A Support and Information Network
The Diabetics Division of the National Federation of the Blind
Volume 11, No. 3, Summer Edition 1996
The VOICE OF THE DIABETIC, published quarterly, is the national news magazine of the Diabetics Division of the National Federation of the Blind. It is read by those interested in all aspects of blindness and diabetes. We show diabetics that they have options regardless of the ramifications they may have had. We have a positive philosophy and know that positive attitudes are contagious. News items, change of address notices, and other magazine correspondence should be sent to: Ed Bryant, Editor, Voice of the Diabetic, 811 Cherry Street, Suite 309, Columbia, Missouri 65201; telephone: (573) 875-8911.
Copyright © 1996 The Diabetics Division, National Federation of the Blind. ISSN 1041-8490.
On January 8, 1996, the VOICE OF THE DIABETIC Editorial Office got a new area code! To call us, you will dial (573) 875-8911. Our old (314) area code is being replaced.
VOICE OF THE DIABETIC is offered absolutely free to any interested person upon request. Readers may receive the publication in standard print, on audio cassette for the blind, or in both formats. To begin receiving the VOICE, please complete the subscription form (or a facsimile), found at the end, and mail it to the editorial office.
Living With Diabetes
by Jim Reed
Non-Invasive Glucose Monitors......
Hypoglycemia — And How To Deal
With It
by Ed Bryant
I've Gotten Attached To My Insulin Pump
by Veronica Elsea
Ask The Doctor
by Wesley W. Wilson, MD
Tactile Coding Meeting At FDA Headquarters
by Ed Bryant
Medicare Facts For 1996
by James Gashel
Cardiovascular Health: Bypass May Be Better For Diabetics
My New Lifestyle
by Frederick R. Claus
Dialogs About Diabetic Dynamos
by Debra Frank
What You Always Wanted To Know But Didn't
Know Where To Ask
(Resource List)
A New Approach To Heart Disease
by Robin McRee
The Culture Of Misunderstanding
by Peter J. Nebergall, PhD
by Jim Reed
I have been asked many questions about living with diabetes and what the future holds; good questions, but very hard to answer. You see, we never know about the future. We can only do the best we can with what we have. Yes, diabetes sucks. It sucks big time! For me, I have had to live with it and with its consequences for most of my life. I am 47 now and was diagnosed with IDDM at age 5 on 5 August 1954, 42 years ago. During that time I have been told I would likely die before I was out of my teens, age 25, age 30, and....be blind, deaf, impotent, a vegetable, etc., if I lived that long. I was told to take more insulin, less insulin, different types of insulin. I was told eat this diet, that diet, and every combination and permutation of food you can dream of as the absolute best diet for a diabetic. I was told not to play sports—that the extreme physical exercise would kill me. In short, I have heard just about everything I can imagine on the best and worst ways to survive diabetes.
And do you know what? They were all right and they were all wrong! I could have died young. Heaven knows many people have done so. Sports might have killed me, but I played at very high levels and I am still here. All of these things could, and likely did, affect me to some extent. At age 47, I do have several forms of neuropathy affecting my feet and legs, my digestion and potency. I do have some vision problems, some of which are related to diabetes and some not. I have had several opportunities to leave this earth but I didn't. More than once as a boy, I cried myself to sleep because of my diabetes. Sometimes I get frustrated enough to still shed a tear or two. I used to worry about the future and sometimes I still worry. But over the years, I have learned a couple of things. One is that what we know changes all time. Today is no predictor of tomorrow. And what we know tomorrow will not be the same thing that we know next year, or in ten years. Current blood glucose testing will be surpassed by noninvasive testing in the near future. I can remember burning my fingers on a test tube and cursing that old method of testing! Cursing the reason I had to do it! And praying for some better way to test. I can remember getting injections with a big old syringe and crying with the frustration of it all. Things change. That's the point. And who knows, maybe in time you won't have to worry about diabetes anymore. Maybe that day will come before you have to worry about complications compromising how you want to live. Maybe it won't. You must learn as much as possible and follow those "new methods" of diabetes care that make sense to you. Get yourself a good medical team. Refuse to take a back seat in your diabetes care. Refuse to be a victim. Support research toward better treatment and a cure. And go out and live life to the fullest. Live without regrets. If complications do come to you, do your best to manage them and minimize their impact on your life.
My life is different now than it was twenty, ten, and even five years ago. I can't do some of the things I used to do in the recent past or at least I can't do them with the same proficiency. But those represent changes, not losses. Finally, share your thoughts and concerns about these things with those who love you. They are a part of you and your life too and deserve to be given the opportunity to help you. It is amazing how much your outlook can improve when your are on the verge of screaming or tears, and someone who loves you and whom you love gives you a big hug to let you know you aren't alone. My wife is an anchor at times and she keeps me from falling off the face of the earth. There is no charge for the love and support she gives me.
Hang in there and live. Learn and do what needs to be done.
The weakest link in traditional blood glucose monitoring is the requirement to pierce a fingertip and draw a blood sample. More than 40 companies are researching new non-invasive blood glucose monitoring techniques that would dispense with the lancet. The new technology will give diabetics an easy, painless way to check and control their blood-sugar levels, helping them avoid or minimize long-term organ damage.
Several of the monitors under development use a beam of light reflected through the skin to measure blood glucose levels. This Near Infrared Spectroscopy (NIR), dubbed the "Dream Beam" by Futrex, Inc., of Gaithersburg, Maryland, one company researching the technology, can determine the chemical makeup of an object by analyzing the signal changes in the wavelengths of light after it has passed through that object. By measuring the glucose- reflected signals, concentration of blood sugar levels can be determined. However, glucose accounts for only 1/1000 of the mass of blood, making it hard to measure the wavelengths absorbed by glucose (also absorbed by other more sizable bodily components such as water and fat). The trick is to focus on those specific wavelengths that, although weakly absorbed by glucose, are even less captured by surrounding tissue.
Biocontrol Technology, Inc., based in Indiana, PA, was the first to submit an application to the Food and Drug Administration for approval. Their glucometer, the Diasensor 1000, uses NIR technology to measure glucose levels. In 1996, an FDA advisory panel turned down the Diasensor, asking Biocontrol to improve its accuracy and provide better documentation before resubmission.
The Diasensor 1000 needs to be calibrated to the specific individual user. It cannot be used in a clinic or hospital setting, and will need to be recalibrated periodically by Biocontrol. And it's big. The Diasensor 1000 is an 11" x 18.5" x 11" machine, not particularly portable. Its expected price will be between $6,000 and $8,000. Another non-invasive technology, being developed by the University of California at San Francisco and Cygnus TherapeuticCorporation in Redwood City, CA, does not employ light. This monitor, the Glucowatch, measures sugar levels transdermally by means of a process called reverse iontophoresis. Worn like a wristwatch, this device uses a minute, steady electrical current to extract glucose molecules from the body, which are then continuously measured. It has two components: the electronics (the Glucowatch) and the sensitized patch (the Glucopad). Cygnus, the eventual manufacturer, envisions daily replacement of the sensitized patch, to insure accuracy. Cygnus is currently in the process of miniaturization. When the production version of the Glucowatch (which the company would like to offer for about $400) is ready, there will be more tests.
Solid-State Farms, from Reno, Nevada, is working on a portable non-invasive meter, the size of a pocket calculator, that will measure glucose levels with high-frequency electromagnetism. Their technology is based on the observation that different ionic solutes respond to alternating electromagnetic fields in predictable ways. These "normal" responses are impeded by the presence of molecules of substances such as glucose. The device uses the behavior of blood sodium as a referent, and, as variations in blood glucose modulate the resonance of blood sodium in known amounts, measurement of that modulation should yield percentage of blood glucose. The company, which claims a high degree of accuracy for its process, is continuing its research; clinical testing on humans has not yet commenced. The home blood glucose testing market is today worth well over 1.5 billion dollars, and many companies are looking at possible entries. The field is constantly changing, as new participants and technologies appear, and some established players discontinue their efforts. No one knows who will be first!
When non-invasive monitors hit the market, they may cost several thousand dollars, though the price is expected to drop with time. The higher price of the non-invasive glucometers will be at least partly mitigated by an end to the need for expensive test strips. A diabetic using a traditional glucometer, testing four times a day, can easily spend $1000 per year in test strips alone.
The Centers for Disease Control estimates each year 15,000 to 39,000 people become blind from diabetes. Just as there are a number of conventional glucometers for which voice synthesis is available, once a non-invasive monitor is approved by the FDA, company representatives say that voice synthesizers may become an accessory.
Meter accuracy, accessibility, and affordability still need to be worked out. FDA approval will come when a manufacturer demonstrates its product is reliable and accurate. Demand for the new meters will be high. Companies involved in the research are aware of the immense profit to be gained by the first to come out with a non-invasive monitor. However, until affordability can be guaranteed, the non-invasive monitors won't benefit anyone—consumers or manufacturers.
by Ed Bryant
A "hypoglycemic reaction," also called an insulin reaction, insulin shock, or low blood sugar reaction, occurs when blood glucose drops to a point where the individual becomes confused and disoriented. By definition, hypoglycemia is "low blood glucose" (described by many health professionals as any blood glucose level below 60mg/dl), and it can affect both insulin- dependent and non-insulin-dependent diabetics, though type "I"s are more at risk.
To maintain good health, a person with diabetes must control both extremes; monitoring blood sugar levels and adjusting diet, exercise, oral medications and insulin, to keep those numbers in the normal range. It is not always easy, and sometimes, working hard to keep our sugars down, we dip too low. Prevention is the best way to treat a low blood sugar reaction. Though the personal "threshold" varies, and some folks can function at levels that would have others disoriented or unconscious, if your sugars stay up around 80 to 120mg/dl, a hypoglycemic reaction won't happen. (Although there is some argument over exactly what is an appropriate "normal" for a diabetic in good control, the point is to provide yourself a healthy range, while ensuring a margin of safety against "hypos." "Tight control" doesn't mean continuously staying below normal range.
Don't just wait for symptoms of a "low" to clue you in; all that shakiness, sweatiness, and confusion; too often a reaction comes on without much warning. Frequent blood glucose monitoring is the best way to warn yourself of impending hypoglycemia. By observing patterns of low blood sugar, by learning how much your body needs, you can make the changes necessary to prevent a reaction. Although some diabetics can function perfectly well with their blood glucose in the low 60s, meters are imperfect—there is a 10% "fudge factor" either way, and an indicated "60" may in fact be closer to a very unsafe "54." To be safe, keep your sugars in the normal range!
Although every effort should be made to prevent hypoglycemia, almost every diabetic, especially those who use insulin, will occasionally experience a reaction. Common causes include straying from the prescribed diet, taking too much insulin or oral medication, not eating the proper amount at the proper time, or doing vigorous exercise. Sometimes a "low" comes on for no apparent reason at all. Alcohol and certain drugs (certain sedatives, sleeping pills, and the "beta blockers") can also lower blood sugar and bring on a reaction. Individuals practicing strict "tight control," holding to a low blood glucose level, increase their risk of hypoglycemic episodes. Although the long- term benefits of tight blood glucose control are great, some individuals may need to relax the numbers a bit, trading higher glucometer readings for an increased margin of safety. THE GOAL SHOULD BE TO USE THE TIGHTEST CONTROL THAT IS RIGHT FOR YOU.
