Managing Diabetes as a blind or low vision person

Lighthouse International 111 East 59th Street The Sol and Lillian Goldman Building New York, NY 10022-1202 Tel: (212) 821-9200 / (800) 829-0500 Fax: (212) 821-9707 – TTY: (212) 821-9713 Appointments 2. Diabetes, Vision Loss, and You By Debra A. Sokol-McKay, MS, CVRT, CLVT, CDE, OTR/L Being in control of your diabetes is hard work, especially when you have a vision loss. But it can be done – and you don’t have to do it alone. Since you’re the one living with diabetes, it’s up to you to know about available services and products. It’s also important to realize that there are people you can turn to for support and information – eyecare and medical professionals, vision rehabilitation therapists, certified diabetes educators and, in many cases, family and friends. It may take more time and effort, but you can achieve the independence you want and learn to manage diabetes your way. Eye Examinations Are Key Diabetes affects vision, so it’s very important to have regular eye examinations by an ophthalmologist and to report any changes in your vision as quickly as possible. When you have a vision loss, an eye exam by an ophthalmologist or optometrist who specializes in low vision care can be an important next step. A low vision exam focuses on the vision you have and, in most cases, optical and/or electronic magnification devices can be prescribed to help you use your remaining vision to perform many diabetes-related and other daily tasks. These may include reading medication and nutrition labels, expiration dates on insulin bottles or blood glucose test strips, and numbers on a syringe. Learning to use these devices successfully and confidently takes some practice, but if it’s important to you to carry out these tasks on your own, it is worth the effort. Managing Diabetes-related Tasks Let’s look at three specific tasks: Blood Glucose Monitoring: Many blood glucose monitors on the market have large displays and bold numbers, making it possible for people with vision loss to continue to test on their own. For those who cannot rely on vision, “talking” blood glucose monitors are available, including one encased in a “voice” unit and others with “voice” attachments that connect to the monitor by a data cable. The voice unit reads aloud the information shown on the monitor display. Your diabetes care professional can provide information about the various monitors with speech capability, such as the Accu-ChekTM VoicemateTM System, an integrated talking system; or the OneTouchR BasicR and OneTouchR SureStepR – each of which can be used with a voice attachment. “Talking” monitors are reimbursable by many insurance companies, including Medicare, as long as your physician writes a detailed prescription and your eye report indicates that you are legally blind (the corrected vision in your better eye is 20/200 or worse). Being able to insert the test strip into the monitor’s port and apply your blood sample to the site on the test strip are essential day-to-day tasks that need to be accomplished visually or by touch. Coding the monitor to the test strips and checking that the monitor is working correctly are also important for proper use and maintenance of your blood glucose monitor. While it takes patience and motivation to learn the steps involved, many people without vision do test their glucose levels independently. But you’ll need a good teacher. A certified diabetes educator (CDE) and/or a vision rehabilitation specialist can help you manage these doable tasks and evaluate which glucose monitor is easiest for you to use. Insulin Management: There are several insulin measurement devices on the market, and a number of techniques you can learn to draw up insulin accurately and safely. It’s important to work with a vision rehabilitation professional along with a CDE or physician to receive proper instruction in the use of these devices, as well as to verify that you are using proper techniques. If you take the same dose of insulin every day, you may be able to use a device that is initially preset by a sighted person and can be used independently thereafter. If your dose varies, you can use a device that measures the insulin by counting and feeling clicks or by counting the number of turns. There are also non-visual techniques to remove air bubbles and to know when your insulin vial is empty. Insulin pens are another alternative for measuring insulin. Your physician or CDE will be able to advise you if the kind of insulin or dose you take is available in this form. Similar to other insulin measurement devices, you can “dial up” your dose with pens by feeling and listening for clicks. Another benefit and safety feature of many insulin pens is that they stop dialing when they’re empty. Many are on the market by such manufacturers as Novo Nordisk, Aventis and Eli Lilly & Co., and require prescriptions. With the exception of one insulin pen specifically designed for users with low vision, all pens have a disclaimer that states a person who is sighted should supervise their use. However, CDEs working with people with vision impairment have long advocated independent insulin pen use following proper instruction. Nutrition Management: Healthy eating – what you eat and how much – is very important to managing diabetes. It’s a good idea to work with a dietician who specializes in diabetes or a CDE to create a meal plan designed