Evaluation of ultrasound examination combined with intensive injection technique education on insulin-induced lipohypertrophy (LH) management: a prospective cohort study in China



This study was aimed to assess the impact of ultrasound examination combined with intensive injection technique education for LH management.


A total of 120 patients with diabetes who were identified as existing clinical LH were enrolled into the study. All patients underwent ultrasound examination and received intensive injection technique education based on ultrasound detection results and Chinese guideline for diabetic injection technology in a prospective single study in China with a follow-up of 3 months. Injection Technique Questionnaire (ITQ) and assessment of glycemic control were used to assess the impact of ultrasound examination combined with intensive injection technique education for LH management.


As expected, after 3 months of intensive injection technique education based on ultrasound examination, the proportion of patients who had mastered insulin injection technique was significantly increased (p<0.05). The mean HbA1c was decreased by 0.60 (0.28)% from 7.61 (0.34)% to 7.01 (0.23)%, mean FBG was decreased by 1.20 (1.05) mmol/L from 8.10 (1.02) mmol/L to 6.90 (0.71) mmol/L, mean 2hPG was decreased by 1.70 (1.31) mmol/L from 11.49 (1.25) mmol/L to 9.79 (0.87) mmol/L without increasing the insulin dosage. The glycemic variability (GV) indicators (LAGE, MBG, SDBG, and PPGE), hypoglycemic, hyperglycemic, and IM injection events were markedly decreased (p<0.05).


Ultrasound examination combined with intensive injection technique education markedly improved glycemic control in diabetes with LH without increasing the insulin dosage, as well as reducing the occurrence of adverse blood glucose events. It can be a new effective approach for LH management.

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  1. 1.

    Landau S. Images in clinical medicine. Insulin-induced lipohypertrophy [J]. N Engl J Med. 2012;366(5):e9.

    CAS  Article  Google Scholar 

  2. 2.

    Grassi G, Scuntero P, Trepiccioni R, Marubbi F, Strauss K. Optimizing insulin injection technique and its effect on blood glucose control [J]. J Clin Transl Endocrinol. 2014;1(4):145–50.

    PubMed  PubMed Central  Google Scholar 

  3. 3.

    Hauner H, Stockamp B, Haastert B. Prevalence of lipohypertrophy in insulin-treated diabetic patients and predisposing factors [J]. Exp Clin Endocrinol Diabetes. 1996;104(2):106–9.

    CAS  Article  Google Scholar 

  4. 4.

    Ji L, Sun Z, Li Q, Qin G, Wei Z, Liu J, et al. Lipohypertrophy in China: prevalence, risk factors, insulin consumption, and clinical impact [J]. Diabetes Technol Ther. 2017;19(1):61–7.

    CAS  Article  Google Scholar 

  5. 5.

    Tao L, Zhang X, Strauss K, Hirsch LJ, Chandran A. Estimated economic burden of insulin injection-related lipohypertrophy in Chinese patients with diabetes [J]. Value Health. 2014;17(7):A748–9.

    CAS  Article  Google Scholar 

  6. 6.

    Frid A, Gunnarsson R, Güntner P, et al. Effects of accidental intramuscular injection on insulin absorption in IDDM [J]. Diabetes Care. 1988;11(1):41–5.

    CAS  Article  Google Scholar 

  7. 7.

    Baron A, Kim D, Weyer C. Novel peptides under development for the treatment of type 1 and type 2 diabetes mellitus [J]. Curr Drug Targets Immune Endocr Metabol Disord. 2002;2(1):63–82.

    CAS  Article  Google Scholar 

  8. 8.

    Martinez L, Consoli S, Monnier L, et al. Studying the Hurdles of Insulin Prescription (SHIP): development, scoring and initial validation of a new self-administered questionnaire [J]. Health Qual Life Outcomes. 2007;5:53.

    Article  Google Scholar 

  9. 9.

    Ghazaleh HA, Hashem R, Forbes A, et al. A systematic review of ultrasound-detected lipohypertrophy in insulin-exposed people with diabetes [J]. Diabetes Ther. 2018;9(5):1741–56.

    Article  Google Scholar 

  10. 10.

    Volkova NI, Davidenko I, Rudakova J, et al. Insulin-induced lipohypertrophy diagnostics in diabetic patients: subcutaneous fat ultrasonography; proceedings of the 17th European Congress of Endocrinology, F, 2015 [C]. BioScientifica.

  11. 11.

    Ji L, Gou X, Huang J, et al. Chinese guideline for diabetic injection technology [J]. Chin J Diabetes Mellitus. 2017;9(2):79–105.

    Google Scholar 

  12. 12.

