) of the oil in a wide nonstick frying pan over medium-high heat.  Add chicken, about half at a time, and cook lifting and turning often, until lightly browned (4 to 5 minutes).  Remove from pan with a slotted spoon and set aside.

 

            When chicken has been cooked, heat remaining 1 ½ teaspoons oil in pan.  Add onion, mushrooms, ginger, and thyme; cook, stirring often, until onion is soft and mushrooms are lightly browned (ten to twelve minutes).

 

            Meanwhile, stir cornstarch mixture and sugar into yogurt and set aside.  Also, in a 4-1/2- to 5-quart (4.3- to 5-liter) pan, cook noodles in 2-1/2 quarts (2.4 liters) boiling water just until tender to bite (about ten minutes); or cook according to package directions.  Drain, then arrange around edge of a warm deep platter; keep warm.

 

            Stir garlic into mushroom mixture and cook for one minute.  Then stir in broth, wine, and sherry.  Bring to a boil, stirring.  Add tomatoes, chicken, and yogurt mixture.  Bring to a boil, stirring until sauce is thickened.  Spoon chicken mixture into center of noodles, and sprinkle with parsley.

 

            Makes 4 servings.  Per serving:  526 calories; 41g protein; 62g carbohydrates; 9g fat (2g saturated); 69mg cholesterol; 5g fiber; 150mg sodium.  Exchanges:  2 3/4 starch, 3/4 other carbohydrates/sugar, 1-1/2 vegetables, 4 very lean meat/protein, 1 3/4 fat.

 

 

Rich Pound Cake

 

 

Ingredients:

 

2          cups whole-wheat pastry flour or half whole-wheat and half white flour

1          teaspoon baking soda

1          teaspoon baking powder

1          teaspoon ground cinnamon

1/4       teaspoon ground coriander

½         cup brown rice syrup

3/4       cup egg substitute or 6 egg whites

1          teaspoon almond extract

1          teaspoon butter flavor extract (optional)

1/4-1/2 cup non-fat buttermilk (start with 1/4 cup, if batter is too stiff, add extra 1/4 cup)

1          tablespoon plus 1 teaspoon canola oil

1          cup non-fat yogurt

 

 

Instructions:

 

            Preheat oven to 350F (175C).  Spray a 9-by-5-inch loaf pan with no-stick cooking spray.  Mix dry ingredients in a small bowl.  Mix liquid ingredients in a large bowl.  Add dry ingredients to liquid ingredients a little at a time, beating with mixer after each addition.  Pour batter into sprayed pan.  Bake fifty to sixty minutes, until golden on top and a wooden pick inserted in center comes out clean.  Cool fifteen minutes and then turn out onto a wire rack.  Serve with strawberries, blueberries, or any sliced fruit.

 

            Makes 14 servings.  Per serving:  99 calories; 2g protein; 15g carbohydrate; 3g fat; 1mg cholesterol; 135mg sodium.

 

 

 

BOOK REVIEWS

 

by Marilyn Helton

 

 

            Porch swings, overhead fans and meals prepared on the outdoor grill...  Now, all you need to round out your lazy days of summer is a stack of good books.  Here are my notes to help you select some topics in your area of interest.

 

            If you've had diabetes for more than 10 years, there's a good chance you're part of the 60% of diabetics who have developed diabetic neuropathy, a nerve disorder caused by diabetes.  Significant clinical neuropathy can develop within the first 10 years after your diagnosis, and the risk increases the longer you have diabetes.

 

            There are three major types of diabetic neuropathy, and they can affect virtually every part of the body.  Focal neuropathy affects the eyes, facial muscles, hearing, pelvis, lower back, thigh and abdomen.  Diffuse (autonomic) neuropathy affects the heart, digestive system, sexual organs, urinary tract and sweat glands.  Diffuse (peripheral) neuropathy affects the legs, feet, arms and hands.

 

            After his diagnosis of peripheral neuropathy, John Senneff, a retired attorney, found there was little information available as he sought to learn more about it.  It is often called the "silent disease" because so few people talk about it, or have even heard its name, but Senneff has managed to explain it detail in his new book:  “Numb Toes and Aching Soles: Coping With Peripheral Neuropathy.”  According to Senneff, "Many who suffer peripheral neuropathy have no idea what makes their feet ache, hands throb or muscles weaken...  (They) don't know what to do when they finally discover they have the malady..."

 

            In “Numb Toes and Aching Soles,” Senneff lays out how peripheral neuropathy(PN) affects your body, its causes, symptoms, tests and treatments (both conventional and alternative), and how over 200 patients revealed which treatments worked for them and which ones didn't.  Special sections dealing with psychotherapy, traditional, alternative, and experimental drugs, and both diabetic and HIV-related neuropathies (up to half of people in these groups get PN), are included.

 

            If your diabetes is or has been out of control for a number of years, you can almost count on being among the 60% of patients who will develop one of the three major types of neuropathy.  John Senneff's research (which at times may almost be a bit too technical for the average reader), is an excellent resource tool.

 

            Published by MedPress, San Antonio TX, you can order a copy toll-free at 1-888-MED-9898 (1-888-633-9898) for $19.95 (softcover).  All major credit cards are accepted.  You can also check out MedPress at www.medpress.com for more information.

 

 

            I can't tell you how many times I've recently accessed the new “Diabetes For Dummies,” by Alan L. Rubin, MD.  Don't let the title put you off, it's one of the best guides to diabetes management I've read.  From causes, symptoms, and side effects to treatments, diet and exercise--this book delivers!  Parents may be interested to know that there's even a chapter on managing a baby or preschooler with diabetes.  Dr. Rubin is way ahead of the headlines, as he's even included dealing with obesity and type 2 diabetes in children in this book.

