Synonyms

• Acanthosis nigricans, Alzheimer's disease, angina, autoimmune disease, beta cells, capillaries, carbohydrate, cortisol, Coxsackie B, c-reactive protein, depression, DI, diabetes insipidus, diabetes mellitus, diabetes type 1, diabetes type 2, diabetic complications, diabetic ketoacidosis, diabetic nephropathy, diabetic neuropathy, diabetic retinopathy, DM, enterovirus, fasting blood glucose test, fructosamines, gastroparesis, gestational diabetes, glucagon, glucose, glycemic, hemolysis, hyperglycemia, hyperglycemic hyperosmolar non-ketotic syndrome, hyperinsulinemia, hyperlipidemia, hypertension, hypoglycemia, IFG, IGT, impaired fasting glucose, impaired glucose tolerance, insulin, insulin resistance syndrome (IRS), insulinoma, islet cells, ketoacidosis, ketones, lipemia, metabolic syndrome, microangiopathy, nesidioblastosis, OGTT, oral glucose tolerance test, pancreas, peripheral neuropathy, polydipsia, polyphagia, polyuria, prediabetes, random blood glucose test, stroke, subcutaneously, syndrome X.

Background

• Diabetes, also known as diabetes mellitus, is a chronic health condition where the body is unable to produce enough insulin and properly break down sugar (glucose) in the blood. Glucose comes from food and is used by the cells for energy. Glucose is also made in the liver. Insulin is a hormone produced by the pancreas, a large gland behind the stomach. Insulin is needed to move sugar into the cells where it can be used for energy needed for body processes.
• After digestion of food, glucose passes into the bloodstream. For glucose to get into cells, insulin must be present. Throughout the pancreas are clusters of cells called the islets of Langerhans. Islets are made up of several types of cells, including beta cells that make insulin. When normal individuals eat, beta cells in the pancreas automatically produce the right amount of insulin to move glucose from blood into the cells of the body. In individuals with diabetes, however, the pancreas either produces little or no insulin, or the cells do not respond appropriately to the insulin that is produced. Glucose builds up in the blood, overflows into the urine, and passes out of the body in the urine. Thus, the body loses its main source of fuel even though the blood contains large amounts of glucose. Glucose may also interact with cells, especially those in very narrow blood vessels. This process may lead to neuropathies and decreased immune function.
• With Type 1 diabetes, the body does not make any insulin. With Type 2 diabetes, the more common type, the body does not make or use insulin properly. Without enough insulin, glucose stays in the blood and causes a condition called hyperglycemia, or high blood sugar levels.
• Diabetes is associated with long-term complications that affect almost every part of the body. The disease often leads to blindness, heart and blood vessel disease, stroke, kidney failure, amputations, and nerve damage. Uncontrolled diabetes can complicate pregnancy, and birth defects are more common in babies born to women with diabetes. Pregnant women can temporarily develop gestational diabetes, a type of diabetes that begins late in pregnancy.
• In 2007, an estimated 20.8 million children and adults in the United States, or 7% of the population, had diabetes mellitus. An estimated 14.6 million have been diagnosed with diabetes (both type 1 and type 2), while 6.2 million people (or nearly one-third) are unaware that they have type 2 diabetes.
• Diabetes is widely recognized as one of the leading causes of death and disability in the United States. The U.S. Centers for Disease Control (CDC) recognizes diabetes as the 6^th leading cause of death in the United States, with over 72,000 deaths in 2004.

Types and Causes of Diabetes

• Pre-diabetes: Individuals with pre-diabetes have blood glucose levels that are higher than normal but not high enough for a diagnosis of diabetes. This condition raises the risk of developing type 2 diabetes, heart disease, and stroke.
• Pre-diabetes is also called impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), depending on the test used to diagnose it. Some individuals have both IFG and IGT. In IFG, glucose levels are a little high when it has been several hours after eating. In IGT, glucose levels are a little higher than normal right after eating.
• Pre-diabetes is becoming more common in the United States, according to estimates provided by the U.S. Department of Health and Human Services (DHHS). Many individuals with pre-diabetes go on to develop type 2 diabetes within 10 years.
• Type 1 diabetes: Type 1 diabetes is an autoimmune disease. An autoimmune disease results when the body's immune system that fights infection begins to attack a part of the body. In diabetes, the immune system attacks and destroys the insulin-producing beta cells in the pancreas. The pancreas then produces no insulin. An individual with type 1 diabetes must take insulin daily for proper blood sugar control.
• It is not known exactly what causes the body's immune system to attack the beta cells, but researchers believe that autoimmune, genetic, viral, and environmental factors may be involved. Type 1 diabetes accounts for about 5-10% of cases of diagnosed diabetes in the United States. Type 1 diabetes develops most often in children and young adults but can appear at any age.
• Symptoms of type 1 diabetes usually develop over a short period, although beta cell destruction can begin years earlier. Symptoms may include increased thirst and urination, constant hunger, weight loss, blurred vision, and extreme fatigue. If not diagnosed and treated with insulin, a person with type 1 diabetes can develop a condition called diabetic ketoacidosis or a low blood pH due to the accumulation of ketones in the blood. Diabetic ketoacidosis may lead to a coma if not treated appropriately.
• Type 2 diabetes: The most common form of diabetes is type 2 diabetes. About 90-95% of individuals with diabetes have type 2. This form of diabetes is most often associated with older age, obesity, family history of diabetes, previous history of gestational diabetes (diabetes developed during pregnancy), physical inactivity, and certain ethnicities. About 80% of individuals with type 2 diabetes are overweight.
• Type 2 diabetes is increasingly being diagnosed in children and adolescents. When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin, but for unknown reasons the body cannot use the insulin effectively. This is a condition called insulin resistance. After several years of making extra insulin because the body cannot use it efficiently, insulin production decreases. The result is the same as for type 1 diabetes - glucose builds up in the blood and the body cannot make efficient use of its main source of fuel.
• Insulin also normally shuts down the ability of the liver to produce glucose. In individuals with type 2 diabetes, however, insulin is unable to inhibit sugar production in the liver, either because the pancreas is not producing enough insulin or because insulin's signal cannot be detected.
• The symptoms of type 2 diabetes develop gradually. Their onset is not as sudden as in type 1 diabetes. Symptoms may include fatigue, frequent urination, increased thirst and hunger, weight loss, blurred vision, and slow healing of wounds or sores. Some individuals have no symptoms.
• Type 2 diabetes can be treated with diet, exercise, and oral prescription medications but may require insulin shots.
• Hyperinsulinemia: Hyperinsulinemia is when an individual has too much insulin in the blood. Hyperinsulinemia is not diabetes, but may lead to type 2 diabetes if not managed appropriately. Hyperinsulinemia is a sign of an underlying problem that is causing the pancreas to secrete excessive amounts of insulin. The most common cause of hyperinsulinemia is insulin resistance, a condition in which the body is resistant to the effects of insulin and the pancreas tries to compensate by making more insulin. Rarely, hyperinsulinemia is caused by a tumor of the insulin-producing cells of the pancreas (insulinoma) or excessive numbers of insulin-producing cells in the pancreas (nesidioblastosis). Hyperinsulinemia may not have signs or symptoms unless it causes low blood sugar (hypoglycemia).
• Metabolic syndrome: Metabolic syndrome, also known as syndrome X or insulin resistance syndrome (IRS), is a set of abnormalities in which type 2 diabetes (insulin resistant) or hyperinsulinemia is almost always present. Insulin resistance causes the tissues to stop responding to insulin. If an individual has insulin resistance, the body will make more and more insulin, but because the tissues do not respond to it, the body will not be able to use glucose (sugar) properly. Insulin resistance often occurs with other health problems, such as diabetes, high cholesterol, high blood pressure and heart attack. When a person has many of these problems together, doctors call it insulin resistance syndrome. Metabolic syndrome includes hypertension (high blood pressure), hyperlipidemia (high cholesterol), large waist size, an increase in cortisol (stress hormone), abnormalities in blood clotting, and an increase in inflammatory responses. A high rate of cardiovascular disease is associated with the metabolic syndrome.
• Diabetes insipidus: Diabetes insipidus (DI) is a rare disease, not widely diagnosed, in which the kidneys produce abnormally large volumes of dilute urine. DI is caused by a deficiency of the antidiuretic hormone (ADH), also known as vasopressin. DI can also be caused by insensitivity of the kidneys to ADH. DI is different from diabetes mellitus (DM), which involves insulin problems and high blood sugar. The symptoms can be similar, such as extreme thirst and frequent urination. However, DI is related to how the kidneys handle fluids. Urine and blood tests can determine which is present.
• Gestational diabetes: Some women develop gestational diabetes late in pregnancy. Although this form of diabetes usually disappears after the birth of the baby, women who have had gestational diabetes have a 20-50% chance of developing type 2 diabetes within 5-10 years. Maintaining a reasonable body weight and being physically active may help prevent development of gestational diabetes turning into type 2 diabetes.
• As with type 2 diabetes, gestational diabetes occurs more often in some ethnic groups and among women with a family history of diabetes. Gestational diabetes is caused by the hormones of pregnancy or a shortage of insulin. Women with gestational diabetes may not experience any symptoms. When a woman has diabetes and her blood sugar is poorly controlled and too high, excess amounts of sugar are transported to the baby. Since the baby does not have diabetes, the fetus is able to increase the production of insulin substantially in order to use this extra sugar. This abnormal cycle of events can result in several complications including macrosomia (large baby, over 8.8 pounds), neonatal hypoglycemia (low blood sugar), stillbirth, and birth defects (such as brain, spinal cord, or heart conditions).
• The only treatment for gestational diabetes is insulin, as oral anti-diabetic medications can not be used in pregnancy due to the possible risks.
• Maturity-onset diabetes of the young (MODY): Maturity-onset diabetes of the young (MODY) is a type of diabetes that is caused by genetic mutations. MODY may occur during childhood or adolescence, but may be misdiagnosed as Type 1 or Type 2 diabetes, or may be unidentified until the patient is an adult. Research indicates that the genetic mutations responsible for MODY interfere with normal pancreatic secretion of insulin. Currently, six gene mutations have been identified as causative factors for MODY, each of which produce several different forms of MODY, named MODY 1-MODY 6. Each type of MODY has different signs and symptoms, clinical manifestations, complications, and treatments.
• It has been estimated that 1- 5% of diabetes cases in the United States are MODY. MODY typically presents during a patients 20s, usually before the age of 25. Patients at risk for MODY have a strong family history of diabetes, and/or have developed diabetes before middle age. In contrast to clinical manifestations in other forms of diabetes, MODY patients are typically not overweight, and are sometimes able to be treated with meal planning, oral diabetes medications, or low doses of insulin. It is recommended for the patient to work closely with their healthcare provider to determine the best treatment, based on the specific type of MODY diagnosed.

