Diabetes

Also indexed as: High Blood Sugar

In this discussion, diabetes refers to diabetes mellitus. Other forms of diabetes (such as diabetes insipidus) are not included.

People with diabetes cannot properly process glucose, a sugar the body uses for energy. As a result, glucose stays in the blood, causing blood glucose to rise. At the same time, however, the cells of the body can be starved for glucose. Diabetes can lead to poor wound healing, higher risk of infections, and many other problems involving the eyes, kidneys, nerves, and heart.

There are two types of diabetes mellitus. Childhood-onset diabetes is also called type 1, or insulin-dependent, diabetes. In type 1 diabetes, the pancreas cannot make the insulin needed to process glucose. Natural therapies cannot cure type 1 diabetes, but they may help by making the body more receptive to insulin supplied by injection. It is particularly critical for people with type 1 diabetes to work carefully with the doctor prescribing insulin before contemplating the use of any herbs, supplements, or dietary changes mentioned in this article. Any change that makes the body more receptive to insulin could require critical changes in insulin dosage that must be determined by the treating physician.

Adult-onset diabetes is also called type 2, or non-insulin-dependent, diabetes. With type 2 diabetes, the pancreas often makes enough insulin, but the body has trouble using the insulin. Type 2 diabetes responds well to natural therapies.

People with diabetes have a high risk for heart disease and atherosclerosis. In addition, those with diabetes have a higher mortality rate if they also have high homocysteine levels.1

Checklist for Diabetes

Rating Nutritional Supplements Herbs
3Stars Alpha lipoic acid
Brewer’s yeast (providing approximately 60 mcg of chromium per tablespoon)
Chromium
Evening primrose oil
Fiber
Glucomannan
Magnesium		 Cayenne (topical for neuropathy)
Fenugreek (seeds)
Psyllium
2Stars Biotin
Coenzyme Q10
L-carnitine
Vitamin B1 (Thiamine)
Vitamin B6 (gestational diabetes only)
Vitamin C
Vitamin E (for prevention of retrolental fibroplasia in premature infants, and for prevention of diabetic retinopathy)
Zinc (preferably for those with a documented deficiency)		 Aloe vera
American ginseng
Asian ginseng
Bilberry
Bitter melon
Gymnema
Hairy Basil (seed)
Holy Basil (leaf)
Onion
1Star Fish oil (EPA/DHA)
Following are associated with diabetic retinopathy: Selenium, vitamin A, vitamin C, and vitamin E (combined)
Fructo-oligosaccharides (FOS)
Inositol
Manganese
Medium chain triglycerides
Quercetin
Taurine
Vanadium (for type 2 diabetes)
Vitamin B12
Vitamin B3 (niacinamide)
Vitamin D
Vitamin E (associated with abetalipoproteinemia)		 Eleuthero
Ginkgo biloba
Mistletoe
Olive leaf
Reishi
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

Dietary changes that may be helpful: The relationship between eating carbohydrates and type 2 diabetes is a complex issue. While eating carbohydrates increases the need for insulin to keep blood sugar normal, diets high in total carbohydrates do not necessarily increase the risk of type 2 diabetes.2 3 Researchers have found that diets very high in sugar may worsen glucose tolerance in nondiabetic animals4 and humans.5 However, the amount of sugar used in these studies in proportion to other foods is much larger than is typically found in human diets.

Years ago, one researcher reported an increase in diabetes among Yemenite Jews who had migrated from a region where no sugar was eaten to one in which they ate a diet including sugar.6 However, other factors, such as weight gain, may explain the increased risk of diabetes that occurred in this group.7 Other studies have found no independent relationship between sugar intake and the development of glucose intolerance.8

Eating carbohydrate-containing foods, whether high in sugar or high in starch (such as bread, potatoes, processed breakfast cereals, and rice), temporarily raises blood sugar and insulin levels.9 The blood sugar-raising effect of a food, called its “glycemic index,” depends on how rapidly its carbohydrate is absorbed. Many starchy foods have a glycemic index similar to sucrose (table sugar).10 People eating large amounts of foods with high glycemic indices (such as those mentioned above), have been reported to be at increased risk of type 2 diabetes.11 12 On the other hand, eating a diet high in carbohydrate-rich foods with low glycemic indices is associated with a low risk of type 2 diabetes.13 14 15 Beans, peas, fruit, and oats, have low glycemic indices, despite their high carbohydrate content, due mostly to the health-promoting effects of soluble fiber.

Diabetes disrupts the mechanisms by which the body controls blood sugar. Until recently, health professionals have recommended sugar restriction to people with diabetes, even though short-term high-sugar diets have been shown, in some studies, not to cause blood sugar problems in people with diabetes.16 17 18 Currently, the American Diabetic Association (ADA) guidelines19 do not prohibit the use of moderate amounts of sugar, as long as the goals of normalizing blood levels of glucose, triglycerides, and cholesterol are being achieved.

