How Can I Manage My Diabetes?

Contributing Editor: Debbie Sokol-McKay, OTR/L, CVRT, CDE, CLVT, vision rehabilitation therapist, diabetes educator, low vision therapist, and licensed occupational therapist

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.

Certified diabetes educators (usually nurses and dieticians), in consultation with primary care physicians and endocrinologists [1] (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 [2] (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 Specialty Practice group are experienced in dealing with blindness, low vision, and other disabilities.
• Diabetes Self-Management [3] provides self-management information from health care professionals and people with diabetes and publishes The Diabetes Self-Management Blog [4], an e-mail newsletter [5], and Diabetes Self-Management [6] magazine, also available via the NFB-NEWSLINE [7] 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 gucose 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 all of the following therapies:

• Blood glucose monitoring
• Medication (oral and/or insulin) and insulin measurement
• Healthy eating
• Physical activity/exercise
• Proper foot care
• Overall health management

1. 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:

• Use magnifier [8] or a closed circuit television (CCTV)/electronic video magnifier [9] with your current monitor.
• Use a flexible-arm task lamp [9] 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 Aviv [10]a [10], the TrueTrack Smart System [11], or the Precision Xtra® Blood Glucose and Ketone Monitoring System [12].



One Touch Ultra

• Obtain a monitor that has a larger-print display and backlighting,such as the One Touch Ultra2 [13]

If you've been certified as legally blind [14], 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:

• The Lifescan One Touch Basic [15] with speech attachment
• The Prodigy Autocode [16] and Prodigy Voice [17] from Independent Living Aids, Inc. 
• The Advocate Talking Blood Glucose Monitor [18]
• The SensoCard Plus [19] (pending FDA approval)

Even 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.
• 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.
• 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.

2. 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 [20] can be used in combination with a flexible-arm task lamp [9] 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 [21]has one pre-set dosage step and is available in three colors (yellow, blue, and red). Find this at Amazon.com. 
• The Unit Calibration Aid [22] has two pre-set dosage steps; its larger size makes it easier to grasp.

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 [23] from Independent Living Aids  accommodates a large dose (up to 100 units). One full turn of the calibrated screw is equal to two units of insulin. It requires a B-D 100 unit or 1cc syringe.
• The Count-A-Dose [24] 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 or 1/2 cc syringe.


Count-A-Dose insulin measuring device

Insulin pens provide another measurement option. Some 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. Always consult with your diabetes health care team before purchasing and using any adaptive insulin measurement device, including insulin pens.

Several brands of insulin pens are currently available, including but not limited to:

• The NovoLog FlexPen [25]
• The Novolin InnoLet [26]
• The Sanofi-aventis SoloSTAR [27]
• The Eli Lilly HumaPen MEMOIR® [28] and HumaPen LUXURA® HD [29]

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 [30] with an illuminated, high-contrast display screen.

You can learn more about these devices, including a comparison of current insulin pumps [31], at DiabetesNet [32]. Your diabetes health care team can provide more information about these devices, including eligibility requirements, insurance coverage, accessibility features, and appropriate training.

3. Healthy Eating

There are many adaptations that can help you follow a nutrition management plan [33], an important component of diabetes self-management treatment. Note: Always consult with your diabetes health care team to select and follow a nutrition management plan that's right for you.

Portion control can be achieved by using any of the following methods and adaptations:

• Nested, large print, color contrasting, or color-coded measuring cups and spoons, such as Color-Coded Measuring Spoons [34], Color-Coded Measuring Cups [35], and Pop-Out Measuring Cups [36] from Independent Living Aids Inc.  [37]

• Portion-controlled serving utensils, such as the Vollrath Grip 'N Serv Spoodle. [38]

• A talking food scale, such as the Talking Tel-Weight Scale [39] from MaxiAids, or the Talking Kitchen Scale  [40] from Independent Living Aids.
• You can also place tactile markings on your own food scale, by using Orange Tactile Paint  [41], Spot 'n Line Pen [42], fabric/craft paint, or a number of other labeling options [43].
• Use dishes that control your food portions: a 4-ounce juice cup, a 9-inch plate, or a 1-cup cereal bowl.
• Use a plate with built-in portions, such as the EZ Weight Plate [44].

