Shireen: Podcasting from Dallas, Texas. I am Shireen, and this is a Yumlish podcast. Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions Like type two diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions. 

Shireen: In this episode, we will be talking with Ms. Melanie Teslik, who is a certified diabetes care and educational specialist. In this episode, we will be discussing Lipohypertrophy, what causes it and tips for management as well as myths and misconceptions she addresses as a diabetes nurse educator

Shireen: Ms. Teslik is a certified diabetes care and education specialist and board certified in Advanced Diabetes Management. She’s been an active member of ADCES for over 12 years, and she’s been working as a diabetes nurse educator for over 12 years at NYU Langone Long Island, and has dedicated her life to always being the patient advocate and teacher. Welcome, Melanie. 

 Melanie: Thank you for having me. 

Shireen: It’s such a pleasure having you on. First things first, what do you enjoy most about what you do?

Melanie: I love education. I love teaching. And when you just get that moment that someone like is like, oh, I didn’t know that. Or their blood sugar’s improved, or their A1C has improved cuz they’ve implemented something you taught them. It’s just a very special feeling.

Shireen: I wanna talk a little bit about this article that we came across as we were sort of researching your background and, you know, the type of work that you’ve done. I came across an article you wrote back in January of 2020 and the article was called, I’m about to butcher the name, so I’m just gonna give a heads up to our listeners but the article was called “Lipohypertrophy, A Forgotten Problem”. Now, I wanna dissect the title of this article and then really get into the meat of it. Can you explain what Lipohypertrophy is?

Melanie: Lipohypertrophy, it’s the swelling of the fat tissue under the skin and what it does, it starts absorbing more and more. You actually get little, like pea size like feelings under the skin, or it could be larger than that because the fat proliferates and then it almost, it’s not scarring, but it, it won’t allow the absorption to occur as readily. 

Shireen: Then why did your article say a forgotten problem? What is, why forgotten?

Melanie: Because when you go back in time for diabetes, people were using pork, or they were using beef insulin, and they were using needles that were eight millimeters or 12 millimeters. This problem was very prevalent at the time. Now we use four-millimeter or five-millimeter needles. We also use synthetic insulin. Theoretically, it should be happening less. But in reality, they’ve done studies and in 66% of the population’s diabetes who are giving injections are going to develop it in their lifetime.

Shireen: And how does this actually work, or how does this actually come about, why is this such a problem?

Melanie: It impacts the absorption, most common reasons or our own behavior, like repetitive behavior, cuz we tend to give in the same site or if someone’s down a site that doesn’t work when you want to keep injecting in that site. They also found that people just wanna reuse the needles because of the cost, but every time they reuse a needle, it gets duller and duller and they’re literally, like, when they go in the skin, they’re tearing the skin, so you’re causing damage to it. So it’s all, it’s mostly human behavior that causes it, but if you can educate them and to use different sites, that’s gonna make a difference.

Shireen: How can we identify Lipohypertrophy? 

Melaine: It’s very easy. You take three fingers and where you give the injections, you just palpate it and keep palpating it and if you feel like a little growth under there, like a pea size, or it could be larger, but if you just feel that growth under the skin, you’re like, “Hmm, that’s an area I should avoid”. The doctor should look at it every visit. The diabetes educator should look for it, on every visit as well as if the worst comes to worst you can see it on the skin. You don’t even have to palpate if there’s been so much damage. Ultimately, the doctor could do an ultrasound, but they’re not gonna do that because you can feel it end or see it.

Shireen: Now you pointed, as you were talking about this, you pointed the stomach. So is this more, for insulin in particular? Like is that where you see it most common? Where, you know, how is it connected? 

Melaine: People who are on insulin, a lot of them are doing at least four injections a day, a long-acting, and then before the meal. So right there you’re constantly giving an injection. My personal interest, and there hasn’t been enough studies on it, is we’re now using a lot more continuous glucose monitors, which people are wearing for 10 days to 14 days. And they’re also using a lot more pumps where they’re wearing a device for three days and has that body going to respond to that foreign object that’s in them. Will that cause more Lipohypertrophy? Few studies show, yes, but there hasn’t been enough really to say that that’s a fact yet.

Shireen: What causes lumps of fat or scar tissue to develop under the skin? What exactly is going on there?

Melanie: It’s just the proliferation of the damage of the skin. There’s nothing you can do, it’s just reusing it. I like to use the example of like a construction worker or a tennis player, and if they keep using the racket or they’re doing a certain thing, they develop calluses on their hands to protect the area. I kind of look at it as like a callus under the skin. That the body’s just protecting us because you’re reusing that site constantly and I just kinda think that’s a good analogy to kind of look at it.

