Amiga Plus 1995 #2/Amiga Plus CD - 1995 - No. 2.iso/internet/faq/englisch/diabetes

Text File | 1995-04-11 | 167.0 KB | 3,734 lines

Archive-name: diabetes/faq/part1
Posting-Frequency: biweekly
Last-modified: 3 February 1995

Changes: change area code for the BDA (10 Nov)
         update mail order info thanks to rick nakroshis (24 Nov)
         mention AOL diabetes support area (26 Nov)
         update mailing list/newsgroup stats, add asdk (22 Dec)
         split into five parts (26 Dec)
         clarify where posted (3 Feb)

Subject: READ THIS FIRST
========================

Copyright 1993-1994 by Edward Reid. Re-use beyond the fair use provisions
of copyright law and convention requires the author's permission.

Advice given in m.h.d is *never* medical advice. That includes this FAQ.
Never substitute advice from the net for a physician's care. Diabetes is a
critical health topic and you should always consult your physician or
personally understand the ramifications before taking any therapeutic action
based on advice found here or elsewhere on the net.

Subject: Table of Contents
==========================

INTRODUCTION (found in all parts)
  READ THIS FIRST
  Table of Contents
GENERAL (found in part 1)
  Where's the FAQ?
  What's this newsgroup like?
  The newsgroup charter
  Newsgroup posting guidelines
  What is glucose? What does "bG" mean?
  What are mmol/L? How do I convert between mmol/L and mg/dl?
  What's type 1 and type 2 diabetes?
  Is it OK to discuss diabetes insipidus here? What is it?
  How about discussing hypoglycemia?
BLOOD GLUCOSE MONITORING (found in part 2)
  How accurate is my meter?
  Ouch! The cost of blood glucose measurement strips hurts my wallet!
  What do meters cost?
  Comparing blood glucose meters (from Lyle Hodgson)
  How can I download data from my One Touch II?
  How can I download data from my Glucometer (tm)?
  Other recordkeeping software
  I've heard of a non-invasive bG meter -- the Dream Beam?
  What's HbA1c and what's it mean?
TREATMENT (found in part 3)
  My diabetic father isn't taking care of himself. What can I do?
  Managing adolescence, including the adult forms
  So-and-so eats sugar! Isn't that poison for diabetics?
  Insulin nomenclature
  Travelling with insulin
  Injectors: Syringe reuse and disposal
  Injectors: Pens
  Injectors: Jets
  Insulin pumps
  Beta cell implants, pancreas transplants, future cures
  What's a glycemic index? How can I get a GI table for foods?
  Should I take a chromium supplement?
  I beat my wife! (and other aspects of hypoglycemia) (not yet written)
  Does falling blood glucose feel like hypoglycemia?
  Alcohol and diabetes (by Peter Stockwell)
  Necrobiosis lipoidica diabeticorum
SOURCES (found in part 4)
  Online resources: diabetes-related newsgroups
  Online resources: diabetes-related mailing lists
  Online resources: commercial services
  Online resources: FTP
  Online resources: World Wide Web
  Online resources: other
  Where can I mail order XYZ?
  How can I contact the American Diabetes Association (ADA) ?
  How can I contact the Juvenile Diabetes Foundation (JDF) ?
  How can I contact the British Diabetic Association (BDA) ?
  How can I contact the Canadian Diabetes Association (CDA) ?
  Could you recommend some good reading?
RESEARCH (found in part 5)
  What is the DCCT? What are the results?
IN CLOSING  (found in all parts)
  Who did this?

Subject: Where's the FAQ?
=========================

Millions of volunteers are working on drafting Periodic Informational
Postings in their Copious Spare Time (tm). Needless to say, this isn't moving
very quickly. If you want to volunteer to research and/or write, contact
Steve Kirchoefer <[e-mail]>.

This FAQ attempts to answer the questions which have been most frequently
asked in misc.health.diabetes (m.h.d). This is not a complete informational
posting. My only criterion for inclusion is that the topic has frequently
appeared in m.h.d, either by an explicit question, or implicitly by posting a
related question or a common misconception. If you obtained this article by
some method other than reading m.h.d, you may wish to refer to the sections
on "Online resources" for more information.

This FAQ is posted biweekly to the Usenet newsgroup misc.health.diabetes.

An informational posting on insulin pumps is posted to m.h.d at the same time
as this FAQ. See below for retrieval information. It was developed and is
maintained by Jim Summers ([e-mail]).

An informational posting on diabetes-related software is posted to m.h.d at
the same time as this FAQ. See below for retrieval information. It was
developed and is maintained by Michael Wolfe <[e-mail]>.

Other informational postings will, we hope, appear as volunteers find the
time to write them.

I've used ideas and information from many people in writing this FAQ. I haven't
attempted to identify them, but I thank them all. The words herein are mine
unless otherwise credited.

If you read this and it helps you, please let me know what part helped, and
why. If you read this and can't find what you want, let me know that too.
Such comments will help me and the other volunteers decide what is worth
working on, and whether. You'd be surprised how little feedback we get.

These documents -- the FAQ, the insulin pump discussion, and the software
overview -- are available from the news.answers archives at rtfm.mit.edu.
Using anonymous ftp, get the files:

   /pub/usenet/news.answers/diabetes/faq/part1
   /pub/usenet/news.answers/diabetes/faq/part2
   /pub/usenet/news.answers/diabetes/faq/part3
   /pub/usenet/news.answers/diabetes/faq/part4
   /pub/usenet/news.answers/diabetes/faq/part5
   /pub/usenet/news.answers/diabetes/insulin-pump-disc
   /pub/usenet/news.answers/diabetes/software

Or send an email message to [e-mail], subject ignored, body
containing:

   send usenet/news.answers/diabetes/faq/part1
   send usenet/news.answers/diabetes/faq/part2
   send usenet/news.answers/diabetes/faq/part3
   send usenet/news.answers/diabetes/faq/part4
   send usenet/news.answers/diabetes/faq/part5
   send usenet/news.answers/diabetes/insulin-pump-disc
   send usenet/news.answers/diabetes/software

If you are using the World Wide Web (aka WWW, W3, lynx, Mosaic), you can reach
a WWW-formatted version of the FAQ and other documents via the URL

   http://www.cis.ohio-state.edu/hypertext/faq/usenet/diabetes/top.html

Subject: What's this newsgroup like?
====================================

Posting topics range through emotional support, treatment techniques,
psychological factors, health care practices, and insurance. We talk about
our problems, frustrations, depressions and complications to find out how
others handle the same issues and for mutual support. The atmosphere is
generally a highly supportive one, and most participants believe strongly
that this is an important aspect. As in other parts of the net, there are one
or two regular participants who believe that it is important to question the
motives and/or knowledge of anyone posting a new problem. If you find that
the first response is antagonistic, please wait a few hours. Every
antagonistic response will elicit a dozen sympathetic responses.

Meta-topics include discussions of how to best convey health information on
the Usenet, ethical treatment of other participants, what topics and
information are appropriate for m.h.d, where to find diabetes information,
and what the newsgroup should be like.

Betsy Butler <[e-mail]> says eloquently:

   The positive posts of people who are in great control are very
   motivating, but it is also helpful to hear from people who don't find
   it so easy. I'm sure there are a lot of people who struggle to keep
   control. The people who are having trouble also need to know that there
   are others who struggle, and that they are not alone. It can be very
   intimidating, and a blow to self-esteem for people to suggest that if
   you would just do X, Y and Z, you will be in control. There are 100s of
   factors to balance, and I think people need to be reassured that "yes,
   it's hard to balance so many things, many of which can't be measured or
   that don't act predictably."

Topics closely related to diabetes mellitus which do not have their own place
in Usenet are welcome. Examples are diabetes insipidus, hypoglycemia, glucose
intolerance, legal and employment ramifications of chronic illness, effects
on family members, and so on. misc.health.diabetes tends to be inclusive of
anyone who needs it.

The same caveat applies here as in all newsgroups: the advice is worth what
you paid for it. This applies in spades to a critical health topic such as
diabetes. Never substitute informal advice for a physician's care. Advice
given in m.h.d is *never* medical advice.

The variety of individual responses to diabetes is exceeded only by the
variety of individual responses to life. No two patients respond alike, and
many respond *very* differently from others. These differences are
physiological, not just psychological. They reflect not only varying
responses, but the fact that diabetes itself probably has many causes, many
more than the few types currently recognized (see section on types). When you
read advice, realize that what works (or doesn't work) for someone else may
not work (or may work) for you. When you give advice, try to remember that
most advice is relative to the individual, not absolute. Recognize that you
can't treat your own diabetes by a set of rules, but only by knowing how your
own individual body and physiology work and by adjusting to your own
mechanisms.

If you obtained this article by some method other than reading Usenet,
refer to the section on "Online resources: diabetes-related newsgroups"
for brief information on how to obtain access to Usenet newsgroups and
misc.health.diabetes in particular.

Subject: The newsgroup charter
==============================

The actual charter which led to the creation of the newsgroup in May 1993
follows. This charter was approved by a public vote of the Usenet readership,
and is the official statement of the scope and purpose of this newsgroup.

  1. The purpose of misc.health.diabetes is to provide a forum for the
     discussion of issues pertaining to diabetes management, i.e.: diet,
     activities, medicine schedules, blood glucose control, exercise, medical
     breakthroughs, etc.  This group addresses the issues of management of
     both Type I (insulin dependent) and Type II (non-insulin dependent)
     diabetes.  Both technical discussions and general support discussions
     relevant to diabetes are welcome.

  2. Postings to misc.health.diabetes are intended to be for discussion
     purposes only, and are in no way to be construed as medical advice.
     Diabetes is a serious medical condition requiring direct supervision
     by a primary health care physician.

Subject: Newsgroup posting guidelines
=====================================

The following posting guidelines were adopted by a vote of m.h.d participants
in September 1994.

Posting guidelines for misc.health.diabetes:

Postings to misc.health.diabetes should be compliant with the standards
for all material posted to Usenet.  The following articles may be found
in news.announce.newusers, and should be reviewed by all posters:

-Emily Postnews Answers Your Questions on Netiquette
-Answers to Frequently Asked Questions about Usenet
-A Primer on How to Work With the Usenet Community
-Rules for posting to Usenet
-What is Usenet?

Posting to misc.health.diabetes should be compliant with the group charter,
[which is in the previous section].

In addition to the above, the following guidelines are emphasized as
particularly relevant for contributions to misc.health.diabetes:

-No personal attacks or insults.  Avoid argumentative debates.  Responses
 should concentrate on the issues presented.

-No private discussions.  Take private discussions to email.  When in
 doubt, use email.

-Edit responses to avoid unnecessary inclusions of earlier postings.

-Edit subject lines as necessary to remain consistent with the topic.

-Support factual statements with your sources.  If you can not recall the
 source, then say so.  Do not imply authority which you can not actually
 support.

Additional information can be found in the general FAQ posted periodically
to this group.

Subject: What is glucose? What does "bG" mean?
==============================================

Glucose is a specific form of sugar, one of the simplest. It is the form
found in the bloodstream. "Blood sugar" always refers to blood glucose, and
is abbreviated bG. All bG meters are specific for glucose and will not
respond to other sugars, such as fructose, sucrose, maltose and lactose.

Although sucrose (table sugar) is the most common sugar in food, glucose is
also common. Most fruits, fruit juices, and soft drinks contain large amounts
of glucose, and many foods contain small amounts. This means that you must be
very careful to clean any food residue from your fingers before drawing blood
for a bG check. Since the normal level of bG is only 1g/L (=100mg/dl), it
only takes a tiny speck of glucose on your finger to contaminate the sample
and give you a falsely high reading. 10 *micrograms* of glucose could raise
the reading enough to cause you to overreact dangerously.

Subject: What are mmol/L? How do I convert between mmol/L and mg/dl?
====================================================================

mmol/L is millimoles/liter, and is the world standard unit for measuring
glucose in blood. Specifically, it is the designated SI (Systeme
Internationale) unit. "World standard", of course, means that mmol/L is used
everywhere in the world except in the US. A mole is about 6*10^23 molecules;
if you want more detail, take a chemistry course.

mg/dl (milligrams/deciliter) is the traditional unit for measuring bG (blood
glucose). All scientific journals are moving quickly toward using mmol/L
exclusively. mg/dl won't disappear soon, and some journals now use mmol/L as
the primary unit but quote mg/dl in parentheses, reflecting the large base of
health care providers and researchers (not to mention patients) who are
already familiar with mg/dl.

Since m.h.d is an international newsgroup, it's polite to quote both figures
when you can. Most discussions take place using mg/dl, and no one really
expects you to pull out your calculator to compose your article.

Many meters now have a switch that allows you to change between units.

To convert mmol/L to mg/dl, multiply by 18.

To convert mg/dl to mmol/L, divide by 18 or multiply by 0.055.

And remember that reflectance meters have a 10-15% error margin at best, and
that plasma readings are 15% higher than whole blood, and that capillary
blood is different from venous blood.  So round off to make values easier to
comprehend and don't sweat the hundredths place.  For example, 4.3 mmol/l
converts to 77.4 mg/dl but should probably be quoted as 75 or 80.  Similarly,
150 mg/dl converts to 8.3333... mmol/l but 8.3 is a reasonable quote, and
even just 8 would usually convey the meaning.

Actually, a table might be more useful than the raw conversion factor, since
we usually talk in approximations anyway.

   mmol/l     mg/dl     interpretation
   ------     -----     --------------
     2.0        35      extremely low, danger of unconciousness
     3.0        55      low, marginal insulin reaction
     4.0        75      slightly low, first symptoms of lethargy etc.
     5.5       100      mecca
    5 - 6     90-110    normal preprandial in nondiabetics
     8.0       150      normal postprandial in nondiabetics
    10.0       180      maximum postprandial in nondiabetics
    11.0       200
    15.0       270      a little high to very high depending on patient
    16.5       300
    20.0       360      getting up there
    22         400      max mg/dl for many meters and strips

Preprandial  = before meal
Postprandial = after meal

Subject: What's type 1 and type 2 diabetes, and gestational diabetes?
=====================================================================

The term diabetes mellitus comes from Greek words for "flow" and "honey",
referring to the excess urinary flow that occurs when diabetes is untreated,
and to the sugar in that urine.

Diabetes mellitus (DM) comes in four classifications (which some will argue
don't really represent the actual types very well):

   type 1 -- characterized by total destruction of the insulin-producing beta
             cells, probably by an autoimmune reaction. Onset is most common
             in childhood, thus the common (but now deprecated) term
             "juvenile-onset", but the onset up to age 40 is not uncommon and
             can even occur later. Patients are susceptible to DKA (diabetic
             ketoacidosis). There seems to be some genetic tendency, but the
             genetic situation is unclear. Most patients are lean. Always
             requires treatment by insulin. Not sex-linked. Also referred to
             as IDDM (insulin dependent diabetes mellitus).

   type 2 -- characterized by insulin resistance despite adequate insulin
             production. A large majority of patients are overweight at onset,
             and a majority are female. Most are over 40, hence the common
             (but now deprecated) terms "adult-onset" or "maturity-onset", but
             onset can occur at any age. Patients are not susceptible to DKA
             (diabetic ketoacidosis). There is a strong genetic tendency, but
             not simple inheritance. Depending on the individual, treatment
             may be by diet, exercise, weight loss, oral drugs which stimulate
             the release of insulin, or insulin injections -- and usually a
             combination of several of these. Also referred to as NIDDM (non
             insulin dependent diabetes mellitus) *even when treated with
             insulin*.

   type 3 -- a catchall for forms not covered by the other types,
             including loss of the entire pancreas to trauma, cancer,
             alcohol abuse, or exposure to chemicals.

   type 4 -- gestational. Occurs in about 3% of all pregnancies as a result of
             insulin antagonists secreted by the placenta. It is recommended
             that all pregnant women receive a screening glucose tolerance
             test (GTT) between the 24th and 28th weeks of pregnancy to detect
             gestational diabetes early if it occurs, as diabetes can cause
             serious difficulties in pregnancy. Usually requires insulin
             treatment. Not susceptible to DKA (diabetic ketoacidosis).
             Usually disappears after childbirth, but about 40% of patients
             develop type 2 diabetes within five years. Most authorities state
             that the typical patient is female ...

These terms are not used entirely consistently. Some doctors will refer to
any diabetic using insulin as type 1, and will refer to the early onset of
type 1 diabetes as type 2 until insulin therapy is required. This usage does
not fit with most modern usage as described above (type 1 is beta cell
destruction, type 2 is insulin resistance). The situation is complicated by
the fact that early in the course of the disease it can be difficult to
determine which type is occuring, especially for patients in their 30's, the
age when the onset of both types is common.

Different patients respond very differently to what is categorized above as
the same disease. The root causes of all forms of diabetes are not
understood, and are likely more complex and varied than the simple categories
show. Type 1 diabetes likely has a few root causes, and type 2 diabetes
probably has a larger number of root causes.

There are also well documented reports of cases of diabetes with unexplained
combinations of syndromes from types 1 and 2. These are sometimes referred to
as "type 1-1/2", and the reasons are not understood.

The classification above is not completely standard, and other classifications
exist.

About 90% of diabetes patients are type 2 (some 12 million in the US), and
about 10% are type 1 (some 1 million in the US). Discussion on m.h.d tends to
run about 2/3 type 1, I'd guess. This probably reflects the fact that type 1
diabetes is harder to ignore, and that type 2 seldom strikes the younger
people who are more likely to have net access. Type 2 is *not* less serious.

"1" and "2" are often written in Roman numerals: type I, type II. Because
typography is often unclear on computer terminals, I've stuck with the Arabic
numeral version.

Diabetes accounts for about 5% of all health care costs in the US, some
US$90 billion per year.