Risk Factors

• Type 1 diabetes:
• Family history: Having a family history of the disease increases the chance that an individual will develop antibodies to the insulin-making cells (beta cells) in the pancreas. But being genetically predisposed to type 1 diabetes does not mean that the individual will develop diabetes. Only about 10-15% of individuals with type 1 diabetes have a family history of the disease. If the father has the disease, a child has a 6% risk of developing it. If a sibling has the disease, a child has a 5% risk of developing it. If the mother has the disease, a child has a 2% risk of developing it. If an identical twin has the disease, the other twin has a 30% to 50% risk of developing it. If both a parent and one sibling have the disease, a child has a 30% risk of developing it.
• Ethnicity: Caucasian individuals have an increased risk for developing type 1 diabetes compared to African-Americans, Asians, or Latinos.
• Presence of islet cell antibodies in the blood: People who have both a family history of type 1 diabetes and islet cell antibodies in their blood are likely to develop the disease.
• Viral infections during childhood: A child who has certain viral infections, particularly Coxsackie B infections, has a risk almost six times greater of developing type 1 diabetes than children who have not had this type of viral infection. However, this does not mean that the child will definitely develop type 1 diabetes. It is unclear how these infections lead to type 1 diabetes.
• Lack of breastfeeding: Children who have a genetic tendency for type 1 diabetes and stop breastfeeding before three months of age or who are given cow's milk formula before four months of age, have a slightly increased risk for developing type 1 diabetes. Children who have a sibling with diabetes and drink more than two, eight ounce glasses of cow's milk per day during childhood may have a four times greater risk of developing antibodies for type 1 diabetes, increasing the risk of developing the disease. Doctors are uncertain how cow's milk actually plays a role in the development of type 1 diabetes. Insulin in the cow's milk may be a factor.
• Type 2 diabetes:
• Age: The risk of developing type 2 diabetes begins to rise significantly at about age 45, and rises considerably after age 65 years. This may be due to a decrease in exercise, loss of muscle mass, and increased weight. However, type 2 diabetes is increasing dramatically among children, adolescents, and younger adults.
• Family history: The risk of type 2 diabetes increases if a parent or sibling has type 2 diabetes.
• Pregnancy: Developing gestational diabetes increases the risk of developing type 2 diabetes later in life. Also, giving birth to a baby weighing more than nine pounds increases the risk of developing type 2 diabetes. About 3-8% of pregnant women in the United States develop gestational diabetes.
• Inactivity: The less active an individual is, the greater the risk of developing type 2 diabetes. Physical activity helps control weight, uses glucose as energy, and makes cells more sensitive to insulin.
• Pre-diabetes: Pre-diabetes is a condition in which the blood sugar level is higher than normal, but not high enough to be classified as type 2 diabetes. Left untreated, pre-diabetes often progresses to type 2 diabetes. Recent research has shown that some long-term damage to the body, especially the heart and circulatory system, may already be occurring during pre-diabetes. There are 54 million people in the United States who have pre-diabetes.
• Ethnicity: Certain ethnic groups, such as African Americans, Native Americans, Latinos, and Japanese Americans, have a greater risk of developing type 2 diabetes than Caucasians.
• Weight: Being overweight is a primary risk factor for type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. Fat cells actually produce hormones, such as leptin and adiponectin, which decrease insulin tissue sensitivity, potentially leading to diabetes mellitus type 2.
• Metabolic syndrome: Metabolic syndrome, including high blood pressure, high cholesterol levels, and abdominal obesity, increases the chances of developing type 2 diabetes.
• Maturity-onset diabetes of the young (MODY):
• Patients at risk for maturity-onset diabetes of the young (MODY) have a strong family history of diabetes, and/or have developed diabetes before middle age. There is a 50% chance for a child to inherit MODY if either parent has MODY. In the field of genetics, this is called autosomal dominant inheritance. MODY is also referred to as a monogenic form of diabetes, which describes its ability to be inherited by a single pair of genes.

Signs and Symptoms

• Type 1 diabetes:
• Symptoms of type 1 diabetes are often dramatic and come on very suddenly. Type 1 diabetes is usually recognized in childhood or early adolescence, often in association with an illness (such as a virus) or injury. The initial symptoms of type 1 diabetes are: an increased production of urine, excessive thirst, fatigue, tiredness, loss of weight, increased appetite, feeling sick, blurred vision, and infections such as thrush or irritation of the genitals.
• Type 1 diabetics can develop diabetic ketoacidosis. Ketoacidosis is a serious condition where the body has dangerously high levels of ketones. Ketones are substances that are made when the body breaks down fat for energy. Normally, the body gets the energy it needs from carbohydrates. However, stored fat is broken down and ketones are made if the diet does not contain enough carbohydrates to supply the body with sugar (glucose) for energy, or if the body cannot use blood sugar (glucose) properly, as in diabetes. Symptoms of ketoacidosis include nausea and vomiting. Dehydration and often-serious disturbances in blood levels of potassium follow. Without treatment, ketoacidosis can lead to coma and death.
• Type 2 diabetes:
• Symptoms of type 2 diabetes are often subtle and may be attributed to aging or obesity. An individual may have type 2 diabetes for many years without knowing it. Individuals with type 2 diabetes can develop hyperglycemic hyperosmolar non-ketotic syndrome, which is characterized by no or few ketones and high glucose in the blood
• Some individuals who have type 2 diabetes have patches of dark, velvety skin in the folds and creases of their bodies, usually in the armpits and neck. This condition, called acanthosis nigricans, is a sign of insulin resistance.
• If not properly treated, type 2 diabetes can lead to complications such as blindness, kidney failure, heart disease, and nerve damage.
• Maturity-onset diabetes of the young (MODY):
• Maturity-onset diabetes of the young (MODY) may occur during childhood or adolescence, but may be misdiagnosed as Type 1 or Type 2 diabetes, or may be unidentified until the patient is an adult. Individuals with MODY may have little to no symptoms of diabetes, or have only mild symptoms, or may have mild to significant hyperglycemia. MODY patients are typically not overweight, and generally do not have similar risk factors as seen with Type 2 diabetes, such as hypertension (high blood pressure), or hyperlipidemia (elevated serum lipids).
• Many patients with MODY do not have any symptoms of diabetes, and may be diagnosed with high serum glucose while in the process of discovering other disorders. Other symptoms may include increased thirst and urination. It is recommended that if an individual has mild to moderate hyperglycemia identified before the age of 30, a family history of diabetes, and low insulin requirements, that they be tested for MODY.
• Common symptoms of Type 1 and Type 2 diabetes:
• Fatigue: In diabetes, the body is inefficient and sometimes unable to use glucose for fuel. The body switches over to metabolizing fat, partially or completely, as a fuel source. This process requires the body to use more energy. The end result is feeling fatigued or constantly tired.
• Unexplained weight loss: Individuals with diabetes are unable to process many of the calories in the foods they eat. Therefore, they may lose weight even though they eat an apparently appropriate or even excessive amount of food. Losing sugar and water in the urine and the accompanying dehydration also contributes to weight loss.
• Excessive thirst (polydipsia): An individual with diabetes develops high blood sugar levels. The body tries to counteract this by sending a signal to the brain to dilute the blood, which translates into thirst. The body encourages more water consumption to dilute the high blood sugar back to normal levels and to compensate for the water lost by excessive urination.
• Excessive urination (polyuria): Polyuria is frequent urination. Another way the body tries to get rid of the extra sugar in the blood is to excrete it in the urine. This can also lead to dehydration because excreting the sugar carries a large amount of water out of the body along with it.
• Excessive eating (polyphagia): Polyphagia is excessive hunger. If the body is able, it will secrete more insulin in order to try to deal with the excessive blood sugar levels. One of the functions of insulin is to stimulate hunger. Therefore, higher insulin levels lead to increased hunger and eating. Despite increased caloric intake, the person may gain very little weight or may even lose weight.
• Poor wound healing: White blood cells are important in defending the body against bacteria and also in cleaning up dead tissue and cells. High blood sugar levels prevent white blood cells from functioning normally. When these cells do not function properly, wounds take much longer to heal and become infected more frequently.
• Vascular problems: Long-term high blood sugar levels are associated with thickening of blood vessels, which prevents good circulation and body tissues from getting enough oxygen and other nutrients.
• Infections: Certain infection syndromes, such as frequent yeast infections, skin infections, and frequent urinary tract infections, may result from suppression of the immune system by diabetes and by the presence of glucose in the tissues, which allow bacteria to grow well. They can also be an indicator of poor blood sugar control in a person known to have diabetes.
• Altered mental status: Agitation, unexplained irritability, inattention, extreme lethargy, or confusion can all be signs of very high blood sugar, ketoacidosis, hyperosmolar hyperglycemia nonketotic syndrome, or hypoglycemia (low sugar). These merit the immediate attention of a medical professional. Call a healthcare provider or 911.
• Blurry vision: The primary cause of legal blindness in the working population of the United States today is diabetes mellitus. Blurry vision is not specific for diabetes but is frequently present with high blood sugar levels.

Complications

• Diabetes mellitus (diabetes) can affect many major organs in the body, including the heart, blood vessels, nerves, eyes, and kidneys. Keeping blood sugar levels close to normal most of the time can dramatically reduce the risk of these complications.
• Short-term complications:
• Short-term complications of diabetes, such as a high blood sugar level, require immediate care. Left untreated, these conditions can cause seizures and loss of consciousness (coma).
• Hyperglycemia: Hyperglycemia is a condition of high blood sugar levels. Blood sugar levels can rise for many reasons, including eating too much, stress, or not taking enough insulin or medications. It is important to check blood sugar levels often and watch for signs and symptoms of high blood sugar, including frequent urination, increased thirst, dry mouth, blurred vision, fatigue, and nausea. If hyperglycemia is present, adjustment to meal plans, medications, or both may be necessary. If blood sugar levels are persistently above 250 mg/dL, consulting a doctor immediately is recommended by healthcare providers. Diabetic hyperosmolar syndrome, a life-threatening condition in which sky-high blood sugar causes blood to become thick and syrupy, may be present.
• Diabetic ketoacidosis: Diabetic ketoacidosis is characterized by high levels of ketones in the blood. If the cells are starved for energy, the body may begin to break down fat. This produces toxic substances known as ketones. It is important to watch for loss of appetite, nausea, vomiting, fever, stomach pain, and a sweet, fruity smell on the breath, especially if the blood sugar level has been consistently higher than 250 milligrams/deciliter. Diabetic ketoacidosis is more common in type 1 diabetes than type 2.
• Hypoglycemia: Hypoglycemia is a condition of low blood sugar. If blood sugar levels drop below the target range, it is known as low blood sugar. Blood sugar levels can drop for reasons including skipping a meal, getting more physical activity than normal, or taking too much diabetic medication. It is important to check blood sugar levels regularly and to watch for early signs and symptoms of low blood sugar, including sweating, shakiness, weakness, hunger, dizziness, and nausea. Later signs and symptoms include slurred speech, drowsiness, and confusion. If signs or symptoms of low blood sugar are present, it is recommended by healthcare providers to eat or drink something that will quickly raise blood sugar levels, such as fruit juice, glucose tablets, hard candy, or regular (not diet) soda. If consciousness is lost, a family member or close contact may need to give an emergency injection of glucagon, a hormone that stimulates the release of sugar into the blood. Glucagon is a medication that is prescribed to some individuals with blood sugar regulation problems.
• Long-term complications:
• Long-term complications of diabetes develop gradually. The earlier the individual develops diabetes and the less controlled the blood sugar levels are, the higher the risk of complications. Eventually, diabetes complications may be disabling or even life-threatening.
• Heart and blood vessel disease: Diabetes dramatically increases the risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke, narrowing of the arteries (atherosclerosis), and high blood pressure. According to the American Heart Association, approximately 75% of individuals who have diabetes die of some type of heart or blood vessel disease. Diabetic microangiopathy is the damage to very small blood vessels due to high blood sugar levels. Microangiopathy causes the walls of very small blood vessels (capillaries) to become so thick and weak that they bleed, leak protein, and slow the flow of blood. Diabetics may develop microangiopathy with thickening of capillaries in many areas including the eyes, feet, legs, and kidneys.
• Diabetic neuropathy: Diabetic neuropathy, or nerve damage, occurs due to excess blood sugar levels that can injure the walls of the tiny blood vessels (capillaries) that nourish the nerves, especially in the legs. Diabetic neuropathy can cause tingling, numbness, burning, or pain that usually begins at the tips of the toes or fingers and over a period of months or years gradually spreads upward. Left untreated, the individual can lose all sense of feeling in the affected limbs. Diabetic neuropathy is a common cause of limb amputations. The injuries to the skin occur and are not felt, due to neuropathy, until infection progresses too far to save the tissue, especially the toes and feet. Damage to the nerves that control digestion can cause problems with nausea, vomiting, diarrhea, or constipation. For men, erectile dysfunction may also occur as a result of poor blood flow to the penis and nerve damage, both caused by diabetes.
• Diabetic nephropathy: Diabetic nephropathy causes kidney damage and is a complication of diabetes that is caused by uncontrolled high blood sugar. High blood sugar damages the filtering system of the kidneys. Over time, the damage can lead to kidney failure. Diabetic nephropathy is the most common cause of kidney failure in the United States. Severe damage can lead to kidney failure or irreversible end-stage kidney disease, requiring dialysis or a kidney transplant.
• Eye damage: Chronic high blood sugar levels damage sensitive blood vessels in the eye, resulting in blurry vision and vision damage. Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially leading to blindness. The primary cause of legal blindness in the working population of the United States today is diabetes mellitus. Diabetes also increases the risk of other serious vision conditions, such as cataracts and glaucoma.
• Foot ulcers: Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications, including diabetic foot ulcers. Left untreated, cuts and blisters can become serious infections. Severe damage might require toe, foot, or even leg amputation.
• Skin and mouth conditions: Diabetes may leave the individual more susceptible to skin problems, including bacterial infections, fungal infections, and itching. Gum infections also may be a concern, especially if there is a history of poor dental hygiene.
• Osteoporosis: Diabetes may lead to lower than normal bone mineral density, increasing the risk of osteoporosis. Osteoporosis is a disease in which bones become fragile and more likely to break. If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks.
• Alzheimer's disease: Type 2 diabetes may increase the risk of Alzheimer's disease (AD). Alzheimer's disease is a progressive degenerative disease of the nervous system that leads to dementia and eventually death. The more uncontrolled blood sugar levels are, the greater the risk of developing AD. Researchers have found that cardiovascular problems caused by diabetes may contribute to dementia by blocking blood flow to the brain or causing strokes (neurological damage caused by lack of oxygen to the brain). Other possibilities are that too much insulin in the blood leads to brain-damaging inflammation, or lack of insulin in the brain deprives brain cells of glucose.
• Gastroparesis: Gastroparesis is a disorder that affects people with both type 1 and type 2 diabetes. In gastroparesis, movement of food through the stomach slows or stops completely. The muscles in the wall of the stomach work poorly or not at all, preventing the stomach from emptying properly. This can interfere with digestion and cause nausea and vomiting, problems with blood sugar control, and malnutrition.
• Depression: Studies report that individuals with diabetes have a greater risk of depression than individuals without diabetes. Causes underlying the association between depression and diabetes are unclear. Depression may develop because of stress but also may result from the metabolic effects of diabetes on the brain. Studies suggest that people with diabetes who have a history of depression are more likely to develop diabetic complications than those without depression.