 

            Being a "checklist" type of person, I like the way this book is laid out, highlighting and summarizing important points in each area, along with chapter references for expanded information on the topic at hand.  For example, one short checklist identifies six things you should be able to do if your child is controlling his diabetes with insulin:

 

1.         Identify the signs and symptoms of hyperglycemia, hypoglycemia and diabetic ketoacidosis (with chapter reference)

 

2.         Administer insulin (with chapter reference)

 

3.         Measure the blood glucose and urine ketones (with chapter reference)

 

4.         Treat hypoglycemia with food or glucagon (with chapter reference)

 

5.         Feed your diabetic child (with chapter reference)

 

6.         Know what to do when your child is sick with another childhood illness (with chapter reference).

 

            “Diabetes For Dummies” is a book you can pick up and read from chapter to chapter, or use as a reference source to answer your questions.  The index is very complete and the Appendixes include a mini-cookbook (my type of book!), diabetic exchange lists, website references (even including one for animals with diabetes) and a good glossary of terms.

 

            I would give “Diabetes For Dummies” a five-star rating.  Check it out at your local library and give it a good reading.  I bet you'll decide to buy your own copy.  “Diabetes For Dummies,” by Alan L. Rubin, MD, published by IDG Books Worldwide, Inc., softcover, $19.99 US, $27.99 CN.

 

 

            People with diabetes are given all sorts of well-meaning advice on what foods they can't have.  Now there's a book available which gives readers positive advice about what foods they should be getting almost every day.

 

            “Tell Me What to Eat if I Have Diabetes,” by Elaine Magee, MPH, RD, provides an overview of diabetes, specifically type 2 diabetes, and how the right nutrition can make a difference.  Readers will learn how much sugar many can tolerate and how other foods can balance its effects; what foods to switch to and why, and weight loss strategies that really help, even when taking insulin.  The "10 Food Steps To Freedom" chapter is the high point of the book and, according to Magee, monitoring blood sugars is the pivotal tool in understanding how certain meals and snacks can affect your personal blood sugars.

 

            “Tell Me What to Eat if I Have Diabetes,” by Elaine Magee, published by Career Press, 1999, $10.99 paperback.  You can order your copy toll-free at:  1-800-CAREER-1 (1-800-226-3371).

 

 

            If you haven't read “Stealth Health:  How To Sneak Nutrition Painlessly Into Your Diet” by Evelyn Tribole, you've missed out on a really terrific, very unique book.  Loaded with delicious recipes, “Stealth Health” is more than a cookbook:  It's a guide to strategies for eating well by adding invisible, effortless and delicious ways to sneak healthy foods into your diet on a regular basis.

 

            Who would guess that the "sneak" ingredient in "Dark Fudge Brownies" would be a can of black beans, pureed and incorporated into such a delicious dessert?  Add to that some espresso or instant coffee powder to intensify the chocolate flavor and you have a fabulous treat!  Note to diabetics:  "Of all the starchy foods, beans generally have the least effect on blood sugar."  (American Journal of Clinical Nutrition 66(6):1452-1460, 1997.)

 

            In chapter after chapter, “Stealth Health” guides the reader with healthy advice, from ways to trim the fat to adding calcium, fiber, iron, soy products, beans, vegetables and fruit, to your diet.  Author Tribole produces some of the best tasting, creative, and good-for-you recipes I've tasted.  Each "sneak" food is highlighted for its unique and healthful properties.  (I frequently include her recipes in issues of “Cinnamon Hearts” and on our website.  This month we've featured the Dark Fudge Brownies in our "You Deserve Dessert" feature on our website).

 

            “Stealth Health:  How To Sneak Nutrition Painlessly Into Your Diet,” by Evelyn Tribole, MS, RD, published by Viking, 1999, 240 pages, $24.95, ISBN:  0-670-87499-X.   Another well-deserved five-star Rating.

 

 

            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 the “Cinnamon Hearts” newsletter are available for $19.80/year (USA):  $21.80 (Canada).  Write to Cinnamon Hearts:  Dept. V, PO Box 578340, Modesto, CA 95357-8340.  More free recipes can be found on our website at http://members.xoom.com/cinnhearts and www.fabulousfoods.com

 

 

 

TALKING BLOOD GLUCOSE MONITORING SYSTEMS

 

by Ed Bryant

 

 

Photo:  Glucose monitoring devices.  Caption:  (L to R):  Sure Drop (on Profile meter), Waco-U-Finger Guide, Smart Dot (on One Touch II Meter).

 

Photo:  Finger guides.  Caption:  Modified LifeScan test strip guides.

 

 

            As editor of VOICE OF THE DIABETIC, I am often asked about the relative strengths and weaknesses of the various voice-enunciation equipped home blood glucose monitors available today.  Although individuals have their preferences, there is no "best" talking glucose meter; no one monitoring system is ideal for everyone.  Features, prices, convenience, and clarity of instructions vary, and new equipment periodically appears.

 

            Although many companies make blood glucose monitors, and some of these display their results in large print, only four currently available meters allow voice enunciation, in which the device's voice synthesizer "speaks" the meter's instructions and test results.

 

            I advise all new blood glucose monitor users, blind or sighted, and all those uncertain of their meter's operation, to obtain further instruction from their health care team, and test in the presence of their doctor or diabetes educator.

