The Appropriateness of the Length of Insulin Needles

based on Determination of Skin and Subcutaneous

Thickness in the Abdomen and Upper Arm
in the type 2 Diabetes Patient

WooSuk University
Hwang, Moon Sook

SCT(SubCutaneous Thickness)

Research Background-1

Insulin should be subcutaneously injected.

Since SCT varies with age, gender, obesity and body regions
and the needle length also have an influence on SC injection,
SCT, injection technique and needle length should be considered for
the insulin injection,

However, needle length is commonly used 8 mm in the clinical practice.

And this needle is too long to make a SC injection.

So, special injection techniques needed such as 45-degree angled injection

or injection with a lifted skinfold.
These injection techniques are so complicated, So they reduce patient
compliance with insulin injection, particularly aged people.
So, they should be simplified.

Research Background-2

In this context,
shorter needles have been developed & recommended.
On the one hand,
somenoe insists that obese patients should use longer needle.
For selecting an appropriate injection site or needle length,
it is required to determine the ST and SCT in Korean
diabetic patients,
and to clarify any factors affecting the thickness.

Research Background-3

In addition,
because repeated injection at same site may cause lipodystrophy
it is instructed to make rotatory injections at least 1-2cm interval.
But almost diabetic patients dont keep to make rotatory injections
So it is necessary to investigate ST & SCT
for establishing scientific bases to make rotatory insulin
injections in the abdomen and upper arm.
In the Korea, although there are some research of ST & SCT,
they have a limitation to support rotatory insulin injections
because they measured just at the single site.
And there is also no research the appropriate needle length for insulin
injection.

So, We had research this topic.

Research Objectives
The objectives of this study are as follows:
1. to investigate into the ST & SCT of the abdomen
and upper arms
2. to clarify any factors affecting the ST & SCT of
the abdomen and upper arm
3. to estimate the possibility of insulin injection
by needle length on the basis of measured ST & SCT

Subjects
Subjects should be diabetic patients.

Inclusion criteria are listed below:

1. Without muscular disorder, neuropathy or injury

in the abdomen and upper arms
2. Without skin problem(wart, abrasion) in the abdomen and
upper arms
3. Without insulin pump in the abdomen
4. Those who do not have mass and connective ds affecting the ST
5. Those who do not have steroid treatment for a long time
6. Those who are able to understand the objectives of this study
and communicate with others

Measurement-1
Data were collected for four days between November 2012
1. Reviewed & approved by the IRB
2. General characteristics were surveyed through questionnaires,
3. BMI was measured using a body composition analyzer
4. ST & SCT were measured using ultrasound system.
5. By needle length, the risk of ID injection is measured number of case
that needle length is lower than ST,
and the risk of IM injection is measured number of case that
needle length is higher than the sum of ST & SCT.
assuming at a right angle to the skin,

Measurement-2
Specially,
ST & SCT were measured at the predetermined sites

(a total of ten sites in the abdomen and eight sites in the upper arms)

as shown in the figure.

9 10 11 12

1
5

13
Measurement site of skin thickness and subcutaneous thickness
on abdomen and upper arm.

Measurement-3

The sonographer was a licensed person having at least

3-year professional experience.
To minimize the variability of the measurement sites,
the labels of insulin injection sites were put on
the abdomen & upper arms prior to measurement.
So, to obtain the clear ultrasound images,
measurements were made at 10MHz,
while if the boundaries of ST & SCT are indefinitely seen,
measurements were made with adjusting in the 7-12MHz.

Axial ultrasound image is as follows

Subcutaneous
thickness

Skin
thickness

Axial ultrasound image of skin thickness and subcutaneous thickness

on measurement site.

Statistical Analysis
Collected data were analyzed by IBM SPSS Program

General characteristics was used N(%) & MSD

ST & SCT were measured with mm by ultrasound.

Differences of ST & SCT by General Characteristics

were used ANOVA

Factors affecting ST & SCT were used multiple linear regression

Risks of ID & IM injection were used n(%).