• You can test your knowledge of portion sizes and portion control with Test Your Portion Size IQ [45] from WebMD and the Portion Control Quiz [46] from About.com.

Accessing printed information on food labels is also necessary for healthy eating, especially when counting carbohydrates. It's possible to obtain nutrition information by using any of the following methods and adaptations:

• A magnifier [8] or a closed circuit television (CCTV)/electronic video magnifier [9]
• A bar code reader, such as the talking bar code reader by OMNI  [47] from Independent Living Aids, Inc.
• The CalorieKing-Joslin Food Awareness Toolbar [48] from the Joslin Diabetes Center
• Enlisting assistance from family and friends

Record nutrition information and save it for future reference by using any of the following methods and adaptations:

• Braille [49] note cards
• Large print made with a wide-tip marker, laundry marker, or felt-tip pen
• Audio methods, such as cassette tape, Sherlock Talking Label System [50] from Independent Living Aids , or the VOXCOM III magnetic card reader [51].

There are a number of online resources and publications that specifically address nutrition, meal planning, and recipe information for individuals with diabetes:

• The Recipe Corner [52] and Exchange Lists for Meal Planning [53] from Voice of the Diabetic [54], published quarterly by the National Federation of the Blind [55]
• A selection of diabetes-friendly recipes [56] from Diabetes Self-Management Magazine [57]
• The Nutrition & Recipes [58] and Cookbook [59] sections of the American Diabetes Association [60] web site

4. Physical Activity and Exercise

Physical activity includes formal exercise as well as sports, leisure or recreational activities, and even household chores. You can accumulate a minimum of 30 minutes of activity throughout the day by making simple changes in your level of physical activity, such as taking the steps instead of the elevator and walking to the store instead of taking the bus or driving.

Physical activity is an important component of diabetes self-management treatment, and some of its many benefits include the following:

• Maintaining and improving overall health
• Increasing strength and endurance
• Improving blood glucose control
• Controlling blood pressure
• Increasing beneficial HDL cholesterol [61] and decreasing unhealthy LDL cholesterol [62]
• Reducing stress, which can increase blood glucose levels
• Helping with weight loss

Note: Always consult with your diabetes health care team to select and follow an individualized exercise program that includes general exercise guidelines, physical and ocular precautions and restrictions, blood glucose monitoring, and management of hypoglycemia.

Here are some helpful hints and adaptations for exercise:

• A treadmill can supplement your walking program.
• A tandem or stationary bicycle is helpful for cycling.
• A rowing machine or cross-country ski trainer can provide aerobic exercise.
• An arm cycle can provide low impact aerobic exercise.


Tabletop arm bike

• Swimming is a good form of exercise if you have physical limitations or difficulty walking or running.
• Stand near a wall or chair to better orient yourself during aerobic exercise.
• Use a talking pedometer, such as the Calorie counting Talking Pedometer with FM radio [63] from Independent Living Aids .
• Create braille or large print exercise records to track and record your progress.
• Wear a medical alert tag or bracelet.
• Test your blood glucose before, after, and during your exercise session if you feel symptoms of hypoglycemia.
• Keep a fast-acting carbohydrate snack nearby.
• Wear proper socks and shoes.
• Perform a foot examination (see the following section) before and after exercise.
• Check the floor space to avoid hazards and obstacles.

Several online resources and publications specifically address physical activity and exercise for individuals who are blind or have low vision:

• Get Moving: Exercising with Complications [64] from Voice of the Diabetic [54], published quarterly by the National Federation of the Blind
• I Hate to Exercise [65] from the American Diabetes Association
• Sports groups and associations [66] from VisionAWARE

5. Proper Foot Care

Proper foot care is a crucial component of diabetes self-management treatment, since several complications related to diabetes can cause serious foot problems:

• Decreased sensation can lead to foot injuries.
• Impaired temperature regulation can cause dry and cracked skin, which can lead to bacterial infections.
• Impaired circulation can lead to impaired healing ability and, in serious cases, amputation.