Most doctors recommend that people with diabetes cut intake of sugar from snacks and processed foods, and replace these foods with high-fiber, whole foods. This tends to lower the glycemic index of the overall diet and has the additional benefit of increasing vitamin, mineral, and fiber intake. Other authorities also recommend lowering the glycemic index of the diet to improve the control of diabetes.20

A high-fiber diet has been shown to work better in controlling diabetes than the diet recommended by the ADA, and may control blood sugar levels as well as oral diabetes drugs.21 In this study, the increase in dietary fiber was accomplished exclusively through the consumption of foods naturally high in fiber—such as leafy green vegetables, granola, and fruit—to a level beyond that recommended by the ADA. No fiber supplements were given. All participants received both the ADA diet (providing 24 grams of fiber per day) and the high-fiber diet (providing 50 grams of fiber per day), for a period of six weeks. After six weeks of following each diet, tests were performed to determine blood glucose, insulin, cholesterol, triglyceride, and other values. When glucose levels were monitored over a 24-hour period, participants eating the high-fiber diet had an average glucose level that was 10% lower than participants eating the ADA diet. Insulin levels were 12% lower in the group eating the high-fiber diet compared to the group eating the ADA diet, indicating a beneficial increase in the body’s sensitivity to insulin. Moreover, people eating the high-fiber diet experienced significant reductions in total cholesterol, triglycerides, and LDL (“bad”) cholesterol compared to those eating the ADA diet. They also had slight decreases in glycosylated hemoglobin, a measure of chronically high blood glucose levels.

High-fiber supplements, such as psyllium,22 23 guar gum (found in beans),24 pectin (from fruit),25 oat bran,26 and glucomannan 27 28 have improved glucose tolerance in some studies. Positive results have also been reported with the consumption of 1–3 ounces of powdered fenugreek seeds per day.29 30 A review of the research revealed that the extent to which moderate amounts of fiber help people with diabetes in the long term is still unknown, and the lack of many long-term studies has led some researchers to question the importance of fiber in improving diabetes.31 Nonetheless, most doctors advise people with diabetes to eat a diet high in fiber. Focus should be placed on fruits, vegetables, seeds, oats, and whole-grain products.

Eating fish also may afford some protection from diabetes.32 Incorporating a fish meal into a weight-loss regimen was more effective than either measure alone at improving glucose and insulin metabolism and high cholesterol.33

Vegetarians have been reported to have a low risk of type 2 diabetes.34 When people with diabetic nerve damage switch to a vegan diet (no meat, dairy, or eggs), improvements have been reported after several days.35 In one trial, pain completely disappeared in 17 of 21 people.36 Fats from meat and dairy also contribute to heart disease, the leading killer of people with diabetes.

Vegetarians also eat less protein than do meat eaters. The reduction of protein intake has lowered kidney damage caused by diabetes37 38 and may also improve glucose tolerance.39 However, in a group of 13 obese males with high blood-insulin levels (as is often seen in diabetes), a high-protein, low-carbohydrate diet resulted in greater weight loss and control of insulin levels, compared with that of a low-carbohydrate diet.40 Switching to either a high- or low-protein diet should be discussed with a doctor.

Diets high in fat, especially saturated fat, worsen glucose tolerance and increase the risk of type 2 diabetes,41 42 43 44 an effect that is not simply the result of weight gain caused by eating high-fat foods. Saturated fat is found primarily in meat, dairy fat, and the dark meat and skins of poultry. In contrast, glucose intolerance has been improved by diets high in monounsaturated oils,45 46 which may be good for people with diabetes.47 There is often difficulty in changing the overall percentage of calories from fat and carbohydrates in the diets of people with type 1 diabetes. However, modifying the quality of the dietary fat is achievable. In adolescents with type 1 diabetes, increasing monounsaturated fats relative to other fats in the diet is associated with better control over blood sugar and cholesterol levels.48 The easiest way to incorporate monounsaturates into the diet is to use oils containing olive oil. However, those who are overweight need to be aware—olive oil is high in calories.

