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 meterscan measure blood glucose with only a one- or two-step process.Most also incorporate no-wipe technology, which means usersdo not have to wipe off excess blood after applying a blooddrop to the reagent strip. In addition, many meters now requireonly a very small amount of blood, thus decreasing the problems with bleeding often seen in advanced diabetics and the elderly and the fear and painof 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 afingertip. This can benefit patients who find constant lancetwounds 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 trendsand to graph reports for more comprehensive data tracking, particularlyfor 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 (Diabenese®), 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 (Bayetta®) 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.

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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. Although earl evidence is promising, additional study is needed before a firm recommendation can be made. Beta-glucan has a Generally Regarded as Safe (GRAS) status in the United States.

Ginseng: Several studies report a blood sugar-lowering effect of American ginseng (Panax quinquefolium) in individuals with type 2 diabetes, both on fasting blood glucose and on postprandial glucose levels. These results are promising, especially as ginseng does not seem to cause dangerous low blood sugar levels. Future research needs to evaluate long-term efficacy of American ginseng in treating type 2 diabetes compared to standard oral hypoglycemic drugs. American ginseng may increase the effects of blood sugar-lowering medications, including insulin.

Gymnema: Preliminary human research reports that gymnema (Gymnema sylvestre) may be beneficial in patients with type 1 or type 2 diabetes when it is added to diabetes drugs being taken by mouth or to insulin. 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.

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 there is currently no conclusive evidence of effectiveness when used for diabetes. Additional study is needed in this area to confirm these findings. Stevia may increase the effects of blood sugar-lowering medications, including insulin.

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 contribution of acupuncture in diabetes.

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 sugars in patients with diabetes or hyperglycemia.

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 diabetes is positive, study results are mixed. More research is needed to explore the effectiveness and safety of aloe in diabetics.

Arabinoxylan: Altering the outer shell of rice bran using enzymes from Hyphomycetes mycelia mushroom extract produces Arabinoxylan compound. 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 diabetics. More study is needed.

Ashwagandha: Based on early study, ashwagandha (Withania somnifera) may decrease blood sugar levels. Additional evidence is required in this area.

Astragalus: Although there is experimental evidence that astragalus (Astragalus membranaceus) alone, and in combination with hypoglycemic medication, has significant hypoglycemic properties, the clinical studies are 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.

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 insulin resistant women. 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.

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 report promising results. However, additional research is necessary before a firm conclusion can be made.

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. Better research is necessary before a firm conclusion can be drawn.

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. The safety and effectiveness of berberine for this indication remains unclear. More research is needed in this area.

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, and animal research suggests that bilberry leaf extract can lower blood sugar levels. Human research is needed in this area.

Biotin: Biotin is an essential water-soluble B vitamin. In preliminary research, biotin has been reported to decrease insulin resistance and improve glucose tolerance - both properties that may be beneficial in patients with types 2 (adult-onset) diabetes. However, there is not sufficient human evidence to form a clear conclusion in this area.

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 sugars. Bitter melon may increase the effects of blood sugar lowering medications, including insulin.

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 is needed.

Cinnamon: Several human studies support the use of cinnamon (Cinnamomum spp.) in diabetes. More research on the proposed health benefits of cinnamon supplementation is warranted.

Dandelion: There is limited animal research on the effects of dandelion (Taraxacum officinale) on blood sugar levels in animals. Effects in humans are not known.

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.

Evening primrose oil: A small number of laboratory studies and theories suggest that evening primrose (Oenothera biennis) oil may be helpful in diabetes, but more information is needed.

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 type 2 diabetes. Additional study is warranted in this area.

Review of the literature also suggests a possible efficacy of fenugreek in type 1 diabetics. Although promising, these data cannot be considered definitive. At this time, there is insufficient evidence to recommend either for or against the use of fenugreek for type 1 diabetes.

Fig: Preliminary evidence suggests that fig (Ficus carica) has antioxidant properties and may be beneficial in type 1 diabetes. Additional study is warranted in this area.

Flaxseed: Human studies on the effect of flaxseed (Linum usitatissimum) on blood sugar levels report mixed results. More research is needed to determine the effect of flaxseed on blood sugar regulation.

Gotu kola: Gotu kola is from the perennial creeping plant, Centella asiatica (formerly known as Hydrocotyle asiatica), which is a member of the parsley family. It is native to India, Madagascar, Sri Lanka, Africa, Australia, China, and Indonesia. Preliminary studies have suggested beneficial effects of the total triterpenoid fraction of Centella asiatica (TTFCA) on subjective and objective parameters of venous insufficiency of the lower extremities. However, additional study is needed in this area.

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.

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.

Honey: Early evidence suggests that honey may help lower blood sugar levels in diabetic patients. Additional study is warranted in this area.

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 support, there is insufficient research in this area.

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 glucose tolerance. However, there is little available research in this area. Additional study is needed.

Kudzu: Preliminary evidence suggests puerarin, a constituent of kudzu (Pueraraia lobata), may improve insulin resistance. Insulin resistance is a condition in which the cells of the body become resistant to the effects of insulin and the normal response to a given amount of insulin is reduced. As a result, higher levels of insulin are needed in order for insulin to have its effects. Insulin resistance precedes the development of type 2 diabetes. Therefore, reversing insulin resistance can lessen chances of developing type 2 diabetes and heart disease. Additional study is needed before a firm conclusion can be made.

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. Preliminary evidence is conflicting.

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 in humans.

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. However, more scientific evidence needs to be found.