 

            MEDICARE PROVIDES COVERAGE FOR THESE MONITORS, AND FOR ADD-ON VOICE SYNTHESIZERS FOR THESE BLOOD GLUCOSE MONITORS.  THEY ARE CLASSED AS "DURABLE MEDICAL EQUIPMENT," AND COVERED UNDER MEDICARE PART B.  BE SURE YOU AND YOUR SUPPLIER FOLLOW ALL GUIDELINES FOR REIMBURSEMENT.  THERE ARE TWO "SPECIFICATIONS" TO NOTE:  EO607, FOR "NON-ADAPTIVE" METERS, AND EO609, FOR METERS AND/OR ADD-ON VOICE SYNTHESIZERS, AVAILABLE FOR DIABETICS AT LEAST LEGALLY BLIND.   For information, telephone:  1-800-633-4227, and ask for "Durable Medical Equipment."

 

 

Highlights

 

            My personal favorite is the Accu-Chek VoiceMate.  This talking meter, which incorporates the proven Accu-Chek Advantage into a system designed and built by Roche Diagnostics, is the most advanced on the market today, and the easiest for a blind person to use.  Its new Comfort Curve test strip allows quick and reliable nonsighted placement of the blood sample.  No more hanging drop of blood--just smear or dab it on; the strip sticks well out of the meter, and you just find the tactile cutout on the side.  Even if you have fairly severe neuropathy in your hands, this feature should make it easy to find the blood placement spot.  And blood never drips onto the meter--so there is far less need to clean it.  Its voice is clear and understandable.  The VoiceMate includes two completely new features:  A "code key" system for calibrating the meter to a new set of strips (no more numbers to punch in!), making this the only talking meter a blind person can calibrate without any sighted aid at all; and an insulin vial identifier.  If you use Eli Lilly insulins, and they are new enough to be barcoded (January 2001 expiration date or later), insert them into the special opening, follow the spoken directions, and the machine will tell you what type of Humulin insulin you have there.  (If your insulins are not barcoded, or not from Eli Lilly, the VoiceMate's other features will still be completely operational.)

 

            The VoiceMate can be ordered through any pharmacist.  Have your pharmacist contact Roche Diagnostics; telephone:  1-800-428-5076, and ask for catalog #2030802.  NOTE:  For Customer Service department and meter user advice, in English or Spanish, you should call:  1-800-858-8072.

 

            The LifeScan One Touch meters:  the Profile, and the now-discontinued One Touch II, are often adapted to voice synthesis.  These two meters use the same procedures, the same test strips, and feature the same detachable test strip holder.  Both require a "hanging drop of blood."  Both meters are accurate, but their operating drill makes them difficult for blind users.  Both accept "talk boxes," but voice synthesizers designed for the One Touch II will NOT operate with the Profile, and vice versa.  Note:  The LifeScan SureStep features a "touchable" test strip, and does not require a hanging drop of blood.

 

            The "voice boxes," speech synthesizer modules that plug into the meter's data port and provide its voice, are not made by LifeScan, but by several competing firms, described below.  These manufacturers have been producing voice units for the old One Touch II, and updated versions for use with the Profile, and now for the SureStep.  If you already have a LifeScan One Touch II, Profile, or SureStep, no modifications are needed to allow use of the appropriate speech synthesizer.  If you do not yet own a LifeScan monitor, shop around, as some pharmacies and major discount stores sell glucose monitors substantially below list price. 

 

Talking Glucose Monitors and Voice Boxes

 

1.)        The Accu-Chek VoiceMate talking glucose monitor:

 

            Roche Diagnostics Corporation, 9115 Hague Road, Indianapolis, IN 46250-0100; telephone:  1-800-858-8072.

 

                        The Accu-Chek VoiceMate, developed in cooperation with Eli Lilly and Company, incorporates the Accu-Chek Advantage glucose monitor.  The VoiceMate is small, portable, and weighs only 12.5 ounces.  It contains a "bar code reader" to describe insulin type (Lilly insulins only).  First offered for sale in 1998, the VoiceMate is supplied with a new test strip, the Comfort Curve, which vastly simplifies the problem of blood sample placement.  Very good audiocassette and large-print instructions are supplied (in English).  Suggested retail $495-$525, available through your pharmacist.  Spanish-language customer service is available.  Purchase price includes a carrying bag with adjustable strap.  The VoiceMate is also offered by the National Federation of the Blind (NFB), Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone:  (410) 659-9314.  Note:  The Materials Center is open 8:00am to 5:00pm, EST, weekdays.  The NFB offers this meter for $475.

 

            The only weakness I have detected in this otherwise excellent meter concerns the lack of a "Not Enough Blood" warning.  The VoiceMate cannot distinguish between not enough blood on the strip and a low blood glucose reading.  This occurrence seems to be uncommon, and Roche advises "double-dosing" the test strip (applying a second drop of blood to the same strip within 15 seconds of the first) in such cases.  You might find it beneficial to test in front of your doctor or diabetes educator, who can advise you if you are not getting adequate blood onto the strip.  I have advised Roche of this problem, and hopefully they will shortly act to rectify it.

 

 

2.)        The Voice-Touch speech synthesizers, for the LifeScan One Touch II or LifeScan Profile:

 

            Myna Corporation, 239 Western Avenue, Bldg. A21, Essex, MA 01929; telephone:  (978) 768-3999.

 

                        Myna makes a pair of light, compact, convenient, and reliable glucose meter speech modules.  The two models are not interchangeable.  The Voice-Touch modules attach firmly to the meter, adding little bulk, and forming a single reliable unit.  There are no separate switches to remember; the modules operate off the controls of the LifeScan monitor.  The box is capable of male or female voice enunciation.  A Spanish-speaking Voice-Touch is also available. 

 

                        The Myna Corporation offers the Voice-Touch speech synthesizers for $225 for One Touch II or Profile, the LifeScan meters alone for $115 (One Touch II or Profile).  An optional AC adapter is offered, as is a carrying case, $15 each.  Myna's instructional cassettes and large-print instructions clearly explain the speech modules, but do not describe operation of the LifeScan glucose monitors.

