Hrev_master Healthcare in Low-resource Settings 2024; volume 12(s1):13065 Insulin injection rotation and Diabetes Mellitus nutritional management education Indah Rosdiana Narahaubun,1 Dian Handayani,2 Heri Kristianto1 1Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Malang, East Java; 2Department of Nutrition, Faculty of Health Sciences, Universitas Brawijaya, Malang, East Java, Indonesia Abstract The management of Diabetes Mellitus (DM) involves imple- menting a healthy lifestyle and pharmacological interventions through the administration of anti-hyperglycemia drugs. An essen- tial aspect of treating DM patients is insulin administration, which facilitates glucose transportation into cells. This study evaluated the effectiveness of insulin injection rotation and nutritional man- agement education for DM. The literature search utilized the key- words “education,”AND “insulin injection,” AND “nutritional management,” AND “DM”, ranged 2021-2023 Searches were conducted on various databases, including Proquest, NCBI, BMC, ScienceDirect, and other relevant platforms such as Google Scholar. Ten journal articles pertinent to the subject matter were identified in the study. Findings indicate that nutritional education facilitates overall health improvement in individuals with DM, contributing to maintaining average body weight and near-normal blood glucose levels. It also enhances lipid profile and insulin receptor sensitivity while being a preventive measure against acute or chronic complications such as hyperglycemia. It is noted that selecting the appropriate injection site can significantly impact patients’ blood glucose levels. While it is recommended to administer injections at consistent locations, repetitive use of the same site may pose risks of side effects, such as lipodystrophy. After conducting a comprehensive review of ten journal articles, it has been concluded that insulin injection rotation and nutritional management education are effective for managing DM. Introduction A total of 422 million Diabetes Mellitus (DM) patients were reported by the data obtained from the World Health Organization (WHO) and International Diabetes Federation (IDF) in 2019. Approximately 10.7 million patients are in the age range of 20-79 years, and the figure is estimated to increase by 11.8% in 2030 and 20451 due to the high incidence of the disease. According to the 2018 Riskesdas data, the prevalence of DM patients aged over 15 years remained at 2%, marking an increase compared to the fig- ures from the 2013 Riskesdas.2 The management can be achieved by implementing a healthy lifestyle with pharmacological intervention and administration of anti-hyperglycemia drugs.3-6 The management of type 2 DM restores blood glucose concentration, allowing patients to feel comfortable and healthy as well as preventing the onset of micro complications and macrovascular complications.7-9 Individuals who have been diagnosed with diabetes often need to rely on insulin therapy to help move glucose from the blood into the body’s cells. This essential process is critical in managing the con- dition and maintaining proper blood sugar levels.10-12 Selection of the right insulin injection site can affect the blood glucose levels of patients. Therefore, changing the injection point is important to prevent the risk of side effects. Lipodystrophy is a side effect of insulin resulting from fat tissue damage to form scars in the form of lumps under the skin. These lumps can interfere with insulin absorption and repetitive injection can cause other complications in the form of skin irritation.13-15 A strong under- standing of nutritional treatment can play a crucial role in helping to stabilize blood glucose levels and support overall health.16-17 Nutritional education improves the general health of DM patients, maintains normal body weight and near-normal blood glucose levels, improves lipid profiles and insulin receptor sensi- tivity, as well as prevents acute or chronic complications such as hyperglycemia.17-19 Achieving success in DM management requires diligent adherence to the guidance provided by healthcare professionals, including physical exercise, pharmacological treat- ment, and dietary recommendations. Therefore, this research aimed to determine the effectiveness of insulin injection rotation and nutritional management education for DM. Materials and Methods Eligibility criteria The articles underwent a rigorous evaluation based on specific criteria and were managed using bibliographic software like Mendeley. The assessment was carried