Develop a reliable foot inspection routine:

• Establish a consistent time to check your feet every day, such as after bathing or before bedtime.
• Pay special attention to previous or existing foot problems.
• Wash your feet daily and dry them carefully, especially between your toes. Apply lotion to your feet, but not between your toes.
• Ask your physician to perform a foot inspection during every visit; in fact, it's perfectly all right to take your shoes off during your appointment to make sure your physician checks your feet.
• Make an appointment with a podiatrist at least once a year. Be sure to tell your podiatrist that you have diabetes.
• Contact your physician if a cut, blister, or sore does not begin to heal after one day; contact your physician immediately if your foot is painful or swollen.
• Note: Medicare Part B and Medicaid recently approved coverage for biannual foot exams for people with decreased sensation in their feet due to diabetes.

Here are some helpful hints for performing a foot inspection:

• You can effectively perform a tactile foot inspection only if sensation is intact in your hands and fingertips.
• Use your fingertips to search for skin and/or foot irregularities, such as cuts, breaks in the skin, blisters, new calluses, swollen areas, bumps, embedded objects, and changes in foot texture and/or shape.
• Feel the entire top and bottom surfaces of each foot, using overlapping strokes in an organized pattern. Be sure to check the nail beds, all pressure points, and the areas between your toes.


Foot with pressure points

• Run the back of your hand over the top and bottom surfaces of each foot, feeling for excessively cool (impaired circulation) or warm (possibly infected) areas. Compare these areas to other parts of your foot or to your other foot.
• Feel for changes in the skin texture or shape of your feet.
• Note any changes in foot odor when removing your socks and shoes.
• Check for wet, moist, or crusty areas on your socks, which can indicate blood or discharge.
• If you have low vision, try using one the following adaptations: a task lamp with a flexible arm [67], or place a dark towel underneath your feet for better contrast.

Here are some tips to help care for your feet [68] and prevent diabetic foot problems:

• Do not smoke. If you do smoke, try to stop. The American Diabetes Association [69] explains the effects of smoking on diabetes and offers advice and tips to help you stop.
• Notify your physician or podiatrist immediately if you detect any problems.
• Avoid temperature extremes when washing your feet.
• If you feel cold at night, wear cotton socks. Do not use hot water bottles or heating pads.
• Do not soak your feet for a prolonged period of time, unless your physician or podiatrist prescribes it. Taking a bath or shower is fine, however.
• Your toenails should be cut or filed straight across (not cut into the corners), ideally by a podiatrist. File your nails with an emery board between cuttings, if necessary.
• Inspect the insides of your shoes every day for torn linings, nail points, and other objects that can damage your feet.
• Do not walk barefoot or in your stocking feet.
• Wear socks or stockings that fit properly, keep your feet dry, and do not have raised seams. Be sure to change your socks every day.
• Do not remove corns or calluses on your own, and do not use commercial corn and callus removal products. Visit your podiatrist for any of these procedures.

In addition, there are a number of online resources and publications that specifically address foot care for individuals with diabetes:

• The Lower Extremity Amputation Prevention (L.E.A.P.) Program [70], which also provides footwear [71] and shoe modification [72] guidelines
• Guidelines for Diabetic Foot Care [73] from eMedicineHealth
• Diabetes Foot Care [74] from ePodiatry.com
• The foot care section from Voice of the Diabetic [54], published quarterly by the National Federation of the Blind [55]

6. Overall Health Management

There are a number of adaptations that can help with maintaining your health or managing illness:

• Visit an ophthalmologist at least once a year.
• A large display or talking blood pressure monitor, such as the Life Source® Talking Blood Pressure Monitor [75] from Dynamic-Living.com
• A large display or talking scale, such as the Phoenix Talking Bathroom Scale [76] from Dynamic-Living.com and the Superior Talking Scale [77] from Independent Living Aids, Inc. 
• A large display or talking thermometer, such as the Talking Thermometer [78] from Independent Living Aids  or the Jumbo Display Digital Thermometer [79] from MaxiAids
• Label your carbohydrate-containing and calorie-free liquids in braille, large print, cassette tape, or another accessible format.