Table 1. General Characteristics

Characteristics
Gender
Age(year)

BMI(Kg/m2)

Insulin use

Complication of DMa

Division
Male
Female
Under 45
45 - < 65
Over 65
Under weight
Normal weight
Over weight
Obesity
Hyper obesity
Yes
No
No
Yes*
Cardio Vascular Disease
Retinopathy
Renal Disease
Cerebro Vascular Disease

Family history of DMa

Others
No*
Yes
Father
Mother
Sibling
Children

n(%)
84(53.8)
72(46.2)
16(10.4)
63(40.9)
75(48.7)
7( 4.5)
58(37.2)
33(21.2)
51(32.7)
7(4.5)
51(32.7)
105(67.3)
93(60.0)
62(40.0)
13( 8.4)
31(20.0)
2( 4.5)
8( 5.2)
33(21.3)
81(52.3)
74(47.7)
23(14.7)
33(21.3)
37(23.9)
8( 5.2)

(N=156)
MSD

62.1513.91

24.093.43

Table 2. Skin Thickness, Subcutaneous Thickness and Skin-Subcutaneous Thickness of Abdomen

(N=156)
Total(n=156)
Male(n=84)
Female(n=72)
Division
MSD
Range
MSD
Range
MSD
Range

ST

SCT

SSCT

Site 01
Site 05
Site 06
Site 07
Site 08
Site 09
Site 10
Site 11
Site 12
Site 13
Total
Site 01
Site 05
Site 06
Site 07
Site 08
Site 09
Site 10
Site 11
Site 12
Site 13
Total
Site 01
Site 05
Site 06
Site 07
Site 08
Site 09
Site 10
Site 11
Site 12
Site 13
Total

2.210.44
2.260.42
2.380.45
2.460.46
2.470.48
2.140.41
2.210.43
2.390.49
2.380.47
1.990.40
2.290.37
7.475.67
7.636.02
9.457.11
12.187.32
12.867.52
7.686.27
9.677.84
13.308.18
13.968.10
7.266.33
10.156.54
9.675.73
9.906.04
11.827.17
14.647.30
15.347.52
9.826.31
11.887.90
15.708.19
16.348.09
9.266.38
12.446.56

1.30-3.30
1.30-3.70
1.00-3.60
1.20-3.70
1.30-3.80
1.10-3.70
1.20-3.70
1.30-3.80
1.30-3.60
1.30-3.20
1.34-3.29
0.40-33.50
0.40-35.80
0.50-38.90
0.80-35.20
0.40-36.30
0.40-37.10
0.30-39.40
0.50-35.40
0.80-36.60
0.20-35.50
0.75-36.34
1.70-35.40
2.30-37.70
1.70-40.80
2.00-37.10
2.00-38.30
2.30-39.00
1.80-41.30
1.80-37.30
2.40-38.50
1.80-37.40
2.24-38.24

2.280.44
2.340.44
2.420.40
2.560.45
2.530.45
2.200.41
2.280.42
2.500.46
2.480.46
2.070.41
2.370.36
5.313.58
5.484.02
6.935.17
9.626.02
10.426.28
5.474.86
7.206.54
10.656.79
11.386.92
5.024.71
7.755.03
7.593.64
7.824.06
9.355.22
12.186.05
12.956.28
7.674.96
9.486.64
13.156.87
13.866.97
7.094.82
10.115.08

1.30-3.20
1.30-3.70
1.60-3.50
1.20-3.70
1.60-3.80
1.30-3.70
1.40-3.30
1.30-3.70
1.50-3.60
1.30-3.20
1.49-3.27
0.80-19.30
1.20-18.70
0.50-25.23
0.80-34.60
0.40-36.30
0.70-31.50
0.60-32.10
0.50-33.70
0.90-34.80
0.50-31.00
0.75-23.65
2.10-21.10
2.70-20.60
2.50-27.63
2.00-36.70
2.00-38.30
2.30-34.30
2.00-34.50
1.80-36.10
2.40-36.90
1.90-33.80
2.24-26.45