Symptoms vary between people; learn what yours are when you "get low." Studies suggest a diabetic's awareness of his or her hypoglycemia is a learned response, is taught, and can be improved by more education. There's no substitute for your glucometer, but "when I feel like this my blood is doing that" is a good line of defense. The old saying "know thyself!" makes sense here. Once you recognize the symptoms, you can take quick action to correct the condition.
If your blood sugars have been quite high for some time, and you act to quickly bring them down, you may experience some hypoglycemic symptoms—but your glucometer can reassure you that it is just your body trying to get used to the new lower level. It will pass.
Symptoms of low blood sugar reaction can be divided into two general stages. The first stage, usually occurring early in a reaction, includes symptoms such as shakiness, sweating, nervousness, fast pulse, dizziness, headache, and pale skin color. Symptoms may appear suddenly. The second, more advanced stage of hypoglycemia, includes mood/behavior changes, confusion, poor coordination, and difficulty in speaking. If you think you might be going into a reaction, have a snack now. Better safe than sorry.
Next to prevention, the best way to treat a low blood sugar reaction is to "nip it in the bud." To do so requires that you realize it is happening. Many diabetics have learned to recognize a reaction by the way they feel. For example, I have learned to recognize that at the first sign of a "low," I feel a kind of inner shakiness, although it is not physically visible to anyone around me. Although difficult to describe, it is a sensation I have learned, and recognize as an early sign of low blood sugar.
Note: Some people have "hypoglycemia unawareness," and cannot sense when a reaction is coming on, or even that a reaction is in progress. There may be few initial symptoms, or they may fail to recognize them. By the time symptoms manifest, these individuals may be too disoriented to help themselves. These folks should be particularly careful to keep to their insulin and eating schedules, and to monitor themselves for low blood glucose levels. (Note: studies suggest a long period of euglycemia, normal blood glucose, achieved by tight control, may restore some ability to perceive low blood glucose.) When such persons experience a reaction, it may appear at the "second stage," with disorientation, confusion, or even loss of consciousness. A diabetic in this condition, while still conscious and able to swallow, needs a concentrated, refined sugar immediately. CAUTION: DO NOT FORCE ANYTHING DOWN THE THROAT OF AN UNCONSCIOUS PERSON—IT CAN BE ASPIRATED INTO THE LUNGS! At the first sign of a reaction, a diabetic needs to put energy, food, into the body immediately. If you have consumed sugar to ward off a "low" (many of us carry glucose tablets for just that purpose) and the symptoms have cleared, food containing complex carbohydrates, such as milk, fruit, crackers, or a peanut butter sandwich, should be then taken. Glucose tablets, sugar cubes, and cake icing all act quickly, but they "burn off" quickly too, and unless they are followed by more substantial food, there is a risk the hypoglycemia will recur. (Note: The Diabetes Control and Complications Trial suggested that diabetics who had experienced a reaction stood a 50% risk of another within 24 hours, and a 25% risk of another in the next 24 hours.) The complex carbohydrates in the foods listed above enter the blood more slowly than does refined sugar, but their effects endure, helping re-establish euglycemia, proper blood glucose level. Don't gorge yourself here! You need to eat—but if you keep "stuffing it in," you may find your blood sugar up above 300 or more! Eat enough to re-establish euglycemia, and STOP, WAIT for the shakiness to fade.
If the diabetic "misses the signals," if, for whatever reason, no action is taken to bring the blood sugars back up, the reaction will progress. The diabetic may shake or sweat. When someone asks if something is wrong, the response may be, "There's nothing wrong," or "I'm all right." Having become confused, the diabetic may ask the speaker to repeat himself, or may state that the question was not understood. A person undergoing a low blood sugar reaction may appear distant, meditative, unusually quiet, "in another world." He or she may stop conversing, or might respond very slowly to questions. Some may become uncooperative or belligerent, spewing obscenities at the offer of assistance. The diabetic experiencing a "low" may seem intoxicated. Unfortunately, every year a few diabetics, thought by police to be drunk, are jailed overnight "for drunkenness." Before morning, their untreated low blood sugar reactions can lead to brain damage, even to death.
I strongly recommend that all diabetics wear medical information jewelry, either a bracelet or necklace, and carry a medical information card with them at all times. I wear a bracelet, and my card is in my wallet. Such information, available at most pharmacies, alerts law enforcement and emergency personnel that the bearer is diabetic, and is subject to low blood sugar reactions. Because hypoglycemia is easily, quickly and inexpensively treated, wearing a medical ID might help prevent an expensive and unnecessary trip to the emergency room.
The diabetic should inform friends and fellow workers about low blood sugar reactions. Relate symptoms and remedies. Tell friends and fellow workers: "When in doubt, give me sugar." Remember: Never use diet drinks, insulin, or "sugar-free" candy to combat a low blood sugar reaction! Sugar substitutes provide no benefit, and one of them, aspartame, in fact slows the absorption of what sugar might be present. Candy bars containing chocolate and nuts should not be used either—unless nothing else is available—because they are too slow. Their high fat content slows absorption of their sugars into the blood. Honey, composed of two sugars, acts rapidly, but may get messy if the diabetic is shaky and disoriented.
Many kinds of concentrated sugar products, developed specifically to combat low blood sugar reactions, are available over the counter in pharmacies. Many are pure glucose. I like Can-Am's "Dex-4" glucose tablets, because they dissolve quickly in the mouth, and the container is easy to open. I take three or four of them to combat a reaction. Such a dose should bring you out of the reaction, to the point where you can eat some complex carbohydrates, more substantial food, as stated above. However, if there is no improvement after 15 to 30 minutes, if you are still unaware, still unsteady, you should consume another three or four glucose tablets, or another small tube of cake decorator's gel. All diabetics are different; one individual may require more or less glucose and time than another, to come out of a low blood sugar reaction.
One inexpensive (and tasty) "insurance policy" against a "low" is Lifesavers! Five of these little candies add up to 12.5 gm of sugar, and provide the same dose as three glucose tablets (though not quite as quickly absorbed). They're easily available, which can be a big advantage.
Another ideal treatment can be granulated table sugar (sucrose). It is far more economical than over-the-counter glucose products, and raises the blood glucose level nearly as rapidly. I am often asked how much table sugar should be taken for a reaction. As a general rule, if an adult diabetic is able to safely swallow without choking, give two heaping tablespoons (about 25 grams) of granulated (table) sugar. Some diabetics will come out of the reaction rapidly, others may take longer. If 15 to 30 minutes don't bring total awareness, give another two heaping tablespoons of sugar. And then, of course, as soon as the diabetic is able, he or she needs to eat more substantial food containing complex carbohydrates as described above, to keep the reaction from recurring.
If a diabetic having a reaction is unable to take some form of refined sugar without assistance, but still able to swallow, someone should mix two heaping tablespoons of sugar in four to five ounces of water and help the individual drink the solution (This method works best with a calm, cooperative person). When a person is unsteady, has trouble opening their mouth, or is uncooperative, it is still possible to use this method, but it can get messy. In the past, when I experienced insulin reactions and my wife tried to get me to drink sugar water, much of the solution went on me rather than in me. To insure that the solution goes into the mouth, try using a 60cc syringe. Draw the sugar-water solution into the syringe, and squirt the solution in, SLOWLY. Make sure the recipient is able to swallow! You should be able to obtain large syringes (without needles) from hospital pharmacies or dialysis centers. In lieu of a large syringe, you might employ a plastic turkey baster, a common kitchen utensil.
Another source of emergency sugar is cake decorating gel (icing). I purchased a small tube of Betty Crocker decorating gel, and found it easy to work with. It weighed .68 oz. (19 grams), with about 65% refined sugar solids, a combination of corn syrup and sugar, and the balance water. A small tube of decorating gel contains about 12 grams solid sugar, ample to treat a low blood sugar reaction in most people. If one tube does not bring a diabetic out of the reaction in 15 to 30 minutes, use a second.
A 35mm film canister is a convenient container for carrying table sugar. It will hold approximately two heaping tablespoons, about 25 grams; the top fits snugly, so the sugar will not spill. Many photography shops have empty film canisters, and shop personnel are often happy to dispose of them. I also keep sugar cubes on hand. If I am shaky, it is sometimes easier to pop them into my mouth than to take loose table sugar. Three small sugar cubes equal one tablespoon of granulated sugar, about 12 grams.
When a diabetic is unconscious due to a low blood sugar reaction, many physicians recommend an injection of glucagon, a prescription drug. It acts rapidly and causes the liver to release stored glucose directly into the blood stream. After an injection, the diabetic should regain consciousness within 10 to30 minutes. Expect a lot of variation—no two diabetics, and no two reactions, are the same.
After giving the injection, apprise the diabetic's physician of the situation. The glucose released after a glucagon injection burns off rapidly. To prevent recurrence of the reaction, it is important for the diabetic to take some food, especially complex carbohydrates. Glucagon may make some diabetics nauseated (there is a risk of vomiting—turn the patient's head to one side and guard against choking). Some individuals may need to wait 20 to 30 minutes after glucagon is administered before having any food. Incidentally, glucagon is expensive. In my area, it costs about $38 per prescription, but I recommend all diabetics keep glucagon emergency kits on hand. Glucagon keeps without refrigeration. There seems to be no medical consensus regarding how much time should elapse before emergency help is sought. However, if a diabetic is not cognizant after two rounds of sugar or two injections of glucagon, emergency medical help should be summoned.
A diabetic walks a thin line between high and low blood sugar. To keep diabetes under control, he/she must follow the recommended diet and exercise, and must take the proper dosage of medication, on time. DON'T OBSESS OVER "TIGHT CONTROL." YOUR GOAL SHOULD BE TO USE THE TIGHTEST CONTROL THAT IS RIGHT FOR YOU. Keep to your schedule—it's your first line of defense. If and when you experience a reaction, the best way to ensure your safety is to know how bring yourself out, keep the tools close at hand (glucose tablets, cake icing, glucagon), and tell your family, friends, and co-workers what to do when you cannot help yourself. A hypoglycemic reaction is an emergency situation, and should be treated quickly to restore normal blood glucose level. Plan, Prepare, and Be Rewarded!
by Veronica Elsea
From the Editor: Veronica Elsea is a professional musician with her own studio, and a member of the Diabetics Division 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. Many blind diabetics successfully do so. Of course pump therapy is not for everyone, but it is an option worth considering. Here's what she says... 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 I 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 theprint 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. (Editor's Note: The Diabetics Division of the National Federation of the Blind offers the 1995 edition of the ADA's "The Exchange Lists for Meal Planning," in Braille and on audiocassette. See our "Resource Column".)
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.
Lois Klug, a National Federation of the Blind member from Grafton, North Dakota, is a direct, plain-spoken lady who has run her own business for decades. She has also been blind for 36 years, and diabetic since 1943, and has let neither stand in her way.