Shireen: And are there methods we can use when injecting insulin to avoid the skin thickening? And can we rotate the needle? Like are there things that can be done?

Melaine: Yes. The first one is to just do the technique, correctly because, it’s very common for people not to be instructed how to do it. The primary doctor may say to them, okay, start insulin and show them in 30 seconds or less how to do it or whatever reason there’s an emergency. And I’ll actually teach someone on the phone and they’re laughing at me. I’m like, okay, turn to this and we’re doing it together on the phone but all of that’s beneficial. It’s just, I think one, that you need the time to educate them. Two you need to follow up because if someone, it’s human nature, if you’re doing something for years and years, you start cutting corners cuz you think like you got a down pat. So I always try to have people return, demonstrate to me when they’re doing it initially as well as when they come I go, I haven’t seen you in a while, let’s like just see how you’re doing it.

It’s very interesting cuz so many times when you see that blood sugar going up for no reason or erratic blood sugars, when you assess it, it really will come down to just doing the correct. In order to prevent that occurring. A cute story, a gentleman, he would set up the insulin pen for his wife and his wife would give it. The wife had a stroke. She was in a rehab, and she came home and he proudly, now, he was giving the injections and her blood sugars kept going up and up and up and up. And I brought her, brought them in, and they were talking about, well, what do we need to do? Do we need to change the insulin so forth? And, I watched him, he was never pushing the plunger on the pen. He was dialing it up and then undying it so she wasn’t even getting insulin. And I use that story cuz you never assume that someone’s doing it correctly.

Shireen: Oh, that is so interesting. As a diabetes educator, if you could explain what should that use look like? Would you mind doing that over our podcast? Sharing that with us. 

Melaine: Luckily we have pens nowadays. Um, the pens, the pen you’re using does not need to be kept in the refrigerator. Just put in a safe place. No extreme temperatures. You don’t wanna leave it in the car. In the winter or the summer when it gets to a hundred degrees. You take it out, you pull the tab off, the pen, needle, you screw it on. Hopefully you’re using a four-millimeter or a five-millimeter because there’s no reason to use a larger needle. You screw it on, don’t you do that. You turn the number two, you squirt, which is called an air shot to make sure you’re doing it like the pen is working, because there have been times that the pen is not working or the needle’s not working. You always make sure it’s starting and then you turn to your dose, you then administer it in the sites. I believe we’re gonna talk about it later, but if it’s okay, I’ll just mention it here. The abdomen, cuz it’s a huge area, is a great place to put it and you want to be two inches away from the belly button.

And I tell people, put a hand starting at the belly button above there, above the other side like that. And just think of this as like the first week, and this is the second week. And then you can move down below the umbilicus. That’s week three, week four. So you know, you’re always rotating the sites. If someone doesn’t get that concept, then I’ll tell them, think of a pair of argyle socks and you wanna go up and down like the argyle socks, and that helps the, like, oh yeah, I gotta go up and down. The other thing is people think that, gotta give the injections in a small area. No, you have your whole area up to, you know, the love handles. If you have a little meat on them, you feel free to go out there so you don’t have to keep using the site repeatedly.

Shireen: So people, what I’m hearing is, for the most part, people will get used to a site and say, okay, my, you know, right. Upper, upper quadrant, and like, I’ll just keep doing that there. And you don’t have to, you can keep rotating it around your abdomen.

Melanie: Mm-hmm. You also can give in your arms. It is hard to give yourself injection, your arms cuz you need to go to the back fatty area. A lot of times you’ll see an error of people put in their muscle and then the absorption is quick. And your blood sugars once again, they could go down quickly. So if you go to the back area, and I always laugh. I go, you know, when you wave and they all laugh at me, but everyone can remember that site. You can do the outer thighs and that’s a good site, but if you’re very muscular, that’s gonna be a little more painful. The absorbs is gonna be a little different and you can do the flanks in the back where the upper buttocks, where you can feel like, again, you can grab a little something there. Those are alternate sites, but the ones that are easiest for anyone to give are obviously their stomach or their leg.

Shireen: The idea being to provide it where some of the fat is just because of the absorption, the slower, right?

