Swimsuit season lasts for at least five months in the South. The good news is that we live close to the beach, but the bad news is that after 25 years of living with diabetes (and three Caesareans), my body is starting to read like a map of my medical journey.
Diabetes used to be an invisible illness. For years, no one knew that there was anything different about me unless I revealed it. I could sneak off to the bathroom and give myself a shot without anyone knowing. I could wipe the small dot of blood onto a tissue and return to the room, and my skin was unmarked and free from scars.
I eventually gained enough confidence to come out of the diabetes closet and stop trying to hide my disease from the world. My journey toward acceptance began when I became a mother and discovered a surprising physical strength. This body that had been a source of shame, fear, and sadness transformed itself into something beautiful in pregnancy and motherhood.
I am now the mother of three boys who shop with me every spring when it's time for a new swimsuit. In years past, their small bodies crowded around me in the narrow, brightly lit dressing room, smiling and telling me I looked pretty in every single suit. They always made me feel beautiful even when my reflection didn't live up to the expectations in my head.
This year was different. "What are those bumps on your stomach?" Miles asked as I fastened the bikini top around my bra. My heart sank. I looked down at the two small lumps on either side of my belly button where I like to do my shots. "They're from Mommy's shots," I said. "Ouch," Miles said, and then, distracted, "Can we go look at the toys now?" I nodded, left the rest of the suits on their hangers, and ushered the boys out of the dressing room. I was not buying a new suit.
I have been injecting insulin into my stomach, arms, legs, and butt since I was fourteen years old. I've maintained good control ever since I became pregnant more than a decade ago, and I have always shrugged off talk of long-term complications. I told myself that because I was in good control, I was going to be just as healthy as anyone else, and free from any visible signs of illness. Until that day in the dressing room.
Lumps and bumps (lipohypertrophy) or depressions (lipoatrophy) below the surface of the skin are formed when a person injects insulin into the same spot over a number of years. Sometimes called "insulin tumors," these benign swellings of fatty tissue are one of the most common complications of insulin therapy. (Hambridge, 2007). Dr Liz Stephens says she sees this condition a lot, "probably more with injections than pumps, but definitely with both; especially in leaner people who don't have a lot of options for sites. I would say it affects, or has affected, over 50 percent of those I see with type 1 diabetes who have had it for more than ten years."
In his study in the British Journal of Nursing, titled "The management of lipohypertrophy in diabetes care," Kevin Hambridge states, "The prevalence of lipohypertrophy is estimated between 28.7% and 65% in patients with type 1 diabetes and between 3.6% and 35% in patients with type 2 diabetes." The reason for the differences between the groups is the frequency of injections.
Claire Blum, a CDE who has type 1 diabetes, says, "I have areas that are no longer useable for pump infusion due to scar tissue (I've worn a pump for nearly 25 years) and areas that pooch as well. I also have a place on my arm where the lipoatrophy never subsided from use of those old, dull needles that I re-sharpened and sterilized....The best option is to rotate religiously, avoiding use of areas within one inch to two inches of previous sites for 30 days or more. You may also want to avoid use of those specific areas entirely, as the appearance does gradually improve."
People with diabetes tend to inject and/or place their pumps into the same site because that area is easy to reach, less painful, and habitual. Legs have shown the highest frequency of lipohypertrophy, at 58 percent, followed by the abdomen at 48 percent, arms at 21 percent, and buttocks at 6 percent. (Hambridge, 2007).
Dull needles and higher frequency of injections are also risk factors for developing lipohypertrophy. Jenny, a member of TuDiabetes, says, "I've been diabetic since 1990, and there just aren't enough places to poke after all those years!"
Not only are lumps and bumps unattractive, but they can also result in poor insulin absorption. "The biggest danger is that absorption is so unpredictable, and blood sugars can do all sorts of things. And then when people move to new sites, their insulin requirement usually drops a lot, which can be risky for hypos," says Dr. Stephens.
Some studies show that patients have been treated successfully with cosmetic and therapeutic treatment by suction-assisted lipectomy. Dr. Stephens says, "In terms of prevention, there is not much to do except to avoid using affected sites, and rotate. I have had a couple of patients who have had plastic surgery, but usually they were people who have had diabetes for decades and had really severe issues and/or disfigurement."
Doctor Darrick Antell, official spokesperson for the American Society of Plastic Surgeons and Professor of Plastic Surgery affiliated with Roosevelt Hospital, says that plastic surgery is a safe option for people with diabetes. Liposuction is Dr. Antell's number-one surgery, and eight to 10 percent of his patients have diabetes . "Diabetes doesn't mean you can't have surgery," he says. "Liposuction can give you a boost in self-image, your clothing will fit better, and it will help with contour issues."
Another option for lipohypertrophy is site rotation. In their study, "Incidence of lipohypertrophy in diabetic patients and a study of influencing factors," Bahar Vardar and Sevgi Kizilci emphasize the importance of site rotation. "If a diabetic uses at least six injection sites (right and left arms, abdomen, legs) and uses each injection site for one week, it will be five weeks before he/she returns to the same site. During this time the tissue is free from the effect of insulin....The development of lipohypertrophy is in this way diminished because of the lessening effect of insulin in the area." The researchers also cited the importance of good self-management training from diabetes educators in order to increase the likelihood of patients sticking with this type of rotation.
Ever since I was 14 years old and my doctors told me the story of my own cells attacking each other, my body has remained a bit of a mystery. Now that I can see the results of this war, it's harder to pretend I'm just like everyone else. Does that mean I will wear my scars with pride? I don't think so, but I'm not sure I'll opt for surgery either. My lumps and bumps are right next to my Caesarean scar, and both are signs of the strength within.
Tips on reducing risks
• Injection sites should be palpated (physical examination) once a year instead of being visually examined.
• Be aware of the importance of site rotation.
• Use a fresh needle for each insulin injection.
• Use a wide site rotation for injection and pay attention to avoid injecting insulin close to sites with lipohypertrophy.
• Talk to your doctor about changing insulin. Newer insulin types (lispro, aspart) have reduced the prevalence of lipohypertrophy to some extent because they are more rapidly absorbed and the fat cells are less exposed to and affected by the insulin.
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1. Hambridge, K. (2007, British Journal of Nursing) The management of lipohypertrophy in diabetes care.
2. Vardar B. and Kizilci S. (2007, Diabetes Research and Clinical Practice) Incidence of lipohypertrophy in diabetic patients and a study of influencing factors.