Subject: Is it OK to discuss diabetes insipidus here? What is it?
=================================================================

Diabetes insipidus (DI) results from abnormalities in the production or use
(two main types) of the hormone arginine vasopressin. The excess urine flow
is devoid of sugar. There are no blood glucose abnormalities, and in fact
there is nothing in common with diabetes mellitus except the excess urination
when untreated. Diabetes insipidus can be treated with hormone replacement
(by nasal spray or injection). DI is much less common than diabetes mellitus,
though a few people have discussed it on misc.health.diabetes and are reading
m.h.d. Such participation is certainly welcome, but because the number of DI
patients is only 1 or 2 per 10,000 population (25,000-50,000 in the US),
there probably isn't a critical mass for discussion on Usenet. One possible
resource for DI patients is

    Diabetes Insipidus and Related Diseases Network
    Route 2 Box 198
    Creston, IA 50801

Subject: How about discussing hypoglycemia?
===========================================

Sure ...

To clarify: the term "hypoglycemia" is used to refer to two distinct
conditions. The word just means "low blood glucose". This can occur as an
insulin reaction, the result of too much injected insulin (taken to treat
diabetes) compared to food intake and exercise. But low blood glucose can
also be a chronic condition resulting from abnormalities of insulin
secretion, and this chronic condition is also called hypoglycemia.

Chronic hypoglycemia may be caused by beta cells which overreact to an
increase in blood glucose (bg) by releasing too much insulin, which then
causes a too-rapid drop in bG. Such a condition, called reactive
hypoglycemia, is usually handled by dietary adjustments, in particular
avoiding refined sugars and large meals which stimulate the overreaction.
This often requires an effort in calculating the diet and monitoring bG
levels that is equal to what anyone with diabetes needs.

Tumors (insulinomas) can cause a steady overproduction of insulin. These
generally require surgical removal.

There are other causes as well. Mayer Davidson discusses some in his book
(see the section Could you recommend some good reading?). I don't believe
anyone claims to understand all the causes.

So chronic hypoglycemia is closely related to diabetes mellitus in being a
disorder of insulin production and use, and requires many of the same
techniques for its treatment. The two are a natural for discussion in the
same newsgroup. Which is good, since there really isn't anywhere else in
Usenet at present to discuss chronic hypoglycemia. Welcome.

Subject: Who did this?
======================
--
Edward Reid          [e-mail] (normal)
PO Box 378           [e-mail] (forwarding)
Greensboro FL 32330  [e-mail]

On the World Wide Web (if the converters come to recognize mailto URLs):

  mailto:[e-mail]

Archive-name: diabetes/faq/part2
Posting-Frequency: biweekly
Last-modified: 26 December 1994

Changes: split into five parts (26 Dec)
         see part 1 for earlier changes

Subject: READ THIS FIRST
========================

Copyright 1993-1994 by Edward Reid. Re-use beyond the fair use provisions
of copyright law and convention requires the author's permission.

Advice given in m.h.d is *never* medical advice. That includes this FAQ.
Never substitute advice from the net for a physician's care. Diabetes is a
critical health topic and you should always consult your physician or
personally understand the ramifications before taking any therapeutic action
based on advice found here or elsewhere on the net.

Subject: Table of Contents
==========================

INTRODUCTION (found in all parts)
  READ THIS FIRST
  Table of Contents
GENERAL (found in part 1)
  Where's the FAQ?
  What's this newsgroup like?
  The newsgroup charter
  Newsgroup posting guidelines
  What is glucose? What does "bG" mean?
  What are mmol/L? How do I convert between mmol/L and mg/dl?
  What's type 1 and type 2 diabetes?
  Is it OK to discuss diabetes insipidus here? What is it?
  How about discussing hypoglycemia?
BLOOD GLUCOSE MONITORING (found in part 2)
  How accurate is my meter?
  Ouch! The cost of blood glucose measurement strips hurts my wallet!
  What do meters cost?
  Comparing blood glucose meters (from Lyle Hodgson)
  How can I download data from my One Touch II?
  How can I download data from my Glucometer (tm)?
  Other recordkeeping software
  I've heard of a non-invasive bG meter -- the Dream Beam?
  What's HbA1c and what's it mean?
TREATMENT (found in part 3)
  My diabetic father isn't taking care of himself. What can I do?
  Managing adolescence, including the adult forms
  So-and-so eats sugar! Isn't that poison for diabetics?
  Insulin nomenclature
  Travelling with insulin
  Injectors: Syringe reuse and disposal
  Injectors: Pens
  Injectors: Jets
  Insulin pumps
  Beta cell implants, pancreas transplants, future cures
  What's a glycemic index? How can I get a GI table for foods?
  Should I take a chromium supplement?
  I beat my wife! (and other aspects of hypoglycemia) (not yet written)
  Does falling blood glucose feel like hypoglycemia?
  Alcohol and diabetes (by Peter Stockwell)
  Necrobiosis lipoidica diabeticorum
SOURCES (found in part 4)
  Online resources: diabetes-related newsgroups
  Online resources: diabetes-related mailing lists
  Online resources: commercial services
  Online resources: FTP
  Online resources: World Wide Web
  Online resources: other
  Where can I mail order XYZ?
  How can I contact the American Diabetes Association (ADA) ?
  How can I contact the Juvenile Diabetes Foundation (JDF) ?
  How can I contact the British Diabetic Association (BDA) ?
  How can I contact the Canadian Diabetes Association (CDA) ?
  Could you recommend some good reading?
RESEARCH (found in part 5)
  What is the DCCT? What are the results?
IN CLOSING  (found in all parts)
  Who did this?

Subject: How accurate is my meter?
==================================

bG (blood glucose) meters are not as accurate as the readings you get from
them imply. For example, you might think that 108 means 108 mg/dl, not 107 or
109. But in fact all meters made for home use have at least a 10-15% error
under ideal conditions. Thus you should interpret "108" as "probably between
100 and 120". (See above for conversion to mmol/L.) This is a random error
and will not be consistent from one determination to the next. You cannot
expect to get exactly the same reading from two checks done one after the
other, nor from two meters using the same blood sample.

This is generally considered acceptable because variations in this range will
not make a major difference in treatment decisions. For example, the
difference between 100 and 120 may make no difference in how you treat
yourself, or at most might make a difference of one unit of insulin. With
present technology, more accurate meters would be much more expensive. This
expense is only justified in research work, where such accuracy might detect
small trends which could go undetected with less accurate measurements.

This discussion applies to ideal conditions. The error may be increased by
poor or missing calibration, temperatures outside the intended range,
outdated strips, improper technique, poor timing, insufficient sample size,
contamination, and probably other factors. Contamination is especially
serious since it can happen so easily and is likely to result in an overdose
of insulin. Glucose is found in fruits, juices, sodas, and many other foods.
Even a smidgen can seriously alter a reading.

When comparing meter readings with lab results, also note that plasma readings
are 15% higher than whole blood, and that capillary blood gives different
readings from venous blood.

Visually read strips are slightly less accurate than meters, with an error
rate around 20-25%.

For some meters, strips are available from manufacturers other than the meter
manufacturer. Some m.h.d. readers have compared the strips side-by-side and
found those from one manufacturer to read consistently lower than the strips
from another. The differences are not likely to make a significant difference
in your treatment, but are large enough to be noticeable and possibly
confusing. For this reason it is not a good idea to change strip
manufacturers without comparing the readings from one with the readings from
the other.

I've seen no such direct comparison of meters, but the possibility exists that
some meters might read consistently lower than others. Be careful when
changing meters.

By "error rate" I mean twice the standard deviation from the mean. An error
rate of 15% says that about 97% of the readings will be within 15% of the
actual value.

Subject: Ouch! The cost of blood glucose measurement strips hurts my wallet!
=======================================================

The cost of blood glucose measurement strips is a complex interaction of R&D
costs, manufacturing costs, marketing strategy, insurance practices, and
undoubtedly other factors. You can ask on the net if you want; you'll get
lots of comments but no answers.

There are a couple of ways of reducing the cost of blood glucose monitoring.
One is to seek out the best price for the strips; large stores such as FEDCO
often have good prices, as do some mail order suppliers (see mail order
section).

A second way is to use visually read strips (Chemstrip bG and a couple of
lesser known brands) and cut them in half or even in thirds. Do the cutting
carefully with a pair of strong, *clean* scissors, and get the strips back
into the vial as quickly as possible. There have been reports that some
manufacturers claim this procedure will cause problems, but those who have
used the technique report that it works well. Visually read strips are
slightly less accurate than meters.

Do *not* cut strips when using them in meters. The results will be totally
incorrect.

Most discussion on m.h.d of the cost of blood glucose measurement strips has
centered on the US. I'm not sure why, though a good guess is that differences
in health care systems and national policies make this issue more critical to
the individual patient in the US. There is no dearth of non-US participants
on m.h.d.

Subject: What do meters cost?
=============================

The flip side of expensive blood glucose measurement strips is that the
manufacturers virtually (and sometimes literally) give away the meters to
hook you on their strips. Don't pay full price for a meter; look for
discounts, rebates, and giveaways. For example, as of this writing I'm
looking at a catalog that shows a Glucometer 3 for US$45, with a US$30
manufacturer's rebate *and* a US$30 trade-in allowance if you already have a
competing meter -- which means you make US$15. There are similar deals on
other meters.

But make sure you consider the cost of strips as well as the cost of meters,
and find out which your insurance will pay for. The most fully featured
meters, such as the One Touch II, don't have such widely advertised deals,
though you can probably find ways of getting them at discount.

If you have insurance that pays for strips but not for the meter, it may be
worth calling the meter manufacturer and trying to persuade them to give you
a meter. If anybody has actually tried this, let us know whether or not it
worked.

As with strips, this discussion of costs applies to the US, and there has
been little discussion of meter costs outside the US on m.h.d., probably
because fewer tradeoffs are available in most countries. An Australian
correspondent notes a much narrower choice and higher cost of meters there,
but subsidized (pardon, subsidised) measurement strips. In Britain, strips
are covered by the National Health Service, but meters may be expensive.
Elsewhere? Please post.

Subject: Comparing blood glucose meters
=======================================

This section is courtesy of Lyle Hodgson <[e-mail]>, who found the
chart published by Hospital Center Pharmacy, got permission to reproduce it,
and entered and formatted the data. Take it, Lyle.

The following Blood Glucose Monitor Comparison Chart is published by the
Hospital Center Pharmacy (433 Brookline Ave. Boston MA 02215; reprinted here
with permission). After I mentioned it a couple weeks ago, Ed encouraged me
to seek the permission to post it and helped in figuring out how to format it
into 80 columns, which was hell since the original was an 8.5x14" landscape
with 8-point text.

Note that I haven't edited anything more than to patch in some grammar where
it was lacking and to abbreviate the hell out of everything.  I don't know
what a Privacy Option is; whether the Previous Test, Last Test, and Latest
Test under "Memory" are all the same thing; whether the cassette available
from the Diascan manufacturer is Audio or Video; or the sizes of most of
these meters.

Hope you find this chart as informative as I found the hard copy. You can get
your own hard copy of the original for free by calling the Hospital Center
Pharmacy yourself, 1-800-824-2401.


Ctrl Soln = Control Solutions.
Trng Cass = training cassette available. A=audio, V=video.
Power Srce= power source (wow): NR=non-replaceable
Mem       = memory. Number of results stored. D/T=date and time also
            stored.
Wrty      = length of warranty.


Product Name/  Range   Time   Ctrl   Trng   Power
Manufacturer   mg/dl   (sec)  Soln   Cass?  Srce   Mem    Wrty

Accuchek III/   20-    120    Lo/Hi  A,V    9V     20,    2 yr
Boehringer-    500                          alka-  D/T
 Mannheim                                   line
   Rejects inadequate sample, must wipe and time. Displays date&time.
   Privacy option.

Companion2     20-      20    Lo/Hi  Video  3V NR  10     4 yr
 Sensor/      600                           lith
Medisense
   Largest display of readings.  No wiping, blotting, or timing; auto
   start.  Easy strip insertion.  No cleaning.

Diascan-S      10-      90    Norm/  Yes    6V J   10     2 yr
 Meter/ Home  600             Elev/         cell
 Diagnostics                  High
   The only smearable strip.  Must wipe and time.  Large easy-to-read
   display.  Privacy option.

Exactech       40-      30    Hi/Lo  Video  NR     last   4 yr
 Companion    450                           lith
 or Pen/
Medisense
   One-button operation.  No wiping, blotting, or timing.

Glucometer3/   20-      60    Norm   A,V    mem:   300,   3 yr
Miles/Ames    500                           NR;    D/T
                                            AA for
                                            LED display
   Alarm clock, meter, & logbook.  Privacy option.

One Touch II/   0-      45    Norm   A,V    6V J   250    3 yr
Lifescan      600                           cell
   No wiping, timing, or blotting.  Signals when meter must be
   cleaned.

One Touch       0-      45    Norm   Audio  6V J   prev   3 yr
 Basic/       600                           cell
Lifescan

Pen2           20-      20    Hi/Lo  Video  NR     10     4 yr
 Sensor/      600                           lith
Medisense
   Largest display of readings.  No wiping, blotting, or timing; auto
   start.  Easy strip insertion.  No cleaning.

Tracer II/     40-     120    Hi/Lo  Video  two    10     2 yr
Boehringer-   400                           3V
 Mannheim                                   lith
   Pocket-sized monitor, smallest strip needs less blood.

Ultra/          0-      45    Lo/    Video  four    2     2 yr
Home Diag-    600             Mid/          1.5V
 nostics                      Hi            "N"
   No timing, wiping, blotting; automatic temperatures; correction.
   Large easy-to-read display.

Accucheck      20-      15-   Lo/    Video  6V     30     3 yr
 Easy/        500       60    Mid/          alka
Boehringer-                   Hi            line
 Mannheim
   Easy calibration; small drop of blood needed.  No wiping, blotting.

Glucometer     40-      60    Hi/    Video  two    latest 5 yr
 Elite/       500             Norm          3V
Miles/Ames                                  lith
   No wiping or timing.  Strip draws up amount of blood needed.

*PARTNER       10-      90    Norm/  Audio  "J"    10     2 yr
 Visually     600             Elev/         cell
 Impaired/                    Abnorm.
Home Diag.                    Elev
   Shoulder strap, durable carry case, extra battery, smearable
   strip.  Large display earpiece.  Privacy option.

CheckMate/     40-      60-   Norm   None   two    40+    lifetime
Cascade       400       90                  3V     D/T    of pur-
 Medical                                    lith          chaser
   Built-in lancing device, 4 programmable alarms.  Strips are
   individually foil wrapped.

Lyle, happy with her Companion2 thanks

Subject: How can I download data from my One Touch II?
======================================================

You can get a cable to hook the One Touch II to a PC from the meter
manufacturer, LifeScan. The cable includes some electronics, not just a
cable, so you probably don't want to make your own. In the US the cable is
free. Elsewhere, LifeScan lets each international office set its own policy
on cable distribution, and some are charging substantial fees. North American
telephone numbers are:

    U.S.A.    1-800-227-8862
              [phone]
    Canada    1-800-663-5521
    elsewhere (If you have trouble locating a phone number for your
               international office, let me know. If this problem is
               recurrent, we will add the list of offices here.)

LifeScan provides some software for downloading the data. According to a
recent posting, it is minimal download software, and you must use other
software (for example, a spreadsheet) for analysis.

Vic Abell's freeware TOUCH2 (described below), by contrast, downloads and
analyzes data and has received rave reviews from its users for its analysis
features. And Vic posts update announcements to misc.health.diabetes.

There is a shareware Windows program called Diabetics Assistant which
downloads from the One Touch II, saves the data in a file, and provides
various analysis and display facilities. I haven't heard from anyone who has
used this program. I know it is available on America Online.

No comparable Macintosh software is known to be available. However,
downloading the raw data using a basic telecom program (such as Kermit or
ZTerm) is feasible. The meter responds to basic simple commands. LifeScan
will send you a list of the commands and responses. Call and ask for the
protocol specification, or FTP it from Vic Abell (see below).

Info from Vic Abell <[e-mail]>:

TOUCH2 is Vic Abell's freeware MS-DOS/PC application for downloading and
analyzing data from the LifeScan One Touch 2 blood glucose meter. TOUCH2
interfaces to the RS-232 data port of the One Touch 2, downloads the data on
command, and provides a variety of analytical displays. It's available via
anonymous ftp from vic.cc.purdue.edu (128.210.15.16) in /pub/touch2.zip or
/pub/touch2.tar.gz, with information in /pub/touch2.README. When ftp asks for
a password, you must provide your valid email address of the standard form
[e-mail].

The protocol specification is available from the same site, same directory,
filename lifescan.ot2.

If you do not have ftp access, you can get a copy of a TOUCH2
distribution by email by sending an email letter to:

[e-mail]

In the body of the letter put:

reply <your_email_reply_address>
connect vic.cc.purdue.edu anonymous <your_email_address>
chunksize 100000
binary
uuencode
get /pub/touch2.zip
quit

If you want touch2.tar.gz or lifescan.ot2 instead, put its name in place of
touch2.zip in the "get" directive. Multiple "get"s are allowed.
<your_email_address> must be in the standard form [e-mail]. If you
want btoa encoding instead of uuencoding, replace the "uuencode" line with
"btoa". If you can't receive email messages of 100K bytes, change the
"chunksize" line. Be patient; the server sometimes takes two or three days to
process the backlog, and recently up to a week.

