By Debra A. Sokol-McKay, MS, CVRT, CDE, CLVT, OTR/L, SCLV Diabetes is a disease that requires 24-hour, 7-day-a-week self-management. It is you who lives with your diabetes and it is you who will make health care decisions when your doctor or other members of your health care team are not available. Blindness or low vision may present challenges, but aren’t necessarily barriers to effective and successful self-management of diabetes. Diabetes Self-Management Blood Glucose Monitoring Insulin and Insulin Measurement Healthy Eating Being Active Proper Foot Care Overall Health Management

Diabetes Self-Management

Certified diabetes educators (usually nurses and dieticians), in consultation with primary care physicians and endocrinologists (physicians who specialize in the diagnosis and treatment of conditions affecting the glands and hormones), can help you learn more about managing your diabetes with diabetes self-management education (DSME) or diabetes self-management training (DSMT): Visit your primary care physician when:
  • You have an episode of very low blood glucose, several days of low blood glucose, or you can’t determine when your blood glucose is becoming low.
  • You want to discuss a change or modification in your diabetes treatment plan.
Visit an endocrinologist when:
  • Your blood glucose levels are consistently higher than you want them to be.
  • You have one or more diabetes complications or medical conditions that makes managing your diabetes difficult.
  • You’d like to change the way you manage your diabetes.
Visit a nurse diabetes educator when: Visit a dietician when:
  • You don’t understand what or how much to eat.
  • You haven’t visited a dietician in several years
  • You don’t have a food plan or your current plan is more than two years old.
The most effective diabetes self-management treatment includes a combination of many therapies. AADE proposes that there are 7 key behaviors that lead to optimum diabetes self-management and health. These are called the AADE7™ Self-Care Behaviors. They include:
  1. Healthy eating: preparing and eating a healthy diet, label reading, and portion control
  2. Being active: engaging in appropriate physical activity and exercise while following necessary precautions
  3. Monitoring: tracking blood glucose levels, blood pressure, foot health, steps walked, weight, and achievement of goals
  4. Taking medication: taking medications in pill, injectable, liquid, and other forms
  5. Problem solving: managing hypoglcemia/hyperglycemia, sick days, vacations
  6. Healthy coping: journaling and other forms of stress reduction
  7. Reducing risks: smoking cessation, foot checks, blood pressure monitoring, self-monitoring of blood glucose, maintenance of personal care records, and regular eye, foot, and dental examinations.

Blood Glucose Monitoring

Blood glucose monitoring allows you to evaluate the effectiveness of your diabetes treatment plan in maintaining your blood glucose levels within a normal range. Monitoring will also help you determine if your blood glucose level is low and, if so, what quantity of glucose-containing products or foods you must eat to raise your blood glucose levels into a safe range.

Monitor with a Standard Visual Display

In order to perform effective and consistent blood glucose monitoring, you must be able to access the numerical readout on your monitor. Here are some suggestions for individuals who have low vision and use a blood glucose monitor with a standard visual display:

Monitor with a Larger Print Display

  • Obtain a monitor that has a larger-print display, backlighting, or contrast/reverse contrast, such as the One Touch IQ, pictured at left.
  • To learn about the full range of larger print monitors, see Blood Glucose Meters (.pdf) at the American Diabetes Association website.

Monitor with Speech Capability

If you’ve been certified as legally blind, it’s likely you’ll meet the requirements of most insurers to obtain a blood glucose monitor with speech capability, also called a talking blood glucose monitor. Be aware that talking monitors fall into two categories – those with partial speech and those with full speech. Those with partial speech may only announce your blood glucose result, while meters with full speech not only announce your result but also announce the results in memory, low battery warning, and audible steps to set the time and other monitor features. Current full speech monitors include: Even if your monitor has a large print display and/or speech capability, you may still want to use additional low vision, tactile, and/or auditory techniques to help with accurate and effective blood glucose monitoring:
  • Explore your test strips either (a) visually to identify color differences or (b) by touch to identify textural features. This will help you position the strip in the proper direction before inserting it into the monitor.
  • Before obtaining a blood drop for self-monitoring of blood glucose, increase blood flow by shaking your hand gently at your side and washing your hands in warm water.
  • Try this technique for inserting the test strip: (1) Use your left index finger as a “marker” and place it parallel with the slot that holds the test strip; (2) Hold the test strip in your right hand so that it is parallel with, and touching, the left, or “marker” finger; (3) Using the “marker” finger as a guide, insert the test strip into the monitor. Reverse these instructions if you are left-handed.
  • If you have low vision and find it difficult to locate the blood droplet/sample after lancing your finger, (a) bring your finger closer to your eye; (b) use additional lighting; or (c) hold your finger with the droplet against a white or other contrasting background.
  • Determine the number of strokes that are required to “milk” your finger and produce a large enough blood sample. Meters are now available that require very small amounts of blood if producing a sufficient blood sample is a problem. To obtain a larger sample, set your lancing device to a deeper penetration; the higher the number the deeper the penetration.
  • Create a mental map of where you lance your finger in relation to your fingernail to help you locate the blood droplet/sample.
  • Use a monitor with a “beep” feature that indicates (a) when you have completed a step and (b) when to proceed to the next step.

