




                    VOICE OF THE DIABETIC

              A Support and Information Network

             The Diabetes Action Network of the
              National Federation of the Blind

           Volume 12, Number 4, Fall Edition 1997

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

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

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

     Copyright 1997 Diabetes Action Network, National
Federation of the Blind.  ISSN 1041-8490

     Note:  The information and advice contained in VOICE OF
THE DIABETIC are for educational purposes, and are not
intended to take the place of personal instruction provided
by your physician, or by your health care team.  Discuss any
changes in your treatment with the appropriate health
professionals.

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                        FREE!  FREE!


     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.

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                      INSIDE THIS ISSUE


SPOTLIGHT:  MAUREEN MOULD

THE IMPORTANCE OF ATTITUDE

VOLUNTEERS NEEDED FOR STUDY

DIABETIC EYE DISEASE
     by Prema Abraham, MD

THE EMOTIONAL SIDE

ISLET CELL TRANSPLANTS HOLD PROMISE FOR DIABETICS
     by Neerajh Sankaran

LETTERS TO THE EDITOR

SOME GUIDELINES FOR RESTRICTING POTASSIUM IN THE RENAL DIET
     by Betty Wedman, PhD, RD, LD

ASK THE DOCTOR
     by Wesley W. Wilson, MD

DIABETES ACTION NETWORK ELECTS NEW BOARD

REVIEW OF ORAL DIABETES MEDICATIONS
     by Peter J. Nebergall, PhD

FORTY YEARS A FEDERATIONIST
     by Thomas Bickford

NEW DIABETES DIAGNOSIS RECOMMENDATIONS
     by Ed Bryant

"CHEATING" ON YOUR DIET
     by Joan Stout

RECIPE CORNER

WHAT IS MANAGED HEALTH CARE?
     by Christine Tobin, MBA, RN, CDE

KEEPING YOUR FEET

DIET VERY CRUCIAL FOR DIABETICS
     by Lisa Riddle

TACTILE INSULIN VIALS:  AN ONGOING SAGA
     by Ed Bryant

WHAT YOU ALWAYS WANTED TO KNOW BUT DIDN'T KNOW WHERE TO ASK
     (Resource Column)

INSULIN MEASUREMENT DEVICES

FOOD FOR THOUGHT

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                  SPOTLIGHT:  MAUREEN MOULD


Photo #1:  portrait;  Caption:  Maureen Mould (right) and
her daughter

Photo #2:  portrait;  Caption:  Maureen Mould (in her clown
costume)


     Maureen Mould has broken the rules.  Somebody said "you
can't do that, because you're diabetic!"  She wasn't
listening.

     Now 45 years old, she was born into a family "pretty
much inundated with the disease."  Her father, sister,
brother, both grandfathers, and some aunts and uncles had
diabetes, and she was diagnosed with the condition at age
five.

     "It didn't stop me from doing much of anything,"
reports Maureen.  "I was a tomboy, very involved in sports. 
I wasn't prone to a lot of insulin reactions.  Could be my
blood sugar was a lot higher than it should have been."

     Until her daughter, now 19, was a year old, Maureen
tested her own urine ("those little clinitest tablets"), and
gave herself insulin injections with a reusable glass
syringe.  "I didn't know any better--I had never gone to a
diabetes education class to be educated on the new things,"
she relates.

     The stresses of pregnancy and delivery caused high
blood pressure, and many of the capillaries in Maureen's
eyes broke.  One day, she dropped her glass syringe.  "I had
lost some of my vision at that time...but I was trying to
feel around for the broken pieces on the floor...  I was
wearing slippers with an open toe, and as I bent over to try
and find it, a piece went right into my toe.  Bleeding
profusely, I ended up having a friend take me to the
hospital for stitches.  Yeah, that was the last of my glass
syringe..."

     As her sight was failing, a friend of Maureen's husband
(a graduate student at Washington State University) found
her an eye specialist in San Francisco.  The Moulds were
students, and poor, but people in their community (Pullman,
Washington) raised money for them to go see this doctor, and
he operated on the worst eye first -- "which happens to be
the eye I'm now seeing out of," says Maureen.

     "It was a horrendous year-and-a-half," she continues,
"because I had five different eye surgeries done, on five
different occasions, in that time.  Sometimes my vision got
better; sometimes it got worse; then it got better; then it
got worse; then it actually stabilized.  After my first eye
surgery I was declared legally blind, and then the state was
able to help with paying the medical bills...  My husband's
department collected money again, and paid up all our
medical bills."

     Once he finished his doctorate, Maureen's husband got
lucky, finding a job right away, in South Bend, Indiana. 
They were there for four years when, as Maureen relates: 
"My husband was getting restless, and wanted to leave his
teaching job there.  He was a bicyclist, and he really
wanted to bike across the country and take his family with
him.  I thought it was crazy!  My daughter was five years
old...

     "We decided to do it for a cause.  I came up with the
name BETA (Bicycle Every Town Across) based on the beta
cells.  Ames Diagnostics [now a division of Bayer]
underwrote our trip.  They gave us all the blood testing
supplies, and also $5000 to purchase our bicycle, custom
built for three.  My husband sat in front, our daughter in
the middle, and I was in back.  It even had a little
trailer...

     "Joslin Diabetes Center also helped underwrite our
trip...  Turtle Top Recreational Vehicle Company lent us a
motor home; that was our support vehicle.  A nurse I had met
when I was selling "World Book Encyclopedias," a single lady
with a five-year-old daughter like mine, agreed to drive the
support vehicle..."

     Everything fell into place for the Moulds.  In 1984
they rode about 3000 miles, from South Bend, Indiana, to
Seattle, Washington, and on the way gave more than 50 talks
about diabetes, and about the need to be aware and educated. 
They sought donations for diabetes research, and raised
about $13,000 on the trip.  Half that figure they donated to
Joslin Diabetes Center, and the other half to "Project
Freedom," a local program in St. Joseph County, Indiana, to
purchase glucose monitors, testing supplies, and pay for
diabetes education, all in the local high schools.

     "I kind of feel the money was put to good use," adds
Maureen.

     But the adventures were far from over.  The Moulds took
the motor home back from Seattle to Indiana, but before,
Maureen's husband had found a job advertisement in Yakima,
Washington, the town he'd grown up in.  On the way home,
they stopped for an interview.  By the time they reached
South Bend, he had the job!

     "When we got to Yakima, my husband started his job
right away," relates Maureen.  "His brother and family were
living in Spokane...  My sister-in-law told me she knew of a
job in Yakima for me -- only three days after we got there. 
I said:  `I'm not working.  You must think I'm crazy!'  But
she persuaded me to call..."

     Told "The job closed the other day.  We had very few
applicants; we will interview you anyway," Maureen went. 
Asked why she applied, she responded:  "I really didn't.  My
sister-in-law said I had to come in and talk to you guys. 
But I really don't want to work."

     By the time her bus reached home, the interviewers had
called to offer her the job!

     It was with Head Start, and her educational background
in Special Education, plus her Masters in Recreation for
Special Populations, and post-graduate work in the Early
Childhood field stood her well.  She kept the job for five
years.

     Feeling ready for a change, she applied for a job
directing a new childcare center.  Her resume arrived at the
last minute, but again, she was interviewed and hired.  She
has been there eight years.

     But the adventures continued.  As she relates:  "Six
years ago, my vision had improved to about 20/60, with all
the eye surgeries I'd had.  Then It started plummeting, and
I lost 200 feet of vision in a year.  At that point, my
husband left me...

     "I'd had cane travel training, but didn't really like
using it...one of the denial things...  My daughter made the
rule that she would no longer go shopping with me if I
didn't have my cane.  Then she really got on my case about
going for a guide dog...

     "I had my dog for two years, then he was diagnosed with
lymphoma, with cancer... Everyone who knew me thought I was
going to die with my dog.  Again the prayers went out, and
two weeks after he died, when I went to my already-scheduled
eye appointment, I was told I had a cataract..."

     The doctor didn't want to operate, but Maureen got a
second opinion.  The second doctor told her it was a high
risk operation, and that he didn't know what to recommend. 
She agreed she'd take the risk.  Six weeks after her dog
died, she had her cataract removed, and overnight, she
gained 700 feet of vision.

     "It was another miracle," she relates.  "Now, with my
glasses, my vision is 20/50 or 20/60, incredible compared to
the  20/800!  Although I have limited peripheral vision, and
don't see a full picture, when I went back for a checkup a
year after my cataract was discovered, the nurse went
berserk.  I told her I believe in miracles..."

     When Maureen had her guide dog, she received a bi-
monthly  newsletter about "how other people were doing with
their lives and their dogs."  In it, she heard of a woman,
also named Maureen, with a yellow Labrador dog like hers,
who had gone to clown class with her dog.  She figured she
could do the same.

     "I'd always wanted to be a clown.  I called the school
and asked if they could get me in touch with the lady.  One
person referred me to another, and I found out about a clown
school in Wisconsin.  My daughter's godparents lived in
Wisconsin.  I made arrangements to go to clown camp in La
Crosse, Wisconsin...

     "Off I went with my dog, Clinton (like the President),
to learn about clown ministry.  But folks often asked:  `Can
you see?  Are you training that dog?'  When I told them I
was legally blind, they became confused.  I started telling
folks I was illegally sighted..."

     Maureen and her dog started doing clown ministry.  She
worked for eight months, preparing a mime representing the
birth, death, and resurrection of Christ, incorporating
communion.  Her first "clown communion," scheduled well in
advance, happened the night after her dog died.

     Since then, without any advertisement, she has been
asked to give services all over Washington, and in Oregon
and Idaho.  She's done hospitals, birthday parties, and
church appearances, but wishes to expand into missionary
work, like her church's upcoming trip to Chiapas, Mexico. 
Money she makes clowning goes toward this upcoming trip.

     Maureen prizes her independence.  "I bike or walk to
work... I can get anywhere I need to be.  Yakima is the
perfect size...  I can really maintain my independence,
which is really important to me.  Co-workers and friends are
very supportive in giving me rides in bad weather."

     Asked if she has any advice for diabetics, Maureen
responds:  "When a person is newly diagnosed, it seems the
end of the world is here, because they hear all the
statistics:  Your lifespan will be shorter, your body is
going to start falling apart, it is the silent killer... 
You read all that stuff and it is not true...

     "I think a positive attitude is the best gift you can
give yourself.  The tools are out there.  You test your
blood sugar...  The lifestyle of the diabetic should be the
lifestyle for everybody.  That's the way to go!  Regular
meals, on schedule, exercise...  Look at it as a positive. 
I've got this, but I can rise above it.  I can do whatever I
want to do:   It really is manageable."

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                 THE IMPORTANCE OF ATTITUDE


     Experts know that a positive attitude is necessary for
successful diabetes care.  We nod in agreement, but have we
really looked at why?

     People persevere at activities they believe are
possible.  Convinced they have the ability to complete a
task, they are willing to attempt it.  Uncertain, or sure of
their own inability, they will defer to others instead.  The
diabetic who trusts his or her own abilities to self-manage
will be more diligent in self-management ("I can do this!")
than one who does not.  The blind diabetic who knows he or
she is fully capable of participating in mainstream society,
with full equality, will work hard to achieve that goal.

     And there is the "stress" element.  This same well-
prepared diabetic, comfortable with the responsibilities and
techniques of self-care, will meet potential crises with the
correct responses, free from panic, and from the frantic
scrambling ("What do I do NOW?") that turns little ones into
big ones, and not incidentally dumps adrenalin into the
blood, making good control that much more of a challenge.

     Attitudes are taught.  We communicate our judgements of
others' abilities in many ways.  If we are in positions of
authority (parent, teacher, instructor), our attitudes shape
others' opinions of their own abilities, and thus their
willingness to act.  Teachers have known for years that the
student who is taught he or she can will outperform those
taught they cannot; that expectations shape performance.

     Attitudes about the limited abilities of blind
individuals have been with us for millennia.  Even today,
blind diabetics  still hear pronouncements like:  "A blind
person can't possibly do that..." or "You won't live long
enough..."  Such statements, from well-meaning individuals,
do a lot of damage.  Remember, if you believe you already
have the answers, however bleak they may be, you don't ask
questions.  The blind diabetic who has been taught by the
professionals, word and deed, that he or she is incapable,
needs sighted assistance, and faces a shortened lifespan, is
not likely to struggle mightily against such pronouncements. 
Great accomplishments come from people who believe in their
own abilities.

     There is every reason to make the achievement of
positive attitude an important part of diabetes care.  We
have the technology; we have the medications; this is the
"human factor."  There are more choices, more options, and
more ways to cope than ever before; and today no one,
regardless of ramifications, needs to be relegated to a
second-class life.  Independence, full participation, and
vocational success are achievable.  Diabetes, at any level,
is a discipline--and positive attitude is an integral part
of successful self-management.

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VOLUNTEERS NEEDED FOR STUDY


     Research centers participating in the Diabetes
Prevention Program (DPP) are looking for volunteers, people
who have a family history of diabetes, are overweight, or
have had gestational diabetes (GDM) when pregnant.  These
individuals will be screened for IGT, impaired glucose
tolerance.  There will be no charge.  As approximately 50%
of individuals who exhibit IGT go on to develop type II
diabetes, research is underway to see if their disease
progression can be halted by appropriate measures, such as
diet, exercise, and medication.

     Many people with IGT are unaware they have the
condition, but Asian, African, Hispanic or Native American
ethnicity confer risk, as do family history, obesity, or
history of GDM.  The elderly are also at increased risk for
IGT.

     The Diabetes Prevention Program is currently underway
in 25 medical centers throughout the country.  It should
ultimately involve 4000 volunteers -- the largest diabetes
prevention study ever undertaken in the United States.

     Screening for the Diabetes Prevention Program is free. 
Interested individuals should call, toll-free, 1-888-377-
5646 for more information.

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                    DIABETIC EYE DISEASE

                    by Prema Abraham, MD


     Dr. Abraham is director of vitreoretinal and
retinovascular services, at Black Hills Regional Eye
Institute, in Rapid City, South Dakota.


Introduction

     Diabetes is a common medical problem which affects the
body's ability to regulate blood sugar levels.  Over a
period of years, high blood sugar will damage small blood
vessels in the body and often cause problems such as kidney
failure, sensory abnormalities in the hands and feet, and
eye problems.  The focus of this presentation is to describe
how diabetes affects vision, what specific factors
contribute to visual loss, and the technological advances
that are available today to evaluate and manage diabetic eye
disease.  Although in the worst cases an individual may
suffer permanent loss of vision in one or both eyes, it is
important to remember that most diabetics who carefully
control their diabetes and get good eye care can prevent
many of the visual complications of the disease.

     Diabetes is present in approximately three percent of
Americans, however individuals in special populations such
as Native Americans and the elderly are much more likely to
suffer from the disease.  For example, nearly 50% of some
Native American groups are affected, and among the nation's
elderly, about 15% are affected.  Because one form of
diabetes (i.e., adult-onset, or type II diabetes) may be
present in a person for several years before the diagnosis
is established, some of the preventable complications may
already be in the early or moderate stages when the
diagnosis is finally made and treatment initiated.


What is Diabetes ?

     Diabetes is much more than having an elevated blood
sugar level.  It is a complex endocrine disorder which can
affect many aspects of the body's metabolism which in turn
have detrimental effects on a variety of vital organs.  Left
unchecked, diabetes may result in complete kidney failure
and require the use of hemodialysis.  The disease also
causes heart disease and is a potent risk factor for heart
attacks.  Nerve endings can also be severely damaged,
leaving the patient with a painful burning sensation in the
hands and feet or causing numbness in the same areas.  This
loss of sensation places the diabetic at increased risk of
hurting him/herself without being aware of the damage.  The
numbness, along with the detrimental effects that diabetes
may have on the immune system, increases the risk of serious
infection.  Eye damage from diabetes may include any one or
a combination of problems such as cataracts, glaucoma, loss
of night vision, double vision, eye infections, fluctuating
vision, and retinopathy, a broad category of problems
affecting the retina.

     There are two categories of diabetes, one which affects
individuals at a younger age (juvenile onset, or type I) and
the other which affects middle-aged and elderly adults
(adult onset, or type II).  Both types are associated with
elevated blood sugars but the complications of the disease
may vary in severity and rate of onset and progression
depending on the type.


How Does the Eye Work ?

     To understand how diabetes affects the eye it is
important to know how the normal eye functions.  The eye
works very much like a camera, with a focusing lens in the
front and the film in the back.  In the eye, the retina
plays the role of a camera's film, receiving the image of
the object at which the camera is focused.  The retina,
which is actually a direct extension of brain tissue,
transmits the visual information through the optic nerve to
areas of the brain which process it into vision.  In a
camera, no matter how clear or strong the lens and how
perfectly focused the image may be, if the film is not
working well the camera will not take good pictures. 
Similarly in the eye, if the retina is diseased vision will
be impaired no matter how clear and strong the lens may be. 
Furthermore, if the space between the lens and the retina is
obscured with blood or other material, vision will be
impaired.  