Should children avoid milk to prevent type 1 diabetes? Worldwide, children whose dietary energy comes primarily from dairy (or meat) products have a significantly higher chance of developing type 1 diabetes than do children whose dietary energy comes primarily from vegetable sources.49 Countries with high milk consumption have a high risk of type 1 (insulin-dependent) diabetes.50 Animal research also indicates that avoiding milk affords protection from type 1 diabetes.51 Milk contains a protein related to a protein in the pancreas, the organ where insulin is made. Some researchers believe that children who are allergic to milk may develop antibodies that attack the pancreas, causing type 1 diabetes. Several studies have linked cows’ milk consumption to the occurrence of type 1 diabetes in children.52 53 54 55 However, other studies have failed to find such a link.56 57 One study even reported a protective effect of higher intake of dairy products on diabetes risk in children.58 One reason for the conflicting results of the research may be that different genetic strains of cows’ milk protein (casein) are associated with different levels of risk.59 Some children who drink cows’ milk produce antibodies to the milk, and it has been hypothesized that these antibodies can cross-react with and damage the insulin-producing cells of the pancreas.60

Immune problems in people with type 1 diabetes have been tied to other allergies as well,61 and the importance of focusing only on the avoidance of dairy products remains unclear.62 Preliminary studies have found that early introduction of cows’ milk formula feeding increases the risk of developing type 1 diabetes, although contradictory results have also been published.63 64 A study of Finnish children (including full-term children with diabetes) showed that early introduction of cows’ milk formula feeding before three months of age (vs. after three months of age) was associated with increased risk of type 1 diabetes.65 This research supports abstaining from dairy products in infancy and early childhood, particularly for children with a family history of type 1 diabetes. Recent research also suggests a possible link between milk consumption in infancy and an increased risk of type 2 (non-insulin-dependent) diabetes.66

Lifestyle changes that may be helpful: Most people with type 2 diabetes are overweight.67 Excess abdominal weight does not stop insulin formation,68 but it does make the body less sensitive to insulin.69 Excess weight can even make healthy people pre-diabetic.70 Weight loss reverses this problem.71 In most studies, type 2 diabetes has improved with weight loss.72 73 74

Increased weight gain in infancy has been associated with a one-and-a half-fold increase in the risk of developing type 1 diabetes in childhood.75 Being overweight also increases the need for insulin. Therefore, people with type 1 diabetes should achieve and maintain appropriate body weight.

Exercise helps decrease body fat76 and improve insulin sensitivity.77 People who exercise are less likely to develop type 2 diabetes than those who do not.78 People with type 1 diabetes who exercise require less insulin.79 However, exercise can induce low blood sugar or even occasionally increased blood sugar.80 Moreover, a preliminary study has shown that long-term physical activity was not associated with control of blood glucose in people with type 1 diabetes.81 Therefore, people with diabetes should never begin an intensive exercise program without consulting a healthcare professional.

Moderate drinking in healthy people improves glucose tolerance.82 83 84 85 However, alcohol has been reported to worsen glucose tolerance in the elderly86 and in people with diabetes87 in some studies. People with diabetes who drink have also been reported to have a high risk for eye88 and nerve damage.89

Questions remain about where the line should be drawn regarding alcohol intake. For healthy people, light drinking will not increase the risk of diabetes, and may even reduce the risk of developing type 2 diabetes;90 however, heavy drinking does increase the risk of developing diabetes and should be avoided.91 People with diabetes should limit alcohol intake to two drinks per day. Total avoidance of alcohol in people with diabetes who are not suffering from alcoholism, liver disease (e.g., cirrhosis), gastritis, ulcers, and other conditions made worse by alcohol might actually be counterproductive. In one report, older people with type 2 diabetes who drank daily, but moderately, had a dramatically lower incidence of deaths from heart disease compared with nondrinkers.92 This outcome is not surprising since moderate alcohol intake is associated with protection from heart disease in most other reports. This finding may be of particular importance because heart disease is the leading killer of people with diabetes. In another study, nondrinkers had a higher incidence of type 2 diabetes than did moderate drinkers.93

People with diabetes who smoke are at higher risk for kidney damage,94 heart disease,95 and other diabetes-linked problems. Smokers are also more likely to develop diabetes;96 therefore, it is important to quit smoking.

Although most healthcare providers agree on the necessity of self-monitoring of blood glucose (SMBG) by people with type 1 diabetes, disagreement exists within the medical community regarding the efficacy and necessity of SMBG by people with type 2 diabetes. A controlled clinical trial found that home glucose monitoring strips did not affect the management of type 2 diabetes.97 Moreover, a review of available literature concluded that the efficacy of SMBG in people with type 2 diabetes is questionable and should be tested in a rigorous high-quality trial.98 Advocates of SMBG, such as the ADA, have observed that SMBG by people with diabetes has revolutionized management of the disease, enabling them to achieve and maintain specific goals.99 These observations are well-supported in the medical literature.100 Detractors point out that indiscriminate use of self-monitoring is of questionable value and adds enormously to healthcare costs.101 The ADA acknowledges that accuracy of SMBG is instrument- and technique-dependent. Errors in technique and inadequate use of control procedures have been shown to lead to inaccurate test results.102 Nevertheless, it is likely that self-monitoring of blood glucose, if used properly, can have a positive effect by increasing patient involvement in overall diabetes care.103 Pharmacists and healthcare practitioners can teach people with diabetes certain skills that will enhance their ability to properly self-manage blood glucose.