Using the World Wide Web, enter the URL

   ftp://vic.cc.purdue.edu/pub/

Subject: How can I download data from my Glucometer (tm)?
=========================================================

Miles Inc, makers of the Glucometer M/M+ blood glucose meters, sells a
program called Glucofacts+ DMS which

 -- downloads and analyzes data from the meters
 -- stores the data in files
 -- produces quite a variety of statistical reports and graphs
    on screen or printed
 -- runs under MS-DOS only
 -- supports only the Glucometer M and M+
 -- requires a nonstandard cable which is supplied with the software
 -- uses a proprietary interface (unlike Lifescan, Miles will not provide the
    specifications of the interface)
 -- does not provide for manual entry of data
 -- a Data-Link Modem available separately provides the capability
    of transferring data directly from the meter to a PC at the
    physician's office, for those lacking a home PC.
 -- can upload the data to the doctor's office (a Data-Link Module provides
    standalone capability for users without a PC)
 -- is *not* available in a demo version

Chris Trippel of Miles <[e-mail]> will answer questions
unofficially and can email copies of a very good description, about 7K long,
of Glucofacts+ DMS. You can also get information and place orders by calling
1-800-348-8100. If ordering, ask for Lloyd Bane, ask for product code 5044B,
and provide the serial number from your meter.

Subject: Other recordkeeping software
=====================================

I searched the PC and Macintosh software libraries on America Online using
the key 'diabetes' and came up with three MS-DOS programs, two Windows
programs, and two Macintosh HyperCard stacks for blood glucose recordkeeping.
Prices range from free to $30, or $16/yr for one of the stacks. The Control
Diabetes program from Nutrisoft has received favorable mention in m.h.d; I
haven't seen any of the others mentioned. The Diabetics Assistant can
download from a One Touch II.

CompuServe has software in the Diabetes Forum.

_Diabetes Forecast_, from the ADA, carries some advertisements for commercial
software. I don't know anything about the packages advertised.

Demon Internet Services is generously providing FTP space for software and
information related to diabetes on ftp.demon.co.uk, directory /pub/diabetes.
See the sections on Online Resources for details. From the WWW:

   ftp://ftp.demon.co.uk/pub/diabetes/

Subject: I've heard of a non-invasive bG meter -- the Dream Beam?
================================================================

***The following information is incomplete, as another company has introduced
   a non-invasive meter for about $8000. It has been discussed in the
   newsgroup. Rumors of other non-invasive (and "non-evasive") meters abound.
   I won't be trying to keep this section up to date until the situation
   stabilizes. ***

There is at least one development project in hot pursuit of a bG monitor
which operates by shining light through flesh (through the thumbnail in one
case) and analyzing the light that passes through. Glucose doesn't affect
light much differently from many other substances in the body, so this is not
an easy task. Some field trials have been done, but the developers have a way
to go to reach acceptable accuracy. A successful product is far from
guaranteed, and may be several years away if it arrives at all.

One estimate is that such a meter might cost about US$1000. Assuming the
per-check cost is zero, this would pay for itself in 1-2 years for many
patients. Look for the insurance companies to throw up some roadblock to
achieving these savings, at least in the US.

Subject: What's HbA1c and what's it mean?
=========================================

Hb = hemoglobin, the compound in the red blood cells that transports oxygen.

A1c is a specific subtype. (The 1 is actually a subscript to the A, and the c
is a subscript to the 1.) Glucose binds slowly but irreversibly to
hemoglobin, forming a stable sub-sub-type which is only eliminated by the
normal recycling of the red blood cells, which have a lifetime of about 90
days. In non-diabetic persons, the formation and destruction reach a steady
state with about 3.0% to 6.5% of the hemoglobin being the A1c subsubtype.
Since most diabetics have a higher average blood glucose (bG) level than
non-diabetics, the steady state level is higher in diabetics. The HbA1c level
thus is an indication of the average bG level over the past 90 days or so.

Interpreting HbA1c values is tricky because several different lab
measurements have been introduced over the last 15 years, measuring slightly
different subtypes with different limits for normal values and thus different
interpretive scales. All are still in use in some places. When you get a lab
result, be sure to look at what the lab considers to be the normal range.
Most discussion of HbA1c values in m.h.d appears to be based on the most
recent lab measurement, where the normal range is approximately 3-6.5%.
Caveat lector.

Subject: Who did this?
======================
--
Edward Reid          [e-mail] (normal)
PO Box 378           [e-mail] (forwarding)
Greensboro FL 32330  [e-mail]

On the World Wide Web (if the converters come to recognize mailto URLs):

  mailto:[e-mail]

Archive-name: diabetes/faq/part3
Posting-Frequency: biweekly
Last-modified: 26 December 1994

Changes: split into five parts (26 Dec)
         see part 1 for earlier changes
         add section on necrobiosis lipoidica diabeticorum (26 Dec)

Subject: READ THIS FIRST
========================

Copyright 1993-1994 by Edward Reid. Re-use beyond the fair use provisions
of copyright law and convention requires the author's permission.

Advice given in m.h.d is *never* medical advice. That includes this FAQ.
Never substitute advice from the net for a physician's care. Diabetes is a
critical health topic and you should always consult your physician or
personally understand the ramifications before taking any therapeutic action
based on advice found here or elsewhere on the net.

Subject: Table of Contents
==========================

INTRODUCTION (found in all parts)
  READ THIS FIRST
  Table of Contents
GENERAL (found in part 1)
  Where's the FAQ?
  What's this newsgroup like?
  The newsgroup charter
  Newsgroup posting guidelines
  What is glucose? What does "bG" mean?
  What are mmol/L? How do I convert between mmol/L and mg/dl?
  What's type 1 and type 2 diabetes?
  Is it OK to discuss diabetes insipidus here? What is it?
  How about discussing hypoglycemia?
BLOOD GLUCOSE MONITORING (found in part 2)
  How accurate is my meter?
  Ouch! The cost of blood glucose measurement strips hurts my wallet!
  What do meters cost?
  Comparing blood glucose meters (from Lyle Hodgson)
  How can I download data from my One Touch II?
  How can I download data from my Glucometer (tm)?
  Other recordkeeping software
  I've heard of a non-invasive bG meter -- the Dream Beam?
  What's HbA1c and what's it mean?
TREATMENT (found in part 3)
  My diabetic father isn't taking care of himself. What can I do?
  Managing adolescence, including the adult forms
  So-and-so eats sugar! Isn't that poison for diabetics?
  Insulin nomenclature
  Travelling with insulin
  Injectors: Syringe reuse and disposal
  Injectors: Pens
  Injectors: Jets
  Insulin pumps
  Beta cell implants, pancreas transplants, future cures
  What's a glycemic index? How can I get a GI table for foods?
  Should I take a chromium supplement?
  I beat my wife! (and other aspects of hypoglycemia) (not yet written)
  Does falling blood glucose feel like hypoglycemia?
  Alcohol and diabetes (by Peter Stockwell)
  Necrobiosis lipoidica diabeticorum
SOURCES (found in part 4)
  Online resources: diabetes-related newsgroups
  Online resources: diabetes-related mailing lists
  Online resources: commercial services
  Online resources: FTP
  Online resources: World Wide Web
  Online resources: other
  Where can I mail order XYZ?
  How can I contact the American Diabetes Association (ADA) ?
  How can I contact the Juvenile Diabetes Foundation (JDF) ?
  How can I contact the British Diabetic Association (BDA) ?
  How can I contact the Canadian Diabetes Association (CDA) ?
  Could you recommend some good reading?
RESEARCH (found in part 5)
  What is the DCCT? What are the results?
IN CLOSING  (found in all parts)
  Who did this?

Subject: My diabetic father isn't taking care of himself. What can I do?
========================================================================

We'll assume your father has type 2 diabetes. See separate section for
definition of types.

Type 2 diabetics, and those who care for them, are in a difficult situation.
Type 2 strikes late in life, so personal habits and patterns are already
formed and solidly engrained. Yet in most cases those habits and patterns are
exactly what must be changed if a newly-diagnosed diabetic is to care
properly for his or her health. This is a difficult psychological problem.

The cornerstones for treating type 2 diabetes are exercise, weight control,
and diet. A high percentage of type 2 patients who apply these therapies
assiduously can control the disease with these therapies alone, without
insulin or oral hypoglycemic drugs. Naturally these are also some of the most
difficult aspects of life to change. There can be no single or simple answer
of how to help or encourage a particular individual find a combination of
therapies which not only controls the disease but also is psychologically
acceptable and which can be incorporated as a lifetime pattern. Helping
depends on knowing the individual's habits, patterns, motivations, desires,
likes and dislikes, and working with all the existing conditions and
everything brought forward from past life.

Doctors and other health care professionals tend to treat type 2 diabetics
with drugs (oral hypoglycemics) and insulin rather than taking the time to
try to get their patients to make the difficult lifestyle changes described
above. This isn't true of all practitioners, but of many. They have good
reason for this tendency: they know all too well (often from painful personal
experience) that most type 2 patients aren't going to make many changes
anyway, and the doctors and other practitioners don't like wasting their time
and breath. So it's likely to fall to friends and relatives who care deeply
to educate themselves about type 2 diabetes and do what they can to encourage
their loved one to make changes. In particular, if the doctor has left the
impression that drugs and insulin are the only treatments, make sure to
counter that impression with information about the value of exercise, diet,
and weight control.

At the same time, it's important to remember that needing oral hypoglycemics
and/or insulin injections as additional tools isn't failure. On the contrary,
a patient who's been actively involved in self treatment already has an
excellent chance of using these additional tools successfully. Those who have
learned to use the exercise - weight control - diet triumvirate will also be
able to utilize insulin and oral drugs as additional treatments when needed.
Choose the appropriate tools and use them effectively.

These treatment choices can interact in positive ways as well. Bringing blood
glucose under control often increases the body's sensitivity to insulin. So
ironically, using insulin may decrease the need for insulin. This is a
positive change which can then be reinforced by the other, interacting
treatments.

You will need far more information than is appropriate for a Usenet FAQ
panel. As a start, call the ADA (see ADA section), get a subscription to
_Diabetes Forecast_ (see journals), and visit a university library and browse
in the diabetes section in the stacks.

Beyond the generalizations above, a few specifics are usually of value:

   Set a good example in your own life. Exercise and eat a good diet.
   The recommendations for diabetics are healthy choices for anyone.

   Share your example. Serve a tasty, low-fat diet to family and friends
   when they are your guests.

   Suggest joint activities. Suggest a walk instead of watching a
   ball game.

   Make sure your diet and activities are visibly enjoyable so your
   guests will accept your invitiation to join you.

Subject: Managing adolescence, including the adult forms
========================================================

Adolescents have special problems in managing diabetes. These include a
variety of physiological problems related to puberty and rapid growth, social
problems related to growing up and the general social pressures of adolescent
life, and the psychological turmoil caused by the expectations of others. I'm
here today to talk about (hey, hold the eggs and tomatoes) expectations.

Actually, this all applies to adults as well, though the subtle points may
differ.

The most important thing to remember, for the adolescent, the parent, and the
health care provider, is


              All Blood Glucose Measurements Are Good.

              There Are No Bad Blood Glucose Readings.


If that doesn't sound right, then please take two steps. First, learn why it
is true. Then chant it like a mantra until you internalize it, so that you
never give off the slightest vibes to the contrary.

Why is it true?

There are two kinds of adolescents (to simplify life enormously): those who
rebel and those who want to please. Ironically, the rebellious are probably
easier to deal with in treating diabetes. "So my blood sugar is 350, so
what?" Bad? No, that's good: you know what's going on, and so does your
child. The point of blood glucose measurement is to respond -- not to be good
or bad -- and only with an accurate report can you and the patient respond.

  [Compulsory digression: 350 mg/dl = 20.0 mmol/L.]

Look what can happen to the eager-to-please child:

   Child: My blood sugar is 350.
   Adult: Oh, that's awful! You must try to be better!
      [next time]
   Child: My blood sugar is ... um [to self: I must be good] 140 ...
   Adult: Oh, that's great!

In short order, the log book looks great but the HbA1c doesn't jibe.

This all happens with the best of intentions from all parties. The child is
trying to please, and is behaving in exactly the ways that elicit approval.
The adult is trying to care for the child's health in the most natural ways.
And the result is one that neither desires.

Thus the positive mantra to replace the half-negative one above:


              All Blood Glucose Measurements Are Good.

           Responding To Blood Glucose Readings Is Good.


. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

An excellent article entitled "Insulin Therapy in the Last Decade: A
Pediatric Perspective", by Julio Santiago, MD, of the St. Louis Children's
Hospital and the Washington University School of Medicine in St. Louis,
Missouri, appears in _Diabetes Care_, volume 16 supplement 3, December 1993,
pp. 143-154. The article discusses many aspects of treating pediatric
diabetes. Santiago spends several pages discussing how to establish realistic
and honest approaches to self-monitoring. I highly recommend the article.

Subject: So-and-so eats sugar! Isn't that poison for diabetics?
===============================================================

This is asked from both sides: the non-diabetic who doesn't understand
diabetes, and the diabetic who gets tired of hearing "I won't put any sugar
on the table" etc etc ad nauseum.

Diabetics should eat a high-quality, healthy diet very similar to that
recommended for everyone. This will include some sugar, and research
indicates that obtaining a moderate amount of carbohydrates in the form of
sugar makes little or no difference in controlling blood glucose levels. There
isn't room here to describe all the aspects of diabetes treatment that make
this so.

No one has suggested a really good, uniformly satisfying answer to the public
know-alls who insist they know more than you do. Feel free to add to this
list:

   That was true before insulin was isolated in 1921.

   Fat is more dangerous than sugar because diabetics have a three-fold
   higher risk of heart disease.

   The whole point of injecting insulin is to balance carbohydrate intake.

   All carbohydrates are converted to sugar in the digestive tract anyway.

Subject: Insulin nomenclature
=============================

The major types of insulin have both generic designations and brand names
used by the manufacturers. Most of the brand names are close enough to the
generic ones that the correspondence is obvious. Novo uses totally different
names. In those parts of the world where Novo has most of the market, the
Novo brand names are used in place of the generic names. To facilitate
communication between Novo users and others, here is the correspondence:

   Generic      Novo
   -------      ----
   Regular      Actrapid
   NPH          Protophane
   Lente        Monotard
   Ultralente   Ultratard

Subject: Travelling with insulin
================================

Insulin does not need to be kept cold.

Insulin is stable at body temperature. This is not surprising when you realize
that the beta cells often store the insulin they produce for days before
releasing it.

A general guide to how long it is safe to store insulin at various
temperatures:

   Refrigerated          a few years
   Room temperature      several months
   Body temperature      a few weeks

Do not allow insulin to freeze. Do not expose insulin to temperatures
significantly above body temperature. I don't know how much heat is required
to destroy insulin, but leaving it in a closed car in the sun would be a very
bad idea.

Short of such extremes, degradation is gradual. You should always be alert for
gradual changes in your blood glucose anyway, since individual sensitivity to
insulin changes over time for reasons unknown. Your normal dosage adjustments
will handle minor degradation that might occur, say, from keeping insulin in
a very hot room for several weeks.

So why do drugstores (pharmacies) keep insulin refrigerated, and why are
"insulin cold packs" advertised? The drugstores are mosty just following
standard procedures. For them, it's a simple precaution not worth violating..

As for cold packs, as long as anyone thinks they are needed, someone will sell
them. As noted, you do need to protect insulin from extremes of temperature,
and the cold packs can help at both extremes. In many situations it may be
just as effective to pack the insulin next to a bottle of water, especially
during outdoor activities when you are carrying water anyway.

Always keep your insulin with you! Keep all your medical supplies with you.
Never pack them in checked luggage. Luggage may sit outside in hot sun or
freezing rain. If you are delayed, or your luggage is waylaid, you could be
without supplies packed in luggage.

Meter manufacturers recommend keeping meters and strips from freezing and
extreme heat.

Subject: Injectors: Syringe reuse and disposal
==============================================

Disposable syringes can be safely reused as long as you take reasonable
precautions. Recap both ends between uses, and discard the syringe if
dropped, dirty, or damaged (especially if the needle is bent). Discard it
when it becomes uncomfortable to use. This varies a great deal, being half a
dozen uses for some patients and several dozen uses for others. Comfort
depends far less on sharpness than on the silicone coating applied to the
needle at manufacture. Never wipe the needle with alcohol, as this will
remove the silicone coating.

Syringe disposal has proven controversial. If you want to be conservative,
buy a needle clipper, get a hard plastic bottle designed for medical waste to
put the syringes in, and take the full bottle to a facility approved for
handling medical waste. Your doctor's office may be able to handle it for
you. Intermediate positions use one of these techniques. At the least
conservative, cap the needle carefully and discard in trash which will not be
subject to illicit searching and possible abuse. If you have trouble capping
the needle without sticking yourself, definitely get a bottle to drop the
uncapped syringes in; a bleach bottle may be adequate. Local or state
regulations may apply.

Subject: Injectors: Pens
========================

A pen injector is a device that holds a small vial of insulin and a
disposable needle, and injects an amount measured with a dial. Advantages
include being compact, convenient, easy to use circumspectly in public, and
accurate and simple in dose measurement. The primary disadvantage is cost.
The special vials may be difficult to obtain in remote areas, and widespread
shortages have occurred occasionally. Falling back to a standard syringe is
always an option. Also, the special vial can be refilled from a standard vial
using a syringe, making sure the rubber stopper is not damaged, though the
manufacturer will not recommend this.

Pens are more popular in Europe than in the US.

Subject: Injectors: Jets
========================

A jet injector uses no needles, but instead squirts the substance being
injected through a narrow orifice under high pressure, producing a fine
stream which penetrates the skin as easily as a needle. Jets are popular with
anyone who is simply scared of needles, for any reason. The jet disperses the
insulin more than a needle does, which probably results in faster absorption.
This can be an advantage or a disadvantage, and requires careful monitoring
when first used. Technique is just as important as with needles, so jets are
no more appropriate than needles for small children. If a jet is used to
avoid needles, equipment failure forcing a fallback to needles may be
traumatic. High cost is a major factor.