     When a diabetic goes to the ophthalmologist, the doctor
looks carefully at the retina.  With special instruments the
blood vessels which normally travel through the optic nerve
can be viewed as they branch out and nourish the retina. 
One small but particularly important area of the retina,
called the macula, is sometimes referred to as the "sweet
spot" of the retina.  This "sweet spot" is the area
responsible for detailed vision such as is required for
reading, driving, needle threading and other similarly
detailed visual functions.  The remainder of the retina is
for side vision -or peripheral vision- and not useful for
fine vision.  In order to maintain meaningful vision for
activities such as reading it is essential that the macula
remain healthy and unobstructed.  If the macula does become
damaged or covered with blood the eye does not necessarily
become blind.  It is possible that the side vision will
remain fully functional but reading and identification of
faces will be extremely difficult or impossible.  For
example, it may be possible to perceive that someone is
approaching but without the "sweet spot" it will be
impossible to visually identify that person.


What is Retinopathy ?

     Retinopathy is the general name given to diseases of
the retina.  In diabetics, it can take a variety of forms
and may affect both type I and type II diabetics.  Type I
diabetics are usually free of retinopathy for the first five
years after diagnosis because there is rarely much time
between disease onset and diagnosis.  On the other hand,
because they may have had the disease for several years
prior to diagnosis, type II diabetics may already have
diabetic eye problems at the time of diagnosis or shortly
thereafter.

     The principal problem of the retina caused by diabetes
involves the very fine blood vessels which nourish the nerve
tissue.  High blood sugar causes these vessels to become
damaged and then leak fluid and fatty material into the
nerve tissue of the retina.  The retina becomes swollen and
does not function normally.  This form of retinopathy is
called background or non-proliferative retinopathy.  The
medical term for swelling is edema; when this process
involves the "sweet spot" of the retina, it is called
macular edema.

     Another, more serious form of diabetic retinopathy, is
called proliferative retinopathy.  Like the
non-proliferative form, this form is initiated by high blood
sugars over a period of years.  However, in the
proliferative form the damage inflicted on the small retinal
blood vessels results in impaired blood flow to the retinal
tissue.  Some vessels actually close off completely and
deprive an area of the retina of much needed oxygen and
other blood-borne nutrients.  Consequently, the oxygen-
deprived tissue sends out a signal which stimulates the
growth of new blood vessels.  Unfortunately the new vessels
are distinctly abnormal and are the source of many serious
diabetic eye complications.


How is Retinopathy Treated ?

     As with many chronic conditions, the best management
strategy is based on prevention.  For the diabetic this
means careful and consistent blood sugar control.  Equally
important to the diabetic individual is frequent eye
evaluations which may permit early detection and treatment
of retinopathy.  When the eye doctor examines the retina of
a diabetic patient and evidence of retinopathy is discovered
the next step usually involves obtaining special photographs
of the retinal blood vessels.  This process, called
fluorescein angiography, utilizes a fluorescent dye injected
into an arm or hand vein which then circulates throughout
the body.  When this dye flows through the retinal blood
vessels, a series of photographs can be taken with
specialized camera equipment.  The photos help locate areas
of abnormal blood vessels and guide the treatment process.

     One straightforward method for managing leaking blood
vessels is to seal them with a highly focused beam of laser
energy.  In effect, zapping leaking retinal vessels stops
further leaking of material from the vessels thereby
limiting the detrimental effect on vision.  When the
angiogram identifies discrete areas of leaking vessels the
laser treatments can be confined to these specific areas. 
This is called focal treatment.  When the leaking is not due
to one or two specific areas a more broad treatment is
required.

     When the problem of leaking vessels is widespread and
excess fluid accumulates in the retinal tissue it becomes
necessary to apply laser treatment scattered over a larger
area.  This is called grid treatment, since the laser spots
are applied in a grid pattern.  This method, like the focal
treatment described above, is useful in the treatment of
macular edema.

     In either situation the goal of treatment is to stop
the vessels damaged by the diabetes from continuing to leak
and to stop the progression of the visual impairment. 
Unfortunately this treatment cannot restore vision that is
already lost.

     The other, more serious form of diabetic retinopathy,
proliferative retinopathy, is also treated with a laser. 
However, whereas the treatments in the non-proliferative
form are directed at sealing leaking vessels and not
destroying tissue, the objective in the treatment of
proliferative retinopathy is to actually destroy unhealthy,
damaged retinal nerve tissue.  To accomplish this, a deeper
laser burn, of larger size, is used.  This may seem
counterproductive to the preservation of vision, but the
outcome of these destructive treatments does ultimately
minimize the cumulative loss of vision.  Remember, it is the
blood and oxygen deprived retinal tissue that stimulates the
growth of abnormal vessels which never provide any benefit
to the retina.  

     Destroying the unhealthy retinal tissue eliminates the
stimulus for the growth of new, abnormal vessels.  These
abnormal vessels are fragile and can bleed into the interior
of the eye, obscuring vision.  Diabetics with proliferative
retinopathy may awaken in the morning with new floaters or
other visual changes because of bleeding which occurred
during the night.  Because of rapid eye movements associated
with dreaming, diabetics are particularly vulnerable to the
breaking of the abnormal vessels while sleeping.

     Treatment of proliferative retinopathy is accomplished
by applying hundreds of destructive spots of laser across
much of the peripheral retina.  Even though there is
relatively widespread treatment there is very little, if
any, sensation of fine visual loss because only the side
viewing retina is treated.  Furthermore, the area of the
retina being treated is already diseased due to the
diabetes.  Patients may notice a reduction in side vision or
night vision and difficulty with light/dark adaptation
following this type of treatment.  This treatment is called
panretinal photocoagulation or PRP, and usually requires
multiple treatment sessions to complete.  As mentioned
above, laser treatment of proliferative retinopathy is
directed at preventing progression of vision loss and does
not result in recovery of vision already lost.

     Today, new multi-wavelength lasers are available which
permit the surgeon to select the most appropriate type of
laser beam for the specific problem the patient may have. 
This flexibility helps the surgeon maximize the beneficial
effects while minimizing the detrimental effects of laser
treatment.

     Another complication of proliferative retinopathy is
the formation of scar tissue in the eye associated with the
growth of the abnormal vessels.  As the scar tissue grows it
may pull on the retina and tear it off of the back of the
eye.  This is called a traction retinal detachment and can
be quite severe.  A traction retinal detachment may cause
severe loss of vision.  In some cases it ultimately results
in loss of the eye altogether.  Panretinal photocoagulation,
by destroying blood and oxygen deprived retinal tissue,
reduces the stimulus for abnormal blood vessels growth 
thereby limits the development of scar tissue.  In turn,
less scar tissue translates into reduced risk of retinal
detachment.


What Other Treatments are Available?

     In some cases bleeding into the eye may occur despite
laser treatment.  If the amount of bleeding is significant
it can obscure vision.  When this happens the blood can be
surgically removed in the operating room by a retinal
surgeon.  In addition to removing the blood from within the
eye, this surgery has the added benefit of removing the
entire jelly-like substance which normally occupies the
space in the eye chamber.  By removing this substance, the
structure into which the abnormal vessels grow is
eliminated, and therefore future abnormal growth is quite
rare.  The jelly-like substance is called the vitreous and
the procedure is called a vitrectomy.  Vitrectomy combined
with other microsurgical techniques is also the procedure
used to repair traction retinal detachments.


Conclusion

     Diabetic eye disease is an important cause of severe
vision loss in patients under age 60.  However, with regular
eye exams problems can be detected in their early stages. 
Early detection means that treatment can be started before
serious visual loss occurs.  All patients with diabetes
should have their eyes examined at least once each year, and
individuals with more advanced disease may benefit from more
frequent evaluations.  These exams should be performed by an
experienced eye care professional who will dilate the pupils
with special eye drops so that the entire retina can be more
easily viewed.  If laser treatment or other surgery is
required, then one may be referred to a retinal specialist.

     Through education and cooperation with medical and eye
care professionals, the diabetic patient can remain
optimistic about successfully managing the disease and its
ocular complications.

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

                     THE EMOTIONAL SIDE


     Diabetes is incurable.  It imposes restrictions on your
lifestyle, causes a long list of complications, and can
shorten your life.  To survive, you have to diligently
follow a prescribed routine, one you did not choose.  On
top, you can go blind.  Diabetes is not subtle, and the
emotional aspects need to be considered.

     "Don't it always seem to go that you don't know what
you got 'til it's gone," sang Joni Mitchell so many years
ago.  Diabetes can certainly make that song ring true, for
every diabetic lives with the threat of complications.  The
Diabetes Control and Complications Trial (DCCT) proved that
the best possible control reduces that threat, but a
significant number do their best and still suffer major
ramifications.  Even with what we know today, there is
always that dreadful uncertainty.  

     Understandably, most diabetes education materials focus
on the physical aspects of the disease.  This is
appropriate.  But the common emotional ramifications of
diabetes need to be taken into account.  An individual's
emotional state may determine whether he/she prevails, or is
felled by circumstances.


Anger

     "Why ME?"  We don't know what causes diabetes. 
Although we can manipulate statistics and use them to make
predictions, we can't tell why a given individual gets
diabetes, or any of its ramifications.  And tight control
helps, but it is no panacea.  

     Folks used to believe that disability was the result of
defective character.  If you developed a disease, you had
brought it on yourself; you were a "failure."  We know
better, but too many of us still judge ourselves harshly,
blaming ourselves for "being weak."  Diabetes is not a sign
of weakness.

     "What did I do to deserve this?"  Nobody gets diabetes,
or ramifications, because they "deserve them."  We don't
know why one person gets it, and another does not.  We have
to do the best we can.  Diabetes can be nasty and
unpleasant, but it is not "diabolical."  It is not a
punishment.


Denial

     "It will never happen to ME!"  Social workers and
psychologists are very familiar with the problem of denial,
the conviction that in spite of the facts, the rules do not
apply in this particular case.  The ramifications of
diabetes do not manifest immediately, but the more time
spent with high blood sugars, the greater the likelihood of
future eye, kidney, and nervous system complications.  The
diabetic who seeks to prove that he or she is "exempt," and
"gets away with it," short term, is only increasing the
likelihood of down-the-line problems.  The literature is
full of stories by folks who were "non-compliant" in their
youth, but saw the error of their ways about the time their
vision began to fail.  Denial is a common problem, and one
that should be addressed right along with the need for
conscientious self-management.

     "NO!  I'm not BLIND!"  Sight loss brings its own
denial.  There are people who won't use their canes, or
learn Braille, or even stop driving, because they cannot
admit they are going blind.  Some delay learning adaptive
skills with, "It's only temporary; I'm sure my sight will
come back!"


Fear



     "What am I going to do?  I won't be able to..."  While
some folks deny they'll ever be affected, others swing to
the opposite extreme.  These diabetics pay close attention,
read the reports, and work diligently, but for them, there
are demons under the bed, and every bullet has their name on
it.  Too many folks are convinced that a diagnosis of
diabetes, or the need to start injecting insulin, or
blindness, or kidney failure, or any of the other possible
complications, means the cessation of life as they know it. 


     It doesn't.  With proper adaptive equipment and
training, blind diabetics, those losing vision, even those
coping with multiple ramifications, such as blindness,
amputation, and kidney failure, can maintain or recover
independence, and remain (or become!) fully productive
participants in mainstream society.  Fear, or the use of
fear to encourage diligent compliance, is counter-
productive, as we shall see below.


Burnout

     "I'm tired of it!"  Diabetes self-management is a
discipline, seven days a week, from now until doomsday. 
There are no reprieves, no opportunity to take breaks, and
short of a pancreas transplant, there is yet no cure.  There
is only the routine, day after day after day.  

     Some folks thrive.  Presented with the findings of the
DCCT, and the need for multiple monitoring and injections,
one young man said, "Of course I will!  I want to stay
healthy as long as possible!"  He was, and is, ready. 
Others find the prospects daunting.  

     A lifetime of dietary restrictions, regular exercise,
blood glucose testing, and multiple injections or oral
medications can become wearing, especially after a number of
years with the condition.  Some folks get tired of it;
others come to hate "doing it because they must."  Still
others stop believing their own welfare is "worth the fuss." 
This is "burnout," psychological rebellion against one's
duties.

     When burnout leads to non-compliance, it is a recipe
for trouble.  Why do some folks "burnout" and not others?    

     The answer is attitude.  The folks who thrive, who make
the best of a less than perfect situation, are like savvy
poker players who, dealt a doubtful hand, play it for all
it's worth.  Often these folks outperform the ones holding
the aces!  It's not the cards you're dealt; it's how you
play the game.

     "Positive attitude" can mean so many different things,
but here it means a wholehearted belief in one's own
capacities, and determination to overcome all obstacles,
regardless of how long it takes.  If you don't believe in
yourself, even the small hills can look impassable.


Loss of independence

     "How can I face my friends?  How can I get anything
done?  I can't DO anything!"  Too many folks respond to
disability, or other trauma, with the "wounded animal
response"-flight to solitude, to "lick one's wounds."  Up
to a point, this is part of the grieving process, the
mourning for what must be let go.  When it passes, 
rehabilitation can begin.

     But some folks "get stuck" there.  Some independent,
self-reliant people, high achievers, can be more traumatized
by their own "incapacity" than by their actual physical
loss.  The belief:  "I have lost something, and am now less
than I was," discourages action.  This can occur with most
any incapacity, but is not uncommon in cases of sight loss.

     An adult type I diabetic, for example, may have been
self-managing for 15 years or more, before retinopathy put
an end to a sight-based lifestyle.  Some folks, with
positive attitude, good instruction and proper adaptive
equipment, make a smooth transition.  Others wilt.  

     It's a question of attitude again, so many times.  An
individual is accustomed to being in charge, to caring for
self and others, and to being "a productive member of
society."  In his or her mind, loss of sight means the end
of their capacity to continue doing so.  Feeling diminished,
feeling ashamed, the individual withdraws from society, and
stays "out of circulation."  Belief in his/her incapacity
has become a self-fulfilling prophecy.

     These people are not lazy.  They are not "slackers,"
taking a long vacation from responsibility.  They are in
emotional agony, grieving for losses they don't know how to
replace.  These people need to be shown their options.  They
need to hear of (or from!) others like themselves, who have
looked the demon of self-doubt in the eye and moved forward
anyhow.  They need support groups and rehabilitation
professionals who will respect their self-doubts--and then
show them how to overcome them.  Some might declare, "You
can't teach attitude!" but what you can do is show such a
person their options, and then get out of the way.  


The Cure

     Nothing about diabetes, or blindness, or any other
disability, diminishes a person's human-ness.  Loss of
sight, or of a limb, or of mobility and independence, does
not make one "incomplete."  There are no "part-people" out
there--we're ALL real.  

     But it hurts to have to give something up.  We are not
oxen, facing our traumas with placid equanimity.  Fear and
pain are perfectly logical responses.  Some folks will pass
smoothly through the stages of grief, and be ready to learn
the necessary adaptive skills.  Most will need the support
of their fellows and the positive examples of their
predecessors, and will need to have their feelings
validated.  Passing this hurdle, they are ready for, and
fully capable of, independent self management and full
participation in the mainstream.  

     The presence of emotional issues is not a sign of
weakness, but of humanity.  Any holistic approach to health
takes a person's mental/emotional state into account, right
along with their specific physical ramifications.  We are
individuals, and we heal in our own way.          

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

      ISLET CELL TRANSPLANTS HOLD PROMISE FOR DIABETICS

                     by Neerajh Sankaran


     As a pet owner and veterinary surgeon, Kent Cochrum
confesses to a special feeling of gratification watching
Brownie chase after a ball while exercising.  This happy,
healthy beagle spells good news twice over:  first as a
success story for a transplantation strategy Cochrum
developed; and secondly as a symbol of hope--that what has
worked in this dog may be used to treat juvenile diabetes in
human patients in the not-too-distant future.

     Juvenile diabetes, also known as type I diabetes or
insulin-dependent diabetes mellitus, is a condition
characterized by insulin deficiency due to the
malfunctioning of a specialized group of pancreatic cells
called the islets of Langerhans.  The causes for islet cell
breakdown are not fully understood, but the major outcome of
the disease is quite clear--without insulin, the body has no
way of controlling its metabolism, and glucose levels in the
bloodstream fluctuate wildly.  This condition, through time,
can lead to a host of chronic, secondary complications
including the thickening of blood vessels, blindness, and
kidney failure.  The most prevalent form of treatment for
this disease (type I diabetes, IDDM) is insulin, which can
only be administered via injection.

     But this approach is far from adequate.

     "Not only are injections inconvenient, but the approach
also fails to address the underlying problem, which is to
maintain the blood glucose at a constant level," said UC
Davis endocrinologist J. Stuart Soeldner.

     The existing alternative--transplanting a working
pancreas into the patient--addresses this problem, but
introduces a whole new set of significant complications.  