Although she can't remember the month, Lois remembers how ill she felt, as a child in 1943. She was drinking a lot of water, and she "peed a lot." She remembers "burning lamps," and how she had to collect urine and mix it with "Benedict's Solution," then heat in a test tube and read the color, to determine her glucose level. Those were the days of glass syringes "you had to boil" and reusable needles, and of $2.98 vials of insulin. She agrees diabetes self-management has come a long way. When her vision failed (acute glaucoma in the right eye, retinal detachment in the left), doctors were confused, and Lois went to three different hospitals, winding up at University of Minnesota, where the iris was removed from her right eye. It made no difference; she has been totally blind since. Diligent in her diabetes self-management, she has always tried to eat what she was supposed to, and to exercise regularly. Her care has paid off in good health and no complications.
At the time she became blind, her daughter was 13 months old. No family member was nearby to act as "caretaker," but she wanted to learn how to do things for herself. Had the family been nearby, someone would have stepped in, but her solitude spurred her independence. She has made such good use of her skills that: "Many folks don't believe I'm blind." She started her babysitting/daycare business after losing sight, and has run it alone since. Bells on their shoes help her keep track of the children, and a chime on the door announces arrivals, even before they speak.
Since the onset of her blindness, she and her husband have adopted five more kids. The youngest is now eight years old. Three of her children are at home, two more in college. Twenty years ago she bought a tandem bike, which she rides "when a co-pilot is available." She has a treadmill and an exercise bike to go with the tandem.
Recently, she obtained an Arkenstone reading machine, a Count-a-Dose to measure her insulin, a talking thermometer, and a talking glucometer, from her local rehab agency. Before that, family members helped her with testing. "Adaptive devices weren't available out here," she says. Lois hasn't had time for much travel. "Too busy," she says, but she doesn't view her blindness as a handicap. "I'd rather be blind than a lot of things," she says. What's her formula for success? "You just have to learn what you can about diabetes, get exercise, and don't overdo yourself..."
by Wesley W. Wilson, MD
NOTE: If you have any questions for "Ask the Doctor," please send them to the VOICE editorial office. The only questions Dr. Wilson will be able to answer are the ones used in this column. Wesley Wilson, MD is an Internal Medicine practitioner at the Western Montana Clinic in Missoula, Montana. Dr. Wilson was diagnosed with type I diabetes in 1956, during his second year of medical school.
Q: I control my type II diabetes with careful diet and a daily aerobics workout. Do I need to do all that blood sugar testing too?
A: I'm pleased you are following a healthy lifestyle, and I'm sure you would agree that it's particularly important for individuals with diabetes to use all available methods to avoid health problems. Persons with diabetes, even if they exercise, watch their diet, and keep blood sugar level near normal, still are at increased risk for diabetic complications. The Diabetes Control and Complications Trial (DCCT) showed that intensive control reduced the risk of complications, but unfortunately did not show intensive treatment, "tight control," would eliminate such risk. One still needs to remain vigilant.
Type II diabetes tends to be more stable than type I, usually with less variation in blood sugar levels. However, in type II diabetes, blood sugars do tend to vary from hour to hour and from day to day, and a person with very stable diabetes often shows marked change in blood sugar levels with relatively little changes in diet, exercise, illness or stress. Our current lifestyle, deadlines, and demands upon our time often interfere with schedule-keeping, setting the stage for the possibility of significant fluctuations in blood sugar levels.
Many persons with diabetes feel they can "sense" blood sugars that are too low or too high. I'd challenge that idea, since most of us cannot detect moderate fluctuations in blood sugar level. Most individuals are unable to detect blood sugar elevations to 190 or 200 mg/dl, but such a blood sugar level seems to increase the risk of diabetic complications, if it is frequent or repeated. Only by testing can anyone be sure their blood sugar is within the safe range they and their physician have established. I'm sorry, but in addition to exercise and diet, your still need to do blood sugar testing, and in addition, you should have periodic hemoglobin A1c testing to determine what your average blood sugar has been.
by Ed Bryant
For the last four and one-half years, the Diabetics Division of the National Federation of the Blind has campaigned to make insulin vials identifiable for the blind and those losing sight. Currently, all insulins are packed in identical vials, distinguished only by the print on the label. Today, to achieve good diabetes control, most diabetics mix their insulins. If you can't read the small print on an insulin vial, you risk injecting yourself with the wrong insulin, and inducing a hypoglycemic reaction — which, depending on degree of misdosage, can have very severe consequences. A serious error can put you in the hospital, or kill you. Tactile coding on insulin vials will enable blind insulin users to safely distinguish between the insulins they must mix, without recourse to impermanent cues such as tape or rubber bands, or to sighted aides.
This is a safety issue for sighted insulin users as well. Dr. Daniel Lorber, Editor in Chief of "Practical Diabetology," in a recent editorial (Vol.14, No.2), reminded readers that the average sighted diabetic mixes up insulins at least once a year. Tactile cues will cut that frequency for the estimated 16 million diabetics in America today. After numerous letters, telephone conversations, and articles in the VOICE, the Food and Drug Administration (FDA) finally agreed insulin vials needed tactile markings. The insulin manufacturers, Eli Lilly & Co., and Novo Nordisk Pharmaceuticals Inc., agreed to participate in meetings to determine what sort oftactile symbols ("codes" or "cues") were needed. The first meeting was held at FDA headquarters, in Rockville, Maryland, on October 19, 1995. Participants discussed various proposals for tactile insulin identification. The meeting ended with both insulin manufacturers agreeing to three months further study of the ideas that had been put forward. Minutes of that meeting (discussed more fully in VOICE Vol.11, No.1) give all credit for making the meeting happen to the Diabetics Division of the National Federation of the Blind, and to my persistence. The minutes also state that at the close of the (October) meeting, all participants had agreed that Lilly and Novo Nordisk were "to come to the next meeting with firm ideas for short-term solutions, and other ideas for long-term solutions."
The second meeting was scheduled for January 19, 1996. The threat of winter storms forced postponement of the second meeting, and it was rescheduled for April 10, 1996. As at the earlier meeting, participants included: FDA staff, organizations of the blind, diabetes associations, and other private organizations. I made the first presentation, reminding the audience that it had been almost six months since the last meeting; that the insulin manufacturers had agreed to evaluate the proposals for tactile marking put forth at that time; and that I was looking forward to seeing what they had accomplished. I distributed a memorandum of my own, with descriptions and photos of a number of tactile-marking proposals (these proposals were also published in the last issue of the VOICE). Novo Nordisk had used the time between meetings to expand and refine the marking system they already use in Europe, in which "R" insulins are marked with a raised dot on the vial's aluminum crimp seal (they had brought European insulin vials to the October meeting).
Their new system would allow them to provide one, two, or three dots, but they agreed these were not appreciably more detectable than their original dots, which all blind meeting participants had previously agreed were too small (see VOICE, Vol.11 No.1). Novo Nordisk also showed samples of a "milled-rim" insulin vial, that was quite detectable, but whose markings would not allow multiple coding.
Discussing tactile cues on the label instead, Novo Nordisk said they "could put tactile stripes on labels," but they had not yet tested such marks, to see if they were sufficiently durable. They preferred to mark the metal crimp seal. They stated that placing markings on insulin pen cartridges might be impossible, as the cartridges fit snugly into the insulin pens. They stated that the injection-molded plastic body of their prefilled syringes would easily allow inclusion of tactile codes on the pen body.
Novo Nordisk spent some time discussing the need to differentiate between groups of products, in meaningful ways that reflected actual usage patterns. They proposed to group all insulins into three classes: long-acting, rapid-acting, and mixes. Assuming users would not mix the new quick-acting Lispro/Humalog insulin with Regular insulin, they proposed to code both the same. Lilly's presenters agreed with the need to assign specific insulins to one of several groups, rather than attempting tactile identification of individual insulin formulations. They discussed the need for a "universal code," meaning that all insulins with the same time of onset would bear the same code, world-wide, regardless of their trade name. Such universality would benefit all insulin users, as a sighted American, visiting Russia or the Middle East, unable to read the foreign script, could still distinguish between insulins, as the tactile markings would be the same as those used at home.
Lilly strongly recommended that quick-acting insulins (such as their new Lispro/Humalog) not be assigned to the same code-group as Regular insulin. They argued there is enough "time/action profile" difference between the two that to mix them up would be a safety issue, as Lispro starts acting about 10 to 15 minutes after injection,and peaks in an hour, while traditional "Regular insulin" starts in about 30 minutes, and peaks some three hours later. They proposed that group #1 be for quick-acting insulins such as Lispro/Humalog, group #2 be "Regular" insulins, and group #3 be all intermediate and long-acting insulins. In support of such division, they pointed out that the FDA advisory committee that had approved Lispro mandated its distribution as a prescription drug (first time for an insulin), precisely because it was so different from previous insulin formulations. Lilly acknowledged that no matter what coding system was finally adopted, there will need to be a period of user-education. They pointed out that the system might have to be expanded, when new insulins with different time/action profiles are developed. Distinguishing between insulins with different time-of-onset is a safety issue.
Lilly's presenters talked about their testing program. One proposed coding system consists of horizontal bars or "stripes" on the label, and these have already passed tests for manufacturability, durability, and low cost. Lilly has also involved about 20 blind individuals, most of whom were diabetics, in tests of code placement and detectability. "All we haven't done yet," they stated, "is look at what regulatory requirements would be, in order to implement."
Lilly is also researching "dot" coding on the vial label, and there was much discussion about which cues, dots or bars, were more detectable by blind individuals and those with neuropathy. Both cue types have supporters. Lilly plans on consulting with at least one more group of blind diabetics, in the next few weeks, to optimize details of cue spacing and placement.
Asked about making the letters "R," "N," "L," or "U" themselves tactile, Lilly responded that they thought it could be done—but that it would be more difficult, as codes would have to coincide with the letters, and a given insulin may have different names in different locations. They also noted some insulins don't have letters. Enlarging the letters on the label, which they agreed would help in low-vision situations (and which I strongly support —both companies should do that now), they termed "a separate issue."
The FDA, asked how much time between code approval and implementation, answered "not very long." Lilly interjected that once the FDA's regulators were finished, they would be able to move quickly.
There was much discussion of whether or not anyone would ever mix Lispro/Humalog and Regular insulin. Lilly pointed out that doctors had figured out ways to mix every other insulin in existence, and would probably continue to do so. When a Novo Nordisk representative asserted that no one would ever mix Regular with Lispro, and thus the two should bear the same code (he "just couldn't see folks mixing two types of short- acting insulin"), there was general disagreement with his proposal. Lilly pointed out that Lispro's extremely rapid onset makes the ability to distinguish it from other types a safety issue. They reminded the audience that the coding they propose is not just for Lispro, but also for all the other quick-acting insulin analogs that will surely follow. There is still a great deal of philosophical difference between meeting participants, and it showed in the subjects discussed. Novo Nordisk, which does not currently offer a competitor to Lilly's quick-acting Lispro/Humalog, strenuously resisted creation of a separate code-group for such quick-acting insulins. Novo's presenters said they feared that, for marketing reasons, manufacturers would seek a new code-group for every new insulin. Yet they wanted to tactile-code the differences between insulin sources, such as beef, pork, mixed beef, recombinant DNA... Lilly (which does not currently offer a premixed insulin) had originally proposed not to place any code on mixed insulins, such as 70/30. As the meeting progressed, they changed their position, suggesting that initial time of onset should determine mixture coding — that a mixture's coding should reflect the presence of its quickest-acting component. A mixture containing Lispro would thus bear a different mark than one containing Regular. Lilly then reminded the audience that we were working on the "short- term solution," and that some codings would have to wait for the long-term.