2.110.43
2.170.39
2.330.51
2.350.45
2.400.51
2.070.41
2.130.44
2.260.49
2.250.46
1.910.38
2.200.36
9.986.58
10.156.94
12.397.93
15.167.62
15.727.87
10.276.75
12.568.29
16.408.60
16.988.37
9.886.97
13.077.03
12.116.71
12.327.02
14.718.04
17.517.62
18.127.92
12.336.82
14.698.35
18.678.63
19.238.39
11.797.03
15.157.06

1.30-3.30
1.30-3.40
1.00-3.60
1.30-3.40
1.30-3.70
1.10-3.40
1.20-3.70
1.40-3.80
1.30-3.50
1.30-3.10
1.34-3.29
0.40-33.50
0.40-35.80
0.70-38.90
1.20-35.20
0.80-36.00
0.40-37.10
0.30-39.40
1.00-35.40
0.80-36.60
0.20-35.50
0.96-36.34
1.70-35.40
2.30-37.70
1.70-40.80
3.70-37.90
2.60-37.90
2.70-39.00
1.80-41.30
3.30-37.30
2.60-38.50
1.80-37.40
2.79-38.24

Table 3. Skin Thickness, Subcutaneous Thickness and Skin-Subcutaneous Thickness of Upper Arm
(N=156)
Total(n=156)
Male(n=84)
Female(n=72)
Division
MSD
Range
MSD
Range
MSD
Range

ST

SCT

SSCT

Site 1
Site 2
Site 3
Site 4
Site 5
Site 6
Site 7
Site 8
Total
Site 1
Site 2
Site 3
Site 4
Site 5
Site 6
Site 7
Site 8
Total
Site 1
Site 2
Site 3
Site 4
Site 5
Site 6
Site 7
Site 8
Total

2.270.43
2.280.43
2.100.44
2.120.42
1.930.41
1.870.39
1.740.39
1.690.36
2.000.34
6.233.06
6.433.10
5.773.12
5.993.16
5.453.09
5.183.10
4.793.36
4.172.93
5.502.68
8.503.10
8.713.07
7.873.15
8.113.18
7.383.12
7.053.13
6.533.44
5.862.98
7.502.68

1.40-3.20
1.30-3.60
1.20-3.20
1.10-3.50
1.10-3.20
0.80-2.90
0.90-2.90
0.80-2.90
1.11-2.90
1.30-18.70
0.60-18.10
0.30-16.20
0.30-17.40
0.20-16.20
0.10-16.00
0.13-17.50
0.20-13.50
0.85-12.69
2.80-21.20
3.20-20.50
1.60-18.90
1.70-19.80
2.20-18.10
1.60-17.50
1.60-19.20
1.40-15.30
2.30-14.85

2.430.41
2.480.41
2.270.42
2.260.44
2.070.40
1.980.36
1.830.39
1.780.35
2.140.31
5.112.66
5.032.44
4.252.17
4.392.08
3.832.07
3.632.08
3.222.34
2.982.30
4.061.79
7.542.75
7.522.52
6.522.29
6.652.17
5.902.21
5.612.17
5.052.49
4.762.40
6.191.87

1.40-3.20
1.50-3.60
1.30-3.20
1.30-3.50
1.20-3.20
0.90-2.90
1.10-2.90
1.10-2.90
1.29-2.90
1.30-18.70
0.60-18.10
0.30-11.70
0.30-9.40
0.20-9.00
0.10-10.90
0.13-11.10
0.20-11.80
0.85-9.99
3.20-21.20
3.20-20.50
1.60-14.80
1.70-11.50
2.20-11.70
1.60-12.50
1.60-13.70
1.40-13.90
2.30-12.21

2.090.38
2.040.32
1.900.38
1.960.32
1.780.36
1.740.38
1.630.36
1.580.35
1.840.29
7.543.00
8.062.99
7.553.14
7.863.19
7.343.01
6.993.11
6.623.44
5.572.98
7.192.56
9.633.12
10.103.09
9.443.29
9.823.33
9.123.13
8.743.26
8.263.61
7.143.09
9.032.68