    Song Z, Guo X, Ji L, et al. Insulin injection technique in China compared with the rest of the world [J]. Diabetes Ther. 2018;9(6):2357–68.

    CAS  Article  Google Scholar 

  13. 13.

    Vardar B, Kizilci S. Incidence of lipohypertrophy in diabetic patients and a study of influencing factors [J]. Diabetes Res Clin Pract. 2007;77(2):231–6.

    Article  Google Scholar 

  14. 14.

    Wang W, Guo X, Shen G, Bai G, Wei Z, Liu J, et al. Skin and subcutaneous tissue thickness at insulin injection sites in Chinese diabetes patients: Clinical implications [J]. Diabetes Metab. 2016;42(5):374–7.

    CAS  Article  Google Scholar 

  15. 15.

    Gupta S, Gupta K, Gathe S, et al. Clinical implications of lipohypertrophy among people with type 1 diabetes in India [J]. Diabetes Technol Ther. 2018;20(7):483–91.

    CAS  Article  Google Scholar 

  16. 16.

    Deeb A, Abdelrahman L, Tomy M, Suliman S, Akle M, Smith M, et al. Impact of insulin injection and infusion routines on lipohypertrophy and glycemic control in children and adults with diabetes [J]. Diabetes Ther. 2019;10(1):259–67.

    CAS  Article  Google Scholar 

  17. 17.

    Volkova NI, Davidenko IY. Clinical significance of lipohypertrophy without visual and palpable changes detected by ultrasonography of subcutaneous fat [J]. Ter Arkh. 2019;91(4):62–6.

    CAS  PubMed  Google Scholar 

  18. 18.

    Campinos C, Petit C, et al. An effective intervention for diabetic lipohypertrophy: results of a randomized, controlled, prospective multicenter study in France [J]. Diabetes Technol Ther. 2017;19(11):623–32.

    CAS  Article  Google Scholar 

  19. 19.

    Smith M, Clapham L, Strauss K. UK lipohypertrophy interventional study [J]. Diabetes Res Clin Pract. 2017;126:248–53.

    Article  Google Scholar 

  20. 20.

    Chen L, Xing Q, Jing LI, et al. 337-OR: Injection Technique (IT) Training in Subjects Injecting into Lipohypertrophy (LH)—The Tianjin Randomized Controlled Trial (RCT)[J]. Diabetes. 2019;68(Supplement 1):337-OR.

  21. 21.

    Ceriello A, Monnier L, Owens D. Glycaemic variability in diabetes: clinical and therapeutic implications [J]. Lancet Diabetes Endocrinol. 2019;7(3):221–30.

    Article  Google Scholar 

  22. 22.

    Famulla S, Hövelmann U, Fischer A, Coester HV, Hermanski L, Kaltheuner M, et al. Insulin injection into lipohypertrophic tissue: blunted and more variable insulin absorption and action and impaired postprandial glucose control [M]. Diabetes Care. 2016;39:1486–92.

    CAS  Article  Google Scholar 

  23. 23.

    Boon IS, Saeed MA. Cautionary tale: subdural haematoma following frequent hypoglycaemia from insulin-induced lipohypertrophy[J]. Bmj Case Reports. 2015;(2015):bcr2015212855.

  24. 24.

    Barola A, Tiwari P, Bhansali A. Insulin-mediated lipohypertrophy: an uncommon cause of diabetic ketoacidosis[J]. Bmj Case Reports. 2017;(2017):bcr-2017-220387.

  25. 25.

    Chowdhury TA, Escudier V. Poor glycaemic control caused by insulin induced lipohypertrophy [J]. BMJ (Clin Res Ed). 2003;327(7411):383–4.

    Article  Google Scholar 

  26. 26.

    Hsu C, Chen Y, Sheu W. Glycemic variability and diabetes retinopathy: a missing link [J]. J Diabetes Complicat. 2015;29(2):302–6.

    Article  Google Scholar 

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We thank the department of ultrasonography of our hospital for providing the ultrasound equipment and technical support.

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Corresponding authors

Correspondence to Mei Tu or HangJu Chen.

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The study was approved by the Ethical Committee of First Hospital of Longyan. Written informed consent from each patient was waived.

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Wang, W., Tong, Y., Chen, Y. et al. Evaluation of ultrasound examination combined with intensive injection technique education on insulin-induced lipohypertrophy (LH) management: a prospective cohort study in China. Int J Diabetes Dev Ctries (2021). https://doi.org/10.1007/s13410-021-00935-7

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  • Lipohypertrophy management
  • Ultrasound examination
  • Intensive injection technique education
  • Glycemic control