Nutritional supplements that may be helpful: A variety of vitamins, minerals, amino acids, and other supplements may help with symptoms and deficiences associated with diabetes.

Chromium
Medical reports dating back to 1853, as well as modern research, indicate that chromium-rich brewer’s yeast (9 grams per day) can be useful in treating diabetes.104 105 In recent years, chromium has been shown to improve glucose and related variables in people with glucose intolerance and type 1, type 2, gestational, and steroid-induced diabetes.106 Improved glucose tolerance with lower or similar levels of insulin have been reported in more than ten trials of chromium supplementation in people with varying degrees of glucose intolerance.107 Chromium supplements improve glucose tolerance in people with both type 2108 and type 1 diabetes, apparently by increasing sensitivity to insulin.109 Chromium improves the processing of glucose in people with prediabetic glucose intolerance110 and in women with diabetes associated with pregnancy.111 Chromium even helps healthy people,112 although one such report found chromium useful only when accompanied by 100 mg of niacin.113 Chromium may also lower total cholesterol, LDL cholesterol, and triglycerides (risk factors in heart disease).114 115

A few trials have reported no beneficial effects from chromium supplementation.116 117 118 All of these trials used 200 mcg or less of supplemental chromium, which is often not adequate for people with diabetes, especially if it is in a form that is poorly absorbed. The typical amount of chromium used in research trials is 200 mcg per day, although as much as 1,000 mcg per day has been used.119 Many doctors recommend up to 1,000 mcg per day for people with diabetes.120

Supplementation with chromium or brewer’s yeast could potentially enhance the effects of drugs for diabetes (e.g., insulin or other blood sugar-lowering agents) and possibly lead to hypoglycemia. Therefore, people with diabetes taking these medications should supplement chromium or brewer’s yeast only under the supervision of a doctor.

Magnesium
People with diabetes tend to have low magnesium levels.121 Double-blind research indicates that supplementing with magnesium overcomes this problem.122 Magnesium supplementation has improved insulin production in elderly people with type 2 diabetes.123 However, one double-blind trial found no effect from 500 mg magnesium per day in people with type 2 diabetes, although twice that amount led to some improvement.124 Elders without diabetes can also produce more insulin as a result of magnesium supplements, according to some,125 but not all, trials.126 In some trials, insulin requirements are lower in people with type 1 diabetes who supplement with magnesium.127 However, in people with type 2 diabetes who nonetheless require insulin, Dutch researchers have reported no improvement in blood sugar levels.128

Diabetes-induced damage to the eyes is more likely to occur in magnesium-deficient people with type 1 diabetes.129 In magnesium-deficient pregnant women with type 1 diabetes, the lack of magnesium may even account for the high rate of spontaneous abortion and birth defects associated with type 1 diabetes.130 The American Diabetes Association admits “strong associations...between magnesium deficiency and insulin resistance” but will not say magnesium deficiency is a risk factor.131 Many doctors, however, recommend that people with diabetes and normal kidney function supplement with 200–600 mg of magnesium per day.

Alpha lipoic acid
Alpha lipoic acid is a powerful natural antioxidant. Preliminary132 133 and double-blind134 135 136 137 138 trials have found that supplementing 600–1,200 mg of lipoic acid per day improves insulin sensitivity and the symptoms of diabetic neuropathy. In a preliminary study, supplementation with 600 mg of alpha-lipoic acid per day for 18 months slowed the progression of kidney damage in patients with type 1 and type 2 diabetes.139

Evening primrose oil
Supplementing with 4 grams of evening primrose oil per day for six months has been found in double-blind research to improve nerve function and to relieve pain symptoms of diabetic neuropathy.140

Glucomannan
Glucomannan is a water-soluble dietary fiber that is derived from konjac root (Amorphophallus konjac). Glucomannan delays stomach emptying, leading to a more gradual absorption of dietary sugar. This effect can reduce the elevation of blood sugar levels that is typical after a meal.141 After-meal blood sugar levels are lower in people with diabetes given glucomannan in their food,142 and overall diabetic control is improved with glucomannan-enriched diets, according to preliminary143 and controlled144 145 clinical trials. One preliminary report suggested that glucomannan may also be helpful in pregnancy-related diabetes.146 For controlling blood sugar, 500–700 mg of glucomannan per 100 calories in the diet has been used successfully in controlled research.

Vitamin E
People with low blood levels of vitamin E are more likely to develop type 1147 and type 2 diabetes.148 Vitamin E supplementation has improved glucose tolerance in people with type 2 diabetes in most,149 150 151 but not all,152 double-blind trials. Vitamin E has also improved glucose tolerance in elderly people without diabetes.153 154 Three months or more of supplementation may be required for benefits to become apparent. The amount used is at least 900 IU of vitamin E per day.