Diagnosis

• The main diagnostic test for diabetes is taking a blood test to measure glucose, either when the individual has been fasting (not consuming food) or at other times of the day. Diagnostic tests are also used routinely during pregnancy to identify gestational diabetes. Some diabetes tests require obtaining a blood sample in a doctor's office.
• Depending on the test used, the level of blood glucose can be affected by many factors including: eating or drinking (water is acceptable); taking medications that are known to raise blood sugar levels, such as oral contraceptives, some diuretics (water pills) and corticosteroids; or a recent injury, physical illness, or surgery that may temporarily alter blood sugar levels.
• Fasting blood glucose test: Fasting blood glucose testing checks blood glucose levels after fasting for between 12-14 hours. The individual can drink water during this time, but should strictly avoid any other beverage. Individuals with diabetes may be asked to delay their diabetes medication or insulin dose until the test is completed. This test can be used to diagnose diabetes or pre-diabetes. The fasting plasma glucose (FPG) is the preferred test for diagnosing diabetes due to convenience and is most reliable when done on an empty stomach in the morning, so the presence of food and natural biorhythms do not cause fluctuations in blood sugar levels.
• If the fasting glucose level is 100-125 milligrams/deciliter, the individual has a form of pre-diabetes called impaired fasting glucose (IFG), meaning that the individual is more likely to develop type 2 diabetes but does not have the condition yet. A level of 126 milligrams/deciliter or above, confirmed by repeating the test on another day, means that the individual has diabetes.
• Oral glucose tolerance test: During an oral glucose tolerance test (OGTT), a high-glucose drink is given to the individual. Blood samples are checked at regular intervals for two hours. Glucose tolerance tests are used when the results of the fasting blood glucose are borderline. They are also used to diagnose diabetes in pregnancy (gestational diabetes). This test can be used to diagnose diabetes or pre-diabetes.
• Random blood glucose test: Random blood glucose testing checks blood glucose levels at various times during the day. It does not matter when the individual last ate. Blood glucose levels tend to stay constant in an individual who does not have diabetes. This test, along with an assessment of symptoms, is used to diagnose diabetes.
• Fructosamine testing: Doctors may measure the level of fructosamines, also known as glycated proteins, in serum or plasma to estimate average glucose levels in diabetic patients during the preceding two to three weeks. In diabetic patients, elevated blood glucose levels correlate with increased fructosamine formation. Fructosamine is formed due to a reaction between fructose and amino acid residues of proteins.
• Fructosamine testing is often prescribed when changes are being made in a diabetes treatment plan and information is needed about how well the new plan is working. High levels of vitamin C (ascorbic acid), lipemia (high amount of fat in the blood), hemolysis (breakdown of RBCs), and hyperthyroidism (high levels of thyroid hormones) can interfere with test results.
• Hemoglobin A1c (A1c): Hemoglobin A1c, also known as glycated hemoglobin or glycosylated hemoglobin, indicates an individual's average blood sugar control over the last two to three months. Sugar (glucose) in the bloodstream can become attached to the hemoglobin (the part of the cell that carries oxygen) in red blood cells. This process is called glycosylation. Once the sugar is attached, it stays there for the life of the red blood cell, which is about 120 days. The higher the level of blood sugar, the more sugar attaches to red blood cells. The hemoglobin A1c test measures the amount of sugar sticking to the hemoglobin in the red blood cells. A1c is formed when glucose in the blood binds irreversibly to hemoglobin to form a stable glycated hemoglobin complex. A1C values are not subject to the fluctuations that are seen with daily blood glucose monitoring. Results are given in percentages.
• The American Diabetes Association (ADA) recommends A1c as the best test to find out if an individual's blood sugar is under control over time. The test should be performed every three months for insulin-treated patients, during treatment changes, or when blood glucose is elevated. For stable patients on oral agents, healthcare professionals recommended testing A1c at least twice per year. The ADA currently recommends an A1c goal of less than 7.0%. Studies have reported that there is a 10% decrease in relative risk of microvascular complications, such as diabetic nephropathy or diabetic neuropathy, for every 1% reduction in hemoglobin A1c.
• Gestational diabetes diagnosis: Gestational diabetes is diagnosed based on blood glucose levels measured during the oral glucose tolerance test (OGTT). Glucose levels are normally lower during pregnancy, so the cutoff levels for diagnosis of diabetes in pregnancy are lower. Blood glucose levels are measured before a woman drinks a beverage containing glucose. Then levels are checked one, two, and three hours afterward. If a woman has two blood glucose levels meeting or exceeding any of the following numbers, she has gestational diabetes: a fasting blood glucose level of 95 milligrams/deciliter, a one-hour level of 180 milligrams/deciliter, a two-hour level of 155 milligrams/deciliter, or a three-hour level of 140 milligrams/deciliter.
• Maturity-onset diabetes of the young (MODY) diagnosis: Genetic testing can help diagnose MODY, however, commercially available genetic tests for MODY are not widely available. In a MODY test a blood sample is collected, and the DNA is isolated and analyzed for mutations characteristic of MODY. Genetic testing may be helpful in selecting specific treatments for MODY, depending on the specific genetic mutation involved. Prenatal testing may also be available for diagnosis of MODY. As each type of MODY has different clinical manifestations, it is recommended for the patient to work with their healthcare provider to discuss testing options, to determine whether genetic testing is appropriate, and to decide which genetic tests are necessary.