1.40-3.10
1.30-2.90
1.20-2.90
1.10-2.70
1.10-2.70
0.80-2.90
0.90-2.70
0.80-2.60
1.11-2.60
1.30-14.30
2.00-16.50
1.20-16.20
2.60-17.40
0.80-16.20
0.75-16.00
1.00-17.50
1.00-13.50
2.35-12.69
2.80-16.30
3.60-18.80
3.30-18.90
3.70-19.80
2.60-18.10
2.80-17.50
2.40-19.20
2.00-15.30
3.84-14.85

Table 4. Skin Thickness, Subcutaneous Thickness and Skin-Subcutaneous Thickness of Abdomen

and Upper Arm according to General Characteristics
(N=156)
Abdomen
Upper arm
Characteristics Division
ST
SCT
ST+SCT
ST
SCT
ST+SCT
MSD
MSD
MSD
MSD
MSD
MSD

Gender
Age
(yr)
BMI
(Kg/m2)

Insulin
use
Familial
heredity
of DM
Complication
of DM

Total
Male
Female
F(p)
Under 45 a
45-< 65 b
Over 65 c
F(p)
Under Weight
Normal Weight
Over Weight c
Obesity d
HyperObesity e
F(p)
Scheffe
Yes
No
F(p)
No
Yes
F(p)
No
Yes
F(p)

2.290.37
10.156.54
12.446.56
2.000.34
5.502.68
7.502.68
2.370.36
7.755.03
10.115.08
2.140.31
4.061.79
6.191.87
2.200.36
12.957.00
15.157.06
1.840.29
7.192.56
9.032.68
8.285(.005) 28.978(<.001) 26.617(<.001) 37.535(<.001) 80.374(<.001) 60.152(<.001)
2.330.40
11.226.37
13.566.52
2.040.30
6.732.84
8.772.90
2.310.36
10.356.31
12.666.37
1.980.31
5.692.78
7.672.81
2.260.38
9.8946.84
12.156.81
2.000.37
5.132.52
7.132.47
0.547(.580)
0.292(.747)
.332(.718)
0.234(.792)
2.621(.076)
2.663(.073)
1.740.33
4.052.89
5.802.97
1.540.38
3.081.45
4.611.70
2.220.29
7.205.45
9.425.39
1.970.35
4.722.34
6.702.27
2.290.32
10.795.22
13.075.09
2.000.36
5.202.63
7.202.51
2.400.38
12.666.43
15.076.42
2.070.31
6.352.40
8.412.37
2.560.58
19.356.43
21.936.30
2.170.31
9.682.60
11.852.68
7.518(<.001) 12.969(<.001) 14.327(<.001)
4.792(.001) 10.290(<.001) 12.345(<.001)
a<b,c,d,e
a<c<e
a<c,d<e
a<b,c,d,e
a<d<e
a<d<e
2.360.58
9.806.86
12.157.04
2.030.40
5.482.83
7.512.92
2.260.32
10.326.40
12.576.34
1.980.30
5.512.62
7.502.57
2.603(.109)
0.218(.641)
.140(.708)
0.632(.428)
0.004(.950)
0.001(.971)
2.290.40
9.967.07
12.257.07
1.99035
5.272.76
7.262.75
2.290.35
10.455.93
12.735.98
2.000.33
5.792.58
7.802.59
.005(.942)
0.213(.645)
.208(.649)
0.103(.749)
1.469(.227)
1.5608(.212)
2.250.39
10.396.97
12.657.00
1.980.35
5.652.87
7.632.88
2.340.34
9.895.86
12.245.88
2.020.32
5.322.38
7.352.36
2.195(.141)
0.215(.644)
.143(.706)
0.510(.476)
0.546(.461)
.421(.517)

Table 5. Factors Affecting Skin Thickness, Subcutaneous Thickness and Skin-Subcutaneous