In one of the few trials to find vitamin E supplementation ineffective for glucose intolerance in people with type 2 diabetes, damage to nerves caused by the diabetes was nonetheless partially reversed by supplementing with vitamin E for six months.155 Animal156 and preliminary human157 data indicate that vitamin E supplementation may protect against diabetic retinopathy and nephropathy, serious complications of diabetes involving the eyes and kidneys, respectively, though no long-term trials in humans have confirmed this preliminary evidence.

Glycosylation is an important measurement of diabetes; it refers to how much sugar attaches abnormally to proteins. Vitamin E supplementation reduces this problem in many,158 159 160 161 162 although not all,163 164 165 studies.

In one report, vitamin E was found to impair glucose tolerance in obese patients with diabetes.166 The reason for the discrepancy between reports is not known.

Vitamin E appears to lower the risk of cerebral infarction, a type of stroke, in people with diabetes who smoke. A review of a large Finnish study of smokers concluded that smokers with diabetes (or hypertension) represent a subset population that can benefit from small amounts of vitamin E (50 IU per day) without experiencing an increased risk of bleeding.167

Vitamin C
People with type 1 diabetes appear to have low vitamin C levels.168 As with vitamin E, vitamin C may reduce glycosylation.169 Vitamin C also lowers sorbitol in people with diabetes.170 Sorbitol is a sugar that can accumulate and damage the eyes, nerves, and kidneys of people with diabetes. Vitamin C may improve glucose tolerance in type 2 diabetes,171 172 although not every study confirms this benefit.173 Vitamin C supplementation (500 mg twice daily for one year) has significantly reduced urinary protein loss in people with diabetes. Urinary protein loss (also called proteinuria) is associated with poor prognosis in diabetes.174 Many doctors suggest that people with diabetes supplement with 1–3 grams per day of vitamin C. Higher amounts could be problematic, however. In one person, 4.5 grams per day was reported to increase blood sugar levels.175

One study examined antioxidant supplement intake, including both vitamins E and C, and the incidence of diabetic retinopathy (damage to the eyes caused by diabetes).176 Surprisingly, people with extensive retinopathy had a greater likelihood of having taken vitamin C and vitamin E supplements. The outcome of this trial, however, does not fit with most other published data and might simply reflect the fact that sicker people are more likely to take supplements in hopes of getting better. For the present, most doctors remain relatively unconcerned about the unexpected outcome of this isolated report.

Vitamin B
Many people with diabetes have low blood levels of vitamin B6.177 178 Levels are even lower in people with diabetes who also have nerve damage (neuropathy).179 Vitamin B6 supplementation has improved glucose tolerance in women with diabetes caused by pregnancy.180 181 Vitamin B6 supplementation is also effective for glucose intolerance induced by birth control pills.182 For other people with diabetes, 1,800 mg per day of a special form of vitamin B6—pyridoxine alpha-ketoglutarate—has improved glucose tolerance dramatically in some research.183 Standard vitamin B6 has helped in some,184 but not all, trials.185

Biotin is a B vitamin needed to process glucose. When people with type 1 diabetes were given 16 mg of biotin per day for one week, their fasting glucose levels dropped by 50%.186 Similar results have been reported using 9 mg per day for two months in people with type 2 diabetes.187 Biotin may also reduce pain from diabetic nerve damage.188 Some doctors try 16 mg of biotin for a few weeks to see if blood sugar levels will fall.

Blood levels of vitamin B1 (thiamine) have been found to be low in people with type 1 diabetes.189 In the 1930s, a trial using 10 mg of vitamin B1 per day for four weeks reported reduced blood sugar levels in six of eleven people with diabetes.190 More recently, administration of both vitamin B1 (25 mg per day) and vitamin B6 (50 mg per day) led to significant improvement of symptoms of diabetic neuropathy after four weeks.191 However, this was a trial conducted among people in a vitamin B1-deficient developing country. Therefore, these improvements might not occur in other people with diabetes. Another trial found that combining vitamin B1 (in a special fat-soluble form) and vitamin B6 plus vitamin B12 in high but variable amounts, led to improvement in some aspects of diabetic neuropathy in 12 weeks.192 As a result, some doctors recommend that people with diabetic neuropathy supplement with vitamin B1, though the optimal level of intake remains unknown.

Coenzyme Q10
Coenzyme Q10 (CoQ10) is needed for normal blood sugar metabolism. Animals with diabetes have been reported to be CoQ10 deficient. People with type 2 diabetes have been found to have significantly lower blood levels of CoQ10 compared with healthy people.193 In one trial, blood sugar levels fell substantially in 31% of people with diabetes after they supplemented with 120 mg per day of CoQ7, a substance similar to CoQ10.194 In people with type 1 diabetes, however, supplementation with 100 mg of CoQ10 per day for three months neither improved glucose control nor reduced the need for insulin.195 The importance of CoQ10 supplementation for people with diabetes remains an unresolved issue, though some doctors recommend approximately 50 mg per day as a way to protect against possible effects associated with diabetes-induced depletion.