for you, and to update it every five years. And you’ll want to be able to organize and identify foods in your cupboard or refrigerator. Here is where a vision rehabilitation professional can help by teaching you methods of organizing your kitchen; identifying foods by using sound, smell and touch; and helping to develop a labeling system that works for you. Many tools are available to obtain proper food portions, including color contrasting/nested measuring cups; portion-controlled serving utensils; and large-display, tactile and talking food scales. Some Helpful Tips You can also apply a number of important vision rehabilitation principles – organization, contrast, lighting and glare control – to help perform many diabetes-related tasks. For example: . When you test your blood glucose or draw up insulin, place your supplies on a solid contrasting surface, or on a tray with a rim or edge. The rim will keep items from getting away from you or accidentally falling on the floor. . Choose a tray color that contrasts with items such as your pills, lancets and blood glucose meter. For example, a dark color tray will make light color items more visible and easier to use. . If you’re measuring insulin, place the syringe against a white surface such as a wall or refrigerator, so that the black plunger tip and syringe markings stand out better. . Consider a flexible-armed desk lamp for your diabetes tasks area. Overhead lighting is usually not sufficient. Position your lamp so that your hand or shoulder does not cast a shadow on your work area. . Avoid glare by covering any shiny surfaces when using diabetes supplies. If glare is a problem when reading the display on a blood glucose monitor, try repositioning the monitor or the lamp. . Consider putting your blood glucose records, food label and other nutrition information in an accessible format – in large print, on a cassette tape or on your computer. It’s in Your Hands Managing your diabetes can feel overwhelming at first. There are many different areas to learn about and a variety of products that can help you on a day-to-day basis. But you’re not alone. While you’re the one to decide what level of independence you’re comfortable with, there are professionals specialized in diabetes care and vision rehabilitation who can guide you. Partner with them, make educated decisions – and stay in charge of your life! Debra A. Sokol-McKay, MS, CVRT, CLVT, CDE, OTR/L, is an Adjunct Faculty at the Pennsylvania College of Optometry’s Graduate Program in Low Vision. She is also Chair of the Disabilities/ Visually Impaired Specialty Group of the American Association of Diabetes Educators. Related Reading: . What is Diabetic Retinopathy? ic-retinopathy/diabetic-retinopathy-overview/ . Symptoms of Diabetic Retinopathy ic-retinopathy/diabetic-retinopathy-symptoms/ . Reducing the Risk of Diabetic Retinopathy tinopathy/ . Diagnosing Diabetic Retinopathy ic-retinopathy/diabetic-retinopathy-diagnosis/ . . Diabetic Retinopathy: Treatment & Care ic-retinopathy/diabetic-retinopathy-treatment-and-care/ 3. Diabetics | National Federation of the Blind Blind diabetics and those losing vision can continue to be independent. The blind can and do accurately draw up insulin, monitor blood glucose levels, etc. ‘Limitations’ are usually self-imposed, and often all that is needed to overcome negative thinking is simply to know where to go for information. Some equipment (i.e. audio output devices) has been adapted for the blind. By using alternative techniques and products, the blind can control their diabetes as efficiently as do their sighted peers. The Diabetes Action Network, a division of the National Federation of the Blind, is a support and information network for all diabetics, especially those who are blind or losing vision. Many of our members have experienced ramifications of diabetes such as blindness, amputation, nerve damage, heart problems, kidney disease, etc. Others have experienced no chronic complications, but want to utilize our services, learn more about diabetes, and be part of a caring support group. In addition to reaching out to fellow diabetics who may be finding it difficult to cope with problems that accompany diabetes, we provide support and information to interested persons. Please join our list serv . We have discussions covering all aspects of living with diabetes. Bridging the Gap – Living with Blindness and Diabetes focuses on nonvisual methods of managing diabetes. This volume has been prepared to answer common questions from blind diabetics. It includes a collection of some of the best articles from the Voice of the Diabetic and a useful resource section. Contact the NFB Independence Market for a copy in print or audio. Additional literature focusing on diabetes as well as blindness related products, which enable the user to perform everyday tasks more independently, can be ordered from the NFB Independence Market . The list, Helpful Tools for Blind Diabetics , found here: describes items which may be of particular interest. Back issues of Voice of the Diabetic are available online. The direct link is here: Each issue contains personal, candid stories written by diabetics, friends, health care professionals, and others who share experiences and expertise on diabetes and its complications. Emphasizing the importance of good diabetes control, proper diet, and independence, this upbeat outreach publication shows