     "Transplantation is a major surgical procedure
requiring patients to be under anesthesia for five to eight
hours," said transplant surgeon Richard Perez.  "It poses
major stress to the system."

     Perhaps even more serious is the need for lifelong 
immunosuppression.

     "In order to prevent the body's immune system from
rejecting the transplant, we need to administer heavy doses
of immunosuppressive drugs," he added.  "This puts the
individual receiving the transplant at a very high risk for
a large number of opportunistic infections, and for the
development of cancers."

     Cochrum's approach--which was to insert specially
coated, functional islet cells obtained from another animal
species into the peritoneal cavity--appears to have
countered both problems.  Brownie, the canine equivalent of
a type I diabetic, is the living proof.  Despite the
surgical removal of her pancreas, for three years she has
lived normally, maintaining appropriate blood sugar levels
without requiring any insulin treatments and without the aid
of immunosuppressive drugs.

     Encouraged by these results in the dog model, which
researchers chose for the similarity of its immune system to
that of humans, Perez, Cochrum, and Soeldner jointly
submitted an application and received approval from the Food
and Drug Administration to test their approach as a possible
treatment for human diabetic patients.  The investigators
hope to begin the first human clinical trials within two
years.

     "The real breakthrough here is Kent's encapsulation
technology," enthused Perez, who will head the human phase
of these clinical trials.  "The method enables us to protect
the islet cells from attack by the immune system of the
recipient.  So there is no need to use immunosuppressants. 
Furthermore, implanting these cells is a very safe, simple
procedure, compared to conventional transplantation surgery. 
It only takes a small incision, and can be performed in less
than an hour, using a local anesthetic.

     "If effective, we will have the means to normalize
blood glucose levels very early in the course of the
disease, and lessen the incidence of secondary
complications."

     "The major advantage of this approach is that there is
a very high probability that a diabetic patient's blood
glucose levels will remain within the normal range
throughout the day," agreed Soeldner.

     The key to the new approach's success is the discovery
of a durable coating material for the islet cells, one which
allows secreted insulin to diffuse into the bloodstream and
to evade attack from the recipient's immune system.

     "Since the 1970s, we have known that a diabetic state
in rats could be cured quite easily using islet cells
isolated from a genetically identical animal.  Allogeneic
grafts, however, which use animals of the same species that
have a different genetic makeup, were rejected very
rapidly," he said.

     Over the years it was found that transplants had a
greater chance of survival when coated with some substance
that afforded the cells some protection from the recipient's
immune system.  But finding a truly biocompatible substance
proved difficult; most substances would either elicit an
immune reaction themselves or be degraded by enzymes in the
host's body.

     Cochrum's search led him to alginate, a polymer
recovered from seaweed.  Alginate has proven highly
biocompatible, both in terms of its immumogenicity and
hardiness.

     "But this is true only of very highly purified
material," he cautioned.  Cochrum and UC Davis hold a number
of patents on the purification protocols for alginate.

     "At the moment we're working on scaling up the
purification procedure, standardizing it according to the
FDA-prescribed guidelines, and on performing additional
preclinical tests," he said.  "We will start the actual
clinical trials only after satisfactorily completing the
scale ups."

     "The trial itself is designed in two phases," Cochrum
explained.  "First we will conduct a study on 12 animals
using the planned protocols, and submit the data to the FDA. 
We will not start the human study until after the dog trials
have been evaluated and approved, which will probably take
about two years."

     Meanwhile Cochrum hopes to improve certain aspects of
the existing procedure.

     "In the current protocol we are introducing the islets
into the peritoneal cavity, which is not the best location
for them," he said.  "Eventually we want to place them so
that they secrete directly into the portal system.  This
would be the most efficient way to get insulin into the
bloodstream as well as the closest mimicry of the
physiological state."

     Although the first human patients will be receiving
grafts of human islets, the investigators hope to apply this
technology to attempt transplanting islet cells across
unrelated species.

     "Our ultimate goal is to be able to transplant islets
from special strains of pigs to human diabetics," offered
Cochrum.  He has already achieved success using xenografts
of rat and canine islets in mice, which he published in
"Transplantation Proceedings" in 1995.

     "The beauty of Kent's method is that the type of islet
we put into the microcapsule does not have to be from the
same species," said Perez.  Although still a controversial
topic, xenotransplantation, use of organs from different
species, would provide several advantages, the researchers
said, including greater availability and lower costs.

     "At present, we are limited to cadaver tissue as a
source for human islet cells, which poses a limitation on
the number of patients we could treat," Perez explained.  A
consistent, more abundant supply of islets would be needed
to use the method as a widespread treatment early in the
course of diabetes, he added.

     In addition, Cochrum said, "The risk of passing an
infectious disease is much higher in a human-to-human graft
than it is in a transplant from a pig to a human."

     With reference to emotional and ethical objections, the
scientists predict that the treatment, once proven
successful, would be widely accepted.  "Because of the
tremendous impact of diabetes, both to individuals and the
health care system, I think a safe, effective therapy that
could benefit a large group of patients would be very will
received by the public," said Perez.

     "Juvenile diabetes places an enormous burden on society
not just momentarily--last year alone this disease cost the
American public some $138 billion--but also in terms of life
span, and the quality of living," said Soeldner.  "The most
serious  problems in diabetes are the secondary
complications, such as amputation, blindness, and kidney
failure."

     Furthermore, the disease affects a huge population. 
The American Diabetes Association estimates that six percent
of the U.S. population has diabetes, whether it is diagnosed
or not, and this figure doesn't take into consideration the
number of individuals who are placed in the caregiver role
because of diabetes.

     "This is a disease that usually strikes people at a
very young age," added Cochrum.  "Neither daily injections
nor immunosuppressive drugs are viable options.

     Any technique that offers a chance of curing diabetes
would be welcomed."


About the Sources

     Dr. Kent C. Cochrum earned his undergraduate and
veterinary medicine degree at University of California-Davis
in 1963 and 1965, respectively.  He completed three post-
doctoral fellowships in hematology and immunology and in the
Department of Surgery at University of California-San
Francisco, where he joined the staff as an assistant
professor of veterinary medicine in surgery.  In 1968 he
worked as an immunologist in the Renal Transplant Service
and established the Histocompatibility Laboratory for the
transplant service there.  In 1975 he was promoted to
associate professor, and from 1972 to 1982 he served as
director of the Histocompatibility Laboratory.  In 1982 his
research focused on transplantation of encapsulated islets
as a means of treating diabetes.  His first encapsulation
methods and patents were developed then.  In 1989 he joined
the faculty at UC Davis as an associate professor of
surgery, where he has continued his research studies in
allotransplantation of encapsulated islets.  He can be
reached at (916) 752-3270.

     Dr. Richard J. Perez earned his undergraduate degree at
UC Santa Barbara and his medical degree at the University of
Hawaii in 1982.  He completed his internship and residency
in general surgery and a research fellowship in the Division
of Transplantation at the University of Cincinnati Hospitals
in Ohio and the University of Minnesota Hospitals and
Clinics.  In 1991 he joined the faculty at UC Davis as an
assistant professor of surgery.  He can be reached at (916)
734-2679.

     Dr. J. Stuart Soeldner earned has undergraduate degree
at Tufts University in 1954 and his medical degree from
Dalhousie University in Halifax, Nova Scotia, in 1959.  He
completed his internship and residency at Victoria General
Hospital in Halifax and his research fellowship at Dalhousie
University and Harvard Medical School.  He joined the staff
at Harvard Medical School as an instructor in medicine in
1964, rising through the ranks to become as associate
professor.  In 1987 he joined the faculty at UC Davis as
professor of medicine in the Division of Endocrinology and
Metabolism.  He is the principal investigator of the
Diabetes Clinical Research Unit and has been focusing his
research on new and novel therapies for diabetes mellitus
and also on long-term studies delineating the causes of both
type I and type II diabetes.  He can be reached at (916)
734-6152.


     (Note:  This article appeared in "Matrix," Volume 3,
No. 11, published by the UC Davis School of Medicine. 
Reprinted with permission.)

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

                    LETTERS TO THE EDITOR

Art:  Quill pen in ink well


February 19, 1997

Please send me the VOICE free, as I am newly diagnosed with
diabetes.  Your newspaper helped me and answered more
questions than any other book I've read about diabetes.  I
love the stories...  Your newspaper was given to me by a
friend of my mother's from the library.  I read it every
second I get, page-to-page, over and over.  It seems to help
me cope better than any thing else I've read.

Thank you,

Johnette Castillo
Houston, TX

                   *  *  *  *  *  *  *  *

February 20, 1997

     I just finished reading my first copy of the VOICE OF
THE DIABETIC!  I am a Personal Care Aide with our county. 
We have many diabetics who we care for in their homes.  I
got the copy from my supervisor!  Great magazine!

Thanks again,

Gail Carriere
Massena, NY

                   *  *  *  *  *  *  *  *

February 21, 1997

     Please add my name to your mailing list.  I saw and
read your paper in the Mayes County Medical Center and
thought it was very informative!

Pat Pathkiller
Pryor, OK

                   *  *  *  *  *  *  *  *

February 25, 1997

     I am a diabetic and greatly appreciate your VOICE OF
THE DIABETIC.  I was never aware of this newspaper until I
came by one.  It should be available to diabetics.  I would
gladly help distribute them to other physicians in my
community if possible.  Fifty copies would serve the
purpose.

Sincerely,

James J. DiCastro, MD
Rome, NY

                   *  *  *  *  *  *  *  *

February 28, 1997

     We were at the doctor's office today (VA Hospital in
Fresno, CA) and my husband spotted your newsletter.  He
normally isn't very interested in diabetic publications, but
he was impressed with your publication.  He is a pill-
dependent diabetic with many of the side-effects of
diabetes, which affect most every area of his life.

Thank you!!!

Sue Wilkerson
Visalia, CA

                   *  *  *  *  *  *  *  *

March 13, 1997

     Thank you for your recent letter.  The VOICE OF THE
DIABETIC is an excellent publication and a great service for
the diabetic.

     I am interested in receiving the pamphlet "Diabetes,
Complications, Options," for my waiting room.  I see so many
diabetic patients daily.

Sincerely,

M.D. Weston, OD
Neosho, MO

                   *  *  *  *  *  *  *  *

March 13, 1997

     So far the response from our home health patients to
VOICE OF THE DIABETIC has been very favorable.  I was
wondering if I needed to request our 100 copies each
quarter, or if you send them automatically?  Also, yes, we
would be pleased to distribute the "Diabetes, Complications,
Options" pamphlets.  One hundred copies would be most
welcome.

     Keep up the good work.  I appreciate reading your paper
and I'm not a diabetic.

Sincerely,

Mrs. Danny Miller
Tunnelton, WV

     (Editor's Note:  If you order multiple copies, they
come regularly, every quarter.  Just call us if you need to
adjust the amount.)

                   *  *  *  *  *  *  *  *

March 15, 1997

     We receive VOICE OF THE DIABETIC and are very happy to
receive this very informative newspaper.  On May 3, we will
be having a seminar...  How can we get 100 copies of
"Diabetes, Complications, Options?"  Thank you.

Sincerely,

Felix Petillo
Staten Island, NY

                   *  *  *  *  *  *  *  *

March 18, 1997

     Thank you for your recent letter in regard to VOICE OF
THE DIABETIC.  It has been a great informative tool for our
clients and our employees...

     In regard to the pamphlet "Diabetes, Complications,
Options," mentioned in your letter, I feel it would also be
a good tool for our office.  If you could send me a quantity
of 20 to share with our clients, I would appreciate it.  I
look forward to receiving your pamphlets.  

     Thank you for supplying these materials; they are very
helpful to our agency and our clients.

Sincerely yours,

Dee Dee Felker
Bradenton, FL

                   *  *  *  *  *  *  *  *

March 19, 1997

     Thank you for supplying Rush North Shore Medical Center
with copies of VOICE OF THE DIABETIC.  The publication
consistently receives high marks from our diabetic patient
population as well as professional staff.

     I would also like to offer the "Diabetes,
Complications, Options" pamphlet to interested clients. 
Please send me 50 copies for distribution, and I'll keep you
updated on the demand/supply ratio.

Sincerely,

Colleen M. Smyrniotis, RN CS
Skokie, IL

                   *  *  *  *  *  *  *  *

March 31, 1997

     I would like to request at least five additional copies
of the VOICE.  I have come into contact with several elderly
low-vision persons, as well as others who have found the
information contained in the VOICE that [unfortunately]
their health care professionals never told them of.  Thank
you.  A loyal reader.

Sincerely,

Renee Jordan
Yellow Springs, OH

                   *  *  *  *  *  *  *  *

April 18, 1997

     Diabetic education IS vital, and I would like to take
advantage of your free literature.  Please send me 250
copies of your publication, to be distributed to our
diabetic patients, members of our diabetic support group,
and my Life Skill students.  

     Thank you for providing an opportunity to further
educate the community.

Sincerely,

Mary Wagner, RNC, BSN
Cottonwood, AZ

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

 SOME GUIDELINES FOR RESTRICTING POTASSIUM IN THE RENAL DIET

                by Betty Wedman, PhD, RD, LD


     Betty Wedman, PhD, RD, LD, is a licensed nutritionist
and environmental health specialist who lives in St.
Petersburg, FL.  This article has been adapted from her
"Kidney Disease:  Book of Menus," available from Wedman at
17929 Gulf Blvd., Suite 606, St. Petersburg, FL 33708; (813)
391-6198, fax (813) 399-2188.  Always check with your
physician or renal dietitian before starting any renal or
renal diabetic diet.


Introduction

     Potassium, a mineral found primarily within the body
cells, is necessary for proper function of muscles and
nerves.  But excessive amounts in the bloodstream may cause
the heart to beat out of rhythm and affect its ability to
pump blood.  Therefore, it's very important for normal heart
function that your blood potassium stay within a certain
range.

     Normally, the kidneys regulate the potassium balance in
the body by eliminating or excreting it when intake is
excessive.  When kidneys are not functioning properly, and
especially when urine volume decreases, the body loses this
ability to excrete potassium.  The potassium level in the
bloodstream can rise quickly.  This condition can be life
threatening and could occur without warning signs or
symptoms.


Food Selection 

     The following miscellaneous items are high in potassium
and should be used with caution or avoided:

*    Cocoa or chocolate
*    Dark or whole grain breads and cereals
*    Dried fruits
*    Dried peas and beans
*    Molasses
*    Nuts and nut butters

     Some vegetables, such as white and sweet potatoes,
contain a great deal of potassium.  Much of it is washed
out, however, if the vegetable is peeled, cubed, and soaked
in water for at least one to two hours and then boiled in
fresh water.

     Some specially prepared low-sodium items are flavored
with  salt substitute, which contains potassium instead of
sodium.  Low-sodium baking powder and salt-free bouillon
(soup stock) are also high in potassium.


High Potassium Foods

     Other foods that are high in potassium include:

*    Apricots
*    Avocado
*    Bananas or plantains
*    Beans (baked)
*    Beans, split peas, black, red, or white
*    Cantaloupe
*    Carrots (raw)
*    Dates
*    Figs (dried)
*    Fish (more than daily allowance)
*    Grapefruit juices
*    Guanabana (South American fruit)
*    Guava
*    Honeydew melon
*    Hubbard squash (green outside, orange inside)
*    Meat (more than daily allowance)
*    Milk [condensed, evaporated, whole, low fat or skim
(more than 8 oz/day)]
*    Nuts, particularly peanuts
*    Oranges and orange juice
*    Papaya
*    Pea soup
*    Poultry (more than daily allowance)
*    Prunes and prune juice
*    Pumpkin
*    Spaghetti sauce
*    Tamarind
*    Tomato soup, paste or sauce


*    Tomatoes (stewed)
*    Winter squash
*    Yogurt (unless taken in place of milk allowance)


"Dialyzed" Vegetables

     Certain vegetables have sodium and potassium levels
which would normally eliminate them from your diet.  By a
special preparation method called dialyzing, however, they
can be used.

     A method to reduce sodium and potassium in white and
sweet potatoes, carrots, beets and rutabagas:

(1)  Use fresh, unpeeled vegetables.

(2)  Peel and eye. Place them in cold water so they won't
darken.

(3)  Slice 1/8-inch thick.

(4)  Rinse in warm water for a few seconds.

(5)  Soak for a minimum of two hours in warm water.  Use 10
times the amount of water to the amount of vegetables.

(6)  Rinse under warm water again for a few seconds.

(7)  Cook for five minutes.  Use five times the amount of
water to the amount of vegetables.

(8)  Place one-serving portions in small plastic bags. 
Freeze.

(9)  Each serving may be cooked in a variety of ways,
including French fried, mashed, boiled, home fried with
onions, and scalloped.

     For lima beans, follow Steps (4)-(9).

     To reduce sodium and potassium in greens, squash,
mushrooms and cauliflower:

(1)  Place such items as frozen kale, mustard or spinach in
a sieve or strainer.

(2)  allow frozen vegetables to thaw at room temperature and
drain.