 

                        The LifeScan One Touch meters and Voice-Touch speech synthesizers are also offered by the National Federation of the Blind (NFB), Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone:  (410) 659-9314.  Note:  The Materials Center is open 8:00am to 5:00pm, EST, weekdays.  The NFB offers the combination (One Touch II meter plus voice module) for $309 (the lowest price for a talking glucose monitor in the U.S.), the voice module alone for $189 (specify whether for One Touch II or Profile), or the glucose meter alone for $120 (One Touch II) or $135 (Profile).  An optional AC adapter costs $12.

 

 

3.)        The Digi-Voice modules:

 

            Science Products, Box 888, Southeastern, PA 19399; telephone:  1-800-888-7400.

 

                        Science Products makes several versions of their robust and reliable Digi-Voice speech module:  The big Digi-Voice Deluxe, and the smaller Mini Digi-Voice.  Voice boxes designed for the One Touch II will not operate with the Profile, and vice versa--and the SureStep requires its own !  The Digi-Voice modules connect to the meter by a 22-inch patch cord, providing audio output for its readings.  Controls are simple; on the Deluxe a volume control knob and a toggle switch run the voice synthesizer, separate from the monitor's controls.  The Mini's single button both turns on the voice box and adjusts the volume control, again, separate from the meter's controls.  Readings are announced in a clear, somewhat military, male voice.  Thorough cassette instructions explain the voice box and briefly cover the Profile meter (Science Products' instructional cassettes do not cover operation of the One Touch II glucose monitor).  No large-print instructions are supplied.  Science Products sells the Digi-Voice Deluxe module alone for $275, and the Mini Digi-Voice modules alone for $199 (9-volt battery) or $219 (with AC adapter).  Remember to specify which meter you own.  They offer the LifeScan Profile glucose monitor for $120.  The One Touch II meter is no longer available.

 

                        Science Products also now offers Digi-Voice modules for the later version of the LifeScan SureStep blood glucose monitor.  (This version features a data-port for downloading to a home computer--and the Digi-Voice talk boxes access to the same port.) 

 

 

4.)        The LHS7 Module, a voice box for the LifeScan Profile:

 

            LS&S Group, P.O. Box 673, Northbrook, IL 60065; telephone:  1-800-468-4789.

 

                        The small and light LHS7 attaches to the bottom of the Profile glucose meter by means of a Velcro patch, and operates through the meter's controls.  Two-position volume control (loud and soft); AC adapter included in purchase price.  English-language voice only; no audiocassette or large-print instructions are provided.  Cost:  $196, or $319 with a new Profile meter.

 

 

5.)        Connecting Cables for Adaptive Computers:

 

            Blazie Engineering, 105 E. Jarretsville Road, Forest Hill, MD 21050; telephone:  (410) 893-9333.

 

                        Users of Blazie's adaptive computers can connect these machines to the LifeScan One Touch II or Profile, by plugging into the meter's data port with the appropriate adaptive cable (such as the Blazie BNS-6).  With the appropriate software (available free from Blazie; One Touch II users need no software) their computer will speak the LifeScan meter's commands and results.

 

 

6.)        The Diascan Partner talking glucose monitor, formerly offered by Home Diagnostics, Inc., of Ft. Lauderdale, Florida, is out of production and unavailable.

 

 

Medicare

 

            As mentioned above, Medicare recognizes home blood glucose monitors as "Durable Medical Equipment," and coverage is provided for diabetics, under Medicare Part B.  Glucose meters without audio output have one specification on the "Fee Schedule" (EO607), and glucose meters with voice synthesis, or add-on voice boxes for home blood glucose monitors, have another (EO609), available to diabetics who are at least legally blind.  Be sure to use the correct specification, and to follow all guidelines for reimbursement.  For further information, call Medicare's main telephone:  1-800-633-4227, and ask for "Durable Medical Equipment."

 

 

An Invitation to Manufacturers

 

            Currently available "talk boxes" (speech synthesizers) make use of the same "data port" installed in the meter to allow interfacing with and downloading to a computer.  For many monitors, the hardware is already in place, and adding speech compatibility should be a simple process.  The National Federation of the Blind urges manufacturers to go the rest of the distance, and make talking versions of their monitors available to those diabetics who need and want them.  NFB Resolution 97-12 (adopted at the 1997 annual convention in New Orleans, Louisiana) calls on monitor manufacturers to make their meters speech-compatible.

 

 

Hints and Tips

 

            If an insufficient amount of blood is placed on the test strip, the test will not take place, or the results will be inaccurate.  Most meters will indicate "not enough blood."  You may even have to prick your finger again!  There are several possible explanations for this frustrating occurrence:

 

            A.  The initial drop of blood was too small:  Some folks don't bleed enough.  They can get more blood by holding hands below waist level for about 15 seconds, shaking them, and/or washing/soaking hands in warm water for a few minutes before the test.  Warm water stimulates the flow of blood to the fingers.  A slightly longer lancet, with deeper penetration, may help some.  "Milking the finger" (squeezing it gently) can also help, as can wrapping a doubled rubber band between the first and second joint of the finger to be lanced.  This will help cause the finger to become engorged with blood.  Hold the rubber band down with the thumb while lancing.  Remove the band as soon as you lance.

 

            Doctors and diabetes educators who treat heart patients have noted that "prophylactic aspirin therapy," an enteric-coated aspirin a day to thin the blood and reduce risk of a heart attack, may make it easier for their diabetic patients to obtain a blood sample.  If you are a "difficult bleeder," the same therapy with enteric-coated aspirin might help you, too.  Be sure to talk to your primary-care doctor about aspirin, and to your eye doctor as well, because blood thinners like enteric aspirin can increase the risk of retinopathy.