diabetics that they have options regardless of the side effects of diabetes. Features include a medical Q and A column, a ‘Recipe Corner,’ and a resource column of aids and appliances. Blind and low-vision diabetics can access Diabetes Forecast and Diabetes Self-Management magazines through NFB- NEWSLINE R, the world’s largest digital talking newspaper service for the blind, available free of charge to anyone who is legally blind. Check out this service here: Thousands of low-vision readers already use NFB-NEWSLINER, which makes the texts of hundreds of local and national newspapers, as well as television broadcast schedules, localized weather alerts, and job listings available on demand to blind readers in an easily accessible format by telephone, online, or via an iPhone/iPad app. Members of the Diabetes Action Network enjoy priority services and unique benefits such as: access to publications, 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. Members of the Diabetes Action Network also automatically become members-at-large of the National Federation of the Blind. NFB DAN Mission The NFB Diabetes Action Network educates, empowers, and inspires people living with diabetes and its complications. We share the Federation’s ‘can-do’ philosophy, through our various publications, volunteer peer support, and advocacy for accessible diabetes technology. Together, we challenge one another to live our best and fullest lives. About the NFB Diabetes Action Network Diabetes is the leading cause of blindness among working-age adults. That’s why the National Federation of the Blind, the largest and most influential membership organization of blind people in the United States, established the NFB Diabetes Action Network (NFB DAN) 22 years ago. The NFB DAN improves lives through advocacy, education, research, technology development, and programs encouraging independence and self-confidence. Originally, the goal of NFB DAN was simple: to educate, empower and inspire blind and visually impaired people with diabetes to manage their condition independently and confidently and to advocate for accessible diabetes products. Thousands of NFB DAN members manage multiple complications, not just vision loss, so our mission has also expanded to include people with all kinds of diabetic complications. NFB DAN volunteers share their experiences and encouragement with those facing similar complications, such as kidney failure, amputation, and neuropathy. For more information please contact: Michael Freeman, President 3101 NE 87th Avenue Vancouver, Washington 98662-6832 Phone: 360-576-5965 E-mail: 4. How Can I Manage My Diabetes? – VisionAware ging-your-diabetes-5709/125 By Debra A. Sokol-McKay Diabetes is a disease that requires 24-hour, 7-day-a-week self-management. It is you who lives with your diabetes and it is you who will make health care decisions when your doctor or other members of your health care team are not available. Blindness or low vision may present challenges, but aren’t necessarily barriers to effective and successful self-management of diabetes. Diabetes Self Management ging-your-diabetes-5709/125#DiabetesSelfManagement Blood Glucose Monitoring ging-your-diabetes-5709/125#BloodGlucoseMonitoring Insulin and Insulin Measurement ging-your-diabetes-5709/125#Insulin_InsulinMeasurement Healthy Eating ging-your-diabetes-5709/125#HealthyEating Being Active ging-your-diabetes-5709/125#BeingActive Proper Foot Care ging-your-diabetes-5709/125#ProperFootCare Overall Health Management ging-your-diabetes-5709/125#OverallHealthManagement Diabetes Self Management Certified diabetes educators (usually nurses and dieticians), in consultation with primary care physicians and endocrinologists (physicians who specialize in the diagnosis and treatment of conditions affecting the glands and hormones), can help you learn more about this type of diabetes management, called diabetes self-management education (DSME) or diabetes self-management training (DSMT): . The American Association of Diabetes Educators (AADE) is the national organization of diabetes educators. * * . AADE provides the “Find A Diabetes Educator” search function to help you find a diabetes educator in your home area. Members of the Disability Community of Interest are experienced in dealing with blindness, low vision, and other disabilities. . The American Occupational Therapy Association (AOTA) has a podcast, Living with Diabetes and a Fact Sheet addressing Occupational Therapy ‘s Role in Diabetes Self-Management (podcast 14) The podcast is found at this link: x . Diabetes Forecast provides a monthly magazine and a yearly Diabetes Resource Guide through the National Library Service for the Blind and Physically Handicapped . Diabetes Self-Management * . . provides self-management information from health care professionals and people with diabetes and publishes The Diabetes Self-Management Blog , * . . an e-mail newsletter , * . . and Diabetes Self-Management magazine which cost for subscription. * key_code=IZSUBDM&type=S&gift_key= . also available free via the NFB-NEWSLINE service. Visit your primary care physician when: . You have an episode of very low blood glucose, several days of low blood glucose, or if you can’t determine when your blood glucose is becoming low. . You want to discuss a change or modification in your diabetes treatment plan. Visit an endocrinologist when: . Your blood glucose levels are