Pract Diab Int May 2002 Vol. 19 No. 4 Copyright © 2002 John Wiley & Sons, Ltd. 123

L E T T E R S T O T H E E D I T O R

Harold – too old for treatmentSir, although most of my working life was devoted to paediatricpractice, I have had type 2 diabetes for 16 years, treated withinsulin for 3 years. I am now aged 79 years. My experience indiabetic care therefore derives from this large but intimateexperience of one case so I am clearly interested in Harold’sproblems.

If his diabetes is of recent onset then his insulin sensitivity hasfallen significantly, accompanied by an increasing fall in β-cellreserve, a situation commonly observed in the elderly type 2diabetic patient. Oral hypoglycaemic agents should beaccompanied by reduced CHO intake, which, for such an agedpatient, is unkind. Harold should be managed using insulintherapy – Humilin M2 insulin is suggested.

The diet in the care home is likely to be reasonably constant incalorie content but there will be some variation so his insulin dose

will have to be gauged from his food intake and exercise. Thediabetes nurse specialist from the diabetic clinic should teach oneor two carers to measure Harold’s blood glucose concentrationbefore breakfast, before lunch (likely to be his largest meal) andbefore bed. The insulin dose should vary against the blood glucoseconcentration at these times; the largest dose (6–10 units) beforebreakfast, and 6 units before his evening meal. A blood glucose ofless than 6 mmol/l before bed requires extra CHO, e.g. biscuits,toast, or chocolate, to avoid hypoglycaemia during sleep.

I strongly advise that insulin treatment is the best way tomanage diabetes in patients over 70 years of age, with routinereview by the clinic nurse. I have written this answer beforereading the ‘expert’ comments.

WILLIAM HAMILTON MD FRCP(G&E) DPH DCH, 81 Woodend Drive, Glasgow G13 1QF, UK

Injection sites for insulinSir, the March 2002 edition of Practical Diabetes International con-tained a supplement devoted to the administration of insulin bysubcutaneous injection. Figure 1 detailed some injection sites andyet again the abdominal injection site was depicted as a relativelysmall area below the umbilicus. This diagram is like so many oth-ers in diabetes texts showing a relatively small area of the anteriorabdominal wall as being suitable for subcutaneous insulin injection.

A complication of insulin injection into the same area is lipo-hypertrophy and a recent report (1) has described a high preva-lence of lipohypertrophy in children and adolescents.This, in part,is due to patients injecting the same area repeatedly. Presumablythey do this as Healthcare Professionals still propagate the myththat in the anterior abdominal wall the area for injection is limitedto a small area below the umbilicus.

The whole of the anterior abdominal wall should be designatedas ideal for insulin injection. Frequently one comes across patientswho are surprised when informed that they are allowed to inject

insulin above their umbilicus! The larger the area available forinjection the less the possibility for repeated injection into thesame area with resultant lipohypertrophy.

Unfortunately diagrams such as figure 1 in the supplement prop-agate one of the unhelpful myths about insulin administration.

DR JAMES D WALKER, Consultant Physician

Reference1. Kordonouri O, Lauterborn R, Deiss D. Lipohypertrophy in Young Patients with Type

1 Diabetes. Diabetes Care 2002; 25: 634

ReplySir, we fully agree with Dr Walker that the whole of the anteriorabdominal wall can be used for insulin injection and thank himfor highlighting this important issue.

D KYNE-GREZBALSKI, L WOOD, J WILBOURNE

C O N F E R E N C E N O T I C E

FENDFederation of European Nurses in Diabetes

Seventh Annual Conference

‘Effective European Coalitions Defending Diabetes’30-31 August 2002

Hilton Hotel, Budapest, Hungary

Cost: j225. To register contact: Stina Wallenkrans, 9747 Husebacken, S-44497 Svenshogen, Sweden.Tel/Fax: +46 303 774111; Email: stina.wallenkrans@telia.com or print off the registration form from theFEND website on www.FEND.org