L-carnitine
L-carnitine is an amino acid needed to properly utilize fat for energy. When people with diabetes were given L-carnitine (1 mg per 2.2 pounds of body weight), high blood levels of fats—both cholesterol and triglycerides—dropped 25–39% in just ten days in one trial.196 In higher amounts (1 gram per day by injection), L-carnitine has been reported to reduce pain from diabetic nerve damage as well.197

Vitamin B12 is needed for normal functioning of nerve cells. Vitamin B12 taken orally, intravenously, or by injection has reduced nerve damage caused by diabetes in most people studied.198 In a preliminary trial, people with nerve damage due to kidney disease or to diabetes plus kidney disease received intravenous injections of 500 mcg of methylcobalamin (the main form of vitamin B12 found in the blood) three times a day for six months in addition to kidney dialysis. Nerve pain was significantly reduced and nerve function significantly improved in those who received the injections.199 Oral vitamin B12 up to 500 mcg three times per day is recommended by some practitioners.

The intake of large amounts of niacin (a form of vitamin B3), such as 2–3 grams per day, may impair glucose tolerance and should be used by people with diabetes only with medical supervision.200 201 Smaller amounts (500–750 mg per day for one month followed by 250 mg per day) may help some people with type 2 diabetes,202 though this research remains preliminary.

Preliminary trials have shown that niacinamide (another form of vitamin B3) supplementation might be useful in the very early stages of type 1 diabetes,203 though not all trials support this claim.204 205 206 Although an analysis of research shows that niacinamide does help preserve some function of insulin-secreting cells in people recently diagnosed with type 1 diabetes, the amount of insulin required for those given niacinamide has remained essentially as high as for those given placebo.207 A controlled trial found no beneficial effect of niacinamide supplementation (700 mg three times per day in addition to intensive insulin therapy) on pancreatic function and glucose tolerance in people newly diagnosed with type 1 diabetes.208

Some,209 but not all,210 reports suggest that healthy children at high risk for type 1 diabetes (such as the healthy siblings of children with type 1 diabetes) may be protected from the disease by supplementing with niacinamide. Parents of children with type 1 diabetes should consult their doctor regarding niacinamide supplementation as a way to prevent diabetes in their other children. Although the optimal amount of niacinamide is not known, recent evidence suggests that 25 mg per 2.2 pounds of body weight per day may be as effective as higher amounts.211

Zinc
People with type 1 diabetes tend to be zinc-deficient,212 which may impair immune function.213 Zinc supplements have lowered blood sugar levels in people with type 1 diabetes,214 though some evidence indicates that zinc supplementation in people with type 2 diabetes does not improve their ability to process sugar.215 Nonetheless, people with type 2 diabetes also have low zinc levels, caused by excess loss of zinc in their urine.216 Many doctors recommend that people with type 2 diabetes supplement with moderate amounts of zinc (15–25 mg per day) as a way to correct for the deficit.

Some doctors are concerned about having people with type 1 diabetes supplement with zinc because of a report that zinc supplementation increased glycosylation,217 generally a sign of deterioration of the condition. This trial is hard to evaluate because zinc supplementation increases the life of blood cells and such an effect artificially increases the lab test results for glycosylation. Until this issue is resolved, those with type 1 diabetes should consult a doctor before considering supplementation with zinc.

Vitamin D
Vitamin D is needed to maintain adequate blood levels of insulin.218 Vitamin D receptors have been found in the pancreas where insulin is made and preliminary evidence suggests that supplementation can increase insulin levels in some people with type 2 diabetes; prolonged supplementation might also help reduce blood sugar levels.219 Not enough is known about optimal amounts of vitamin D for people with diabetes, and high amounts of vitamin D can be toxic. Therefore, people with diabetes considering vitamin D supplementation should talk with, and have vitamin D status assessed by, a doctor.