out meticulously through a systematic three-step review to determine their suitability for inclusion in the study. This comprehensive process involved the initial scrutiny of the title, abstract, and full text. The inclusion cri- [Healthcare in Low-resource Settings 2024;12(s1):13065] [page 117] Significance for public health The management of Diabetes Mellitus (DM) entails adopting a healthy lifestyle, utilizing anti-hyperglycemic medications, and administering insulin. Proper selection and rotation of injection sites are imperative to mitigate potential side effects. This research emphasizes the significance of nutritional education in enhancing overall health and averting complications in DM patients. Non -co mmerc ial us e o nly teria encompassed articles published within the past three years (2021-2023), original qualitative and quantitative research, content relevant to the specified search terms, and availability as open access. The exclusion criteria included content irrelevant to the topics. Search strategy An extensive electronic search was conducted across five databases: Proquest, NCBI, BMC, ScienceDirect, and Google Scholar. The search period ranged from 2021 to 2023, focusing on specific keywords including “Education,” AND “Insulin Injection,” AND “Nutritional Management,” AND “Diabetes Mellitus.” Following the retrieval of articles, predefined inclusion criteria were applied to filter the results and identify relevant con- tent for further analysis. Article selection process The review article selection process employed the PRISMA method. A comprehensive search across Proquest, NCBI, BMC, ScienceDirect, and Google Scholar yielded 39,490 articles. Following filtering based on specified year criteria, the number was refined to 19,728. Subsequently, a thorough evaluation of the title and abstract and a scoping review identified 30 suitable arti- cles. Finally, after the third stage of screening, 16 articles were selected (Figure 1). Articles selected shown in Supplementary materials, Table 1. Results and Discussion Optimizing the administration of insulin injections Insulin, a vital hormone, is pivotal in regulating the body’s glu- cose levels. The degree of insulin sensitivity varies among individ- uals and is influenced by diverse lifestyle and dietary factors. Notably, approximately 40% of adults in the United States experi- ence low insulin sensitivity, also known as insulin resistance, which elevates the risk of developing type 2 diabetes. Improving insulin sensitivity and diminishing insulin resistance can yield sig- nificant benefits for individuals with type 2 diabetes or those pre- disposed to the condition. Embracing positive lifestyle modifica- tions, such as regular physical activity and a well-balanced diet, can substantially enhance insulin sensitivity and mitigate the risk of type 2 diabetes.20 The efficacy of diabetes therapy hinges on the accurate admin- istration of insulin through proper injection techniques. Despite existing guidelines and evidence, it is imperative to identify barri- ers to this technique among patients and foster awareness among patients and healthcare professionals regarding the significance of refining insulin injection practices.21 Administration of insulin injections necessitates careful atten- tion to optimizing patient care. A study by Zhang and Chen eluci- dated the specific requirements for this procedure. Compared to the control group, the cohort receiving consistent care and opti- mized insulin injection techniques demonstrated marked enhance- ments in health. These improvements included decreased blood glucose and HbA1c levels, fewer reported insulin-related compli- cations and reduced pain scores. Additionally, the intervention group exhibited expedited training and achieved a higher success rate for initial subcutaneous injections. Moreover, the intervention group experienced a lower frequency of subcutaneous fat hyper- plasia. Conversely, while not statistically significant, the control group displayed a higher incidence of hypoglycemia.22 A study compared the effects of IT education on diabetes management in two groups. Both groups had similar demographics and baseline IT behaviour. HbA1c reduction was similar in both groups in the intention-to-treat analysis but significant in the per-protocol analy- sis. Total daily dose (TDD) insulin changes were more important in the IT education group. Control patients showed “contamina- tion” of IT education behaviours, decreasing HbA1c.23 A new auto- matic insulin injection log device with an algorithm improved