Treatment

• Treatment for diabetes is a lifelong commitment of monitoring blood sugar, taking insulin if prescribed, maintaining a healthy weight, eating healthy foods, and exercising regularly. The goal is to keep your blood sugar level as close to normal as possible to delay or prevent complications. In fact, tight control of blood sugar levels can reduce the risk of diabetes-related heart attacks and strokes by more than 50%.
• Lifestyle choices:
• If an individual has been diagnosed with diabetes, healthy lifestyle choices, including diet and exercise, are necessary. These healthy choices will help to improve glycemic (blood sugar) control and prevent or minimize complications of diabetes.
• Diet: A healthy diet is important in controlling blood sugar levels and preventing diabetes complications. Eat a consistent, well-balanced diet that is high in fiber, low in saturated fat, and low in concentrated sweets. A consistent diet that includes roughly the same number of calories at about the same times of day helps a healthcare provider prescribe the correct dose of medication or insulin.
• What and how much an individual eats will affect their blood sugar level. Blood sugar is typically highest one to two hours after a meal. One way individuals with diabetes can manage their food intake to keep their blood glucose as close to normal as possible is by calculating how many grams of carbohydrate they eat. Carbohydrates tend to have the greatest effect on blood glucose. The balance between the amount of carbohydrate eaten and the available insulin determines how much the blood glucose level goes up after meals or snacks. To help control your blood glucose, individuals should know which foods contain carbohydrates, the size of a "serving" of different foods, and how many carbohydrate servings to eat each day. A dietician can help individuals work out a dietary plan that is right for them.
• Foods that contain carbohydrates include grains, pasta, and rice; breads, crackers, and cereals; starchy vegetables, including potatoes, corn, peas, and winter squash; legumes such as beans, peas, and lentils; fruits and fruit juices; milk and yogurt; and sweets and desserts. Non-starchy vegetables such as spinach, kale, broccoli, salad greens, and green beans are very low in carbohydrates. Carbohydrate counting can ensure that the right amount of carbohydrate is eaten at each meal and snack.
• The amount of food an individual eats is also closely related to blood glucose control. If an individual eats more food than is recommended on a meal plan, their blood glucose goes up. Although foods containing carbohydrates have the most impact on blood glucose, most foods will have some effect.
• Exercise and weight control: Regular exercise, in any form, can help reduce the risk of developing diabetes. Physical activity moves sugar from the blood into the cells. The more active an individual is, the lower the blood sugar level. Activity can also reduce the risk of developing complications of diabetes such as heart disease, stroke, kidney failure, blindness, and leg ulcers. Exercise will also help to keep blood sugar at a relatively even level and avoid excessively low or high blood sugar levels, which can be dangerous and even life threatening. As little as 20 minutes of walking, three times a week, has a proven beneficial effect. No matter how light or how long, some exercise is better than no exercise. If the individual has complications of diabetes, such as eye, kidney, or nerve problems, they may be limited both in type of exercise and amount of exercise that can safely be performed without worsening the condition. Individuals taking insulin may need to lower the insulin dose before unusual physical activity and exercise. A doctor will help in determining these changes.
• If the individual is overweight, losing even ten pounds can reduce the risk of diabetes. To keep weight in a healthy range, it is recommended by healthcare professionals to focus on permanent changes to eating and exercise habits. A dietitian or a weight modification program can help an individual reach their goal.
• Self-monitoring blood glucose: Checking blood sugar levels frequently, at least before meals and at bedtime, is important in controlling diabetes. Even if the individual takes insulin and eats on a rigid schedule, the amount of sugar in the blood can change unpredictably. Depending on what type of insulin therapy the individual is prescribed, such as single dose injections, multiple dose injections, or an insulin pump, the individual may need to check and record blood sugar levels up to four or more times a day. Careful monitoring is the only way to make sure that the blood sugar level remains within target range. A range of 90-130 milligrams/deciliter before meals is suggested for most individuals with diabetes. A doctor will tell the individual what their target range should be.
• Also, results should be recorded in a logbook that should include insulin or oral medication doses and times, when and what was eaten, when and for how long exercise occurred, and any significant events of the day such as high or low blood sugar levels and how the problem was treated. A daily blood sugar logbook or diary is invaluable to the healthcare team in seeing how the individual is responding to medications, diet, and exercise in the treatment of their diabetes.
• Better equipment now available makes testing blood sugar levels less painful and less complicated. Medicare now pays for diabetic testing supplies, as do many private insurers and Medicaid.
• A doctor or healthcare team will help the individual decide what type of meter to buy. There are more than 20 types of meters available on the market. Examples include Accu-check®, Lifescan®, and OneTouch®. Meters vary in size, weight, test time, blood sample requirements, memory capabilities, and other special features. Most meters can measure blood glucose with only a one- or two-step process. Most also incorporate no-wipe technology, which means users do not have to wipe off excess blood after applying a blood drop to the reagent strip. In addition, many meters now require only a very small amount of blood, thus decreasing the problems with bleeding often seen in advanced diabetics and the elderly and the fear and pain of wounds from the lancet.
• A few of the newer meters offer the option of obtaining blood samples from alternate sites, such as a forearm instead of a fingertip. This can benefit patients who find constant lancet wounds on their fingers difficult to tolerate. The fingers have many nerve endings and are a very painful site for testing, although they are the most reliable. More complex meters have features to aid in identifying trends and to graph reports for more comprehensive data tracking, particularly for patients who test several times a day.
• In order to get an accurate blood glucose result, the individual needs to make sure that the meter is clean, that its code matches the test strips, that their finger is clean, and that an adequate-size drop of blood is being tested. Before pricking the finger, it is recommended by healthcare professionals to wash the hands with warm water, shake the hands below the waist, and squeeze the finger a few times.
• GlucoWatch®: In 2001, the U.S. Food and Drug Administration (FDA) approved the GlucoWatch®, a watch-like device that helps individuals with diabetes measure their blood glucose via tiny electric currents. It draws small amounts of fluid from the skin and measures blood glucose levels three times per hour for up to 12 hours. The GlucoWatch® is considered a first step toward noninvasive, continuous glucose monitoring, but it does have some shortfalls. GlucoWatch® is not considered as accurate as a blood test, so any measurements that fall outside of normal ranges will need to be re-tested with a finger stick test.
• Medications:
• Insulin and oral medications: Many individuals with diabetes can manage their blood sugar with diet and exercise alone, but some need diabetes medications or insulin therapy. In addition to diabetes medications, a doctor might prescribe low-dose aspirin therapy to help prevent heart and blood vessel disease. Aspirin prevents blood from clotting by blocking the production of thromboxane A-2, a chemical that platelets produce that causes them to clump. Aspirin accomplishes this by inhibiting the enzyme cyclo-oxygenase-1 (COX-1) that produces thromboxane A-2.
• Many oral or injected medications can be used to treat type 2 diabetes. Some diabetes medications stimulate the pancreas to produce and release more insulin. Others inhibit the production and release of glucose from the liver, which means the individual needs less insulin to transport sugar into the cells. Still others block the action of stomach enzymes that break down carbohydrates or make tissues more sensitive to insulin.
• The decision about which medications are best depends on many factors, including blood sugar levels and the presence of any other health problems. Medications taken by mouth for diabetes and blood sugar regulation include:
• Sulfonylureas: Sulfonylureas help the pancreas make more insulin, which then lowers blood glucose. They also help the body use the insulin it makes to better lower blood glucose. For these medications to work, the pancreas has to make some insulin. Possible side effects include hypoglycemia (low blood sugar levels), an upset stomach, a skin rash or itching, and weight gain. Examples of sulfonylurea medications include glimepiride (Amaryl®), glyburide (DiaBeta®), chlorpropamide (Diabinese®), acetohexamide (Dymelor®), glipizide (Glucotrol®, Glucotrol XL®), glyburide (Glynase®, Micronase®), tolbutamide (Orinase®), and tolazamide (Tolinase®).
• Biguanides: Biguanides helps lower blood glucose by making sure the liver does not make too much glucose. Biguanides also lowers the amount of insulin in the body. Metformin (Glucophage®) is currently the only biguanide available. Individuals may lose a few pounds when starting metformin. This weight loss can help control blood glucose. Metformin can also improve blood fat and cholesterol levels, which are often not normal if the individual has type 2 diabetes. Metformin does not generally cause blood glucose to get too low (hypoglycemia), unless it is combined with other medications that increase insulin. Metformin may cause nausea and vomiting if more than about two to four alcoholic drinks a week are consumed while on the medication. Other side effects include nausea, diarrhea, headache, and weakness. A metallic taste in the mouth may be noticed.
• Alpha-glucosidase inhibitors: Alpha-glucosidase inhibitors are a class of oral medications for type 2 diabetes that decrease the absorption of carbohydrates from the intestine, resulting in a slower and lower rise in blood glucose throughout the day, especially right after meals. Before carbohydrates are absorbed from food, they must be broken down into smaller sugar particles like glucose by enzymes in the small intestine. One of the enzymes involved in breaking down carbohydrates is called alpha glucosidase. By inhibiting this enzyme, carbohydrates are not broken down as efficiently and glucose absorption is delayed. The alpha-glucosidase inhibitors include acarbose (Precose®) and miglitol (Glyset®).
• Thiazolidinediones: Thiazolidinediones help make the cells more sensitive to insulin. The insulin can then move glucose more efficiently from the blood into the cells for energy. Side effects of these medications may include weight gain, anemia (less red blood cells which causes the blood to carry less oxygen than normal), and edema (fluid accumulation). More serious side effects include liver damage and chronic heart failure. A doctor will monitor the individual's liver function while taking thiazolidinediones. Examples of thiazolidinediones includes pioglitazone (Actos®) and rosiglitazone (Avandia®).
• Meglitinides: Meglitinides helps the pancreas make more insulin right after meals, which lowers blood glucose. A doctor might prescribe a meglitinide medication by itself or with metformin (Glucophage®) if one medicine alone does not control blood glucose levels. Possible side effects of meglitinides include hypoglycemia (low blood sugar) and weight gain. Examples include repaglinide (Prandin®).
• D-phenylalanine derivative: D-phenylalanine derivatives helps the pancreas make more insulin quickly and for a short time. Then the insulin helps lower blood glucose after eating a meal. These medications may cause blood glucose levels to drop too low. Doctors will check liver function while taking d-phenylalanine derivatives. An example of a d-phenylalanine derivative is nateglinide (Starlix®).
• DPP-4 inhibitor: DPP-4 (dipeptidyl-peptidase 4) inhibitors enhance the body's own ability to control blood sugar levels, increase insulin when blood sugar is high, especially after eating, and reduce the amount of sugar made by the liver after eating. Sitagliptin (Januvia®) is currently the only DPP-4 inhibitor available. Side effects of DPP-4 inhibitors include a runny or stuffy nose, sore throat, headache, nausea, stomach pain, or diarrhea.
• Exenatide (Byetta®): Exenatide (Byetta®) is an injectable drug that reduces the level of sugar (glucose) in the blood. It is used for treating type 2 diabetes. Exenatide belongs in a class of drugs called incretin mimetics because these drugs mimic the effects of incretins. Incretins, such as human-glucagon-like peptide-1 (GLP-1), are hormones that are produced and released into the blood by the intestine in response to food. GLP-1 increases the secretion of insulin from the pancreas, slows absorption of glucose from the gut, and reduces the action of glucagon. Glucagon is a hormone that increases glucose production by the liver. All three of these actions reduce levels of glucose in the blood. In addition, GLP-1 reduces appetite. Exenatide is a synthetic (man-made) hormone that resembles and acts like GLP-1. In studies, exenatide-treated patients achieved lower blood glucose levels and experienced weight loss. Exenatide was approved by the U.S. Food and Drug Administration (FDA) in May 2005.
• Combination medications: Some anti-diabetic medications may be combined to provide glucose and insulin control. An example of a combination drug is glyburide combined with metformin (Glucovance®). Side effects of combination drugs are similar to those associated with the individual drugs in the product.
• Insulin: Insulin is a naturally-occurring hormone secreted by the pancreas. Insulin is required by the cells of the body in order for them to remove and use glucose from the blood. Insulin may need to be taken by type 1 and type 2 diabetics. Because stomach enzymes interfere with insulin taken by mouth, insulin must be injected or inhaled. Often, insulin is injected using a fine needle and syringe or an insulin pen injector (a device that looks like an ink pen, except the cartridge is filled with insulin).
• Individuals with diabetes mellitus have an inability to take up and use glucose from the blood and, as a result, the glucose level in the blood rises. In type 1 diabetes, the pancreas cannot produce insulin. Therefore, insulin therapy is needed. In type 2 diabetes, individuals produce insulin, but cells throughout the body do not respond normally to the insulin. Nevertheless, insulin also may be used in type 2 diabetes to overcome the resistance of the cells to insulin. By increasing the uptake of glucose by cells and reducing the concentration of glucose in the blood, insulin prevents or reduces the long-term complications of diabetes, including damage to the blood vessels, eyes, kidneys, and nerves. Insulin is administered by injection under the skin (subcutaneously). The subcutaneous tissue of the abdomen is preferred because absorption of the insulin is more consistent from this location than subcutaneous tissues in other locations.
• There are several types of insulin, classified by how soon and how long they act. It is helpful to know when the insulin starts to work, its peak (when the insulin is working its hardest), and the duration (how long the insulin works). Premixed combinations of slower- and fast-acting insulin are also available. Depending on the individual's needs, a doctor may prescribe a mixture of insulin types to use throughout the day and night. Insulin medications can be made from bovine, porcine, and recombinant human insulin sources. However, in the United States, bovine-tissue derived insulin is no longer available as of 1999, due to U.S. Food and Drug Administration (FDA) concerns over the possible transmission of bovine spongiform encephalopathy (also known as mad-cow disease), and most porcine derived formulations have been discontinued as well. Nearly all insulin on the market today is now produced from bacteria and is identical to human insulin.
• Regular (rapid onset of action, short duration of action) and NPH (slower onset of action, longer duration of action) human insulin are the most commonly-used preparations. Regular insulin has an onset of action (begins to reduce blood sugar) within 30 minutes of injection, reaches a peak effect at one to three hours, and has effects that last six to eight hours. NPH insulin is insulin with an intermediate duration of action. It has an onset of action starting about two hours following injection. It has a peak effect 4-12 hours after injection and aduration of action of 18-26 hours.
• Lente insulin is also insulin with an intermediate duration of action. It has an onset of action two to four hours after injection, a peak activity 6-12 hours after injection, and aduration of action of 18-26 hours. Ultralente insulin is long-acting insulin with an onset of action four to eight hours after injection, a peak effect 10-30 hours after injection, and aduration of action of more than 36 hours.
• An ultra rapid-acting insulin, insulin lispro (Humalog®), is a chemically-modified, natural insulin. When compared to regular insulin, insulin lispro has a more rapid onset of action, an earlier peak effect, and a shorter duration of action. It reaches peak activity 0.5-2.5 hours after injection. Therefore, insulin lispro should be injected 15 minutes before a meal as compared to regular insulin, which is injected 30-60 minutes before a meal.
• Insulin aspart (Novolog®) and insulin glargine (Lantus®) are both human insulins that have had their chemical composition slightly altered. The chemical changes provide insulin aspart with a faster onset of action (20 minutes) and a shorter duration of action (three to five hours) than regular human insulin. It reaches peak activity one to three hours after injection. Insulin glargine has a slower onset of action (70 minutes) and a longer duration of action (24 hours) than regular human insulin. Its activity does not peak.
• Premixed insulins are a combination of specific proportions of intermediate-acting and short-acting insulin in one bottle or insulin pen (the numbers following the brand name indicate the percentage of each type of insulin). Examples of premixed insulins include Humalog mix 75/25, Novolog 70/30, Novolin 70/30, and Humulin 70/30.
• Healthcare professionals recommend storing unopened bottles of insulin in the refrigerator; also, insulin should not be used after the expiration date. Insulin should not be frozen. Store bottles that are being used at room temperature (59-86 degrees Fahrenheit) for 28-30 days. Discard after 30 days. Avoid exposing the bottles to temperature extremes (less than 36 degrees Fahrenheit or more than 86 degrees Fahrenheit). Regular insulin should not be used if it becomes cloudy in appearance. NPH insulin should not be used if it becomes clumped or crystallized or if the bottle becomes frosted. Make sure that dosages are rechecked whenever changing insulin. Get guidance from a healthcare professional before mixing insulins.
• Insulin pump: An insulin pump also may be an option. The pump is a device about the size of a cell phone worn on the outside of the body. A tube connects the reservoir of insulin to a catheter that is inserted under the skin of the abdomen. The pump is programmed to dispense specific amounts of insulin automatically. It can be adjusted to deliver more or less insulin depending on meals, activity level, and blood sugar level.
• Inhaled insulin: Inhaled insulin (Exubera®) is also available. Inhaled insulin is a powdered form of insulin that is rapid acting, usually taken before a meal. It replaces only short-acting forms of injectable insulin, not the longer acting (basal) insulin that may be required as part of a diabetes treatment plan. Inhaled insulin is not approved for anyone younger than 18 and should not be used by individuals who smoke or who have given up cigarettes within the past six months. However, it is considered safe for individuals who live with smokers. Exubera® is not recommended for individuals with asthma, bronchitis, emphysema, or any form of active lung disease. Baseline tests for lung function are recommended by healthcare providers before starting treatment, after the first six months of treatment, and every year thereafter, even if no pulmonary symptoms such as lung or breathing problems exist.
• Surgery:
• Pancreas transplant: Many individuals with type 1 diabetes can manage their disease by following a diet and exercise plan, monitoring blood glucose levels, and using insulin injections. But for some individuals, this is a difficult task, resulting in a number of serious short- and long-term complications. A pancreas transplant is the closest thing to restoring normal pancreas function. A pancreas transplant is not the best option for all people with type 1 diabetes, however, and is primarily recommended for individuals with kidney failure.
• Pancreas transplants pose serious health risks and are not always successful. The individual will need to take immune-suppressing drugs, such as cyclosporine (Sandimmune®), to prevent organ rejection. These drugs can have serious side effects, including a high risk of infection and organ injury. Because the side effects can be more dangerous than the diabetes, pancreas transplants are usually reserved for individuals whose diabetes cannot be controlled or those who have serious complications.
• Other surgeries: Islet transplantation is an experimental procedure where islets (special cells in the pancreas that make insulin) are taken from the pancreas of a deceased healthy organ donor. The islets are purified, processed, and transferred into the individual with type 1 diabetes. Once implanted, the beta cells in these islets begin to make and release insulin. Researchers hope that islet transplantation will help people with type 1 diabetes live without daily injections of insulin. Stem cell transplants may also offer help to those suffering from type 1 diabetes, but the benefits are controversial in the United States.