Subject: Insulin pumps
======================

An insulin pump provides a Continuous Subcutaneous Insulin Infusion, or CSII,
via an indwelling needle or catheter. That is, a small needle (similar to
those on insulin syringes) or tube is inserted through the skin and fixed in
place for two or three days at a time. An external box pumps insulin through
the needle steadily.

Pumps don't solve all the problems of treating diabetes for two main reasons:

  1) The infusion is still subcutaneous, so the insulin still must be
     absorbed before it can be used. Insulin from the pancreas goes directly
     into the bloodstream and takes effect much more quickly.
  2) Current pumps are open-loop -- that is, there is no feedback from blood
     glucose (bG) to the pump. The patient must still self-monitor bG and
     program the pump.

Nonetheless, many patients get much better results with a pump than from
intensive therapy without a pump, and those patients tend to be extremely
happy with the pump. It isn't clear at present how to decide whether a given
patient should use a pump. Different studies have obtained varying results,
ranging from 85% success to 85% dropout! Unfortunately, no studies seem to
have been done since the mid-1980s, and it is likely that the pumps and pump
therapy have become much more consistently successful since then. A few
important factors seem clear, though:

  1) Motivation. A meter takes extra effort and attention.
  2) Knowledge. If you aren't already familiar with intensive therapy,
     think more than twice before jumping for a pump. You should
     probably try intensive therapy with multiple injections first.
  3) Treatment team. Successful users are backed by teams of physicians
     and educators who are experienced *with pumps*. Don't try a pump on
     your own (the manufacturers won't let you anyway), and don't try it
     with inexperienced providers -- these are recipes for unnecessary
     failure.
  4) Funding. Pumps represent a nontrivial capital outlay. If you don't
     have insurance or other public programs that will pay for the pump,
     you will need personal financial resources.

Most or all pump manufacturers allow a trial period, so you can try a pump
without financial risk. You will probably know fairly soon whether you want
to continue with the pump.

A long discussion about many aspects of pumps is posted monthly at the same
time as this FAQ. See the section "Where's the FAQ?" for retrieval
information. The insulin pump discussion was developed and is maintained by
Jim Summers <[e-mail]>.

Subject: Beta cell implants, pancreas transplants, future cures
===============================================================

Beta cells can be isolated and implanted, requiring only outpatient surgery
for implantation. But foreign beta cells are quickly rejected without
immunosuppressant drugs. Even with the recent advances in drugs, especially
cyclosporin, using immunosuppressants is much more dangerous than living with
diabetes. As a result, beta cell implantation is not currently used to treat
diabetes.

Current research is investigating two general methods of implanting beta
cells without the use of immunosuppressant drugs. The first (immunoisolation)
encapsulates the beta cells within a barrier so that nutrients, glucose, and
insulin can pass freely through the barrier but the proteins which provoke
the immune response, and the cells which respond, cannot pass. The second
(immunoalteration) involves altering the proteins on the surface of the cells
which provoke the immune response. The first human trial began earlier in
1993 on immunoisolated beta cells, and human trials may begin late in 1993 on
immunoaltered beta cells.

Don't expect these treatments to be available on a standard basis any time
soon. I've been reading about this research for nearly 15 years, and the
results are always just around the corner. Serious problems remain to be
solved: safety of the immunoisolated implants, long-term survival, ability to
use beta cells from non-human species, perfection of both techniques -- all
these must be resolved before beta cell implantation moves beyond the
experimental stage. Other problems will likely be encountered along the way,
since this is cutting edge medical research. I'll be surprised if it gets out
of the lab before the year 2000; 2010 is probably a better guess. And it may
fail -- it's always possible that unsolvable problems will yet arise.
Finally, it's not yet clear that even completely normal bG profiles will cure
all the problems of type 1 diabetes. Some may be related to the autoimmune
reaction that is the immediate cause of diabetes. This question cannot be
answered until it is possible to normalize bG levels for a period of many
years.

Whole pancreas transplants have the same rejection problems as beta cell
implants, and also require major surgery. For these reasons, whole pancreas
transplants have only been used 1) in desperate cases in medical schools with
exceptional capabilities, and 2) in conjunction with kidney transplants.
Kidney transplants are (relatively) common in diabetics with advanced
complications. A kidney recipient is taking immunosuppressant drugs anyway,
and the same surgery that implants the kidney can stick in a pancreas with
little extra effort or trauma. As a result, the double transplant is now
recommended, at least for consideration, for any diabetic patient who
requires a kidney transplant. The only disadvantage would seem to be that the
pancreas donor must be dead; whereas a living kidney donor is feasible.
However, at some organ banks the double transplants get in a different queue,
and in some cases the queue for double transplants may be shorter. This will
not be true in all cases and may depend on whether the double transplant is
considered experimental at that institution. It is worth investigating which
choice would get quicker results.

Also note that these treatments apply only to type 1 diabetes. Type 2 diabetes
is the result of insulin resistance or other forms of improper use of insulin
within the body, not an absolute lack of insulin. Type 2 patients have normal
beta cells. There is no treatment of comparable promise on the horizon for
type 2 diabetes.

Subject: What's a glycemic index? How can I get a GI table for foods?
=====================================================================

The glycemic index, or GI, is a measure of how a given food affects blood
glucose (bG). Some complex carbohydrates affect bG much more drastically than
others, and some (such as white bread) even more than sugar. This was quite a
surprise when the research was first published around 1980 [[[[[need to check
date]]]]].

The problem with using the GI extensively in diet is that it is not additive.
That is, different foods interact to produce a combined GI that cannot easily
be predicted from the separate GIs. For example, a baked potato has a very
high GI (one of the famous, unexpected examples), but adding butter to it
lowers the GI greatly. Research is continuing, and eventually it may be
possible to predict the GI of a complete meal.

For now, the important thing is to understand that foods may affect your bG
profile in ways that you wouldn't expect from categorizations such as "simple
sugar" and "complex carbohydrate". Build your knowledge about your own
response to different foods and meals by monitoring and keeping records, and
avoid assumptions.

There have been requests for GI tables on m.h.d. To my knowledge, none is
available in electronic form.

Subject: Should I take a chromium supplement?
=============================================

The short answer is "no". I'll quote the ADA's longer answer, from the May
1994 _Diabetes Forecast_, p.73. The ADA's editorial board says:

    Some popular books on diabetes have claimed that chromium, which is
    found in many common foods such as animal meats, grains, and
    brewer's yeast, is good for people with diabetes. Not so. Though
    chromium supplements may benefit people who are significantly
    malnourished and have an actual chromium deficiency, there is no
    significant evidence that consuming extra chromium helps people
    with diabetes who are even close to being well nourished.

    Taken at the dosages listed on the bottle, however, chromium is not
    likely to be harmful. But your money is better spent on more useful
    items!

Subject: I beat my wife! (and other aspects of hypoglycemia)
============================================================

(not yet written)

Subject: Does falling blood glucose feel like hypoglycemia?
===========================================================

Sometimes. Symptoms of hypoglycemia are divided into the adrenergic and the
neuroglycopenic.  Adrenergic responses are caused by increased activity of
the autonomic nervous system and may be triggered by a rapid fall in blood
glucose (bG) or by low absolute bG levels; symptoms include

  weakness
  sweating
  tachycardia
  palpitations
  tremor
  nervousness
  irritability (sound familiar?)
  tingling of mouth and fingers
  hunger
  nausea or vomiting (unusual)

The autonomic nervous system activity also causes the secretion of epinephrine,
glucagon, cortisol and growth hormone.  The first two are secreted rapidly and
eliminated rapidly.  The second two are secreted slowly and remain active for
4-6 hours, and may cause reactive hyperglycemia.

Neuroglycopenic responses are caused by decreased activity of the central
nervous system and are triggered only by low absolute bG levels; symptoms
include

  headache
  hypothermia
  visual disturbances
  mental dullness
  confusion
  amnesia
  seizures
  coma

The above information is from Mayer Davidson's _Diabetes Mellitus: Diagnosis
and Treatment_.

Remember, as always, that individual responses vary greatly. The exact set of
symptoms encountered will vary. It's not impossible that some of the symptoms
will fall in the other category for some individuals.

Subject: Alcohol and Diabetes
=============================

This section provided by Peter Stockwell <[e-mail]>.

Having diabetes does not prevent the consumption of alcoholic drinks,
but there are some considerations:
  - Alcohol can metabolised to produce energy and so has dietary
      consequences.
  - Alcohol promotes the uptake of blood glucose into liver glycogen
      causing a drop in bG.
  - Many alcoholic drinks contain sugar, particularly mixed drinks.
  - The symptoms of drunkenness and hypoglycaemia are similar - alcohol
      may mask the effects of a hypo.
  - Diabetics must remain sober enough to care for themselves (perform
      injections on schedule, etc).
  - Excess alcohol consumption can cause increased serum triglycerides.

Few difficulties arise if following points are observed.

Acceptable in moderation:
  - Red wines.
  - Dry or medium-dry white wines.
  - Dry sherries.
  - Dry light beers (lagers, light ales fermented with low residual
      sugar).
  - Spirits (whiskey, gin, vodka, etc) with "diet" mixers.

Use with extreme caution due to high sugar content:
  - Sweet wines or sherries.
  - Ports.
  - Heavy or dark sweetened beers (stout, porters, etc which have
      high residual sugar).
  - Wine coolers.
  - Spirits with normal mixers.
  - Cocktails.
  - Liqueurs.

Use with extreme caution due to very high alcohol concentration:
  - Neat (undiluted) spirits.

General rules:
  - Simple drinks (wine, beer) are more reliable than complex mixed
      drinks, especially in company where you have less control over
      the contents or concentration.
  - Drink with or after food to avoid hypo problems.
  - Approach anything with caution if you are in doubt.
  - Low alcohol beers are not necessarily preferred - many of them are
      rather sweet.
  - Alcohol provides about 7 cal/g of food energy. Some is lost in the
      urine, but most is converted by the liver into forms which can be
      used for energy elsewhere in the body or stored as fat.

Clearly these succinct rules are simplified and there are exceptions to
them (for example, there are dry ports) but they are intended as a
general guide.  I make no attempt to define the term moderation, this
will depend on the individual.

Subject: Necrobiosis lipoidica diabeticorum
===========================================

Necrobiosis lipoidica diabeticorum (NLD) consists of oval plaques, usually on
the lower legs. It may start as small red spots or raised areas, which
develop a shiny, porcelain-like appearance. The plaques often turn a light
color due to extracellular fat (the "lipoidica"). They are often itchy or
painful. Typically the spots turn a brownish color, which fades slowly but
is permanent.

NLD is not related to any other complication of diabetes. In particular, NLD
does not presage eye, kidney or vascular problems.

NLD is much more common in diabetics, who account for perhaps 2/3 of all
cases. Many of the remainder develop diabetes, and NLD should be considered a
warning sign of diabetes. Reports vary widely on exactly who is most at risk.
About 1% of diabetics have some degree of NLD ... plus or minus 1%, depending
on which report you read. Some reports say NLD occurs more often in young
women, but some textbooks disagree.

The real dangers seem to be ulceration, infection, and the stress from the
appearance. Ulceration sometimes occurs spontaneously, and often as a result
of trauma.

Ulceration is often a result of scratching or trauma, and the ulceration from
scratching sometimes heals very slowly. Thus avoiding scratching and trauma
decreases the amount of ulceration, though some ulceration will occur anyway.

No particularly good treatment seems to be known. Topical steroids (that is,
creams) are the most common first choice. The ulcerations usually heal if
cared for properly, and drastic measures are not called for in most cases.
William Biggs reports that skin grafts may be necessary in cases of severe
ulceration, but do not tend to give results that are cosmetically attractive.

Other treatments reported to help sometimes are oral aspirin, pentoxifylline,
dipyridamole, locally injected steroids, and systemic steroids. No one claims
to be able to predict what will work on any given patient, and often not much
of anything is effective. However, the ulcers usually heal if given
supportive treatment. Surgery should be avoided.

STEROID WARNING: locally injected and systemic steroids raise blood glucose
and cause severe problems regulating blood glucose. These should be used only
as a last resort. Topical steroids (creams and inhalers) cause no such
problems.

Note that treatment is not a medical necessity except for ulcerations and
infections. Otherwise, the purpose of treatment is to prevent ulcerations
and infections, decrease pain and itching, and improve the appearance.

NLD is the subject of occasional articles in scientific journals on diabetes
and on dermatology. Betsy Butler has researched the medical journals, finding
little beyond what I've reported above -- in her words, "no good answers".
_Therapy for Diabetes Mellitus and Related Disorders_, published by the ADA,
has a section on necrobiosis lipoidica diabeticorum and its treatment

I thank the following people, especially Betsy, who posted the information
from which I derived this section:

    Betsy Butler <[e-mail]>
    William Biggs <[e-mail]>
    Tari M. Birch <[e-mail]>
    Terence Griffin <[e-mail]>
    Bill Barner <[e-mail]>

Subject: Who did this?
======================
--
Edward Reid          [e-mail] (normal)
PO Box 378           [e-mail] (forwarding)
Greensboro FL 32330  [e-mail]

On the World Wide Web (if the converters come to recognize mailto URLs):

  mailto:[e-mail]

Archive-name: diabetes/faq/part4
Posting-Frequency: biweekly
Last-modified: 4 February 1995

Changes: split into five parts (26 Dec)
         see part 1 for earlier changes
         add an ADA book; misc edits (26 Dec)
         expand AOL description (26 Dec)
         add CDA and NLM info (28 Dec)
         add PENpages to online resources (31 Dec)
         update mail order sources (31 Dec)
         fix country code for Canada (21 Jan)
         update info on Joslin books (29 Jan & 4 Feb)

Subject: READ THIS FIRST
========================

Copyright 1993-1994 by Edward Reid. Re-use beyond the fair use provisions
of copyright law and convention requires the author's permission.

Advice given in m.h.d is *never* medical advice. That includes this FAQ.
Never substitute advice from the net for a physician's care. Diabetes is a
critical health topic and you should always consult your physician or
personally understand the ramifications before taking any therapeutic action
based on advice found here or elsewhere on the net.

Subject: Table of Contents
==========================

INTRODUCTION (found in all parts)
  READ THIS FIRST
  Table of Contents
GENERAL (found in part 1)
  Where's the FAQ?
  What's this newsgroup like?
  The newsgroup charter
  Newsgroup posting guidelines
  What is glucose? What does "bG" mean?
  What are mmol/L? How do I convert between mmol/L and mg/dl?
  What's type 1 and type 2 diabetes?
  Is it OK to discuss diabetes insipidus here? What is it?
  How about discussing hypoglycemia?
BLOOD GLUCOSE MONITORING (found in part 2)
  How accurate is my meter?
  Ouch! The cost of blood glucose measurement strips hurts my wallet!
  What do meters cost?
  Comparing blood glucose meters (from Lyle Hodgson)
  How can I download data from my One Touch II?
  How can I download data from my Glucometer (tm)?
  Other recordkeeping software
  I've heard of a non-invasive bG meter -- the Dream Beam?
  What's HbA1c and what's it mean?
TREATMENT (found in part 3)
  My diabetic father isn't taking care of himself. What can I do?
  Managing adolescence, including the adult forms
  So-and-so eats sugar! Isn't that poison for diabetics?
  Insulin nomenclature
  Travelling with insulin
  Injectors: Syringe reuse and disposal
  Injectors: Pens
  Injectors: Jets
  Insulin pumps
  Beta cell implants, pancreas transplants, future cures
  What's a glycemic index? How can I get a GI table for foods?
  Should I take a chromium supplement?
  I beat my wife! (and other aspects of hypoglycemia) (not yet written)
  Does falling blood glucose feel like hypoglycemia?
  Alcohol and diabetes (by Peter Stockwell)
  Necrobiosis lipoidica diabeticorum
SOURCES (found in part 4)
  Online resources: diabetes-related newsgroups
  Online resources: diabetes-related mailing lists
  Online resources: commercial services
  Online resources: FTP
  Online resources: World Wide Web
  Online resources: other
  Where can I mail order XYZ?
  How can I contact the American Diabetes Association (ADA) ?
  How can I contact the Juvenile Diabetes Foundation (JDF) ?
  How can I contact the British Diabetic Association (BDA) ?
  How can I contact the Canadian Diabetes Association (CDA) ?
  Could you recommend some good reading?
RESEARCH (found in part 5)
  What is the DCCT? What are the results?
IN CLOSING  (found in all parts)
  Who did this?

Subject: Online resources: diabetes-related newsgroups
======================================================

On the Usenet, the misc.health.diabetes newsgroup carries most of the
messages related to diabetes. Volume runs about 35-40 articles/day. Suppose
you obtained this FAQ by some method other than by reading m.h.d and you want
to participate. If you already have access to Usenet news, just subscribe to
misc.health.diabetes; the exact method depends on the software used at your
site, so you should inquire locally for details. If you do not have access to
Usenet news, inquire locally about obtaining such access. The key words are
"I want to participate in the Usenet newsgroup misc.health.diabetes". Usenet
is available at most colleges and universities, many companies, some of the
large commercial services (including Delphi, Netcom, America Online,
world.std.com, the WELL), many smaller local services, most Freenet systems,
and many locally run BBSs. Some of these have selective news feeds, and you
will have to ask them to get misc.health.diabetes before you can subscribe
via their system.

m.h.d is not gatewayed to any mailing list, and to my knowledge is not
archived anywhere.

Another newsgroup, alt.support.diabetes.kids, has a much smaller volume of
articles, about 2-3 per day. Being in the alt.* hierarchy of newsgroups, its
propagation is somewhat restricted compared to misc.health.diabetes. To
obtain access, follow the same instructions as for m.h.d, above.