Melaine: But you want subcutaneous, you don’t, we’re not giving an intermuscular shot. It’s like a surface shot again, those needles are tiny. I always tell people, even if they’re afraid of a needle, I’m like, trust me, it hurts more to do a finger stick than it does to give the injection. They doubt me and sometimes we’ll start someone in the office just to make it like, get over the fear. You’re together doing it and they’re like, that didn’t hurt at all. You know, but they don’t know it until they do it and it’s true. The finger stick probably stings a little bit more.

Shireen: Mm-hmm. Speaking of the, the body fat piece of it, does body fat percent really affect lipohypertrophy?

Melanie: Theoretically, yes and no. It’s not a direct answer. One of the causes of lipohypertrophy can be obesity because there’s more fat cell. But if you’re rotating and using different sites, then that should not be a factor. 

Shireen: And then in just your years of experience that you’ve had, you know, Melanie, what are some of the things that you tell someone who is newly diagnosed with diabetes? Just barely trying to understand. Insulin is all the different medication, all the lifestyle changes they need to make everything that they then need to quickly understand and adapt. What do you see as a diabetes educator to them?

Melanie: First thing is we’re a team that you’re not alone, that we’re working together. At each visit you assess what their needs are. The first and foremost, when they leave here, they’re safe. They can check their blood sugar and whatever regiment you put them on, they’re able to like complete. It’s also written for them. We have handouts to reinforce it and hypoglycemia. Because if someone’s had a high blood sugar, they’re not gonna be aware necessarily, like what a hypoglycemia episode is like. Tthe teaching of the basics, and there’s some, like, especially the type ones, they’ll come in sometimes they come with their parents.

Sometimes it’s someone who’s 70 who’s just gotten diagnosed with and they’re petrified. You’re just leaving them safe. I repeat, we’re gonna repeat all this again and bring ’em back in like two weeks when I’m calling them during the week, just so that they’re comfortable. And then you focus in on the exercise 150 minutes a week, 30 minutes, five times a week or whatever. You focus on the diet. The diet’s always entertaining because someone’s birthday was the other day. I was like, oh, do you have a piece of cake? And they started laughing cuz it’s like, I could have a piece of cake and of course it’s like moderation. And it’s just like, what? How big? And when you don’t take anything away from anyone, then they’re more likely to participate in it.

Whatever your education plan is, so that you’re not constantly, you know, oh, you cannot, there’s nothing. You can have whatever you want. It’s just moderation and how often you’re having. Then we focus on weight loss, if that’s a factor. We focus as they’re more comfortable then we’ll talk more of the chronic conditions that are potential with diabetes. It’s really coming from where the patient’s at and their family and what they’re able to hear.

Shireen: their willingness to change, right? Because sometimes you can have someone who’s just not just not ready. 

Melanie: There’s a willingness change. It’s degrees of change. It’s degrees of change. Like I had, um, someone who was mentally challenged, adorable. His time and range, which is between 70 and 180 was 29% of the time, and the rest were high. So he came in and we actually set up a whole contract. We wrote it together like what his schedule would look like for the day, and his first goal was 39%. Now, if I said to someone, you’re supposed to be at least 70% time in range, if I said, oh, 39%, what kind of an educator are you?

And it’s coming where the patient’s from. He came back, he got to 42% and now he’s at 68%. It’s just adorable, you know, it’s like, and that’s what you look for, just working with whoever it is, whatever where they are. What are their priorities? If you don’t listen to ’em, it’s worthless. It’s, they’re not gonna hear you. They might not be ready for insulin. They might not be ready to check their blood sugars or only do it once a day, but, you have to look at the individual and say, “As a team, can we work on?”

Shireen: I appreciate that a lot because it’s, it’s not about all or nothing is what I’m hearing you say. It can be baby steps, it can be, you know, your journey to getting there. It doesn’t have to be entirely like, it’s not all black or white, like either you’re compliant or not. It’s, it’s just not that. 

Melanie: And like one of the fun things in New York is cuz we have New York bagels that are like gigantic in size and they’re all over 65 grams, which is a meal in itself. So it’s fun, you’ll put on a continuous glucose and go, that was your bagel. And they’re like, oh, but, but you know, like, yay big with nothing on it. And they like, hmm. I’m like, but you can have a half a bagel or a third a bagel once a week. And they’re like, oh, okay. And as I said, if you’re not taking anything, they’re more likely to grow and be empowered with the education.

Shireen: Mm-hmm. I love that. What is the biggest misconception or myth that you have seen as, as, you know, nurse diabetes educator, that you think, man, I wish people just knew this.