Novo Nordisk, deeply committed to its dot-cues on the rim, did also bring samples of tactile bars on the vial label, but these appeared to be hand-fashioned, and they admitted they had not tested the bars: "At this point we just haven't done what Lilly has. As a result we just don't have data in our pocket to present."
I informed Novo Nordisk that I belong to a number of support groups, and I had taken samples of their vials with the little dot, for inspection by sighted, visually-impaired, and blind diabetics. Some said they could distinguish the dot, but several mentioned that with much sight loss, or any appreciable neuropathy, lines on the label would be easier to distinguish. There were many other exchanges. Both companies seemed determined not to accept each others' proposals. But it came down to the fact that Lilly had more thoroughly "done its homework." Novo Nordisk, who, like Lilly, had agreed at the October 1995 meeting to test and evaluate all major proposals for tactile marking, wound up asking for three more months, in which to test prototypes.
We agreed to meet again in three months. Since the meeting, I have been in contact with both insulin manufacturers. Although they did not reveal it at the meeting, many blind participants in Lilly's tests had preferred dot-cues to tactile bars. Of course the test participants had been told what to look for, but, as covered at the meeting, a new insulin user, or one with profound neuropathy, would find the bars easier to detect.
I suggested to both companies, who are currently investigating a set of four horizontal bars to identify the different insulin types, that they consider a horizontal row of close-spaced dots (instead of one bar) as a cue for the quick-acting (Lispro) code group.
In the next issue of the VOICE, I will let you know what progress was made at the July meeting. Hopefully then we will have an implementation date for our long-delayed "short-term solution."
"If Blindness Comes," by Kenneth Jernigan, is a 248-page large print book published by the National Federation of the Blind (NFB). It is packed with information about the Federation and its services, and with tips on how to cope with vision loss. The book is formatted in large print (single copies free) and audiocassette ($3 each), and is available from the NFB Materials Center, which also offers a variety of products and publications for the blind. The Materials Center stocks everything from white canes and Braille-marked utensils to talking glucometers and thermometers, from check-writing guides to adaptive insulin measurement devices.
To learn more about the NFB, to obtain a large-print or Braille copy of the "Aids and Appliances Order Form," or to order any of our products or literature, contact: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314. The Materials Center is open 12:30 to 5:00 p.m. Eastern time, Monday through Friday.
by James Gashel
Note: This article appeared in the April 1995 edition of the "Braille Monitor," published by the National Federation of the Blind. From the "Monitor" Editor: Jim Gashel is the Director of Governmental Affairs for the National Federation of the Blind.
In the January, 1996, issue of the "Braille Monitor," we reported the annual Social Security program adjustments now in effect for 1996. The article was titled "Social Security and SSI Facts for 1996." Since changes are made in Social Security programs at the beginning of each new year, we ordinarily report the new information in the "Monitor." Medicare facts are usually included. Due to the controversy over the federal budget, changes in Medicare for 1996 had not been decided, however, when our January article was prepared. That controversy is not yet settled, but the Medicare facts for 1996 are. Here are the new facts for 1996:
MEDICARE DEDUCTIBLES AND CO-INSURANCE:
Medicare Part A coverage provides hospital insurance to most Social Security beneficiaries. The co-insurance payment is the charge that the hospital makes to a Medicare beneficiary for any hospital stay. Medicare then pays the hospital charges above the beneficiary's co-insurance amount.
The Part A co-insurance amount charged for hospital services within a benefit period of not longer than 60 days was $716 during 1995 and is increased to $736 during 1996. Beginning the sixty-first day through the ninetieth day, there is a daily co- insurance amount of $184 per day, up from $179 in 1995. Each Medicare beneficiary has 60 "reserve days" for hospital services provided within a benefit period longer then 90 days. The co- insurance amount to be paid during each reserve day is $368, up from $358 in 1995.
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 $92 per day, up from $89.50 in 1995. For most beneficiaries there is no monthly premium charge for Medicare Part A coverage. People who become eligible 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 1996 is $289 per month. During 1996 this premium rate is $188 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 1996. This is an annual deductible amount. The Medicare Part B basic monthly premium rate will decrease from $46.10 charged to each beneficiary and withheld from Social Security checks in 1995 to $42.50 per month during 1996. Medicare Part B coverage may be continued for those who complete a trial work period and become ineligible to receive Social Security Disability Insurance cash benefits. This monthly premium rate is $42.50, the same amount paid by Social Security beneficiaries through withholding from their monthly Social Security checks.
PROGRAMS WHICH HELP WITH MEDICARE DEDUCTIBLES AND PREMIUMS:
Low-income Medicare beneficiaries may qualify for help with payments. Assistance is available through two programs—QMB (Qualified Medicare Beneficiary program) and SLMB (Specified Low- income Medicare Beneficiary program). Under the QMB program states are required to pay the Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) premiums, deductibles, and coinsurance expenses for Medicare beneficiaries who meet the program's income and resource requirements. Under the SLMB program states pay only the full Medicare Part B monthly premium ($42.50 in 1996). Eligibility for the SLMB program may be retroactive for up to three calendar months.
Both programs are administered by the Health Care Financing Administration (HCFA) in conjunction with the states. The rules vary from state to state; but in general: An individual may qualify for the QMB program if his or her income is near the national poverty level, approximately $7,980 annually for an individual ($665 per month) and $10,608 annually for a family of two (or $884 per month). 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 $9,576 annually for an individual (or $798 per month) and $12,780 annually for a family of two (or $1,065 per month). In Hawaii the income threshold used to define poverty is approximately $8,856 (or $738 per month) annually for an individual and $11,796 annually (or $983 per month) for a family of two.
For the SLMB program annual income must be 110 percent or less of the national poverty levels. Under both programs $20 in monthly income is not counted toward the limit. Resources such as bank accounts or stocks may not exceed $4,000 for one person or $6,000 for a family of two. (Resources generally are things you own. However, not everything is counted: the house you live in, for example, doesn't count, and in some circumstances your car may not count either.) Here's an idea of what the QMB program provides in 1996. Under Part A the hospital insurance deductibles are $736 for the first 60 days of a hospital stay and $184 per day for days 61 through 90 in the hospital. The QMB program will pay these expenses for eligible beneficiaries. However, to qualify for help under the QMB program, you must file an application. If you think you qualify but you have not filed for Medicare Part A, contact Social Security to find out if you need to file an application. Further information about filing for Medicare is available from your local Social Security office or Social Security's toll-free number: (800) 772-1213.
Remember, only your state can decide if you're eligible for help from the QMB or SLMB program. So, if you're elderly or disabled, have low income and very limited assets, and are a Medicare beneficiary, contact your state or local welfare or social service agency to apply. For further information about either program, call HCFA's toll-free telephone: (800) 638-6833.
If you or a friend would like to remember the Diabetics Division of the National Federation of the Blind in your will, you can do so by employing the following language: "I give, devise, and bequeath unto the Diabetics Division of the National Federation of the Blind, 1800 Johnson Street, Baltimore, Maryland 21230, a District of Columbia nonprofit corporation, the sum of $___________________" (or "___________ percent of my net estate" or "the following stocks and bonds:___________") to be used for its worthy purposes on behalf of blind persons."
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...
Mexican Fiesta Casserole
from Betty Johnson of Lewiston, ID
1/2 lb. extra lean hamburger
1 1/4 cups red beans, cooked
1 small onion
1/2 tsp. garlic salt
2 (8-oz.) cans tomato sauce
1 cup lowfat plain yogurt
1 cup lowfat cottage cheese
1 small can chilies, chopped
1 (6-oz.) package taco chips
1 1/2 cups (6-oz.) Mozzarella cheese, shredded
Brown hamburger and onion together in a nonstick pan. Drain. Add garlic salt, red beans, and tomato sauce. Mix yogurt, cottage cheese, and chopped chilies together. Crush taco chips. In a 2-qt. casserole, layer half the chips, meat mixture, cottage cheese mixture, and shredded cheese. Repeat layers, bake at 350 degrees for 30 minutes. Yield: 8 servings; Calories: 330; Exchanges: 2 lean meats, 2 starch, 1 fat.
Tangy Cauliflower
from Boone Hospital Center of Columbia, MO
1 medium head cauliflower
1/2 cup fat-free mayonnaise
1 1/2 tsp. prepared mustard
1 green onion, sliced
2 oz. reduced-fat cheese, grated (or 1/2 cup)
In large saucepan, cook cauliflower in boiling water until crisp-tender. Drain well and place in serving dish. Meanwhile, in small bowl combine mayonnaise, mustard and onion. Mix well. Spoon and spread over hot cauliflower. Sprinkle with cheese. Cover. Let stand a few minutes until cheese is melted. Yield: 8 servings; Per serving: 45 calories, 5gm protein, 2gm fat, 0.3gm saturated fat, 4gm carbohydrates, 130mg sodium; Diabetic Exchanges: 1 vegetable, 1/2 fat.
Savory Green Beans
from Boone Hospital Center of Columbia, MO
4 cups fresh green beans (or 1 16-oz. bag frozen)
1/4 cup water
2 tbsp. butter flavor granules (or 2 tbsp. reduced-fat margarine)
1 tablespoon lemon juice
1 tbsp. chopped fresh summer savory (may substitute 1 tsp. dried savory)
Bring water to boil in medium saucepan. Add beans and cook over medium heat 10 to 15 minutes or until crisp-tender. Drain. Stir in remaining ingredients and mix well. Yield: 8 servings (1 serving = 1/2 cup); Per serving: 15 calories, 1gm protein, 0gm fat, 0gm saturated fat, 4gm carbohydrates, 22mg sodium; Diabetic Exchanges: free.
Holiday Cherry Cheesecake
from Cosmopolitan International Diabetes Center of Columbia, MO
1 whole graham cracker, crushed
1 cup 1% cottage cheese
1 small package sugar-free Jello
2/3 cup boiling water
8 oz. fat-free pasteurized processed cream cheese spread
2 cups Cool Whip Lite
1 cup reduced-calorie cherry pie filling
Spray a 9-inch pie-pan with nonstick spray (like "Pam"). Sprinkle sides of pan with half the graham cracker crumbs. Dissolve Jello in boiling water; pour into blender. Add cottage cheese and cream cheese. Blend at medium speed for two minutes, or until smooth; pour into large mixing bowl. Gently fold in Cool Whip. Pour mixture into pie-pan and smooth. Sprinkle remaining crumbs on top. Chill until set (approximately four hours). Before serving, top cheesecake with pie filling. Yield: 8 servings; calories 120; 2.3gm fat. Exchanges: 1 skim milk, 1/2 fruit.
LifeScan, Inc., of Milpitas, California, maker of the "One Touch" series of glucometers, announces a new meter. Called "SureStep," it is much smaller than their other meters, and is not part of the "One Touch" system. The SureStep measures only 3-3/8" x 2-3/8" x 7/8", and uses a new test strip and testing technique.
The SureStep test strip is designed to receive the blood sample ("dropped or dabbed") outside of the machine. The strip's absorbent pad allows easy application of the blood sample, and its blue "confirmation dot" shows when enough blood has been applied. Operating procedures are simple and straightforward, and the system is meant to be forgiving of imprecise user technique. Although there is no provision for voice synthesis, the meter's numerical display is bold and easy to read, 150% larger than that of the much larger One Touch Profile (19/32" as opposed to 13/32", 15mm vs 10mm).