 

 

            B.  There may have been enough blood, but it was placed onto the wrong part of the test strip ( i.e."You Missed"}:  Some folks bleed fast, and may lose the blood off the finger before they're ready.  By the time they get the finger to the test strip, the blood has fallen in the wrong place.  A fast bleeder needs to work closer to the test strip, and perhaps to employ one of the blood placement aids discussed in this article.  Users of the LifeScan SureStep should try bending up the tail of the test strip as an aid to location and placement.  If you are new to your meter, I suggest you test in front of your diabetes educator, or someone familiar with your meter--perhaps there is some part of the drill you could do better.

 

 

            C.  Some enthusiastic people, placing the blood on the strip, press down too hard and push the blood out of its correct position, squishing it onto the wrong part of the strip:  If you use the LifeScan One Touch II or Profile, it is best to very gently deposit a hanging drop of blood onto the test strip.  Marla Bernbaum, MD, writing in “The ADEVIP Monitor,” offered the following suggestion, pertinent to diabetics with severe neuropathy (who wouldn't feel the otherwise painful fingertip "stick" she discusses here):

 

                        I have discovered another way to apply blood to the LifeScan test strip, which has been useful for several of our patients.  This method allows them to stick the tip rather than the side of the finger.  We use the same platform modification [described below], with a dot of Hi-Marks or T-shirt paint on each side of the strip guide near the depression where the blood is to be applied.  For this approach the meter should be turned sideways.  The patient can then place the pad of the finger on the raised dot perpendicular to the length of the strip and rock the finger forward so that the tip of the finger lines up with the depression on the strip and deposits the blood droplet in the appropriate place.  This method increases the portion of the fingertip that can be used, and is preferable for some patients, particularly for those who bleed slowly and therefore must place the blood drop in precisely the right location.

 

 

LifeScan Modifications

 

            If you use any of the LifeScan "One Touch" series glucose meters, some blood placement problems can be solved by modification of the Test Strip Holder (LifeScan Part #043-123, and note this same part fits all LifeScan "One Touch" meters).  The idea is simply to provide tactile locating aids for finger location and placement of the blood sample on the test strip.  A raised dot on either side of the test strip will work for some, but diabetics with limited sensation in the fingertips may find a U-shaped guide more useful.  Most diabetics puncture the side of a fingertip, but those with severe neuropathy, who can't feel the lancet, and who prick the center of the fingertip, may be helped by the U-shaped guide.  With practice, and the use of such tactile cues, blind diabetics can correctly place blood samples on the test strip.  (EDITOR’S NOTE:  Thanks to Ann S. Williams, RN, MSN, CDE, for providing the modified LifeScan Test Strip Holders mentioned here.)

 

            The Test Strip Holder is detachable, and modifications as described will in no way interfere with the operation, accuracy, or cleaning of the LifeScan meter.  LifeScan's Technical Services Department (phone:  1-800-227-8862) will provide a spare Test Strip Holder upon request, without charge.  It is recommended that the modifications be to this spare.

 

            The dots and U-shaped ridge were created with T-shirt paint, of the type that stands up sharply from a fabric surface.  Upon application, the paint spreads a little, so apply sparingly.  Best results come from "tack-painting," applying a small amount, then letting it dry (minimum 12 hours), with subsequent applications to build up the height.  Practice first on some other material (posterboard or paper plate), as the paint can come out quickly.  Be sure to have the Test Strip Holder OFF THE METER when applying the T-shirt paint.  For best results, insert a test strip in the holder as an aid to placement of the dots or U-shaped ridge.  T-shirt paint is inexpensive and is available at most craft and fabric stores.  Although a full spectrum of colors is available, bright, contrasty colors like orange may aid in low vision situations.  Brands and types vary; find one that gives you a nice hard tactile ridge.  Some paints feel too rubbery.  "Puffy paint" flakes off too easily.  You may have to experiment.

 

            Several vendors offer commercial alternatives to modifying the test strip holder.  One slips over the LifeScan meter, and the other attaches directly to the test strip holder.  Both devices aid in proper finger placement, and serve to guide the drop of blood more surely to the test strip.  Science Products (address above, telephone:  1-800-888-7400), makes the Sure Drop, which slips over the body of the meter.  The special Teflon-like coating on the surface of the device helps direct the blood, but can be damaged by bleach or a hard brushing--clean with mild soap and warm water.  A Sure Drop made for the One Touch II will not fit the Profile, and vice versa.  The unit for the Profile appears well-made and easy to use.  Both units are priced at $24.95 each.

 

            The Pharmacy Counter, 2655 West Central Avenue, Toledo, OH 43606; telephone:  (419)-473-1493, has a supply of the now-discontinued Smart Dot finger guide, which clips directly to the test strip holder of the LifeScan One Touch II meter.  This plastic platform is easy to clean and convenient to use, but there have been cases of it detaching from the meter in mid-test.  Cost:  $15.95.

 

            Don Kramolis and Gary Allman, Blind Rehab Specialists (Manual Skills), at  Waco VA Medical Center, Blind Rehab Clinic, Bldg. 7, BRU, 4800 Memorial Drive, Waco, TX 76711; telephone:  (254) 752-6581 ext. 7489, have developed the Waco-U-Finger Guide, which fits any LifeScan Meter.  Much like the T-shirt paint described above, the Waco Guide helps finger orientation.  The guide's other features help tactile strip insertion.  Its designers do not sell finished guides, but offer plans and advice to interested individuals.

 

            I have discussed the strengths and weaknesses of the blood glucose monitoring systems with voice enunciation currently manufactured.  This evaluation should help blind diabetics and those losing vision, who are just as capable as the sighted of independently testing their blood sugar levels, and performing all the other tasks of daily diabetes self-management.  Both blind and sighted diabetics are encouraged to consult with their health care team, and with individuals experienced in use of glucose monitoring equipment.