Insulin and Insulin Measurement

Insulin is the medication most often associated with diabetes. Insulin therapy is used when other forms of therapy (diet, exercise, and oral medications) are no longer effective in controlling your blood glucose levels. Here are some important facts about insulin:
  • Insulin must be timed to coincide with your food and activity levels. For example, if you take your usual dose of insulin in the morning and then decide to eat a lighter lunch than you originally planned, your blood glucose levels could become very low. Be sure to discuss insulin problem-solving strategies with your diabetes health care team.
  • Insulin in a vial, like any other medication, has an expiration date. Talk with your physician if you use your insulin for more than 30 days or keep it beyond its expiration date.

Adaptive Devices for Insulin Measurement

There are several adaptive devices currently available that can help with insulin measurement if you are blind or have low vision. Please note: Always consult with your diabetes health care team before purchasing and using any adaptive insulin measurement device, including insulin pens.

1. For low vision insulin measurement

2. For non-visual insulin measurement

Fixed-dose insulin measurement devices are appropriate for individuals whose insulin dosage remains consistent from day to day:
  • The Safe Shot Syringe Loader from LS&S has one pre-set dosage step and is available in three colors (yellow, blue, and red).
Flexible-dose insulin measurement devices are appropriate for individuals who need to vary their daily insulin dosage, due to changing blood glucose levels and/or carbohydrate intake:
  • The Count-a-Dose from Independent Living Aids (pictured at left) accommodates a smaller dose (up to 50 units). It holds one or two vials of insulin and makes a distinctive click that can be heard and felt with each unit increment. It requires a B-D 50 unit/ ½ cc syringe.
  • The Syringe Support from Maxi Aids accommodates a large dose (up to 100 units). A white, raised marking permits the user to differentiate each full turn of the calibrated screw. Each single full turn of the calibrated screw is equal to two units of insulin. It requires a B-D 100 unit/1cc syringe.
Insulin pens provide another non-visual measurement option: Many are disposable and pre-filled with insulin, while others are refillable. All pens make a distinctive click that can be heard and felt with each unit. Individuals who require smaller doses can use a pen with a ½ unit increment. A 2010 study provided evidence of the safe use of insulin pens by persons with vision loss, despite earlier disclaimers that persons using insulin pens could not do so independently without supervision. Insulin pens require a doctor’s prescription. Each of the three insulin manufacturers make their own disposable insulin pens:

3. The insulin pump for continuous (24/7) insulin delivery

An insulin pump is a computerized device – approximately the size of a pager or iPod Mini – that administers insulin, via flexible plastic tubing, to a small needle inserted just beneath the skin. It is programmed to closely mimic the body’s normal release of insulin from the pancreas. Some models have tactile controls and audio features, but not all features are accessible by individuals who are blind or have low vision.
  • The Animas OneTouch Ping has an illuminated, high-contrast display screen (pictured at left).
  • The V-Go, an alternate disposable insulin delivery system also known as a “patch pump,” has recently come to market. The system has two parts: (1) a “patch” that is filled with insulin and (2) a device called the EZ Fill that is used to fill the patch. It has tactile buttons and can be operated through clothing.
  • The American Diabetes Association provides a listing and comparison of all current insulin pumps at Product Guide: Insulin Pumps (.pdf).

4. Inhaled insulin

Afrezza, an orally inhaled insulin, consists of an inhaler and three different doses of insulin in cartridge format. Your diabetes health care team can provide more information about these devices, including eligibility requirements, insurance coverage, accessibility features, and appropriate training. For more information about guides that can help you locate diabetes-related products and technology, see Helpful Products and Technology for Living with Vision Loss on the VisionAware website.