Thickness of Abdomen
(N=156)
Adjusted
Variables
B
SE

t
p
F
P
R2
Abdomen
Constant
Age
ST
Gender(F)
BMI
Constant
Age
SCT
Gender(F)
BMI
Constant
Age
SSCT
Gender(F)
BMI

1.424
-.003
-.142
.040

.235
.002
.054
.008

-13.420
-.018
5.345
1.140

2.941
.024
.682
.099

-11.996
-.021
5.203
1.180

2.912
.024
.676
.098

-.104
-.192
.371

6.069
-1.411
2.610
5.045

<.001
.160
.010
<.001

.185

12.472

< .001

-.041
.430
.633

-4.563
-.741
-7.833
11.501

<.001
.460
<.001
<.001

.544

61.476

< .001

-.047
.416
.651

-.4.119
-.862
7.701
12.022

<.001
.390
<.001
<.001

.558

64.942

< .001

Table 5. Factors Affecting Skin Thickness, Subcutaneous Thickness and Skin-Subcutaneous

Thickness of Upper Arm
(N=156)
Adjusted
Variables
B
SE

t
p
F
P
R2
Upper Arm
Constant
Age
ST
Gender(F)
BMI
Constant
Age
SCT
Gender(F)
BMI
Constant
Age
SSCT
Gender(F)
BMI

1.284
-.002
-.283
.029

.202
.002
.047
.007

-.614
-.029
3.345
.403

1.146
.009
.266
.039

.670
-.031
3.060
.503

1.176
.010
.270
.069

-.086
-.418
.293

6.353
-1.243
6.027
4.215

<.001
.216
<.001
<.001

.274

20.118

< .001

-.152
.621
.516

-.536
-3.101
12.575
10.434

.593
.002
<.001
<.001

.632

87.835

< .001

-.162
.569
.645

.570
-3.219
-11.315
7.276

.571
.002
<.001
<.001

.613

81.290

< .001

Table 6. Possible ID and IM risk based on Needle Length and BMI(90Insertion, no raised skin fold)
(N=156)
Needle

Risk of ID

Length

n(%)

Risk of IM
Total

Under Wt

Normal Wt

Over Wt

Obesity Hyper Ob

(n=7)

(n=58)

(n=33)

(n=51)

(n=7)

Abdomen
4 mm

0(0.0)

3( 1.9)

2(28.6)

1( 1.7)

0( 0.0)

0(0.0)

0(0.0)

5 mm

0(0.0)

8( 5.1)

3(42.9)

5( 8.6)

0( 0.0)

0(0.0)

0(0.0)

6 mm

0(0.0)

20(12.8)

4(57.1)

15(25.9)

0( 0.0)

1(2.0)

0(0.0)

8 mm

0(0.0)

45(28.8)

5(71.4)

29(50.0)

4(12.1)

7(13.7)

0(0.0)

4 mm

0(0.0)

5( 3.2)

3(42.9)

1(1.7)

1( 3.0)

0(0.0)

0(0.0)

5 mm

0(0.0)

32(20.5)

5(71.4)

16(27.6)

9(27.3)

2(3.9)

0(0.0)

6 mm

0(0.0)

55(35.3)

5(71.4)

30(51.7)

11(33.3)

9(17.6)

0(0.0)

8 mm

0(0.0)

92(58.9)

7(100.0)

43(74.1)

20.(60.6)

21(41.2)

1(14.3)

Upper Arm

CONCLUSION
Thickness

Abdomen

Upper arm

ST

2.29mm

2.00mm

SCT

10.15mm

5.50mm

Affecting factor

Abdomen

Upper arm

ST

Gender, BMI

Gender, BMI

SCT

Gender, BMI

Gender, BMI, Age

Insulin fluids may not appear to be IDly injected

into the abdomen and upper arms at any needle lengths,
-The risk of IM injection is likely to increase with longer
needles and lower BMI.
This study findings indicate that 4mm needles will
deliver insulin subcutaneouly for Korean diabetic patients.

If you have a Question, Please contact me by E-mail.

My E-mail number is msyellow45@hanmail.net
Thank you very much for your attention