Other Usenet newsgroups which might be relevant are

    rec.food and its subgroups
    the sci.med hierarchy
    the alt.support hierarchy, especially alt.support.diet
    bit.listserv.transplant (only available at sites that carry bit.* --
                             see the description below of the TRNSPLNT list)

Subject: Online resources: diabetes-related mailing lists
=========================================================

Three public electronic mailing lists have diabetes-related content. The
major one is the DIABETIC list, which carries about 60-80 messages/day. Its
charter is to be "a support and information group for diabetics". The overall
flavor and atmosphere are different from the m.h.d newsgroup, so if you find
that you are uncomfortable with one, try the other. If you subscribe to the
DIABETIC list, be prepared for the large volume of messages. If you have not
dealt with this volume of email before, it will be quite disconcerting to see
so many messages appear in your personal mailbox, and I advise that you
consider one of the following methods to avoid being overwhelmed:

    -- set up a mailbox (aka userid, account, screen name) separate from
       your normal personal mailbox in which to receive the mailing list.
       You will have to ask locally whether this is possible on your system.

    -- convert to the digest as soon as you have subscribed. The digest
       option collects messages into large postings called digests (a misuse
       of the word, as all messages are included in their entirety). This
       digest is sent daily, or when its size passes a limit (currently 2000
       lines). Convert to digest form by sending a message addressed to the
       listserv (see below) with a message body containing

           set diabetic mail digest

DIABETES is a low volume mailing list intended as "a technical discussion for
researchers". However, it is clear that most of the few participants are not
researchers, and the content is poorly focussed. It carries one or two
messages/day.

TRNSPLNT is a low volume mailing list for discussion of organ transplants. It
carries about 10 messages/day. It is relevant to diabetes because
complications of diabetes often lead to kidney transplants. TRNSPLNT is
gatewayed with the newsgroup bit.listserv.transplant, which is available at
Usenet sites which carry the bit.* hierarchy of newsgroups.

To subscribe to the mailing list in the first column, send a message to the
email address in the second column (or to the alternate if given) containing
the command in the third column. Note that Firstname Lastname is your real
name, such as John Doe. The listserv software will use the email address in
your message header for your subscription. If you have trouble sending email
to the listserv, or if you receive no response, then you will need the help
of someone at your site.

  DIABETIC   [e-mail]        subscribe diabetic Firstname Lastname

  DIABETES   [e-mail]    subscribe diabetes Firstname Lastname
             [e-mail]

  TRNSPLNT   [e-mail]      subscribe trnsplnt Firstname Lastname
             [e-mail]

These addresses are subject to change, so if you are looking at an old
version of this FAQ and get no response from the listserv, find an up to date
copy of the FAQ.

Subject: Online resources: commercial services
==============================================

Compuserve (CIS) has a very active Diabetes Forum.

America Online has a diabetes support area. It seems to be newer and smaller
than Compuserve's, but growing. The health forum has a number of information
files on diabetes which users can read and download. These files generally
contain good advice and some explanation, but not in-depth explanation.

Also on AOL, each Sunday evening at 8:30 Eastern Time (US) a diabetes support
group meets in a "private room" named "Diabetes". For more information, email
Jim Lewis <[e-mail]>.

I am not aware of any other commercial service that has an area focussed on
diabetes.

Subject: Online resources: FTP
==============================

Demon Internet Services, a UK service provider, has donated FTP space for
diabetes-related materials due to the urging and coordination of Ian Preece
<[e-mail]>. This cooperative endeavor was launched with an
empty directory in June 1994, and depends on the efforts of all of us to
populate that directory with useful materials. Appropriate materials include
software (freeware, shareware, demos), tables of data and information, news
and research articles (with permission please), periodic postings from the
newsgroups and mailing lists, and any other information files.

Short guide: anonymous ftp to ftp.demon.co.uk, directory /pub/diabetes.

Using the World Wide Web:

  ftp://ftp.demon.co.uk/pub/diabetes/

A few pointers for those not familiar with ftp follow. However, if you do
not know how to invoke ftp at all, please ask locally.

  FTP to:      ftp.demon.co.uk
  Log in as:   anonymous
  Password:    <your email address>         (please give your true address)
  Commands:    cd /pub/diabetes             gets to the diabetes directory
               dir                          lists contents
               binary                       prepare to xfer binary files
               ascii                        prepare to xfer text files
               get <filename>               xfer file to your system
  To submit:   cd /incoming                 do before put
               ascii                        prepare to xfer text files ONLY
               binary                       prepare to xfer binary files
               put <filename>               xfer file to Demon ftp dir

After making a submission by FTP, send email to Ian Preece
<[e-mail]> telling him about the file you have submitted. If
you are unable to send files by FTP, send email to Ian at the same address,
asking him how to submit files by email.

Subject: Online resources: World Wide Web
=========================================

If you are using the World Wide Web (aka WWW, W3, lynx, Mosaic), you can reach
a WWW-formatted version of the FAQ via the URL

   http://www.cis.ohio-state.edu/hypertext/faq/usenet/diabetes/top.html

Donald Lehn <[e-mail]> has put a WWW server with diabetes
information on the web at:

   http://islet.medsch.wisc.edu/index.htm

Subject: Online resources: other
================================

The B.C. - Yukon Division of the Canadian Diabetes Association maintains an
information center on the Vancouver Freenet, accessible via telnet. They have
several useful information files, information about the CDA and the division,
and a listing of publications offered by the division office in Vancouver for
loan and sale. (I don't know whether they will ship outside of Canada.)

To get there,

   telnet freenet.vancouver.bc.ca

(other freenets may have a menu item for the Vancouver Freenet)

   Log in as 'guest'.
   Select item 3 (subjects).
   Select item 6 (health).
   Select item 2 (Canadian Diabetes Association).

The US National Library of Medicine has its catalog and a list of resources
online. telnet to locator.nlm.nih.gov and log in as 'locator'. You can search
the holdings catalog and a list of health-related resource providers. You can
email the search results to yourself. Note that the catalog search only shows
books and journals; it is not an article-level search.

Pennsylvania State University maintains a collection called PENpages of
full-text documents. The emphasis is strongly on food and nutrition (the
service is part of the College of Agricultural Sciences), but has a lot of
information related to diabetes. A keyword search on diabetes returns 87
documents as of 30 Dec 1994. Coverage is spotty, but what's there can be
quite valuable. The depth ranges from mass readership advice to recipes to
position statements to technical research papers. It's the only online site
I've found with a lot of professional level information.

  telnet psupen.psu.edu
  Username: login in as a two-letter US state abbreviation
  Keyword search: diabetes

Local phone numbers to dial in directly are available for most of
Pennsylvania.

Subject: Where can I mail order XYZ?
====================================

XYZ is most often blood glucose measurement strips, especially for those who
don't live near discount pharmacies. Mail order prices are not always lower
than local prices. Remember that there is an advantage to going to a single
pharmacist for all your drugs, if that pharmacist is knowledgeable about
interactions and tracks all the drugs you use. Adjustments will be slower if
you mail order. Never mail order unless you are certain about what you need.

That said, here's a list of mail order firms specializing in diabetes
supplies. Aside from those listed below, I've not heard of any outside the
US, perhaps because the health care systems elsewhere don't encourage the
practice. Most of these advertise in _Diabetes Forecast_ (see section on
journals). This list is presented with no recommendations, pro or con. Each
issue of _Diabetes Forecast_ also contains a column summarizing
recommendations for ordering health supplies by mail. Most will send a
catalog or price list on request.

* A R Medical Supplies         1-800-525-8362
*@American Medical Supplies    1-800-434-3536
  Chronimed Pharmacy           1-800-876-6540
                           or [phone]
  Diabetes Supplies            1-800-622-5587
* Diabetic Care Center         1-800-633-7167
 @Diabetic Depot               1-800-537-0404
  Diabetic Emporium            1-800-231-6827 sugar-free foods
  Diabetic Express             1-800-338-4656
  Diabetic Promotions          1-800-433-1477
                           or [phone]
* Edwards Healthcare Svcs      1-800-793-1995
  GEM Edwards                  1-800-793-1995
  H-S Medical Supplies         1-800-344-7633
  Hospital Center Pharmacy     1-800-824-2401 part of the Joslin Diabetes Ctr
                                              ask for bg meter comparison chart
* Liberty Medical Supply       1-800-762-8026
* National Diabetic Pharmacies 1-800-467-8546
                           or [phone]
* Patient Care Svcs            1-800-882-5238
* Preferred Rx                 1-800-843-7038
* Suncoast Pharmacy            1-800-799-1991
*@Thriftee Home Diabetes Care  1-800-847-4383

* = specializes in insurance or Medicare billing
@ = advertises "Hablamos Espanol"

in Canada:

  Diabetes Specialty Shop      1-800-465-3336 (Canada)

In Australia:

  Diabetics Australia    149 Pitt St    Redfern NSW 2016

Subject: How can I contact the American Diabetes Association (ADA) ?
====================================================================

The ADA has local offices in many cities. Check your local phone book first.

To contact the national organization, call 1-800-232-3472 or [phone].
This will reach all departments. Or write

   American Diabetes Association
   1660 Duke Street
   Alexandria, VA 22314
   USA

The ADA offers aid to diabetic patients, books, and journals ranging from
general to research. All can be ordered by phone. They maintain lists of
physicians with special interest and/or training in diabetes. New patients
and their families needing advice are encouraged to call. They may be able to
help in dealing with bureaucratic problems.

Subject: How can I contact the Juvenile Diabetes Foundation (JDF) ?
===================================================================

Check your phone book for a local office, or call 1-800-533-2873.

(It has been pointed out to me that the JDF provides many services and
support. I need more information to include here.)

Subject: How can I contact the British Diabetic Association (BDA) ?
===================================================================

    The British Diabetic Association
    10 Queen Anne Street
    London W1M 0BD
    Telephone [phone]  ([phone])

The BDA produces a bi-monthly magazine for members called "Balance".
Membership is UKP 12 a year.

Subject: How can I contact the Canadian Diabetes Association (CDA) ?
====================================================================

The CDA has local offices in many cities. Check your local phone book first.

To contact the national organization, call [phone], or write

        Canadian Diabetes Association
        Suite 1001
        15 Toronto St,
        Toronto, Ontario  M5C 2E3
        Canada

The B.C. - Yukon Division of the CDA maintains an information center on the
Vancouver Freenet. It includes contact information for regional divisions of
the CDA. See the section "Online resources: other".

Subject: Could you recommend some good reading?
===============================================

You mean to curl up with on the sofa? Oh, diabetes ... OK.

My favorite book is Mayer Davidson's _Diabetes Mellitus: Diagnosis and
Treatment_. Though written as a medical text, anyone willing to plow through
an occasional dense passage and keep a dictionary handy will have no trouble
with it. (See below about medical terminology.) Being written mostly by a
single person, it is much better focussed than the "committee" books which
are so common. And it's very cheap for medical books, US$42 in 1994.

Charles Coughran <[e-mail]> recommends _Management of Diabetes
Mellitus Perspectives of Care Across the Lifespan_, Debra Haire-Joshu
(editor), Mosby Year Book, 1992, ISBN 0-8016-2429-0. He says it's as good as
Davidson, readable, and aimed at a similar audience.

Coughran and Steve Kirchoefer <[e-mail]> recommend
_Joslin's Diabetes Manual_ by Krall and Beaser, Lea&Febiger 1988. Though
somewhat lacking in consistency due to the multitude of writers, it's a
useful practical book. The Joslin Institute is world reknowned for its
support of diabetes research and treatment, and the price of the book is
reasonable.

Coughran further recommends _Joslin's Diabetes Mellitus (13th edition) edited
by Kahn and Weir, 1994. It's another book that suffers a lack of consistency
due to the multitude of writers, but it contains a wealth of information.
Lots of biochemistry and also sections on practical day-to-day management.
Oriented toward health care professionals. 1068 pages, $125.

Terence Griffin <[e-mail]> recommends _Therapy for Diabetes
Mellitus and Related Disorders_. It's a professional level book compiled and
published by the ADA, now in its second edition. See below for ADA ordering
information.

A full list of a variety of books and periodicals would be a useful online
resource. Ask and you shall volunteer. In the meantime, any university
library will have a large number of books on diabetes, and they will be
grouped together on the shelves. Go and browse.

The rest of what I have to talk about is periodicals.

_Diabetes Interview_ is a monthly newsletter emphasizing interviews with
famous researchers and patients, with some other tips and news and humor and
a minimum of advertising. It's a small business endeavor. Lyle Hodgson
<[e-mail]> and others recommend it strongly. One year, US$14; two
years, US$24 (probably more outside the USA).  Their address: 3715 Balboa
Street, San Francisco, CA 94121. Use Visa or MC and call 415-387-4002.

_Diabetes Self-Management_ is a bimonthly costing US$12/yr. Write 150 West
22nd St, New York NY 10011, or in the US call 800-234-0923. According to
Richard Simpson <[e-mail]>, who recommends it, the magazine

    has a reading and 'interest' level close to the average population --
    more like 'people' magazine than 'Scientific American.' It contains diet
    advice, basic terminology,  health warnings. Naturally, it is loaded with
    insulin, etc. ads. It seems very middle-of-the-road -- no miracle cures
    or herb remedies!

Everything else I have to recommend comes from the ADA (see section on ADA).

Here's what the ADA says about its own publications:

    _Diabetes_ -- the world's most-cited journal of basic diabetes research
    brings you the latest findings from the world's top scientists.

    _Diabetes Care_ -- the premier journal of clinical diabetes research and
    treatment. _Diabetes Care_ keeps you current with original research
    reports, commentaries, and reviews.

    _Diabetes Reviews_ -- the comprehensive but concise review articles in
    ADA's newest journal are a convenient way for the busy clinician to
    keep up-to-date on what's truly new in research.

    _Diabetes Spectrum_ -- translates research into practice for nurses,
    dietitians, and other health-care professionals involved in patient
    education and counseling.

    _Clinical Diabetes_ -- For the primary-care physician as well as other
    health-care professionals, this newsletter offers articles and
    abstracts highlighting recent advances in diabetes treatment.

    _Diabetes Forecast_ -- ADA's magazine for patients and their families
    features advice on diet, exercise, and other lifestyle changes, plus
    the latest developments in new technology and research. It is a
    valuable tool for patient education.

Now for my own opinions.

_Diabetes Forecast_ is the mass market magazine, intended to be readable by
all literate diabetics. For US$24/year you can hardly go wrong. The biggest
problem with DF is that in the attempt to reach almost everyone, it aims at a
very low reading level -- perhaps eighth grade, I'm not sure. This makes it
tonally annoying and dilutes the information content. Still, it contains
useful information and is excellent at promoting self-care and a positive
self-image for persons with diabetes.

The remaining journals are of interest if you want to follow what is new and
under investigation in medical practice and research. The journals vary in
difficulty of reading. Though some knowledge of statistics and chemistry
helps, a general acquaintance with scientific method is perhaps more
important, and a smattering of familiarity with medical terminology helps
most. Luckily, medical terminology is basically simple -- it mostly consists
of putting together roots and affixes to make specific terms. Learn a few
dozen roots and you can make out most of it. Try to have a dictionary at hand
at first.

_Diabetes Care_ publishes papers on clinical research. I find many of the
papers to be interesting and applicable to my own management.

_Diabetes_ is the ADA's journal primarily for basic research. Some of the
articles are interesting, but they run much more toward biochemistry and
mechanisms of metabolism. As important as basic research is, few of the
reports say little of value directly to patients.

_Diabetes Spectrum_ is the ADA journal most oriented toward health care
practitioners. It consists of reprints of important articles (sometimes
several on a topic) and summaries of related articles, plus original
commentaries from other authors. As such, it provides a broad overview of
topics for readers who don't have time to track down lots of separate
original articles. If you only have time to read one technical publication,
_Diabetes Spectrum_ is probably the best choice.

The ADA has price structures for regular members and professional members. A
basic regular membership with _Diabetes Forecast_ is US$24/year (in the US,
$41.93 in Canada, $39 in Mexico, $49 elsewhere, all in US funds). The other
ADA journals will set you back about US$75/year apiece. A professional
membership allows you to pick and choose journals at the listed rates.

The ADA takes checks, money orders, Visa, Mastercard and American Excess.
Unfortunately, orders of books from outside the USA incur an additional $15
shipping charge. Phone numbers

   1-800-232-3472
   [phone]
   [phone] fax

or write

   American Diabetes Association
   Subscription Services
   1660 Duke Street
   Alexandria, VA 22314
   USA

Subject: Who did this?
======================
--
Edward Reid          [e-mail] (normal)
PO Box 378           [e-mail] (forwarding)
Greensboro FL 32330  [e-mail]

On the World Wide Web (if the converters come to recognize mailto URLs):

  mailto:[e-mail]

Archive-name: diabetes/faq/part5
Posting-Frequency: biweekly
Last-modified: 26 December 1994

Changes: split into five parts (26 Dec)
         see part 1 for earlier changes

Subject: READ THIS FIRST
========================

Copyright 1993-1994 by Edward Reid. Re-use beyond the fair use provisions
of copyright law and convention requires the author's permission.

Advice given in m.h.d is *never* medical advice. That includes this FAQ.
Never substitute advice from the net for a physician's care. Diabetes is a
critical health topic and you should always consult your physician or
personally understand the ramifications before taking any therapeutic action
based on advice found here or elsewhere on the net.