Healthy Eating

There are many adaptations that can help you follow a nutrition management plan, which is an important component of diabetes self-managementtreatment. Please note: Always consult with your diabetes health care team to select and follow a nutrition management plan that’s right for you. 1. Achieve Portion Control by using any of the following methods and adaptations:
  • Nested, large print, color contrasting, or color-coded measuring cups and spoons (pictured at left)
  • Portion-controlled serving utensils, available at restaurant supply stores
  • Use a talking food scale, or place tactile markings on your own food scale. To learn more about labeling products and techniques for people who are blind or have low vision, see Labeling and Marking and Find Labeling Products.
  • Use dishes that control your food portions: a 4-ounce juice cup, a 9-inch plate, or a 1-cup cereal bowl.
  • Use a plate with built-in portions (pictured at left).
  • You can test your knowledge of portion sizes and portion control with Test Your Portion Size IQ from WebMD and the Portion Control Quiz from
2. Accessing printed information on food labels is also necessary for healthy eating, especially when counting carbohydrates. It’s possible to obtain nutrition information by using any of the following methods and adaptations: 3. Record nutrition information and save it for future reference by using any of the following methods and adaptations:
  • Braille note cards
  • Large print made with a wide-tip marker, laundry marker, or felt-tip pen
  • Audio recording methods: The VOXCOM III Voice Labeling System records audio talk labels and messages by depressing a button and inserting a card into the unit. The PenFriend (pictured at left) is a voice labeling system that allows users to record, and re-record, information on to self-adhesive labels.
  • Labeling apps for smartphones, such as Digit-Eyes
  • You can find these and other electronic recording/labeling systems at Sources of Specialty Products in the APH Directory of Services.
4. There are a number of online resources and publications that specifically address nutrition, meal planning, and recipe information for individuals with diabetes:

Being Active

Physical activity includes formal exercise as well as sports, leisure or recreational activities, and even household chores. You can accumulate a minimum of 30 minutes of activity throughout the day by making simple changes in your level of physical activity, such as taking the steps instead of the elevator and walking to the store instead of taking the bus or driving. To improve health, the U.S. Surgeon General recommends moderate physical activity most, and preferably all, days of the week. What is moderate physical activity?
  • Mild intensity: Bowling, strolling (walking 2 mi/hr), billiards, stretching, stationary cycling (5 mi/hr)
  • Moderate intensity: Calisthenics, ballroom dancing, golf (walking/carrying clubs), water exercise, walking (3 mi/hr)
  • High intensity: Cycling (>10 mi/hr), swimming (moderate effort), brisk walking (>4 mi/hr), vigorous dance (square dancing)
Physical activity is an important component of diabetes self-management treatment, and some of its many benefits include the following:
  • Maintaining and improving overall health
  • Increasing strength and endurance
  • Improving blood glucose control
  • Controlling blood pressure
  • Increasing beneficial HDL cholesterol and decreasing unhealthy LDL cholesterol
  • Reducing stress, which can increase blood glucose levels
  • Helping with weight loss
Note: Always consult with your diabetes health care team to select and follow an individualized exercise program that includes general exercise guidelines, physical and ocular precautions and restrictions, blood glucose monitoring, and management of hypoglycemia. Some exercise precautions with diabetic eye disease include:
  • Avoid activities that raise the blood pressure in the body or head, such as when lifting free weights.
  • Avoid bending the head forward below the level of the heart/waist, such as when doing toe touches.
  • Avoid holding your breath or straining, as when tightening stomach muscles and lifting legs.
  • Avoid activities that jar or bounce the head, such as when jogging.
  • Avoid strenuous, high-impact activities, such as high-impact aerobic dance.
Here are some helpful hints and adaptations for exercise:
  • A treadmill can supplement your walking program.
  • A tandem or stationary bicycle is helpful for cycling.
  • A rowing machine or cross-country ski trainer can provide aerobic exercise.
  • Mark exercise machine controls with raised markings if possible
  • An arm cycle (pictured at left) can provide low impact aerobic exercise.
  • Swimming is a good form of exercise if you have physical limitations or difficulty walking or running. Swim near the wall or use lane markers if you have vision loss.
  • Stand near a wall or chair to better orient yourself during aerobic exercise.
  • Use a talking pedometer.
  • Create large print or braille exercise records to track and record your progress.
  • Wear a medical alert tag or bracelet.
  • Test your blood glucose before, after, and during your exercise session if you feel symptoms of hypoglycemia.
  • Keep a fast-acting carbohydrate snack nearby.
  • Wear proper socks and shoes.
  • Perform a foot examination before and after exercise.
  • Check the floor space to avoid hazards and obstacles.

