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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
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
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
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.
What is Diabetic
Symptoms of Diabetic
Reducing the Risk of Diabetic Retinopathy
Retinopathy: Treatment & 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
4. How Can I Manage My Diabetes? – VisionAware
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 Self Management
Blood Glucose Monitoring
Insulin and Insulin Measurement
Proper Foot Care
Overall Health Management
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
. The American Association of Diabetes Educators
(AADE) is the national organization of
. 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
‘s Role in Diabetes Self-Management (podcast 14) The podcast is found at
. 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
cost for subscription.
. also available free via the NFB-NEWSLINE
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
. You want to discuss a change or modification in your diabetes
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
. 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
. 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
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
5. Problem solving: managing hypoglcemia/hyperglycemia, sick days,
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.
. Obtain a monitor that has a larger-print display, such as the
ACCU-CHEK Aviva Plus System
. the TrueTrack Smart System ,
* http://www.prestigesmartsystem.com, 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
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
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
. 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 –
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
. 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
. 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
. 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
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
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
pre-set dosage step and is available in three colors (yellow, blue, and
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
* 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
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
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
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
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: www.diabeteshealth.com/charts/
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
at DiabetesNet . Your diabetes health care
team can provide more information about these devices, including eligibility
requirements, insurance coverage, accessibility features, and appropriate
Diabetesnet.com | Where the world learns about Diabetes