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 type 2 diabetic patients. More research is warranted to make a strong recommendation.

Nopal: Traditionally, nopal, or prickly pear, has both food and medicinal uses. Animal studies have shown that nopal may reduce blood glucose levels in diabetes. Based on available clinical trial, there is some preliminary clinical evidence that prickly pear cactus can decrease blood glucose levels in patients with type 2 diabetes. However, the quality of available studies is low and more research needs to be performed.

Onion: One clinical trial found that fresh onion (Allium cepa) significantly decreased serum glucose levels in diabetics. More research is needed in this area to confirm these results.

Psychotherapy: Psychotherapy may improve blood sugar control in teens and adults with poorly-controlled type I diabetes, especially if blood sugar problems are related to depression.

Cognitive behavior therapy may reduce depression and improve blood sugar level control in patients with type II diabetes. Therapy may be less effective in people with diabetes complications or poorly-controlled blood sugar levels. More studies are needed.

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 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).

Pycnogenol®: Pycnogenol® is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster ssp. atlantica), which is grown in coastal south-west France. Supplementation of Pycnogenol® with conventional diabetes treatment may lower glucose levels and improve endothelial function. Also, supplementation with Pycnogenol® may improve symptoms associated with diabetic microangiopathy. Further research is needed to confirm these results.

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.

Red yeast rice: Red yeast rice is the product of yeast (Monascuspurpureus) grown on rice, and is served as a dietary staple in some Asian countries. Early human evidence suggests the potential for benefits in diabetics. Additional study is needed. There is limited evidence about the side effects of red yeast. Mild headache and abdominal discomfort can 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.

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 diabetes. Long-term studies with larger sample size are needed to evaluate the efficacy and safety of Ganopoly® in treating diabetic patients. The authors are closely related to the manufacturer of Ganopoly®. Reishi may increase bleeding in sensitive individuals, including those taking blood thinning medications such as aspirin or warfarin (Coumadin®).

Safflower: Lipid (fat) abnormalities are commonly associated with diabetes, 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 in fish oil.

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 lower blood sugar levels. However, there are no reliable human studies available to support a recommendation for use in diabetes. Seaweeds may alter thyroid hormone levels.

Soy: Several small studies have examined the effects of soy (Glycine max) supplements on blood sugars in people with type 2 ("adult-onset") 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 sugars can be clearly described.

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. In fact, spirulina contains more beta-carotene than carrots. 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.

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 use taurine in the treatment of diabetes.

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 these results.

Vitamin E: Vitamin E is a fat-soluble vitamin with antioxidant properties. Vitamin E has been proposed for the prevention of types I or II diabetes; for the improvement of abnormal sugar control in diabetes; for prevention of platelet dysfunction and atherosclerosis in diabetes; for the correction of vitamin E deficiency in diabetic patients; and for the prevention of diabetic complications of the eye, kidneys, and nervous system (neuropathy, retinopathy, nephropathy). It is not clear that vitamin E is beneficial in any of these areas, and further evidence is necessary. Vitamin E may increase bleeding in sensitive individuals, including those taking blood thinning medications such as aspirin or warfarin (Coumadin®).

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.

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.

Zinc: Zinc formulations have been used since ancient Egyptian times to enhance wound healing, although the usefulness of this approach is only partially confirmed by clinical data of today. Diabetic patients typically have significantly lower serum zinc levels compared with healthy controls. Based on one randomized, controlled trial, zinc supplementation for type-2 diabetics may have beneficial effects in elevating their serum zinc level, and in improving their glycemic control that is shown by decreasing their HbA1c% concentration. Also, oral zinc supplementation may improve glycemic control and severity of peripheral neuropathy. Further research is needed.

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.

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. Garlic may increase bleeding in sensitive individuals, including those taking blood thinning medications such as aspirin or warfarin (Coumadin®).

Omega-3 fatty acids (fish oil): 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.

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.

Therapeutic touch: There is initial research that therapeutic touch does not affect blood sugar levels in patients with type I (insulin-dependent) diabetes mellitus.

Traditional or theoretical uses lacking sufficient evidence :

Integrative therapies used in diabetes or related conditions that have historical or theoretical uses but lack sufficient clinical evidence, include: 5-HTP (5-hydroxytryptophan), acerola (Malpighia glabra, Malpighia punicifolia), homeopathic aconite (Aconitum napellus), agave (Agave americana), annatto (Bixa orellana), applied kinesiology, asparagus (Asparagus officinalis), astaxanthin, beta-carotene, bovine colostrum, calamus (Acorus calamus), chelation therapy, chlorophyll, cordyceps (Cordyceps sinensis), detoxification therapy, fo-ti (Polygonum multiflorum), folic acid, garcinia (Garcinia cambogia), hydroxycitric acid, goldenseal (Hydrastis canadensis), grapefruit (Citrus paradisi), guided imagery, horsetail (Equisetum arvense), hydrazine sulfate, hypnotherapy, iridology, lemongrass (Cymbopogon spp.), lycopene, mangosteen (Garcinia mangostana), massage, MSM (methysulfonylmethane), music therapy, neem (Azadirachta indica), noni (Morinda citrifolia), pet therapy, qi gong, reflexology, reiki, relaxation therapy, rosemary (Rosmarinus officinalis), selenium, spiritual healing, turmeric (Curcuma longa), and vitamin C.

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 assoft drinks and fruit punches, is recommended by healthcare professionals.Avoid high-fat foods like ice cream, butter, and high-fatmeats.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 perday for men, and none if there is difficulty controllingalcohol 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.