Proper Foot Care

Proper foot care is a crucial component of diabetes self-management treatment, since several complications related to diabetes can cause serious foot problems:
  • Decreased sensation can lead to foot injuries.
  • Impaired temperature regulation can cause dry and cracked skin on the feet, which can lead to bacterial infections.
  • Impaired circulation can lead to impaired healing ability and, in serious cases, amputation.
Develop a reliable foot inspection routine:
  • Establish a consistent time to check your feet every day, such as after bathing or before bedtime.
  • Pay special attention to previous or existing foot problems.
  • Wash your feet daily and dry them carefully, especially between your toes. Apply lotion to your feet, but not between your toes.
  • Ask your physician to perform a foot inspection during every visit; in fact, it’s perfectly all right to take your shoes off during your appointment to make sure your physician checks your feet.
  • Make an appointment with a podiatrist at least once a year. Be sure to tell your podiatrist that you have diabetes.
  • Contact your physician if a cut, blister, or sore does not begin to heal after one day; contact your physician immediately if your foot is painful or swollen.
Please note: Medicare Part B and Medicaid coverage is available for biannual foot exams for people with decreased sensation in their feet due to diabetes. Medicare Part B covers 80% of the cost of one pair of custom-molded shoes (including inserts) and two additional pairs of inserts per year. One pair of depth shoes which provide extra room to allow for differently-shaped feet and toes is also allowed each year. A physician’s prescription is required for adaptive footwear or accessories. Here are some helpful hints for performing a foot inspection:
  • You can perform a tactile foot inspection effectively only if sensation is intact in your hands and fingertips.
  • Use your fingertips to search for skin and/or foot irregularities, such as cuts, breaks in the skin, blisters, new calluses, swollen areas, bumps, embedded objects, and changes in foot texture and/or shape.
  • Feel the entire top and bottom surfaces of each foot, using overlapping strokes in an organized pattern. Be sure to check the nail beds, all pressure points, and the areas between your toes.
  • Run the back of your hand (which is more sensitive to temperature changes) over the top and bottom surfaces of each foot, feeling for excessively cool (impaired circulation) or warm (possibly infected) areas. Compare these areas to other parts of your foot or to your other foot.
  • Feel for changes in the skin texture or shape of your feet.
  • Note any changes in foot odor when removing your socks and shoes.
  • Check for wet, moist, or crusty areas on your socks, which can indicate blood or discharge.
  • If you have low vision, try using one the following adaptations: a task lamp with a flexible arm, or place a dark towel underneath your feet for better contrast.
Here are some tips to help care for your feet and prevent diabetic foot problems:
  • Do not smoke. If you do smoke, try to stop.
  • Notify your physician or podiatrist immediately if you detect any problems.
  • Avoid temperature extremes when washing your feet.
  • If you feel cold at night, wear cotton socks. Do not use hot water bottles or heating pads.
  • Do not soak your feet for a prolonged period of time, unless your physician or podiatrist prescribes it. Taking a bath or shower is fine, however.
  • Your toenails should be cut or filed straight across (not cut into the corners), ideally by a podiatrist. File your nails with an emery board between cuttings, if necessary. Foot care specialists strongly recommend that people with visual impairment have their toenails cut by a podiatrist, which has the added advantage of providing frequent expert foot inspection.
  • Inspect the insides of your shoes every day for torn linings, nail points, and other objects that can damage your feet.
  • Do not walk barefoot or in your stocking feet.
  • Wear socks or stockings that fit properly, keep your feet dry, and do not have raised seams. Be sure to change your socks every day.
  • Do not remove corns or calluses on your own, and do not use commercial corn and callus removal products. Visit your podiatrist for any of these procedures.
  • The Lower Extremity Amputation Prevention (L.E.A.P.) Program provides footwear and shoe modification guidelines and provides a free testing kit to assess the feeling in your feet using a stiff nylon string called a monofilament.

Overall Health Management

There are a number of adaptations that can help with maintaining your health or managing illness:
  • A large display or talking blood pressure monitor
  • A large display or talking weight scale
  • A large display or talking thermometer
  • A large display or talking food scale
  • A talking pedometer
  • Label your carbohydrate-containing and calorie-free liquids in braille, large print, or another accessible format.