(3)  Rinse in warm water for a few seconds.

(4)  See (5) above.

(5)  See (6) above.

(6)  Cook in the usual way, but with five times the amount
of water to the amount of vegetables.


SOURCE:

     Tsaltas, Dr. TT.  "The American Journal of Clinical
Nutrition."  1969(4); 22(4):  490-493.


     (Note:  Reprinted, with permission, from the
March/April 1995 issue of "For Patients Only," published by
"Contemporary Dialysis & Nephrology" magazine, 6300 Variel
Avenue, Suite I, Woodland Hills, CA 91367.)

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


                       ASK THE DOCTOR

                   by Wesley W. Wilson, MD


Art:  Medical caduceus


     NOTE:  If you have any questions for "Ask the Doctor,"
please send them to the VOICE editorial office.  The only
questions Dr. Wilson will be able to answer are the ones
used in this column. 

     Wesley 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 am working hard to control my diabetes and check
blood sugars before each meal and at bedtime.  I also
occasionally check between meals or when I suspect my blood
sugar is "not right."  My fingers are sore from all the
blood tests.  Can I use any other spot?

     A:  Your attention to detail is great.  Careful control
does require frequent blood sugar testing, and for most
persons with diabetes, that tends to be the most troublesome
part of managing their illness.  You brought up a point that
is important to me personally, since I like to know where my
blood sugar is, but don't like to stick my fingers, nor do I
like having holes in my protective skin over my fingers,
particularly when I see patients in my office who have
hepatitis or other infectious problems.

     There are more nerve endings in the fingertips than
almost any other part of the body, so blood sugar sampling
from fingertips, even with the new super-sharp lancets,
sometimes causes discomfort.

     Because I wish to have my fingertip skin left intact
but test frequently, I did a study several years ago in
which I checked a blood sugar from my finger, another from
the area just above my kneecap, and another venous blood
sample taken by the laboratory and run on their precise
equipment to check blood sugars.  All the tests were done
within five minutes.  Then I compared the three test group
results after I had done the three tests on 40 separate
occasions.

     The blood sugar samples from the finger were dropped
onto the test strip.  The blood sample from above the knee
required squeezing the skin to get a large drop of blood on
the surface of the skin, and then the test device had to be
turned upside down and placed on top of the drop of blood.  

     The three separate tests all matched very closely.  The
blood sugar from the knee was as accurate as the blood sugar
from the fingertips, and they all agreed very closely with
venous blood samples done in the laboratory.

     I have used this method with a variety of glucose
monitors, including Glucometer, Accu-Chek Advantage, and
Medisense; and they all seem to work reasonably well, though
some are more convenient than others.  Some glucose meters
require the blood to be applied to a strip already inserted,
making it very difficult to get a drop of blood on the test
area.

     The point is, it is important to check sugars
frequently, and the blood can be obtained from spots other
than the finger.  The important requirements for testing
from above the kneecap are: (1) your need to get a large
enough sample of blood, (2) you need a meter whose test
strips are such that the blood can be non-traditionally
applied, and (3) squeezing the punctured skin to force the
drop of blood out does not affect test accuracy.

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

          DIABETES ACTION NETWORK ELECTS NEW BOARD


     The annual business meeting of the Diabetes Action
Network of the National Federation of the Blind (NFB) took
place on July 1, 1997, at the NFB Annual Convention in New
Orleans, Louisiana.  Tom Ley, immediate past president,
becomes Board Member at Large, and the presidency passes to
Ed Bryant.


The 1997-98 Diabetes Action Network Board is:

     President:  Ed Bryant (Columbia, MO ); First Vice-
President:  Janet Lee (Cedar, MN); Second Vice-President: 
Sandie Addy (Prescott Valley, AZ); Treasurer:  Mary Hurt
(Louisville, KY); Secretary:  Sally York (Castro Valley,
CA); Board-Members-at-Large; Tom Ley (Baltimore, MD), and
Eric Woods (Denver, CO).


New president Bryant says:

     As president, I will be energetic and accessible. 
There is a great deal for us to do, and I intend to take an
active hand, pursuing the goals of the Diabetes Action
Network and the National Federation of the Blind.  I feel
honored to be president.  My door will always be open, for
your calls, letters, or faxes.  Along with my duties as
president, I will remain editor of our VOICE OF THE
DIABETIC.  You will hear from me often, and I hope to hear
from you often, as well.

     Almost before the dust of Convention 1997 had settled,
we lost our National Division Treasurer, John Yark.  First
elected to the board in 1994, John, efficient and energetic,
brought us maturity and wisdom.  Tragically, he died on July
10.  He was both a colleague and a friend.  

     Although losing John hurts, I know he would want our
division to move ahead with all our outreach orograms.  We
will.  He leaves a son, Eric, and his wife, Irene.  We will
miss him.

     Mary Hurt (from Louisville KY), a former division
treasurer, will serve the remainder of John's term.  Like
John, Mary is a doer, and she is already working on projects
that could help our division financially.

     In closing, I would ask you to remember that our
national support and information network is a collection of
people looking after each other.  Every one of our members
is part of the team.  I welcome all suggestions.  I will
keep our division focused on serving diabetics, especially
those who are blind or losing vision.  Let us hear from you!

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

             REVIEW OF ORAL DIABETES MEDICATIONS

                 by Peter J. Nebergall, PhD


Photo:  portrait;  Caption:  Peter J. Nebergall


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

     Oral medications are not insulin pills, rather four
classes of drugs designed to improve the body's utilization
of what insulin is still present.  These are:  The
sulfonylureas, metformin, troglitazone, and acarbose.

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

     But the sulfonylureas grow ever less effective with the
passage of time.  They drive the failing pancreas to greater
effort, but the patient may well require ever-increasing
doses.  At some point, no further increase in medication
will be effective; the pancreas isn't doing its job, and the
patient needs to start injecting insulin.  When the islet
cells of the pancreas stop making sufficient insulin,
insulin must be injected.

     Metformin, the second of the oral diabetes medications,
works to raise the body's sensitivity to its own insulin. 
Used for decades in Europe, it can be prescribed alone or
with the sulfonylureas.  Metformin helps the type II
diabetic make better use of the insulin he or she has left. 
Like the sulfonylureas, it becomes useless when the pancreas
ceases producing adequate insulin.  

     Troglitazone (trade name Rezulin, from Parke-Davis) is
the third oral medication.  Rezulin directly attacks the
problem of insulin resistance, the increasing inability to
process insulin, that is the chief component of type II
diabetes.  In tests, Rezulin enabled many diabetics to
reduce volume and frequency of insulin injections.  A few
were able to discontinue insulin injections entirely.   

     Initially, Rezulin was tested and approved for use with
insulin-using type II diabetics.  As tests continued, it
became clear that it was also an effective blood glucose
reducer either alone (in combination with diet and exercise)
or in combination with a sulfonylurea, for type II diabetics
who did not need insulin (although not a replacement for the
sulfonylureas).  On August 4, 1997, the Food and Drug
Administration approved Rezulin for these new uses.

     As with other oral diabetes medications, Rezulin's
effectiveness depends on the presence of insulin.  If
sufficient insulin is not present, it must be injected, and
Rezulin therapy will not change that fact.  Where insulin
supply rather than insulin resistance is the issue (as in
type I diabetes), Rezulin therapy offers nothing. 
Investigations continue, and new uses may come with time. 
"Because of its mechanism of action," states Parke-Davis,
"Rezulin is active only in the presence of insulin. 
Therefore, Rezulin should not be used in type I diabetes or
for the treatment of diabetic ketoacidosis."

     Published data state that although degree of renal
insufficiency has no effect on Rezulin dosage, persons with
hepatic (liver) disease should exercise caution.  Other data
warn that in premenopausal anovulatory women, Rezulin
therapy may result in resumption of ovulation, and risk of
pregnancy.  There is further recommendation to proceed with
caution if the individual is taking antirejection drugs such
as cyclosporine or tacrolimus.

     Acarbose, the fourth of the current "oral meds" is
completely different.  A carbohydrase inhibitor, it
temporarily suppresses the digestive enzymes which turn
carbohydrate into glucose, slowing digestion and glucose
absorption, keeping glucose levels more even.  More a
management tool than an antidote to insulin shortage,
acarbose helps some diabetics keep a more constant blood
glucose level.  A "temperamental" medication, it has many
side effects, and is less than universal in its utility.  


Problems

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

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


Oral Insulin?

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


The Future

     Researchers at Johns Hopkins are testing
aminoguanidine, a new medication that may prevent or reduce
some of the ramifications of diabetes.  Ergo Scientific
Company's Ergoset, currently in Phase III clinicals, appears
to reduce the high plasma lipid levels common in type II
diabetes, and thus the risk of diabetic heart disease.  
Swedish and American researchers are testing still another
(APO A1 MILANO, covered in VOICE Volume 10, Number 4) that
may help reduce diabetic heart disease.  Aerosol spray
insulin (for nasal administration) is being tested, and may
someday supplant injection.  Trental (pentoxifyline, from
Hoechst Marion Roussel) is now available to treat
"intermittent claudication," a painful circulatory ailment
and frequent companion of peripheral neuropathy.  ACE
inhibitors, a class of blood pressure medications like
Capoten (Captopril), have been proven to deter and retard
diabetic kidney complications.  Other oral medications are
constantly being evaluated for possible diabetic
applications.  Change is coming quickly.

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

                 FORTY YEARS A FEDERATIONIST

                     by Thomas Bickford


Photo:  portrait;  Caption:  Thomas Bickford


     (This article appeared in the BRAILLE MONITOR, July
1997, published by the National Federation of the Blind.)


     From the MONITOR Editor:  Tom Bickford has been a
federationist for many years.  In many ways that experience
has shaped and defined who he is and the gifts he has to
offer in every part of his life.  This is what he says about
the enriching influence of the NFB in a person's life:

     It was in October of 1956 that I first joined the
National Federation of the Blind.  Kenneth Jernigan was the
president of the chapter in Oakland, California, at the
time, and that is where I got a thorough grounding in
Federationism.  I didn't know what I was getting into, but
the more I participated, the better it got for me.

     You had better believe that we had an active chapter. 
We sold raffle tickets. We wrote letters to legislators.  We
traveled to the state capital to appear at hearings.  We
made friendly visits to nearby chapters.  We participated in
the NFB state conventions.  On top of all that we got
together for dinner parties.  As you see, we were busy.

     The most important part of these activities for me was
a growing understanding that it was all being done by blind
people.  Meetings were chaired.  Reports were given.  Trips
were taken.  Activities were organized.  I became part of
all that, and I was just as blind as everybody else in the
chapter.

     My first National Convention was the next summer in New
Orleans.  Many members of the Federation know what a
learning experience that can be for a young person.  Three
days by Trailways bus from Oakland to New Orleans was just
the beginning.  I had my first experience with that southern
food called grits and observed racially segregated
facilities for the first time.  I had yet to learn how close
that would come to my own life.  I learned a lot about the
Federation, but I learned even more about myself.  I have
missed more National Conventions than I have attended--some
for good reasons and some for bad, but every one of those I
attended was full of fun, fellowship, learning, and
inspiration.

     The thorough grounding in Federationism I got has stood
me in good stead through the decades.  I consider my
achievements in and through the Federation as glory to the
cause.  I have enough ego to be glad when I hear my name
spoken or find it published, but I know it is there because
I stayed with the Federation, its principles, and its
members.  Over the years I have served as president, vice-
president, secretary, and treasurer in the chapters where I
was a member as well as chairman and member of many
committees.  If I tell you of my three proudest
achievements, you must believe that they are glory for the
cause as well as for me.

     In 1968 and 1969 I chaired the committee that presented
several candidates for the NFB official song.  The
convention chose the "Battle Song," and that song has
inspired us through the years.  I am glad that we also
inspired more people to write more songs, and now we have
books full of songs.

     In 1971 and 1972 I chaired a committee in Washington,
DC., which presented testimony before Congress that led to
the passage of the White Cane Law covering the District of
Columbia.  It all started when I was trying to help two
blind men through a discriminatory situation in a local
movie theater.  That led to contacting their local
Congressman, to whom I sent a copy of Dr. tenBroek's Model
White Cane Law.  When it was all over I got a souvenir pen
from the Nixon White House with the Presidential seal on it.

     In 1992 I found myself explaining to a sighted friend
some of the techniques I use to know when to get off the
bus.  I decided to write it down, and that was the beginning
of "Care and Feeding of the Long White Cane."  I spent lots
of evenings and weekends with my Braille writer on my lap,
and I received lots of help from my Federation friends in
the form of ideas and the physical production of the
manuscript.

     In November of 1993 the Federation published the book,
which I am delighted to say has already helped hundreds of
people.  There is always more work to be done for the cause. 

     How do you know what to do?  The more you get involved,
the more will come to your attention.  If you can do more
things and better than I have done, more power to you. 
There are gavels ready to be pounded; paper waiting for your
ink or Braille; interviewers looking for subjects; cakes to
be baked and sold; and always more people who need us and
whom we need.  If you need help, ask, and people and
materials will be on your doorstep.

     Lots of us collect quotations which we find helpful, so
here is one for today.  "An artist is not a special kind of
person, but every person is a special kind of artist."  I
would add that all of us have more than one talent to bring
to the cause.  Sometimes I am just a warm body, sometimes a
loud voice, maybe a not-so-perfect typist writing a letter,
now and again a song leader at a picnic, or part of a
brainstorming session deciding how to make use of someone
ELSE's talents.  Some of these abilities I brought to the
Federation, but others I developed after I joined.  What
kind of artist are you?

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

                    BLINDNESS INFORMATION


Photo:  portrait;  Caption:  Kenneth Jernigan


     "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 glucose
monitors and thermometers, from check-writing guides to
adaptive insulin measurement devices.

     To learn more about the NFB, to obtain a free 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.

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

           NEW DIABETES DIAGNOSIS RECOMMENDATIONS

                        by Ed Bryant


Photo:  color portrait;  Caption:  Ed Bryant


     On June 23, the American Diabetes Association sponsored
a telephone news conference in which members of "the Expert
Committee on the Diagnosis and Classification of Diabetes
Mellitus" presented their findings regarding the need to
revise diabetes diagnosis and classification, and answered
audience questions.  Current  estimates are that over 100
billion dollars a year (in direct and indirect costs), are
poured into treating diabetes and its complications.  This
figure includes as much as 15% of managed care costs and 20%
of the Medicare budget.  The committee, which started
addressing this problem in 1995, and finished this year, saw
its report accepted for publication  in the professional 
journal "Diabetes Care," Volume 20, No. 7, for July 1997.

     First presenter was Dr. James Gavin, Senior Scientific
Officer of Howard Hughes Medical Institute, past president
of the American Diabetes Association, and the Chair of the
Expert Committee.  Other presenters were:  Dr. Frank
Vinicor, Director of the Office of Diabetes Translation,
Centers for Disease Control and Prevention; Dr. Richard
Eastman, Director of the Division of Diabetes,
Endocrinology, and Metabolism, of the National Institute of
Diabetes, Digestive, and Kidney Diseases; and Dr. George
Alberti, Director of the Human Diabetes and Metabolic
Research Center, part of the World Health Organization,
Collaborating Center for Research and Development for
Laboratory Techniques and Diabetes.

     Dr. Gavin reminded listeners of the seriousness of
diabetes, its impact on over 16 million Americans, and its
explosive growth (The past 30 years have brought more than a
tripling in the U.S. A.), and much of its cost has been for
treatment of its long-term complications.  These
complications are driven largely by the high blood sugars of
the disease, and we now know they can be prevented or
delayed by early and aggressive treatment.  Today we know
more about diabetes than ever before.  This heightened
understanding has caused us to reevaluate the way diabetes
is diagnosed and classified.

     The  current medical classifications and glucose test
levels that would indicate an individual has the condition
were last updated in 1979, and were based on then-current
knowledge.  In 1979 we didn't know about the autoimmune
aspects of type I diabetes, we didn't know about genetic 
susceptibility, and we had far less understanding of the
sub-types of diabetes.   We have more than 16 years of new
research to draw on.  The Expert Committee's work represents
an update of what we knew about diabetes back then. 
Conclusive data on population based research show serious
complications of diabetes beginning earlier than previously
thought, and at a lower level of blood sugar.  With what we
know now, it is time to revise, so as to take better
advantage of the multiple opportunities for early
intervention we now possess.

     The single most important recommendation made by the
committee is to move the "cut point" for a diagnosis of
diabetes, downward from its current 140mg/dl fasting plasma
glucose (FPG) to an FPG of 126.  This 14-point drop, the
researchers argue, will catch more of the estimated 8
million undiagnosed diabetics in the United States, perhaps
up to 2 million, and catch them sooner than the current 7 to
10 years after onset.  A "normal" (non-diabetic) fasting
plasma glucose, they define as 110mg/dl or less.