Subject: Table of Contents
==========================

INTRODUCTION (found in all parts)
  READ THIS FIRST
  Table of Contents
GENERAL (found in part 1)
  Where's the FAQ?
  What's this newsgroup like?
  The newsgroup charter
  Newsgroup posting guidelines
  What is glucose? What does "bG" mean?
  What are mmol/L? How do I convert between mmol/L and mg/dl?
  What's type 1 and type 2 diabetes?
  Is it OK to discuss diabetes insipidus here? What is it?
  How about discussing hypoglycemia?
BLOOD GLUCOSE MONITORING (found in part 2)
  How accurate is my meter?
  Ouch! The cost of blood glucose measurement strips hurts my wallet!
  What do meters cost?
  Comparing blood glucose meters (from Lyle Hodgson)
  How can I download data from my One Touch II?
  How can I download data from my Glucometer (tm)?
  Other recordkeeping software
  I've heard of a non-invasive bG meter -- the Dream Beam?
  What's HbA1c and what's it mean?
TREATMENT (found in part 3)
  My diabetic father isn't taking care of himself. What can I do?
  Managing adolescence, including the adult forms
  So-and-so eats sugar! Isn't that poison for diabetics?
  Insulin nomenclature
  Travelling with insulin
  Injectors: Syringe reuse and disposal
  Injectors: Pens
  Injectors: Jets
  Insulin pumps
  Beta cell implants, pancreas transplants, future cures
  What's a glycemic index? How can I get a GI table for foods?
  Should I take a chromium supplement?
  I beat my wife! (and other aspects of hypoglycemia) (not yet written)
  Does falling blood glucose feel like hypoglycemia?
  Alcohol and diabetes (by Peter Stockwell)
  Necrobiosis lipoidica diabeticorum
SOURCES (found in part 4)
  Online resources: diabetes-related newsgroups
  Online resources: diabetes-related mailing lists
  Online resources: commercial services
  Online resources: FTP
  Online resources: World Wide Web
  Online resources: other
  Where can I mail order XYZ?
  How can I contact the American Diabetes Association (ADA) ?
  How can I contact the Juvenile Diabetes Foundation (JDF) ?
  How can I contact the British Diabetic Association (BDA) ?
  How can I contact the Canadian Diabetes Association (CDA) ?
  Could you recommend some good reading?
RESEARCH (found in part 5)
  What is the DCCT? What are the results?
IN CLOSING  (found in all parts)
  Who did this?

Subject: What is the DCCT? What are the results?
================================================

The DCCT was a large multi-center trial involving over 1400 volunteer
patients with type 1 diabetes. It began in 1983, ramped up to full speed by
1989, and ended early in 1993 when the investigators felt the results were
clear. The volunteers were all undergoing "standard" treatment when they were
recruited, meaning one or two injections per day. They were randomly assigned
to two groups. One group continued as before. The other group received
intensive treatment aimed at achieving blood glucose (bG) profiles as close
as possible to normal. The intensive treatment involved multiple bG checks
per day, multiple injections and/or an insulin pump, and access to and
regular consultation with a team of treatment experts.

It is particularly important to note that intensive treatment was defined as
a collaborative effort involving the patient and a skilled team of health
care professionals. It was not defined by particular techniques, although
certain techniques were typically used. The frequent consultations and
availability of a professional team were critical components of intensive
therapy.

The results show that the intensive treatment group did indeed achieve bG
levels closer to normal, and that they experienced far fewer diabetic
complications though also more hypoglycemia. In particular, patients who
maintained HbA1c levels around 7% appear to be much better off than those
whose HbA1c hovers around 9%. (See caveats in the section on HbA1c.) Though
it is not possible to separate the effects of all the aspects of the
intensive treatment, it is reasonable to believe that lowering average bG may
be effective even in isolation from the other aspects of the intensive
treatment. In its position statement, the ADA says

   Patients should aim for the best level of glucose control they can
   achieve without placing themselves at undue risk for hypoglycemia or
   other hazards associated with tight control.

Though type 2 patients were not included in the study, it is generally
believed that the results showing the benefits of tight control apply to
type 2 patients as well.

The entire position statement was published in most of the ADA's publications
(see "could you recommend some good reading") in the summer and fall of 1993.

The formal report detailing the results was published in The New England
Journal of Medicine, aka NEJM, of September 30,1993 (v 329 pp 977-986). The
following discussion is based on that article.

The study placed subjects into two cohorts, primary prevention or secondary
intervention, depending on duration of diabetes and existing complications --
the primary prevention cohort were those with essentially no complications.

Specifically: all subjects met these criteria:

    Insulin dependent as evidenced by deficient C-peptide secretion
    Age 13 to 39 years at entry to the study
    No hypertension, hypercholesterolemia, severe diabetic complications,
        or other severe medical conditions
    Meet the criteria for one of the cohorts

and were separated into the two cohorts by these criteria:

                              Primary          Secondary
                             Prevention       Intervention
                              Cohort            Cohort

    Duration of IDDM        1-5 yrs           1-15 yrs
    Retinopathy             none detectable   very mild to moderate
                                                  nonproliferative
    Urinary albumin         < 40 mg / 24 hr   < 200 mg / 24 hr

Within each cohort, the subjects were randomly assigned to either
conventional therapy or intensive therapy. Thus the study compared intensive
to conventional therapy in two different cohorts. The two questions the study
was mainly designed to answer were

  1) Will intensive therapy prevent the development of diabetic retinopathy
     in patients with no retinopathy (primary prevention), and
  2) Will intensive therapy affect the progression of early retinopathy
     (secondary intervention)?

Conventional therapy included one or two injections per day, daily self
monitoring of blood or urine glucose, education, quarterly consultations, and
intensive therapy during pregnancy. Intensive therapy included three or more
daily injections or an insulin pump, bG monitoring at least 4x/day,
adjustment of insulin dosage for bG level and food and exercise, monthly
personal consultations and more frequent phone consultations.

To simplify a lot, the DCCT showed the following changes in the intensive
therapy groups compared to the conventional therapy groups. Note that '-'
shows a decrease, '+' shows an increase, in the number of patients affected.
Patients were judged as affected or not based on binary criteria, so the
results only say how many subjects were affected, not how severely those
subjects were affected.

Intensive therapy compared to conventional therapy:

                                Primary                    Secondary
  Complication                 Prevention    Combined     Intervention
  ------------                 ----------    --------     ------------
  Retinopathy(*)                 - 75%                       - 55%
  Nephropathy(*)                 - 35%                       - 45%
  Neuropathy(*)                  - 70%                       - 55%
  Hypoglycemia(*)                              +200%
  Weight gain(*)                               + 33%
  Hypercholesterolemia(*)                      - 35%

(*) This brief table begs many questions about what exactly was measured and
how. For more details, read the paper.

There were no detectable differences on several measures:

  Macrovascular disease
  Mortality
  Changes in neuropsychological function
    (a feared result of severe hypoglycemia)
  Quality of life (based on a questionnaire)

Some limitations of the study: type 1 only, patients young and with short
duration (under 15 years) of diabetes, and short duration of the study (5-9
years). Measured only number of subjects affected according to binary
criteria, not by measurement of severity of complications. Excluded patients
who already had severe complications and who thus might benefit the most. The
difference between the groups increased during the study, but there is no
proof that the difference would continue to increase with time. It is
tempting to extrapolate the results to all diabetic patients -- all types,
ages, and durations -- and there is at least some support for doing so.
However, the DCCT by itself does not show results for type 2 patients, older
patients, patients who have had diabetes for many years, or those who already
have severe complications. On the other hand, a different group of subjects
might shows differences in areas such as mortality and macrovascular disease,
where the young DCCT cohorts simply did not have significantly measurable
incidence. The DCCT subjects are being tracked in a followup study which may
shed light on some of the unanswered questions.

Secondary analysis of the data indicates that retinopathy decreases with
decreasing HbA1c. This measure was not part of the study design and is more
difficult to interpret, but still shows clearly a correlation between HbA1c
and retinopathy.

It is often stated that the DCCT proved that tight control or lowered HbA1c
reduces complications. This is not the case. The controlled variable in the
DCCT was intensive vs conventional therapy, and intensive therapy was defined
by several factors including a team of skilled health care professionals
acting in partnership with the patient. The results show that intensive
therapy results in both lowered HbA1c and fewer complications, but do not
show that one causes the other. The lead authors provide a good summary of
this point in a followup (NEJM 330:642, March 3, 1994):

    We want to stress that the most valid interpretation of the trial is that
    intensive therapy, with the **goal** of achieving blood glucose
    concentrations as close to the nondiabetic range as possible, delays the
    onset and slows the progression of long-term diabetic complications. The
    secondary analyses support the notion that lower glycosylated hemoglobin
    values are associated with a lower risk of progression of retinopathy,
    but they do not prove that hyperglycemia in itself causes retinopathy.
    [emphasis added]

Many of us believe, and believed before the DCCT, that actually achieving
good control aids our health. The DCCT adds weight to this case but does not
prove the point.

Several DCCT subjects participate in m.h.d and are willing to answer
questions related to the personal aspects of DCCT participation.

Subject: Who did this?
======================
--
Edward Reid          [e-mail] (normal)
PO Box 378           [e-mail] (forwarding)
Greensboro FL 32330  [e-mail]

On the World Wide Web (if the converters come to recognize mailto URLs):

  mailto:[e-mail]

Archive-name: diabetes/software
Posting-Frequency: monthly
Last-modified: 8 Feb 95


    Information Technology Resources to Support Persons
        Involved with Diabetes


Copyright 1994 by Michael Wolfe. Re-use beyond the fair use provisions
of copyright law and convention requires the author's permission.


New since last posting: Medmaster Update (review not yet available)
            Contact Information for Insulin Analysis
                (software not available    for review)
            Lifescan free cable no longer free
            Windows/Pentium problem

Introduction

There are now many information technology products that can help with diabetes
management. These include a variety of software and other on-line information
resources. Software is now available for meal planning and information
recording. In addition, for users of meters with memory and download features,
there is now software that can automatically download readings and display
them in more informative ways than the usual logbook.

Most of this review is about these programs to download data from Touch II
meters; however, I have started to add information about other software, as
well as other on-line information sources, both commercial providers and the
Internet. So far, I have found one ftp site and one Web site.

I also mention America Online and Compuserve. I haven't had time to check the
other commercial information providers, but Prodigy and some of the other
providers also have some resources to aid with diabetes management..

Basically, then, this article is divided into three parts:

I. Software to download and analyze blood glucose readings from home
   monitoring devices
II. Other software (nutritional databases, logbooks, etc.)
III. Other Electronic Information Resources (ftp, Web, commercial sources)


Acknowledgements: Vic Abell gets special mention for his help, as does
Jo Anne Jacques who sent in two programs I haven't seen anywhere
else. Biostore corporation and Medmaster donated copies of their
commercial software. Thanks also to Ed Reid who sent me a number of
programs to review and helped me get started with this review.

   I. Software to download and analyze blood glucose readings from home
                   monitoring devices

Many authors have written software (of varying degrees of sophistication) to
help with home diabetes management. The programs are available for many
machines and many operating systems. The majority of the programs are what I
would call "Electronic Logbooks," i.e., record-keeping programs which require
users to type in their blood glucose levels. Some of these electronic logbooks
also allow the entry of other data such as insulin, meals, exercise, etc. Many
of these programs may be found on America Online and Compuserve. Searching for
more programs on these services is discussed at the end of this review. At
least one program is available for free over the Internet, and one is available
from the meter manufacturer.

This section covers only those packages that will download data from a meter.

The programs are grouped as follows:

Section A are programs for the Lifescan Touch2 meter
Section B are programs that download data from other meters.

All these programs run in DOS or Windows on a standard PC. I have found no
"turn-key" Macintosh applications at this time; however, Mac users can download
to a Mac with a terminal emulator and chart the data with any charting program
(I use Excel and Delta Graph). Also (again in the interest of completeness) a
Macintosh program is under development and the user interface (with nothing
behind it) is available for perusal on Compuserve.

I recently noticed, since being upgraded from a 486 to a Pentium, that all
the Windows-based download programs are crashing, some on the second attempt to
download, others on the first. Many people have trouble downloading if their
meter is connected to COM3 or COM4 due to IRQ conflicts. Only Medmaster had
heard of the Pentium/Windows problem. New drivers for the serial port are
supposed to fix it. As a result, my evaluations of Windows products are limited
until I either get access to a 486 or new drivers.

IRQ conflict problems are the most common reason why a program won't work.
The Touch2 distribution by Vic Abell (ftp://vic.cc.purdue.edu/pub/touch2.zip)
explains what to do. Also, Biostore has offered to help people with this
problem if they call 1-805-288-1301.

The programs are reviewed below.

------------------
Section A. Software for the Lifescan One Touch meters

Note: to download data from a One Touch meter it is necessary to obtain
a cable from Lifescan. The cable is proprietary (it is not just an
RS232.) The cable is $5.00 + two UPC codes from Lifescan strips in the U.S.
Other Lifescan country offices have their own policies. To get the cable,
U.S. users must call the 800 number on their meter and request a special
order form. Lifescan US was unable to explain the policies outside the U.S.
but posts to misc.health.diabetes indicate that the cable may be hard
(or at least very expensive) to obtain outside the U.S., and no one has
had any luck in replicating it.

For non-U.S. readers, if your local Lifescan office charges more than $5.00 for
the cable, you still MUST get the cable to use the download feature (I suggest
trying to get a friend in the  US to get the cable for you).

This section is organized as follows: Part 1 is for DOS, Part 2 is for
Windows.

Part I. DOS Based Programs

1. UTILITY, the Lifescan-provided utility software

Cost: varies by country. free in the U.S. to purchasers of One Touch strips.

This is the most accessible program: Lifescan will provide this program at no
cost to U.S. users who have purchased the cable by calling their 800 number on
the back of the meter (1-800-277-8862 US; 1-800-663-5521 Canada). The Lifescan
offices in each country are independent, and some charge (an exhorbitant
amount) for the cable and software, while others (including the U.S. office)
make these available for $5.00 to users of Lifescan strips (exclusive users of
clone strips are now precluded from using the download features). Some country
offices will also send a copy of the program at no charge. It only took me
about two weeks to get the cable, but it took me about six weeks to get the
software since it was out of stock and had to be backordered. Other people
report receiving the software rather quickly, then having to wait for the
cable. Lifescan has been changing its policy, so this information is only valid
as of February, 1995.

For non-US readers, if your local Lifescan office charges, you may not want to
pay for this software.


Requirements: A PC running DOS. Lifescan will sell you the necessary cable.

Review: This program downloads a One Touch or Touch 2 meter to a PC. It does
not perform any analysis or graphing. The manual suggests that the data
may be analyzed with a spreadsheet and shows how the data looks when opened
into Microsoft Excel for Windows. Details on how to do this are not provided
in the manual. This is a very basic program, but may be all that some people
need. The downloaded data can be imported into some of the electronic
logbooks available.

One advantage to this program is that it works for most meter settings, since
it does not try to analyze the data. The user need know nothing about COM
ports or BAUD rates, the program automatically selects the correct settings.
It may not work if the language has been changed to anything other than English
or Spanish, and will not work if the meter has been used with the old Lifescan
Datamanager until the communications settings have been reset to the factory
settings. For most users, it will work with no problems, except for printing.
Instructions for printing have a typo, they should say:

PRINT/D:LPT1, (the manual says PRINT D:/LPT1, which is wrong).

In any case, users MUST call the number on the back of their meter, obtain
and fill out the form from Lifescan, and order the cable. After obtaining the
cable, the software may be included at no extra charge (Lifescan wasn't
clear on this).

2. TOUCH2 by Vic Abell

Recommended. An excellent freeware program.

Cost: freeware

Available as described below by the author.

> My MS-DOS program, called TOUCH2, will possibly do what you want.
> It is available via anonymous ftp from vic.cc.purdue.edu in
> pub/touch2.zip  {note: this address is subject to change}
>
> If you do not have ftp access, you can get a copy of a TOUCH2
> distribution file by email by sending an email letter to:
>
> [e-mail]
>
> In the body of the letter put:
>
> reply <your_email_address>
> connect vic.cc.purdue.edu anonymous <your_email_address>
> chunksize 100000
> binary
> uuencode
> get /pub/touch2.zip
> quit
>
> If you want touch2.tar.Z instead, put its name in place of touch2.zip
> in the "get" directive.  If you want btoa encoding instead of
> uuencoding, replace the "uuencode" line with "btoa".
>
> CAUTION: <your_email_address> MUST be RFC822-compliant -- e.g.,
> [e-mail] or [e-mail].
>
>
> Vic Abell <[e-mail]>
>

The program is also available on Compuserve, in the Diabetes forum. It may be
accessed by typing

GO DIABETES
Library: 9
Download: Touch2.zip


Requirements: Any IBM compatible wiht a serial port and 128K memory (and,
of course, the Lifescan cable).

Review:

For those of you familiar with the old TOUCH2, there is a new and much improved
version, 1.16, which was released in early 1995. The new version, like the old
one, is very easy to use. It downloads the data from the meter and displays
both the numeric glucose levels and a graph. It provides average blood sugar
readings, as well as average checkstrip and control readings. It also allows
users to set all the adjustments on their meters from their PC, e.g., to turn
the beep on or off, set for US or metric readings, etc. Readings can now be
partitioned by time of day or by event code. In other words, the program will
now plot separate graphs for fasting, lunch, dinner, and bedtime values.  This
feature was labelled "essential" by my doctor. The latest edition allows values
to be plotted in chronological order (previous edition only allowed reverse
chronological order.)

I had no trouble at all downloading and installing with ftp (but was unable to
get my mailer to read the code).

Printing the graph is done with DOS characters, so it provides the basic
information, but does not look as attractive as a more sophisticated graphics
program. Users wishing nice graphs can import the data into a graphics
package.

For programmers, source code is available, so any desired feature can be added
by anyone with a C compiler.

One drawback is that users must have ftp and pkware, and know how to
use them. Users without ftp access to the internet must have a good email
package. This is "freeware", so limited support is available, although Mr.
Abell gave me quite a bit of help via email. He also includes his phone
number with the program, but I haven't called him.

Another drawback is that this is a DOS program that may be incompatible with
Windows.  Based on one internet posting, some users have had trouble getting
the program to  work in a DOS window under Windows; however, I had no problems
getting the program to function in a DOS Window, and, of course, no trouble
at all if I don't start Windows.

Finally, as Mr. Abell says, this is not a finished, polished product. It does
everything I need, but is a bit more awkwared to use than some of the
commercial or shareware packages.