Test strips for the new meter (which should cost about the same as One Touch strips) have been specifically designed to cut strip wastage and lessen the need to re-test. Also, the strip's absorbent pad guarantees it will enter the machine almost dry, making cleaning easier. The application of blood sample to strip before insertion into the machine, the "enough blood" confirmation dot, and the overall extreme simplicity of meter operation may make this meter a good choice for the beginning tester or the diabetic whose physical limitations interfere with traditional strip use.
We tested the meter, using the new technique of bringing test strip to lanced finger. We "dabbed" (touched the test square to the blood drop), then checked that the dot had turned blue. Everything functioned perfectly. Retail price for the SureStep meter should be about $62.50, but a $30 manufacturer's rebate and a $20 trade-in allowance for your old glucometer can reduce the price to around $12.50. For information, contact your pharmacist or LifeScan, Inc., 1000 Gibraltar Drive, Milpitas, CA 95035-6314; telephone: 1-800-227-8862.
Not a week passes without details of some new research of potential interest to the diabetic community! At this time, Washington University School of Medicine, in St. Louis, Missouri, is researching a number of new developments. A team headed by Janet McGill, MD, is testing the efficacy of a new investigational insulin specifically formulated for veteran type II diabetics who are ready to make the switch from oral medications to injected insulin. Oral diabetes medications often lose their efficacy after a number of years, requiring a switch to insulin injections to maintain good control. There is always a certain reluctance to switch from pills to injections (industry insiders call this "psychological insulin resistance") and it is hoped the new formulation can ease the transition.
Other Washington University studies include evaluation of the new kidney drug aminoguanidine, and a study of treatments for neuropathy pain. Researchers at Washington University School of Medicine and many other centers are always looking for volunteers, people with type I or type II diabetes, to participate in their clinical evaluations. We at VOICE OF THE DIABETIC suggest you consider participation. Readers in the St. Louis area can telephone the Washington University School of Medicine's "Volunteer for Health" line at: (314) 362-1000.
Individuals with severe coronary artery disease face the risk of vascular blockage, which can lead to angina, weakness, and heart attack. Traditionally, these folks have received one of two treatments: CABG (bypass surgery) or PTCA (percutaneous transluminal coronary angioplasty, "balloon angioplasty"). Diabetes is a major cause of heart disease, and enough diabetics have undergone one or the other procedure to form a statistical picture of these procedures' effectiveness. PTCA uses a catheter, which is inserted into the obstructed vessel from an entry point in the groin, and inflates like a balloon, to dilate the blocked vessel at the point of obstruction, allowing blood to flow past the blockage. CABG, a major operation, involves opening the chest and providing a new channel, or "bypass," for the blood to flow. Both treatments alleviate the effects of coronary artery disease, but neither alters the natural course of the disease.
One might expect the "success" rates of the two procedures to be about the same, or for the less invasive, PTCA, to be better. Beginning in August 1988, the Bypass Angioplasty Revascularization Investigation (BARI), a major study sponsored by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health, compared the effectiveness of the two procedures. Results were surprising. Using "mortality after 5 years of follow-up" as a yardstick, the BARI study found that for non-diabetic patients, both procedures scored equally, with a 9% mortality rate. For diabetics on insulin or oral hypoglycemics (type I or type II), the 5-year mortality rate following PTCA, the less invasive procedure, was 35%, and the rate for CABG, bypass surgery, was 19%. Although the higher overall mortality rate from diabetic heart disease was not unexpected, the excess mortality with balloon angioplasty had not been anticipated. Results of the study indicate that bypass surgery should be the preferred treatment for diabetic patients on insulin or oral medications, who have multivessel coronary artery disease and need a "first coronary revascularization" (first-time PTCA or CABG). As the Centers for Disease Control reports that, in 1989, about 48% of all diabetes-related deaths had major cardiovascular disease as the underlying factor, these findings are expected to have major impact.
Patients were eligible for the BARI trial if they had coronary artery disease with a 50% or more luminal obstruction (as measured by calipers) in at least two of the coronary vessels supplying two or three major coronary territories. They had to have clinically severe ischemia (measurable obstruction to blood flow), and no prior revascularization. Patients were ineligible, if, for example, they had insufficient angina or ischemia, required emergency revascularization, had left main stenosis of 50% or greater, had a noncardiac illness expected to result in limited survival, primary coronary spasm, or a poor-quality angiogram (x-ray examination of the circulatory system). All patients accepted for the test received "risk factor modification": help with smoking cessation, appropriate exercise, and diet.
Findings of the BARI study were reviewed on September 13, 1995, by the Data and Safety Monitoring Board, a panel of PTCA experts, cardiovascular surgeons, clinical cardiologists, biostatistics experts and ethics specialists. The Board concluded that the differential results of the two treatments, and the unfavorable mortality for diabetics on insulin or oral hypoglycemics, were unlikely to be due to chance. The Board recommended to the National institutes of Health that physicians, other health professionals, and the public be promptly informed of the results.
In summary: The BARI study was a careful comparison of the results of two medical procedures frequently used in response to multiple coronary artery disease. Many "endpoints" were investigated, including: Patients' anginal status, number of diseased vessels, functional status, quality of life, gender, age, race, and presence/absence of diabetes. Although the study considered many issues, its findings for diabetics were particularly significant. The study strongly suggests that if you are diabetic, using insulin or oral hypoglycemic agents (sulfonylureas), and you suffer from multiple coronary artery disease, and if you are at the point of needing a first revascularization, you will probably fare better with CABG, bypass surgery, than with PTCA, balloon angioplasty, as an initial treatment.
Anyone who has evidence of coronary artery disease, with or without a prior PTCA or CABG, needs, under close physician monitoring, to aggressively reduce known risk factors, such as smoking cessation, appropriate control of blood pressure and serum cholesterol, and needs to achieve optimal control of their diabetes.
[From the Editor: I've had bypass surgery. Several doctors have told me the best way to determine if you have coronary artery disease is with a "routine exercise treadmill test." While you work out, electrical instruments measure your heart rate, heart rhythm, EKG, and blood pressure, and the doctor will note any other symptom you may have. Added together, all the test data give a good picture of the state of your heart. You can have a normal pulse, and significant coronary artery disease. Diabetics (and non-diabetics) can have normal EKGs, too, even in the early stages of a heart attack. One physician told me: "the absence of electrocardiographic abnormalities does not preclude the presence of significant heart disease."
My doctors said that if you have multiple risk factors, like cholesterol, hypertension, smoking, cardiac arrhythmia ("heart murmur"), or a family history of heart trouble (another is the presence of diabetes), you ought to have periodic treadmill checks, to see how your heart is doing. If you've had diabetes for 20 years (IDDM or NIDDM) you could benefit from this test. If heart disease is discovered soon enough, medical intervention can make a difference.]
by Frederick R. Claus
My decision to lose weight was a long time coming. I had looked at those new and "fad" diets, and even tried some of them. It did not take me long to realize they were not for me—I could not regulate my life to a piece of paper with food listed on it. This bothered me quite a bit, but for me momentous life-changing decisions just don't come when I try to force them. So I just quit trying to push the issue. As usual, I had it "working down inside" and after some time it came to me that what I needed was not a new diet; what I needed was a new life-style. So I set about developing one... In fact it is still under development, and probably will always be! One of the things that came to me was that first I needed to be more flexible. At age 61, one tends to become "locked in" to a lot of things. This I changed. I am presently causing great concern to my kids and grand-kids. They now fear for my sanity.
It is the old "Grampa ain't what he always was" syndrome, and some of them do not know how to handle the changes. I examined the way I was living. My wife died back in February of 1994, and since then I had been merely existing. My meals were taken where I was, while I was doing whatever. I was a junk food junkie. I talked about my feelings with a very dear friend, last July, and she gave me some pointers on how she looked at healthy eating. I began to look more closely at the food on the grocery store shelves. I began buying the "Healthy Choice" brand of foods for my breakfast and supper meals, and I quit buying "fast food" junk such as burgers and fries.
My meals now consist of:
BREAKFAST: Bowl of Healthy Choice multi-grain cereal, non-fat milk, and black coffee.
LUNCH: A Garden Salad from Wendy's (or the like) with one prepackaged dressing, and a Diet Pepsi. (I do not like Coke.)
SNACK WHEN I GET HOME FROM WORK: Usually two hard boiled eggs and/or an apple.
SUPPER: One of the frozen Healthy Choice prepackaged meals that just has to be popped into the microwave for a few minutes.
Usually for dessert, I have some low-fat ice cream.
Recently I have begun to expand my choices for supper. I now buy codfish, skinless chicken breasts, crabmeat, turkey, and vegetables such as okra, lima beans, asparagus, broccoli, and peas. I eat stir-fry vegetables and prepackaged salads. I cook the fresh things in between the frozen meals as I feel like it. And, of course, I have a ribeye steak and baked potato every once in a while. As you can see my "diet" is very flexible. I hate regimentation.
There are times when I do not stick to my diet. I sometimes go ahead and eat things I know are detrimental to my health. This Friday I have a dinner date with some friends and depending on what strikes me on the menu, I may just eat something like a "Kentucky Hot Brown," which is turkey, ham, bacon, toast, tomato, SMOTHERED in a very thick rich cheese sauce. (Here's to flexibility!) Oh yes! Another thing I have done is give up hard liquor entirely. That is probably the biggest difference my kids see in me. They are used to "dad" sipping away at his "toddies" all weekend long, and on holidays. But no more—and they find that strange. I do have a beer now and then, and kinda over-imbibe on my spring and fall fishing trips with the guys. But for the most part I leave alcohol alone.
My exercise is mostly limited to my stationary bike. I "ride" it in the mornings before work and afternoons right after work for 15 minutes a session. When I started, I had all I could do to stay on it for five minutes. It took me about three weeks to get to 10 minutes and then about three more to get to 15. It has a little read-out thing that tells me the distance I ride, the calories I burn, the time I am on it, and the speed I am pedaling. At first I was pedaling at about 8.5 to 9 mph. That has increased slowly, and now I am comfortably up to a little over 11 mph. In a 15-minute workout, I now travel 2.7 miles, and burn a little over 110 calories.
When I began I had enough natural padding on my rear so that the seat was not uncomfortable. As I grow more fit, I find the seat getting harder and harder on my butt. I wear sweat pants for "riding," but one of the secretaries at work recommended I get regular bike-riding pants to reduce the abrasion problems I am now having with the seat. She wears them, and she rides hers for an HOUR every day! I am not looking forward to an hour on that thing! I use a stopwatch to check my heart rate while I am on my bike. I find it runs around 125 to 130 or so after I have been riding for five minutes, then it holds fairly steady. Every once in a while I just go nuts and pedal like a fool, cranking the speed up to about 12 miles per hour, but I do not hold it there for long, and it does not seem to adversely affect my heart rate.
I hope the above has been helpful to you. I probably ought to tell you that the real incentive for me doing all this is because I am in love and want to be healthy and live a long time, and grow very old with the woman I hope to marry in the not too distant future. I love my darling!