consistently higher than you want them to be. . You have one or more diabetes complications or medical conditions that makes managing your diabetes difficult. . You’d like to change the way you manage your diabetes. Visit a nurse diabetes educator when: . You want to better understand how diabetes affects your entire body. . You want basic training to manage your diabetes. . You’re having difficulty with at least one diabetes-related task, such as monitoring your blood glucose. . You’re having problems coping with the emotional aspects of your diabetes. . You want to start an exercise program or find physical activities to help you keep your diabetes in better control. Visit a dietician when: . You don’t understand what or how much to eat. . You haven’t visited a dietician in several years . You don’t have a food plan or your current plan is more than two years old. The most effective diabetes self-management treatment includes a combination of many therapies. AADE proposes that there are 7 key behaviors that lead to optimum diabetes self-management and health. These are called the AADE7T Self-Care Behaviors. They include: 1. Healthy eating: preparing and eating a healthy diet 2. Being active: engaging in appropriate physical activity and exercise while following necessary precautions 3. Monitoring: tracking blood glucose levels, blood pressure, foot health, steps walked, weight, and achievement of goals 4. Taking medication: taking medications in pill, injectable, liquid and other forms 5. Problem solving: managing hypoglcemia/hyperglycemia, sick days, vacations 6. Healthy coping: journaling and other forms of stress reduction 7. Reducing risks: smoking cessation, foot checks, blood pressure monitoring, self-monitoring of blood glucose, maintenance of personal care records, and regular eye, foot, and dental examinations. Blood Glucose Monitoring Blood glucose monitoring allows you to evaluate the effectiveness of your diabetes treatment plan in maintaining your blood glucose levels within a normal range (as described previously). Monitoring will also help you determine if your blood glucose level is low and, if so, what quantity of glucose-containing products or foods you must eat to raise your blood glucose levels into a safe range. In order to perform effective and consistent blood glucose monitoring, you must be able to access the numerical readout on your monitor. Here are some suggestions for individuals who have low vision and use a blood glucose monitor with a standard visual display: Lamp and tray for contrast . Use magnifier or an electronic video magnifier with your current monitor. . Use a flexible-arm task lamp and position it near your better-seeing eye. . Place your monitoring equipment on a contrasting surface; for example, place dark equipment on a light-colored tray. ACCU-CHEK Aviva . Obtain a monitor that has a larger-print display, such as the ACCU-CHEK Aviva Plus System , . . the TrueTrack Smart System , *, or the FreedomStyle Freedom Lite System. FreeStyle Freedom One Touch Ultra One Touch Ultra . Obtain a monitor that has a larger-print display and backlighting,such as the One Touch Ultra2 , * * . ReliOn Ultima, Precision Xtra Blood Glucose and Ketone Monitoring System or a number of the Wavesense monitors; for other models see Accu-Chek Compact Plus PLus Accu-Chek Nano If you’ve been certified as legally blind , it’s likely you’ll meet the requirements of most insurers to obtain a blood glucose monitor with speech capability, also called a talking blood glucose monitor . Blood Glucose Meters – American Foundation for the Blind d-results/blood-glucose-meters/1245 Be aware that talking meters fall into 2 categories – those with partial speech and those with full speech. Those with partial speech may only announce your blood glucose result while meters with full speech not only announce your result but also the results in memory, low battery warning, and audible steps to set the time and other monitor features:. Full speech monitors include: . The Prodigy Voice . . The Vocal Point From SMS – Speciality Medical Supplies . . Fora V20 * From FORA – ForaCare Voice Blood Glucose Meters, Bluetooth Blood Glucose Meters, and Diabetes Management Supplies * . Solus V2 From Talking Blood Glucose Meter | Solus V2 by Biosense Medical Devices – Solus v2 uuEven if your monitor has a large print display and/or speech capability, you may still want to use additional low vision, tactile, and/or auditory techniques to help with accurate and effective blood glucose monitoring: . Explore your test strips either (a) visually to identify color differences or (b) tactilely to identify textural features. This will help you position the strip in the proper direction before inserting it into the monitor. . Before obtaining a blood drop for self-monitoring of blood glucose, increase blood flow by shaking your hand gently at your side and washing your hands in warm water. . Try this technique: (1) Use your left index finger as a “marker” and place it parallel with the slot that holds the test strip; (2) Hold the test strip in your right hand so that it is parallel with, and touching, the left, or “marker” finger; (3) Using the “marker” finger as a guide, insert the test strip into the monitor. Reverse these instructions if you are left-handed. . If you have low vision and find it difficult to locate the blood droplet/sample after lancing your finger, (a) bring your