injection rotation in the abdominal area, potentially reducing lipo hypertrophy lesions and promoting better glucose control.24 The prevalence of lipohypertrophy among individuals with diabetes mellitus is notably high, linked to insufficient health edu- cation on proper injection techniques. Implementing a system of rotating injection sites has been shown to enhance glycemic con- trol in both type 1 and type 2 diabetes mellitus subjects. Moreover, it has been observed that the level of education influences glucose control in type 1 diabetes mellitus subjects. However, further com- prehensive research is necessary to extrapolate these findings and to establish definitive causal relationships between injection tech- niques and glycemic control.25 Proper insulin administration is paramount to avoiding serious complications. Healthcare providers must educate patients on appropriate techniques, insulin storage, injection sites, and poten- tial complications to mitigate errors resulting from a lack of knowledge. Effective diabetes management relies on healthcare providers’ assessment of patient understanding and utilization of engaging educational methods. Given time constraints, physicians require support in effectively educating and providing patient feed- back. Notably, patients improved their injection technique during follow-up visits by addressing factors such as injection force and 4th International Nursing and Health Sciences Symposium Figure 1. Article selection process. [page 118] [Healthcare in Low-resource Settings 2024;12(s1):13065] Non -co mmerc ial us e o nly area size. Educational interventions to improve insulin injection techniques can potentially enhance glycemic control in individuals with diabetes mellitus. It is imperative to incorporate evidence- based recommendations and guidelines for insulin injection tech- niques and adopt technological and innovative solutions to advance this endeavour.26-28 Improving nutritional management for patients with type 2 diabetes mellitus Type 2 diabetes is characterized by impaired glucose utiliza- tion and energy storage, leading to elevated blood sugar levels. Insulin resistance, a hallmark of this condition, impedes the entry of sugar into cells, while insufficient insulin production by the pan- creas further contributes to the increased blood sugar levels.29 Effectively managing type 2 diabetes necessitates lifestyle modifi- cations, self-care practices, and medication to prevent complica- tions associated with the eyes, kidneys, and nerves. Regular mon- itoring of blood sugar levels, as well as the regulation of blood pressure and cholesterol, are vital aspects of management. Adhering to a nutritious diet, engaging in physical activity, and adhering to prescribed medications are integral to diabetes man- agement. Seeking guidance from a qualified dietitian is advanta- geous in formulating a personalized plan that aligns with individu- al needs and preferences.8 The preceding study elucidates the nutritional enhancements following a targeted dietary intervention.30-35 A study focused on two individuals aged 39 and 67 with low body weights and BMIs. Their nutritional deficiencies were addressed through assessments, oral hygiene interventions, and diabetes-specific dietary education. Following the educational session, the patient’s weight and BMI showed improvement.30 Before the educational interventions, 70.5% of the patients had poor blood sugar levels, with 47.7% exhibiting moderate levels. Adherence to dietary recommendations notably impacted the blood sugar levels of individuals with type II diabetes.31 The study involved 159 patients divided into three groups, resulting in varied outcomes. The intervention group sig- nificantly improved HbA1c levels, metabolic parameters, dietary intake, and physical activity.34 While healthcare providers recognized challenges in maintain- ing a healthy diet, patients demonstrated positive self-management indicators.34-35 Healthcare providers hold diverse perspectives regarding patients’ challenges in maintaining a healthy diet. Some patients demonstrate proactive self-management behaviours, such as consistently monitoring their blood glucose levels and display- ing a strong interest in acquiring knowledge about dietary prac- tices. Nevertheless, providers have indicated that they often lack the necessary time to engage in extensive discussions about diet with their patients and would prefer to delegate dietary education to other individuals.36 Managing diabetes well involves learning about it, planning meals, staying