Survey of Insulin Site Rotation in Youth With Type 1 Diabetes Mellitus

Depending on the child's age, surveys were completed by either a parent/caregiver and/or the child. Forty-one percent of surveys were completed by youth independently, while 59% were completed by youth with assistance from a parent. No difference was found in the number of sites reported when surveys were completed by a parent versus the youth alone (t[194] =–1.13, P=.26); therefore, data were collapsed for analysis.

With respect to insulin administration, the average number of sites used by youth was 2.34±1.0. Thirty-six percent of youth reported using two sites, followed by three sites (25%), one site (22%), and four sites (15%). Thus, our hypothesis, which predicted at least 50% of youth would report using four or more sites, was not supported. A significant difference was found in the mean number of sites reported by youth on CSII versus MDI regimens (t[197]=8.19, P=.001). Specifically, youth on an MDI regimen reported more sites in their rotation plan (2.81±0.90) than did youth on a CSII regimen (1.81±0.82). More than 94% of youth on an MDI regimen reported two or more different sites in their rotation plan. In contrast, 81% of youth on a CSII regimen reported using only one or two sites. Consistent with existing research, there was a positive correlation between a child's age and his or her HbA1c level, suggesting a tendency for older youth in this study to report higher HbA1c levels (r=0.39, P=.001). However, contrary to our hypothesis, there was no correlation between HbA1c level and the number of sites reported by youth (r=0.13, P=.08).

Regular rotation of insulin sites is a standard recommendation for diabetes self-care (, ). We designed this study to collect survey data from youth with type 1 diabetes and their parents to assess the youths' current plan for site rotation and their perceptions of barriers to using multiple insulin sites. The theoretical framework used to guide this study was the HBM, which predicts that a patient will adhere to a specific self-care behavior based on how the patient perceives its importance and likelihood to benefit his or her overall health along with the cost of adherence (, ). In this study, more than 80% of youth reported receiving instructions for using multiple sites as part of their diabetes management. However, our findings also suggest that youth with type 1 diabetes and their families may not be following an adequate plan for site rotation. Our clinic teaches families to consider all eight approved areas for insulin administration in their rotation plan regardless of their insulin regimen (). Thus, when considering the possibility of eight distinct insulin sites, our data suggest that youth on an MDI regimen are using only about one third of available sites as part of their rotation plan and youth on a CSII regimen are using approximately one quarter of available sites. If the upper thighs are removed from a rotation plan, a recommendation that is sometimes made to patients on a CSII regimen because of concerns related to the rate of insulin uptake in the tissue, our data suggest youth on a CSII regimen are similarly using only one third of available sites as part of their rotation plan, a number that still may not offer youth adequate opportunity to rotate to novel sites and avoid the development of lipodystrophy.

Lipodystrophy is the most common adverse consequence associated with inadequate insulin site rotation (, , ). Lipodystrophy is a degenerative disorder of subcutaneous tissue that can cause thickening of the tissue and sometimes lumps or dents in affected areas (). Lipodystrophy is not dangerous in itself. However, research suggests that it can reduce the absorption of insulin at the site by as much as 25%, which in turn can lead to poorer blood glucose control (). Also, because of increased insulin resistance at the site, some patients with lipodystrophy may require higher total doses of insulin to achieve optimal glycemic control. In cases of mild lipodystrophy, early detection and time off from administering insulin at the site may provide an opportunity for the affected tissue to heal and reverse many of the effects of dystrophy. However, in some patients and/or more severe cases, the dystrophic tissue may never heal completely, making these sites suboptimal for insulin administration (, ). In all cases, detection is key to preventing further skin damage, and/or adjusting insulin recommendations for patients (). To detect lipodystrophy, a physical examination with finger palpation of insulin sites should be conducted because lipodystrophy often can be hard to detect with a visual inspection alone (). To palpate the site, providers should use their fingers to firmly rub injection sites back and forth in a sweeping motion, seeking areas where the tissue feels changed from normal (). As stated previously, dystrophy can feel like areas of hardened tissue (e.g., tissue may feel muscular in nature and lumpy), or in some cases, it may feel very soft to the touch, and visual inspection may show a protuberance in the affected area. In addition, areas of lipodystrophy may show red marks, suggesting repeated insulin injections. Nurses and primary care providers can play an important role in helping to detect dystrophy and can make recommendations for site rotation. Similarly, as an additional prevention tool, it may be helpful to educate parents and youth about the signs of dystrophy and encourage parents and youth to monitor insulin sites and schedule an appointment with their health care provider if they are concerned that a site may be becoming dystrophic.