One big plus to the program is that source is distributed, so programmers can
add any features they need. Also, the program is free and readily available to
anyone on the Internet.

Other Requirements:


For someone with ftp access, the zip file mentioned above requires PKUNZIP
version 2 or later. For someone without ftp access, the ftpmail version arrives
uuencoded in two parts. My mail package (Pegasus) cannot handle two-part
uuencoded files, so I was unable to use the ftpmailed version. Basically,
anyone who must use ftpmail is dependent on having a good email package on
their system. Vic Abell sent me a number of suggestions that I tried to get
the mailed version to work, for which I thank him; however, none of them worked
with my email package.

There is also a Unix (R) tar version.

The diabetic community owes Vic Abell a debt of thanks for writing this program
and making it freely available. This program was developed before the UTILITY
program mentioned above, and, with the latest enhancements, provides "for free"
the essentials available in the shareware and commercial programs listed below.

While support is limited, Mr. Abell has been very helpful via email. The
documentation included has one of the most lucid explanations I have seen of
IRQ problems and how to solve them.

---------------
Aside: the above instructions for getting touch2 from vic.cc.purdue.edu apply
to getting software from ftp.demon.co.uk, as well as other ftp sites.

---------------


3. OTVIEW by Merritt Island Technologies

This program is shareware

Cost: $25.00, if download, $29.00 if disk is ordered by mail, $30.45
if ordered by credit card.

Available for downloading from ftp.demon.co.uk, Compuserve, and many local
bulletin boards, including their own SPACECON BBS [phone]. More
information can be obtained by writing to [e-mail]
or to
TOM MCKEEVER
MERRITT ISLAND TECHNOLOGIES, INC.
253 MERRITT SQUARE, SUITE 616
MERRITT ISLAND, FL 32952

Requirements:

Any PC with DOS 2.1 or later and a little over 200K of memory, i.e.,
almost any PC acquired in the last 5 years. It can run from Windows,
although it is a DOS program, and it supports a Mouse. To use the
graphics, an EGA or VGA graphics adapter is required. The PC must have
a modem port as well. Finally, the free cable obtained from Lifescan
with Utility is required. The program does not require a hard drive in
order to run: it will fit on a 360K floppy disk. Like TOUCH2, if
downloaded as a ZIP file, it does require PKUNZIP. If obtained by
ftpmail, the same problems mentioned in the TOUCH2 review may be
encountered.

Review: I found this program easier to install and use than TOUCH2; on the
other hand, it costs $25 more than Touch2. OTVIEW provides basic
downloading and graphics. Unfortunately, my diabetologist does not find the
output from any of the above programs very useful: she needs Morning, Noon,
Evening, and Bedtime readings provided separately. I would probably use TOUCH2
or UTILITY, both of which are free, rather than pay $25 for this program.

4. Blood Glucose Monitor Version 1.1

This program is shareware.

Cost: "No specific amount will be charged by the author." People who need the
program and can't afford it are allowed to use if for free.

"ALL OTHERS ARE EXPECTED TO PAY an amount that indicates the degree of
usefulness they believe this program offers."


Available for downloading from Compuserve Diabetes Forum or

from
Norman E. Shimmel
1015 Bonniebrook Road
Butler, PA 16001
[e-mail]

Phone: [phone]

Requirements: Any DOS machine (and, of course, the Lifescan cable).
Can be run without a hard drive.

Review: An easy to use DOS program for reviewing results. Printing options are
limited for those users who need hardcopy to take to their physicians.

Part 2. Windows Software

Note: While I had no trouble downloading data with any of the DOS programs,
all the Windows programs had problems with my Pentium. The first two
allowed me to download once. If I had to download again, the machine crashed.
The remaining programs crashed before downloading any data. Only Medmaster
had seen the problem, and is sending me new drivers. I'll report on the
drivers in the next edition of this report.

Only Diabetics Assistant worked on my real meter. Diabetics Assistant
and Biostore both worked on my test meter.

1. Diabetics Assistant by Douglas Williams

Recommended. This program is shareware. For the price, it is a good deal.

Cost: $30.00

Available for downloading from America Online, Compuserve, or by writing

Douglas A. Williams
13725 174th Ave NE
Redmond, WA 98052

This is available on ftp.demon.co.uk in 3 files.

Requirements:


Windows 3.1, Dos 3.3 or later, 286 processor, 2 MD RAM, 2.5 MB free hard drive
space, mouse or other pointing device.

Review: This is a nice Windows-based point and click program, but is written by
a red-blooded American for red-blooded Americans (:-). i.e., the program cannot
be configured to accept data from any meter that has been changed from
standard US settings. A cryptic error message ensues if the meter has been
changed to another language, MMOL, or European date formats. Baud rate cannot
be set in the program, but must be set on the meter to 9600. The meter cannot be
configured at all from the program.

The program will take the data and produce a facsimile of a normal (i.e. paper)
logbook for users who prefer the old-style data display. Some doctors prefer
this format, and this program allows users to check their blood with their One
Touch, then generate the log book just before their scheduled visit to the
doctor. Color 3-D graphs are also available. The logbook will have readings for
fasting, noon, dinner, and bedtime.

The user can use the meter event codes for fasting, normal, bedtime, etc.
The program can then graph each event code separately.

This is shareware, and some users may experience difficulty.

My only real complaint with this program is that it is somewhat
difficult to install. As I mentioned above, it is only compatible with
the standard US settings on the Touch 2 meter. It also requires the
user to understand the SHARE utility.

My own experience was that, fifteen minutes before my scheduled appointment
with my doctor, I tried to download the readings from my meter,
and the program crashed my PC. The problem is that my PC was set up with
SHARE installed using the defaults. A message is provided if SHARE has
not been installed at all. Diabetics Assistant requires that SHARE
be installed with /L:500. Again, this is shareware, so users must carefully
read the install manual. Once properly installed, the program will satisfy
most users' requirements.

Apparently, Ian Preece has used this program with almost no problems (once he
changed his meter from European units to American units.)

(Thanks to Ed Reid for sending me a copy of this program to review.)
(Also note that Ian Preece is planning to put this on his anonymous ftp site.
He has also written a much more extensive review and posted it to the site.)

2. Biostore L

Cost: $49.95 + $5.00 S&H

        Call 1-800-435-1992 (orders)
                     1-805-250-9709 (information only)


Requirements: Lifescan cable. Windows Verion requires 286 (386 or better
recommended.) 2MB RAM minimum, 2MB Hard Disk Space minimum.

DOS version requires PC-XT or better, 640K RAM, 2MB hard disk space.

Key features: Downloads data from a Touch 2 meter. Does 30 event and 7 event
graphs, partitioned by time or event code. Provides support for modem
communications with diabetes clinic.

Review:

This is a commercial package with many more features than the freeware
and shareware programs.

Installation: I had a little trouble installing the package on my
system, but the technical support walked me through the problem. (Some of the
Windows file names were in conflict with some of the programs I had installed.)
For people with a "clean" Windows, this program has a SETUP.EXE which should
do all the installation with no problem.

Technical Support: The help line is NOT toll free, but is well staffed. On
MHD, this support line was offered to a user of another download program
as a public service. This is highly commendable.

Features: This program downloads data from the Touch2. A planned enhancement
also import data from other meters. The user may manually enter blood sugar,
insulin, and ketones into the program's database. Blood sugar readings are
diplayed with bold for out-of-range readings. These may be displayed in a
classic "log book" style, or graphed.

Graphs include line, bar, and pie charts. The line chart is a display of one
kind of reading (e.g. before breakfast, before lunch, bedtime, etc.) for 7 or
30 events. The pie chart shows the percentage of high, normal, and low
readings.

If a clinic adopts the program, it is set up to allow the patients to
communicate their readings over a modem. The program is set up to send and
receive data, provided the clinic and patient both have copies of the program
and compatible modems. This could save patients a great deal of
unnecessary travel. A few clinics are using the program in this way. Since
the program was written with clinics as one class of potential customers, the
program will accept data in any language and units, and display in any other
of the Lifescan languages and units. The clinic could, for example, have
patients who sent their readings in in Spanish, French, and Italian, while
the doctors read the readings in German.

The display is more sophisticated than the shareware or free programs, with
high and low readings displayed with color and bold type (the user sets the
definition of high and low).

The program is quite flexible: it allows the user to set the language, units,
date and time format, etc.

The program has been tested on a number of diabetologist who found the
displays informative. Apparently, this led to the design decision to not
allow the user to display more than 30 events on a single graph. The program
does allow the user to set start and end dates so that all readings may be
captured in a series of graphs. By default, the program uses only the most
recent events, although this can be manually overridden to graph all the
data in the meter.


Summary: Overall, this is the best and most sophisticated program I have
seen. I had some trouble with installation, but the help desk walked me
through the procedure. Downloading is a bit more trouble than with the DOS
programs, but the final results are easier for my doctor to interpret.



3. Medmaster

Cost $79 (includes S&H)

Call 1-800-455-4GSC


Installation: The software arrives on disks which must be unprotected. The
installation disks are not copy protected, and the manual advises making a
backup. Installation follows the usual Windows protocol: run a:setup from the
program manager in Windows. As with Biostore, I had some trouble, but the
support staff were very helpful. Unfortunately, my Pentium appears to need
a new driver, so this review will not be available until the next posting.

This program started out in section 2 as a sophisticated logbook in which
users could record exercise, meals, and insulin and plot the impact of each.
With the addition of the download feature, it appears to be a very powerful
and full-featured program. I am anxiously waiting the arrival of the Pentium
driver to write this review.

4. Diastats 2.0


Cost $29.95 + 3.50 S&H


Call 1-800-252-7492

or write

Orchard Enterprises
P.O. Box 847
La Miranda, CA 90637


Review: Not available at this time.


5. Level

Cost: $79.00 (includes shipping and handling)

Call: 1-800-682-9375 or write

HealthWare
P.O. Box 5396
Buena Park, CA 90620

System Requirements: Windows 3.0 (3.1 recommended), IBM or compatible 286
or above. If the software is to be used with a Touch II meter, the
user must obtain the LifeScan cable (mentioned above) to use with the
meter. Cabling requirements for other meters are not known at this time.

Features: Downloads data from LifeScan One Touch II, Ames GlucoMeter, Merlin
AccuChek.

Review: Not available at this time. A demo version will be sent to anyone
calling the 800 number, but I do not have a full version available to
review. The demo version crashed my (admittedly fragile) machine.

===================================
Section B: Software for other meters.

1. Glucofacts(R)+ Diabetes Management System software

I have reproduced (without comment) a description of a software package for
the Glucometer M/M+. This description was emailed to me by Chris Trippel, who
works for the manufacturer. (I don't have a Glucometer.)

This software works with the Glucometer M and M+ meters.

Cost:  $49.95.

Call: 1-800-348-8100.

The following is a description of the Glucofacts(R)+ Diabetes Management
System software.

Miles Inc., Diagnostics Division developed the Glucofacts(R)+ Diabetes
Management System to collect data from Glucometer(R) M and
Glucometer(R) M+ Blood Glucose Meters, store the data in files, and
integrate this data into a complete series of useful statistical
reports and graphs which can be evaluated on-screen or via hard copy.


Notes: Glucofacts+ DMS runs in the DOS environment.
       The Glucofacts+ DMS version 2.01 ships on 3 1/2" disk only.
       There is no demo software.

       The price for the Glucofacts+ DMS version 2.01 is $49.95.
       The product code is 5044B.
       The Glucofacts+ DMS version 2.01 (5044B) can be ordered by
       calling 1-800-348-8100.  You will be asked to provide the serial
       number on your Glucometer M+/M.

For more information on data management products such as Glucofacts+ DMS
please contact:

Miles Inc. - 1-800-348-8100

Thank you for your interest in Glucofacts+ DMS.

Chris Trippel

2. Level (referenced above). This program does One Touch, Glucometer, and
AccuChek meters, and does have a demo version. $79.00

For all meters, hardware must be ordered from the meter vendor; for the
Glucometer and AccuCheck, basic download software must be ordered as
well. This program then imports the downloaded data and does additional
analyses beyond that provided by the vendor-supplied software.

=============End of Part I=================



II. Other Software Programs (Nutritional Databases, etc.)

----------------------
Commercial Logbooks (these programs track your data like paper logbooks,
but do not download from a meter). All track test results, insulin, and meals.

Insulin Therapy Analysis

System: Windows
Cost $49.95 + $4 S&H

Call: 1-800-510-1024

Predicts impact on blood glucose of various events.


Glucostat

System: Windows
Cost: $55+S&H
Phone: [phone]


Blood Glucose Diary

Downloadable from Prodigy

Cost: freeware
-------------------------
Food Databases

The MEALMATE.ZIP on ftp.demon.co.uk is a typical example of a shareware food
database. It has exchange equivalents for many common foods, and  a recipe
function that adds ingredients to compute the exchange equivalent of the recipe.
It is a simple, easy to use program, although a cracker was listed as a meat
exchange, so, like all shareware, it is to be used at the user's risk.
The author requests donations of whatever the user thinks the program is worth.

A number of food databases are available from Nutrisoft for persons with heart
problem, obesity, etc. The one most relevant to this group is Diabetic
Nutrition. All these databases are available from Nutrisoft, P.O. Box 8226
Stanford, CA 94309. The cost is $39 per copy. The entire database includes
approximately 10,000 food items. Shareware versions may be obtained from America
Online, Compuserve, ftp.cica.indiana.edu in /pub/pc/win3/misc/nsdn33.zip
(URL: ftp://ftp.cica.indiana.edu/pub/pc/win3/misc/nsdn33.zip) This has been
submitted to ftp.demon.co.uk as well, but is not yet available. These programs, while distributed as
shareware, are commercial quality with a nice user interface and a large
database of food items. They also have nutritional information based on
current weight, activity level, etc. They can be reached by email at
[e-mail]


================End of Part II=====================



Part III. Other Electronic Information Resources

FTP Site

Ian Preece has also set up an anonymous ftp site just for diabetes related
programs at ftp.demon.co.uk

He has an article about this site and how to use it in this newsgrous.
Readers with ftp or a good mail program can get software from this
site; as of September 1994, very few programs were available. I found a
meal planning program, MEALMATE.ZIP, a simple meter reading program,
OTVIEW.ZIP, and the Diabetic Assistant as of October 1994, but I expect many
other shareware and freeware programs will be posted here over the next few
weeks. A brief discussion of ftp and ftpmail is in the FAQ (general) by Ed
Reid, and is repeated below in the section on getting the Touch2 program by Vic
Abell.

Web Sites

For those with a web viewer, the following URLs has a great deal of diabetes
related information:

http://islet.medsch.wisc.edu

This is maintained by the University of Wisconsin Childrens Diabetes Center,
and includes connections to the American , the Juvenile Diabetes Foundation,
the Canadian Diabetes Association, and the British Diabetes Association.


Also, some diabetic information may be found at

http://cancer.med.upenn.edu:3000/

Commercial Services

Software, discussion and support groups, and general information on diabetes
are available from America Online, Compuserve, and Prodigy. Compuserve
proabably has the most extensive collection of information, but is also the
most expensive (as of this writing) and I, personally, found it the most
difficult to use. Browing Diabetes Related information and downloading software
on America Online and Prodigy costs $3/hour. Compuserve costs about $4/hour.
All three are frequently changing rates and plans, so these rates may have
changed by now.

America Online

I find this the easiest to use. For example, for users who want to download
software, America Online has three versions: DOS, Windows, and Macintosh, and
each version has a file search tool which will find all programs for that
operating system by keyword. The "Diabetes" keyword will find about a dozen
programs, total.

There are three Mac programs. All are written in Hypercard,
and all are electronic logbooks that require manual data entry. One is a
day-by-day calendar for 1990, the second is the 1990 calendar updated for 1993,
and the third is yet another Hypercard stack for manually entering your
blood sugar readings, along with some general information on diabetes.

There are also four logbooks for windows and DOS: Control Diabetes, for Windows,
a $29 shareware program from Nutrisoft, Blood Glucose Program, a freeware
program for DOS written with a dbase compiler (I'm not sure which one);
diabetic glucose monitor, a $5.00 Geos shareware program (I can't even read the
instructions without a copy of Geos); and sugar31, a $20.00+$2.00 shipping DOS
shareware program written in Clipper. (Thanks to Ed Reid who sent me copies of
these programs to review.)

America Online now has a regular chat program for diabetics. Each Sunday
evening at 8:30PM Eastern time there is a live diabetes support group meeting
on America On Line. It takes place in an AOL "private" room named, "Diabetes."
America OnLine currently charges approximately $3.00 per hour.

Compuserve.

A large library of programs is available on Compuserve, but I, personally, had
difficult finding and downloading them. Compuserve has two tools, IBMFF and
MACFF which search some of the forums for programs for the appropriate
operating system, but the diabetes forums are not searched by these software
searching tools, so only about four programs (none very useful) turn up in an
IBMFF or MACFF search. Searching is somewhat easier with a navigator program
such as CIM. Without the CIM, Compuserve is rather user-hostile, and even with
the CIM, Compuserve can be difficult to use to find relevant Diabetes
information and software.

In addition to the America Online programs, one interesting program I only
found on Compuserve is Fast Monitor. This is written as Windows DLL files which
are accessed via an Excel macro. While I found this interesting (and at
least one person on the Compuserve forum really likes it, I couldn't get this
to work.

For those who get this program to work, Compuserve also has a macro that is an
add-on to FastMonitor, called Arrange, which has been recommended as a very
useful add-on to FastMonitor.

The Compuserve forum, Diabetes, is highly recommended on the internet by
participants. While I found diabetes related software easier to find on
America Online, the Compuserve Forum is easier to find than the America
OnLine equivalent, and the Compuserve forum has much more information.
Currently, it is $4.80/hour.