Integrative Therapies

• Strong scientific evidence:
• Alpha-lipoic acid: Many studies have shown that ALA may improve blood sugar levels among patients with type 2 diabetes. Higher-quality studies are needed to provide more definitive answers in the future.
• Avoid if allergic to ALA. Use cautiously with diabetes and thyroid diseases. Avoid with thiamine deficiency or alcoholism. Avoid if pregnant or breastfeeding.
• Good scientific evidence:
• Beta-glucan: Beta-glucan is a soluble fiber derived from the cell walls of algae, bacteria, fungi, yeast, and plants. It is commonly used for its cholesterol-lowering effects. There are several human trials supporting the use of beta-glucan for glycemic (blood sugar) control in patients with diabetes. Although early evidence is promising, additional study is needed before a firm recommendation can be made.
• Avoid if allergic or hypersensitive to beta-glucan. When taken by mouth, beta-glucan is generally considered safe. Use cautiously with AIDS or AIDS-related complex (ARC). Avoid using particulate beta-glucan. Avoid if pregnant or breastfeeding.
• Chromium: Chromium has been studied in the treatment of hypoglycemia (low blood sugar). More research is needed in this area.
• Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, and stroke and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.
• Ginseng: Several studies report a blood sugar-lowering effect of American ginseng (Panax quinquefolium) in individuals with type 2 diabetes and hyperglycemia. Future research is needed to evaluate long-term efficacy of American ginseng compared to standard oral hypoglycemic drugs.
• Ginseng may increase the effects of blood sugar lowering medications, including insulin. Avoid ginseng with a known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.
• Gymnema: Preliminary human research reports that gymnema (Gymnema sylvestre) may be beneficial in patients with type 1 diabetes mellitus or type 2 diabetes mellitus. Further studies of dosing, safety, and effectiveness are needed before a strong recommendation can be made.
• Gymnema may increase the effects of blood sugar lowering medications, including insulin. Gymnema may alter the ability to detect sweet tastes. Avoid if allergic or sensitive to plants in the Asclepiadaceae (milkweed) family. Use cautiously with prescription drugs that may lower blood sugar levels. Dosing adjustments may be necessary.
• Stevia: Stevia (Stevia rebaudiana) has been widely used for diabetes in South America and animal studies have had promising results. Studies report decreases in plasma glucose when stevia was taken in normal volunteers, but conclusive evidence of effectiveness when used for diabetes or hyperglycemia is currently lacking. Additional study is needed in this area.
• Stevia may increase the effects of blood sugar-lowering medications, including insulin. Avoid if allergic or hypersensitive to the daisy family (Asteraceae/Compositae) including plants like ragweed, chrysanthemums, marigolds, and many other herbs. Use cautiously with hypotension (high blood pressure), hypocalcemia (calcium deficiency), and hypoglycemia (low blood sugar). Avoid with impaired kidney function or other kidney diseases. Avoid if pregnant or breastfeeding.
• Unclear or conflicting scientific evidence:
• Acupuncture: The practice of acupuncture originated in China 5,000 years ago. Today it is widely used throughout the world and is one of the main pillars of Chinese medicine. Although preliminary results are promising, there is a lack of well-designed studies to determine the effect of acupuncture on diabetes.
• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, or with agents that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, and neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary diseases (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
• Alfalfa: A small number of animal studies report reductions in blood sugar levels following ingestion of alfalfa (Medicago sativa). Human data are limited, and it remains unclear if alfalfa can aid in the control of sugar in patients with diabetes or hyperglycemia.
• Avoid if allergic to alfalfa, clover, or grass. Avoid with a history of lupus. Avoid before any surgery/dental/diagnostic procedures that may have a risk of bleeding, and avoid use immediately after these procedures. Use cautiously with stroke, hormone conditions (breast tenderness, breast cancer, ovarian cancer, menstrual problems), diabetes, hypoglycemia, thyroid disease, gout, blood clots, seizures, liver disease, or kidney disease. Use cautiously with blood sugar-altering medications, aspirin or any aspirin products, ibuprofen, and blood-thinners (like warfarin). Use cautiously if operating heavy machinery or driving. Alfalfa may be contaminated with dangerous bacteria (like E. coli, Salmonella, Listeria). Avoid if pregnant or breastfeeding.
• Aloe: Transparent gel from the pulp of the meaty leaves of Aloe vera has been used topically for thousands of years to treat wounds, skin infections, burns, and numerous other dermatologic conditions. Dried latex from the inner lining of the leaf has traditionally been used as an oral laxative. Although some preliminary research for using aloe in type 2 diabetes is positive, study results are mixed. More research is needed to explore the effectiveness and safety of aloe in diabetics.
• Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Avoid injecting aloe. Avoid applying to open, surgical wounds or pressure ulcers. Avoid taking by mouth with diarrhea, bowel blockage, intestinal diseases, bloody stools, hepatitis, a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.
• Amylase inhibitors: Amylase inhibitors have been shown to decrease levels of blood glucose. Large, well-designed studies are needed before a firm recommendation can be made for patients with diabetes.
• Amylase inhibitors are generally considered safe. Avoid if allergic or sensitive to amylase inhibitors, wheat, or legumes. Use cautiously with diabetes or hypoglycemia or if taking agents that lower blood sugar. Use cautiously with digestive, kidney, or liver problems. Use cautiously if pregnant or breastfeeding.
• Arabinogalactan: Arabinogalactan's effects on blood sugar and insulin levels have been studied. In people without diabetes, it has not been shown to affect these levels. Additional research is needed for patients with hyperglycemia.
• Avoid if allergic or sensitive to arabinogalactan or larch. People who are exposed to arabinogalactan or larch dust may have irritation of the eyes, lungs, or skin. Use cautiously in people with diabetes, digestive problems, or immune system disorders, and in people who consume a diet that is high in fiber or low in galactose. Arabinogalactan should not be used during pregnancy or breastfeeding.
• Arabinoxylan: Altering the outer shell of rice bran using enzymes from Hyphomycetes mycelia mushroom extract produces the compound arabinoxylan. The product called MGN-3 (or BioBran® in Japan) is a complex containing arabinoxylan as a major component. Although preliminary research is positive, there is currently a lack of scientific evidence investigating the role of arabinoxylan in patients with type 2 diabetes. More study is needed.
• Use cautiously if elderly or with kidney dysfunction. Use cautiously with diabetes. Avoid if pregnant or breastfeeding. Users of MGN-3 should be aware of other constituents (cornstarch, dextrin, tricalcium phosphate, silicon dioxide). Patients with allergies to other constituents should not take MGN-3.
• Arginine: Arginine, or L-arginine, is considered a semi-essential amino acid because although it is normally synthesized in sufficient amounts by the body, supplementation is sometimes required. Early studies in humans suggest that arginine supplements may decrease the severity of type 1 or type 2 diabetes. Large, well-designed studies are needed to understand this relationship.
• Avoid if allergic to arginine, with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control blood sugar levels.
• Ashwagandha: Based on early study, ashwagandha (Withania somnifera) may decrease blood sugar levels in patients with type 2 diabetes. Additional evidence is required.
• Avoid if allergic or hypersensitive to ashwagandha products or any of their ingredients. Dermatitis has been reported. There are few reports of adverse effects associated with ashwagandha, but there are few human trials using ashwagandha, and most do not report the doses or standardization/preparation used. Avoid with peptic ulcer disease. Ashwagandha may cause abortion based on anecdotal reports. Avoid if pregnant or breastfeeding.
• Astragalus: Although there is experimental evidence that astragalus (Astragalus membranaceus) alone, and in combination with hypoglycemic medication, has significant hypoglycemic properties, available clinical studies have been poorly designed and results inadequately presented. The clinical data suggest that astragalus-containing herbal remedies plus conventional therapy (oral hypoglycemics) in the treatment of non-insulin dependent diabetes mellitus (NIDDM) are more effective than conventional oral hypoglycemics alone. More research is required in this area.
• Avoid if allergic to astragalus, peas, or any related plants or with a history of Quillaja bark-induced asthma. Avoid with aspirin or aspirin products or herbs or supplements with similar effects. Avoid with inflammation (swelling) or fever, stroke, transplants, or autoimmune diseases (like HIV/AIDS). Stop use two weeks before surgery/dental/diagnostic procedures with a risk of bleeding and avoid use immediately after these procedures. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders or kidney disorders. Use cautiously with blood-thinners, blood sugar drugs, or diuretics or herbs and supplements with similar effects. Avoid if pregnant or breastfeeding.
• Atkin's diet: The Atkins diet proposes that, in order to lose weight, one should adopt an eating style that radically departs from the U.S. Food and Drug Administration's (FDA) food pyramid. It proposes the elimination of most carbohydrates as a source of energy; in the place of carbohydrates, the diet advocates the significantly increased consumption of fats, including trans fats and hydrogenated oils. Carbohydrate-restricted diets have been shown to have positive effects on serum insulin in both diabetics and non-diabetics and insulin requirements in diabetics. Preliminary evidence suggests that following the Atkins Diet® may result in improvements in metabolic parameters in patients with diabetes. Furthermore, a decrease in HbA1c and medication requirements were noted in type 2 diabetics. Long term safety studies are still required in this field, as well as additional well-designed clinical trials.
• Avoid with severe kidney disease, renal disorders. Avoid if using growth hormone. Use cautiously with mood disorders, such as depression, schizophrenia, or bipolar disorder, as well as individuals using medications for these purposes. Use cautiously in athletes due to potential for muscle cramps, negative feelings towards exercise, fatigue, and hypoglycemia. Use cautiously with osteoporosis, gout, diabetes, menstrual disorders, gastrointestinal disorders, celiac disease, skin conditions, epilepsy, and cardiovascular disease. Use cautiously in malnourished individuals, vegetarians, or individuals with absorption concerns. Use cautiously if taking diuretics, medications that alter cholesterol, medications that alter blood sugar, medications for seizures, steroids, or NSAIDS. Use cautiously in anemic individuals, individuals with thyroid concerns, and in individuals with previous history of stroke or heart attack. Avoid if pregnant or breastfeeding.
• Ayurveda: Several studies have been conducted with various Ayurvedic treatments for diabetes, with mixed or modest results. The traditional antidiabetic remedy Coccinia indica may help improve glucose tolerance in adult-onset diabetes. An herbal tea containing Salacia reticulata (Kothala Himbutu tea) may improve glycemic control and reduce the need for Glibenclamide treatment in patients with type II diabetes mellitus. Drinking an aqueous suspension of the vegetable pulp from the herb Momordica charantia, a bitter vegetable popularly known as Karolla, may reduce serum glucose levels in people with moderate non-insulin dependent diabetes. A traditional Ayurvedic formula called Pancreas Tonic, taken in a powder capsule form, may bring intermediate term glucose control in type II diabetic patients with elevated HbA(1c) levels. The Ayurvedic herb Vijayasar (Pterocarpus marsupium), also called Bijaka, Pitasara, or Pitashalaka, may help modulate blood glucose levels in newly diagnosed or untreated non-insulin dependent diabetes mellitus. In all the above remedies, better-designed trials are needed to more clearly determine safety and effectiveness.
• Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages and medical conditions that require surgery.
• Banaba: Banaba (Lagerstroemia speciosa) is a medicinal plant that grows in India, Southeast Asia, and the Philippines. Preliminary research investigating the effects of banaba on diabetes reports promising results. However, additional research is necessary before a firm conclusion can be made.
• Banaba is generally considered to be safe when taken orally for 15 days for the treatment of type 2 diabetes. Caution should be exercised in patients with known allergy/hypersensitivity to banaba, its constituents or any members of the Lythraceae family. Use cautiously in patients with diabetes since banaba may lower blood sugar. Avoid if pregnant or breastfeeding.
• Barley: Barley (Hordeum vulgare) is a cereal used as a staple food in many countries. It is commonly used as an ingredient in baked products and soup in Europe and the United States. Barley malt is used to make beer and as a natural sweetener called malt sugar or barley jelly sugar. Preliminary evidence suggests that barley meal may improve glucose tolerance and hyperglycemia. This is believed to be due to fermentation of undigested carbohydrates in barley, which decreases hepatic glucose production by up to 30%. Barley products have been shown to have lower glycemic index compared to wheat or rice. Better research is necessary before a firm conclusion can be drawn.
• Avoid if allergic or hypersensitive to barley flour or beer. Barley appears to be well tolerated in non-allergic, healthy adults in recommended doses for short periods of time, as a cereal or in the form of beer. Use cautiously with diabetes, asthma or arrhythmia (irregular heartbeat). Contamination of barley with fungus has occurred. Traditionally, women have been advised against eating large amounts of barley sprouts during pregnancy. Infants fed with a formula containing barley water, whole milk, and corn syrup have developed malnutrition and anemia, possibly due to vitamin deficiencies.
• Beet: Limited available study has evaluated the effect of beets on secretion of gastric hormones in patients with type 2 diabetes following meals. Additional research is needed.
• Use cautiously in patients with a known allergy or hypersensitivity to any part of the beet plant, including the beetroot, beet leaves, beet sugar, or beet fiber, or any other members of the Chenopodiaceae family. Avoid feeding beets and other high-nitrate vegetables to infants under three months of age, as advised by the American Academy of Pediatrics, due to high nitrate content and the risk of nitrate poisoning.
• Berberine: Berberine is a bitter-tasting, yellow, plant alkaloid with a long history of medicinal use in Chinese and Ayurvedic medicine. Berberine is present in the roots, rhizomes, and stem bark of various plants including goldenseal (Hydrastis canadensis). Historically, berberine has been suggested to aid in glycemic regulation. However, the safety and effectiveness of berberine for type 2 diabetes remains unclear. More research is needed in this area.
• Avoid if allergic or hypersensitive to berberine, to plants that contain berberine (Hydrastis canadensis (goldenseal), Coptis chinensis (coptis or goldenthread), Berberis aquifolium (Oregon grape), Berberis vulgaris (barberry), and Berberis aristata (tree turmeric)), or to members of the Berberidaceae family. Avoid in newborns due to potential for increase in free bilirubin, jaundice, and development of kernicterus. Use cautiously with cardiovascular disease, gastrointestinal disorders, hematologic disorders, leucopenia, kidney disease, liver disease, respiratory disorders, cancer, hypertyraminemia, diabetes, or hypotension. Use cautiously in children due to lack of safety information. Use cautiously in individuals with high exposure to sunlight or artificial light. Use cautiously for longer than eight weeks due to theoretical changes in bacterial gut flora. Use cautiously if taking anticoagulants, antihypertensives, sedatives, anti-inflammatories, medications metabolized by CYP P450 3A4 including cyclosporin, or any prescription medications. Avoid if pregnant or breastfeeding.