In addition to providing patient education specific to the causes and effects of lipodystrophy, our findings highlight a need for nurses and diabetes educators to work directly with youth and parents to help to address perceived barriers to adequate site rotation. Consistent with the HBM, if patients perceive that barriers to site rotation are significant, these barriers may prevent them from adopting new sites, even in cases where youth and parents understand the benefits of having multiple sites available for insulin (). In this study, common barriers to using new insulin sites were fear that sites would hurt, problems reaching sites or concern that sites would be awkward, and comfort with the existing routine. For youth and parents who are concerned about reaching unfamiliar sites, scheduling an education appointment to practice using these new sites with guidance from a nurse or diabetes educator may be a necessary strategy to overcome this barrier and build confidence. It also may be helpful for the nurse or diabetes educator to assist families in identifying someone else to administer injections at new sites. For example, for youth attending schools with a nurse or aide, it may be possible to work out a plan for the school nurse or aide to use only new sites for injections at school and save existing sites for home management. For youth and parents who are concerned that using unfamiliar sites will be painful, teaching coping strategies may be helpful. For example, for young children, it may effective to teach parents how to use distraction to help their child to cope with their fear while they become more familiar with new injection sites. Common distraction techniques that parents could try with their young children include singing, use of interactive toys or puzzles, making believe they are blowing out candles, or reading books. For older children and adolescents, brief cognitive behavioral techniques may be needed, such as relaxation training, cognitive distraction, cognitive re-appraisal, comforting self-talk, and reducing any behavior or thoughts that may cue children to be fearful of new sites (e.g., saying to the child at the time of the injection, “I promise this won't hurt”). Alternatively, behavioral strategies, including use of an incentive plan for adequate site rotation, could help youth to try new sites and maintain adequate site rotation over time. In tracking goals related to site rotation, older youth or parents may find it helpful to use a modified log book where they can record injection sites across the day. In our clinic, when counseling families, we typically do not recommend that youth and parents introduce a new site through use of a topical analgesic or by applying an ice cube to the site before injection. While these strategies can be very effective in managing pain for behaviors performed infrequently (e.g., annual venous blood draws or placing a continuous glucose sensor to complete a glucose profile), we do not find them to be practical for daily insulin injections because of the extra planning and time they require. Similarly, we caution families about using these strategies when placing infusion sites, because they increase the length of time needed to place the site and actually may contribute to greater anticipatory anxiety as youth wait for the infusion site to be placed. Finally, for youth and parents who seem ambivalent about changing their personal rotation plan or report comfort with their current routine, it may be helpful to use components of motivational interviewing to help them recognize the connection between proper site rotation and the realization of their own diabetes care goals, such as greater independence in diabetes self-care, improved glycemic control, and/or improved physical well-being, in order to create the behavior change (, ).

The current study has some limitations. First, this study used survey data obtained directly from youth and families. While all participants were instructed that their data would be kept confidential, self-report data are vulnerable to a social desirability bias. Thus, it is possible that these data may over-report the actual number of insulin sites used by youth with type 1 diabetes. Second, this study used a convenience sample of youth with type 1 diabetes recruited at one of their regularly scheduled diabetes appointment. This study did not make attempts to recruit youth with type 1 diabetes who were not coming to their diabetes appointments as recommended or youth who came only annually to the pediatric diabetes clinic. Thus, it is possible that the results may not generalize to all youth with type 1 diabetes, especially youth who only seek care intermittently from a tertiary pediatric diabetes clinic. Finally, this study did not collect data from practitioners to compare with the youths' self-report. Therefore, no data can be reported specifically quantifying patients' adherence to their rotation plan as defined by their diabetes practitioner. Future research may want to include physician/nurse responses to quantify youths' adherence to site rotations as a component of their insulin management.

The results of this study have implications for clinical practice. First, these findings suggest that many youth with type 1 diabetes may not be adhering to an adequate site rotation plan. Thus, regular assessment of insulin administration sites and follow-up on recommendations to rotate sites is important for detecting lipodystrophy in youth with type 1 diabetes. As mentioned earlier, areas that are dystrophic may appear as a lump, a dent, or as red and swollen tissue that is hard to the touch. In most cases, it is easier to detect lipodystrophy using finger palpation versus visual inspection, and early detection and time off from using the site may help preserve the site for future insulin use (, , ). Nurses and primary care providers can play an important role in recognizing the signs of dystrophy and counseling youth and families on adequate site rotation in between youths' quarterly diabetes clinic appointments.

Second, this study suggests that information on site rotation alone is not sufficient to lead most families of youth with type 1 diabetes to try new sites in their rotation plan. Therefore, to help families overcome perceived barriers to use of multiple insulin sites, medical providers may need to become creative and use a combination of education and behavioral techniques to help families implement adequate site rotation.

We thank the following persons who assisted with subject recruitment: Drs. My Lien, Ram Menon, Ming Chen, Josephine Kasa-Vubu, Delia Vazquez, and Joyce Lee; Jane Burton, MSW; Donna Doyle, RN, CDE; and Mary Hodge, RD, CDE. We thank Drs. Jessica Kichler, Emily Fredericks, Dawn Dore-Stites, and Matt Myrvik for their review of the manuscript. Finally, we thank the families who participated.