     The researchers addressed the problem of where to place
individuals whose blood sugars are above the new "normal"
cutoff of 110mg/dl FPG, but below the new diagnostic point
of 126mg/dl FPG, an intermediate stage.  The committee
recommends two subdivisions of this new impaired glucose
homeostasis category:  Impaired Fasting Glucose (IFG), when
the test results run between 110 and 126mg/dl, and Impaired
Glucose Tolerance (IGT) when the Glucose Tolerance Test
(OGTT) produces a reading of over 140 but less than
200mg/dl.  This latter group is known to be at risk of
microvascular complications, and for progression to full-
blown type II diabetes.

     The committee also looked at Gestational Diabetes
(GDM), which only appears in pregnant women, and for which
different diagnostic criteria must be used.  As many women
who experience GDM go on to type II diabetes, this
classification is of great interest.  The old recommendation
for universal screening of all pregnant women has been
replaced by an assessment of risk factors such as family
history of diabetes, obesity, age at pregnancy (below 25 is
considered low risk for GDM), and ethnicity.

     An important committee recommendation was that the
health care community should consider testing for diabetes
in all adults age 45 and above, with repeat testing at
three-year intervals.  Individuals judged at high risk
(obese, high blood pressure, family history of diabetes, or
of Hispanic, Asian, or Native American or African ethnicity)
should be tested more regularly, and at a younger age.  The
new "cut point" criteria, and recommended increase in
testing activity would not increase the number of diabetics,
but would lessen the number of those yet undiagnosed.  Dr.
Gavin pointed out, in response to a question, that there are
many people whose blood sugars would fall into the "not
normal" range,  yet fall short of the "cut point" for full-
blown diabetes.  Such people need increased vigilance and
counseling, as they are at risk.

     The committee also recommends the universal adoption of
the FPG as standard diagnostic test for diabetes.  The OGTT
(glucose tolerance test), a sensitive but expensive and
time-consuming test,  has been used for some diagnoses, but
not others, with the results imperfectly mapping onto those
produced by the FPG.  Also the FPG is convenient, easy to
administer, acceptable to patients, and very low in cost. 
(The HBA1C, or glycosylated hemoglobin test, while an
excellent monitoring tool, is not recommended for
diagnosis.)

     Dr. Frank Vinicor, of the Centers for Disease Control,
spoke on the public health impact of diabetes complications,
and their preventability if diagnosed early.  CDC approved
of the new recommendations, he reported, and he anticipated
their acceptance as government policy, both through his
agency and other groups concerned with public health and
epidemiology.  Although the article and presentations were
merely "committee recommendations," the Expert Committee's
report has already been accepted (or is currently under
review) by a number of agencies, including the American
Academy of Physician's Assistants, the American Association
of Clinical Endocrinologists, the American Association of
Diabetes Educators, the American Diabetes Association, the
American Dietetic Association, the Canadian Diabetes
Association, the Centers for Disease Control, the Diabetes
Treatment Centers of America, the Endocrine Society, Joslin
Diabetes Centers, the Juvenile Diabetes Foundation
International, the National Institute of Diabetes,
Digestive, and Kidney Diseases, and the International
Diabetes Center.  Conference speakers said they expect their
recommendations to become standard in the next few years.

     A statement Dr. Gavin made struck me as the best
possible explanation for the shift to new diagnostic
criteria.  In his own words:

          We feel passionately that people need to take
     diabetes more seriously.  Just because it doesn't hurt
     doesn't mean it isn't hurting you.  It's a disease that
     is completely treatable, and we now know we can prevent
     or delay its complications, with early effective
     treatment.  For adults in America, especially family
     members of people with diabetes and other high-risk
     individuals, these people should be more vigilant in
     getting checked for this disease on a regular basis,
     and should try to reduce their risk, by maintaining
     ideal weight, and seeking to control blood pressure and
     blood fat levels.

     These new recommendations will not create new patients
with diabetes, but will move more of them from the
undiagnosed to the diagnosed category.  Diagnoses, if these
recommendations are followed, will be greatly simplified,
less expensive, and we expect they will be made earlier,
more often, and will allow us to eliminate those instances
where we diagnose people late, often years after the onset
of the disease, when they already have complications.

     It is our hope and our expectation that these global
recommendations will be embraced by the medical community
for the benefit of all patients with diabetes.

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

                  VOICE DISTRIBUTORS NEEDED


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

     Diabetes education is essential.  Anyone who
distributes the VOICE will be helping people with diabetes,
and their families, to learn about the disease and its
ramifications; to learn that they have options; and that
their world is far greater than whatever "limits" may be
imposed by the disease.  If you would like to help spread
the word by distributing the publication, please contact: 
Voice of the Diabetic, 811 Cherry Street, Suite 309,
Columbia, MO 65201; telephone:  (573) 875-8911.

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

                   "CHEATING" ON YOUR DIET

                        by Joan Stout


     I don't like the "cheating" word, and I am trying to
obliterate it from the vocabulary of my support group
members.  I prefer to think of it as a choice.  That helps
me to look at it in a more positive light.  Once I learned
how to safely allow some "forbidden" food items in my diet,
I gave myself permission to have them now and then.  Now
that those "forbidden items" are no longer so forbidden, I
don't want them as frequently.

     Another benefit of considering it as a choice is the
fact that I can rationally decide if I really want that
grilled cheese with bacon sandwich.  I know why it's good
for me, and I know why it's bad for me.  Do I want it enough
to closely monitor my blood glucose for several hours after
eating it?  Sometimes yes, sometimes no.  Do I want it
enough to give myself the extra fat and protein that I don't
need?  Sometimes yes (the psychological benefits can be
great), sometimes no.  If the answer is yes, I will probably
have rice for my next meal.

     Having a flexible insulin regimen is important for
making these kinds of choices!  I know that it's more
difficult without insulin.  As for the question of choosing
a carbo snack over a fat snack, it depends.  If you are on
insulin and can keep your BG in control after eating the
carb snack, that might be an acceptable choice.  If not, the
fat snack might be a better choice.  If you are not on
insulin or don't know how to make adjustments, and/or if you
are overweight, you might try to opt for the sugar-free
Jello instead!  I encourage you to talk to your doctor and
dietitian about a treatment regimen that allows you some of
your favorite foods.

     A difficult factor here is that "trigger foods," those
we mindlessly consume in great volume (like popcorn, salt
peanuts, potato chips, etc.),  are sometimes the things we
crave the most, and with a trigger food, it's very difficult
to stop with one serving.  I try to never have trigger foods
in my house and to eat them only when portion size is
controlled.  For example, I might have a small bag of potato
chips at lunch, where a small bag is all I'll receive, but I
would never buy a large bag of potato chips to have at home. 
And never leave me alone with a can of Pringles!

     Remember -- everything in moderation, including
moderation!

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

                        RECIPE CORNER


Art:  Fruits and vegetables


     Send your great food ideas to the editor.  Your recipes
will be evaluated by dietitians, and if necessary, adjusted
to make them more diabetically appropriate.  Then he gets to
taste them...


                        Cucumber Soup

                   from Rosemarie Ventura
                       of Buffalo, NY


1 large cucumber, peeled and shredded
1 cup non-fat plain yogurt
1 small onion, diced
2 cloves garlic, diced
lemon juice
salt and pepper to taste (optional)
diced tomato (optional)
spinach (optional)
3 oz chicken or beef strips (optional)

     Throw cucumber, yogurt, onion, garlic in a blender or
food processor and blend it for a while to combine
throughly. Put in lemon juice to taste.  I start with 1
tablespoon.  Give it a little blend to mix and taste.  When
you balance out the lemon, salt and pepper to your liking,
you're done.  Don't blend the tomatoes (if you use them),
they need to stay solid.

     If you want to add spinach or meat, steam the spinach
lightly first to keep the leaves a little crisp but not raw. 
Broil the meat, then quickly sear it on both sides in a hot
frying pan to give it the right finished flavor.  Dice the
meat and toss it in the soup.

     The soup can be served hot or cold, with a pita bread
for dunking on the side.  (Remember to count the pita bread
if you use it.)  Makes 2 Servings.  "Optionals" not counted
in servings.

     Per serving:  100 calories; 16 grams carbohydrate; 8
grams protein; < 1 grams fat; 1 exchange.


                     Beef and Bean Stew

                     from Dave Griffith
                 of London, Ontario, Canada


2 tsp canola oil
1 lb lean ground beef (or TVP, for the non-carnivores in our
group)
1/2 cup chopped onion
2 cloves of minced garlic
1/2 tsp salt
1/4 tsp freshly ground black pepper


1/4 tsp ground thyme
1 cup diced carrots
1 cup diced turnip (or potatoes, if you are not a turnip
person)
1/2 cup sliced celery
1/2 cup chopped green pepper
1 can crushed tomatoes
3 cups cooked kindey beans

     Heat oil at medim heat and cook ground beef, onion,
garlic, salt, pepper and thyme.  Cook until the meat is no
longer pink.  Remove any excess fat.

     Add carrots, turnip, celery, green pepper, tomatoes,
and beans.  Bring to a boil, reduce heat and simmer until
the vegetables are tender.  Makes 8 servings.

     Per serving:  283 calories, 10 grams total fat, 3 grams
saturated fat, 31 mg cholesterol, 20 grams protein, 29 grams
carbohydrate, 275mg sodium, 892mg potassium.  Exchanges:  2
starch, 2 lean meats.


               Sandy's Strudel-Style Apple Pie

             from "Straight Talk about Diabetes"
              by P.J. Nebergall, in preparation


(9-inch pie)

Filling:

1-1/2 lbs  Golden Delicious Apples (about 4 medium apples)
2 tbsp lemon juice
6 oz water

     Stew vigorously for 10 minutes until moisture reduces
to one half.  While it's going, prepare the pastry:

8 oz flour
2 tsp baking powder
4 oz low-fat, no-salt margarine

     Cut in margarine with a pastry blender until dough
forms; roll out pastry, thinly.

     Line 9-inch piepan, place stewed apple and juice onto
pastry.  Sprinkle one rounded tbsp seedless raisins, and 1/2
tsp cinnamon onto apple.  Top with pastry lid.  Brush top
with milk, and bake at 375 for about 35 minutes until
lightly browned.

     Yes, apple pie without sugar!  I use lemon juice to
keep fruits from discolouring, and to prepare apples for
recipes.  After I had stewed the apples with water and lemon
juice, I tasted this, and it was most certainly not sour. 
Some of the starches contained in the apples had been
converted whilst cooking with the acid lemon juice.  So I
thought by adding the raisins this would increase the
sweetness level somewhat.  This is exactly what it did. 
Cinnamon was added just to complete the taste.  If you like
your food not saturated with sweetness, you will enjoy this 
(Sandra Nebergall).  Makes 6  Servings.

     Per serving:  215 calories; 34 grams carbohydrate; 2.5
grams protein; 8 grams fat;  exchanges: 2 carbohydrates, 1
fat.


                      Mock Fruit Butter

                   from Ms. Belver Ladson
                       of New York, NY


Ingredients:

10 dried apricots
1/2 cup raisins
2 medium apples (peeled and sliced)
1/2 teaspoon cinnamon

     Place the apples in a blender and blend for about 30
seconds.  You should see some liquid.  Add the raisins and
apricots.  Blend until the mixture is thick and smooth. 
Store in the refrigerator until ready to use.

     One serving:  (one tablespoon):  20 calories; 5 grams
carbohydrates, 0 grams protein; 0 grams fat.  Exchanges: 
1/3 fruit.

     (Recipe courtesy of Diabetic Friends Action Network. 
For more information, send e-mail to:  belve@aol.com) 

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

                WHAT IS MANAGED HEALTH CARE?

              By Christine Tobin, MBA, RN, CDE


     For many of us, the growth of "managed health care" has
been frustrating and confusing.  We are angry and upset at a
system in transition, which we do not yet fully understand. 
Some areas of the country are just beginning to feel the
impact of managed care, while other regions are fully
involved.  These different stages in the evolution of
managed care compound our lack of understanding.

     Simply stated, managed care is a system that integrates
the financing and delivery of appropriate health care using
a comprehensive set of services.  Managed care is any method
of organizing health care providers to achieve the dual
goals of controlling health care costs and managing quality
of care.

     In the United States, we have a private and competitive
health insurance system which will cause managed care to
continue to evolve.  Competition and rising costs of health
care have even led indemnity plans to incorporate elements
of managed care, resulting in fewer "traditional" indemnity
plans.  There are several key elements common to all managed
care arrangements:

*    explicit standards for selecting providers;

*    formal programs for ongoing quality improvement and
utilization review;

*    emphasis on keeping enrollees healthy to reduce use of
services;

*    financial incentives for enrollees to use providers and
procedures associated with the plan.

     Managed care is a system that integrates the financing
and delivery of appropriate health care using a
comprehensive set of services.  Managed care is a broad term
which encompasses many types of organizations and insurance
options including: 

*    health maintenance organizations (HMOs), which provide
a wide range of services for a fixed, periodic prepayment;

*    preferred provider organizations (PPOs), consisting of
groups of hospitals, physicians and other providers who
contract with an insurer, employer, third-party
administrator or other group to provide health care services
to covered persons;

*    point-of-service plans (POSs), which combine HMO and
PPO features, Members can choose which option they want to
use at the  time of service;

*    indemnity or fee-for-service plans which incorporate
features of managed care and provide benefits in a
predetermined amount for covered services;

*    self-insurance plans, where employers and businesses
assume fiscal liability and the responsibilities of an
insurer for their own employees.  These plans typically
incorporate features of managed care.  The employer may
contract out administration of the plan.

     Managed care organizations (MCOs) try to achieve their
goals by controlling patient access to specialized care and
eliminating unnecessary services; integrating health care
delivery and payment systems through prepaid member fees;
limiting provider fees by establishing fixed rates for
physicians and hospital services; and controlling drug costs
by implementing pharmacy benefits management plans.


Features common to managed care include:

*    pre-authorization;

*    rigorous utilization review;

*    emphasis on use of primary physicians and other health
care providers;

*    quality improvement programs and payment systems that
make  physicians, hospitals and other providers financially
accountable for cost and quality of medical services.

     Educators have been struggling with the lack of
reimbursement for diabetes education and medical nutrition
therapy for years.  I believe the evolution of managed care
can greatly benefit both access to and coverage of diabetes
education services.  The health insurance industry views
wellness and prevention as part of managed health care.  

     (Note:  Reprinted from "AADE News," January 1997,
Volume 23, Number I, published by the American Association
of Diabetes Educators.  Used with permission.) 

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

                      KEEPING YOUR FEET


     (This article appeared in VOICE OF THE DIABETIC, Volume
12, Number 4, Fall 1997, published by the Diabetes Action
Network of the National Federation of the Blind.)


     The October 1996 issue of the journal "Biomechanics"
carried an article, by Christopher E. Attinger, MD, which
reexamined traditional attitudes toward salvage vs.
amputation of badly infected lower limbs, where the patient
was a diabetic experiencing renal failure.  The prevailing
attitude has been one of pessimism; and Dr. Attinger and his
associates at Georgetown University School of Medicine, in
Washington DC, wished to see if such was justified.

     Their findings were enlightening.  First, recent
advances in wound care have dramatically improved the odds
of healing.  Wounds which once offered little option but
outright amputation now respond to aggressive therapies that
include debridement, topical wound care, intravenous
antibiotics, and sophisticated revascularization techniques. 
Infection and gangrene are now much more controllable.

     Second, the study found that diabetics who had a kidney
transplant healed twice as fast as those on dialysis, or
experiencing chronic renal failure.  Alongside the better
healing rate, transplant patients' average hospital stay,
for treatment of foot wounds, was half as long.  

     Third, the study catalogued a 23 percent "recurrence
rate," in which healed wounds reopened and needed further
attention.  Dr. Attinger reports that most of these were due
to "inadequate shoewear, biomechanical abnormality, and
patient neglect."  These numbers, he reports, could be
improved with better shoewear and closer attention to
specific biomechanical problems.

     For previous studies, the best success rate (limb
salvage) had been about 65 percent.  Dr. Attinger's study,
55 threatened lower extremities, achieved a 91 percent limb
salvage rate (measured at two plus years after operation). 
With these numbers, he reports, "the current pessimism in
the medical literature toward attempting to salvage the
threatened extremity in the renal failure diabetic patient
may be unjustified."
     
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

              DIET VERY CRUCIAL FOR DIABETICS 

                       by Lisa Riddle


     Chances are diabetes affects you or someone you know.

     The message at hand for National Diabetes Education
Week recently was:  "Take charge of your diabetes--team up
with a Diabetes Educator."  A successful approach to blood
sugar control includes on-going care.

     For the more than 14 million people living with
diabetes, each day brings new challenges.  Certified
Diabetes Educators (CDE) are there to help you make healthy
choices.  A dietitian on your team can help guide the way to
fine-tune with the ever-challenging task of planning meals
and snacks for good blood sugar levels.

     Ingredients to a healthy plan for managing diabetes
include:

*    A realistic meal plan based on your everyday habits--
school or work schedule, daily routine and eating habits and
special needs.