Future reviews will include these programs.
Archive-name: diabetes/insulin-pump-disc
Posting-Frequency: biweekly
Last-modified: 26 Oct 1994

=====================================================================
                        Insulin Pump FAQ 1.4
                                 by
                             Jim Summers
=====================================================================
>From _Diabetes Forecast_, October 1992

The insulin pump is not an artificial pancreas because you still have
to monitor your blood glucose level. But many people prefer this
continuous system of insulin delivery over injections.

Insulin pumps are miniature, computerized pumps, about the size of a
call-beeper, that you can wear on your belt or in your pocket. They
deliver a steady, measured dose of insulin through a cannula (a flexible
plastic tube) with a small needle that is inserted through the skin into
the fatty tissue and taped in place. In the newer Sof-set product, the
needle is removed and the soft, Teflon catheter remains in place. On
your command, the pump releases a bolus (a surge) of insulin; this is
usually done just before eating to counter the rise in blood glucose.

Because the pump can release an incredibly small dose of insulin
continuously, this delivery system most closely mimics the body's normal
release of insulin. Finding this ideal basal rate for continuous flow
plus the appropriate boluses for your body requires time and a great
deal of communication between you and a health-care team that is
familiar with insulin pumps.

Insulin pumps are not for everyone. To use a pump, you must be willing
to test your blood glucose at least four times a day and learn how to
make adjustments in insulin, food, and exercise in response to those
test results. You also need to understand that an insulin pump will not
cure diabetes - and in fact may even require more work than your
previous treatment plan.

You'll want to check with your insurance carrier before you buy a pump
and all the supplies, although most carriers (except Medicare) do cover
these items.

Many people have chosen the insulin pump because they believe it enables
them to enjoy a more flexible lifestyle. But pumps deliver very precise
insulin doses for different times of day, which in many instances are
necessary to correct the pre-dawn phenomenon. Before you consider pump
therapy, ask yourself: Am I willing to assume this level of
responsibility for my diabetes care?

It is easier to spill ketones if there is a blockage or disrupted flow
when you are on a pump because you have no long-acting insulin in store.
The hardware can be awkward at times because you wear it 24 hours a day,
and you have to be fastidious about cleanliness, so it's not for
everyone.

End Article
=======================================================================
Further information is written by Jim Summers.

An insulin pump delivers Regular insulin 24 hours a day at a set rate
("basal rate"), plus it gives you the ability to "bolus" at meal-times
to account for the influx of calories.  Some are waterproof or
"water-resistant," others are not.  The pump has a line (tubing) that
runs from the pump to a site (usually in the abdomen) that the user
changes every 2-4 days.  Some people seem to wear the same site for
many days, others have to change the sites very frequently.  Insulin
travels from the pump to the body through an infusion set. The
infusion set is a piece of plastic tubing that has a threaded end to
connect to the pump. On the other end is a needle or a Teflon
catheter.  The infusion set is one of a few different types: a
straight or bent needle, with or without a butterfly to help hold the
set in, or more expensive Sof-Set catheters. I use a catheter with a
Tegaderm covering.

=====================================================================

As far as different models go, I have personally worn the following:

Betatron ][              6 years
Betatron IV              3 months
MiniMed 504             11 months
Disetronic H-Tron V100   3 days (loaner test)
MiniMed 506              Since 12 November 1992

------------------------------------------------------------------------
I rate the pumps below, though not the Betatrons -- they are no longer
being produced, so you don't need in-depth analysis of them. I will
mention good features that they had when looking at the newer pumps.
The only pumps on the market right now are manufactured by MiniMed and
Disetronic.  All comments given to me are edited for brevity and
inserted (though hopefully I keep the intent :).


At the moment there are two insulin pumps out there, the MiniMed 506
and the H-Tron V100.  Most brochures say something like the following
"you are prime to be considered for a pump _if_ you":

o  desire to maintain closer control of blood sugars

o  do not have rigid schedules but wish rigid control

o  are willing to test your blood sugars more frequently


>From there, there are a number of things to consider about a pump, one
of the biggest being, "Will my insurance pay for this thing?"  After
that, you choose a model.  There are a lot of things to consider.
Below is generally what *I* think is important, with added details and
issues brought forth by the other authors, and a rep from MiniMed and
Disetronic. (My rep was here for questions while I edited this; I
called Disetronic and asked them relevant information).  Your Health
Care Professional may disagree, and you should discuss any decisions
with them.


====================================================================

1) Number of basal rates.  Do you need different rates at different
times of day?  [504:4], [506:6], [V100:24].  The V100 definitely wins
here -- you set every hour of the day: VERY NICE!!  Of course, you
probably don't need more than 6. (I use 5, but I am playing with it
right now.  I had no problem using only 4 with the MiniMed 504.)  Over
the life of the pump, your need for basal rates may change.

====================================================================

2) Battery life.  The 504 and 506 use 3 watch batteries (357s).  You
change them every ~1.5 months for about $6 for 3.  I also like the
fact that you can just run to any store and buy new batteries for the
504/506 any time of day.  You have to order the V100 batteries.  The
V100 uses Disetronic batteries.  They cost $75/10. One battery is for
electronics, and one is for the pump motor. Each battery needs to be
replaced every 2-4 months.

The V100 also has one battery dedicated to electronics and one to
pumping, while the MiniMed Pumps run the electronics and the pump off
of the same batteries.

Battery life:
  504:  3 Eveready 357 / Month
  506:  3 Eveready 357 / 2 Months
 V100: ~4 Disetronic   / 6 Months

====================================================================
3) Water-resistance.  Can I take it into the shower?  Can I get it
wet?  If I get pushed into a swimming pool am I out an insulin pump?
The V100 is waterproof in swimming pool and bathing situations.  The
504 and 506 are "water-resistant," or "splash proof," depending upon
the rep you talk to.  You aren't to take them into the shower, but if
they get submerged it will probably (!!??) be okay.

[NB: see other water and waterproof issues near the end of the FAQ.]
====================================================================
4) Ease of figuring out how the damn thing works.  If I'm in insulin
shock, I don't want to remember a 5 code key sequence to stop it.  The
506 EASY, V100 MEDIUM, 504 HARD.

The 504 is very hard to do stuff with, lots of holding down two
buttons at the same time to do something.  The 506 is menu driven,
push one button at a time, type of operation.  One button is a menu
that flips you to different screens (bolus, basal rates, daily dosage,
special items, HOLD, ect.).  I favor this over the V100.  I would
hazard a guess that once you learn a pump, it seems pretty easy, no
matter how hard it looks at first.

====================================================================

5) Daily dosage.  How much did I take today?  Yesterday?  The day
before?  Knowing how much you took before is GREAT to enforce dieting
-- if I stick to 35-40 units a day and stay in control, I lose weight.
Easy, eh?  If I took 60+ units yesterday, it means I snacked too much,
even if I am in control:

                504  Amount from 12am
                V100 Amount from 12am; last bolus, regardless of time
                506  Memory of last 7 days, 12am to 12am.

Some people don't really care how much insulin they had the day
before.  Its a matter of taste and what you rely on to help control
your Bgs.  The 506 has it if you want it; the other two aren't very
useful here unless you want to check it at 11:59 to see you dosage for
that 24 hour period.

====================================================================

6) Where do you wear it?  The 504/506 has a belt clamp that is great
-- I don't have to wear a belt, it has a beeper-like hook on it.  The
V100 can be worn on a belt or like a beeper. Both pumps are small
enough for many women to tuck into a bra (around 3oz.), which doesn't
help me much :).

====================================================================

7) Easy-to-press buttons.  504 and 506 NO, V100 YES.  The 504/506 have
inset buttons like most modern microwave ovens.  You may have to press
them more than once before you get a signal through.  The V100 has big
pooched out blue buttons, placed so you can hold the pump and press the
buttons at the same time with one hand.  The 504 and 506 need two hands.

====================================================================

8) Fast representative service:  I have been screwed over by MiniMed
lately; I haven't worked much with Disetronic, but they seem more
eager to please and offered alternatives for whom to meet with.  I am
at the moment furious at MiniMed at the way they've treated me, but I
haven't met with the rep. yet, perhaps I'll feel more conciliatory
after venting my anger on him.  CPI (Betatron) was very attentive to
my needs, though I didn't have one steady rep.
  I should note that, while I haven't fared well with MiniMed, I am
most likely an isolated case, and you should not decide not to go with
them for this point. (However, point it out to your rep. when you meet
him/her that you WILL NOT be ignored, and you've heard very good
things about Disetronic and their treatment of customers (see below).

====================================================================

9) Can I drop it on concrete?  I haven't tested this thoroughly, but
be sure to ask about fragility.  I have dropped the 504 numerous times
on a variety of surfaces, and it has never fazed it at all. I think
the V100 would win here -- it has molded, rounded plastic that looks
like it could star in one of those luggage commercials.

====================================================================

10) Can I visually check the insulin level and determine if I am
indeed getting correct dosages? 504 and 506 yes. V100 sort of.

Actually, for the 504 and 506 you need only look in a little window.
Alternately, you can lift a small lid and look.  For the V100 you need
to unscrew the syringe from the pump, take it out (the drive shaft
will come too) and then look at the syringe.  The V100 has an unmarked
glass syringe; the MiniMed syringe is plastic and has markings every
20 units along the outside (more on plastic vs. glass later).

Note that the V100 does count down with a counter how many units it
thinks you have left.  However, this number is artificial -- it starts
at 315 units and goes from there, but it doesn't REALLY know if you
started with 315 units or not.  If you fill your syringe correctly it
should be darn close, but I'm paranoid, and I like visual checking.

====================================================================

11) When does the occlusion alarm go off (i.e. the alarm that tells
you that you haven't been getting insulin, that the line is somehow
jammed).  MiniMed and Disetronic have different things to say here,
I'll give you what the reps gave me in both cases:

                              **MiniMed**
  PSI occlusion alarm    MiniMed  504/506:         4-11 psi (~2.5u)
                         Disetronic H-Tron V100:  14-35 psi (~10 u)

                              **Disetronic**
  The pressure we are talking about is too sensitive to really gauge
psi -- those figures are bogus.  Actual rates are influenced by a
number of factors:
 o type of infusion set
 o battery age and strength
 o usual basal rates
This usually causes an alarm to go off on all pumps between 3-9 units,
and it doesn't really matter which pump you use.  The quote here was
that MiniMed's numbers were "irrelevant."

====================================================================
12)  Glass vs. plastic syringes.
[  This issue was brought up by the Disetronic rep.  MiniMed published
a study showing that the plastic in tubing can degrade insulin very
slowly over time.  This report was used to hype their "Polyfin
Tubing."  However, their syringes are made with plastic that CAN very
slowly degrade insulin.  If you are on very low levels of insulin a
day, this can be significant.]
The Disetronic uses glass syringes.  While this means that you can't be
as casual with it (glass breaks easier than plastic), it also means
that the only reason insulin is going to degrade in the syringe is due
to heat.

=======================================================================

This is the pump comparison that _Diabetes Forecast_ published in their
October '93 Buyer's Guide.

Two pumps compared:      MiniMed 506
                         (MiniMed Technologies)

                         H-Tron V100
                         (Disetronic Medical Systems)

Size (inches):           (506)  3.40 x 2.0  x 0.8
                         (V100) 3.36 x 2.16 x .75

Wgt. (ounces):           (506)  3.6
                         (V100) Less than 3.5

Battery type/life/cost:  (506)  Three 1.5-volt Eveready (2-3 mo. life).
                                Available in drugstores.
                         (V100) Two 3-volt silveroxide. 2-4 mo. life.

Infusion set:            (506)  24" & 42" Polyfin (insulin-compatible
                                tubing). 24" & 42" Sof-set (non-needle).
                         (V100) 21", 31", 43" polyolefin tubing,
                                straight or bent needle, with or without
                                butterfly.

Basals (# & range):      (506)  6 profiles, advanced temporary basal
                                rate (can deliver more or less insulin
                                for a set duration of 30 minutes to 16
                                hours). Range: 0.0-25.0 U/hr.
                         (V100) 24 plus temporary. 20 deliveries per
                                hour at any programmed rate. Range:
                                0.0-10.0 U/hr.

Smallest bolus:          (506)  0.1 unit
                         (V100) 0.1 unit

Alarms:                  Both pumps have alarms for occlusion, runaway,
                         and near empty.

Warranty:                (506)  3 yr. with lifetime motor guarantee
                         (V100) 4 yrs.

Features:                (506)  Toll-free 24-hour service and support.
                                Memory recall (up to seven days). Pump
                                conducts a safety check every minute,
                                every programming change, and before
                                each motor stroke. Free video on pump
                                therapy. Waterproof, floatable, and
                                impact-resistant protective case
                                available.
                         (V100) Patient receives two pumps and free
                                safety inspections. The pump is
                                waterproof without an additional case.
                                Video and manual available. Toll free
                                24 hour support service. The pump is
                                compatible with all infusion sets.

====================================================================
Hey, my rep just walked in while I was working on this!  I therefore
have the following "Unofficial MiniMed Spiel."  The rep was Corey
Bailey, my local rep (Salt Lake City, MidWest area).


MiniMed has a "love-it-or-leave-it" program to see if pump therapy is
right for you.  If, after 30 days, you do not like your pump, you can
return it for a full refund.  I have been notified that this program
is no longer in effect.  However, you can still get a free 30 day test
of the pump.

For a 30+ day MiniMed test drive call: 1-800-933-3322.  From there
they will transfer you to a district manager for more information,
education, training, and test use.  MiniMed also handles insurance
verification at no cost to you.  You can of course get a flyer from
this same number free of charge.  [JIM: this program has been
discontinued at this time, but ask your doctor/rep to try to get you a
test anyway.]

Cost (with insurance 80%):
  MiniMed 504  : $600
  MiniMed 506  : $799


Publications: "Introduction to Insulin Pump Therapy" a published FAQ
about pump therapy by MiniMed, is a free publication.
This is the best thing to get to start you deciding if you want to use
any pump or not.  I personally have a copy, and I give it 5 stars.  I
assume you can order this at the 1-800 number, but I haven't verified
this.

Videos:  "Beyond Injections" -- interviews with pumpers from various
backgrounds, ect.  The rep was big on this -- sounds like those
people on "you may already be a winner" to me.  Mileage May Vary.

Comments about Disetronic: The rep. was down on Disetronic for a
variety of reasons, the two most important being the PSI argument
presented above, and the fact that if you leave on the cap you can get
a BAD bolus problem from the V100 in an airplane, and if the cap isn't
on, your pump isn't waterproof, only water-resistant.  The rest I
junked as being inapplicable to this argument.

====================================================================
I called the Disetronic 1-800 number and talked to a rep there, here
is the information I got from them.  I guess you could consider this
the "Unofficial Disetronic Spiel."  The rep was Dick Carlson (who wears
the Disetronic pump).


Number to call for more information: 1-800-688-4578

Test policy:  Depends on local Distributor, but basically:
  Fill out paperwork to purchase (i.e. insurance data and bio). Then
you get 30+ day trial.  *OR* Often your doctor will have a loaner, and
then you don't need the paperwork.  He sounded like this was the best
way to go.  Also try your local diabetes support group.  They might have
loaner pumps as well (our local Diabetes Supply Story also had a
loaner it was willing to share on test-drives).

Cost (with insurance 80%): $740

For this you get _2_ pumps (one backup), each w/ 2 year warranty. Each
pump is programmed to run for two years. You get "end of use" warnings
before the two years expires. At the end of the two years, you return
the pump to the company. They service it and return it to you with
another two years on it. There is no charge for this unless the pump
needs repairs not covered by warranty. You can continue this cycle
indefinitely.

Publications: Book printed in Europe for Medical Professionals only,
 "Insulin Pump Therapy: Indication, Method, Technology," translated by
Richard G. Carpenter, publisher Walter D. Gruyter (out of Berlin and
New York).  This is for doctors, not for patients, but you might want
to look at it.

Videos: Untitled.  Introductory video on pump use, why pumps are good,
basics of programming the V100.

General comments by rep (comparing this to MiniMed): The Disetronic
gives a bolus every three minutes, up to .02 U.  The MiniMed cannot
give a smaller dosage than .1 U, so of you are on VERY small basal
rates, you are much more likely to get occlusion on a MiniMed because
it is moving insulin so rarely.  The Disetronic will keep small
movement going every 3 minutes.

====================================================================
NOTES:

Now that the reps have had their bit, remember that they ARE trying to
sell their product.

Also, remember that both pumps come with various amounts of "sugar,"
i.e. more batteries, syringes, a couple Sof-Sets and different types
of skin tapes.  This helps ease the initial cost of the pump, but
remember that you have to buy these same items for as long as you own
your pump.  Both companies are obviously quite willing to give you
incentives to buy their pump.

The 506 comes with 12 batteries, leather belt case, plastic belt clip,
sample Sof-set and bent needle infusion sets, with 2 syringes as well.
I think you can probably get more out of MiniMed -- especially belt
cases and clips.



====================================================================


Finally, I would like to add to this that, if you are interested in a
pump and your physician thinks pump therapy is a good idea, try more
than one.  Why not?  Call a variety of companies (at least the big two
mentioned here) and get their information packet, and if the pump
looks interesting, call and see if they have a "loaner program" for
you to test their pump.  They want your business, they are willing to
expend resources to instruct you in the pump.  Take advantage of this
to find the pump that suits your needs the best.  Numbers for MiniMed
and Disetronic are listed above.


Hope this helps.  Will other pumpers please comment/add to this list?
Also, if you decide to get a pump and this information helped you,
please drop my name to your rep -- maybe I can get a free set of
syringes out of it. :)

LostBoy
jim summers
[e-mail]
[phone]

Version Information:
1.0  24 Nov 1992
1.1   5 May 1993  Updated loaner info
1.3  20 May 1993  Removed "-=" for speech synthesizers
=====================================================================