(From the Editor: Quitting hard liquor improves diabetes control. "Healthy Choice" frozen meals have the diabetic exchanges posted on the package. But beware of "fat-free" ice cream—it isn't SUGAR-free, and it certainly isn't FREE FOOD! When eating anything high in fat and/or sugar, remember to "indulge in moderation!")
by Debra Frank, Exercise Physiology M.S., Recreation Therapy M.S.
Cross-Country Skiing
Although this is the Summer Edition of the 1996 VOICE OF THE DIABETIC, it's never too early to plan for winter sports. Some of us, even now, are not quite finished with our snow adventures. In fact many of us travel the planet, in search of snow and fun. For the cross-country skier, blind or sighted, "following the snow" can be a tricky situation, especially if you live in Texas, and the coldest temperature you are accustomed to is 40 degrees Fahrenheit! But Linda Moores, from Houston, Texas, has picked up sports she can enjoy year round. If she has the urge and opportunity to go sailing, she just might join the gang heading for New Zealand this year as she did in 1991. But in 1989 she was introduced to "Ski For Light" (SFL), a program for blind or mobility-impaired individuals interested in cross-country, or "Nordic" skiing.
The SFL program is simple and safe, and allows tremendous freedom. Participants use conventional skiing gear, and are untethered, on their own. They set their own pace, and travel at a speed comfortable to them. A sighted guide is nearby, but only to warn skiers who drift off the prepared track. 1995 marked the 20th year of SFL. Many of the participants at this winter's SFL gathering in South Dakota reflected back on what they had discovered over the years. One, Annemarie Cooke, said, "My first hesitant strides on cross country skis five years ago became one of the most life-changing experiences of my adult life!"
Ron and Jo Farra, co-chairs of the Nordic committee for the North American Ski Journalist Association, have been advocating and promoting Nordic/cross country skiing for individuals with disabilities for decades. "Whether they want to compete in the ParaOlympics or Special Olympics, or they just want to go out and have some real fun and get fit, Nordic skiing is a safe, truly full body conditioning activity. Anyone who wants to learn can be instructed, and if necessary, adaptive equipment will be provided" says Ron.
Like many outdoor sports enthusiasts, the Farras try everything available to them for recreation. They agree Nordic skiing's cost and relaxed atmosphere are very appealing to families, seniors, people with orthopedic weaknesses, folks afraid of heights, and blind individuals like Linda Moores.
Over the years, Nordic skiing has seen a resurgence of popularity within the American population. Much of this rebirth stems from increased interest in the environment, awareness of overall wellness and health benefits, and the true convenience of the sport. For a diabetic, the opportunity to participate in such a terrific low-impact, highly aerobic and muscle-strengthening activity, allowing the freedom to roam the snow-covered trails at one's own pace, is truly a gift of nature and God.
As Linda describes it, "I am able to travel with my companions at a pace I enjoy, and I am able to slow down and stop whenever I need. I carry a pack with all my diabetic necessities and there's room enough for a full course meal to boot!! Cross county skiing is truly refreshing. The ultimate invigorating sport—it allows me to burn lots of calories while having lots of fun!" When there's an abundance of snow you can get up and go...anywhere, if you have your own skis. Unfortunately, weather and snow conditions are not always favorable or reliable for the ideal Nordic outing. So one must get up and go to where the snow is abundant. For Linda that might mean going back to New Zealand for a summer excursion. She'll be touring the thousands of kilometers of pristine snow—and if I'm lucky she will ask me to join her. That sounds like a plan to me! Two diabetic females go a "walkabout" on cross country skis during the heat of the New York and Texas summers. We may never come back. See you between the snow flakes!
For more information on Nordic Skiing contact Jo and Ron Farra: (518) 584-2256; for more information on "Ski For Light" contact: (612) 827-3232.
Dorland's Medical Dictionary defines ketoacidosis as an acid condition of the blood marked by the presence of ketones, as in diabetic ketoacidosis (DKA). This dangerous condition can occur in individuals who have had very high blood sugars (hyperglycemia) for an extended period of time. Remembering that insulin allows the body to digest and utilize glucose, an untreated type I diabetic with long-term high blood sugar is literally starving to death, no matter how much food he or she may consume. Without the means to process the glucose so overabundant in the blood, the body begins consuming stored fat and muscle. When the body begins burning its stored reserves, ketones are produced. Ketone production is normal, especially during exercise or weight-loss dieting, but the healthy body excretes the ketones it produces, so there is no harmful buildup. Diabetes, however, changes the rules.
The prolonged high blood glucose of untreated IDDM impairs the kidneys' normal ability to excrete ketones. Serious problems follow, when unexcreted ketones, products of fat and muscle metabolization, build up in blood already saturated with sugars. Such condition can cause diabetic coma, and without immediate medical intervention, can cause death. Although anorexics, hunger strikers, and people marooned for long periods without food or water, or facing dehydrating illness, can experience ketosis (ketone buildup in the blood), DKA, the one-two punch combination of ketosis and high blood acidity from sustained elevated blood glucose, is particularly deadly to the diabetic. Ketoacidosis takes time to develop, and is one more solid argument for tight control and frequent blood glucose monitoring. If you are ill, or know your sugars have been running over 240 for some time, you should test your urine for the presence of ketones. When in doubt, test (several urine-tests for ketones are available), and remember to keep your health care team informed. Take care of yourself!
Since the VOICE is now offered free, our Diabetics Division will provide extra copies to anyone wanting to help spread the word. We will gladly send from five to five hundred-plus copies each quarter to be used as free literature. Medical facilities can order as needed for patients. Individuals can usually place copies of the VOICE in libraries, pharmacies, hospitals, doctors' offices, or other public locations. Diabetes education is essential. Anyone who distributes the VOICE will be helping people with diabetes, and their families, to learn about the disease and its ramifications; to learn that they have options; and that their world is far greater than whatever "limits" may be imposed by the disease. If you would like to help spread the word by distributing the publication, please contact: VOICE OF THE DIABETIC, 811 Cherry Street, Suite 309, Columbia, MO 65201; telephone: (573) 875-8911.
Inclusion of materials in this publication is for information only and does not imply endorsement by the Diabetics Division of the NFB.
Sugar Free Marketplace
Not quite everything for sale at the Sugar Free Marketplace is good for the diabetic diet. They also sell cookbooks, books about diabetes, and diabetic socks. The edible products they list, according to the catalog, are all made without refined sugar, corn syrup, honey or molasses. For more information about the many food products offered by the Sugar Free Marketplace, or their non-food product lines, or for a free copy of their catalog, contact: Sugar Free Marketplace, 6710 N. University Drive, Tamarac, FL 33321; telephone: 1-800-726-6191.
New Magazine
"Vision Enhancement" is a new quarterly publication promising relevant information for both consumers and professionals in the vision-impaired community. It contains articles on current medical research, the latest technological aids, tips on dealing with vision loss, and the newest books, magazines and videos of interest to the vision-impaired. The magazine is formatted in large print, audiocassette, and computer disk (with a Braille-translated file for accessibility by deaf-blind computer users), and costs (in the U.S.): $20 for one year; $35 for two year; $50 for three year subscription. Single copies are $6.50 each. Contact: Vision World Wide, Inc., 5707 Brockton Drive, #302, Indianapolis, IN 46220-5481; telephone: 1-800-431-5481; e-mail: patprice@aol.com
Diabetes Information
Through its HealthShare division, the Cleveland Clinic, an academic medical center, now offers the following: "Diabetes: Your Questions Answered" (booklet), priced at $4.95; "Your Diabetes Guide" (manual), priced at $24.95; and "Taking Charge of Your Diabetes" (videotape), priced at $19.95. All three are available as a package, at the price of $44.90. Contact: HealthShare, The Cleveland Clinic Foundation, 9500 Euclid Ave, KK11, Cleveland, OH 44195-5020; telephone: 1-800-238-6750.
New 1995 Food Exchange List
The new 1995 "Exchange Lists for Meal Planning" is now available in Braille (74 pages) and on audio cassette. This update, the result of a joint effort of the American Diabetes Association and the American Dietetic Association, reflects the new emphasis on total carbohydrate intake, rather than restricting specific sugar types. Users should find its new orientation simpler, and its meal plans vastly more flexible. In its new form, the Exchange List will continue to play a pivotal role in dietary self-management of diabetes. To purchase, make tax deductible checks payable to: National Federation of the Blind. Cost: Braille $10, cassette $2. Order from: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314.
Greeting Cards
The Iffin Group, a North Carolina-based graphic design studio, has just released a series of greeting cards for the blind and their families and friends. Created by blind artist Mickey Cabe, the cards, called "hAndrew," have both visual and embossed elements. The cards, which cover a range of selections, have verses printed in both Braille and ink. More cards will be available in the near future. For information, contact: The Iffin Group, PO Box 8847, Asheville, NC 28814; telephone: (704) 684-6176.
Diabetes Kits
"Do Your Level Best" is an information kit for both type I and type II diabetics, published by the National Institute of Diabetes, Digestive, and Kidney Diseases (NIDDK). The kit contains a 60-page easy to read booklet, and is free upon request. Contact Jere Suter at NIDDK; telephone: 1-800-438-5383. "Feet Can Last a Lifetime" is the title of two kits, one professional, one for patients, available from the National Diabetes Outreach Program, part of the NIDDK. The professional kit includes two videotapes, a 5.07/10g monofilament used for peripheral neuropathy diagnosis, reprints of journal articles, a doorknob reminder card, and a button. Cost is $15 per kit, for shipping and handling; quantities of the patient kit are available free of charge. Contact NIDDK; telephone: 1-800-438-5383.
Dex-4 Glucose Tablets
Sold in pharmacies and supermarkets nationwide, Dex-4 glucose tablets come in lemon, raspberry, orange and grape. Each fruit-flavored, easy to chew glucose tablet contains four grams of fast-acting carbohydrate, with no fat, sodium, caffeine, or cholesterol, and only 17 calories. These value-priced tablets are available in tubes of 10 tablets or economy size bottles of 50. For further information, contact your pharmacist or Can-Am Care Corporation, Cimetra Industrial Park, Box 98, Chazy, NY 12921-0098; telephone: 1-800-461-7448.
Blood Collector-Dropper
Developed for diabetics with unsteady hands and those who are blind or losing vision, the new Smart Dot Blood Collector-Dropper places the droplet for a glucose reading from Lifescan's One Touch II or One Touch Basic meter. With a 30-day money-back guarantee, it costs $10.95 plus $3.50 shipping and handling. Visa, Mastercharge, Discover and AMEX are accepted. To order, contact Smart Dot, 2655 West Central Ave., Toledo, Ohio 43606; telephone: 1-800-984-1137.
New Resource Guide
The NFB Diabetics Division announces the updated "Resource Guide to Aids and Appliances." Once again, we have compiled a list of companies and individuals who offer products and/or information for diabetics, especially those blind or losing vision, to help them self-manage their diabetes. The "Resource Guide" features six subject categories: General and Miscellaneous, Automatic Insulin Injection Systems, Blood Glucose Monitoring Systems, Syringe Magnifiers, Insulin Pumps, and Large Distributors of Diabetes Equipment and/or Supplies.