Melanie: I don’t know if it’s a myth so much, but personally I just, a pet peeve is what people go to YouTube to learn everything, and it just, it drives me crazy. I’ve gone to see like what people have said and I’m like, you gotta be kidding me. Every manufacturer of whatever insulin device who pick anything, diets, we have professional organizations. We have sites that you can trust and I rather they go to there and they might send them to YouTube, but at least you know it’s the correct method to do it as opposed to someone just sitting there going, oh, this is how I do it. I look and I cringe inside because I know it’s the wrong method.

Shireen: So it’s a lot of misinformation that exists that people…

Melanie: A lot of misinformation and people believe it. And it’s just, you know, all you can do is share with them facts. And once you do that, where are they coming from? And like, okay, let’s focus on this. And then if they trust you and they, Hey, you were. You’re able to empower them more. But it’s the misinformation that I think is what upsets me the most out there.

Shireen: You know, coming back to lipohypertrophy, when you do see cases of that, what are certain things that you tell individuals to do? What would you say is the recommended distance even between each injection site? You mentioned sort of rotating it if someone were looking at their stomach, like, you know, the space and if they’re not using the quadrant method that you mentioned, what are certain things that they can do there? 

Melanie: Well, according to the guidelines, you wanna be one millimeter, no one’s gonna take out a tape and measure. If you just like, move your finger over, so today here, tomorrow there tomorrow. It’s a fingers breath and as I said earlier, whatever method’s going to get them to understand it. Some of the pen manufacturers, they actually have, they call it a turtle, but it goes around it’s paper and it has holes in it, and it’s like, okay, and you can mark them 1, 2, 3, 4, 5. So there’s lots of things out there to help you move that one millimeter or more. 

Shireen: Mm-hmm. 

Melanie: You can get creative with that.

Shireen: Is there any coming back, you know, how how long does it take for the skin to heal? Can it come back?

Melanie: That’s a little bit of a harder answer. It depends on how bad the proliferation is of the area. It could take up to six months, it could take up to a year. It could never heal, if it’s been, if it’s been so abused. If you wanna come back to it, you’re gonna have impact of, again absorption. That becomes an issue, especially for a lot of the type ones who have been on insulin for years and years and years. Like if you’ve been, had diabetes or friends had it for over 50. He’s not running outta sight, but he’s careful where he is picking his sites because through the years it’s harder to find a new site. 

Shireen: Well, with that, we are rounding out to the end of the episode at this point, Melanie, can you tell our listeners how they can connect with you? Just learn more about your work. If they’ve got more questions or anything like that, can they reach out to you please?

Melanie: Please! You can reach out to me at my email address and I believe you’re providing. As well as ADCE S. They are fountain of information but they can also get in contact me and I’d be more than happy to answer any questions or to put you in a different direction that’s more helpful. 

Shireen: That’d be great. And so that’s ADCES’ website. Google it, you know, individuals can find it very readily. 

Melanie: ADA has a lot of resources as well. 

Shireen: Thank you for sharing that and thank you so much, Melanie, for coming on the episode today for enlightening us about this challenge that I didn’t even know really existed until I started reading and I was like, ha, here’s an interesting one. I’m still, I’m still struggling with the name though, but we know what, its nonetheless. 

Melanie: Lipohypertrophy. 

Shireen: Lipohypertrophy. I think I got it. I’m getting closer. I’m getting closer, but with that, thank you so very much for your time. I reall appreciate it. 

Melanie: Thank you so much for having me, and I look forward to any questions you might have.

Shireen: That is great. To our listeners, if you were listening to us here today, you made it all the way toward the end of the episode, head over to our Facebook, our Instagram, find this podcast post and comment below for the following question. So tell us, are you taking your insulin the same injection site? Are you starting to rotate it around more now that you understand exactly what lipohypertrophy. Head over again to our Facebook, our Instagram, and let us know again, find this particular podcast post and comment below to let us know what you learned, and then if you are now rotating your injection site. And with that, we will see you there after the episode. Melanie it has been an absolute pleasure.

Melanie: Thank you so much for having me.

Shireen: Thank you for listening to the YumlisPodcast. Make sure to follow us on social media at Yumlis_ on Instagram and Twitter and atYumlish on Facebook and LinkedIn for tips about managing your diabetes and other chronic conditions, and to chat and connect with us about your journey and perspective. You can also visit our website, Yumlish.com for more recipes, advice, and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week’s show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we’ll see you next time. Remember, your health always comes first.

Stay well.

Connect with Melanie:

• ADCES