• Bilberry: Bilberry (Vaccinium myrtillus), a close relative of blueberry, has a long history of medicinal use. Bilberry has been used traditionally in the treatment of diabetes mellitus, and animal research suggests that bilberry leaf extract may lower blood sugar levels. Human research is needed in this area.
• Avoid if allergic to plants in the Ericaceae family or to anthocyanosides (a component of bilberry). Avoid with a history of low blood pressure, heart disease, bleeding, diabetes, blood clots, or stroke. Avoid if pregnant or breastfeeding. Stop use before surgeries or dental or diagnostic procedures involving blood tests.
• Biotin: Biotin is an essential water-soluble B vitamin. In preliminary research, biotin has been reported to decrease insulin resistance and improve glucose tolerance, properties that may be beneficial in patients with diabetes mellitus. However, there is not sufficient human evidence to form a clear conclusion in this area.
• Avoid if hypersensitive to constituents of biotin supplements.
• Bitter melon: Bitter melon (Momordica charantia) has traditionally been used as a remedy for lowering blood glucose in patients with diabetes mellitus. Preliminary study has indicated that bitter melon may decrease serum glucose levels. However, because safety and efficacy have not been established, bitter melon should be avoided by diabetics except under the strict supervision of a qualified healthcare professional, including a pharmacist, with careful monitoring of serum blood sugar.
• Bitter melon may increase the effects of blood sugar lowering medications, including insulin. Avoid if allergic or hypersensitive to bitter melon or members of the Curcurbitaceae (gourd or melon) family, including Persian melon, honeydew, casaba, muskmelon, and cantaloupe. Avoid ingestion of bitter melon seeds or outer rind, due to toxic lectins. Avoid if pregnant or breastfeeding.
• Black tea: Black tea is made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Black tea may lower blood sugar levels. In early study, a combination of black tea and green tea extract did not lower blood sugar levels in patients with type 2 diabetes. However, black tea alone did lower blood sugar and increased insulin levels in healthy patients. Additional research with black tea alone in diabetic patients is needed.
• Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported after caffeine ingestion. Use cautiously with diabetes. Use cautiously if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. If breastfeeding mothers consume black tea, it may lead to anemia, decreased iron metabolism, and irritability in their infants.
• Burdock: Animal research and initial human studies suggest possible blood sugar-lowering effects of burdock (Arctium lappa) root or fruit. However, the available human research has not been well designed, and further study in patients with diabetes is needed.
• Avoid with known allergy to burdock, its constituents, or members of the Asteraceae/Compositae family, including ragweed, chrysanthemums, marigolds, and daisies. Use cautiously with allergies or intolerance to pectin, diabetes, glucose intolerance, electrolyte imbalances, or dehydration. Use cautiously if taking antidiabetic agents, diuretics, or blood thinners. Avoid if pregnant or breastfeeding.
• Chromium: Chromium has been studied for sugar abnormalities in patients with types 1 and 2 diabetes mellitus, as well as at-risk populations. Some studies suggest that taking chromium by mouth may lower blood sugar levels, whereas other studies show no effects. Better studies are needed to provide more definitive answers.
• Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, and stroke and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.
• Chrysanthemum: Based on early study, the chrysanthemum product jiangtangkang may be beneficial for patients with non-insulin dependent diabetes. However, results are mixed and additional studies are needed before a firm recommendation can be made.
• Avoid if allergic or hypersensitive to chrysanthemum, its constituents, or members of the Asteraceae/Compositae family, such as dandelion, goldenrod, ragweed, sunflower, and daisies. Use cautiously if taking medication for gout, cancer, or HIV. Use cautiously with compromised immune systems or if taking immunomodulators. Avoid with photosensitivity or if taking photosensitizers. Avoid large acute or chronic doses of ingested pyrethrin. Avoid pyrethrin with compromised liver function, epilepsy, or asthma. Avoid ocular exposure to pyrethrin. Avoid if pregnant or breastfeeding.
• Cinnamon: Several human studies support the use of cinnamon (Cinnamomum spp.) in type 2 diabetes. More research on the proposed health benefits of cinnamon supplementation is warranted.
• Avoid if allergic or hypersensitive to cinnamon, its constituents, members of the Lauraceae family, or Balsam of Peru. Use cautiously if prone to atopic reactions or if taking cytochrome P450 metabolized agents, anticoagulants (blood thinners), insulin or blood sugar-altering medications, antibiotics, or cardiovascular agents. Avoid if pregnant or breastfeeding.
• Dandelion: There is limited animal research on the effects of dandelion (Taraxacum officinale) on blood sugar levels in animals. Effects in humans with diabetes are not known.
• Avoid if allergic to chamomile, feverfew, honey, yarrow, or any related plants such as aster, daisies, sunflower, chrysanthemum, mugwort, ragweed, or ragwort. Use cautiously with diabetes or bleeding disorders, gastroesophageal reflux disease (GERD), kidney or liver diseases, or a history of stroke or electrolyte disorders. Potassium blood levels should be monitored. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
• Devil's club: The hypoglycemic (blood sugar-lowering) effect is one of many reported uses for devil's club (Oplopanax horridus), which had a traditional use in diabetes and continues to be used for this condition. Although early evidence looks promising, additional high-quality trials are needed to make a firm recommendation.
• Avoid if allergic or hypersensitive to devil's club, its related species or other member of the ginseng (Araliaceae) family. The spines on the stems and leaves may cause an allergic reaction of the skin. Use cautiously with drugs for diabetes. Avoid if pregnant or breastfeeding.
• Evening primrose oil: A small number of laboratory studies suggest that evening primrose (Oenothera biennis) oil may be helpful in diabetes, but more research is needed.
• Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.
• Fenugreek: Fenugreek (Trigonella foenum-graecum) has been found to lower serum glucose levels both acutely and chronically. Although promising, these data cannot be considered definitive, and at this time there is insufficient evidence to recommend either for or against fenugreek for either type 1 diabetes or type 2 diabetes.
• Avoid if allergic to fenugreek or chickpeas. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously with asthma, diabetes, or a history of ulcers or stroke. Avoid if pregnant. Children should not take doses larger than what is commonly found in foods.
• Fig: Preliminary evidence suggests that fig (Ficus carica) has antioxidant properties and may be beneficial in for type 1 diabetes. Additional study is warranted in this area.
• Avoid if allergic/hypersensitive to Fig or members of the Moraceae family. Use cautiously if allergic to kiwi fruit, papaya, avocado, pineapple, and banana. Use cautiously with bleeding disorders and sensitive skin. Use cautiously if pregnant or breastfeeding. Excessive sunlight or ultraviolet light exposure should be avoided while using products that contain fig leaf.
• Flaxseed: Human studies on the effect of flaxseed (Linum usitatissimum) on blood sugar levels report mixed results. Flaxseed cannot be recommended as a treatment for hyperglycemia or diabetes at this time.
• Flaxseed has been well-tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil, or other plants of the Linaceae family. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed with a history of esophageal stricture, ileus, gastrointestinal stricture, or bowel obstruction. Avoid with history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis, or inflammatory bowel disease. Use cautiously with history of a bleeding disorder or with drugs that cause bleeding risk (like anticoagulants and non-steroidal anti-inflammatories (like aspirin, warfarin, Advil®), high triglyceride levels, diabetes, mania, seizures, or asthma. Avoid if pregnant or breastfeeding. Avoid with prostate cancer, breast cancer, uterine cancer or endometriosis. Avoid ingestion of immature flaxseed pods.
• Glucosamine: Early research suggests that glucosamine does not improve blood sugar control, lipid levels, or apolipoprotein levels in patients with diabetes. Additional research is needed.
• Avoid if allergic or hypersensitive to shellfish or iodine. Some reports suggest a link between glucosamine/chondroitin products and asthma. Use caution with diabetes or history of bleeding disorders. Avoid if pregnant or breastfeeding.
• Green tea: Green tea is made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Green tea has a long history of use, dating back to China approximately 5,000 years ago. Green tea, black tea, and oolong tea are all derived from the same plant. More studies are required to determine if green tea and polyphenols have any therapeutic benefit for diabetes prevention or treatment.
• Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease.
• Holy basil: Holy basil (Ocimum sanctum) may have blood sugar-lowering effects and may be useful as an adjunct to dietary therapy and drug treatment in mild to moderate diabetes mellitus. It is unknown whether common culinary basil (Ocimum basilicum) would have similar effects. More research is warranted.
• Avoid if allergic or hypersensitive to Ocimum sanctum, the Lamiaceae family, or any of the components of holy basil. Use cautiously with diabetes, sensitive skin or bleeding disorders. Avoid if pregnant or breastfeeding.
• Honey: Early evidence suggests that honey may help lower blood sugar levels in patients with type 2 diabetes mellitus. Additional study is warranted.
• Avoid if allergic or hypersensitive to honey, pollen, celery, or bees. Honey is generally considered safe in the recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.
• Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. Although hydrotherapy is used by healthcare practitioners for diabetes mellitus support, there is insufficient research in this area.
• Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.
• Jackfruit: Jackfruit (Artocarpus heterophyllus), which refers to both a species of tree and its fruit, is native to southwestern India and Sri Lanka. Jackfruit was reportedly cultivated for food as early as the 6^th Century B.C. in India. Jackfruit leaves may improve high blood sugar or glucose intolerance. However, there is little available research in this area. Additional study is needed.
• Avoid if allergic or hypersensitive to jackfruit (Artocarpus heterophyllus), its constituents, or members of the Moraceae family. Use cautiously with birch pollen allergies, coagulation disorders, and diabetes. Use cautiously if taking anticoagulants, using immunosuppression therapy, or with transplanted tissues. Use cautiously in patients attempting to become pregnant. Avoid if pregnant or breastfeeding.
• Kudzu: Preliminary evidence suggests puerarin, a constituent of kudzu (Pueraraia lobata), may improve insulin resistance in patients with diabetes. Additional study is needed before a firm conclusion can be made.
• Use caution with anticoagulants/anti-platelet and blood pressure lowering agents, hormones, antiarrhythmics, benzodiazepines, bisphosphonates, diabetes medications, drugs that are metabolized by the liver's cytochrome P450 enzymes, mecamylamine, neurologic agents, and methotrexate. Well designed studies on the long-term effects of kudzu are currently unavailable. Avoid if allergic or hypersensitive to Pueraria lobata or members of the Fabaceae/Leguminosae family. Avoid if pregnant or breastfeeding.
• L-Carnitine: It has been suggested that L-carnitine under constant infusion may increase insulin sensitivity in patients with type 2 diabetes mellitus and enhance glucose oxidation. Carnitine may also decrease fasting blood glucose and Lp(a). Additional study is needed before a firm recommendation can be made.
• Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
• Lutein: Lutein is found in high levels in foods such as green vegetables, egg yolk, kiwi fruit, grapes, orange juice, zucchini, squash, and corn. For some commercially available supplements, lutein is extracted from marigold petals. Currently, there is insufficient available evidence to recommend for or against the use of lutein for diabetes mellitus. Preliminary evidence is conflicting.
• Avoid if allergic or hypersensitive to lutein or zeaxanthin. Use cautiously if at risk for cardiovascular disease or cancer. Avoid if pregnant or breastfeeding.
• Maitake: Maitake is the Japanese name for the edible fungus Grifola frondosa, which is characterized by a large fruiting body and overlapping caps. Maitake has been used traditionally both as a food and for medicinal purposes. In animal studies, maitake extracts are reported to lower blood sugar levels. However, little is known about the effect of maitake on blood sugar and diabetes in humans.
• Maitake has not been studied thoroughly in humans, and its effects are not well known. Because it has been used historically as a food, it is thought that low doses may be safe. Avoid if allergic or hypersensitive to Grifola frondosa (maitake) or its constituents. Use cautiously with low blood pressure, diabetes, or low blood sugar. Use cautiously if taking blood pressure medications, antidiabetic agents, immunostimulants, immunosuppressants, or interferons. Avoid if pregnant or breastfeeding.
• Massage: There is early evidence suggesting that parental massage of children with diabetes may benefit blood sugar levels and symptom levels. There is also some evidence suggesting that self-massage of injection sites may increase insulin absorption.
• Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
• Milk thistle: A small number of studies suggest possible improvements of blood sugar control using milk thistle (Silybum marianum) supplementation in cirrhotic patients with diabetes mellitus. More research is needed.
• Avoid if allergic to plants in the aster family (Compositea, Asteraceae), daisies, artichoke, common thistle, or kiwi. Use cautiously with diabetes. Avoid if pregnant or breastfeeding.
• Myrcia: Myrcia is a medium-sized shrub that grows in drier regions of the Amazon and other parts of Brazil. In Brazil, the common name pedra hume caá refers to three species of myrcia plants that are used interchangeably: Myrcia salicifolia, Myrcia uniflorus, and Myrcia sphaerocarpa. Myrcia has been used traditionally by indigenous tribes in the rainforest to treat diabetes. Human study has not confirmed a blood sugar-lowering benefit in patients with type 2 diabetes. More research is warranted.
• Avoid if allergic/hypersensitive to myrcia or members of the myrtle family (Myrtaceae). Use cautiously with diabetes, low blood sugar (hypoglycemia), high blood pressure (hypertension) and overactive thyroid (hyperthyroidism). Avoid with gastrointestinal disorders or obstructions. Avoid if pregnant or breastfeeding.
• Niacin: Niacinamide has been shown to exert a protective effect on pancreatic cell function in animal studies. Further research is warranted to better determine effects in patients with type 1 diabetes and type 2 diabetes.
• Avoid if allergic to niacin or niacinamide. Avoid with history of liver disease or dysfunction, irregular heartbeats (arrhythmia), heart disease, blood clotting, bleeding disorders, asthma, anxiety, panic attacks, thyroid disorders, stomach ulcers, gout or diabetes. Avoid if pregnant or breastfeeding.
• Nopal: Traditionally, nopal, or prickly pear, has been used as both a food and medicine. Animal studies have shown that nopal may reduce blood glucose levels in patients with diabetes. However, the quality of available studies is low and more research needs to be performed.
• Avoid if allergic/hypersensitive to nopal (Opuntia spp.), any of its constituents, or members of the Cactaceae family. Use cautiously if taking medications that alter blood sugar, cholesterol, or blood pressure. Use cautiously with thyroid dysfunction, rhinitis (runny or congested nose), or asthma. Avoid with immunosuppression or impaired liver function. Avoid if pregnant or breastfeeding. The nopal plant should be handled cautiously, as it is covered in long sharp spines and shorter soft-appearing barbs of glochids, which may be painful and difficult to remove once they are imbedded in the skin. It is recommended that oral doses of dried nopal be taken with at least eight ounces (250mL) of water.