finger closer to your eye; (b) use additional lighting; or (c) hold your finger with the droplet against a white or other contrasting background. . Determine the number of strokes that are required to “milk” your finger and produce a large enough blood sample. Meters are now available that require very small amounts of blood if producing a sufficient blood sample is a problem. To obtain a larger sample, set your lancing device to a deeper penetration. Generally the higher the number the deeper the penetration. . Create a mental map of where you lance your finger in relation to your fingernail to help you locate the blood droplet/sample. . Use a monitor with a “beep” feature that indicates (a) when you have completed a step and (b) when to proceed to the next step. Insulin and Insulin Measurement Insulin is the medication most often associated with diabetes. Insulin therapy is used when other forms of therapy (diet, exercise, and oral medications) are no longer effective in controlling blood glucose levels. Research is also in progress to develop insulin in pill, patch, and nasal spray forms. Here are some important facts about insulin: . Insulin must be timed to coincide with your food and activity levels. For example, if you take your usual dose of insulin in the morning and then decide to eat a lighter lunch than you originally planned, your blood glucose levels could become very low. Be sure to discuss insulin problem-solving strategies with your diabetes health care team. . Insulin in a vial, like any other medication, has an expiration date. Talk with your physician if you use your insulin for more than 30 days or keep it beyond its expiration date. Note: Always consult with your diabetes health care team before purchasing and using any adaptive insulin measurement device. There are several adaptive devices currently available that can help with insulin measurement if you are blind or have low vision: For low vision insulin measurement: . A syringe magnifier can be used in combination with a flexible-arm task lamp and a contrasting background. Syringe magnifiers offer minimal magnification, however. For non-visual insulin measurement: Fixed-dose insulin measurement devices are appropriate for individuals whose insulin dosage remains consistent from day to day: . The Safe Shot Insulin Loader Description: Description: one pre-set dosage step and is available in three colors (yellow, blue, and red). &tag=vi0c-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=B000BI7WXY Flexible dose insulin measurement devices are appropriate for individuals who need to vary their daily insulin dosage, due to changing blood glucose levels and/or carbohydrate intake: . The Syringe Support from * Syringe Support – Measurers-Guides-Holders – MaxiAids * . or Independent Living Aids accommodates a large dose (up to 100 units). A white, raised marking permits the user to differentiate each full turn of the calibrated screw. Each single full turn of the calibrated screw is equal to two units of insulin. It requires a B-D 100 unit/1cc syringe. . The Count-A-Dose from Independent Living Aids accommodates a smaller dose (up to 50 units). It holds one or two vials of insulin and makes a distinctive click that can be heard and felt with each unit increment. It requires a B-D 50 unit/1/2cc syringe. Description: Description: Count-A-Dose insulin measurement device with two insulin vials, credit: Independent Living Aids Count-A-Dose insulin measuring device Insulin pens provide another measurement option. Many are disposable and pre-filled with insulin, while others are refillable. All pens make a distinctive click that can be heard and felt with each unit or 1/2 unit increment. Although most insulin pens come with a disclaimer stating that individuals who are blind or have low vision cannot use them independently, many diabetes educators disagree with this assessment and continue to recommend them. A 2010 study provided preliminary evidence of the safe use of insulin pens by persons with vision loss. Insulin pens require a doctor’s prescription. Always consult with your diabetes health care team before purchasing and using any adaptive insulin measurement device, including insulin pens. Each of the three insulin manufacturers make their disposable insulin pen. These are listed below: . The Novo Nordisk FlexPen This links also leads to an audio file. . The Sanofi-aventis SoloSTAR . . The Eli Lilly KwikPen For a listing of insulin pens visit: The insulin pump for continuous (24/7) insulin delivery An insulin pump is a computerized device – approximately the size of a pager or iPod Mini – that administers insulin, via flexible plastic tubing, to a small needle inserted just beneath the skin. It is programmed to closely mimic the body’s normal release of insulin from the pancreas. Some models have tactile controls and audio features and have been used successfully by individuals who are blind or have low vision, such as the Animas One Touch Ping with an illuminated, high-contrast display screen. You can learn more about these devices, including a comparison of current insulin pumps , at DiabetesNet . Your diabetes health care team can provide more information about these devices, including eligibility requirements, insurance coverage, accessibility features, and appropriate training. | Where the world learns about Diabetes]]>

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