 

            Choosing the most appropriate home blood glucose monitor is an important step in diabetes self-management.  As blind diabetics increase their participation in the mainstream, efficient glycemic control is needed to maintain good quality of life.  The Diabetes Action Network of the National Federation of the Blind, a support and information network, welcomes your input on blood glucose testing.

 

 

LANTUS INSULIN:  CAUTIONS

 

            “ISMP MEDICATION SAFETY ALERT,” Vol. 5, No. 9, for May 2000, published by the Institute for Safe Medication Practice, contained the following note of caution about Aventis' new LANTUS insulin:

 

            LANTUS is administered subcutaneously once daily, at bedtime.  Unlike other insulins, it maintains a relatively constant level over 24 hours, with no pronounced peak.  Concern is mounting that oral or written orders for LANTUS may be mistaken as "Lente" insulin, which has a more rapid effect and shorter duration of activity than LANTUS.  Furthermore, prescribers have been known to designate the type of insulin by using the associated one-letter abbreviation appearing on insulin vials.  For example, 16 units of Lente insulin is sometimes written as "L-16 units."  Since LANTUS also begins with an "L," it is possible that mix-ups with Lente insulin may occur.  We've communicated these concerns to the FDA and the manufacturer.

 

            In addition to concerns about the name, wrong time errors are also possible, as LANTUS is given at bedtime, not in the morning like other insulins.  Therefore, special consideration must be given to the way prescribers communicate orders.  If the drug is simply labelled "daily," those administering the drug may assume it should be given in the morning.

 

 

 

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.

 

SUGAR-FREE CANDIES

 

            In our experience, most food defined by what it is not (like "fat free," or "sugar-free") tastes the part.  It never lets you forget what you're missing.  Liberty Orchards' candies are a very pleasant exception.  Based on the ancient recipe for Rahat Locum (Loukoumi, or Turkish Delight), these candies lack nothing but a bit of sugar.  It's hard to describe them, full of fruit and nuts, but you can get a free sample, and a free catalog, by contacting them:  Liberty Orchards, PO Box 179, Cashmere, WA 98815-0179; telephone:  1-800-888-5696; website:  http://www.libertyorchards.com

 

 

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 Reisterstown Road, Pikesville, MD 21208; telephone:  1-877-263-8603.

 

 

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

 

 

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.

 

 

THE TYPE ‘N SPEAK

 

            The Type 'n Speak 2000 is a portable, adaptive computer/notetaker for the blind, that provides speech access (in a number of languages), Braille translation compatibility, and industry-standard connection ports to your other equipment.  The unit does all this with a standard "typewriter" keyboard, and its rechargeable battery gives you 25 hours between charges.  Prices start at $1,395.  Contact:  Blazie Engineering, 105 East Jarretsvillw Rd., Forest Hill, MD 21050; telephone:  (410) 893-9333; website:  http://www.blazie.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 6.2 screen magnifier, and tutorials on cassette for programs like Internet Explorer and Microsoft Word 8.  They also offer Windows 95, 98, and NT compatibility, training audiocassettes free with purchase, and downloadable demo programs available from their website:  http://www.hj.com.  For information, or to purchase via the internet, contact:  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

 

 

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.

 

 

EASY DIABETIC COOKBOOK

 

            If you want to prepare healthy diabetic meals, but find most cookbooks just too complicated, you need Linda Coffee and Emily Cale's “The Diabetic 4 Ingredient Cookbook.”  There are over 200 recipes, in all food categories, with complete nutritional and exchange information, each one using four ingredients.  The book costs $9.95 (+$2.95 shipping), from:  Coffee and Cale, PO Box 2121, Kerrville, TX 78029; telephone:  1-800-757-0838.

 

 

NUTRITION SUPPLEMENT

 

            Your insulin or oral diabetes medications are only part of your diabetes self-management.  Although food supplements do not replace your medications, and the U.S. Food and Drug Administration has not evaluated their efficacy to prevent or treat any disease, a healthy diet is important, and research is continuing on the role specific supplements may play in controlling diabetes.  AlphaBetic Multi-Vitamin Supplement is a food supplement formulated for the special needs of diabetics.  A blend of vitamins, antioxidants, and minerals, it is available in sugar-free caplets.  Contact:  Abkit, Inc. New York, NY 10128; telephone:  1-800-226-6227; website http://www.alphabetic.com

 

 

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 large 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.

 

 

DIABETIC SKIN CARE

 

            Diabetes frequently leads to dry, cracked feet.  Since untreated, this dryness can lead to dangerous wounds and infections, prevention is the best cure.  Neoteric Diabetic Skin Care encourages healthy skin, and helps heal the small lesions that might otherwise progress.  Available in lotion or cream, suggested price $12.29 each.  To find a retailer near you, or to order on line, contact:  Neoteric Cosmetics, Inc., 4880 Havana Street, Denver, CO 80239; telephone:  1-800-343-9555; fax:  (303) 576-6151; website:  http://www.neotericdiabetic.com

 

 

ALTERNATIVE LANCET

 

            We have been asked to announce:  Although diabetics need to regularly test their blood sugars, all that jabbing with sharp lancets, to get a blood sample, can give you a pain!  Now there’s an alternative.

 

            The Personal Lasette, from Cell Robotics, is a laser lancet.  It burns a small, clean hole sufficient for a blood test, and the manufacturer claims there is no pain.  Cost:  $995.  Contact:  Cell Robotics, Inc., 2715 Broadbent Pkwy., NE, Suite A, Albuquerque, NM 87107; telephone:  1-800-846-0590, ext 100.