Inositol
Inositol is needed for normal nerve function. Diabetes can cause a type of nerve damage known as diabetic neuropathy. This condition has been reported in some, but not all, trials to improve with inositol supplementation (500 mg taken twice per day).220

Taurine
Taurine is an amino acid found in protein-rich food. People with type 1 diabetes have been reported to have low blood taurine levels, a condition that increases the risk of heart disease by altering blood viscosity. Supplementing with taurine (1.5 grams per day) has restored blood taurine to normal levels and corrected the problem of blood viscosity within three months.221 However, in a double-blind trial, taurine supplementation (2 grams per day for 12 months) failed to improve kidney complications associated with type 2 diabetes.222

Fish oil
Glucose tolerance improves in healthy people taking omega-3 fatty acid supplements.223 Some studies have found that fish oil supplementation improves glucose tolerance,224 high triglycerides,225 and cholesterol levels in people with diabetes.226 However, other studies have found that cholesterol increases227 and diabetes worsens with fish oil supplementation.228 229 230

Until this issue is resolved, people with diabetes should feel free to increase their fish intake, but they should consult a doctor before taking fish oil supplements. Sometimes, such supplementation may be considered. In one trial, people with diabetic neuropathy and diabetic nephropathy experienced significant improvement when given 600 mg three times per day of purified EPA—one of the two major omega-3 fatty acids found in fish oil supplements—for 48 weeks.231

Doctors have suggested that quercetin might help people with diabetes because of its ability to reduce levels of sorbitol—a sugar that accumulates in nerve cells, kidney cells, and cells within the eyes of people with diabetes—and has been linked to damage to those organs.232 Clinical trials have yet to explore whether quercetin actually protects people with diabetes from neuropathy, nephropathy, or retinopathy.

Vanadium
Vanadyl sulfate, a form of vanadium, may improve glucose control in people with type 2 diabetes,233 234 235 though it may not help people with type 1 diabetes.236 Over a six-week period, a small group of people with type 2 diabetes were given 75–300 mg of vanadyl sulfate per day.237 Only in the groups receiving 150 mg or 300 mg was glucose metabolism improved, fasting blood sugar decreased, and another marker for chronic high blood sugar reduced. At the 300 mg level, total cholesterol decreased, although not without an accompanying reduction in the protective HDL cholesterol. None of the amounts improved insulin sensitivity. Although there was no evidence of toxicity after six weeks of vanadyl sulfate supplementation, gastrointestinal side effects were experienced by some of the participants taking 150 mg per day and by all of the participants taking 300 mg per day. The long-term safety of the large amounts of vanadium needed to help people with type 2 diabetes (typically 100 mg per day) remains unknown. Many doctors expect that amounts this high may prove to be unsafe in the long term.

Fructo-oligosaccharides
In a preliminary trial, supplementation with fructo-oligosaccharides (FOS) (8 grams per day for two weeks) significantly lowered fasting blood-sugar levels and serum total-cholesterol levels in people with type 2 diabetes.238 However, in another trial, supplementing with FOS (15 grams per day) for 20 days had no effect on blood-glucose or lipid levels in people with type 2 diabetes.239 In addition, some double-blind trials showed that supplementing with FOS or galacto-oligosaccharides (GOS) for eight weeks had no effect on blood-sugar levels, insulin secretion, or blood lipids in healthy people.240 241 Because of these conflicting results, more research is needed to determine the effect of FOS and inulin on diabetes and lipid levels.

Manganese
People with diabetes may have low blood levels of manganese.242 Animal research suggests that manganese deficiency can contribute to glucose intolerance and may be reversed by supplementation.243 A young adult with insulin-dependent diabetes who received oral manganese chloride (3–5 mg per day) reportedly experienced a significant fall in blood glucose, sometimes to dangerously low levels. In four other cases, manganese supplementation had no effect on blood glucose levels.244 People with diabetes wishing to supplement with manganese should do so only with a doctor’s close supervision.

Medium chain triglycerides
Based on the results of a short-term clinical trial that found that medium chain triglycerides (MCT) lower blood glucose levels,245 a group of researchers investigated the use of MCT to treat people with type 2 diabetes mellitus. Supplementation with MCT for an average of 17.5% of their total calorie intake for 30 days failed to improve most measures of diabetic control.246

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful: Several herbs may help in managing symptoms associated with diabetes, including the control of blood sugar levels.

Cayenne
Double-blind trials have shown that topical application of creams containing 0.025–0.075% capsaicin (from cayenne [Capsicum frutescens]) can relieve symptoms of diabetic neuropathy (numbness and tingling in the extremities caused by diabetes).247 248 Four or more applications per day may be required to relieve severe pain. This should be done only under a doctor’s supervision.