*    Family and friends included in class to provide
support.

*    On-going education in new developments for diabetes
care.

*    Continual follow-up with diabetes team.

*    Careful record keeping of blood sugar readings.

*    Regular exercise.

*    Weight management.

*    Healthy eating habits.

*    Using medications as prescribed.

*    Stress reduction.

     Putting all these ingredients together can be baffling
at times, which is why your CDE's help can be so valuable.

     Many people say that the toughest part of the plan is
nutrition.  Everyone has certain foods they don't want to
give up!  Ask your dietitian about the healthy alternatives
to the high-fat, high-sugar foods you may crave. 
Information from the Diabetes Control and Complications
Trial tells us that some favorites may be worked in your
meal plan on occasion.

     Pinpoint the time of the day that you seem to be
hungriest.  Stay with your routine by planning a healthy
snack at that time.  Find "free foods" that you enjoy to
help with curbing the munchies.

     Plan for days "on-the-run" and keep foods in the
cabinet that will be quick and easy to use.  If you travel,
be sure to carry foods that will get you through parts of
the trip when "junk-food" is all that is available. 

     A key to good glucose levels is consistency.  Eating
about the same amounts of the same types of foods about the
same time every day will factor in consistency.  Your
diabetes team can help you discover a plan that will allow
you to manage your diabetes and live life to its fullest.

     For a diabetes educator near you, call 1-800-TEAMUP4.

             Healthy Dessert:  Cranberry Sorbet


3 cups low calorie cranberry juice cocktail, divided
1 pkg. (4-serving size) raspberry sugar-free Jell-O
1 cup cold evaporated skim milk

     Bring 1 and one-half cups of juice to boil in saucepan. 
Stir into Jell-O powder in large bowl until dissolved.  Stir
in remaining 1 1/2 cups juice and milk.  Pour into 13 x 9
inch pan.  Freeze 1 and one-half hours or until frozen 1
inch from edges.  Spoon in food processor or blender and
process until smooth.  Pour in a bowl and freeze 3 hours or
until firm.  Makes 8 servings.  Exchange:  1 fruit, 50
calories.

     (Note:  This article appeared in the "Monroe
News-Star", Monroe, LA.)

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
KB
           TACTILE INSULIN VIALS:  AN ONGOING SAGA

                        by Ed Bryant


     In the last issue of VOICE OF THE DIABETIC, Vol. 12,
No. 3, I reported that, on June 3, 1997, the third meeting
had been held at the Food and Drug Administration (FDA),
between insulin manufacturers, government regulators, and
interested consumer groups.  We went to these meetings to
push for change in the current insulin vial labeling system,
the one that only distinguishes between vials of R, N, L, U,
mixtures, or quick-acting Humalog, by print on the label. 
Blind diabetics and those losing vision find the system
dangerous and discriminatory, requiring sighted aid or
reliance on impermanent markers such as rubber bands or
tape.  It was and is too dangerous to continue.

     In our series of meetings, we reached a consensus that
all U.S. insulin vials should be marked with a tactile code
of one through four horizontal bars:  a single bar for the
"rapid-acting" types like Humalog, two bars for "Regular"
insulins, three bars for mixed insulin preparations (70/30
and 50/50 in the U.S.), and four bars for the longer-acting
insulins:  NPH, Lente, and Ultralente.

     The FDA agreed.  Insulin manufacturer Eli Lilly and
Company agreed, and made it clear they were "ready to go"
with the four-bar system as soon as official permission was
given to do so.  Vial label manufacturer CCL Label agreed,
and stated they had the technology to produce the labels,
and that label reliability ("robustness") could be 100%
guaranteed.  All consumer groups present agreed, including
the watchdog ISMP (Institute for Safe Medication Practices),
the Juvenile Diabetes Foundation, the American Council of
the Blind, the American Diabetes Association, and the
American Association of Diabetes Educators.  Of course we,
the Diabetes Action Network of the National Federation of
the Blind, started the ball rolling.

     The only naysayer was Novo Nordisk Pharmaceuticals
Inc., the huge Danish insulin manufacturer.  In past VOICE
articles, I reported how Novo has repeatedly sought more
time "to test alternatives," how they failed to keep their
commitments to complete research and deliver findings to the
FDA on time, and how they clung to an alternative system
("dots on the vial caps") long after all other meeting
participants had found that system inadequate.

     As the June 3 meeting closed, we seemed to have reached


a consensus.  Novo could take its case to the International
Diabetes Federation meeting in Helsinki, Finland, but if
there was no major outpouring of resistance to the U.S.
plan, the four-bar system would become a requirement for
insulins sold in the United States.

     The FDA agreed to let all participants know, by fax on
or about August 1, whether or not there was cause for
further delay.  They did not do so.  On August 13, I finally
reached Dr. William Berlin, chair of the June 3 meeting, who
stated he had been out of the country.  He reported he "had
not caught up yet," had much more to read, but he thought
he'd seen a note from Novo Nordisk asking for yet another
delay.  He promised again, to let all meeting partcipants
know the outcome.  As of today (August 28) I have heard
nothing further from Dr. Berlin, and I have no idea what
Novo may have said to him.

     Novo tried, as I've mentioned, to bring their European
"dot on the cap" system into the U.S. market, but the coding
couldn't carry enough different messages, and wasn't
pronounced enough to fill the needs of blind users.  Novo
also pushed hard to have their Novolin System insulin pens
and prefilled syringes designated as "tactile-coded," but
again consumer groups found their markings inadequate (as
did the FDA, who require all insulin pens sold in the United
States to be packaged with the warning "Not for use by blind
or visually-impaired persons without sighted aid").

     Some time ago, when a four-bar system of tactile
insulin vial codes was first proposed, CCL Label created
"mock-ups" of tactile labels, and sent them around for
comment (I got some too).  Since that time, Eli Lilly has
perfected both the labels and the manufacturing technology
necessary to produce them, test them, and ensure their
reliability.  At the June 3 meeting, both Lilly and CCL
declared their readiness to proceed.

     But not Novo Nordisk.  With arguments that left me
confused, Novo declared that they were not satisfied with
either the robustness or reliability of the tactile bars. 
They claimed, there at the June 3 meeting, that
approximately one percent of their test labels failed.  They
then passed around a sample, "proof of failure," that turned
out to be part of the mock-up sent them by CCL Label, over a
year before, meant to show conformation of the proposed
system, not its durability!

     When CCL Label set the record straight, and declared
they had developed the labels into a system they could test
and would guarantee, Novo seemed astonished.  A Lilly
representative then stated his company had performed "rather
rigorous testing" of labels, that they had satisfied
themselves THE TACTILE BARS WERE MORE DURABLE THAN THE
PRINTED LABEL, that they had even soaked the vials in
alcohol, destroying the printed label, "without the bars
falling off," and could find no evidence of damage to any of
the tactile codes.  A Novo Nordisk representative admitted
his company had not developed a single specific test
protocol to determine label reliability.

     I couldn't believe it.  How can one sit there and
proclaim statistics, or declare percentages, without a test
protocol to produce them?  No findings are any more reliable
than the tests used to generate them.  Not to slight Novo
Nordisk's perfectly valid questions about label reliability,
but the answers they offered were not straightforward, to
say the least.

     So where did that leave us?  Novo agreed to accept the
four-bar system, if there was no outcry to the contrary at
Helsinki.  They have not come back to us, or to the FDA,
claiming the weight of world opinion.  In fact, they've been
rather scarce of late.

     The FDA has not been much in evidence either.  Although
they promised to let all participants know whether they
could proceed (as I discussed above), they have not done so.

     Eli Lilly and Company indicated its acceptance of the
system, and its readiness to move forward, a long time ago. 
Dr. Jerry Buehler, part of Lilly's delegation to the
meetings, told me:

          We had no problems going in, and we...were
     satisfied with the outcome.  I think they [the FDA]
     were waiting only for any potential objection from
     Novo.  I'm assuming since we haven't heard anything,
     that there are none.  We [Lilly] are proceeding
     ahead... on our own pace to go ahead and implement
     this...  We're going ahead with everything just as we
     would have planned.

     As I mentioned in earlier articles, the "Code of
Federal Regulations" (CFR), does not specifically address
the issue of tactile markings on vials of injectable
medication.  Because of this, FDA regulators have declared
that the long process of regulatory change could be greatly
accelerated in this case.  The FDA even agreed to allow one
company to proceed in advance of the other, once they issue
formal permission.

     But while we wait, the misdosages continue.  The
midnight ambulance rides continue.  The threat of death
remains with any serious hypoglycemic episode.  All credit
to Lilly for tiring of the wait, but we're still waiting for
the FDA to issue a definite opinion that they may proceed. 
And whatever Novo Nordisk is doing, in my opinion it does
not reflect concern or respect for diabetics in the United
States.

     I hope to have more positive input soon.

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

     If you or a friend would like to remember the Diabetes
Action Network of the National Federation of the Blind in
your will, you can do so by employing the following
language:

     "I give, devise, and bequeath unto the Diabetics Action
Network of the National Federation of the Blind, 1800
Johnson Street, Baltimore, Maryland 21230, a District of
Columbia nonprofit corporation, the sum of
$___________________" (or "___________ percent of my net
estate" or "the following stocks and bonds:___________") to
be used for its worthy purposes on behalf of blind persons."

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

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

                      (Resource Column)


     Inclusion of materials in this publication is for
information only and does not imply endorsement by the
Diabetes Action Network of the NFB.


                   Equipment and Supplies

     Comprehensive Health Services, Inc., offers a customer
direct diabetic supply program.  They stock glucose monitors
for the sighted and visually impaired, test strips,
syringes, and other diabetic products.  Medicare and private
insurance accepted; free and convenient home delivery; 24-
hour toll-free telephone; training and emergency customer
support.  Guaranteed full refund on supplies returned within
30 days of purchase.  To qualifying customers, no "out of
pocket" cost for diabetes supplies; no insurance paperwork
to fill out.

     For information, call 1-800-261-8917, or contact: 
Comprehensive Health Services, 602 U.S. Hwy. 117 N., Burgaw,
NC 28425.


                      Large Print Books

     The Doubleday Large Print Home Library is a book club,
offering best sellers and other selections, in hardback, in
easy-to-read 16-point type.  Prices are competitive with the
same titles in standard type, and satisfaction is
guaranteed.  To learn more, or for a free catalog, contact: 
The Doubleday Large Print Home Library, 6550 East 30th
Street, PO Box 6309, Indianapolis, IN 46206-6309.


                      Diabetes Supplies

     Heritage Diabetic Supply is a small, personalized
source for your diabetes needs (insulin included), offering
reasonable prices and one-on-one service.  If you need
something hard to find (like Diascan test strips), they will
get it for you.  Heritage handles Medicare and private
insurance paperwork (no HMOs), and offers a free RSG glucose
monitor just for signing up!  Contact:  Heritage Diabetic
Supply, PO Box 1270, Marion, NC 28752; telephone:  1-800-
267-6509.


                     Diabetic Diet Help

     Doctors and dietitians tell us in microscopic detail
just what we should and should not eat.  The problem is
following their instructions, on a daily basis.  Keeping
track of what you should eat, what you've already had, and
what's not in your meal plan is easier now, with the
Diabetic Tracking System.

     The Diabetic Tracking System is a set of color-coded
cards, labelled in large print (Braille headers available)
divided into the different food groups (starch, vegetables,
fruit, protein, milk/yogurt, fats).  Each card represents
one serving.  Once you and your doctor or nutritionist have
determined how many and which of the cards you should use,
start each day with all your cards in the NOT USED stack,
and when you eat, move the cards that represent the foods
eaten to the USED stack.

     To order a set of Diabetic Tracking System cards, in
large print, or in large print with Braille headers, send
check or money order for $17.95 (+ $2.95 shipping) to: 
Diabetic Tracking System, PO Box 506, Cypress, TX 77410-
0506.


                     Skin Care Products

     From the Editor:  MI FINE SKIN is a line of skin care
products of interest to diabetics.  The line includes a
cream, a lotion, and a soap-free cleanser, all appropriate
for the dry skin we face as a consequence of our diabetes. 
I've used the lotion and the cream, and highly approve of
them both.  The cream is especially appropriate for our dry
feet, and has been endorsed by diabetes educators and
podiatrists as appropriate for diabetic foot care (a useful
"diabetic foot care" pamphlet is furnished with the cream). 
I tried the cream on my feet; it's not greasy, and it works!

     The soap-free cleanser comes in two varieties: "for
normal, dry, or sensitive skin" (16 oz. bottle) and "for
oily skin" (8 oz. bottle).  The face and body lotion comes
in an 8 oz. bottle, and the cream is packed in a 4 oz. jar. 
FREE SAMPLES OF THE CREAM AND LOTION ARE AVAILABLE.

     For information, or to obtain a free sample, contact: 
MI SKIN, INC., 3645 Warrensville Center Road, Suite 321,
Shaker Heights, OH 44122; telephone: 1-800-754-6066.


                       Foot Protection

     Lam-in-Sole safety insoles slip into your boots, work
shoes, dress shoes or jogging shoes, and take up no more
space than commercially available cushion inserts.  But the
Lam-in-Sole is different; it starts with a piece of flexible
.02" rustproof steel, then adds a foam latex pad for
comfort.  Where a conventional shoe or boot is little
protection if you step on a nail, broken glass, or other
sharp object, the Lam-in-Sole will withstand an exposed
piercing object at more than 300 pounds pressure.  Cost: 
$19.95.  Help prevent those foot injuries that can turn
serious!  For information, contact:  Prevention Safety
Products, 99 Marshall Street, Winthrop, MA 02152; telephone: 
1-800-484-6753 (then enter "8089" when it asks for the 4-
digit security code) or:  (617) 846-7042; fax:  (617) 539-
1951.


                    WINDOWS Screen Reader

     GW Micro has developed "WINDOW-EYES," a screen reader
for Microsoft WINDOWS 3.1x and WINDOWS 95.  Once equipped
with a voice synthesizer such as the Dectalk (your standard
soundcard won't do), any computer that can run WINDOWS can
run WINDOW-EYES.  A free demo disk is available!  The
WINDOW-EYES program costs $495, and is available from:  GW
Micro, 715 Airport North Office Park, Fort Wayne, IN 46825;
telephone:  (219) 489-3671.


                      Talking Computers

     Henter-Joyce, Inc., maker of the "JAWS" series of
computer screen readers, offers screen-to-speech software
including "JAWS For WINDOWS" (JFW 3.0), now capable of
reading WINDOWS 95.  The company also produces "JAWS for
WINDOWS NT," and software for the DECtalk speech
synthesizer.  Find out more at their website: 
http://www.hj.com, or contact them for information:  Henter-
Joyce, Inc., 11800 31st Court North, St. Petersburg, FL
33716; telephone:  1-800-336-5658 or 1-800-803-8000; fax: 
(813) 803-8001; email:  info@hj.com


                     Adaptive Computing

     HumanWare, Inc., a leader in adaptive computer
technology for the blind and visually impaired, offers
Braille computer terminals, Braille printers, electronic
print magnifiers (CCTVs), talking palmtop organizers, speech
synthesizers, adaptive software products, specially
configured talking computers, scanners and reading systems. 
New to their catalog are the Kurzweil Omni 1000 and Omni
3000 text-to-speech systems, Ultimate Reader and TextHELP,
and the Braille Window display.  For information about these
and other products, contact:  HumanWare, Inc., 6245 King
Road, Loomis, CA 95650; telephone:  1-800-722-3393.


                     Carry Your Syringes

     Carrying syringes to work, or "on the go" has always
been an inconvenience at best.  But now, the safe
transportation of pre-filled insulin syringes is as simple
as carriying a pen.  The Wright Prefilled Syringe Case
accommodates a wide variety of U-100 syringes, including B-
D, EZ-Ject, Terumo, and PharmaPlast.  Sold in sets of two: 
one white and one black case; cost is $16.95.  Contact:  LLW
Enterprises, Inc., PO Box 591353, Houston, TX 77259-1353;
telephone:  1-800-824-2401 or (281) 480-1506.


                 Diabetic Skin Care Products

     The Anastasia Marie Diabetic Pure Skin Therapy Total
Skin Care System for Face & Body is a complete line of
products specifically formulated for diabetic dry skin,
including:  Diapedic Foot Cream, Hand and Body Cream,
Azulene Night Repair, and Day Protection Formula SPF 15. 
These products should be available at pharmacies nationwide. 
For more information or ordering assistance call:  Consumers
Choice Systems, Inc., Bellvue, WA 98005; telephone:  1-800-
479-5232.


                      Diabetes Supplies

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


                 Discount Diabetes Supplies

     Can-Am Care Corporation manufactures many discount-
priced diabetes supplies, including Dex4 glucose tablets, E-
ZJect lancets, and the Quick Check line of generic test
strips.  Its test strip lineup includes those for the
LifeScan One Touch blood glucose monitors.  For further
information, or to receive their "Questions and Answers"
pamphlet, contact Can-Am Care Corporation, Cimetra
Industrial Park, Box 98, Chazy, NY 12921-0098; telephone: 
1-800-461-7448.