 

 

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

 

 

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.

 

 

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

 

 

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 = 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

 

 

NEW METER

 

            The Prestige Smart System home blood glucose monitors, from Home Diagnostics Incorporated, offer touchable test strips, high accuracy, fast results, large memory, and the largest screen display in the business.  Now available at Walgreens, Eckerd Pharmacy, and CVS.  For information, contact:  Home Diagnostics Inc.; telephone:  1-888-777-7357; website:  http://www.prestigesmartsystem.com

 

 

DIABETIC PRODUCTS

 

            Health Care Products makes many over-the-counter medications and supplements for diabetics, including DiabetiSweet sugar substitute and DiabetiGest antacid/calcium supplement.  Find these products in the diabetic section of Wal-Mart, Rite Aid, Walgreens, K-Mart, and other retailers.  For information, contact:  Health Care Products, 369 Bayview Avenue, Amityville NY 11701; telephone:  1-800-899-3116; website:  http://www.diabeticproducts.com 

 

 

DIABETES SUPPLIES

 

            American Diabetic Supply, Inc., will ship your diabetes supplies to your door.  They handle all insurance claims and provide free delivery.  Folks with Medicare and/or private insurance (no HMOs) may receive supplies with no further cost.  For information, contact:  American Diabetic Supply, Inc., 400 S. Atlantic Ave., Suite 108, Ormond Beach, FL 32176; telephone:  1-800-453-9033.

 

 

DIABETES TOOLS

 

            PALCO Labs makes tools for independent diabetes self-management.  Their Insul-eze is a combination syringe guide and magnifier, for easier insulin draw-up.  Their Load-Matic is a tactile insulin measuring device that aligns needle with vial, and loads a B-D 100-unit syringe by separate ten- or single-unit increments.  For information, or a catalog, contact:  Palco Labs, 8030 Soquel Ave., Santa Cruz, CA 95062; telephone:  1-800-346-4488; website: http://www.palcolabs.com 

 

 

Diabetes Supplies

 

            Can-Am Corporation carries a full line of discount-priced diabetes supplies, including:  Dex-4 glucose tablets, skin cream, and Excel GE test strips for the Glucometer Elite monitor.  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.

 

 

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.

 

 

FOOD FOR THOUGHT

 

 

Artwork:  Dancing fruits and vegetables

 

 

            We invite blurbs and tidbit articles for inclusion in this column.  Materials received may be edited and used as space permits.  Products and services included in this column are for information only and do not imply endorsement by the Diabetes Action Network of the NFB.

 

 

NEW FOOT CARE TREATMENT

 

            Diabetic foot disease is a serious complication of diabetes.  When diabetic neuropathy leads to numbness, and wounds and lesions go unrecognized and untreated, the resulting infections can lead to amputation.  The care of slow-healing diabetic foot wounds and lesions is an important issue.

 

            On May 8, 2000, an FDA panel recommended expanded approval of Novartis Pharmaceuticals' new Apligraf, for use in the treatment of diabetic foot ulcers.  Apligraf is a skin substitute, the only one approved for marketing in the United States.  Apligraf is available now.

 

            For more information, see your pharmacist, or have your doctor contact:  Novartis Pharmaceuticals Corporation, PO Box 11, #59 Route No 10, East Hanover, NJ  07936 USA; telephone:  (973) 781-8300; website:  http://www.novartis.com

 

 

SYRINGE CAUTION

 

            Becton Dickinson (BD) makes insulin syringes, in 1cc, 1/2cc, and .3cc sizes.  If you are insulin-dependent, blind, and a user of tactile insulin measuring devices, like the Syringe Support, Load-Matic, or Count-A-Dose, you use BD syringes.  Be aware they now offer the "BD Ultra-Fine II Short Needle 1cc syringe," with a 30ga, 5/16" needle.  Yes, it is more comfortable to inject, but users of tactile insulin measurement devices may experience problems drawing up consistent and reliable dosages with the short needle syringes.  Use caution.  The package states:  "Before changing to a shorter needle, consult your health care professional."

 

 

NEW GENERIC CYCLOSPORINE

 

            On January 18, Eon Labs Manufacturing announced that the U.S. Food and Drug Administration had approved its Cyclosporine Softgel Capsules, USP (Modified) as a generic equivalent to Novartis Pharmaceuticals' Neoral, the biggest-selling softgel immunosuppressant for organ transplant recipients.  The new medication will be available in the brand-equivalent strengths:  25mg and 100mg.

 

            Over 66,000 patients are currently awaiting organ transplants in the U.S. alone, more than triple the number who received transplants in 1998.  Because the human body attempts to "reject" transplanted organs, treat them as "invaders" needing to be destroyed, transplant recipients must take immunosuppressive medication for life, to keep their new organ.  Neoral is effective but expensive, and the availability of a generic competitor should force down the price, and save thousands of dollars for the transplant recipient.

 

            For information on this medication, or others they produce, contact:  Eon Labs Manufacturing, Inc., 227-15 N. Conduit Avenue, Laurelton, NY 11413; telephone:  1-800-526-0225; website:  http://www.hims.online.com

 

 

NEWSLINE FOR THE BLIND

 

            The National Federation of the Blind announces the availability of Newsline, an electronic publication of major daily newspapers, specifically tailored for blind and visually-impaired readers.  With 72 local "hubs" in 33 states, Newsline electronically "reads" all of each day's  edition, which is immediately made available via modem to the local distribution centers.  Users telephone the nearest local center (or place a long-distance call to the National Center for the Blind) and listen to the articles they choose, read to them in a synthesized voice.  The reader is free to jump between articles, sections, and publications, and to pick the speed of reading to suit their needs.  There is no subscription fee or other charge to access the system; however, long-distance phone charges  may apply, if the nearest local service center is not in your vicinity.