• Onion: Limited available clinical study found that fresh onion (Allium cepa) significantly decreased serum glucose levels in patients with diabetes. More research is needed in this area.
• Avoid if allergic or hypersensitive to onion (Allium cepa), its constituents, or members of the Lilaceae family. Use cautiously with hematologic (blood) disorders, diabetes, hypoglycemia (low blood sugar), and hypotension (low blood pressure). Use cautiously if taking anticoagulants or antiplatelets (blood thinners). Avoid in medicinal doses if pregnant or breastfeeding.
• Psychotherapy: Psychotherapy may improve blood sugar control in patients with type 1 diabetes mellitus or type 2 diabetes mellitus. More studies are needed.
• Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression.
• Psyllium: Psyllium, also referred to as ispaghula, is derived from the husks of the seeds of Plantago ovata. Psyllium contains a high level of soluble dietary fiber and is the chief ingredient in many commonly used bulk laxatives, including products such as Metamucil®. Several studies have examined the administration of psyllium with meals or just prior to meals in order to measure effects on hyperglycemia (high blood sugar levels). Better evidence is necessary before a firm conclusion can be drawn.
• Psyllium-containing products may delay gastric emptying time and reduce absorption of some drugs. It is advised that drugs be taken at separate administration times from psyllium to minimize potential interactions (for example, one hour before or a few hours after taking psyllium). Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantains (Plantago lanceolata). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, and previous bowel surgery. Avoid in individuals with repeated or prolonged psyllium exposure who have not manifested allergic or hypersensitive symptoms. Adequate fluid intake is required when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.
• Pycnogenol®: Pycnogenol® is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster spp. atlantica), which is grown in coastal south-west France. Supplementation of Pycnogenol® with conventional treatment for type 2 diabetes may lower glucose levels and improve endothelial function. Further research is needed.
• Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia, or bleeding disorders. Use cautiously if taking hypolipidemics, medications that may increase the risk of bleeding, hypertensive medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.
• Qi gong: There is some evidence that patients with diabetes may benefit from Qi gong. However, more research is needed.
• Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders.
• Red clover: Red clover (Trifolium praetense) has been studied in patients with type 2 diabetes to determine potential benefits in diabetic complications such as high blood pressure and narrowing of the arteries and veins. Further research is needed.
• Red clover is not recommended during pregnancy and breastfeeding due to its estrogen-like activity. Avoid if allergic to red clover or other isoflavones. Use cautiously with hormone replacement therapy (HRT) or birth control pills. Use cautiously with history of a bleeding disorder, breast cancer, or endometrial caner. Use cautiously with drugs that thin the blood. Avoid if pregnant or breastfeeding.
• Red yeast rice: Red yeast rice is the product of yeast (Monascus purpureus) grown on rice, and is served as a dietary staple in some Asian countries. Early human evidence suggests the potential for benefits in patients with diabetes. Additional study is needed.
• There is limited evidence about the side effects of red yeast. Mild headache and abdominal discomfort may occur. Side effects may be similar to those for the prescription drug lovastatin (Mevacor®). Heartburn, gas, bloating, muscle pain or damage, dizziness, asthma, and kidney problems are possible. People with liver disease should not use red yeast products. Avoid if allergic or hypersensitive to red yeast. Use cautiously with bleeding disorders. Avoid if pregnant or breastfeeding.
• Reflexology: Reflexology may help manage type 2 diabetes in some patients. More clinical trials are necessary to determine whether reflexology is an effective treatment for this indication.
• Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.
• Reishi mushroom: Reishi mushroom (Ganoderma lucidum), also known as ling zhi in China, grows wild on decaying logs and tree stumps. Based on animal studies that demonstrated the blood sugar and lipid-lowering activities of Ganoderma lucidum (ling zhi, reishi mushroom), a clinical study was conducted to evaluate the effect of Ganopoly® versus placebo in diabetic patients. The treatment of Ganopoly® slightly decreased the levels of plasma glucose and glycosylated hemoglobin and improved other markers for type 2 diabetes mellitus. Long-term studies with larger sample size are needed to evaluate the efficacy and safety of Ganopoly® in treating diabetic patients.
• Reishi may increase bleeding in sensitive individuals, including those taking blood thinning medications such as aspirin or warfarin (Coumadin®). Avoid if allergic or hypersensitive to any constituents of Ganoderma lucidum or any member of its family. Avoid if pregnant or breastfeeding.
• Safflower: Lipid (fat) abnormalities are commonly associated with type 2 diabetes mellitus, and complications of atherosclerotic disease are frequently associated with diabetes. Safflower (Carthamus tinctorius) oil may negatively affect glucose metabolism due to the extra intake of energy or fat, but these effects may be less pronounced than with use fish oil. Additional research is needed in this area.
• Avoid if allergic/hypersensitive to safflower, Carthamus tinctorius, safflower oil, daisies, ragweed, chrysanthemums, marigolds or any related constituents. Use parenteral safflower oil emulsions cautiously in newborns. Use cautiously if taking anticoagulants (blood thinners) or anti-platelet drugs, immunodepressants, or pentobarbital. Use cautiously with diabetes, hypotension, inadequate liver function, hypercoagulability, and skin pigmentation conditions. Use cautiously if pregnant or breastfeeding.
• Seaweed: Fucus vesiculosus is a brown seaweed that grows on the northern coasts of the Atlantic and Pacific oceans and the North and Baltic seas. Its name is sometimes used for Ascophyllum nodosum, which is another brown seaweed that grows alongside Fucus vesiculosus. These species are often included in kelp preparations along with other types of seaweed. Based on animal research, extracts of bladderwrack may be of benefit for hyperglycemia. However, reliable human studies are currently lacking.
• Seaweeds may alter thyroid hormone levels. Avoid if allergic or hypersensitive to Fucus vesiculosus and iodine. Avoid with history of thyroid disease, bleeding, acne, kidney disease, blood clots, nerve disorders, high blood pressure, stroke, or diabetes. Avoid if pregnant or breastfeeding.
• Soy: Several small studies have examined the effects of soy (Glycine max) supplements on blood sugar in patients with type 2 diabetes. Results are mixed, with some research reporting decreased blood glucose levels, and other trials noting no effects. Overall, research in this area is not well designed and better information is needed before the effects of soy on blood sugar can be clearly described.
• Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. There has been a case report of vitamin D deficiency rickets in an infant nursed with soybean milk (not specifically designed for infants). People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian, or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy.
• Spirulina: The term spirulina refers to a large number of cyanobacteria, or blue-green algae. Spirulina is a rich source of nutrients, containing up to 70% protein, B-complex vitamins, phycocyanin, chlorophyll, beta-carotene, vitamin E, and numerous minerals. Preliminary study of people with type 2 diabetes mellitus reports that spirulina may reduce fasting blood sugar levels after two months of treatment. More research is needed before a firm conclusion can be drawn.
• Avoid if allergic or hypersensitive to spirulina or blue-green algae. Use cautiously with phenylketonuria (a genetic disorder of a liver enzyme that disrupts normal body functions), autoimmune diseases, bleeding disorders, diabetes, and osteoporosis. Use cautiously with products containing the blue-green algae species Anabaena spp., Aphanizomenon spp., and Microcystis spp.; in underweight patients or in those taking antiobesity agents or appetite suppressants; and if consuming a high-protein diet. Avoid in children and if pregnant or breastfeeding.
• Tai chi: Tai chi has been suggested as a possible therapy for improving body composition and improving blood sugar regulation in diabetics. Early results are mixed, and additional study is needed. Tai chi is not recommended over current standard of care for diabetes control.
• Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.
• Taurine: Taurine is a nonessential amino acid-like compound. Taurine is found in high abundance in the tissues of many animals, especially sea animals, and in much lower concentrations in plants, fungi, and some bacteria. It has been proposed that diabetes patients have decreased taurine levels. Currently, there is limited available evidence to support the use taurine in the treatment of type 2 diabetes mellitus.
• Taurine is an amino acid and it is unlikely that there are allergies related to this constituent. However, allergies may occur from multi-ingredient products that contain taurine. Use cautiously in patients with high cholesterol, low blood pressure, coagulation disorders, potential for mania, or epilepsy. Avoid consumption of energy drinks containing taurine, caffeine, glucuronolactone, B vitamins, and other ingredients, then consuming alcohol or exercising. Use cautiously if pregnant or breastfeeding because taurine is a natural component of breast milk.
• Therapeutic touch: There is currently not enough evidence to recommend therapeutic touch as an effective treatment for diabetes. Additional research is needed in this area.
• Therapeutic touch is believed to be safe for most people. Therapeutic touch should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.
• Thymus extract: Preliminary evidence in conventionally treated patients with type I diabetes suggests that a combination of azathioprine and thymostimulin increased remission. Thymostimulin alone had no effect. Additional study is needed in this area.
• Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.
• Vitamin D: Vitamin D is found in numerous dietary sources such as fish, eggs, fortified milk, and cod liver oil. The sun is also a significant contributor to our daily production of vitamin D and as little as 10 minutes of exposure is thought to be enough to prevent deficiencies. It has been reported that infants given calcitriol during the first year of life are less likely to develop type 1 diabetes than infants fed lesser amounts of vitamin D. Other related studies have suggested using cod liver oil as a source of vitamin D to reduce the incidence of type 1 diabetes. There is currently insufficient evidence to form a clear conclusion in this area. In recent studies, adults given vitamin D supplementation were shown to improve insulin sensitivity. Further research is needed to confirm the effects of vitamin D on type 1 diabetes and type 2 diabetes.
• Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.
• Vitamin E: Vitamin E is a fat-soluble vitamin with antioxidant properties. Vitamin E has been proposed for improvement of abnormal sugar levels in diabetes mellitus. Further evidence is necessary.
• Vitamin E may increase bleeding in sensitive individuals, including those taking blood thinning medications such as aspirin or warfarin (Coumadin®). Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Avoid above the recommended daily level in pregnant women and breastfeeding women.
• White horehound: Animal studies and early human studies suggest that white horehound (Marrubium vulgare) may lower blood sugar levels. White horehound has been used for diabetes in some countries, including Mexico. Further well-designed human trials are needed.
• Avoid if allergic or hypersensitive to white horehound or any member of the Lamiaceae family (mint family). White horehound is generally considered safe when used to flavor foods. Use cautiously with diabetes, high/low/unstable blood pressure, high levels of sodium in the blood, irregular heartbeats or gastrointestinal diseases (like ileus, atony or obstruction). Use cautiously with diuretics (drugs that increase urine production). Avoid if pregnant or breastfeeding.
• Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Several preliminary human studies suggest that daily yoga may improve control of blood sugar levels in people with type 2 diabetes when it is added to standard drug therapy. It is not clear if yoga is better than any other form of exercise therapy. Better research is needed.
• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
• Zinc: Diabetic patients typically have significantly lower serum zinc levels compared with healthy controls. Based on clinical study, zinc supplementation may elevate serum zinc levels and improve glycemic control in patients with diabetes. Further research is needed.
• Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.
• Fair negative scientific evidence:
• Coenzyme Q10: Preliminary evidence suggests that CoQ10 does not affect blood sugar levels in patients with type 1 or type 2 diabetes and does not alter the need for diabetes medications.
• Allergy associated with Coenzyme Q10 supplements has not been reported, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin, warfarin, clopidogrel (like Plavix®), or blood pressure, blood sugar, cholesterol, or thyroid drugs. Avoid if pregnant or breastfeeding.
• Garlic: Animal studies suggest that garlic (Allium sativum) may lower blood sugar and increase the release of insulin, but studies in humans do not confirm this effect for type 2 diabetes.
• Garlic may increase bleeding in sensitive individuals, including those taking blood thinning medications such as aspirin or warfarin (Coumadin®). Avoid if allergic or hypersensitive to garlic or other members of the Lilaceae (lily) family (like hyacinth, tulip, onion, leek, chive). Avoid with history of bleeding problems, asthma, diabetes, low blood pressure or thyroid disorders. Stop using supplemental garlic two weeks before dental/surgical/diagnostic procedures and avoid using immediately after such procedures to avoid bleeding problems. Avoid in supplemental doses if pregnant or breastfeeding.
• Niacin: Results from several clinical trials suggest that niacinamide may not be effective for type 1 diabetes mellitus prevention.
• Avoid if allergic to niacin or niacinamide. Avoid with history of liver disease or dysfunction, irregular heartbeats (arrhythmia), heart disease, blood clotting, bleeding disorders, asthma, anxiety, panic attacks, thyroid disorders, stomach ulcers, gout or diabetes. Avoid if pregnant or breastfeeding.
• Omega-3 fatty acids: The available scientific evidence suggests that there are no significant long-term effects of fish oil in patients with diabetes. Most studies in this area are not well designed.
• Caution is advised when taking omega-3 supplements, as numerous adverse effects including an increase in bleeding and drug interactions are possible. Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single 6-ounce meal per week, and in young children to less than 2 ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat 7 ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).
• Prayer: Prayer has not been shown to help prevent or treat diabetes or related health issues. Diabetes should be treated by a qualified healthcare professional using proven therapies.
• Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers.
• Selenium: Some studies have suggested that selenium supplementation may help with type 2 diabetes prevention by improving glucose metabolism. However, results from the Nutritional Prevention of Cancer (NPC) trial showed increased rates of type 2 diabetes in subjects taking selenium supplements. Although diabetes was not the primary focus of this study, these results indicate a potential risk of selenium supplementation that needs further examination.
• Avoid if allergic or sensitive to products containing selenium. Avoid with history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.