                     Diabetic Foot Care

     Comforteze Sock Company manufactures large,
comfortable, non-binding, all-cotton socks.  Sizes medium,
large, and extra large, they fit easily over bandages, and
provide relief for sore and swollen feet.  Price $6 per
pair; money back guarantee.  Call toll-free:  1-888-433-
6636.


                 Insulin Vial Identification

     The Ident-A-Cap system, manufactured by Terron, Inc.,
is a simple way to mark different insulin types, helping to
cut misidentification and dosage errors.  Utilizing
brightly-colored plastic snap-caps with raised letters, it
can help pharmacists, caregivers, and some visually impaired
diabetics distinguish between insulins.  Until the insulin
industry adopts uniform tactile vial markings, this may be a
worthwhile option.  Cost:  $1.99 for a set of two caps. 
Available from Diabetic Promotions; telephone:  1-800-433-
1477, or from:  Terron, Inc., 202 B North 4th Street,
Sanger, TX 76266; telephone:  1-800-862-2348.


                Diabetes Education Materials

     The Pennsylvania Diabetes Academy offers a large
selection of diabetes education materials, geared for
medical professionals, teachers and counselors, patients,
family and friends.  These include "flip charts," videos,
booklets, and the board game "Caretaker."  Many products are
available in Spanish as well.  For information, or free
catalog, contact:  Pennsylvania Diabetes Academy, 777 East
Park Drive, PO Box 8820, Harrisburg, PA 17105-8820;
telephone:  (717) 558-7750, extension 1271.


                     Diabetes Literature

     Krames Communications, a health information publishing
company, now includes diabetes literature in its catalog. 
Pamphlets and tear sheets include material on type I, type
II, foot care, gestational diabetes, retinopathy, long-term
complications, meal planning, sick days, and more.  For
catalog and ordering information, contact:  Krames
Communications, 1100 Grundy Lane, San Bruno, CA 94066-3030;
telephone:  1-800-333-3032; http://www.krames.com


                   Rehabilitation Centers

     Many "blind rehab" centers offer training in the
adaptive skills of blindness, but the following three work
closely with the National Federation of the Blind, and
adhere to its philosophy:  that with appropriate training,
equipment, and opportunity, blind people can be fully
independent, productive, and involved in the mainstream.  If
you have need of training in non-visual computer skills,
travel skills, or general life skills, or know someone who
does, please consider:

     B.L.I.N.D., Inc., Director:  Joyce Scanlan, 100 E. 22nd
Street, Minneapolis, MN 55404; telephone:  (612) 872-0100.

     The Colorado Center for the Blind, Director:  Homer
Page, 1830 S. Acoma Street, Denver, CO 80223-3606;
telephone:  1-800-401-4632.

     The Louisiana Center for the Blind, Director:  Joanne
Wilson, 101 S. Trenton, Ruston, LA 71270; telephone:  1-800-
234-4166 or (318) 251-2891.


                    Diabetes Publications

     Our office regularly receives requests  for diabetes
information. Education is essential, and although most
diabetes periodicals will not list their competitors, we at
VOICE OF THE DIABETIC feel our readers are best served by
knowing all their options.  Here are the major national
consumer diabetes publications, listed in descending order
of circulation size: 

1.   "Diabetes Self-Management":  Rapaport Publishing, PO
Box 51125, Boulder, CO 80323-1125.  Published bi-monthly;
general diabetes information.  Cost: $18 per year. 
Circulation:  341,832.

2.   "Diabetes Forecast":  American Diabetes Association,
Inc., 1600 Duke Street, Alexandria, VA 22314; telephone:  1-
800-232-3472.  Published monthly; general diabetes
information.  Cost:  $24 per year.  Circulation:  284,000. 
You can access "Diabetes Forecast" on the World Wide Web at: 
http://www.ada.judds.com/magazine/forecast/default.htm

3.   VOICE OF THE DIABETIC:  The Diabetes Action Network of
the National Federation of the Blind, 811 Cherry Street,
Suite 309, Columbia, MO 65201; telephone:  (573) 875-8911. 
Published quarterly; general diabetes information. 
Distributed free on request, in standard print or
audiocassette for the blind (the VOICE is the only diabetes
magazine available in adaptive format).  Circulation: 
202,610.  You can access the VOICE on the World Wide Web,
at:  http://www.nfb.org/voice.htm

4.   "The Diabetes Advisor":  American Diabetes Association,
1600 Duke Street, Alexandria, VA 22314; telephone:  1-800-
232-3472.  Published bi-monthly; contains advice for
diabetics.  Cost:  $9.95 per year.  Circulation:  60,000.  

5.   "Diabetes Countdown":  Juvenile Diabetes Foundation
International, 120 Wall Street, New York, NY 10005;
telephone:  1-800-223-1138.  

     Published quarterly, "Countdown" reflect's the JDF's
focus on cure-oriented research.  Cost:  $25 per year. 
Circulation:  50,000.  Find "Countdown" on the World Wide
Web at:  http://www.jdfcure.com  

6.   "Diabetes Interview":  3715 Balboa Street, San
Francisco, CA 94121; telephone:  1-800-488-8468.  Published
monthly; general diabetes information.  Cost:  $17.95 per
year.  Circulation:  30,000.

7.   "Two Types":  Patients Publishing Co., Inc., 454 E.
Paces Ferry Road, Atlanta, GA 30305; telephone:  1-800-678-
9691.  A new consumer diabetes magazine, published monthly. 
General diabetes information.  Cost:  $34.95.  Circulation: 
figures not available.

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

                 INSULIN MEASUREMENT DEVICES


     (This article appeared in the VOICE OF THE DIABETIC,
Vol. 11, No. 4, Fall 1996, published by the Diabetes Action
Network of the National Federation of the Blind.  Updated
September 1997.  We received many requests for this type of
information, and, as much has changed, decided to run it
again.)


     Most diabetics, blind or sighted, want and need to
achieve control, independent self-management, of their
diabetes.  But if a diabetic cannot rely on vision to
accurately measure insulin, then, to maintain independence,
he or she MUST have effective alternative techniques,
specifically designed for individuals with partial or
complete vision loss.  Many manufacturers have risen to the
occasion, and with the appropriate adaptive equipment,
non-sighted self-management is a reality.  People's
abilities (and ramifications) vary, and it is important to
remember that different devices best meet different needs.

     Some diabetics, with fluctuating vision, will find that
at certain times of the day they can rely on their vision to
accurately measure insulin.  At other times their visual
acuity may diminish, leaving them guessing at their dose of
insulin or relying on sighted aid.  A diabetic's eye
condition can change daily, making reliance on visual
techniques unsafe. 

     The following is a catalog of alternative devices for
insulin measurement.  Some are designed for those with
partial sight.  Others are intended from the start for
non-visual operation.  A few are the simplest of home-made
aids, some designed by resourceful blind diabetics.  NOTE: 
Prices quoted do not include shipping charges.  


                 Insulin Measurement Systems

     The Count-A-Dose:  This insulin measuring device is
manufactured by Jordan Medical Enterprises, 12555 Garden
Grove Blvd., Suite 507, Garden Grove, CA 92643; telephone: 
1-800-541-1193.  Cassette instructions are supplied.  Its
suggested retail price is $49.95, but the National
Federation of the Blind (NFB) sells it for $40, the lowest
price on record.  Order through:  Aids, Appliances, and
Materials Center (hours of operation 12:30 PM to 5:00 PM
EST, weekdays), National Federation of the Blind, 1800
Johnson St., Baltimore, MD 21230; telephone:  (410) 659-
9314.

     Designed for the Becton Dickinson (B-D) .5cc LoDose
(50-unit) syringe, the Count-A-Dose holds two insulin vials
and directs the syringe needle into the vials' rubber
stoppers.  The user can easily mix two different insulins,
and the "T-bar" that holds the vials has clear and obvious
tactile marks to aid insulin differentiation.  Dose size is
adjusted with the thumb-wheel, which clicks for each unit
measured (clicks can be both heard and felt) up to 50 units. 
The device provides easy, reliable, and accurate non-sighted
insulin measurement.

     (NOTE:  The NFB Materials Center has a supply of the
older, now discontinued, 1cc/100-unit Count-A-Dose. 
Operation is similar, but this device uses the B-D 100-unit
syringe, and each click of the thumb-wheel draws two units. 
No cassette instructions.  Price is $40.)

     The Syringe Support:  This device is manufactured in
Canada by the Fondation Centre Louis-Hebert, 525 Boulevard
Hamel Est, Aile J, Quebec City (Quebec), Canada GIM 2S8;
telephone:  (418) 529-6991.  Instructions (standard print
only) are bilingual.  In the U.S., the Syringe Support may
be purchased (cost $19.95) through:  Lighthouse Consumer
Products, 36-02 Northern Blvd., Long Island City, NY 11101-
1614; telephone:  1-800-829-0500.

     The Syringe Support uses only the B-D 1cc/100-unit
disposable syringe, and measures insulin in 1- or 2-unit
increments, in doses of one to 100 units.  To mix insulins
with the device, it is necessary to remove vials from the
apparatus.  To draw a measured dose, the Syringe Support
depends on a set screw with a raised flange, its only
landmark, at 12 o'clock.  One full turn draws two units. 
One half-turn draws a single unit.  Although the dial lacks
definite tactile or audio indicators, in most cases any
error would be fractional.  Still, the Syringe Support
performs best for those who must draw doses of greater than
10 units. 

     The Load-Matic:  This device is available for $49.95
from Palco Labs, Inc., 8030 Soquel Ave., Santa Cruz, CA
95062; telephone:  1-800-346-4488.

     This device allows two different measurement
increments:  10-unit and/or single units of insulin.  It
uses only 1cc/100-unit B-D syringes.  Depressing the lever
measures a 10-unit increment, and turning the dial one click
measures a single unit.  To mix insulins with the Load-
Matic, as with the Syringe Support, it is necessary to
remove and replace insulin vials from the device.

     Although an intriguing design, the Load-Matic features
an overly complex operating drill, with many opportunities
for user error.  Ambiguous and incomplete instructions take
a high degree of familiarity for granted, and may confuse
the inexperienced.  Its 10-unit lever, if incompletely
depressed, is capable of dispensing the unwary user an
incorrect dose.  The Load-Matic's cassette instructions tell
the blind user to draw only about 700 units out of an
insulin vial with the device, as "this assures that you will
never draw air into your syringe instead of insulin."  The
printed instructions lack this statement.  The instructions
make no provision for removing air bubbles from the syringe,
which can easily be accomplished by drawing four or five
units of insulin, reinjecting them into the vial, three
times, and drawing the full measured dose the fourth time
(insulin mixers need do this only with their Regular
insulin, the first they draw.)


             Homemade Insulin Measurement Gauges

     The simplest insulin gauges are devices which allow the
plunger on an insulin syringe to descend a set distance and
no more.  The distance corresponds to a measured dose of
insulin, and the gauge enables that dose to be reliably
duplicated without sight.  To draw a different dose, you
must use a different gauge.  You may need quite a
collection!  Gauges may be of a number of shapes (flat,
corner-molding, tube...), and can be constructed of many
different materials (wood, plastic, metal, old credit
cards...), but most of them will be rigid, flat, several
inches square, and on one end of the gauge there will be an
L-shaped notch.  This L-notch will fit on the plastic collar
located between the flanges and the plunger of the insulin
syringe.

     Further down the insulin gauge will be the small slot
where the plunger seats, once you have reached the correct
dose for that particular gauge.  When making an insulin
gauge, keep the slot very narrow, to insure that when the
plunger is seated in the slot there is no play (which would
allow a variation in the dose).  The L-notch and the slot
must both be on the same side of the insulin gauge. 

     Although many people make their own insulin gauges, out
of all types of materials, commercial gauges are available. 
Meditec, Inc., 3322 S. Oneida Way, Denver, CO 80224;
telephone:  (303) 758-6978, offers Insulgages, flat plastic
gauges analogous to the homemade types described above, but
labeled in Braille with raised numbers.  Priced at $9.75
each, these are cut for either B-D or Monoject syringes, and
many sizes are available; one insulgage per dose.  Use of
Insulgages in conjunction with the Holdease needle guide and
syringe/vial holder, also sold by Meditec (cost:  $15.75),
enables non-sighted insulin measurement.

     The best insulin gauges, homemade or commercial, are
those most durable.  Insulin gauges constructed from
cardboard or staples, however inexpensive, are NOT
RECOMMENDED.  They distort and break too easily.

     A more complex homemade insulin measuring device was
designed, years ago, by VOICE editor Ed Bryant.  His gauge
was a carefully carved block of wood that allowed precise
syringe placement, non-sighted insertion of needle into
vial, and reliable tactile duplication of preset doses.  To
change the dose, he had only to replace one wooden or
plastic preset with another.  It worked well, but he feels
that as most folks do not have access to the necessary
precision woodworking, blind diabetics would be better
served by the Count-A-Dose, which he now uses.

     The use of non-standard or homemade insulin measuring
devices should only follow a thorough checkout of such
devices.

     It is important to understand that insulin gauges are
"cut" for a specific brand and size of syringe.  Therefore,
an insulin gauge that has been cut for a Monoject, Terumo,
or other type syringe cannot be used, will not produce an
accurate reading, on a B-D syringe and vice versa.  An
insulin gauge cut for a 1cc B-D syringe cannot be
successfully used on the 1/2cc (Lo-Dose) or 30-unit B-D
syringe, for the same reason.


                     Other Alternatives

Appliances and Holders

     The Insulcap, a color-coded, tactile-cue equipped
plastic fitting, attaches to an insulin vial and guides
insertion of the syringe, holding the needle at the correct
depth.  The syringe won't shift and bend the needle, as the
Insulcap holds the bottle to the syringe, freeing both hands
for the filling operation.  Offered by Diabetic Insulcap,
Inc., P.O. Box 34347, Las Vegas, NV 89133-4347; telephone: 
(702) 363-0426, the Insulcap is sold in sets of two: one
blue, without tactile cues; and one orange, with tactile
cues.  Suggested retail price is $7.95.  Individuals with
low vision, arthritis, or other conditions causing
unsteadiness may benefit, though those without sight would
be better served by devices such as the Count-A-Dose.

     The Ident-A-Cap, similar to the above, offers a
selection of color-coded and tactile cues.  Each package
includes two different vial caps, which also attach to the
neck of the vial, providing some nonvisual identification of
the contents.  (There are six choices--when you order, they
will send you the right caps.)  Until tactile-marked insulin
vials become widely available, this product may be of
benefit.  Cost:  $1.99 for a package of two.  Available from
Diabetic Promotions; telephone: 1-800-433-1477, or from
Terron, Inc., P.O. Box 958, Sanger, TX 76266; telephone: 1-
800-862-2348.

     The Inject-Aid is a syringe/vial holder incorporating a
preset that allows consistent non-sighted drawing of a set,
pre-determined insulin dose.  Note that insulin adjustment
requires sighted aid.  The Inject-Aid costs $24.95, and is
available from George Wright Industries, 3741 Faulkner
Drive, Apt. 301, Lincoln, NE 68516; telephone:  (402) 423-
3253.



     The Uni-Cal-Aid is similar to the Inject-Aid, but
incorporates two adjustable preset stoppers, allowing two
different doses or insulin mixing.  It accepts all syringe
types, but any adjustment of dose requires sighted aid. 
Price $25 U.S. or $30 Canadian, available from:  Uni-Cal-
Aid, P.O. Box 1000, Hope, B.C., Canada V0X ILO; telephone: 
(604) 869-5648.


                    Pen Injection Devices

     The Novolin Pens:  Novo-Nordisk Pharmaceuticals Inc.,
100 Overlook Center, Suite 200, Princeton, NJ 08540;
telephone:  1-800-727-6500, produces three pen-type devices. 
They offer the "Novolin Pen," which retails at $40
(excluding insulin cartridge), and uses 150-unit "Novolin
System" insulin cartridges (R, N, or 70/30 mix) and
"Penneedle" replacement needles.  This device delivers a
measured dose of between two and 38 units, in two-unit
increments.  Novo-Nordisk also offers "Novolin Prefilled"
disposable syringes.  These devices are smaller than a pen
injector, hold 150 units of R, N, or 70/30 mix insulin, and
are packed five syringes to a package; suggested retail
price (package of five syringes):  $19.10; comparable to the
cost of cartridge replacements for the Novolin Pen. 

     Novo Nordisk has a new pen injection device, the "Novo
Pen 1.5."  Similar to the Novolin pens, it uses the 150-unit
Novolin insulin cartridges, and delivers insulin in one-unit
increments.

     According to the manufacturer of the Novo-Nordisk pens
and the prefilled Novolin syringes:  "None of our devices
are recommended for use by blind or visually impaired
persons without sighted aid." 