Blind diabetics can and do accurately draw up insulin, monitor blood glucose, and perform the other tasks of independent self-management. By using alternative techniques and products they can continue being independent, and can control their diabetes as efficiently as do their sighted peers. Limitations are usually self-imposed—often all that is needed to overcome negative thinking is simply to know where to go for information.
The new "Resource Guide" costs $2 per copy and is available in Braille (30 pages), large print (14 pages), and audiocassette. Make checks payable to National Federation of the Blind (Visa, Mastercard or Discover also accepted). Order from: National Federation of the Blind, Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314.
WINDOWS Screen Reader
GW Micro has developed "WINDOW-EYES," a screen reader for Microsoft WINDOWS. Once equipped with a voice synthesizer such as the Dectalk (your CD-ROM soundcard won't do), any computer that can run WINDOWS can run WINDOW-EYES. The WINDOW-EYES program costs $495, and is available from: GW Micro, 310 Racquet Street, Fort Wayne, IN 46825; telephone: (219) 483-3625.
Pocket Manuals
Two inexpensive new pocket reference guides offer portable advice to the diabetic. The first, "Charting: The Systematic Approach to Achieving Control," by Janice L. Roth, RN, BSN, CDE, shows both type I and type II diabetics how to analyze their body's responses to diet, exercise, and medication, and how to create a personalized systematic program for diabetes control. Price is $3.95.
"Eating Out: Your Guide to More Enjoyable Dining," by Hope S. Warshaw, RD, CDE, provides tips for eating in all kinds of restaurants, without fear of weight gain or uncontrolled rise in blood sugar. The book provides general guidelines for healthy eating, and shows how to select appetizing meals that still meet your diet requirements, even in pizza parlors and sub shops. Price is $4.95. There is a shipping charge of $1.50 per book. Order from:
"Diabetes Self-Management," Book Division, 150 West 22nd Street, New York, NY 10011. Diabetes Supplies Medi-Mail, inc., of Naples, Florida, is a new, small diabetes supply company offering a high level of customer service. They bill Medicare and secondary insurance carriers, accept assignment, and carry sometimes-hard-to-find items like Diascan test strips. They carry diabetes literature and information, and all their employees have received instruction from diabetes educators. For information, contact: Medi-Mail, Inc., 1594 Northgate Drive, Naples, FL 33942; telephone: 1-800-883-9146.
by Robin McRee
In a day when the Centers for Disease Control reports that diabetics are two to three times more likely to die from cardiovascular disease than are non-diabetics, any therapy providing lower cholesterol levels and reduced fatty deposits in arteries is worth checking into. While preliminary animal tests are expected to last two or more years for the new heart drug, APO-A1 Milano, the time has come to ask if there is something which can be started today. The resounding answer is Yes!
The Preventive Medicine Research Institute, of Sausalito, California, in a report recently published in the journal "Lancet," showed that meditation and yoga, when used in conjunction with a lowfat diet, can actually reverse heart disease. Recognizing the connection between workplace stress and heart disease, some businesses have incorporated stress-reduction programs into their daily routine. Symmetrix, a consulting firm in Lexington, Massachusetts, started one such after its workers participated in a program with an instructor from Harvard's Mind/Body Medical Institute, where they were taught relaxation and meditation techniques. One diabetic worker noticed a big health benefit: His insulin requirements dropped 15% after using the relaxation techniques for only three weeks.
In July of 1992, Mutual of Omaha, America's largest family insurer, became the first to cover the $3500 cost of a 12-week program of diet, exercise, and stress management. Their program was developed by Dean Ornish, MD, director of PMRI, who refers to it as a "reversal program." Participants eat a vegetarian diet in which 10% of total calories come from fat, exercise moderately, practice managing their stress through meditation and yoga, and take part in support groups to help them stick with their new lifestyle changes. In three studies over the past 17 years, both privately- funded and by the National Institutes of Health, Dr. Ornish's program has proved it doesn't just slow down heart disease, but can in fact reverse it. So my question is this: Why sit idle waiting for a new heart drug when healing can begin today?
by Peter J. Nebergall, PhD
A person's conception of his role, capacities, and appropriate behavior, is part of his culture. It is learned behavior, enculturated, picked up from parents and peers. His attitude toward the capacities of others is equally part of his culture. Assimilated early, it becomes part of his character, the standard by which new information is judged. He may be taught that a black skin is a badge of inferiority, or that a white cane is a symbol of inability. In his culture, such views are "appropriate," and he is in conformity with his fellows to hold them. But consensus, while a sign of agreement, is no guarantor of accuracy—and if his views limit others from the full realization of their capacities, such consensus cannot be seen as beneficial to the culture as a whole.
There are still peoples today who view disability as a reflection on an individual's ancestry, or as punishment for sin. In some of these groups the very existence of a family member who is "not whole" is an insult to the family—so these folks keep their disabled out of sight, out of mind, or worse. But what of the "civilized" world? To what degree are our interactions, and those of our fellows, predisposed by inappropriate attitudes assimilated long ago? And for those of us in positions of power and public policy, how many of our decisions are shaped by old ideas of inappropriateness, inferiority, and inability? If I am raised to believe that person A, by definition, cannot do job X, I am not likely to spend much time working on ways to provide him or her the means to do so—because, by definition, members of that group can't. If I am a racist, and I think a group is stupid, I am not likely to worry about their lack of management opportunities—as by definition they are not qualified to hold them. If I have been taught that blindness = clientage, a lifetime of subservience to sighted custodians, I am not likely to look with favor on alternative interpretations. And, who cares what these affected groups think—if I think this way, if I was raised to believe this, I will resist change—because my beliefs are part of my culture. So what does it take to change the culture of misunderstanding? First, we all need to confront our own cognitive maps. What do we believe? What are our convictions about the abilities of others? Everything must be on the table, so we can really learn what we think. I am convinced that a great many people whose viewpoints drive others to tears and fury are genuinely unaware of the faulty premises upon which their views are based.
Let us become aware. Let us open our eyes to the facts, to the achievements of those we used to think couldn't handle the mainstream. When we become aware of each others' abilities, we will stop inflicting upon them our old ideas of inappropriateness, inferiority, and inability. This is our urgent responsibility.
We invite blurbs and tidbit articles for inclusion in this column. Materials received may be edited and used as space permits. Products and services included in this column are for information only and do not imply endorsement by the Diabetics Division of the NFB.
New Insulin Update
On February 29, Eli Lilly and Company's new Humalog insulin (generic name Lispro) was unanimously recommended for marketing clearance by an advisory panel of the U.S. Food and Drug Administration. All that remains is for the FDA to settle the administrative details, such as the specifics of labeling and packaging. Final approval should come some time this year. This new quick-acting insulin is very different from past formulations, and the FDA review panel recommended that Humalog initially be available only by prescription. Traditional "R" insulins start to act about 30 minutes after injection (different people will react at different rates) and peaks in about 3.5 hours. Humalog starts up in 10 to 15 minutes, and peaks in one hour, much more like the insulin secreted by the healthy pancreas of a non-diabetic.
Hot Insulin
Summer brings hours of fun, at the beach, the park, the mall, or wherever, and you may find yourself carrying extra insulin. That's a good idea, but remember that insulin is very sensitive to extremes of temperature. Remember last time you got in your car after a day in the summer sun? It was an OVEN. A closed car in the summer sun can get up to 140 degrees Fahrenheit—hot enough to kill your dog, and hot enough to cause physical changes in the insulin you left in the glove compartment. How hot is "too hot?" A good rule is, if it's too hot foryou, don't leave your insulin there. If you let that insulin get hot, and then use it, you may find it isn't working, and your sugars are going up fast! Exposure to freezing, or to high humidity, can also damage your insulin. Be prepared to replace doubtful insulin—it's cheaper than an ambulance call.
NFB on the Internet
The National Federation of the Blind has a homepage on the World Wide Web. At this website you can learn more about our organization and its services, or review our national publications. From the homepage, you can also access VOICE OF THE DIABETIC. To get to the NFB homepage, enter the following address at the "URL" prompt: http://www.nfb.org. To reach the VOICE from the NFB homepage, follow the link for "diabetes," and then the link for VOICE OF THE DIABETIC.
Choosing Finger-Lancing Sites
The Diabetes Control and Complications Trial ushered in the era of "tight control," with multiple injections and LOTS of blood-glucose testing. People are sticking their fingers more often, and to avoid sore fingers, calluses, etc., it is necessary to rotate test sites. How do you keep track of where you should put the lancet next? Ann S. Williams, MSN, RN, CDE, herself a type II diabetic, chooses her test sites by day of the week and time of day. Her left index finger is for Monday, left middle finger for Tuesday, left ring finger for Wednesday, etc. On each finger, the side toward the thumb, opposite the base of the fingernail, is for fasting, the other side opposite the base of the fingernail is for suppertime, and the same side, opposite the middle of the fingernail, is for bedtime. Any extra tests are done in the area around the top of the fingernail. She writes: "By using this method, you end up lancing the same site only once a week. I like doing it this way because I have such a hard time remembering where I last lanced, and this way I can figure out where I am supposed to be by day of the week and time of day...but when I wake up and can't remember what day of the week it is, I am in trouble."
Diabetes Information on the Web
Tom Baccanti, owner of "The Outpost," a World Wide Web site for the blind, announces a new, very comprehensive, resource page for diabetics. Packed with cross-links to major diabetes information providers, it joins his many other pages keyed to major issues about blindness. He invites readers to: "Please use this page and let me know if there is anything you can't find there, and I will hunt it up for you." Access "The Outpost" at http://www.deltanet.com/users/tdb.
Medicare Question:
Q: Why do some doctors send bills only to Medicare and not to secondary insurance? Some doctors send to both. This is very confusing and always takes longer to work things out.
A: The government requires doctors to submit claims to Medicare for you. The government does not, however, require doctors to send claims to secondary insurance. Medicare does forward some claims to Medigap insurers or crossover companies. If you have secondary insurance, your doctor should include this information on the claim. If it is a company we forward claims to, Medicare will send the proper information to your other insurance. (From "Beneficiary News," Vol. 5, No. 1, Spring 1996, published by Medicare.)
"A Touch of Sugar"...or?
Too many folks, both health professionals and patients, diminish the seriousness of type II diabetes, calling it just "a touch of sugar." Such description encourages inaction, and discourages the diabetic from adopting appropriate measures to deal with his or her hyperglycemia. It also misses a major point: Excess sugar in the blood (uncontrolled high blood glucose) is acidic, destructive, and behaves much like a poison. So let us imagine a different scenario—would anyone deprecate the threat posed by "a touch of arsenic?" Of course that statement is ridiculous...or is it? If blood glucose tests reveal an abnormally high level of sugar in your blood, you need to take appropriate measures to get it under control and keep it there, just as if you caught someone feeding you arsenic, you'd make them stop, NOW! So laugh at the old fogies who still talk about "a touch of sugar," and keep your blood glucose under the best possible control. It's worth it.
Fat! When nutrition is discussed today, the topic of fat seems to be at the center of the discussion. The reason is simple; high fat diets have been linked to health problems and weight gain. Where's the Fat? When we think of fat, we think of things like salad dressing and butter. But there is fat in almost all foods. Some you can see, like the fat on meat, but some is hidden, as in cheese, chocolate, and baked goods. What's Wrong with Fat? Fat is high in calories. Eating fat can make your body produce more cholesterol, a waxy substance that can build up in the blood. Fatty deposits then build up in the arteries, blocking normal blood flow. (Editor's Note: This is especially true for diabetics!) A low fat diet can help keep your blood vessels open, and may also help to prevent colon, prostate, and breast cancer. Too much fat in the blood seems to inhibit the body's ability to protect itself from damage.