Psyllium
Supplementing with psyllium has been shown to be a safe and well-tolerated way to improve control of blood glucose and cholesterol. In a double-blind trial, men with type 2 diabetes who took 5.1 grams of psyllium per day for eight weeks lowered their blood glucose levels by 11% to 19.2%, their total cholesterol by 8.9%, and their LDL (bad) cholesterol by 13%, compared to a placebo.249

Asian ginseng
Asian ginseng is commonly used in Traditional Chinese Medicine to treat diabetes. It has been shown in test tube and animal studies to enhance the release of insulin from the pancreas and to increase the number of insulin receptors.250 251 Animal research has also revealed a direct blood sugar-lowering effect of ginseng.252 A double-blind trial found that 200 mg of ginseng extract per day improved blood sugar control, as well as energy levels in people with type 2 diabetes.253

American ginseng
In a small preliminary trial, 3 grams of American ginseng was found to lower the rise in blood sugar following the consumption of a drink high in glucose by people with type 2 diabetes.254 The study found no difference in blood sugar-lowering effect if the herb was taken either 40 minutes before the drink or at the same time. A follow-up to this study found that increasing the amount of American ginseng to either 6 or 9 grams did not increase the effect on blood sugar following the high-glucose drink in people with type 2 diabetes.255 This study also found that American ginseng was equally effective in controlling the rise in blood sugar whether it was given together with the drink or up to two hours before.

Basil
Preliminary trials of holy basil (Ocimim sanctum) leaves and hairy basil (Ocimum canum) seeds have shown that these herbs may help people with type 2 diabetes control their blood sugar levels.256 257 258 While the mechanism of action of holy basil leaf is not understood, hairy basil seed may work by replacing simple sugars in the diet (which rapidly and detrimentally elevate blood sugar levels) with dietary fiber (which raises blood sugar levels more slowly for better control). It is unknown whether common culinary basil (Ocimum basilicum) would have similar effects.

Gymnema
Gymnema may stimulate the pancreas to produce insulin in people with type 2 diabetes. Gymnema also improves the ability of insulin to lower blood sugar in people with both type 1 and type 2 diabetes. So far, no double-blind trials have confirmed the efficacy of gymnema for people with any type of diabetes. One preliminary trial found that 400 mg of gymnema extract per day could reduce or eliminate the need for oral blood sugar-lowering drugs in some people with type 2 diabetes.259 Another preliminary trial suggested the same amount of the extract could allow for use of less insulin in people with type 1 diabetes.260 Gymnema is not a substitute for insulin.

Aloe vera
Two preliminary trials found that aloe vera juice (containing 80% aloe gel) helps lower blood sugar levels in people with type 2 diabetes. One trial found that 1 Tbsp (15 grams) twice daily reduced the amount of the blood sugar-lowering drug glibenclamide required to manage blood sugar levels.261 The other trial found the juice by itself was effective.262

Bitter melon
Whole, fried slices,263 water extracts,264 and juice265 of bitter melon may improve blood-sugar control in people with type 2 diabetes, according to preliminary trials. However, double-blind trials are needed to confirm this potential benefit.

Onion
Preliminary trials and at least one double-blind trial have shown that large amounts of onion can lower blood sugar levels in people with diabetes.266 267 268 The mechanism of onion’s blood sugar-lowering action is not precisely known, though there is evidence that constituents in onions block the breakdown of insulin in the liver. This would lead to higher levels of insulin in the body.269

Bilberry
Bilberry may lower the risk of some diabetic complications, such as diabetic cataracts and retinopathy. One preliminary trial found that supplementation with a standardized extract of bilberry improved signs of retinal damage in some people with diabetic retinopathy.270

Ginkgo biloba
Ginkgo biloba extract may prove useful for prevention and treatment of early-stage diabetic neuropathy, though research is at best very preliminary in this area.271 Other herbs that may help are fenugreek seeds and eleuthero (Siberian ginseng).

Mistletoe
Mistletoe extract has been shown to stimulate insulin release from pancreas cells,272 and animal research found that it reduces symptoms of diabetes.273 No research in humans has yet been published; however, given mistletoe’s worldwide reputation as a traditional remedy for diabetes, clinical trials are warranted to validate these promising preliminary findings. Traditionally, mistletoe is prepared by soaking 2–4 teaspoons of chopped mistletoe in two cups of water overnight. The mixture is drunk first thing in the morning and sweetened with honey if desired. Another batch may be left to steep during the day and drunk at bedtime.

Olive leaf
Olive leaf extracts have been used experimentally to lower elevated blood-sugar levels in diabetic animals.274 These results have not been reproduced in human clinical trials.

Reishi
Animal studies275 and some very preliminary trials in humans suggest reishi may have some beneficial action in people with diabetes.276

Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

Other integrative approaches that maybe helpful: Acupuncture may be helpful in the treatment of diabetes, or complications associated with diabetes. Preliminary trials have suggested that acupuncture can lower blood sugar277 278 279 and improve insulin production280 in people with type 2 diabetes, but trials on long-term effects have not been concluded. In a preliminary trial, 77% of people suffering from diabetic neuropathy experienced significant reduction in pain following up to six acupuncture treatments over a ten-week period. Many were also able to reduce pain medications, but no long-term change in blood-sugar control was observed.281 Bladder control problems, a complication of long-term diabetes, responded to acupuncture treatment with a significant reduction in symptoms in both controlled282 and uncontrolled283 trials.

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