     The Autopen is a British-made insulin pen injector,
designed to use the Novolin system cartridges and disposable
needles.  In the U.S. it is marketed by Owen Mumford, Inc.,
849 Pickens Industrial Drive, Suite 12, Marietta, GA 30062;
telephone:  1-800-421-6936.  It is available in two
versions: a one-unit increment (administers up to 16 units)
and two-unit increment (up to 32 units) pen, differentiated
only by color.  Each is priced at $33.50.

     Becton Dickinson Corporation (in partnership with Eli
Lilly and Company) offers the B-D Pen.  Similar to the Novo
Nordisk and Mumford pens, the system dispenses 150 units of
R, N, Humalog, or 70/30 insulin, in one-unit increments,
from one to 30 units.  Although B-D does not specify a
"suggested list price," the pen should cost about $40.  B-D
also offers a "pen magnifier" (similar to the syringe
magnifiers described below) that clips to the pen to aid
low-vision operation.  This magnifier is available free of
charge, by calling Becton-Dickinson at:  1-800-237-4554. 
The B-D Pen should be available at most pharmacies.


                     Syringe Magnifiers

     The Insul-Eze 6000, manufactured by Palco Labs (listed
above) is a syringe-and-vial holder incorporating a full-
length 2x lens, allowing the insulin-drawing operation to be
closely monitored. Insulin vials can be changed for mixing
without disturbing the syringe.  Adaptable, the Insul-Eze
works with most types of syringes in the 30-, 50-, and 100-
unit size.  Cost:  $11.

     The Truhand, a device similar to the Insul-Eze, is
offered by Whittier Medical, Inc., 865 Turnpike Street,
North Andover, MA 01845; telephone:   1-800-645-1115.  It
allows use of different syringe types and sizes, and firmly
holds the vial, while providing a 3x magnified view of the
scale.  Vials can be changed for mixing without disturbing
the syringe.  Cost:  $29.95.

     The Magniguide, offered by Becton Dickinson Consumer
Products, One Becton Drive, Franklin Lakes, NJ 07417-1883;
telephone:  1-800-237-4554, is another syringe magnifier. 
It attaches to the insulin vial, and provides 2.5x
magnification, to aid needle insertion, precise dose
measurement, and location of bubbles in the syringe.  The
Magniguide is available (cost: $3.95) from Independent
Living Aids, Inc., 27 East Mall, Plainview, NJ 11803-4404;
telephone:  1-800-537-2118.

     The Ezy-Dose Syringe Magnifier fits all 1/2cc and 1cc
syringes, and clips to the syringe barrel, magnifying the
scale 2x to aid precise dose measurement.  Manufactured by
Apothecary Products, Inc., 11531 Rupp Drive, Burnsville, MN
55337-1295; telephone:  1-800-328-2742, the device does not
affect needle insertion, which must be done visually. 
Price:  $4.95, available from LS&S Group, Inc., P.O. Box
673, Northbrook, IL 60065; telephone:  1-800-468-4789.

     The Cemco Syringe Magnifier, available in three sizes
(to fit syringes of 1cc, .5cc, and .33cc), is offered by
Cemco, P.O. Box 31, Scandia, MN 55073; telephone:  (612)
433-3374.  The magnifier clips to the syringe and aids
precise filling, but needle insertion into the vial must be
done visually.  Price:  $5 retail, or $42 per dozen (any
combination of sizes).

     The Diabetes Action Network of the National Federation
of the Blind is a support and information network for all
diabetics.  We have many members willing to share their
expertise in non-sighted techniques of diabetes self-
management.  If you have any questions about diabetes and
blindness, feel free to contact us. 

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

                      FOOD FOR THOUGHT



Art:  Dancing fruits and vegetables


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


                 Cold Remedies and BG Levels

     Some cold sufferers may notice that as they sneeze,
cough, and grope for relief, their blood sugars are
unusually elevated.  Some of this rise will be the body's
normal response to the stress of infection, but some may
also come from the over-the-counter products we take to feel
better.  Many decongestants contain ephedrine or
pseudoephedrine, a cousin to adrenalin.  This tends to raise
blood glucose levels.  Many liquid medications contain a lot
of sugar (ask your pharmacist about sugar-free medications). 
Many liquid "cough and cold" medicines contain alcohol up to
25%.  Take care, and remember to test your blood more
frequently when you are ill.


              Bypass Better for Some Diabetics

     The National Heart, Lung, and Blood Institute (NHLBI),
in late September 1996, issued a clinical alert recommending
bypass surgery instead of angioplasty for some diabetics who
have coronary artery disease.  

     The recommendations apply to diabetics with more than
one blocked artery and who take insulin or oral medication
to lower blood sugar.

     An NHLBI study, the largest to date comparing the two
procedures, found that 19 percent of these diabetics died
within five years after bypass surgery, compared to 35
percent of those after angioplasty.

     The findings do not apply to heart patients without
diabetes, whose death rate, at nine percent, was the same
for both treatments.


                      Night-time Hypo's

     Successful diabetes self management is a balancing act
between medication, diet, exercise, and the unique nature of
an individual's diabetes.  To preserve tight control, many
folks cut their per-meal food intake to the limit, and then
some of them find they need a late night snack to keep
sugars from dipping too low before morning.  What should you
eat?  Is there anything that you can take at bedtime, to
keep from having to get up and eat at 2 or 3 a.m.?

     Medical Foods, Inc., announces NiteBite timed-release
Glucose Bar.  NiteBite, available in chocolate fudge or
peanut butter flavor, 100 calories per bar, is specifically
formulated to release some of its glucose quickly, some
after several hours, and more several hours after that.  It
can help keep you from dropping into hypoglycemia hours
before breakfast.  (NOTE:  THIS PRODUCT HELPS PREVENT
HYPOGLYCEMIC REACTIONS; IT IS NOT FOR USE IN TREATING A "LOW
BLOOD SUGAR" THAT IS ALREADY UNDERWAY!)

     NiteBite is available in six-packs ($7.50) or "thrifty-
packs" of 30 ($30 each).  Please include $4.95 shipping per
order.  Credit cards accepted; free samples are available. 
Contact:  Medical Foods, Inc., 201 Broadway, Fifth Floor,
Cambridge, MA 02139-1955; telephone:  1-800-795-1880.


                     1997 Raffle Winners

     At the keynote banquet for the 1997 annual convention
of the National Federation of the Blind, in New Orleans,
Louisiana, the winning ticket was drawn in the Diabetes
Action Network raffle.  Winning ticketholder was Margaret
Harmon, of Glendale, Arizona.  

     Lots of people helped sell tickets, and the following
folks each sold 50 or more.  In descending order of tickets
sold:  Karen Mayry, of Rapid City, SD; Ken Staley, of
Chicago, IL; Martha Young, of Kansas City, MO; Ed Bryant, of
Columbia, MO; Jerry Antone, of French Lick, IN; John Yark,
of Stamford, CT; Lynn McCallum, of Eugene, OR; Kerry Smith,
of St. Louis, MO; Sandie Addy, of Prescott Valley, AZ; Mary
Hook, of West Hartford, CT; Donovan Cooper, of Burbank, CA;
Gisela Distel, of Albany, NY;  Edna Stevens, of Springfield,
MO; and Bob Ritter, of Myrtle Beach, SC.   Truly a winning
performance--See you next time!


                          For Sale

     Gail Bryant, of Columbia, MO, is selling a Braille
Dictionary:  "Webster's New World Dictionary," 72 volumes. 
$1000 or best offer.  Respond c/o VOICE OF THE DIABETIC, 811
Cherry Street, Suite 309, Columbia, MO 65201; telephone: 
(573) 875-8911, or reach her by e-mail:  
gbryant@mail.coin.missouri.edu


                     Talking Merchandise

     We have been asked to announce:  "Speak To Me!" a
merchandiser of useful, esoteric, and humorous items, all of
which feature synthesized speech, now offers their
Fall/Winter 1997 catalog. Included are talking holiday
items, singing and talking greeting cards, children's items,
talking gags, and useful items like talking clocks, watches,


calculators, caller IDs, and even a talking bread machine. 
For a free catalog, in print, cassette, or IBM computer
disk, contact:  Speak To Me!, 17913 108th Ave. SE, Suite
155, Renton, WA 98005; telephone:  1-800-248-9965: 
http://www.clickshop.com/speak/


                  Insulin Labelling Errors

     "Medication Safety Alert," the newsletter of the
Institute for Safe Medication Practices, reports that
doctors' traditional practice of abbreviating "U" (units) on
prescriptions and medication orders can cause trouble, when
the prescription is insulin.  Not only is there potential
for confusion between insulin "U" (units) and "U" insulin
(Ultralente), but ambiguous penmanship has led to "U"s being
read as "N"s, with misdosage as result.  Health
professionals need to take extra care in the reading and
writing of prescriptions and medication orders!


                       Free Literature

     Parke-Davis, maker of the new oral medication Rezulin,
offers a free pamphlet about insulin resistance, titled
"Improve Your I.R.I.Q."  To learn more about insulin
resistance, type II diabetes, and your options, contact: 
Parke-Davis, 201 Tabor Road, Morris Plains, NJ 07950, and
ask for a copy of their free "I.R.I.Q." pamphlet.


                       To Our Readers

     To hold down costs, both the VOICE and many of our
divisional mailings are sent via "bulk mail."  When we have
your current address, this works very well, but when we
don't, the Post Office throws it away, or returns it to us
with a hefty "postage due" attached.  They do NOT
automatically forward bulk mail!

     If you move, please let us know promptly.  If the VOICE
doesn't follow you to your new address, we may not have your
new address.  Don't miss a single issue.


         Diabetes Action Network Support Committees

     For more than eleven years, our support committees have
been reaching out with listening ears and helping hands to
diabetics in need of advice and information.  Network
members with personal  experience in these matters staff the
following committees:  Blindness/Visual Dysfunction,
Amputation and Treatment, Heart Disease and Stroke, Insulin
Pump, Pancreas Transplantation, Renal Failure--Dialysis and
Transplantation, Womens' issues, and Sexual Dysfunction/Male
Impotence.  To access our support committees, contact the
VOICE editorial office.


                 Diabetes Prevention Trials

     Right now, in several different parts of the world,
tests are
underway to determine if type I (insulin-dependent) diabetes
can be prevented.  These are the Diabetes Prevention Trials.

     All of them focus on the recognition of type I as an
autoimmune disease, a condition in which the human immune
system mistakenly attacks and destroys part of the body, in
this case the islet cells of the pancreas.  If this
misguided attack could be deterred or halted, the damage
would not take place.

     Although the researchers, in Canada, Europe, Australia
and the United States, do not know what triggers the
autoimmune attack that causes type I diabetes, they do know
what it targets:  several specific genes and proinsulin
peptides.  As the human thymus is responsible for training
the immune system to tolerate its own tissues, research is
focusing there.  

     Researchers have also identified a substance that
protects against autoimmune attack, called Interlukin-2. 
They are investigating the nature of the shortage or defect
in this substance that might encourage autoimmunity.  If
problems with the supply of this substance cause the
autoimmune attack that causes type I diabetes, exogenous
Interlukin-2 might play a significant role in diabetes
prevention.

     Researchers are also looking at the genetic makeup of
the Beta cells themselves, with an eye to strengthening
their resistance to autoimmune attack.  Though success is
years away, immune-resistant Beta cells might be more easily
transplantable.

     There is some effort to use oral or aerosol insulin to
"desensitize" the immune systems of people judged at risk
for type I diabetes.  Researchers are attempting to moderate
the autoimmune attack by familiarizing the body with
insulin.  If successful, this tack may produce a diabetes
"vaccine."

     It is an exciting time.  A number of productive lines
of inquiry are being followed, and all of them could remake
diabetes medicine as we know it.  We'll be watching!


                      Bible on Cassette

     We have been asked to announce:  The Aurora Ministries
Bible Alliance offers Bible tapes, without charge, to
persons who are legally blind or print handicapped.  Forty-
five different languages are currently offered, from Amharic
to Zande, and the service is without charge to anyone who
meets the criteria set up by the National Library Service
for the Blind and Physically Handicapped.  For information,
contact:  Aurora Ministries Bible Alliance, PO Box 621,
Bradenton, FL 34206; telephone:  (941) 748-3031.


                       Eye Information

     The National Eye Health Education Program of the
National Eye Institute (NEI) provides a number of free
publications for the public, including fact sheets,
technical reports, educational brochures for patients and
the general public, information packages, and combined
health information database searches.  To request a list of
publications, contact (Monday through Friday 8 a.m. to 4
p.m. CST):  the National Eye Institute; telephone:  1-800-
869-2020.


                Yeast Infections and Diabetes

     The NFB of Cleveland (Ohio) Diabetic Committee
Newsletter reports a case in which a woman who had been
repeatedly bothered by female yeast infections sought
medical advice.  The "clued-up" doctor tested her blood
sugar, found it quite high, and discovered type II diabetes. 
When her glucose level came down, the infections cleared up.


                        New Research

     Researchers at Eastern Virginia Medical School, in
partnership with McGill University in Montreal, Canada, and
insulin manufacturer Eli Lilly and Company, have discovered
a gene that apparently controls the replication of Beta
cells in the human pancreas.  In tests, the gene, called
INGAP, caused growth and regeneration in pancreatic cells,
and reversed the effects of diabetes in hamsters.

     Although researchers emphasize that years of tests are
needed, at some point, therapy with INGAP may provide a cure
for type I diabetes.  Stay tuned!


                      Articles Needed!

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

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

     Perhaps you have not experienced side effects?  Your
unique insight, coping strategies, and lifestyle can still
inspire others.  Are you a relative, a friend, or a health
professional?  More than 202,610 VOICE readers could benefit
from your story.

     For information and article submission guidelines,
contact:  VOICE OF THE DIABETIC, 811 Cherry St., Suite 309,
Columbia, MO 65201; telephone:   (573) 875-8911.


                        VOICE Formats

     VOICE OF THE DIABETIC is offered in two formats: 
standard print, and 15/16 ips audiocassette, "talking book"
speed.  Anyone who is currently receiving the VOICE in print
and having difficulty reading it, may receive it on cassette
at no charge.  VOICE tapes require the special tape player
available free to the legally blind from Regional Libraries
for the Blind and Physically Handicapped, which can be
obtained by telephoning the National Library Service at 1-
800-424-8567.

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

     All a subscriber needs to do, to switch from standard
print to tape, or to receive both formats, free of charge,
is contact us at the VOICE editorial office.

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

                         ADVERTISERS


     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 189,
635, offers such an outlet.  Make your voice heard.  For
VOICE OF THE DIABETIC advertising information contact:

                        Eileen Rivera
             National Advertising Sales Manager 
                      726 E. Belvedere
                    Baltimore, MD, 21212
                   phone:  (410) 435-3648
                    fax:  (410) 435-6159

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

                 SUBSCRIPTION/DONATION FORM


     The VOICE OF THE DIABETIC is a quarterly magazine
published by the Diabetes Action Network of the National
Federation of the Blind (NFB) for anyone interested in
diabetes, especially diabetics who are blind or are losing
vision.  An outreach publication, it emphasizes good
diabetes control, diet, and independence.

     Donations are gladly accepted and appreciated. 
Contributions are not only tax deductible but are needed to
keep the VOICE and the Diabetes Action Network moving
forward to help people with all aspects of diabetes.

     Members of the NFB Diabetes Action Network enjoy
priority services and unique benefits such as a continuous
free subscription to the VOICE, automatic access to
committees covering all aspects of diabetes, free counseling
concerning all facets of blindness and diabetes, as well as
access to diabetics who have experienced complications.

     The VOICE is free to any interested person upon
request.  Each subscription costs the Diabetes Action
Network approximately $20 per year.  To help defray
publication expenses, members are invited, and nonmembers
are encouraged, to cover the subscription cost.

     To begin receiving the VOICE, please check one:

[ ]  I would like to become a member of the NFB Diabetes
     Action Network and receive the VOICE OF THE DIABETIC.
     (Members are entitled to special benefits.)

[ ]  I would like to receive the VOICE OF THE DIABETIC as a
     nonmember.  (Nonmembers are encouraged to pay the 
     institutional rate of $20/one year; $35/two years;
     $50/three years.)


Send the VOICE in (check one):

[ ] print   [ ] cassette tape for the blind    [ ] both
                and physically handicapped
                (recorded at slower-than-
                standard speed of 15/16 IPS)


Optionally check this box:

[ ]  I would like to make (or add) a tax-deductible
     contribution of $__________ to the Diabetes Action
     Network of the National Federation of the Blind.


                    Please print clearly

Name:_____________________________________________________

Address:__________________________________________________

        __________________________________________________

City:_______________________  State:______  Zip:__________

Telephone:  (     )________________________


Send this form or a facsimile to:  

Voice of the Diabetic
811 Cherry Street, Suite 309
Columbia, MO 65201


Please make all checks payable to:

NATIONAL FEDERATION OF THE BLIND

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

END of VOICE OF THE DIABETIC, Volume 12, Number 4, Fall
Edition 1997
 