 

            Newsline is not the Internet, and no computer is necessary to use it.  The system is easy to learn, and easy to access.  Service is available to any person at least legally blind, and again, there is no charge.

 

            “USA Today,” “The New York Times,” ”The Washington Post,” “The Los Angeles Times,” “The Toronto Globe and Mail,” “The Wall Street Journal,” and the “Chicago Tribune” already participate.  More publications, including local papers, are expected to join shortly.  As the system expands, even more blind individuals will have rapid and comprehensive access to daily print news media, a substantial improvement over "live reader" services.  The goal is to make the service available to every blind person in the country, and soon.

 

            The NFB is looking for individuals and organizations willing to sponsor and maintain more new local distribution centers, in areas not yet served.  For further information, about participating or sponsorship, contact Newsline Network, National Federation of the Blind, 1800 Johnson Street, Baltimore, MD 21230; telephone:  (410) 659-9314.

 

 

NEW APPROVALS FOR HUMALOG

 

            Humalog, Eli Lilly and Company's quick-acting insulin, was approved by the Food and Drug Administration (FDA) several years ago, for adult diabetics, between ages 12 and 65.  Their package documentation always stated the necessary tests had not been performed with children or the aged.  That has changed.

 

            On May 2, 2000, Lilly announced the FDA had approved the use of Humalog insulin in children over the age of three and adults over age 65, for treatment of diabetic high blood sugars. 

 

            Humalog is powerful and quick, and is available by prescription only.  For more information, talk to your pharmacist, or contact:  Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN 46285; telephone:  1-800-545-5979; website:  http:/www.lilly.com

 

 

EYE SPECIALISTS DEFINED

 

            So you need to see the eye doctor?  What kind of eye doctor?  An ophthalmologist is a physician (MD or DO) who specializes in eye care, and the treatment of eye diseases and conditions.  This individual has completed a general medical degree, plus three or more years of specialized training in eye care.

 

            An optometrist is a licensed health care professional trained to provide the following services:  Comprehensive eye examinations, diagnosis and treatment of eye diseases and vision disorders, prescribing of glasses, contact lenses, and low-vision aids, certain surgical procedures, low vision rehabilitation, vision therapy and medications, and vision counseling.  This individual is not a physician, but has completed a four-year graduate program, to earn the degree of OD, Doctor of Optometry.

 

 

TASTES AWFUL

 

            Canada is a land of cold, and of colds.  Now, from Canada comes Buckley's Mixture, a powerful, sugar-free, alcohol-free cough medicine without artificial flavors or colors.  Does a strong medicine have to taste really bad?  Maybe so, but it's guaranteed to work.  Already available at Rite Aid, Eckerd, K-Mart, and www.homepharmacy.com, Buckley's may soon be available at your pharmacy.  Try it.  You won't like the taste, but you'll feel better.  For more information, Contact:  Buckley's; telephone: 1-800-434-1034; website:  http://www.buckleys.com

 

 

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

 

 

VOICE FORMATS

 

            VOICE OF THE DIBAETIC is offered in two formats:  standard print, and 15/16 ips audiocassette, "talking book" speed.  Anyone who is currently receiving the VOICE in print and having difficulty reading it, may receive it on cassette at no charge.  VOICE tapes require the special tape player available free to the legally blind from Regional Libraries for the Blind and Physically Handicapped, which can be obtained by telephoning the National Library Service at:  1-800-424-8567.  Note:  Attempting to play VOICE tapes (or any other tapes in NLS format) on a conventional music-speed tape player will yield incomprehensible "chipmunk sounds."    

            Periodically, we receive requests for the VOICE in Braille or large print.  It is not available in either of those formats at this time.

 

            All a subscriber needs to do, to switch from standard print to tape, or to receive both formats, free of charge, is contact us at the VOICE OF THE DIABETIC Editorial Office.

 

 

ARTICLES NEEDED

 

            If you have diabetes, are a family member or friend of a diabetic, or a health professional with an interest in diabetes, we invite you to submit an article for publication in the VOICE OF THE DIABETIC.

 

            Our philosophy regarding diabetes is positive.  Do you have an inspiring, enlightening story?  We, the Diabetes Action Network of the National Federation of the Blind, seek to show people they are not alone, and do have options, regardless of diabetic complications.  If you have experienced ramifications, others, who may be facing the same side-effects, could benefit from what you have to say.

 

            Perhaps you have not experienced complications--your unique insight, coping strategies, and lifestyle can still inspire others.  Are you a relative, a friend, or a health professional?  More than 286,411 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.

 

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VOICE DISTRIBUTORS NEEDED

 

 

            Since the VOICE is now offered free, our Diabetes Action Network will provide extra copies to anyone wanting to help spread the word.  We will gladly send from five to five hundred-plus copies each quarter to be used as free literature.  Medical facilities can order as needed for patients.  Individuals can usually place copies of the VOICE in libraries, pharmacies, hospitals, doctors' offices, or other public locations.

 

            Diabetes education is essential.  Anyone who distributes the VOICE will be helping people with diabetes, and their families, to learn about the disease and its ramifications; to learn that they have options; and that their world is far greater than whatever "limits" may be imposed by the disease.  If you would like to help spread the word by distributing the publication, please contact:  Voice of the Diabetic, 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. 

 

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SUBSCRIPTION/DONATION FORM

 

 

            The VOICE OF THE DIABETIC is a quarterly magazine published by the Diabetes Action Network of the National Federation of the Blind (NFB) for anyone interested in diabetes, especially diabetics who are blind or are losing vision.  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 3, Summer 2000 Edition