active, taking medication as prescribed, and check- ing blood sugar levels regularly. Modalities encompass insulin therapy, oral medications, complementary and alternative medicine, surgical interventions, and lifestyle modifications. The rotation of insulin injections and nutritional knowledge significant- ly impact diabetes management and overall understanding. Healthcare professionals employ counselling techniques and pro- vide educational resources to enhance treatment outcomes. Conclusions In conclusion, the effective management of diabetes mellitus (DM) can be enhanced by implementing five key pillars: educa- tion, meal planning, physical exercise, pharmacological interven- tion, and blood sugar monitoring. Treatment options comprise insulin therapy, oral medications, exploration of alternative thera- pies, surgical interventions, and lifestyle improvements such as dietary modifications and regular exercise. The proficient rotation of insulin injections and provision of nutritional education signifi- cantly impact patients’ blood glucose control and knowledge lev- els. Healthcare professionals deliver education through coun- selling and the distribution of educational materials, including booklets, leaflets, and modules, to augment treatment success. References 1. Setyawati AD, Ngo THL, Padila P, Andri J. Obesity and Heredity for Diabetes Mellitus among Elderly. JOSING 2020;1:26–31. 2. Ministry of Health Republic of Indonesia. Basic Health Research. Jakarta: Ministry of Health Republic of Indonesia; 2018. 3. Perkeni. Management and Prevention of Type 2 Diabetes Mellitus in Indonesia. Jakarta: Indonesian Endocrinology Society; 2021. 4. Fujiwara Y, Eguchi S, Murayama H, et al. Relationship between diet/exercise and pharmacotherapy to enhance the GLP-1 levels in type 2 diabetes. Endocrinol Diabetes Metab 2019;2:e00068. 5. Davies MJ, Aroda VR, Collins BS, et al. 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Momongan N, Paruntu O, Barangmanise S, Takahipe N. Diet Education With Booklet Media In Improving Diet Compliance And Blood Sugar Levels In Type II DM Patients. Gizido Journal 2021;13:24-2. 34. Isaksson SS, Bacos MB, Eliasson B, et al. Effects of nutrition education using a food-based approach, carbohydrate counting or routine care in type 1 diabetes: 12 months prospective ran- 4th International Nursing and Health Sciences Symposium Correspondence: Indah Rosdiana Narahaubun, Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya, Jl. Puncak Dieng, Kunci, Kalisongo, Kec. Dau, Malang, East Java, Indonesia, 65151. Tel.: +62341569117- Fax: +62341564755. E-mail: indahnarahaubun05@gmail.com Key words: Diabetes Mellitus; education; injection rotation; insulin; nutritional management Contributions: the content of the reviewed article is the sole responsibil- ity of each author who has made significant contributions. They have meticulously assessed its quality, participated in preparing the manu- script, and authorized its submission. Conflict of interests: the authors declare no conflicts of interest Funding: the authors receive support from the Department of Nursing, Faculty of Health Sciences, Universitas Brawijaya Ethics approval: not applicable. Clinical trials: not applicable. Conference presentation: part of this article was presented at the 4th International Nursing and Health Sciences Symposium, from 27th-28th of October 2023, Universitas Brawijaya, Malang, East Java, Indonesia. Acknowledgments: the authors extend their gratitude to all those who contributed to enhancing the quality of this scientific article. Received: 3 November 2023. Accepted: 8 June 2024. Early view: 10 September 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12(s1):13065 doi:10.4081/hls.2024.13065 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 120] [Healthcare in Low-resource Settings 2024;12(s1):13065] Non -co mmerc ial us e o nly domized trial. BMJ Open Diabetes Research and Care 2021;9:e001971. 35. Hashim SA, Mohd Yusof BN, Abu Saad H, et al. Effectiveness of simplified diabetes nutrition education on glycemic control and other diabetes-related outcomes in patients with type 2 dia- betes mellitus. Clin Nutr ESPEN 2021;45:141-9. 36. Bross R, Genter P, Lu Y, et al. Barriers to Healthy Eating and Diabetes Diet Education: Divergent Perspectives of Patients and Their Providers. Health Education Behavior 2022;49:658- 666. 4th International Nursing and Health Sciences Symposium [Healthcare in Low-resource Settings 2024;12(s1):13065] [page 121] Online supplementary materials Table 1. Selected articles Non -co mmerc ial us e o nly