Managing and Preventing Diabetes

• Healthy lifestyle choices can help prevent type 2 diabetes and manage type 1 diabetes. Even if diabetes runs in the individual's family, diet and exercise can help prevent the disease. Healthy lifestyle choices can help individuals prevent potentially serious complications of diabetes, such as stroke, nerve damage, and heart disease.
• Dental health: Diabetes may leave individuals prone to gum infections. Healthcare professionals recommend brushing the teeth at least twice daily, flossing the teeth once a day, and schedule dental exams at least twice a year. Contacting a dentist right away if the gums bleed or look red or swollen is recommended.
• Diet: It is important to choose foods low in fat and calories. Fresh fruits, vegetables, and whole grains. It is best to eliminate all refined carbohydrates (sugars and white flour) and hydrogenated oils. Limiting the amount of high-sugar beverages, such as soft drinks and fruit punches, is recommended by healthcare professionals. Avoid high-fat foods like ice cream, butter, and high-fat meats. Decreasing the consumption of milk and dairy products may also help with blood sugar control. Lean poultry and fish should be eaten more often than red meat. It is best not to cook with butter, margarine, lard, and hydrogenated oils. Olive oil or vegetable oils such as safflower are recommended by healthcare professionals.
• Eating healthy foods and exercising regularly can also help control high blood pressure and high cholesterol levels.
• Alcohol consumption should be limited to no more than one drink per day for women, two per day for men, and none if there is difficulty controlling alcohol intake (addiction) or uncontrolled blood sugar levels.
• Foot health: Healthcare professionals recommend to wash the feet daily in lukewarm water and top dry them gently, especially between the toes. It is important to moisturize the feet with lotion. Checking the feet every day for blisters, cuts, sores, redness, or swelling is important. It is recommended to consult a doctor if a sore or other foot problem that does not heal within a few days exists.
• Glucagon kit: Keeping a glucagon kit nearby in case of a low blood sugar emergency is important. Glucagon is an important hormone involved in carbohydrate metabolism. Produced by the pancreas, it is released when the glucose level in the blood is low (hypoglycemia), causing the liver to convert stored glycogen into glucose and release it into the bloodstream. The action of glucagon is thus opposite to that of insulin, which instructs the body's cells to take in glucose from the blood in times of satiation. An injection of glucagon will raise blood sugar levels.
• Identification tags: Healthcare professionals recommend that individuals with diabetes wear a tag or bracelet identifying the condition.
• Ketones: Individuals can test to see if the body is making ketones by doing a simple urine test. There are several products available for ketone testing that can be purchased without a prescription. Common product names include Ketostix®, Chemstrip K®, and Acetest®. The test result can be negative or show small, moderate, or large quantities of ketones. Healthcare professionals recommend testing for ketones during the following situations: anytime the blood glucose is over 250 milograms/deciliter for two checks in a row; when the individual is ill - often illness, infections, or injuries will cause sudden high blood glucose and this is an especially important time to check for ketones; when the individual is planning to exercise and the blood glucose is over 250 milligrams/deciliter; and when pregnant, individuals should test for ketones each morning before breakfast and anytime the blood glucose is over 250 miligrams/deciliter. As long as blood glucose levels are not too high, the presence of ketones is not a problem. Untreated high blood glucose with ketones can lead to a life-threatening condition called diabetic ketoacidosis (DKA). If the ketone test is positive, healthcare providers recommend calling a doctor immediately.
• Physical activity and weight control: Healthcare professionals recommend 30 minutes of moderate physical activity a day, where tolerated. Taking a brisk daily walk, riding a bike, or swimming laps are good exercises for individuals with diabetes. Losing weight is very important in maintaining healthy blood sugar levels.
• Studies have reported that individuals can lower the risk of developing diabetes by losing 5-7% of body weight through diet and increased physical activity. Diet and exercise resulting in a 5-7% weight loss (approximately 10-14 pounds in an individual weighing 200 pounds) can lower the incidence of type 2 diabetes by nearly 60%.
• Proper glucose control: The single best thing an individual can do is to keep their blood sugar level within the suggested range every day. The only way to do this is through a combination of regular blood sugar checks (self blood glucose monitoring), a balanced diet low in simple sugars and fat and high in complex carbohydrates and fiber, and appropriate medical treatment. A nutritionist, a doctor, and others on the healthcare team will help set up appropriate diabetes treatment strategies for the individual.
• Regular doctor visits: Scheduling regular health check-ups is important. However, regular diabetes checkups are not meant to replace yearly physicals or routine eye exams. Doctors will look for any diabetes-related complications, such as neuropathy, as well as screen for other medical problems. An eye care specialist will check for signs of retinal damage, cataracts, and glaucoma.
• Smoking cessation: Smoking cigarettes or use of any other form of tobacco raises the risks for developing complications from diabetes, such as heart attack, stroke, nerve damage, and kidney disease. Smoking damages blood vessels and contributes to heart disease, stroke, and poor circulation in the limbs. Smokers who have diabetes are three times more likely to die of cardiovascular disease than are nonsmokers who have diabetes, according to the American Diabetes Association (ADA). A doctor can help plan a strategy to stop smoking or to stop using other types of tobacco.
• Stress reduction: Chronic stress can lead to the adrenal glands releasing the stress hormone cortisol. Chronic release of cortisol can lead to health problems such as blood sugar regulation problems such as hyperinsulinemia, high cholesterol levels, inflammation, poor immunity, and obesity. Stress can be controlled through integrative therapies, such as meditation, breathing, yoga, and certain herbs and vitamins. Getting plenty of rest may also help with decreasing stress and improving immunity. High blood sugar levels can weaken the immune system.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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