Not All Fats are Created Equal! Cholesterol levels can be lowered, and your risk of heart disease reduced, by cutting back your intake of fats. There are two classes of fats, and one is more harmful to your health than the other. Cholesterol and saturated fats are the hardest on your health. Saturated fats include butter, coconut and palm oil, and the fat in meat and cheese. These fats raise blood cholesterol. Total saturated fat is shown on the nutrition label. Try to eat as little saturated fat as possible. Unsaturated fats include olive, canola, corn, and sunflower oils, and the fat in nuts, olives, and avocados. These fats are not as bad as the saturated ones, but they're still high in calories, so use them sparingly.
How much Fat? Keep the total amount of fat (shown on the food label in grams) within the following ranges: Men: To maintain weight, no more than 60-90 grams daily. To lose weight: 40-60 grams daily. Women: To maintain weight: 40-70 grams daily. To lose weight: 25-40 grams daily. No more than 20-30% of your total calories should come from fat. You need to watch both type and total amount you eat. (Thanks to Boone County Council on Aging, Columbia, MO, for this information.)
The Lemon Law
In June of 1995 Missouri joined the ranks of states providing one-year warranty and "lemon" protection to purchasers of certain assistive devices used by persons with disabilities. The law defines an "assistive device" as: "Any device used by a person with a disability to assist in performing a major life activity...including, but not limited to, motorized/manual wheelchairs, scooters, hearing aids, telecommunication devices, speech synthesizers, scanners, and other devices which enable a person with a disability to see, hear, or maneuver. To qualify as a "lemon," an assistive device must undergo repair for a substantial defect four times within the one-year warranty, or must be out of service for at least 30 days of the warranty period. The defect must be of the device itself and not the result of consumer abuse.
As the Americans with Disabilities Act (ADA) defines diabetes as a disability, Missouri's new "lemon law" may shortly be extended to diabetes self-management equipment such as glucometers. When it does, or when other states join in extending this broad protection to the disabled, VOICE OF THE DIABETIC will report it.
Diabetes Hotline
The Lifescan Tele-Library offers recorded diabetes information in English or Spanish. Subjects covered include symptoms, complications, and ways to manage the disease. To access this resource: call 1-800-847-7226.
Glaucoma
Glaucoma is an increase in fluid pressure inside the eye. It can quickly bring about optic nerve damage and loss of vision. Glaucoma occurs twice as frequently among diabetics as among non-diabetics. If caught early, glaucoma is treatable, but no medical procedure can restore what is already lost. The National Eye Institute urges you to get your eyes examined, through dilated pupils, every year. Do not wait until the onset of vision difficulties to get your eyes examined! For more information contact: National Eye Health Education Program, 20/20 Vision Place, Bethesda, MD 20892-3655; telephone: (301) 496-5248.
Internet Access
We have been asked to announce: National Braille Press announces release of COMMO, an internet access program that works well with speech and Braille. COMMO is a shareware program, priced at $40 ($30 for students). Free evaluation copies are available on some electronic bulletin boards. National Braille Press has also prepared a reference card, in Braille, for users of COMMO. The card is priced at $5. For information, or to order, contact: National Braille Press, 88 St. Stephen Street, Boston, MA 02115; telephone: (617) 266-6160.
What is Diabetes Insipidus?
As if the types and terms of diabetes mellitus were not enough to remember, there is an unrelated medical condition also called "diabetes." This is diabetes insipidus. Diabetes insipidus (DI) results from the body's inability to properly retain and concentrate urine, so the kidneys just keep flushing it out. The word "diabetes" in this case refers to the very rapid flow of water through and out of the body. The sufferer's urine is almost colorless and odorless. Unlike the more common diabetes mellitus, this condition does not alter blood glucose levels. The cause of this incontinence is in the pituitary gland, located in the brain. Normally the pituitary secretes a hormone called vasopressin, which acts on the kidneys to retain water, allowing concentration of urine. If this hormone is absent or in short supply ("central cranial DI"), or if the kidneys fail to respond to its commands ("nephrogenic DI"), large volumes of dilute urine will be passed.
Although the impact of diabetes insipidus is benign (provided one ingests enough fluid to replace urinary losses), such is not always possible. When a person with DI is unable to ingest sufficient fluids, severe dehydration can result. Central cranial DI can be treated with DDADP (desmopressin acetate antidiuretic replacement therapy), administered by nasal spray. Diabetes insipidus is fairly rare, and is unrelated to diabetes mellitus, but one can have both conditions. Of course men who have unexplained urinary incontinence should consult their doctor, as prostate difficulties can cause some of the same symptoms.
Free Diabetes Alert Necklace
The Diabetes Wellness Network offers free medical emergency necklaces for diabetics. The necklace reads: "I have Diabetes—please test my blood before treating me," and may help save your life. Part of the Diabetes Research and Wellness Foundation, the medical jewelry program is 100% free to diabetics. For information contact: Diabetes Wellness Network, PO Box 3837, Merrifield, VA 22116-3837.
New Study
MiniMed, Inc., of Sylmar, CA, a maker of insulin pumps, is currently testing a new type of blood glucose monitor. Where current monitors require a "finger-stick" and blood sample for each measurement, and provide only intermittent readings, the new sensor, inserted under the skin, would provide a continuous readout. Minimed plans for the glucose measurement data to be displayed on a pocketable or wristwatch-sized device, which will contain alarms for "too low" and "too high." Clinical trials of the new device are scheduled to start late this year, and if all goes well, the device may be available in 1998. VOICE OF THE DIABETIC will report on the results of clinical trials as they become available.
Sports for the Blind
BLINDSPORT is a new e-mail list dealing specifically with sports for the blind. Topics may range from announcements of upcoming tournaments, how to make sports more accessible to the blind, results of tournaments and events, sports training camps, and any other related topics. To subscribe, send e-mail to: jmeddaugh@cris.com, statingthat you want to subscribe to the BLINDSPORT list. This is not a LISTSERV address, so do not send LISTSERV commands. Be sure to state the name of the list that you are subscribing to, as several lists are run through this same address.
Syringe Disposal
We have been asked to announce: The B-D Home Sharps Container provides a safe and convenient receptacle for disposal of used insulin syringes and lancets. This 1.5-quart leak-proof container holds 70 to 100 syringes, helping to protect the user and the environment. Suggested retail price is $2.22 each. B-D also offers the Safe-Clip needle remover, which safely removes the needles from used syringes prior to disposal. Suggested retail price is $3.10. For further information, contact your pharmacist or Becton Dickinson Consumer Services, One Becton Drive, Franklin Lakes, NJ 07417-1883; telephone: 1-800-237-4554.
Renal Self Test
Doctors have known for some time that the presence of protein in the urine is a warning sign, and may indicate kidney problems. You can take this test yourself—first thing in the morning, before any physical exercise. If you get positive results two out of three times, call your doctor. Miles, Inc. (now Bayer) makes a product called "Albustix," which works much like the old urinalysis glucose test strips—only it tests for protein. Priced at $39.69 (at Walgreens), the product is available from Bayer Corporation, Diagnostics Division, Elkhart, IN 46515; telephone: 1-800-348-8100.
New Program For Blind Diabetics
The Colorado Center for the Blind announces a new program for blind diabetics and those losing vision. Recognizing that blind diabetics face a unique set ofchallenges, the Center's new three-month intensive program (offered four times a year, and you don't have to live in Colorado) will focus on further development of skills and attitudes necessary for full participation in the mainstream.
For the first six weeks, participants will attend classes covering: Medical implications of diabetes, adjustment to blindness, planning for the future, creating a healthy lifestyle, and strategies for setting and achieving personal and vocational goals. Both medical professionals and blind diabetics will offer presentations.
In the second segment of the program, individual participants will work, in their own home environment, with members of the Center staff, translating lessons learned into practice, and implementing their goals for community and vocational involvement. Regardless of ramifications, blind diabetics can draw their own insulin, test blood glucose, and perform all the other tasks of independent diabetes self-management. They are not alone. The techniques and technologies are there; programs like this one can help provide the necessary knowledge and positive attitudes. For information contact: Diane McGeorge, Program Coordinator, The Colorado Center for the Blind, 1830 South Acoma Street, Denver, CO 80223-3606; telephone: 1-800-401-4632 or (303) 778-1130.
The Diabetics Division of the National Federation of the Bind. (You may contact these leaders through our Editorial Office.)
President: Tom Ley, Baltimore, MD
First Vice-President: Ed Bryant, Columbia, MO
Second Vice-President: Janet Lee, Cedar, MN
Treasurer: John Yark, Stamford, CT
Secretary: Sandie Addy, Prescott Valley, AZ
The next issue of the VOICE will include: ways to prevail over impotence, information about the glycosylated hemoglobin (A1c) test, and many other personal and newsworthy stories.
Effective advertising doesn't scream at its audience. It persuades. It sells. The key to cost-effective advertising is making your voice heard where an audience is already listening. VOICE OF THE DIABETIC, circulation 142,000+, offers such an outlet. Make your voice heard. For advertising information contact: VOICE OF THE DIABETIC, Ed Bryant, Editor, 811 Cherry Street, Suite 309, Columbia, MO 65201-4892; phone: (573) 875-8911
The VOICE OF THE DIABETIC is a free quarterly news magazine published by the Diabetics Division of the National Federation of the Blind (NFB) for anyone interested in diabetes, especially diabetics who are blind or are losing vision. An outreach publication, it emphasizes good diabetes control, proper diet, independence, and positive outlook. Donations are gladly accepted and appreciated. Contributions are not only tax deductible; they are needed to keep the VOICE and the Diabetics Division moving forward; helping people with all aspects of diabetes. Members of the NFB Diabetics Division enjoy priority services and unique benefits such as a continuous free subscription to the VOICE, automatic access to committees covering all aspects of diabetes, free counseling concerning all facets of blindness and diabetes, as well as access to diabetics who have experienced complications.
The VOICE is free to any interested person upon request. Each subscription costs the Diabetics Division approximately $20 per year. To help defray publication expenses, members are invited, and nonmembers are encouraged, to cover the subscription cost.
To begin receiving the VOICE, please check one:
[ ] I would like to become a member of the NFB Diabetics Division and receive the VOICE OF THE DIABETIC. (Members are entitled to special benefits.)
[ ] I would like to receive the VOICE OF THE DIABETIC as a nonmember. (Nonmembers are encouraged to pay the institutional rate of $20/one year; $35/two years; $50/three years.)
Send the VOICE in (check one):
[ ] cassette tape for the blind and physically handicapped
(recorded at slower-than-standard speed of 15/16 IPS)
[ ] both
Optionally check this box:
[ ] I would like to make (or add) a tax-deductible contribution of $__________ to the Diabetics Division of the NFB.
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
Please make all checks payable to: NATIONAL FEDERATION OF THE BLIND
End of VOICE OF THE DIABETIC, Vol. 11, No. 3, Summer 1996 Edition